1. Stress Testing Daymar College Lisa H. Young, RN, BSN, MA Ed.

2. Kattus or Stress Testing Diagnostic Procedure Chest Pain Determine function capacity of the heart after surgery or MI Screen for heart disease (CAD) Set limitations for exercise program Abnormal heart rhythms Effectiveness of heart medications Post angioplasty Family history of heart disease http://www.youtube.com/watch?v=Z8nJgg59JsM&list=PL510FBA78000A7A05http://www.youtube.com/watch?v=Z8nJgg59JsM&list=PL510FBA78000A7A05 & http://www.youtube.com/watch?v=W9mxeMp7zHg http://www.youtube.com/watch?v=W9mxeMp7zHg

3. Absolute Contraindications Acute or Recent MI Unstable angina or angina at rest Rapid atrial or ventricular rhythms Severe aortic stenosis Dissecting aneurysm 2 or 3 degree heart block Inflammation surrounding the heart Severe anemia Uncontrolled Hypertension CHF

4. Relative Contraindications Uncontrolled rapid supraventricular rhythms Frequent PVCs Uncontrolled hypertension Mild or moderate aortic stenosis

5. Educating the Patient Educating the Patient Possible complications and safety measures Reason for the test Explain the procedure “Informed Consent” Clothing Medications

6. Preparing for the Stress Test Equipment check Supplies Emergency supplies Physician’s order Complete medical history, vital signs, EKG Informed consent Safety equipment Test protocol Belt length X cycles/minute (RPM) = speed

7. Post Stress Test Procedure Monitor and observe patient Collect supplies Avoid tobacco, caffeine and alcohol Avoid extreme temperature changes Rest Results in approximately 10 days Documentation

8. 12 Lead Electrode Placement for Ambulatory Monitoring/ Stress Test

9. Arm Ergometer

10. Leg Ergometer

11. Metabolic Equivalents Reflection of oxygen consumption 1 MET = person at rest/ 3.5 ml oxygen/kg/min 3 – 6 METs = moderate physical activity 4 METs = possible ischemia with CAD patient

12. Bruce and Modified Bruce Protocol

13. Naughton Protocol

14. Double Product Determine the level of exercise achieved HR X SBP = DP Exampled: SBP = 118 HR = 88 DP = 10384

15. Target or Maximum Heart Rate 220 minus age At least 85% of THR is achieved Example: pt age 60 220 --- 60 = 160 85% of 160 = 136 70% post MI

16. Termination of Stress Test ST segment elevation/ ST depression > 3mm Sustained Ventricular tachycardia or frequent PVCs Chest pain/ pale and diaphoretic Drop in blood pressure or failure of the BP to rise with exercise/ elevation of 240mmHg or diastolic BP above 120 mmHg Bradycardia, especially development of AV block Pt voices inability to continue; symptoms

17. Stress Test Expected EKG Changes Shortened PR interval, RT interval & QT interval Decreased R wave amplitude (lower voltage QRS) Tall P waves; increased amplitude Rightward axis shift T wave may become taller or inverted Increased heart rate (shorter R-R intervals) Increased ectopic activity with maximum exercise Chronotropic reserve Chronotropic incompetence

18. Expected Clinical Symptoms Vasodilation decreasing systemic vascular resistance Increased respiratory rate Sweating Fatigue Muscle cramping J point depression Increased systolic blood pressure and slight (5 – 10 mmHg) increase in diastolic pressure Inotropic reserve / inotropic incompetence

19. Positive Stress Test ST segment depression or elevation of 1 mm or more U wave inversion or new appearance Increased R wave amplitude in multiple leads QT interval lengthens with exercise with CAD

20. Reliability of Stress Test Angiogram Sensitivity Positive Specificity Negative

21. Categories of Stress Test True Positive False Positive True Negative False Negative

22. Bayes’s Theorem Accuracy Patient’s probability of disease Risk assessment

23. Factors Affecting Interpretation Assess the equipment and settings Patient characteristics: activity level medical problems medications Interpretation of ECG strip: heart rate regularity ST segment changes

24. Post Stress Test “Cooling down” 10 – 15 minutes Rest Avoid extreme temperature changes Avoid stimulants for at least 3 hours Do not take a hot shower / bath Results in about 10 days Discuss results with physician

25. Poor Prognostic Findings Low workload Less than 6.5 METs Less than 5 – 6 minutes Low peak heart rate Low systolic blood pressure Significant ST segment depression or prolonged ST segment depression

26. Nuclear Stress Test Radioactive substance (radiotracer) Noninvasive procedure/ 4- 6 hours Depict how the heart muscle is working Resting portion and exercise portion

27. Exercise Echo or Stress Echo Combines echocardiogram with exercise Diagnose coronary heart disease, assess results of coronary procedures, certain types of heart muscle or heart valve disease Performed at rest, then during and after exercise test 3 phases: resting echo images, exercise, & second echo images http://www.youtube.com/watch?v=87XWZTIr-Xc

28. Pharmacologic Stress Test Physical limitations IV dose of medication o Cardiolyte o Dobutamine o Dipyridamole o Adenosine http://www.youtube.com/watch?v=wY347r1gFSg Homer Heart Attack

29. Lexiscan Regadenoson IV dose 5 ml (0.4 mg) Not given with second or third degree AV blocks or sinus node dysfunction (pacemaker) No caffeine for 12 hours before test Monitor for hypersensitivity

30. Dobutamine Stress Test Most commonly used medication Adrenergic agonist Increased blood pressure and heart rate Increased workload of the heart http://www.youtube.com/watch?v=t qfwdzgB9cU

31. Dipyridamole or Persantine Stress Test Antiplatelet agent Dilates coronary vessels Accumulation adenosine http://www.youtube.com/watch?v=PZKScVAUEsk

32. Cardiolyte Stress Test Radioactive technetium Exercise and rest With a pharmacologic stress test Labels red blood cells http://www.youtube.com/watch?v=g9LtAyJ4gZw

33. Adenosine or Cardiac Stress Test http://www.youtube.com/watch?v=4tU9DC5ueio

34. Thallium Stress Test Myocardial perfusion Thallium 201 “cold spot” vs “hot spot” Side effects http://www.youtube.com/watch?v=fmtG4hx5F0Q

35. Tilt Table Test http://www.youtube.com/watch?v=5H5FZTAic7c&list=PLjjz5qBEvYVX c8yyflUWJcTC7NsEr_SAR

36. Tilt Table Procedure Supine position on table (feet flush to edge) Strap patient to table BP and 6 lead EKG Tilt table 80 degrees for 30- 45 minutes Isuprel infusion started Alternate tilting table and increasing isuprel Positive vs. Negative results Recovery

37. Cardiac Scoring Test to assess risk of heart disease High-speed CT scanner 10 minutes Images of hardening arteries http://www.youtube.com/watch?v=HFeQZA0Ygrg

38. MUGA Stress Test

39. Echocardiogram: TE Transthoracic echocardiogram Ultrasonic waves Diagnosis heart problems Doppler http://www.youtube.com/watch?v=ZpGTq0vuO7E http://www.youtube.com/watch?v=yVZ7jvsgyU4

40. Transesophageal Echocardiogram Scope with ultrasound transducer Passed into esophagus Diagnose heart damage Valve damage http://www.youtube.com/watch?v=42vaOjNdErQ http://www.youtube.com/watch?v=VB4kDng3Frg

41. Intravascular Ultrasound http://www.youtube.com/watch?v=N9Za6K2HyIQ

42. Positron Emission Tomography http://www.youtube.com/watch?v=ltesoTEu7JE

43. CT Scanner/ CTA http://www.youtube.com/watch?v=D3WynbxwTuI

44. MRI Scanner http://www.youtube.com/watch?v=xeRyGuwpxWs

45. Life Vest http://www.bing.com/videos/search?q=lifevest+video&FORM=VIRE12#vie w=detail&mid=9F37968281C2800935AF9F37968281C2800935AF