1. Exercise testing involves monitoring a patient's physiological responses like ECG, heart rate, and blood pressure as the level of physical activity is gradually increased in a controlled setting. 2. It is used to evaluate cardiac function and exercise capacity in patients with conditions like heart disease or claudication. 3. Contraindications include recent heart attacks or procedures, unstable angina, and certain arrhythmias or heart failure. Precautions like rest and informed consent are required.

1. EXERCISE TESTING
PRESENTER-
Ms. Anshu
M.Sc. Nursing
KGMU Institute of Nursing

2. EXERCISE TESTING
• Exercise test are used to assess a patients
ability to tolerate increased physical activity
while electrocardiographic, hemodynamic and
symptomatic responses are monitored in a
controlled environment.

3. INDICATIONS
• physiologic response of post MI and post
revascularization patients to exercise.
• Functional capacity for the purpose of exercise
prescription
• Exercise capacity for the purpose of work classification
and risk stratification.
• The efficacy of medical, surgical or pharmacologic
treatment.
• The presence and severity of arrhythmias
• Preoperative physiologic status.
• Intermittent claudication.

4. CONTRAINDICATION
• A recent change in the resting ECG suggesting
infarction or other acute cardiac event.
• Recent complicated MI.
• Unstable angina.
• Uncontrolled ventricular arrhythmias
• 3rd degree AV block
• Acute congestive HF.
• Severe aortic stenosis

5. CONTI…
• Suspected or known dissecting aneurysm
• Active or suspected myocarditis or
pericarditis.
• Thrombophlebitis
• Recent systemic or pulmonary embolism
• Acute infection
• Significant emotional distress.

6. PRETEST CONSIDERATIONS
• All patient should undergo a complete medical
history and a physical examination to identify
contraindications to exercise testing.
• Detailed verbal and written instruction,
provided to the patient in advance, it include
refrain from ingesting food, alcohol, and
caffeine or using tobacco products within 3
hrs of testing.

7. Conti….
• Patient should be well rested and avoid vigorous
activity the day of the test.
• Clothing should be comfortable and provide
freedom of movement as well as allow access for
electrode and blood pressure cuff placement.
• Properly fitting shoes with rubber soles should be
worn to ensure good traction, particularly if a
treadmill is the mode of testing.
• Provide written and verbal informed consent.

8. PREPARATION FOR ECG
• Sites of ECG electrode placement should be
rubbed with alcohol pad to remove skin oil.
• Place the electrode after applying conducting
gel.
• Mason-Likar limb lead placement is the
standard configuration clinically because it
provides a 12 lead ECG with fewer artifact and
less restriction to movement than the
standard lead placement.

10. EXERCISES PROTOCOL
• Bruce treadmill protocol
• Balke treadmill protocol
• Naughton treadmill protocol
• Ramp testing
• Stress testing

11. 1. Bruce treadmill
• It has 3 min period to allow achievement of a
steady state before workload is increased.
• For Individuals with limited exercise capacity,
Bruce’s protocol can be modified by 2-3 min
warm up stages at 1.7 mph and 0% grade and
1.7mph with 5% grade and speed gradually
increased upto 5.5mph in stages.
• There are total 7 stages in Bruce protocal.

13. • Limitation:-
• Large increase in O2 between stages and
traditional energy cost of running as
compared with walking at stages in excess of
Bruce’s stage III.

14. 2. BALKE TREADMILL
• The Balke protocol and modifications of it,
has been widely used for clinical exercise
testing.
• It uses constant walking speeds (2 or 3mph)
and modest increments in grade (2.5% or 5%)
and it has been used particularly often in
studies assessing angina responses.

15. Conti…
• One modification, developed by the United
States School of Aerospace Medicine(Balke
ware) consist of 5% grade increases every
2min and a constant brisk walking speed of
3.3mph(after an initial warmup of 2mph),
which has been considerd the most efficient
speed for walking.

16. 3. NAUGHTON TREADMILL
• It is a low level test that has become common
for multicenter trials in patients with chronic
heart failure.
• The test begins with 2 min stages at 1 and
2mph and 0%grade, then continually increases
grade in approximately 1 MET increaments at
a constant speed of 2mph for the next 8min.

17. Conti…
• Speed then increase to 3mph with a slight
drop in grade, followed by increases in grade
equivalent to approximately 1 MET.
• This protocol has been used extensively in
patient with congestive heart failure.

18. 4. RAMP TESTING
• It uses a constant and continuous increase in
metabolic demand that replaces the “staging”
used in conventional exercise test.
• The uniform increase in work allows for a
steady rise in cardiopulmonary responses and
permits a more accurate estimation of oxygen
uptake.

19. 5. PHARMACOLOGIC STRESS
TECHNIQUE
• Used for patients Who are unable to do exercise
on a treadmill or cycle ergometer to and
adequate level.
This includes patients having:-
• Orthopedic limitation
• Peripheral vascular disease
• COPD
• Elderly patient with low functional capacity
• DM patient with severe neuropathy
• Patient with neuromuscular

20. Two types of pharmacologic stress agents have
been used:-
• Those that increase coronary blood flow
through coronary vasodilation.
• Those that increase myocardial oxygen
demand by increasing heart rate.

21. 1.increase coronary blood flow
through coronary vasodilation.
• The commonly used coronary vasodilators are
adenosine and dipyridamole (persantine),
where as dobutamine is used to increase
myocardial oxygen demand.
• The vasodilator cause greatly increased
endocardial and epicardial blood flow in
normal coronary arteries but not in stenotic
segment.

22. 2.increase myocardial oxygen demand
by increasing heart rate.
• Dobutamine is used which can create an
imbalance between myocardial oxygen supply
and demand by increasing heart rate and
contractility.

23. • These drugs are administered IV and when
associated with an imaging technique such as
thallium-201 scintigraphy, sestamibi or
echocardiography, can provide important
information about coronary artery stenosis.

24. INTERPRETATION OF EXERCISE
TESTING
Heart rate:-
• Heart rate increases linearly with oxygen
uptake during exercise.
• The inability to appropriately increase heart
rate during exercise has been associated with
the presence of heart disease.

25. Blood pressure:-
• Assess the BP at rest and during exercise.
• BP should be assessed during last minute of
each exercise stage and more frequently if
hypotensive or hypertensive responses are
observed.
• Systolic > 250 mmHg and diastolic >115mmHg
is an indication of termination of exercise.
• A decrease in systolic BP with progressive
exercise suggest that cardiac output is unable
to increase in accordance with the work rate
and is reflection of ischemia.

26. Exercise capacity:-
• Exercise capacity is expressed in METs
(metabolic equivalents).
• MET value can be ascribed to any speed and
grade on a trademill or workload achieved on
a cycle ergometer; therefore exercise capacity
can be compared uniformly between protocol.
• MET refers to a unit of O2 uptake. 1MET is
3.5mlO2/Kg/min of body wt.

27. ECG responses:-
ECG should be repeated every 3 min.
In CAD cases exercise can cause an imbalance
between myocardial O2 demand which can
result in alteration in ST segment.

28. Subjective responses:-
• Angina and dyspnea are the subjective
responses.
• Angina and dyspnea are carefully explained to
patient.

29. ANGINA SCALE:-
• 1+ onset of discomfort.
• 2+ moderate
• 3+ moderately severe
• 4+ severe

30. DYSPNEA SCALE:-
• 1+ mild, noticeable to patient but not to
observer.
• 2+ mild, some difficulty, noticeable to
observer
• 3+ moderate difficulty, but can continue
• 4+ severe difficulty, patient cannot continue.

31. TEST TERMINATION
• Drop in systolic BP>10 mmHg from baseline.
• Moderate to severe angina
• Increasing symptoms of ataxia, dizziness or
syncope.
• Subject desire to stop
• Sustained VT
• ST elevation (1mm) without diagnostic Q wave.

32. RECOVERY PERIOD
• Active recovery consist of walking on the
treadmill at a speed of 1.5 – 2mph.
• An active recovery decreases the risk of
hypotension and dysrhythmias.
• A passive standing recovery should be avoided
because of potential complication of venous
pooling.
• Patient should be monitored for 6-8min after
exercise.

33. • BP, ECG and other symptoms should be
monitored and recorded at 2min intervals .
• Recovery period can be extended to resolve
the symptoms.

34. INSTRUCTIONS
• Avoid long standing, hot showers.
• Patient may experience fatigue and muscle
soreness
• Avoid heavy exertion on same day.
• Any discomfort or pain day after test should
be reported.