1. Exercise ECG Stress Testing for
Internists
Salah Abusin, MD, MRCP, ABIM, ABIM (Card)
Interventional Cardiologist
Dubuque, IA, USA
2. Stress Testing for Internists
• Principles & Purpose
• Patient Preparation
• Understanding the report
• When NOT to do it – Contraindications
• When to do it - Indications
3. Exercise ECG Stress Testing
Principles
• Elicit cardiovascular & ECG abnormalities not
present at rest and to determine the adequacy
of cardiac function.
4. Exercise ECG Stress Testing
Purpose
• estimate prognosis/determine functional
capacity
• the likelihood and extent of coronary artery
disease (CAD)
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. 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. 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.
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. 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. 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. 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)
16. 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
17. 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
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21. 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
22.
23.
24. Indications – Unstable Angina
• Risk Stratification for Low risk Unstable Angina
(negative troponin) after 8-12 hours
25. 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
