1. Sensitivity is True positives 60 Total CAD 100 Sensitivity and Specificity CAD by CAG No CAD by CAG TMT + VE True Positives 60 False Positives 60 TMT – VE False Negative 40 True Negatives 240 Total CAD 100 Total No CAD 300 TEST GOLD STANDARD Specificity is True Negatives 240 Total No CAD 300 SnNOUT (Rules out 60%) SpPIN (Confirms 80%)

2. Indications of Exercise Test Atypical and typical Chest pain  CV risk profile Unstable Angina – Decision on need for CAGRisk stratification after MI and assess CABGTo prescribe exercise in CAD / AtheletsAsymptomatic pt without CV Risk factors ??

3. Pre Test Probability of CAD by Symptoms, Gender and Age

4. Clinical Presentation CV Risk Factors Derive Pretest Probability Low (<20%)No Testing Intermediate 20% to 75% Stress TestingHigh ( >75%)Angiography CAD Testing Algorithm Use a computer model or Use the probability table

5. Testing Algorithm contd.. Intermediate Probability 20% - 75% Assess ECG and Exercise Tolerance Normal ECG Can exercise Treadmill test Duke score Negative No more testing Positive Abnormal ECG or Can’t exercise MPI or ESE or CSEAngiography

6. Absolute contra indications for ETT Acute myocardial infarction (within 2 days) High-risk unstable angina Uncontrolled cardiac arrhythmias Symptomatic severe aortic stenosis Uncontrolled symptomatic heart failure Acute pulmonary embolus or pulmonary infarction Acute myocarditis or pericarditis Acute aortic dissection Indications to terminate ETT Drop in SBP of >10 mm Hg from baseline BP with accompanying evidence of ischemia Moderate to severe angina Nervousness, ataxia, dizziness Poor perfusion - cyanosis or pallor Difficulty in monitoring ECG /SBP Subject’s desire to stop; Sustained ventricular tachycardia ST elevation (≥1.0 mm)