EXERCISE Stress Testing FOR HEART

Stress Testing :
Which Test to Choose?

Gary J. Balady, MD
Professor of Medicine
Boston University School of Medicine
Stress Testing at
Boston Medical Center
Exercise ECG ( treadmill test)

Exercise Echo
Exercise Nuclear
Cardiopulmonary ( Metabolic )
Dobutamine Echo
Pharmacologic (regadenoson) nuclear
SPECT
PET
SCM Order Set: stress test selector
supply
demand
supply
coronary arteries
atherosclerosis
coronary vasospasm
hypoxemia
anemia
hypotension
coronary anomalies
coronary vasculitis
demand
factors
HR x BP
contractility
wall stress
Supply
Degree of obstruction
Length of lesion
Dynamic properties of lesion
Dynamic properties of
distal vascular bed
thickness of myocardium
Supply
Collateral flow
supply
demand
factors
HR x BP
contractility
History
Chest discomfort
Types of angina
Quality of discomfort/location
Provocative factors
Relief
Age/Gender/Risk Factors
Classes of Angina
Physical Examination
hypertension
weight/body habitus
vascular bruits
heart size
skin
eye grounds
Resting Electrocardiogram
Exercise Testing Protocols
Work = force x distance

Workrate = work/time
VO2 is directly related to workrate
Treadmill
Force = body weight
Distance/time=
Treadmill speed
Estimated VO2
(ml/kg/min)
ACSM regression
equations
METs
Stationary Cycle
Force = resistance
against the flywheel
Distance/time=
Cycling speed
Estimated VO2 (ml/min)

ACSM regression
equations
Need body weight to
calculate METs
METs
Stepped
METs
Ramp
Time
10 min
Bruce Protocol for Treadmill Testing
Boston Medical Center Ramp

Protocols
Duke Activity Status Index
Diagnostic level of stress: 85% maximum predicted HR

where MPHR = (220-age)
Normal Response
Ischemic
Response
Sensitivity/Specificity/Predictive Value
high prevalence population
CAD
Positive
Test
Negative
Test
Total N
No CAD
Predictive
Value
63
95
27
21
90
10
exercise ecg test: 70% sensitive/ 70% specific
Sensitivity/Specificity/Predictive Value
low prevalence population
Positive
Test
Negative
Test
Total N
CAD
No CAD
Predictive
Value
27
21
63
95
10
90
exercise ecg test: 70% sensitive/ 70% specific
Duke Prognostic Scoring System
x
x
Heart Rate Recovery
Heart Rate Recovery:

Risk of mortality at 6 years
Cole, et al. NEJM 1999: 341:1351
Cleveland Clinic ETT Score
Lauer, et al. Ann Int Med 147:821-828; 2007
Hypertension During Exercise:

BPs > 180 at 7 METs
Circulation 2010: 121: 2109
Oxygen Uptake - Workrate relationship
VO2
No handrail
?
Workrate
Handrail
CPX System
Oxygen sensor
Carbon dioxide sensor
Volume measures/flow meters
Breath by breath measures
BTPS
Expired air
Oxygen uptake
Carbon Dioxide production
Ventilation
Indications for CPX

Accurate assessment of exercise capacity
Clinical
Research
Diagnosis
Dyspnea on exertion
Prognosis
Heart failure
Congenital Heart Disease
Disability assessment
Treatment
Pacemaker settings
Exercise Testing
additional indications
Adequacy of therapy
medical
revascularization ( imaging tests)
Activity counseling
MET Chart
Exercise prescription
Rhythm assessment
Valvular Heart Disease
Aortic stenosis
Mitral stenosis
Mitral regurgitation
Hypertrophic obstructive cardiomyopathy
Exercise Prescription
Patients with CHD
Intensity
Exercise Test
calculate heart rate reserve (HRR)

peak HR minus resting HR
moderate intensity:
50% HRR plus resting HR to
70% HRR plus resting HR
keep peak peak HR 10 beats < HR at ischemia
Risk Stratify using AHA criteria
Stress Imaging Tests

Abnormal resting ECG
ST segments
Left bundle branch block
LVH with strain
Need for increased

diagnostic accuracy
sensitivity 85-90%
specificity 85-90%
localize ischemia to
specific coronary vascular territory
Contrast Echo
Stress Echocardiogram: Apical septal wall ischemia
Stress Nuclear Testing

tomographic imaging planes
Short Axis
base to apex
Vertical Long Axis

septal to lateral
Horizontal Long Axis

anterior to inferior
normal nuclear perfusion scan

stress
rest
stress
rest
stress
rest
lateral ischemia on nuclear perfusion scan

stress
rest
stress
rest
stress
rest
Pharmacological Stress Tests

dobutamine echo
Dobutamine
beta agonist
increases myocardial oxygen demand
increases HR, BP, contractility
Pharmacological Stress Tests

nuclear perfusion scan
Adenosine or Dipyridimole
direct coronary vasodilator
causes shifts in flow leading to
relative reduction in flow distal to
coronary stenosis
minimal change in HR, BP, and
contractility
Myocardial Perfusion
Imaging:
Pharmacologic Positron Emission Tomography
(PET) vs.
Single Photon Emission Computed
PETTomography (SPECT)
SPECT
Energy: 511 KeV

Resolution: 1.5 cm
Protocol: 45 min
Stress EF
Myocardial flow
quantification
More expensive
than SPECT
Energy: 80-140 KeV

Resolution: 2.0 cm
Protocol: 2-3 h ( or
2 d)
Post-Stress EF
Courtesy of Edward Miller, MD,
For more information
www.americanheart.org
Scientific publications
Statements and guidelines
Exercise standards -2013
Elective in Stress Testing
Second and third year residents

3 weeks preferably continuous
Fellow surrogate
Certification in Exercise-ECG Testing
Supervision and interpretation
Exposure to stress echo and stress

nuclear
Approximate METs during Stationary

Cycle
Testing
Body weight
Exercise rate (kg m min and watts)
-1
kg
Lb
Kpms
300
Watts
50
450
600
750
900
1050
1200
75
100
125
150
175
200
50
110
5.1
6.9
8.6
10.3
12.0
13.7
15.4
60
132
4.3
5.7
7.1
8.6
10.0
11.4
12.9
70
154
3.7
4.9
6.1
7.3
8.6
9.8
11.0
80
176
3.2
4.3
5.4
6.4
7.5
8.6
9.6
90
198
2.9
3.8
4.8
5.7
6.7
7.6
8.6
100
220
2.6
3.4
4.3
5.1
6.0
6.9
7.7
Myocardial Contractility
Myocardial Wall Stress
Th
Wall stress =
P x R/ Th

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What are different types of stress tests discussed?

What are different types of stress tests discussed?

What factors affect myocardial oxygen demand?

What factors affect myocardial oxygen demand?

Stress Testing :

Which Test to Choose?

Exercise ECG ( treadmill test)

SCM Order Set: stress test selector

Exercise Testing Protocols

Work = force x distance

Estimated VO2 (ml/min)

Bruce Protocol for Treadmill Testing

Boston Medical Center Ramp

Duke Activity Status Index

Diagnostic level of stress: 85% maximum predicted HR

exercise ecg test: 70% sensitive/ 70% specific

exercise ecg test: 70% sensitive/ 70% specific

Duke Prognostic Scoring System

Heart Rate Recovery

Heart Rate Recovery:

Cole, et al. NEJM 1999: 341:1351

Cleveland Clinic ETT Score

Lauer, et al. Ann Int Med 147:821-828; 2007

Hypertension During Exercise:

Circulation 2010: 121: 2109

Oxygen Uptake - Workrate relationship

Indications for CPX

calculate heart rate reserve (HRR)

Risk Stratify using AHA criteria

Stress Imaging Tests

Need for increased

Stress Echocardiogram: Apical septal wall ischemia

Stress Nuclear Testing

Vertical Long Axis

Horizontal Long Axis

normal nuclear perfusion scan

lateral ischemia on nuclear perfusion scan

Pharmacological Stress Tests

Pharmacological Stress Tests

Energy: 511 KeV

Energy: 80-140 KeV

Courtesy of Edward Miller, MD,

For more information

Elective in Stress Testing

Second and third year residents

Exposure to stress echo and stress

Approximate METs during Stationary

Myocardial Wall Stress

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