stress testing Flashcards
was first described in
1772 by the English physician
William Heberden
Angina
Angina was first described in
___ by the English physician
William Heberden
1772
Angina was first described in
1772 by the English physician
___
William Heberden
The “cornerstone” of modern stress testing
was the recognition of the importance of
____ to predict the
presence of coronary artery disease
(CAD)
ST segment changes
stress testing is used to detect what disease?
coronary artery disease or CAD
___ST depression first noted during angina (Bousfield)
1918
a graphic recording of the electrical activity of the heart
ECG
REPRESENT VENTRICULAR DEPOLARIZATION
QRS complex
REPRESENTS VENTRICULAR REPOLARIZATION
t wave
REPRESENTS TOTAL TIME REQUIRED FOR VENTRICULAR DEPOLARIZATION AND REPOLARIZATION
QT interval
YEAR WHEN IRISH SCIENTIST MAREY ANALYZES THE ELECTRIC PATTERN OF A FROGS HEART
1876
HE INCREASED WILSON’S UNIPOLAR LEAD VOLTAGE BY 50% AND MADE AUGMENTED LEADS
goldberger
THE NOBLE PRIZE FOR PHYSIOLOGY WAS GIVEN TO HIM FOR HIS WORK ON EKG
einthoven
CORRECT ABOUT 6 CHEST LEADS
I,III,IV
I-V1, III- V4, IV-V6
QRS COMPLEX
E no answer
ST changes during exercise (sit ups) are associated with chest pain &
decreased cardiac blood flow (Feil & Siegel
1928
Master’s Step test, first “standard” exercise protocol (Master)
1929
ST depression is present in only 75% of patients with angina during
exercise (similar to percentages today). (Goldhammer & Scherf)
1932
First to use maximal exercise testing to test for CAD (Missal)
1938
Continuous EKG monitoring, depression > 1.0 mm is clinically
significant (Riseman et al.)
1940
EKG changes after exercise can be useful to detect CAD (Master
& Jaffe)
1941
The Harvard Step Test used to assess fitness from HR during
recovery (Johnson et al.)
1942
Maximal exercise (stair climbing) was more sensitive (88%) to
detect CAD than submaximal exercise (39%) (Master’s test) (Wood et al
1950
Treadmill testing used with set criteria to screen for CAD (Yu et al.)
ST depression > 1.0 mm
1952
Cycle tests used to predict fitness (Astrand)
1954
Bruce established the guidelines used today: treadmill, with EKG,
during exercise
1956
Refined interpretation of ST changes (V5 or CM5 most sensitive
leads) (Blackburn et al.)
1969
The probability of a “true” positive stress test depends on the pre-test risk of
the patient
Bayes Theorem (1970s and 1980s)
Test used in Medicine to measure heart’s ability to respond to external
stress in a controlled clinical environment
stress testing
3 type of stress testing
exercise
pharmacologic
nuclear
exercise stress testing are
treadmill and bicycle
pharmacologic st are
A. Regadenoson
B. Dobutamine
C. Persantine
D. Adenosine
shows how your heart works during physical activity.
exrcise st
́ it usually involves walking on a treadmill or riding a stationary bike
exercise st
indications of st
only have 3 - DDG
́ Diagnose coronary artery disease.
́ Diagnose heart rhythm problems (arrhythmias).
́ Guide treatment of heart disorders.
risk for ST
we have 3 as well - LAH
́ Low blood pressure
́ Abnormal heart rhythms (arrhythmias).
́ Heart attack (myocardial infarction).
Contraindications
́ Acute M.I
́ High risk of unstable angina
́ Uncontrolled cardiac arrthymias
́ Symptomatic severe aortic stenosis
́ Pulmonary infarction
́ Acute myocarditis
́ Acute aortic dissection
Safety Precautions and Equipment
́The treadmill should have Front and side rails for subjects to steady
themselves.
́ An emergency stop button should be readily available to the staff only.
Pre –Test Preparation
́ Any history of light headedness, fainting while exercising should be asked.
́ The physician should also ask about family history and general medical
history, making note of any considerations that may increase the risk of sudden death.
́ A brief physical examination should always be performed prior to testing to
rule out significant outflow obstruction.
Preparation for Exercise Testing
́ The subject should be instructed not to eat or smoke at least 2 hours prior to
the test.
́ Unusual physical exertion should be avoided before testing.
́ Specific questioning should determine which drugs are being taken.
́ Because of a greater potential for cardiac events with the sudden
cessation of -blockers , they should not be automatically stopped prior to
testing.
It usually involves walking on a treadmill at increasing levels of difficulty,
while electrocardiogram, heart rate, and blood pressure are monitored.
Treadmill Test
́
Exercise Protocols
In general, 6 to 12 minutes of continuous progressive exercise during which
the myocardial oxygen demand is elevated to the patient’s maximal level
is optimal for diagnostic and prognostic purposes.
́ The protocol should include a suitable recovery or cool-down period.
Various Protocols FOR TREADMILL
a. Bruce
b. Cornell
c. Balke ware
d. Acip
e. mAcip
f. Naughton
g. Weber
another protocol aside the treadmill protocol
Bicycle ergometer
The ___ multistage maximal treadmill protocol has 3-minute periods to
allow achievement of a steady state before work-load is increased for next
stage
Bruce protocol
Termination of Exercise Testing
́ Moderate to severe chest pain
́ Severe shortness of breath
́ Abnormally high or low blood pressure
́ An abnormal heart rhythm
́ Dizziness
́ Fatigue
́ Certain changes in your electrocardiogram
Positive test
A flat or down sloping depression of the ST segment > 0.1 mV below baseline
Negative test
Target heart rate is not achieved
Limitations of Treadmill Stress Test
́ Sensitivity- 68%
́ Specificity- 77 %
2 ways in Pharmacological Stress Test
- Vasodilators
- B2 agonist
example of vasodilators
Adenosine and Dipyridamole
example of b2 agonist
Dobutamine
INDICATIONS OF PHARMACOLOGICAL
STRESS TESTING
́ Patients inability to exercise adequately.
́ The chosen test cannot be performed readily with exercise
how Nuclear Stress Test is conducted
A radiotracer (Tc-99 sestamibi or thallium)
is injected
what is used in nulear testing
radiotracer
example of radiotracer
Tc-99 sestamibi or thallium
nuclear testing, Scans are acquired with a ___ to capture images of the blood
flow.
gamma
camera
how many days is the nuclear testing done
2 separate days
