Exercise electrocardiography is a Non- invasive tool to evaluate the cardio vascular system's response to exercise under carefully controlled conditions. Exercise is the body’s most common physiologic stress- most practical test of cardiac perfusion and function. During exercise body increases its metabolic rate to greater than 20 times that of rest; cardiac out put as much as six fold. (depends on age,sex,type of exercise,size etc)  Evaluation of functional capacity, heart rate changes, burden of ectopy, and dynamic electrocardiographic changes during and after exercise have emerged as powerful prognostic indicators

1. CENTER FOR PHYSIOTHERAPY AND
REHABILITATION SCIENCE JAMIA MILLIA
ISLAMIA
Topic: Introduction to exercise electrocardiography
Javid Ahmad Dar
MPT- 3rd Semester
Roll no.- 19MPC0003

2. INTRODUCTION
• Exercise electrocardiography is a Non- invasive tool to evaluate the
cardio vascular system's response to exercise under carefully
controlled conditions.
• Exercise is the body’s most common physiologic stress- most
practical test of cardiac perfusion and function.
• During exercise body increases its metabolic rate to greater than 20
times that of rest; cardiac out put as much as six fold. (depends on
age,sex,type of exercise,size etc)
• Evaluation of functional capacity, heart rate changes, burden of
ectopy, and dynamic electrocardiographic changes during and after
exercise have emerged as powerful prognostic indicators.

3. Advantages
• Ability to assess a variety of prognostic markers, most importantly
functional capacity, which is a powerful predictor of mortality,
• Widespread availability,
• Safety,
• Ease of administration, and
• •Relatively low cost.

4. Disadvantages
• As a screening test for CAD in persons without symptoms, exercise
electrocardiography is not helpful.
• It has a low sensitivity and specificity, which can be improved with
careful selection of the patient populationundergoing testing.

5. Submaximal exercise electrocardiographic testing Useful
assessment before hospital discharge for patients who have had
MI
• The advantages are as follows:
• 1. It assists in setting safe levels of exercise (exercise prescription) and
reassuring patients and families.
• 2. It is beneficial in optimizing medical therapy, in triage for intensity
of follow up testing and care, and in recognition of exercise-induced
ischemia and arrhythmias.
• 3. For patients with uncomplicated MI who have received
reperfusion therapy, submaximal exercise testing may be safely
performed as early as 3 days after MI, with maximal exercise testing 3
to 6 weeks later.

6. INDICATIONS
• Divided into three classes on the basis of degree of likelihood of
disease or severity of diagnosed disease:
• 1. Exercise testing in diagnosis of obstructive coronary artery disease.
• 2. Risk assessment and prognosis among patients with symptoms or a
history of coronary artery disease. (After acute myocardial infarction)
• 3. Exercise testing for persons without symptoms or known coronary
artery disease.

7. CONTRAINDICATIONS Absolute
contraindications
• Acute myocardial infarction (within 2 days).
• High-risk unstable angina.
• Uncontrolled cardiac arrhythmias causing symptoms or hemodynamic
compromise.
• Symptomatic, severe aortic stenosis.
• Uncontrolled symptomatic heart failure.
• Acute pulmonary embolus or pulmonary infarction.
• Suspected or known dissecting aneurysm.
• Active or suspected myocarditis, pericarditis, or endocarditis.
• Acute noncardiac disorder that may affect exercise performance or be aggravated
by exercise (e.g., infection, renal failure, or thyrotoxicosis).
• Considerable emotional distress (psychosis).

8. CONTRAINDICATIONS Relative contra
indications
• Left main coronary stenosis or its equivalent.
• Moderate stenotic valvular heart disease.
• Resting diastolic blood pressure> 110 mm Hg or resting systolic blood pressure >200 mm
Hg.
• Electrolyte abnormalities (e.g., hypokalemia, hypomagnesemia).
• Fixed-rate pacemaker.
• High-degree atrioventricular block.
• Frequent or complex ventricular ectopy.
• Ventricular aneurysm.
• Uncontrolled metabolic disease (e.g., diabetes, thyrotOXicosis, myxedema).
• Chronic infectious disease (e.g., mononucleosis, hepatitiS, acquired immunodeficiency
syndrome).
• Neuromuscular, musculoskeletal, or rheumatoid disorders exacerbated by exercise.
• Advanced or complicated pregnancy.
• Hypertrophic cardiomyopathy and other forms of outflow tract obstruction.
• Mental impairment leading to inability to cooperate.

9. Primary Prevention of Ischemic Heart Disease (Meadows et al .,
2007)
• Exercise Testing Exercise electrocardiography has been proposed as a
screening tool for asymptomatic subjects thought to be at intermediate risk
for developing clinical coronary disease. Important measures during
exercise testing that predict CHD risk include non electrocardiographic
measures such as exercise or functional capacity, chronotropic response,
heart rate recovery, and the development of ventricular ectopy.
• Many studies have shown that the most important marker of vascular risk
yielded by exercise testing is the measure of functional capacity.
Population-based studies have confirmed the importance of functional
ability to predict CHD mortality and cardiovascular risk in asymptomatic
patients.
• The role of exercise testing in asymptomatic patients for primary
prevention has not yet been clearly defined.120 It is unknown whether
routine exercise testing in selected asymptomatic patients attenuates
cardiac morbidity and mortality.

10. Angina Pectoris and Stable Ischemic Heart Disease (William et al., 2012)
• Exercise Electrocardiography An exercise ECG is the preferred test in
patients who have suspected angina pectoris and are considered to have a
moderate probability of coronary artery disease if the resting ECG is
normal (i.e., ST segments are not obscured by structural heart disease or
medication), provided that subjects are capable of achieving an adequate
workload.
• Interpretation of the exercise ECG should include the exercise capacity
achieved (duration and metabolic equivalents of the external workload; the
magnitude and extent of ST segment deviation, and clinical and
hemodynamic responses to exercise. The exercise test protocol is usually
adjusted to a patient's tolerance, aiming for 6 to 12 minutes of exercise
time (i.e., Bruce protocol stages II to IV) to achieve maximal oxygen
consumption and to elicit objective evidence of inducible ischemia, if
present. Exercise stress testing is generally very safe, with death or MI
occurring in less than one case per 2500 tests, when such provocative
testing is avoided in patients with severe aortic stenosis, severe
hypertension, or uncontrolled heart failure.

11. • Meadows, J., Danik, J. S., & Albert, M. A. (2007). Primary prevention
of ischemic heart disease. In Cardiovascular Therapeutics (pp. 178-
220). WB Saunders.
• Jesper K. Jensen, ... Connor A. Emdin, in Chronic Coronary Artery
Disease, 2018

13. Thank you