exercise testing

1. EXERCISE TESTING
By
Adebowale Temitope J.(PT)

2. OUTLINE
• INTRODUCTION
• INDICATION OF EXERCISE TESTING
• CONTRAINDICATIONS
• TYPES OF EXERCISE
• EXERCISE PHYSIOLOGY
• CONDUCTIONG THE TEST
• BRUCE PROTOCOL
• COMPLICATIONS SECONDARY TO THE TEST
• CONCLUSION
• REFERENCES

3. INTRODUCTION
• Exercise testing is a noninvasive tool to evaluate the cardiovascular
system’s response to exercise under carefully controlled conditions1.
• Exercise is the body’s most common physiologic stress, and it places
major demands on the cardiopulmonary system.
• Exercise can be considered the most practical test of cardiac perfusion
and function.

4. INTRODUCTION
• Exercise test complements the medical history and the physical
examination
• The second most commonly performed cardiologic procedure next to
ECG.
• It involves monitoring the HR, BP and ECG

5. BENEFIT OF EXERCISE TEST
• Work out possible causes of chest pain and other symptoms
• Help in identifying people at risk of developing hypertension
• Find out if arteries to the heart are narrowed or blocked
• Assess general fitness
• Find irregular heart rhythms during or after exercise
• Monitor heart’s response to treatment.

6. INDICATION
Exercise testing has been used for the provocation and identification of
myocardial ischemia for >6 decades2
• Chest pain
• Research has demonstrated that classifying heart failure according to
how well someone functions during physical activity(exertion) can be
an important indicator of prognosis.3

7. CONTRAINDICATION
RELATIVE CONTRAINDICATION
• Known obstructive left main coronary artery stenosis
• Recent stroke or TIA
• Mental impairment with limited ability to cooperate
• Resting hypertension with BP ≥ 200/110mmhg
• Uncorrected medical conditions, such as significant anaemia

8. CONTRAINDICATION
ABSOLUTE CONTRAINDICATION
• Acute Myocardial infarction within 2 days
• Ongoing unstable angina
• Uncontrolled cardiac arrhythmias with hemodynamics compromise
• Active endocarditis
• Symptomatic severe aortic stenosis
• Acute myocarditis and pericarditis
• Physical disability that preclude safe and adequate testing
• Acute aortic dissection

9. TYPES OF EXERCISE
• Three types of exercise can be used to stress the cardiovascular
system
Isometric
Dynamic
Combination of the two
• Isometric exercise, defined as a constant muscular contraction
without movement (e.g handgrip) imposes a disproportionate
pressure load on the left ventricle relative to the body’s ability to
supply oxygen.
• Dynamic exercise is defined as rhythmic activity resulting in
movement, initiates a more appropriate increase in cardiac output
and oxygen exchange4

10. EXERCISE PHYSIOLOGY
• Sympathetic activation
• Parasympathetic withdrawal
• Vasoconstriction, except in-
• Exercising muscle
• Cerebral circulation
• Coronary circulation
• ↑Norepinephrine and Renin
• ↑02 extraction (up to 3fold)
• ↑Ventricular contractility
• ↓Peripheral resistance
• ↑SBP
• DBP- No significant change
• Pulmonary vascular bed can
accommodate 6 fold CO
• CO ↑4-6times4

11. AGE PREDICTED MAXIMUM HR
• Age predicted maximum HR = 220-age in years
• Targeted HR = 85% of Max predicted HR
• Maximum HR ↓ with age
• It is used as an indicator for max exertion in ETT/ indication to
terminate the test5

12. CONDUCTING THE TEST
• Explanation of procedure to patient
• Patient preparation
Patient should not eat or smoke for at least an hour before the test
The last meal eaten should be light, not a hot cooked meal
Patient can drink water, tea or coffee but not alcohol
Diabetic patients are to adjust their medication that day.

13. CONDUCTING THE TEST
• ECG testing every 30sec interval. Also recorded at rest, during
exercise and after exercise(recovery phase) at the same intervals
• Heart rates are monitored throughout the exercise noting any abnormal
rhythm
• The test should be stopped when the subject cannot continue due to
fatigue or pain or due to any other medical condition6

14. EQUIPMENTS REQUIRED
• Treadmill/Bicycle ergometer
• Stopwatch
• A 12 lead ECG machine & leads
• Blood pressure monitor
• Clips
• Pulse Oximeter

16. BRUCE PROTOCOL
• It is a standardized multistage treadmill test for assessing cardiovascular
health.
• Developed by Robert A. Bruce in 1963 who was an American Cardiologist
• Patient walks on an uphill treadmill in a graded exercise test with
electrodes on the chest to monitor
• Every 3 min the speed & incline of the treadmill are increased7.
• There are 7 such stages

17. STAGES
• Level 1 - 10% Incline at 2.7 km/h
• Level 2 - 12% Incline at 4.02 km/h
• Level 3 - 14% Incline at 5.47 km/h
• Level 4 - 16% Incline at 6.76 km/h
• Level 5 - 18% Incline at 8.05 km/h
• Level 6 - 20% Incline at 8.85 km/h
• Level 7 - 22% Incline at 9.65 km/h

18. COMPLICATIONS SECONDARY TO ET
• Cardiac
• Bradyarrythemias
• Tachyarrythemias
• Acute coronary syndrome
• Heart failure
• Hypotension
• Dealth
• Non cardiac
• Musculoskeletal trauma
• Soft tissue injury
• fatigue

19. CONCLUSION
• Exercise tolerance is the most useful overall assessment of general
fitness as it is a summation of respiratory and cardiac factors, as well
as taking into account de-conditioning and motivation.
• Exercise testing helps in evaluating cardiac function and fitness level
of individual.

20. References
1. Myers JN. Essentials of Cardiopulmonary Exercise Testing. Champaign, Ill: Human
Kinetics; 1996.
2. Crouter SE, Antczak A, Hudak JR, DellaValle DM, Haas JD. Accuracy and reliability of
the ParvoMedics TrueOne 2400 and MedGraphics VO2000 metabolic systems. Eur J
Appl Physiol. 2006;98:139 –151.
3. Carter J, Jeukendrup AE. Validity and reliability of three commercially available breath-
by-breath respiratory systems. Eur J Appl Physiol. 2002;86:435– 441
4. Principles of Exercise Testing and Interpretation, 5th edition,
5. Dr. Karl Wasserman Cardiopulmonary Exercise Testing How Do We Differentiate the
Cause of Dyspnea
6. Milani, RV, Lavie CJ, Mehra MR., Circulation.2004; 110: e27-e31 Clinician’s Guide to
Cardiopulmonary Exercise Testing in Adults, A Scientific Statement From the American
Heart Association, Circulation.2010; 122: 191-225
7. Robert A. Bruce; Frank W. Lovejoy Jr.; Raymond Pearson; Paul N. G. Yu; George B.
Brothers; Tulio Velasquez (1949). "Normal respiratory and circulatory pathways of
adaptation in exercise". J Clin Invest. 28 (6 Pt 2): 1423–
30. doi:10.1172/JCI102207. PMC 439698. PMID 15407661.

21. THANKS FOR LISTENING