Clinical Exercise Testing Flashcards
Gold standard textbook
ACSM’s guidelines for exercise testing and prescription
Guidelines for exercise testing
Provide a habituation period with exercise mode
Utilize large muscle groups unless an ortho. or peripheral limitation present
Avoid isometric contractions (handrails)
Start well below max levels
Should last 8-12 minutes
Guidelines for exercise testing: should last 8-12 minutes
1 to 3 minutes per stage
Ramped protocols should have a gradual and regular increase in workload (1 MET/minute)
Guidelines for exercise testing: environment
Room temperature should be 72F with less than 60% humidity
General movement of air (fan)
Proper exercise morality equipment, monitoring equipment, and emergency items
Trained personnel
Exercise testing indicators
Eval. cause of symptoms
ID CAD before it presents
Eval. effectiveness of therapy interventions
Develop exercise prescription
Return of work
Rule of MI
Exercise testing indications: risk stratifications
Post MI patients to help with follow up therapy and intervention options
Patients considered for coronary revascularization
Before noncardiac surgery in patients with CAD
Pretesting
Review medical history/reason for test and meds they are on
Explain test
Informed consent
Resting BP (supine and standing)
Most accurate diagnosis of CAD
Made at or near max HR
Don’t stop just because they achieved age predicted max HR
Overall ABSOLUTE contraindications to exercise testing
Recent change in resting ECG indicative of ischemia (recent MI within past 2 days)
Unstable angina
Uncontrolled cardiac dysrhythmia
Symptomatic sever aortic stenosis
Uncontrolled symptomatic heart disease
Acute systemic infection
Acute pulmonary embolism/infarction
Suspected or known dissecting aneurysm
Overall RELATIVE contraindications to exercise testing
Left coronary stenosis
Moderate stenotic valvular disease
Electrolyte abnormalities
Arterial hypertension at rest > 200/110
Tachy or brady
Hypertrophic cardiomyopathy
NM, MS, or rheumatoid disorders exacerbated by exercise
High degree AV block/arrhythmia
Ventricular aneurysm
Uncontrolled metabolic disease (diabetes)
Chronic infection
Mental or physical impairment
During the test
Use protocol with 2-3 minute stages
Begin at submax level
Progress in stages long enough to allow accommodations
Have increments between stages that are reasonable to person’s exercise capacity
During the test: heart rate
HR should increase 10 +/- 2 BPM with each 1 MET increase
Know effects of medications (beta blockers)
During the test: heart rate concerns
If HR fails to increase linearly with an increased workload or peak HR is less than 20 BPM below predicted max
Failure of HR to decrease appropriately (more than 12 BPM in the first minute) during recovery, whether sitting or performing low intensity exercise
During the test: SBP
Should be a 10 +/- 2 mmHg increase in SBP with each 1 MET level increase
Realize medication impacts
Stop test if patient’s SBP rises above ~250mmHg
During the test: concerns SBP
Flat or hypotension response in SBP to an increased workload
Following exercise, SBP should decrease in an orderly way and be checked 1 minute post and 3 minutes post exercise then compared
During the test concerns SBP: flat or hypotension response in SBP to an increased workload
Less than 20mmHg increase in SBP from rest, max SBP less than 140mmHg
A decrease below resting SBP values
A 10mmHg decrease in SBP with an increase workload
Indicators to stop the test
Any occurrence of ABSOLUTE indications
RELATIVE indications
Purpose of test is achieved
Indicators to stop the test: purpose of the test
Evaluation presenting symptoms
Screening of occult CAD
Obtaining max MET level for return to work
PRIMARY CONSIDERATION
Indicators to stop the test: any occurrence of an ABSOLUTE contraindication
HR
SBP
Indicators to stop the test: any occurrence of RELATIVE contraindications
How the patients feels and looks
Post test
Obtain max BP, HR, RPE, and ECG readings
Decrease workload slowly and have patient continue to exercise to prevent post exercise hypotension
Monitor pattern of recovery as failure of BP and HR to recover adequately is an unfavorable sign
Continue ECG monitoring until HR is less than 100 BPM and ECG has normalized
Alternative test considerations
COPD and other pulmonary diseases should be considered for nuclear testing
LBBB should be considered for pharmacological testing
Nuclear testing
Looks at contrast in the lungs
Used for COPD and pulmonary disease patients
Vasodilator pharmacological testing
Medication given to stimulate heart as if they were actually exercising
Used for LBBB patients
Treadmill based testing
Commonly used
Uses greater amount of muscle compared to biking=higher metabolic demand and higher max HR and BP
More difficult to take BP and ECG
Handrails May impact results
Treadmill based testing: protocol
Bruce protocol
3 minute stages that increase in speed and grade each stage
Modified Bruce protocol
Designed for individuals who are unable to exercise vigorously
Stages are short and increased more progressively
Commonly used to assess MI
Modified Balke protocol
Submax protocol constant speed and increasing grade
Can be taken to max is desired but testing normally exceeds 8-12 minutes
Terminate at predetermined RPE of 17
Modified Naughton protocol
Very commonly used with CAD patients
Highly effective at detecting ischemic abnormalities following MI
Cycle ergometer testing
Good for patients who have ambulatory, ortho, or peripheral vascular limitations
Less expensive, portable, easier to take BP and ECG
Lower HR and higher SBP
Cycle ergometer testing: concerns
Localized leg fatigue before reaching CV max
Difficult to track pedal rate
Arm ergometer testing
Used if precinct can’t perform lower body exercise
Has been replaced by pharmacological stress testing
Arm ergometer testing: concerns
Less muscle mass involved
Lower VO2 peak
Difficulty in taking BP and ECG
Test ends due to arm pain, not CV max
