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  1. 1. Nesrine Rio  Treadmill Exercise Stress Test
  2. 2. Indications of stress test !
  3. 3. Treadmill Exercise Stress Test <ul><li>What is stress test? </li></ul><ul><li>What are the different types of stress test? </li></ul><ul><li>Why is the treadmill stress test? </li></ul><ul><li>Why is treadmill stress test done? </li></ul><ul><li>purpose of stress test </li></ul><ul><li>risks </li></ul><ul><li>side effect </li></ul><ul><li>diagnostic value </li></ul><ul><li>preparation </li></ul><ul><li>When dose regular stress test done? </li></ul><ul><li>How is regular treadmill stress performed? </li></ul><ul><li>Nursing role </li></ul><ul><li>conclusion </li></ul><ul><li>references </li></ul>Outlines :
  4. 4. Treadmill Exercise Stress Test <ul><li>Is a medical test performed to evaluate arterial blood flow to (and indirectly the amount of oxygen that will reach) the myocardium (heart muscle) during physical exercise, compared to blood flow while at reflect overall physical fitness .These test do not assess emotional stress or other connotations of the term. Stress test abnormalities (i.e., “positive stress” results) are an indication of imbalances of relative blood flow to the left ventricular muscle tissue which performs the greatest amount of work involved in pumping blood around the body. Stress testing does not detect blood floe imbalances within the other three heart chambers. </li></ul>What is stress test?
  5. 5. <ul><li>Dobutamin stress ECHO </li></ul><ul><li>Persantin stress test </li></ul><ul><li>Exercise stress test with nuclear imagining </li></ul><ul><li>Exercise stress test without nuclear imagining </li></ul><ul><li>Most stress test involves some form of exercise such as </li></ul><ul><li>treadmill. </li></ul>Treadmill Exercise Stress Test What are the different types of stress test?
  6. 6. Treadmill Exercise Stress Test <ul><li>A treadmill stress test the hearts electrical activity ( rate & rhythm) during exercise. </li></ul><ul><li>During the test the cardiologist and a technician are present. </li></ul><ul><li>Electrodes will be placed on the chest the same as for 12 leads ECG. </li></ul><ul><li>The patient will be asked to walk on a motorized treadmill. </li></ul><ul><li>The speed and incline of the treadmill will be gradually increased. </li></ul><ul><li>This test must be ordered by the doctor. </li></ul>What is the treadmill stress test?
  7. 7. <ul><li>The doctor will be looking for the changes in the ECG patterns ( ST – segment, rhythm and rate ) and any symptoms that the patient may experience. </li></ul><ul><li>The patient may be on the treadmill for up to 15 minutes, depending upon his level of recovery and cardiovascular conditioning. </li></ul><ul><li>The test will be stopped if the patient becomes too tiered , has any symptoms such as chest pain or SOB. </li></ul><ul><li>The test will last about 30 minutes. </li></ul>(Continues………….)
  8. 8. <ul><li>To evaluate the patient cardiac condition related to: </li></ul><ul><li>Irregular heart rhythm. </li></ul><ul><li>If there is decreased supply of blood and oxygen to the heart with the exercise. </li></ul><ul><li>How hard the heart can work before symptoms developed. </li></ul><ul><li>How quickly the heart recovers after the exercise. </li></ul><ul><li>The patient overall level of cardiovascular conditioning and fitness. </li></ul><ul><li>What is the patient maximum heart rate and target heart rate should be. </li></ul>Treadmill Exercise Stress Test Why is a treadmill stress test done?
  9. 9. <ul><li>Purpose: </li></ul><ul><li>ECG treadmill stress test recommended </li></ul><ul><li>as the first choice for patient with </li></ul><ul><li>medium risk of coronary heart disease </li></ul><ul><li>based on the risk factors of smoking , </li></ul><ul><li>family history of coronary stenosis , </li></ul><ul><li>hypertension , diabetes and high </li></ul><ul><li>cholesterol. </li></ul><ul><li>Diagnostic value: </li></ul><ul><li>Treadmill test: sensitivity of 67%, </li></ul><ul><li>specificity of 70%. </li></ul><ul><li>Nuclear stress test: sensitivity of 81%, </li></ul><ul><li>specificity of 85-95%. </li></ul>Treadmill Exercise Stress Test
  10. 10. Treadmill Exercise Stress Test <ul><li>Contraindicated with: </li></ul><ul><li>Acute myocardial infarction within 48 hours </li></ul><ul><li>Unstable angina </li></ul><ul><li>Symptomatic severe aortic stenosis </li></ul><ul><li>Aortic dissection </li></ul><ul><li>Pulmonary embolism </li></ul><ul><li>Pericarditis </li></ul>Risks
  11. 11. Treadmill Exercise Stress Test <ul><li>Possibility of inducing MI especially in patient with severe multi-vessel coronary artery disease. </li></ul><ul><li>Heart attack, stroke, peripheral artery clot and embolism. </li></ul><ul><li>Hypotension caused by exercise stress testing or dobutamine is almost always abnormal and should raise suspicion for severe coronary disease. </li></ul><ul><li>Palpitation </li></ul><ul><li>Chest pain </li></ul><ul><li>Shortness of breaths </li></ul><ul><li>Headache </li></ul><ul><li>Nausea </li></ul><ul><li>Fatigue </li></ul><ul><li>Hypotension or hypertension </li></ul>Another major risk: Major side effects
  12. 12. <ul><li>NPO four hours prior to test. </li></ul><ul><li>No caffeine or smoking 24 hour before test. </li></ul><ul><li>Inform the patient how to adjust insulin and food intake prior to the test. </li></ul><ul><li>Check patient medication and evaluate if he can stop beta blockers 72 hours prior the test which is recommended for best results. </li></ul><ul><li>Patient should not apply lotions ,oil or powder to the chest area. </li></ul><ul><li>Patient should wear comfortable clothing ( shorts or pants with shirt or blouse) and jogging shoes. </li></ul>Treadmill Exercise Stress Test What preparation is needed?
  13. 13. <ul><li>Patient with symptoms or signs that are suggestive of coronary artery disease. </li></ul><ul><li>Patient with significant risk factors for (CAD). </li></ul><ul><li>To evaluate exercise tolerance when patients have unexplained fatigue and shortness of breath. </li></ul><ul><li>To evaluate blood pressure response to exercise in patients with borderline hypertension. </li></ul><ul><li>To look for exercise-induced serious irregular heart beats. </li></ul>When does a regular ordered? Treadmill Exercise Stress Test
  14. 14. <ul><li>Regular stress test is heavily dependent </li></ul><ul><li>upon interpretation of EKG changes </li></ul><ul><li>produced by exercise. Therefore ,the </li></ul><ul><li>reliability drops drastically if there are </li></ul><ul><li>significant EKG changes at rest(for </li></ul><ul><li>example in patients with long standing </li></ul><ul><li>high blood pressure, an artificial cardiac </li></ul><ul><li>pacemaker , use of medications like </li></ul><ul><li>digitalis, or presence of a bundle branch </li></ul><ul><li>block pattern ,etc.). In all Nuclear </li></ul><ul><li>Stress, the physician will usually order </li></ul><ul><li>and ECHO Stress Test or a Nuclear </li></ul><ul><li>Stress Test. </li></ul>(Continues………….)
  15. 15. <ul><li>Leads 2, 3 and a VF= bottom or inferior portion of the heart. </li></ul><ul><li>Leads V1 and V2 = septum or partition of the heart. </li></ul><ul><li>Leads V3, V4, V5 and V6 = anterior or front portion of the heart. </li></ul><ul><li>Leads 1 and a VL= superior or top and left portion of the heart. </li></ul><ul><li>Lead a VR looks at the cavity of heart and has almost no clinical value in identifying coronary disease. </li></ul><ul><li>The treadmill is started at a relatively slow “warm-up” speed. The treadmill speed and </li></ul><ul><li>it’s slope or inclination are increased every three minutes according to programmed </li></ul>How is a Regular Treadmill Stress Performed? A 12-lead EKG is recorded on paper. Each lead of the EKG represents a different portion of the heart, with adjacent leads representing a single wall. Example: Treadmill Exercise Stress Test
  16. 16. <ul><li>protocol (Bruce is the commonest protocol. Each three minute interval is known as a </li></ul><ul><li>stage(stage1, stage 2, stage 3, etc). The patient’s blood pressure is usually recorded </li></ul><ul><li>during the second minute of each stage. It is also recorded on paper at one minute </li></ul><ul><li>intervals. The physician and the nurse pay particular attention to the heart rate , </li></ul><ul><li>blood pressure , changes in the ECG patterns( rhythm and St- segment shift) and </li></ul><ul><li>the patient appearance and the Symptoms .The treadmill is stopped when the patient </li></ul><ul><li>achieves a target heart rate ( this is 85% of maximum heart rate predicted for the </li></ul><ul><li>patient’s age). </li></ul><ul><li>The test may be stopped prior to achievement of target heart rate if the patient </li></ul><ul><li>develops significant chest discomfort, shortness of breaths , dizziness , unsteady gate </li></ul><ul><li>etc., or if the ECG shows alarming changes ( st-segment shift )or serious irregular </li></ul><ul><li>heart beats ( short runs of ventricular tachycardia). It may also stopped if the blood </li></ul><ul><li>pressure rises or falls beyond acceptable limits.. </li></ul>(Continues………….)
  17. 17. <ul><li>N.B: </li></ul><ul><li>- Systolic blood pressure may </li></ul><ul><li>normally rise to 200 at peak exercise: </li></ul><ul><li>- Diastolic blood pressure remains </li></ul><ul><li>unchanged or falls to a slight degree. </li></ul><ul><li>- The BP of patients with hypertension will show a rise of both systolic and diastolic readings. </li></ul>(Continues………….)
  18. 18. <ul><li>Nursing role : </li></ul><ul><li>To give proper instructions to the patient before the procedure. </li></ul><ul><li>Explain the procedure to the patient step by step. </li></ul><ul><li>Connect the patient to the ECG electrode and BP monitor. </li></ul><ul><li>Calculate the maximum heart rate for age and it’s 85%. </li></ul><ul><li>Recording the resting ECG and blood pressure. </li></ul><ul><li>Monitor the patient during the exercise and after the exercise. </li></ul>Treadmill Exercise Stress Test
  19. 19. <ul><li>Give patient further instruction of how to </li></ul><ul><li>use the new medications, stop smoking, </li></ul><ul><li>having low cholesterol diet, maintain blood </li></ul><ul><li>pressure , improve daily life style , having a </li></ul><ul><li>regular daily exercise or the preparation to have </li></ul><ul><li>an appointment for urgent angiography </li></ul><ul><li>according to the procedure results. </li></ul>(Continues………….)
  20. 20. Treadmill Exercise Stress Test <ul><li>Stress test is the established method of </li></ul><ul><li>investigating moderate risk patients for </li></ul><ul><li>coronary artery disease. </li></ul>Conclusion : References: Circulation, Fletcher et al. AHA Exercise Standards for testing.201:104:1694. National Guidelines clearinghouse. Cardiac stress test supplement. ICSI:2003 Nov.26p87.
  21. 21. Thank you