This document outlines indications for terminating exercise testing and risk stratifies cardiac patients. It lists absolute and relative indications for terminating an exercise test, such as ST segment elevation, blood pressure changes, chest pain, or patient request. It then stratifies cardiac patients as high, low, or moderate risk based on factors like ejection fraction, symptoms, test results, and exercise capacity. High risk patients may have reduced ejection fraction, arrhythmias, or limited exercise tolerance. Low risk patients have normal ejection fraction and test results and are asymptomatic. Moderate risk patients fall between these categories.

1. Cardiopulmonary Rehabilitation

2. Indications for terminating exercise testing
Absolute Indications
• ST-segment elevation (>1.0 mm) in leads without Q waves
(other than V1 or aVR)
• drop in systolic blood pressure >10 mmHg (persistently below
baseline), despite an increase in workload, when
accompanied by any other evidence of ischemia
• moderate-to-severe angina (grade 3 to 4); Table 5 details
descriptions and grades for angina scale
• central nervous system symptoms (eg, ataxia, dizziness, or
near syncope)

3. • sustained ventricular tachycardia
• technical difficulties in monitoring the ECG or
systolic blood pressure
• signs of poor perfusion (cyanosis or pallor)
• patient’s request to stop.

4. Relative Indications
• ST or QRS changes such as excessive ST displacement
(horizontal or down sloping of >2 mm) or marked axis
shift
• drop in systolic blood pressure >10 mm Hg (persistently
below baseline), despite an increase in workload, in the
absence of other evidence of ischemia
• increasing chest pain
• fatigue, shortness of breath, wheezing, leg cramps, or
claudication

5. • arrhythmias other than sustained ventricular
tachycardia, including multifocal ectopic, ventricular
triplets, supraventricular tachycardia, heart block, or
bradyarrhythmias
• hypertensive response (systolic blood pressure >250
mmHg and/or diastolic blood pressure >115 mmHg)
• development of bundle-branch block that cannot be
distinguished from ventricular tachycardia.

6. Risk Stratification of cardiac patients according
to AACVPR
Patient is at HIGH RISK
• Left ventricular ejection fraction < 40%
• Survivor of cardiac arrest
• Complex ventricular dysrhythmias (ventricular
tachycardia, frequent [> 6/min] multiform PVCs) at
rest or with exercise
• MI or cardiac surgery complicated by cardiogenic
shock, CHF, and/or signs/symptoms of post-
procedure ischemia

7. • Abnormal hemodynamics with exercise, especially flat
or decreasing systolic blood pressure or chronotropic
incompetence with increasing workload
• Significant silent ischemia (ST depression 2mm or
greater without symptoms) with exercise or in recovery
• Signs/symptoms including angina pectoris, dizziness,
lightheadedness or dyspnea at low levels of exercise (<
5.0 METs) or in recovery
• Maximal functional capacity less than 5.0 METs
• Clinically significant depression or depressive
symptoms

8. Patient is at LOW RISK
• Left ventricular ejection fraction > 50%
• No resting or exercise-induced complex dysrhythmias
• Uncomplicated MI, CABG, angioplasty, atherectomy,
or stent: Absence of CHF or signs/symptoms
indicating post-event ischemia
• Normal hemodynamic and ECG responses with
exercise and in recovery

9. • Asymptomatic with exercise or in recovery, including
absence of angina
• Maximal functional capacity at least 7.0 METs
• Absence of clinical depression or depressive
symptoms

10. Patient is at MODERATE RISK
• Left ventricular ejection fraction = 40–50%
• Signs/symptoms including angina at “moderate”
levels of exercise (60–75% of maximal functional
capacity) or in recover
• Mild to moderate silent ischemia (ST depression less
than 2mm) with exercise or in recovery

11. Abbreviation
• multiform PVCs: Premature ventricular contractions--
extra beats disrupt your regular heart rhythm, sometimes
causing you to feel a flip-flop or skipped beat in your chest
• CHF: Congestive heart failure
• METs: The Metabolic Equivalent of Task--
physiological measure expressing the energy cost of physical
activities and is defined as the ratio of metabolic rate (and
therefore the rate of energy consumption) during a specific
physical activity to a reference metabolic rate
• CABG: Coronary artery bypass grafting-- surgery that
improves blood flow to the heart
• MI : Myocardial infarction