Exercise ECG Stress Testing for
Internists
Salah Abusin, MD, MRCP, ABIM, ABIM (Card)
Interventional Cardiologist
Dubuque, ...
Stress Testing for Internists
• Principles & Purpose
• Patient Preparation
• Understanding the report
• When NOT to do it ...
Exercise ECG Stress Testing
Principles
• Elicit cardiovascular & ECG abnormalities not
present at rest and to determine th...
Exercise ECG Stress Testing
Purpose
• estimate prognosis/determine functional
capacity
• the likelihood and extent of coro...
Procedure
1. Patient is connected to ECG monitor in treadmill
2. Check Baseline BP & 12 lead ECG
3. Start treadmill
4. Mon...
When to stop
• Symptoms
– Patient develops exercise limiting symptoms
• BP changes
– Drop in BP or rise above 250/115
• EC...
Patient Preparation
• Patients should refrain from ingesting food, alcohol,
or caffeine or using tobacco products within 3...
Understanding the Report
Duration of Exercise
• The most important prognostic information
from the ECG Stress Test
Understanding the Report
Target HR achieved?
• The target HR is measured as follows
– 220 – Age
• HR with exercise should ...
Understanding the Report
Did the patient develop any
symptoms?
• Development of chest pain (with
hemodynamic/ECG changes) ...
Understanding the Report
BP changes during exercise
• SBP should rise with exercise
• A drop in SBP with exercise is consi...
Understanding the Report
ST segment changes with Exercise
• Development of significant ST depression
during Exercise incre...
Understanding the Report
Arrhythmias during Exercise
• Development of VT is considered a poor
prognostic sign (indication ...
When not to do it?
When it is not safe
• ACS – Acute Phase
• Uncontrolled arrhythmia
• Uncontrolled HF, uncontrolled HTN
•...
When not to do it?
When the ECG cannot be interpreted
• ACS
• Uncontrolled arrhythmia
• Uncontrolled HF, uncontrolled HTN
...
Indications - Stable Angina
• Diagnosis of Obstructive CAD
– Highest Yield in patients with intermediate
probability
– Whe...
Indications – Unstable Angina
• Risk Stratification for Low risk Unstable Angina
(negative troponin) after 8-12 hours
Indications – STEMI
• Before discharge for patients who underwent
successful thrombolysis and did NOT undergo
diagnostic c...
• Thanks
CAD 2014 - Introduction to Stress testing
CAD 2014 - Introduction to Stress testing
CAD 2014 - Introduction to Stress testing
CAD 2014 - Introduction to Stress testing
CAD 2014 - Introduction to Stress testing
CAD 2014 - Introduction to Stress testing
CAD 2014 - Introduction to Stress testing
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CAD 2014 - Introduction to Stress testing

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Stress Testing

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CAD 2014 - Introduction to Stress testing

  1. 1. Exercise ECG Stress Testing for Internists Salah Abusin, MD, MRCP, ABIM, ABIM (Card) Interventional Cardiologist Dubuque, IA, USA
  2. 2. Stress Testing for Internists • Principles & Purpose • Patient Preparation • Understanding the report • When NOT to do it – Contraindications • When to do it - Indications
  3. 3. Exercise ECG Stress Testing Principles • Elicit cardiovascular & ECG abnormalities not present at rest and to determine the adequacy of cardiac function.
  4. 4. Exercise ECG Stress Testing Purpose • estimate prognosis/determine functional capacity • the likelihood and extent of coronary artery disease (CAD)
  5. 5. Procedure 1. Patient is connected to ECG monitor in treadmill 2. Check Baseline BP & 12 lead ECG 3. Start treadmill 4. Monitor patient for symptoms 5. Check BP every 3 minutes 6. Treadmill ECG machine records 12 lead ECG periodically
  6. 6. When to stop • Symptoms – Patient develops exercise limiting symptoms • BP changes – Drop in BP or rise above 250/115 • ECG Changes – Significant arrhythmias – Pronounced ST changes from baseline
  7. 7. Patient Preparation • Patients should refrain from ingesting food, alcohol, or caffeine or using tobacco products within 3 hours of testing. • Patients should be rested for the assessment, avoiding significant exertion or exercise on the day of the assessment. • Patients should wear clothing that allows freedom of movement, including walking or running shoes, and a loose-fitting shirt with short sleeves that buttons down the front. They should not wear restrictive undergarments during the test.
  8. 8. Understanding the Report Duration of Exercise • The most important prognostic information from the ECG Stress Test
  9. 9. Understanding the Report Target HR achieved? • The target HR is measured as follows – 220 – Age • HR with exercise should rise to > 85% of target HR to consider this sufficient exercise • If the test is stopped early (in the absence of evidence of ischemia) before >85% of target HR is achieved then the test is considered inconclusive
  10. 10. Understanding the Report Did the patient develop any symptoms? • Development of chest pain (with hemodynamic/ECG changes) suggested an increased likelihood of CAD • Chest pain at low workload is considered a poor prognostic sign
  11. 11. Understanding the Report BP changes during exercise • SBP should rise with exercise • A drop in SBP with exercise is considered a poor prognostic sign (indication to stop the test)
  12. 12. Understanding the Report ST segment changes with Exercise • Development of significant ST depression during Exercise increases the likelihood of significant CAD • Development of ST Elevation is considered a poor prognostic sign (indication to stop the test)
  13. 13. Understanding the Report Arrhythmias during Exercise • Development of VT is considered a poor prognostic sign (indication to stop the test)
  14. 14. When not to do it? When it is not safe • ACS – Acute Phase • Uncontrolled arrhythmia • Uncontrolled HF, uncontrolled HTN • Symptomatic Severe Ao stenosis • Acute PE • 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
  15. 15. When not to do it? When the ECG cannot be interpreted • ACS • Uncontrolled arrhythmia • Uncontrolled HF, uncontrolled HTN • Symptomatic Severe Ao stenosis • Acute PE • 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
  16. 16. Indications - Stable Angina • Diagnosis of Obstructive CAD – Highest Yield in patients with intermediate probability – When used in patients with low probability, increases likelihood of false positive (especially in women) • Risk Stratification in patients high probability of CAD
  17. 17. Indications – Unstable Angina • Risk Stratification for Low risk Unstable Angina (negative troponin) after 8-12 hours
  18. 18. Indications – STEMI • Before discharge for patients who underwent successful thrombolysis and did NOT undergo diagnostic coronary angiography • Before discharge in patients who came with late presenting STEMI and did NOT undergo diagnostic coronary angiography
  19. 19. • Thanks

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