1. Exercise Treadmill Testing
Chris Place, MD
December 2, 2004

2. Overview Basic EKG Review Introduction to Treadmill Test
Indications and Safety
Equipment and Protocols
Exercise End Points
Basics of Interpretation of the Exercise Test
Exercise Testing to Diagnose Obstructive Coronary Artery Disease
Rationale and Guidelines
Pretest Probability
ST-Segment Interpretation
Confounders of Stress ECG Interpretation
Result Reporting

3. Basic EKG Review

4. Simple Method of EKG Interpretation
Rate
Rhythm
Axis
Hypertrophy
Infarction and Ischemia

5. Rate

6. Rhythm Identify basic rhythm… Always:
…then scan entire tracing for pauses, premature beats, irregularity, and abnormal waves.
Always:
Check for:
P before each QRS.
QRS after each P.

7. Axis

8. Hypertrophy

10. Infarction and Ischemia

13. Normal EKG

14. Atrial Fibrillation with Rapid Ventricular Response

15. Inferior Acute MI and RBBB

16. Anterior Acute MI

17. Left Ventricular Hypertrophy

18. Ventricular Fibrillation

19. Overview Basic EKG Review Introduction to Treadmill Test
Indications and Safety
Equipment and Protocols
Exercise End Points
Basics of Interpretation of the Exercise Test
Exercise Testing to Diagnose Obstructive Coronary Artery Disease
Rationale and Guidelines
Pretest Probability
ST-Segment Interpretation
Confounders of Stress ECG Interpretation
Result Reporting

20. Indications and Safety
Generally a safe procedure, but both myocardial infarction and death have been reported and can be expected to occur at a rate of up to 1 per 2500 tests.
Good clinical judgment should therefore be used in deciding which patients should undergo exercise testing.
Exercise testing should be supervised by an appropriately trained physician.
The electrocardiogram (ECG), heart rate, and blood pressure should be monitored carefully and recorded during each stage of exercise and during ST-segment abnormalities and chest pain.

21. Equipment and Protocols
Both treadmill and cycle ergometer devices are available for exercise testing.
Much of the published data are based on the Bruce protocol, there are clear advantages to customizing the protocol to the individual patient to allow 6 to 12 minutes of exercise.
Exercise capacity should be reported in estimated metabolic equivalents (METs) of exercise.

22. Exercise Endpoints
Commonly terminated when subjects reach an arbitrary percentage of predicted maximum heart rate.
Other end points (summarized next slide) are strongly preferred.
The use of rating of perceived exertion scales, such as the Borg scale is often helpful in assessment of patient fatigue.

24. The Modified Borg Scale
SEVERITY
No Breathlessness* At All
0.5
Very Very Slight (Just Noticeable) 1
Very Slight 2
Slight Breathlessness 3
Moderate 4
Somewhat Severe 5
Severe Breathlessness 6 7
Very Severe Breathlessness 8 9
Very Very Severe (Almost Maximum) 10
Maximum

25. Basics of Interpretation of the Exercise Treadmill Test
Interpretation of the exercise test should include exercise capacity and clinical, hemodynamic, and electrocardiographic response.
The occurrence of ischemic chest pain consistent with angina is important, particularly if it forces termination of the test.
The most important electrocardiographic findings are ST depression and elevation.
Positive exercise test result is greater than or equal to 1 mm of horizontal or downsloping ST-segment depression or elevation for at least 60 to 80 milliseconds (ms) after the end of the QRS complex

26. Overview Basic EKG Review Introduction to Treadmill Test
Indications and Safety
Equipment and Protocols
Exercise End Points
Basics of Interpretation of the Exercise Test
Exercise Testing to Diagnose Obstructive Coronary Artery Disease
Rationale and Guidelines
Pretest Probability
ST-Segment Interpretation
Confounders of Stress ECG Interpretation
Result Reporting

27. Rationale for Using ETT to Diagnose Obstructive CAD
Most predictive clinical finding is a history of chest pain or discomfort.
Myocardial ischemia is the most important cause of chest pain and is most commonly a consequence of underlying coronary disease.
CAD that has not resulted in sufficient luminal occlusion to cause ischemia during stress can still lead to ischemic events through spasm, plaque rupture, and thrombosis, but most catastrophic events are associated with extensive atherosclerosis.
These nonobstructive lesions explain some of the events that occur after a normal exercise test.
Although the coronary angiogram has obvious limitations, angiographic lesions remain the clinical gold standard.

28. The ACC/AHA Guidelines for the Diagnostic Use of the Standard Exercise Test
Class I (Definitely appropriate) - Adult males or females (including RBBB or < 1mm resting ST depression) with an intermediate pre-test probability of coronary artery disease based on gender, age and symptoms (specific exceptions are noted under Class II and III below).
Class IIa (Probably appropriate) - Patients with vasospastic angina.

29. Class IIb (maybe appropriate)
The ACC/AHA Guidelines for the Diagnostic Use of the Standard Exercise Test
Class IIb (maybe appropriate)
Patients with a high pretest probability of CAD by age, symptoms, and gender.
Patients with a low pretest probability of CAD by age, symptoms, and gender.
Patients with less than 1 mm of baseline ST depression and taking digoxin.
Patients with electrocardiographic criteria for left ventricular hypertrophy (LVH) and less than 1 mm of baseline ST depression.

30. Class III (Not appropriate) -
The ACC/AHA Guidelines for the Diagnostic Use of the Standard Exercise Test, cont’d
Class III (Not appropriate) -
1. To use the ST segment response in the diagnosis of coronary artery disease in patients who demonstrate the following baseline ECG abnormalities:
pre-excitation (WPW) syndrome;
electronically paced ventricular rhythm;
more than one millimeter of resting ST depression;
LBBB
2. To use the ST segment response in the diagnosis of coronary artery disease in MI patients

31. Pretest Probability
Based on the patient's history (including age, gender, and chest pain characteristics), physical examination and initial testing, and the clinician's experience with this type of problem.
Typical or definite angina makes the pretest probability of disease so high that the test result does not dramatically change the probability.
Atypical or probable angina in a 50-year-old man or a 60-year-old woman is associated with approximately a 50% probability of CAD.
Diagnostic testing is most valuable in this intermediate pretest probability category, because the test result has the largest potential effect on diagnostic outcome.
Typical or definite angina can be defined as 1) substernal chest pain or discomfort that is 2) provoked by exertion or emotional stress and 3) relieved by rest and/or nitroglycerin.

32. Pre Test Probability of Coronary Disease by Symptoms, Gender and Age

33. ST Segment Interpretation
Computer summaries can help find possible areas of ischemia – then review raw data carefully!
Determine PQ junction, J point, ST80, and estimate slope
Elevation
Depression
Upsloping
Horizontal
Downsloping

34. Magnified ischemic exercise-induced ECG pattern
Magnified ischemic exercise-induced ECG pattern. Three consecutive complexes with a relatively stable baseline are selected. The PQ junction (1) and J point (2) are determined; the ST 80 (3) is determined at 80 msec after the J point. In this example, average J point displacement is 0.2 mV (2 mm) and ST 80 is 0.24 mV (2.4 mm). The average slope measurement from the J point to ST 80 is –1.1 mV/sec.

35. Normal
Rapid Upsloping
Minor ST Depression
Slow Upsloping

36. Horizontal
Downsloping
Elevation (non Q lead)
Elevation (Q wave lead)

37. J point depression of 2 to 3 mm in leads V4 to V6 with rapid upsloping ST segments depressed approximately 1 mm 80 msec after the J point. The ST segment slope in leads V4 and V5 is 3.0 mV/sec. This response should not be considered abnormal.
Upsloping

38. In lead V4 , the exercise ECG result is abnormal early in the test, reaching 0.3 mV (3 mm) of horizontal ST segment depression at the end of exercise.
Consistent with a severe ischemic response.

39. The J point at peak exertion is depressed 2
The J point at peak exertion is depressed 2.5 mm, the ST segment slope is 1.5 mV/sec, and the ST segment level at 80 msec after the J point is depressed 1.6 mm.
This “slow upsloping” ST segment at peak exercise indicates an ischemic pattern in patients with a high coronary disease prevalence pretest.
A typical ischemic pattern is seen at 3 minutes of the recovery phase when the ST segment is horizontal and 5 minutes after exertion when the ST segment is downsloping.

40. Becomes abnormal at 9:30 minutes (horizontal arrow right) of a 12-minute exercise test and resolves in the immediate recovery phase.
This ECG pattern in which the ST segment becomes abnormal only at high exercise workloads and returns to baseline in the immediate recovery phase may indicate a false-positive result in an asymptomatic individual without atherosclerotic risk factors.

41. A 48-year-old man with several atherosclerotic risk factors and a normal rest ECG result developed marked ST segment elevation (4 mm [arrows]) in leads V2 and V3 with lesser degrees of ST segment elevation in leads V1 and V4 and J point depression with upsloping ST segments in lead II, associated with angina.
This type of ECG pattern is usually associated with a full-thickness, reversible myocardial perfusion defect in the corresponding left ventricular myocardial segments and high-grade intraluminal narrowing at coronary angiography. Rarely, coronary vasospasm produces this result in the absence of significant intraluminal atherosclerotic narrowing.(

42. Confounders of Exercise Treadmill Test Interpretation
Digoxin
Produces an abnormal ST-segment response to exercise. This abnormal ST depression occurs in 25% to 40% of healthy subjects studied and is directly related to age.
Left Ventricular Hypertrophy
Decreased specificity of exercise testing, but sensitivity is unaffected. Therefore, a standard exercise test may still be the first test, with referrals for additional tests only indicated in patients with an abnormal test result.
Resting ST Depression
Resting ST-segment depression has been identified as a marker for adverse cardiac events in patients with and without known CAD.
Left Bundle-Branch Block
Exercise-induced ST depression usually occurs with left bundle-branch block and has no association with ischemia. Even up to 1 cm of ST depression can occur in healthy normal subjects. There is no level of ST-segment depression that confers diagnostic significance in left bundle-branch block.
Right Bundle-Branch Block
The presence of right bundle-branch block does not appear to reduce the sensitivity, specificity, or predictive value of the stress ECG for the diagnosis of ischemia.
Beta Blocker Therapy
For routine exercise testing, it appears unnecessary for physicians to accept the risk of stopping beta-blockers before testing when a patient exhibits possible symptoms of ischemia or has hypertension. However, exercise testing in patients taking beta-blockers may have reduced diagnostic or prognostic value because of inadequate heart rate response.

43. Overview Basic EKG Review Introduction to Treadmill Test
Indications and Safety
Equipment and Protocols
Exercise End Points
Basics of Interpretation of the Exercise Test
Exercise Testing to Diagnose Obstructive Coronary Artery Disease
Rationale and Guidelines
Pretest Probability
ST-Segment Interpretation
Confounders of Stress ECG Interpretation
Result Reporting

44. Comparison of Tests for Diagnosis of CAD
Grouping
# of
Studies
Total #
Patients
Sens
Spec
Predictive
Accuracy
Standard ET
147
24,047
68%
77%
73%
ET Scores 24
11,788
80%
Score S
trategy 2
>
1000
85%
92%
88%
Thallium
Scint 59 6 , 38
SPECT
16+14
5,272 88 % 7 2% 80
Adenosine SPECT 10 +4
2,137 89 8 5
Exercise ECHO 58
000
84%
75%
Dobutamine ECHO
<1000
86%
Dobutamine Scint 20
1014
74%
81% E
lectron B
eam
Tomography (EBCT) 16
3,683 60 70 65

45. Results Reporting Hope Medical Group Exercise Treadmill Test
Results Report – rev. 11/04
Patient Name: Date of Test:
Chart Number:
Reason for Test:
________________________________________________________________________
Digoxin? _______
Beta blocker? ________
Resting EKG interpretation:
LVH? ___________
LBBB? __________
RBBB? ___________
Resting ST Depression? _________
Cardiac Risk Factors (circle)
Age
Gender
Diabetes
HTN
Hypercholesterolemia
Smoker
Sedentary/Obese
Total Number:
Estimate pretest probability – use table for reference (very low, low, intermediate, high, very high):
_______________________________________________________________________
Reason for test if pretest probability not intermediate:

46. Results Reporting – Page 2
1. Exercise Capacity
METS achieved: _______________
Minutes exercised: _______________
2. Clinical response to exercise
Chest pain during test? ___________
Chest pain reason for stopping test? __________
Perceived exertion scale (BORG scale reached – 6 to 20): _________
Reason for stopping test:_____________
3. Electrocardiographic response to exercise
ST elevation (yes/no) ? ____________
ST depression (yes/no)? ____________
(positive = 1 mm of horizontal or downsloping ST-segment depression or elevation for at least 60 to 80 milliseconds (ms) after the end of the QRS complex)
What leads? ___________
ST quality (upsloping, horizontal, downsloping):_______________
ST depression amount (mm): ___________
Dysrhythmia? _____________
Other:
____________________________________________________
4. Hemodynamic response to exercise
Systolic BP response: ______________
Diastolic BP response: ______________
Maximum heart rate achieved: ________________
2 minute heart rate recovery (should be at least 22 bpm by 2 minutes): ______________
Results Reporting – Page 2

47. What is a MET? Metabolic Equivalent Term
1 MET = "Basal" aerobic oxygen consumption to stay alive = 3.5 ml O2 /Kg/min
Actually differs with thyroid status, post exercise, obesity, disease states

48. Key MET Values 1 MET = "Basal" = 3.5 ml O2 /Kg/min
2 METs = 2 mph on level
4 METs = 4 mph on level
< 5METs = Poor prognosis if < 65;

49. Key MET Values (part 2)
10 METs = As good a prognosis with medical therapy as CABG
13 METs = Excellent prognosis, regardless of other exercise responses
16 METs = Aerobic master athlete
20 METs = Aerobic athlete

50. Calculation of METs on the Treadmill
METs = Speed x [0.1 + (Grade x 1.8)]
Calculated automatically by Device!
Note: Speed in meters/minute
conversion = MPH x 26.8
Grade expressed as a fraction

51. Results Reporting – Page 3
5. Duke treadmill scores (see nomogram or use calculator):
5-year survival _______
Average annual mortality __________
VA treadmill score: _________
Final conclusions and recommendation for follow-up:
______________________________________________________________

52. Duke treadmill score = duration of exercise in minutes on the Bruce protocol
- (minus) 5x maximal mm ST deviation
- (minus) 4x treadmill angina index
Treadmill Angina Index:
0 if no angina.
1 if non-limiting angina.
2 if limiting angina.
High Risk = treadmill score < % 4-year survival
Moderate Risk = treadmill score -10 to +4 95% 4-year survival
Low Risk = treadmill score >+5 99% 4-year survival

53. Duke Nomogram for 2 mm depression, non-limiting chest pain at 5 METS.

54. Choose only one per group
Variable
Circle response
Sum
Maximal Heart Rate
Less than 100 bpm = 30
100 to 129 bpm = 24
130 to 159 bpm =18
160 to 189 bpm =12
190 to 220 bpm =6
Exercise ST Depression
1-2mm =15
> 2mm =25
Age
>55 yrs =20
40 to 55 yrs = 12
Angina History
Definite/Typical = 5
Probable/atypical =3
Non-cardiac pain =1
Hypercholesterolemia?
Yes=5
Diabetes?
Exercise test
Occurred =3
induced Angina
Reason for stopping =5
Total Score:
Males
Choose only one per group
<40=low prob
40-60= intermediate probability
>60=high probability

55. Choose only one per group
Positive=-5, Negative=5
Total Score
Reason for stopping =15
induced Angina
Estrogen Status
Occurred =9
Exercise test
Yes=10
Diabetes?
Smoking?
Non-cardiac pain =2
Probable/atypical =6
Definite/Typical = 10
Angina History
50 to 65 yrs = 15
>65 yrs =25
Age
> 2mm =10
Depression
1-2mm =6
Exercise ST
190 to 220 bpm =4
160 to 189 bpm =8
130 to 159 bpm =12
100 to 129 bpm = 16
Rate
Less than 100 bpm = 20
Maximal Heart
Sum
Circle response
Variable
Women
Choose only one per group
<37=low prob
37-57= intermediate probability
>57=high probability

56. Review Basic EKG Review Introduction to Treadmill Test
Indications and Safety
Equipment and Protocols
Exercise End Points
Basics of Interpretation of the Exercise Test
Exercise Testing to Diagnose Obstructive Coronary Artery Disease
Rationale and Guidelines
Pretest Probability
ST-Segment Interpretation
Confounders of Stress ECG Interpretation
Result Reporting