EXAM1/CH5- Graded Exercise Testing Flashcards
3 general uses of graded exercise testing (GXT)
-diagnostic
-prognostic
-therapeautic
diagnostic use of GXT
identify abnormal responses
prognostic use of GXT
identify future, given the presence of disease
therapeautic use of GXT
identify impact of intervention
which individuals need GXT prior to an exercise program
moderate + high risk
-low risk doesn’t need
who are considered low risk + therefore don’t need GXT prior to exercise program
individuals with fewer than 2 NET CV risk factors
who are moderate risk + need GXT prior to exercise program
individuals with 2 or more NET CV risk factors
who is high risk + therefore needs GXT prior to exercise program
individuals with 1 or more signs/symptoms of CV/pulmonary/metabolic disease
-net doesn’t matter for this one; if they have a diagnosis of disease they are automatically high risk
-ex: diabetic = automatically high risk due to having known metabolic disease
-another risk if having a known MI a year ago
can you still do GXT prior to exercise program for low risk individuals
yes, there are benefits but we don’t HAVE to
positive CV risk factors (diagram)
-age
-family history
-cigarette smoking
-physical inactivity
-obesity
-hypertension
-dyslipidemia
-diabetes
negative CV risk factors (diagram)
high density lipoprotein cholesterol (HDL-C)
how does the positive/negative CV risk factors diagram work
-any positive risk factor = +1
-negative risk factor = -1, cancels out positive
-we calculate the NET
CV risk factor diagram- age
-men greater or equal to 45 years
-women greater or equal to 55 years
CV risk factor diagram- family history
-MI
-coronary revascularization
-sudden death before 55 years in father or other male first-degree relative OR before 65 years in mother or female first-degree relative
CV risk factor diagram- cigarette smoking
-current cigarette smoker
-quit within the previous 6 months
-exposure to environmental tobacco smoke
CV risk factor diagram- physical inactivity
not participating in at least 30 min of moderate intensity on at least 3 days of the week for at least 3 months
CV risk factor diagram- obesity
-BMI greater or equal to 30
-waist girth greater than 102 cm (40 in) for men
-waist girth greater than 88 cm (35 in) for women
CV risk factor diagram- hypertension
-SBP greater or equal to 120 mmHg
-DBP greater or equal to 80 mmHg
(confirmed by measurements on at least 2 separate occasions)
-OR on antihypertensive medication
CV risk factor diagram- dyslipidemia
-LDL (low-density lipoprotein) cholesterol greater or equal to 130
-HDL (high-density lipoprotein) cholesterol less than 40
-OR on lipid-lowering medication
-if total serum cholesterol is all that is avilable, use greater or equal to 200
CV risk factor diagram- diabetes
-fasting plasma glucose greater or equal to 126
-2 hour plasma glucose levels in oral glucose tolerance test (OGTT) greater or equal to 200
-HbA greater or equal to 6.5%
CV NEGATIVE risk factor diagram- high-density lipoprotein cholesterol (HDL-C)
greater or equal to 60
types of GXTs
-stress ECG/EKG
-regular stress test
-cardiac stress test
-graded exercise test (GXT)
-sign + symptom-limited GXT (Sx-GXT)
KNOW that all these things essentially mean the same thing
elements for GXT
-appearance + quantification of symptoms
-test termination
-resting, exercise, + recovery ECG abnormalities
-assessment of functional capacity
-interpretation of findings + generation of final summary report
pre-test considerations for GXT
JUST AS IMPORTANT AS THE ACTUAL TEST
-testing personnel
-informed consent
-general interview + physical examinatin
-pretest likelihood for CHD
-prestest instructions + subject preparation for ECG
-selection of exercise protocol + modality
pre-test considerations- testing personnel
-in an ideal world, you would have 2 people conducting the test with 1 doing EKG/other data + the other doing the test
-physician won’t be present unless they are trying to push the limit with the patient
-what REALLY happens- only 1 technician managing EKG, protocol, changing equipment, measuring vitals, making sure patient is okay, etc.
-clinical ex physiologist, PT, RN, NP, PA can all do initial interpretation but not final
-regardless of who does the initial interpretation, the FINAL INTERPRETATION MUST BE DONE BY THE PHYSICIAN THAT ORDERED THE TEST
pre-test considerations- informed consent
-reason for tet
-test procedures
-explanation of risks, major + minor
-patient explains or verbalizes ALL of these back to test supervisor
-anyone who has gotten procedure/test has done this
-for legal purposes
-in extreme detail
what is the most important part of informed consent
explanation of risks
-every risk from most minor to most major should be listed, most major is typically death
pre-test considerations- general interview + examination
-refer back to ch4 for specifics
-must make sure no changes have occurred in the clinical status
-review medical record prior to testing
-determine indications vs contraindications
indications
reasons for Rx
-KNOW this
-if asked for ex of indication, she is asking why we are doing a test + the specific reason why the test was ordered
contraindications
reasons not to do a medical treatment
generally, how would the general interview/examination work in terms of GXT
ideally they would come in for first appointment to do general interview + examination so that you could have time to think about what protocol would be good for them
-SOMETIMES you must do this + GXT in the same appointment
-make sure medical records have not changed since previous appointment
pre-test considerations- indications
aka reasons for the test
-assess symptoms to assist in the diagnosis of coronary heart disease or other medical conditions
-identify a patient’s future risk or prognosis
-evaluate pacemaker, HR, or BP response to exertion
-evaluate for return-to-work guidelines + disability
-determine effectiveness of an intervention
indications- “assess symptoms to assist in the diagnosis of CHD or other medical conditions”
-one of the most common reasons why GXTs are done
-most GXTs are sign + symptom limited
indications- “identify a patient’s future risk or prognosis”
-where we identify future risk or prognosis
-this works because FUNCTIONAL CAPACITY is highly correlated to prognosis
functional capacity
how well someone performs on tests
functional capacity is highly correlated to ___
prognosis
indications- “evaluate for return-to-work guidelines + diability determination”
-if you have a job that is physically strenuous, the GXT will indicate how you will do back at work
-also helps confirm if people can apply for disability
-government uses GXTs to see if you truly have a disability
indications- “determine effectiveness of an intervention”
more of a therapeautic reason
pre-test considerations- absolute contraindications
-MI within prior 2 days or other acute cardiac event
-change in ECG suggesting MI or other acute event
-unstable angina
-symptomatic severe aortic stenosis
-uncontrolled symptomatic heart failure
-acute myocarditis or pericarditis
-acute infection
2 types of contraindications
-absolute
-relative
absolute contraindications
-black + white
-no room for interpretation
-if there are present you will absolutely not do exercise testing (absolute = NO exercise)
-doesn’t mean this can’t change + they will eventually be able (ex: infection can clear up)
aortic stenosis
when aortic valve narrows + blood cannot flow normally
acute myocarditis
condition causing inflammation of heart muscle (myocardium)
acute pericarditis
painful condition where fluid-filled pouch (pericardium) around heart is inflamed
relative contraindications
-the gray area
-specific to individual
-might have to delay testing but not always
pre-test considerations- relative contraindications
-left main coronary stenosis
-severe arterial hypertension at rest (SBP greater than 200 or DBP greater than 110)
-tachycardia at rest or marked bradycardia
-uncontrolled metabolic disease or electrolyte abnormality
left main coronary stenosis
serious condition when left main coronary artery narrows, causing reduction in blood flow to left ventricle of heart
relative contraindications- when might severe arterial hypertension at rest occur
if patient is incredibly nervous
-you could do things to calm them down but if it stays elevated, we cannot do the test
relative contraindications- high BP
pressure could be high because they forgot to take medication
-we would have them come back another day
pre-test considerations- subject preparation
-clothing + shoes
-continue medications? timing of medications?
-food + water
-substances to avoid
-skin preparation for ECG
-electrode placement
when does subject preparation occur
doesn’t just happen on day of test, happens on days leading up to it too
-ex: when you have surgery, you get directions for how to prep few days before surgery
-NEVER ASSUME THESE THINGS ARE COMMON SENSE, because they aren’t
subject preparation- clothing + shoes
-comfortable workout wear
-appropriate shoes (no high heels, no sandals)
subject preparation- medications
-continue medications? timing of medications?
-physician will be the one that determines this
-IF PHYSICIAN DOESN’T INCLUDE IN RX, YOU MUST CONTACT THEM TO MAKE SURE
-reason for test (diagnostic, prognostic, exercise program)
subject preparation- food + water
-hydrate days leading up to the test
-avoid caffeine (stimulant so will affect BP + HR in response to exercise)
-small snack before test (ex: granola bar)
subject preparation- substances to avoid
-ETOH (ethanol aka alcohol)
-cigarettes
subject preparation- skin preparation for ECG
eliminate oils + hair, lotions, etc. (makes it difficult for electrodes to stay stuck to skin)
subject preparation- electrode placement
-use standard lead placement OR alter site for pacer implant or ICD implant
-electrodes must be placed regardless of reason for test
-males- ask if they are okay shaving beforehand so we can put electrodes in those areas; hair will come off regardless when you take electrodes off
-DO NOT PUT ELECTRODES DIRECTLY OVER ANY TYPE OF IMPLANT
pre-test considerations- select protocol
-steady state vs ramp? maximal vs submaximal?
-try to match work rate increments (in estimated METs) to patient capabilities (ex: walk a flight of stairs)
-test duration: 8-12 min
-use a common protocol
-use protocol appropriate for testing
is steady state or ramp protocol more common
ramp
submaximal vs maximal
submax is more on the safe side
what protocol is #1
Bruce protocol
-most physicians know this one
-try to use this one because common in clinical setting + physician will better understand
-also easily modified- the standard values given by the protocol can be easily adjusted higher/lower based on patient needs
what stage do we want patient to get to in protocol
stage 4-5ish
-if we only get to stage 2, you will probably never get a Rx from that physician again
pre-test considerations- select mode
(treadmill, bike, arm ergometer, etc.)
-quantified, incremental, graded work
-athletes: specificity of testing + training
-occupational concerns
-accomodate patient needs (orthopedic, body habitus, gait + balance)
body habitus
the shape of someone’s body
2 commonly used protocols
-Balke
-Bruce
which protocol is most common
Bruce protocol
appearance + quantification of symptoms
-maintain regular communication between staff + patient
-rating of perceived exertion (RPE)
-use of handrails required?
-accomodate other common languages through translation
appearance + quantification of symptoms- maintain regular communication between staff + patient
-use thumbs up/down
-these would be communicated BEFORE the test
appearance + quantification of symptoms- RPE
RPE = rating of perceived exertion
what is used to quantify RPE
Borg scale
appearance + quantification of symptoms- use of handrails required?
ideally we don’t want patient to be reliant on the handrails
-if they rely on them more than not, make a note of this
-doesn’t mean it is fault in the test/us/patient BUT important to make note + let physician know
Borg scale
MODIFIED Borg scale is more common due to numbers used
-0-10 is easier to use than 6-20
numbers for Borg scale
6-20
-6 = light
-20 = hard
numbers for modified Borg scale
0-10
-0 = rest
-10 = very,very hard
what do we use RPE/Borg for
to see how well the person is doing throughout the test
-shows how suitable the protocol is for them
MET level
a way to measure amount of energy the body uses during physical activity compared to resting
2 types of test termination
-submaximal GXT
-symptom limited
test termination- submaximal GXT
reaches a predetermined MET level
test termination- symptom limited
terminated because of onset of symptoms
most clinical GXT are submaximal or symptom limited
symptom limited
-the test is complete once the presence of a specific sign/symptom appears
angina
chest pain or discomfort that occufrs when the heart muscle doesn’t receive enough oxygen-rich blood
dyspnea
shortness of breath
peripheral vascular disease
occurs when blood vessels narrow or become blocked, reducing blood flow to organs + limbs outside the heart + brain
intermittent claudication
lower extremity skeletal muscle pain that occurs during exercise
besides knowing when a symptom kicks in, what else is important
knowing their ability to do ADLs
-there are varying levels for angina/dyspnea, etc.
angina scale
0- no symptom
1- light, barely noticable
2- moderate, bothersome
3- moderately severe, very uncomfortable
4- most severe or intense pain ever experienced
dyspnea scale
0- no symptoms
1- mild, noticeable to patient but not observer
2- mild, some difficulty, noticeable to observer
3- moderate difficulty, but patient can continue
4- severe difficulty, patient cannot continue
(not sure if you need to know) peripheral vascuar disease scale for assessment of intermittent claudication
0- no symptoms
1- definite discomfort or pain but only of initial or modest levels (established but minimal)
2- moderate discomfort or pain from which the patient’s attention can be diverted by a number of common stimuli (conversation, interesting TV show, etc.)
3- intense pain from which the patient’s attention cannot be diverted except by catastrophic events (fire, explosion, etc.)
3- excruciating + unbearable pain
resting, exercise, + recovery ECG abnormalities- RESTING abnormalities
don’t need to know resting abnormalities
-KNOW that resting abnormalities listed here are things probably already identified in medical report + we are just confirming the presence of these
resting, exercise, + recovery ECG abnormalities- abnormalities DURING the ECG
-ST-segment depression (presence of subendocardial ischemia)
-ST-segment elevation (stop test immediately)
-T-wave changes (concern when tied to ST-segment changes)
-arrhythmia
abnormalities during the ECG- ST-segment depression
representative of myocardial ischemia
-physically the person would experience angina
-when patient says they are experiencing chest pain, you SHOULD be able to see ST-segment depression on ECG
-if you see on ECG but patient hasn’t reported, you know that angina is on the way
myocardial ischemia
adequate oxygen isn’t reaching myocardia
ST-segment depression indicates what
presence of subendocardial ischemia
what to do if we see ST-segment elevation
stop test immediately
when are T-wave changes a concern
when tied to ST-segment changes
assessment of functional capacity
-exercise duration
-estimated METs
-VO2max
what is functional capacity linked to
ability to do ADLs
-also linked to prognosis
assessment of functional capacity- what might you need to define to the physician
METs
-also helpful to include normative data; take your patient + compare them to the norm
how does VO2 max decline for healthy, inactive individual
5-10% per decade
how does VO2 max decline for healthy, active individual
3-6% per decade
interpretation of findings + generation of final summary report- 6 items to address
-angina status
-ECG findings (ischemia)
-ECG findings (arrhythmia)
-functional capacity
-HR response
-BP response
KNOW THAT THESE 6 ITEMS MUST BE SENT TO PHYSICIAN AS A MINIMUM EVERY SINGLE TIME!!!!!!
-even if the test had nothing to do with any of the 6 things, STILL MUST INCLUDE
-ex: if someone is being seen for pulmonary issues + not cardiac, they still may experience angina since it is associated with lack of oxygen to the heart
interpretation- angina status
-typical angina, atypical/noncardiac angina, none
-time to onset, test limiting, time to resolution, therapies needed to help resolve
what does TYPICAL angina look like
-when they begin to exert themselves, the angina begins
-when they stop + relax, the angina goes away
ATYPICAL/NONCARDAIC angina
no rhyme or reason it when it onsets + stops
test limiting
the symptom (ex: angina) made the patient say they couldn’t do the test any more
interpretation- ECG findings ischemia
-ST segment depression for ischemia diagnosis
-time of onset, magnitude of change, + time to resolve
for ischemia, what does magnitude of change refer to
the actual measured depression
-ECG will tell you this
interpretation- ECG findings arrhythmia
-state findings
-time of onset, time to resolve
-important to note if it is an arrhythmia the person has all the time rather than an onset arrhythmia
interpretation- functional capacity
-peak MET level + compare to normative data
-reason for stopped test
interpretation- HR response
before, during, + after exercise
interpretation- BP response
before, during, + after exercise
if a patient cannot complete exercise or it is too high risk, what do we do
use chemicals to mimic the same reaction
WHO decides if a patient is able to complete exercise or go drug route
the PHYSICIAN, NOT THE CEP
what drugs are used to induce same effect as exercise
dobutamine
-increases HR + BP
what does dobutamine do
increase HR + BP
-just like exercise does
stress EKG with imaging is used for what
people who cannot complete exercise themselves
2 types of stress EKG with imaging
-EKG with echocardiogram (stress echo)
-EKG with radionuclide imaging (nuclear stress test)
EKG with echocardiogram (stress echo)
allows for assessment of wall motion abnormalities
EKG with radionuclide imaging (nuclear stress test)
allows for assessment of distribution of blood flow
-uses radioactive tracer to see how blood flows through the heart
who would administer the dobutamine
NURSE, not the CEP
see slides 36 + 37 for images of echo vs nuclear stress test
nuclear stress test provides which images
slices of the heart from different angles
-illumination of the radioactive tracer through the heart
in an abnormal nuclear stress test, what could be indicated
plaque buildup could cause blockage
-an individual would need surgery to go + clear out the plaque
biggest takeaway about GXT
do what is safest for the patient
-NEVER sacrifice this
-we want to find the balance of getting the best/safest effort of the patient to fulfill the needs of the physician
GXT conclusion
-GXT is a useful + often the first diagnostic tool used to assess the presence of significant CAD with or without nuclear perfusion or echo imaging
-can be used for diagnosis but also PROGNOSIS + help design an exercise training program
