Exercise Treadmill Testing


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Exercise Treadmill Testing

  1. 1. Exercise Treadmill Testing Part I <ul><li>Eugene Orientale, Jr., MD </li></ul><ul><li>Associate Professor, Family Medicine </li></ul><ul><li>University of Connecticut School of Medicine </li></ul>
  2. 2. ETT Workshop Format <ul><li>Introduction </li></ul><ul><li>Feasibility / Equipment </li></ul><ul><li>ETT basics </li></ul><ul><li>Other diagnostic tests... </li></ul><ul><li>Clinical Cases / Discussion </li></ul>
  3. 3. OBJECTIVES <ul><li>To improve the current office screening practice of patients with possible coronary artery disease. </li></ul><ul><li>To facilitate greater understanding amongst faculty and residents of the use of diagnostic office ETT. </li></ul><ul><li>To augment the diagnostic capabilities of a Family Medicine office practice. </li></ul><ul><li>To further educate and validate the need for resident education in the use of electrocardiography and ACLS. </li></ul>
  4. 4. ETT by Family Physicians ? <ul><li>A random sample of 211 practicing members of the Nebraska AFP found that 58% performed Exercise Stress Testing </li></ul>Goeschel DP et al, J Fam Pract 1994; 38:132
  5. 5. ETT by Family Physicians ? <ul><li>“ 92 % of Family Practice Residency Program Directors surveyed believed that FPs should be taught this skill...” </li></ul>Jurica,JW et al. Graded Exercise Stress Testing in Family Practice and Internal Medicine Residencies . J Fam Pract 1989; 29: 537-41
  6. 6. Why ETT? <ul><li>“ Clinically, inclusion of Exercise Testing in a Family Physician’s array of diagnostic procedures increases physician confidence and security in evaluating and managing the overwhelming majority of patients who are seen in the office for chest pain.” </li></ul><ul><li>- Ken Grauer, MD </li></ul>
  7. 7. Why ETT? <ul><li>“ Even if there were enough cardiologists in the country to perform exercise testing on all persons with potentially valid indications for the test, the fact remains that patients with minimal or no symptoms do not routinely present to a cardiologist’s office with these concerns in mind.” - Ken Grauer </li></ul>
  8. 8. Why ETT by Family Physicians? <ul><li>Patient Care </li></ul><ul><li>Cost Containment </li></ul><ul><li>Comprehensive Care </li></ul><ul><li>Financial Considerations </li></ul>
  9. 9. Reasons cited by FPs not performing ETT: <ul><li>Never had training </li></ul><ul><li>No time in practice to perform procedure </li></ul><ul><li>Cannot afford to purchase the unit </li></ul><ul><li>No access to a treadmill unit </li></ul><ul><li>Lack of hospital privileges </li></ul><ul><li>No interest in the procedure </li></ul><ul><li>Inadequate reimbursement </li></ul>J Fam Pract 1994 ; 38 (2) : 135
  10. 10. Conclusion <ul><li>“ Whether family physicians should be doing Exercise Stress Testing is academic. Family physicians will continue to perform the test because demographics and public awareness and expectations will require it. We need to recognize this reality and focus our efforts toward providing competent and well-trained physicians to serve the needs of the public.” </li></ul>Goeschel, DP et al. Geographic Variation in Exercise Testing by Family Physicians. J Fam Pract 1994; 38 (2):132-137
  11. 11. Feasibility <ul><li>Current UConn Family Practice referral rate for ETT </li></ul><ul><li>is 5--6 / month. </li></ul><ul><li>This amounts to 60-72 referrals per year. </li></ul><ul><li>Yearly revenue lost (assuming $250 / test) is: </li></ul><ul><ul><ul><li>60 tests: $15,000 </li></ul></ul></ul><ul><ul><ul><li>72 tests: $18,000 </li></ul></ul></ul><ul><li>CPT code for ETT/Interpretation is 93015 </li></ul><ul><li>Medicare reimbursement: $126 - 200 </li></ul><ul><li>Common office charge: $229 - 285 </li></ul><ul><li>UConn Family Medicine ETT charge: $250 </li></ul>
  12. 12. Clinical Competence in ETT: ACP / ACC / AHA Task Force, 1990 <ul><li>“ Some Internal Medicine residency programs provide training in exercise testing, often as an elective. A minimum of 4 weeks should be devoted to this training to achieve competence... The number of procedures necessary to insure competence has not been established by objective criteria... The majority opinion of this committee and its consultants is that the trainee should participate in at least 50 exercise procedures during training... However, it is recoqnized that not all training or practice environments are the same and a greater or smaller number of procedures may be deemed appropriate.” </li></ul>
  13. 13. Maintenance of Competence: ACP / ACC / AHA Task Force, 1990 <ul><li>“ Twenty five tests per year are suggested as the minimum number the physician should perform to maintain clinical competence. Successful completion of a course in ACLS and renewal on a regular basis is necessary.” </li></ul>
  14. 14. ACC / AHA Task Force, 1997 <ul><li>“ Exercise testing should be supervised by an appropriately trained physician… exercise testing in selected patients can be safely performed by properly trained nurses, exercise physiologists, physical therapists, or medical technicians working directly under the supervision of a physician, who should be in the immediate vicinity and available for emergencies.” </li></ul>
  15. 15. Treadmill Systems Evaluated Spacelabs / Burdick Quest Stress System <ul><li>Marquette </li></ul><ul><ul><li>Max-1 Stress System </li></ul></ul><ul><ul><li>Case 8000 Stress System </li></ul></ul><ul><li>Quinton </li></ul><ul><ul><li>Q4500 Stress Test System </li></ul></ul><ul><ul><li>Q Stress System </li></ul></ul>
  16. 16. Treadmill Systems <ul><li>Quinton Q Stress System </li></ul><ul><ul><li>- durable treadmill construction </li></ul></ul><ul><ul><li>- powerful motor (3HP) </li></ul></ul><ul><ul><li>- programming ease </li></ul></ul><ul><ul><li>- stores numerous testing protocols </li></ul></ul><ul><ul><li>- software upgradeable </li></ul></ul><ul><ul><li>- ease-of-use </li></ul></ul><ul><ul><li>- “filter” technology for cleaner tracings </li></ul></ul><ul><ul><li>- design your own display format </li></ul></ul><ul><ul><li>- longest treadmill available (for athletic training / testing) </li></ul></ul><ul><ul><li>- Q-care service contract </li></ul></ul>
  17. 17. ETT System Layout Treadmill BP Cuff Recorder Monitor Controller Crash Cart
  18. 18. Treadmill System <ul><li>Treadmill </li></ul><ul><ul><li>slope 0 - 25 degrees </li></ul></ul><ul><ul><li>speed 1 - 15 mph </li></ul></ul><ul><li>Monitor </li></ul><ul><ul><li>displays 3 or 12 leads </li></ul></ul><ul><ul><li>computerized (digital) technology </li></ul></ul><ul><li>Recorder </li></ul><ul><ul><li>prints reports </li></ul></ul><ul><ul><li>includes customized summary report </li></ul></ul>
  19. 19. Patient Selection Criteria <ul><li>Always have a purpose in mind when selecting patients for Exercise Treadmill Testing... </li></ul>
  20. 20. Chest Pain... <ul><li>Atypical Chest Pain </li></ul><ul><li>Atypical Angina </li></ul><ul><li>Typical Angina </li></ul>
  21. 21. Risk Factors: Coronary Artery Disease <ul><li>Hypertension </li></ul><ul><li>Hypercholesterolemia </li></ul><ul><li>Smoking </li></ul><ul><li>Family History </li></ul><ul><li>Male >40, Postmenopausal Female </li></ul><ul><li>Diabetes Mellitus </li></ul><ul><li>Abnormal ECG </li></ul><ul><li>Obesity </li></ul>
  22. 22. Other Indications for ETT... <ul><li>Evaluating Dysrhythmias </li></ul><ul><li>Determining Functional Capacity </li></ul><ul><li>Evaluating Antianginal or Antihypertensive therapy </li></ul>
  23. 23. Patient Selection Criteria Indications for Office-Based Graded Exercise Testing: Screening for ischemic heart disease in asymptomatic individuals (especially those with multiple cardiac risk factors) Evaluation of (atypical) chest pain Determining exercise capacity; and giving an exercise prescription.
  24. 24. Patient Selection Criteria <ul><li>Relative Contraindications to ETT : </li></ul><ul><li>Left Bundle Branch Block </li></ul><ul><li>WPW (pre-excitation syndrome) </li></ul><ul><li>Marked ST-segment changes at rest (e.g. drug effect from digoxin) </li></ul><ul><li>Prior Q wave infarction. </li></ul><ul><li>Middle Aged Female... </li></ul>
  25. 25. Patient Selection Criteria <ul><li>Absolute Contraindications to ETT : </li></ul><ul><li>Acute MI </li></ul><ul><li>Unstable Angina </li></ul><ul><li>Concurrent CHF </li></ul><ul><li>Hx. rapid ventricular or atrial dysrhythmia </li></ul><ul><li>IHSS </li></ul><ul><li>Hx. recent pulmonary embolism </li></ul>
  26. 26. Before the ETT... <ul><li>Perform a complete medical examination </li></ul><ul><li>Obtain informed consent </li></ul><ul><li>Withhold any medication that may affect the ST wave or any interval </li></ul><ul><ul><ul><li>e.g. Digoxin, B- Blockers, </li></ul></ul></ul><ul><ul><ul><ul><ul><li>Ca Channel Blockers </li></ul></ul></ul></ul></ul><ul><li>In patients on diuretics, confirm a normal potassium level </li></ul>
  27. 27. Informed Consent <ul><li>Complications are rare </li></ul><ul><ul><ul><li>Dysrhythmias 5 : 10,000 </li></ul></ul></ul><ul><ul><ul><li>Infarction 5 : 10,000 </li></ul></ul></ul><ul><ul><ul><li>Death 1 : 10,000 </li></ul></ul></ul>
  28. 28. Complications of ETT <ul><li>Hypotension </li></ul><ul><li>CHF </li></ul><ul><li>Severe Cardiac Dysrhythmia </li></ul><ul><li>Cardiac Arrest </li></ul><ul><li>Acute Myocardial Infarction </li></ul><ul><li>Acute CNS event (syncope, stroke) </li></ul><ul><li>Accidental trauma (falls, etc) </li></ul><ul><li>Death </li></ul>
  29. 29. Five Year Experience: ETT in a FP Residency, Scottsdale Arizona <ul><li>202 ETT tests </li></ul><ul><li>88 % male, mean age 48.3 </li></ul><ul><li>No serious complications or adverse outcomes </li></ul><ul><li>most common indications: </li></ul><ul><li>fitness for duty (106)... 3.8 % abnormal </li></ul><ul><li>multiple risk factors (50) ... 6 % abnormal </li></ul><ul><li>Chest pain (27)... 18.5% abnormal </li></ul>Fam Med 1994; 26:290-292
  30. 30. How long? How fast? <ul><li>“ Maximal” Test </li></ul><ul><ul><li>The patient achieves 85% of MPHR </li></ul></ul><ul><ul><li>(maximal predicted HR = 220 - Age) </li></ul></ul><ul><li>“ Submaximal” Test </li></ul><ul><ul><li>The patient becomes symptomatic, </li></ul></ul><ul><ul><li>i.e. chest pain, dyspnea </li></ul></ul><ul><ul><li>( MPR generally not achieved) </li></ul></ul><ul><li>Until a positive result is achieved </li></ul>
  31. 31. Which ETT Protocol ? <ul><li>Bruce slope / rate ; very strenuous </li></ul><ul><li>Modified Bruce slower rate ; strenuous </li></ul><ul><li>Balke II slope only; moderate </li></ul><ul><li>Balke I slope only; mild </li></ul><ul><li>Naughton slope only; mild </li></ul>
  32. 32. ETT Tracing... <ul><li>ST morphology </li></ul><ul><li>Depth of change </li></ul><ul><li>duration of depression, and recovery </li></ul>
  33. 33. Patterns indicative of ischemia...
  34. 34. Exercise induced ST Depression ... <ul><li>Does not localize ischemia </li></ul><ul><li>It is a global subendocardial phenomenon </li></ul>
  35. 35. Patterns not indicative of ischemia...
  36. 36. Sign/Symptom Testing Endpoints <ul><li>Dyspnea, fatigue, chest pain </li></ul><ul><li>Systolic blood pressure drop </li></ul><ul><li>ECG-ST changes, arrhythmias </li></ul><ul><li>Physician assessment </li></ul><ul><li>Borg Scale </li></ul>
  37. 37. Relative Indications for terminating the ETT... <ul><li>Moderate chest pain, claudication or dyspnea </li></ul><ul><li>Marked ST segment depression ( > 2 mm) </li></ul><ul><li>Marked Hypertension </li></ul><ul><li>Failure of the SBP to rise 22mm Hg after stage 3 </li></ul><ul><li>Acute ECG change, e.g. BBB </li></ul>
  38. 38. Absolutely terminate the test when... <ul><li>At the patient’s request </li></ul><ul><li>Decreasing SBP </li></ul><ul><li>Serious Dysrhythmias </li></ul><ul><ul><ul><li>Atrial Fibrillation or Flutter </li></ul></ul></ul><ul><ul><ul><li>Second or Third Degree Heart Block </li></ul></ul></ul><ul><ul><ul><li>3 consecutive PVCs </li></ul></ul></ul><ul><ul><ul><li>Ventricular dysrhythmias </li></ul></ul></ul><ul><li>Evidence of acute MI </li></ul><ul><li>Equipment malfunctions </li></ul>
  39. 39. Possible causes of False Positive ETT for CAD: <ul><li>Female gender </li></ul><ul><li>Hyperventilation </li></ul><ul><li>Mitral Valve Prolapse Syndrome </li></ul><ul><li>LVH </li></ul><ul><li>Drugs (digoxin ) </li></ul><ul><li>Anemia </li></ul><ul><li>Electrolyte disturbances ( hypokalemia ) </li></ul><ul><li>Lead Misplacement </li></ul><ul><li>Pre-existing cardiac abnormalities (e.g. LBBB, WPW, Cardiomyopathy, Valvular Heart Disease </li></ul>
  40. 40. Options for evaluating ischemia <ul><li>Holter - ECG during everyday activities </li></ul><ul><li>Exercise ECG with Treadmill (ETT) </li></ul><ul><li>Nuclear perfusion (Thallium) to increase sensitivity and localize perfusion deficits </li></ul><ul><li>Add-ons: ECHO, VO2 </li></ul><ul><li>Pharmacologic stressors: </li></ul><ul><li>Dobutamine/ </li></ul><ul><li>Persantine/Adenosine </li></ul>
  41. 41. Echocardiography <ul><li>Wall motion abnormalities </li></ul><ul><li>pre- and post- exercise </li></ul><ul><li>Ejection fraction </li></ul><ul><li>Valvular heart disease </li></ul>
  42. 42. Testing options... <ul><li>ETT $191 </li></ul><ul><li>Thallium ETT $1075 </li></ul><ul><li>Persantine Thallium Scan $1314 </li></ul><ul><li>Cardiac Catheterization </li></ul><ul><ul><li>Left heart, with coronaries $1744 </li></ul></ul><ul><ul><li>Right/Left heart, with coronaries $2178 </li></ul></ul><ul><ul><li>These are hospital charges alone, at BMH from April 1994. </li></ul></ul>
  43. 43. When is a Thallium ETT needed? <ul><li>BBB (especially LBBB) </li></ul><ul><li>WPW </li></ul><ul><li>Marked ST wave changes at rest (or with hyperventilation) </li></ul><ul><li>Q wave infarctions (with baseline ST changes) </li></ul><ul><li>Unable to stop medications (such as digoxin, quinidine, or procainamide) </li></ul>
  44. 44. Sensitivity / Specificity <ul><li>Sensitivity: % of those with disease that have an abnormal test </li></ul><ul><li>(TP/TP+FN) </li></ul><ul><li>Specificity: % of those free of disease with a normal test </li></ul><ul><li>(TN/TN+FP) </li></ul>
  45. 45. Sensitivity / Specificity ( $ 250) ($ 1300 +) ($ 3000+)
  46. 46. Clinical Case 1 <ul><li>A 43 y.o. female smoker is seen for a chief complaint of left sided chest pain, which is non-exertional, sporadic, and lasts a few minutes during each episode. She has approximately two episodes per week, and there has been no change in several months. Other risk factors are negative. </li></ul><ul><li>Physical examination and resting ECG are unrevealing. </li></ul><ul><li>Would you order an ETT? </li></ul>
  47. 47. Clinical Case 2 <ul><li>A 53 y.o. black male with stable hypertension (on a thiazide diuretic) is seen for a complaint of left sided chest pain which is exertional, lasts minutes, is sometimes associated with dyspnea, and responds to oral nitrates. Pain has increased in both severity and intensity over the past month. The number of episodes has progressed from intermittent to daily. </li></ul><ul><li>Physical exam and ECG are negative. </li></ul><ul><li>Would you order an ETT? </li></ul>
  48. 48. Clinical Case 3 <ul><li>A 60 y.o. white male smoker is seen for his regular annual exam. He has a history of hypercholesterolemia, which has been well controlled on lovastatin. He notes that things are going well, and he is able to tend to his job as a farmer. He is ocassionally bothered by chest pain, which is quickly relieved by sublingual nitrates. There has been no change in the character or frequency of his pain over the past three years. </li></ul><ul><li>His physical examination is noncontributory. His resting ECG is once again normal. </li></ul><ul><li>Would you order an ETT? </li></ul>
  49. 49. Clinical Case 4 <ul><li>A 40 y.o. black male complains of vague, intermittent chest pains, which come and go. Episodes can last up to a few minutes, and arise both with exertion and rest. He has a family history notable for a father who died of an MI at age 59. The patient’s exam is remarkable for his weight which exceeds his I.B.W. by 30 lbs. He has moderate truncal obesity. His resting ECG is notable only for low voltage. </li></ul><ul><li>Would you order an ETT? </li></ul>
  50. 50. Clinical Case 5 <ul><li>A 52 y.o. postmenopausal white female is seen for her routine annual visit. She quit smoking 3 years ago after accumulating a 40 pack year history. She is tolerating estrogen replacement therapy well, but notes vague intermittent chest discomfort which she “can’t quite put a finger on.” Pain is intermittent, last minutes, and is centrally located within the chest. Her physical exam is unrevealing. Her ECG reveals a pattern consistent with a Left Bundle Branch Block (LBBB). </li></ul><ul><li>Would you order an ETT? A Thallium ETT? </li></ul>
  51. 51. Caveats on ETT... <ul><li>Small decrease in SBP at high stages of ETT may not be consistent with CAD </li></ul><ul><li>Use the double product as one means of establishing surgical clearance, i.e. HR x SBP : > 18,000 is acceptable </li></ul><ul><li>Most specific finding: downsloping ST depression > 2mm </li></ul><ul><li>Patients with unusually high pre-test likelihood of CAD, e.g. men with “classic” angina should be considered for a more specific test, e.g. Thallium ETT, or cardiac cath. </li></ul>
  52. 52. Referral from clinical sites <ul><li>Discuss necessity of procedure with an Attending </li></ul><ul><li>Have staff obtain insurance authorization for referral </li></ul><ul><li>Fill out UConn referral form (include baseline ECG) </li></ul><ul><li>Have staff contact UConn Family Medicine office to schedule patient </li></ul><ul><li>You will be mailed a full report </li></ul>