Cardiac Stress Testing

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introduction

Normally, the coronary arteries dilate to

four times their usual diameter in
response to increased metabolic
demands for oxygen and nutrients.
However, coronary arteries affected by
atherosclerosis dilate less, compromising
blood flow to the myocardium and
causing ischemia. Therefore,
abnormalities in cardiovascular function
are more likely to be detected during
times of increased demand, or ³stress.´
 —efinition/—escription

! Cardiac stress test Àor Cardiac diagnostic test) is a test

used in medicine and cardiology to measure the heart's
ability to respond to external stress in a controlled clinical
environment.
! The stress response is induced by exercise or drug
stimulation. Cardiac stress tests compare the coronary
circulation while the patient is at rest with the same
patient's circulation observed during maximum physical
exertion, showing any abnormal blood flow to the
myocardium. The results can be interpreted as a reflection
on the general physical condition of the test patient. This
test can be used to diagnose ischemic heart disease, and for
patient prognosis after a myocardial infarction.
! Os an electrophysiologic study performed
to measure cardiac function during
physical stress.
! Ot is performed to assist in diagnosing
coronary artery disease ÀCA—) and to
evaluate the safe level of activity or
activity tolerance for work or cardiac
rehabilitation.
! The physical stress is provided by walking
on a treadmill, climbing stairs, or pedaling
an exercise bicycle, with the treadmill
most commonly used.
! The heart, pulse, and blood pressure are
monitored continuously during the
procedure by ECG, pulse, and blood
pressure devices.
! The client exercises to 80 to 90 percent
of the maximal heart rate determined by
age and gender.
! This rate is known as the target heart rate
! Changes in the ECG Àarrhythmias), blood
pressure Àhypotension), pulse
Àtachycardia), respirations Àdyspnea), and
symptoms such as chest pain and extreme
fatigue during the procedure indicate a
reduction in cardiac efficiency and
presence of or risk for heart disease.
! The test is discontinued if these
abnormalities occur
 indications
!—etect obstructive CA—
!Evaluate subsequent risk based on
perfusion changes in patients with known
CA—
!Evaluate treatment regimen of patients
with known CA—
! ost-MO risk stratification before or after
hospital discharge
!Risk stratification before non-cardiac
surgery in patients with known CA—
 © solute Contraindications
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©dverse Effects

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! alpitations, chest pain, shortness of
breath, headache, nausea or fatigue.
! Adenosine and dipyridamole can cause
mild hypotension.
! As the tracers used for this test are
carcinogenic, frequent use of these tests
carries a small risk of cancer.
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EXPECTED TEST OUTCOMES

!Normal heart rate during physical

exercise; no cardiac abnormalities
on the ECG or presence of
associated symptoms at 80 to 90
percent of maximal heart rate based
on client age and gender
TEST OUTCOME DEVI©TIONS
! èailure of systolic B to rise, falling
systolic B , Bradycardia, excessive
tachycardia, ventricular tachycardia,
multifocal
Cs, atrial tachycardia, 2nd or
3rd degree heart block, pacemaker failure,
ST segment elevation or depression
!
entricular or supraventricular ectopics
! Cyanosis, pallor, mottling, cold sweat,
piloerection, ataxia, gallop rhythms,
valvular regurgitation, abnormal cardiac
impulse
 Preparations
ÿ66
 
! Receive the drugs necessary for a heart response, as indicated by
the attending physician
! Bring any currently prescribed cardiac medication or inhalers to the
test
! Have his or her blood sugar level measured
! Wear comfortable clothing and running shoes
! —o stretches and warm-ups to prevent cramps
! Remain well-hydrated
ÿ66
 

! Eat or drink for several hours
! Consume caffeine in any form Àcola, coffee etc) for 2 hrs prior to
the test.
! Smoke tobacco in the hours leading up to the test.
PROCEDURE

! The skin sites are cleansed with alcohol and rubbed

until red and the electrodes are placed in the
appropriate positions.
! Clothing from the waist up is removed from a
male client, and a hospital gown that opens in the
front can be worn by a female client.
! A physician is in attendance during this study.
! A blood pressure cuff is applied to the arm and
connected to a monitoring device.
! Oxygen consumption using a mouthpiece can also
be monitored continuously by blood pressure and
ECG.
! A baseline ECG tracing and a blood pressure
reading are obtained.
! Heart sounds are auscultated and recorded if the
physician requests or performs this physical
assessment.
! The client is requested to walk on a treadmill Àmost
commonly used) or pedal a bicycle after the setting
of the apparatus to stages of increased grade and
miles per hour.
! As the stress is increased, the client is requested to
report any symptoms such as chest or leg pain,
dyspnea, or fatigue.
! The stress is increased until the client¶s maximal
heart rate is reached.
! The client is reminded that symptoms such as
di iness or nausea can be experienced and are
normal.
! The test is terminated if pain or fatigue is severe or
when maximum heart rate under stress is attained.
! A 3- to 10-minute rest period in a sitting position
follows the exercise period, during which time the
ECG, blood pressure, and heart rate are monitored.
During the test, the following are
monitored:
! Two or more ECG leads for heart rate,
rhythm, & ischemic changes
! Blood pressure
! Skin temperature
! hysical appearance
! erceived exertion
! Symptoms: chest pain, dyspnea,
di iness, leg cramping & fatigue
|

  
   
  
   
  
    

‰ chest pain
‰ extreme fatigue
‰ —ecreased B or pulse rate
‰ Serious dysrhythmias or ST segment
changes on the ECG
‰ Other complications
 ositive Result

!ST segment depressions or

elevations.

è   
 




     

   
PRETEST C©RE
! èood, fluids, and smoking are avoided for
at least hours before the test.
! Onstruct the client to wear comfortable
shoes and clothing for the exercises and
inform the client that fatigue, sweating,
and breathlessness can occur during the
test as the speed is increased.
! Onform the client that a total time of 5 to
90 minutes is needed to complete the
procedure.
! rovide assurance that the test has very
few risks and that exercising can be
terminated if extreme symptoms occur.
! Onstruct the client to discontinue specific
medications that interfere with test results
before the study.
! Obtain baseline vital signs and ECG to use
as a comparison in evaluating the study.
POSTTEST C©RE

! rovide a period of rest and monitor vital

signs and ECG in 3-, 10-, and 30-minute
intervals.
! Remove the electrodes and paste and
cleanse the skin sites.
! Cardiac arrhythmias: Note and report
abnormal ECG cardiac cycle impulses.
Terminate test and administer ordered
medication Àantiarrhythmics).
! Myocardial infarction: Note and report chest
pain and abnormal ECG recordings, pallor, skin
mottling, and diaphoresis. Terminate test and
administer ordered oxygen and medications
Àmorphine sulfate).
! ©nginal pain: Note and report chest pain, fatigue,
and cyanosis. Terminate test and administer
ordered oxygen and medications Àvasodilators).
! Dizziness or fainting: Note and report extreme
faintness, confusion, and di iness. Terminate test
and allow the client to sit on a chair. Administer an
ordered stimulant.