Clinical Exercise TestingApplications

Pre-discharge/post MI, PTCA, CABG Functional Disease progression Disability/Return to Work Diagnostic (usually Bruce TM test) chest pain dyspnea syncope/dizziness

Diagnostic Testing-Measurements
HR (85% PMHR) & Bp
Signs and symptoms EKG (ectopic beats and ST segment changes)

1mm @ .08 sec = significant ST segment depression = ischemia

ST-T wave segment changes

ST depression
ST elevation T wave inversion

Ischemia

ST segment slope
Upslope less suggestive
Flat more suggestive Downslope most suggestive

Magnitude of ischemia

ST Segment Depression

Magnitude of ischemia is directly proportional to:

ST segment slope # of EKG leads involved Persistence of ST-T wave changes during

recovery Amount of ST depression (1mm vs. 5)

Sensitivity/Specificity
Sensitivity-% of patients tested who have CAD and an abnormal test (ST chgs.)
TPR=70% ; FPR30% Specificity-% of patients w/o CAD who will have a negative test TNR=80% ; FNR=20%

False Positive Rate=30% / Factors contributing to FPR

Female gender (Thallium GXT)
Resting ECG changes (LVH) Some meds (digitalis)

Magnitude of ischemia is inversely proportional to:

Double product (rate pressure product) SBP x

HR Maximal HR achieved SBP Oxygen uptake achieved

Test Modalities
Cycle
TM Arm ergometer

advantages/disadvantages

Testing Protocols-Fig. 5.3

TM Bruce/Modified Bruce Balke-Ware USAFSAM Naughton/Modified Naughton Cycle YMCA PWC-170

Treadmill Testing
Bruce Treadmill Test Stages
Stage 1 = 1.7 mph at 10% Grade

Stage 2 = 2.5 mph at 12% Grade Stage 3 = 3.4 mph at 14% Grade Stage 4 = 4.2 mph at 16% Grade Stage 5 = 5.0 mph at 18% Grade Stage 6 = 5.5 mph at 20% Grade Stage 7 = 6.0 mph at 22% Grade Stage 8 = 6.5 mph at 24% Grade Stage 9 = 7.0 mph at 26% Grade

The Bruce Protocol Formula for Estimating VO2 Max

For Men VO2 max = 14.8 - (1.379 x T) +

(0.451 x T) - (0.012 x T) For Women VO2 max = 4.38 x T - 3.9

T = Total time on the treadmill measured as a fraction of a

minute (i.e.: A test time of 9 minutes 30 seconds would be written as T=9.5).

Bruce Norms
VO2 Max Norms for Men Measured in ml/kg/min Age Very Poor 13-19 20-29 30-39 40-49 50-59 60+ <35.0 <33.0 <31.5 <30.2 <26.1 <20.5

Poor 35.0-38.3 33.0-36.4 31.5-35.4 30.2-33.5 26.1-30.9 20.5-26.0

Fair 38.4-45.1 36.5-42.4 35.5-40.9 33.6-38.9 31.0-35.7 26.1-32.2

Good 45.2-50.9 42.5-46.4 41.0-44.9 39.0-43.7 35.8-40.9 32.3-36.4

Excellent 51.0-55.9 46.5-52.4 45.0-49.4 43.8-48.0 41.0-45.3 36.5-44.2

Superior >55.9 >52.4 >49.4 >48.0 >45.3 >44.2

Bruce Norms
VO2 Max values for Women as measured in ml/kg/min Age Very Poor 13-19 <25.0 20-29 <23.6 30-39 <22.8 40-49 <21.0 50-59 <20.2 60+ <17.5

Poor 25.0-30.9 23.6-28.9 22.8-26.9 21.0-24.4 20.2-22.7 17.5-20.1

Fair Good Excellent 31.0-34.9 35.0-38.9 39.0-41.9 29.0-32.9 33.0-36.9 37.0-41.0 27.0-31.4 31.5-35.6 35.7-40.0 24.5-28.9 29.0-32.8 32.9-36.9 22.8-26.9 27.0-31.4 31.5-35.7 20.2-24.4 24.5-30.2 30.3-31.4

Superior >41.9 >41.0 >40.0 >36.9 >35.7 >31.4

Functional Aerobic Impairment (FAI)

% FAI = predicted VO2 measured VO2 x 100 predicted VO2 Predicted (male): 57.8 (.445 x age)

Measured: 14.8 - (1.379 x T) + (0.451 x T) -

(0.012 x T)

Example-FAI
50 y/o male Predicted Vo2 = 57.8 (.445 x 50) = 35.5 ml/kg/min Measured VO2 = 20.2 ml/kg/min (TM time) 35.5 20.2 FAI = ______________ x 100 = 43% 35.5 FAC = 57%

Protocols cont.
Step wise vs. ramp
Increments8-12 mins HR, BP & ECG monitored pre-post exercise(6-

8 mins or until any changes return to baseline (Table 5.2) RPE, angina scale & claudication scales (Fig.5.4)

Indications for stopping a test (Box 5.2) Absolute/Relative

Drop in SBP (>10 mmHg) with other signs if

ischemia? Mod-severe angina (3 on standard scale) Sustained ventricular tachycardia ST elevation (1.0 mm) Excessive ST depression (>2mm horizontal or downsloping) arrhythmias

Gas exchange and ventilatory measurements: CP-GXT

Utility: Accuracy of VO2 measurement Distinguish b/w cardiac and pulmonary limitations (dyspnea) Additional assessments of cardiac function (O2 pulse; VTh) Rule out malingering (RER)

Critical Measurements:
HR, Bp, EKG and signs/symptoms VO2 measured vs. estimated (obesity; lung

disease) VE airflow limitation? (VE/MVV) RER effort VTh cardiac function VE/VO2 ; VE/VCO2 ventilating efficiency SaO2 or PaO2 gas exchange limitation? O2 pulse VO2/HR (indirect indicator of SV)

Thallium201 Stress Test (or Technetium99)

Thallium Scan

Echocardiography (Ultrasound)
Transesophageal echocardiogram. Doppler echocardiogram. Stress echocardiogram.

LVH

Mitral valve prolapse

Pharmacological Stress Testing

Dobutamine stress echo detection of wall motion abnormalities (+ chronotropic agent)
Dipyridamole (persantine) or adenosine

vasodilators used to assess coronary perfusion in conjunction with a nuclear imaging agent (increased blood flow in normal CA; steals blood flow from stenotic vessels) Accuracy = ~86%

Considerations for Pulmonary Patients-Essential Measurements

Spirometry (FVC, FEV1, MVV, TLC) VE (VE/MVV) - calculation of breathing reserve airflow limitation SaO2/PaO2 oxygenation gas exchange
limitation; ABG or pulse oximetry

VO2/VCO2 (direct measurements) VT and Fb

Asthma and Exercise-Induced Asthma (EIA)

Incidence 20 million; by ~5% per year 80% of asthmatics have EIA (EIB) Only 5-15% of non asthmatics have EIA High incidence in winter sport athletes (4050%) Mechanism: loss of H2O and airway drying histamine from mast cells bronchoconstriction and inflammation

Asmogenic Agents/Symptoms
Allergens

animal dander, dust mites, pollen Irritants smoke, air pollution, cold air, sulfites (wine), chlorine? Exercise (especially in cold air) Symptoms cough, wheeze, dyspnea, chest tightness

Testing Protocols for EIA (bronchial provocation test)

85% PMHR ( VE) 6-8 mins duration FEV1 measured before and at 5 min intervals

after exercise 15 % drop in FEV1 = EIA

Testing for PVD

Ankle-brachial index (ABI) Arterial pedal pulses doppler

tibialis anterior posterior pedal Normal value > .90

Example: At rest: ankle = 110 ; brachial = 120 110/120 = .91 Moderate-to-Severe Occlusion (post-exercise) ankle = 70; brachial = 140 70/140 = .50