This document provides information about exercise electrocardiogram (ECG) stress testing for internists. It discusses the principles, purpose, procedures, patient preparation, understanding the report, contraindications, and indications for stress testing. The main points are: stress testing elicits cardiovascular abnormalities not seen at rest and determines cardiac function; it estimates prognosis and likelihood of coronary artery disease; procedures involve monitoring ECG and symptoms during treadmill exercise; the report details exercise duration, heart rate changes, symptoms, and any ECG abnormalities; contraindications include recent acute cardiac issues or inability to interpret ECG; and indications include diagnosing stable angina and risk stratifying unstable angina or recent heart attacks.

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.

8. Understanding the Report
Duration of Exercise
• The most important prognostic information
from the ECG Stress 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)

13. Understanding the Report
Arrhythmias during Exercise
• Development of VT 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

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

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

26. • Thanks