The document details the purposes and guidelines for exercise testing, particularly focusing on its role in diagnosing coronary artery disease (CAD), evaluating physical capacity, and predicting cardiovascular events. It includes contraindications, patient preparation, assessment protocols, monitoring during tests, and interpretations of electrocardiographic data. Additionally, it addresses complications, functional capacity markers, and prognostic tools such as the Duke treadmill score and heart rate recovery metrics.

2. Purposes of Exercise Testing
• Detection of coronary artery disease (CAD) in patients
with chest pain (chest discomfort) syndromes or
potential symptom equivalents
• Evaluation of the anatomic and functional severity of
CAD
• Prediction of cardiovascular events and all-cause
death
• Evaluation of physical capacity and effort tolerance
• Evaluation of exercise-related symptoms
• Assessment of chronotropic competence,
arrhythmias, and response to implanted device
therapy
• Assessment of the response to medical interventions

3. GUIDELINES FOR EXERCISE STRESS
TESTING

4. Exercise Testing in the Diagnosis of
Obstructive CAD
• CLASS IA
• Adult patients (including those with complete
right bundle branch block or <1 mm of resting
ST-depression) with an intermediate pretest
probability of CAD on the basis of sex, age,
and symptoms
• Class IIa
• Patients with vasospastic angina

6. Risk Assessment and Prognosis Among
Patients With Symptoms or a History of
CAD
• CLASS I
• Patients undergoing initial evaluation with suspected or known
CAD (exceptions in class IIb), including those with complete right
bundle branch block or <1 mm of resting ST- depression
• Patients with suspected or known CAD previously evaluated, now
presenting with marked change in clinical status
• Low-risk unstable angina patients 8–12 h after presentation who
have been free of active ischemic or heart failure symptoms
• Intermediate-risk unstable angina patients 2–3 d after
presentation who have been free of active ischemic or heart
failure symptoms

8. AFTER ACUTE MI
• CLASS I
• Before discharge for prognostic assessment, activity
prescription, or evaluation of medical therapy
(submaximal at about 4– 6 d)
• Early after discharge for prognostic assessment and
cardiac rehabilitation if the predischarge exercise test
was not performed (symptom limited, about 14–21 d)
• Late after discharge for prognostic assessment, activity
prescription, evaluation of medical therapy, and
cardiac rehabilitation if the early exercise test was
submaximal (symptom limited, about 3–6 wk)

10. Exercise Testing for Persons without
Symptoms or Known CAD

11. Exercise Testing for Persons with
Valvular Heart Disease

13. Absolute Contraindications
• Acute myocardial infarction (MI), within 2 days
• Ongoing unstable angina
• Uncontrolled cardiac arrhythmia with hemodynamic
compromise
• Active endocarditis
• Symptomatic severe Aortic stenosis
• Decompensated heart failure
• Acute pulmonary embolism, pulmonary infarction, or deep
vein thrombosis
• Acute myocarditis or pericarditis
• Acute aortic dissection
• Physical disability that precludes safe and adequate testing

14. Relative Contraindications
• Known obstructive left main coronary artery stenosis
• Moderate to severe aortic stenosis with uncertain relation to
symptoms
• Tachyarrhythmias with uncontrolled ventricular rates
• Acquired advanced or complete heart block
• Hypertrophic obstructive cardiomyopathy with severe resting
gradient
• Recent stroke or transient ischemic attack
• Mental impairment with limited ability to cooperate
• Resting hypertension with systolic or diastolic blood pressures
>200/110 mmHg
• Uncorrected medical conditions, such as significant anemia,
electrolyte imbalance, and hyperthyroidism

15. Patient Preparation
• The subject or patient should not eat for 3 hours
before the test.
• Routine medications may be taken with small
amounts of water.
• Subjects should dress in comfortable clothing and
wear comfortable walking shoes or sneakers.
• The subject or patient should receive a detailed
explanation of the testing procedure and purpose
of the test, including the nature of the
progressive exercise, symptom and sign, end
points, and possible complications.

17. • A brief history and physical examination are
required to rule out contraindications to testing
and to detect important clinical signs, such as
cardiac murmur, gallop sounds, pulmonary
wheezing, or rales.
• Subjects with a history of worsening unstable
angina or decompensated heart failure should not
undergo exercise testing until their condition
stabilizes.
• Physical examination should screen for valvular or
congenital heart disease

18. • In patients with permanent cardiac pacemakers, it is
important to obtain information regarding the type
of pacemaker (single or dual chamber), programmed
mode, rate responsiveness, and pacing HR limits
before the test.
• In patients with Implantable Cardioverter Defibrillators
(ICDs), the peak HR during the exercise test is maintained
at least 10 beats/min below the programmed HR
threshold for antitachycardia pacing and defibrillation

19. PATIENT ASSESSMENT FOR
EXERCISE TESTING

20. HISTORY
• Medical history: including cardiovascular disease (known
existing coronary artery disease [CAD], previous myocardial
infarction, or coronary revascularization);
• Arrhythmias
• Syncope or presyncope;
• Pulmonary disease, including asthma, emphysema, and
bronchitis or recent pulmonary embolism;
• Cerebrovascular disease, including stroke;
• Peripheral artery disease;
• Current pregnancy;
• Musculoskeletal, neuromuscular, or joint disease.

21. • Symptoms: Angina; chest, jaw, or arm discomfort;
shortness of breath; and palpitations.
• Risk factors for atherosclerotic disease: Hypertension,
diabetes, obesity, dyslipidemia, and smoking
• If patient is without known CAD, determine the
pretest probability of CAD.
• Recent illness, hospitalization, or surgical procedure
• Medication dose and schedule
• Ability to perform physical activity

23. Physical Examination
• Pulse rate and regularity
• Resting blood pressure sitting and standing
• Auscultation of the lungs
• Auscultation of the heart, particularly in
patients with heart failure or valvular disease
• Examination related to orthopedic,
neurologic, or other medical conditions that
might limit exercise

24. PATIENT MONITORING DURING
EXERCISE TESTING

25. During the Exercise Period
• 12-lead ECG during last minute of each stage,
or at least every 3 minutes
• Blood pressure during last minute of each
stage, or at least every 3 minutes
• Symptom rating scales as appropriate for the
test indication and laboratory protocol

26. During the Recovery Period
• Monitoring for a minimum of 6 minutes after exercise in sitting or
supine position, or until near baseline heart rate, blood pressure,
ECG, and symptom measures are reached.
• A period of active cool-down may be included in the recovery
period, particularly following high levels of exercise, to minimize
the postexercise hypotensive effects of venous pooling in the
lower extremities.
• 12-lead ECG every minute
• Heart rate and blood pressure immediately after exercise, then
every 1 or 2 minutes until near-baseline measures are reached
• Symptomatic ratings every minute as long as they persist after
exercise.
• Patients should be observed until all symptoms have resolved or
returned to baseline levels.

27. Complications Secondary to Exercise
Testing
• CARDIAC-
• Bradyarrhythmias,Tachyarrhythmias
,Acute coronary syndromes, Heart failure,
Hypotension, syncope, and shock, Death (0.5
per 10 000 tests)

28. • Noncardiac - Musculoskeletal trauma,
Soft-tissue injury
• Miscellaneous - Severe fatigue (malaise),
sometimes persisting for days, dizziness, body
aches

29. Absolute Indications for Termination of
Exercise Testing
• ST-segment elevation (>1.0 mm) in leads without preexisting Q waves
because of prior MI (other than aVR, aVL, and V1)
• Drop in systolic blood pressure >10 mmHg, despite an increase in
workload, when accompanied by any other evidence of ischemia
• Moderate-to-severe angina
• Central nervous system symptoms (eg, ataxia, dizziness, near syncope)
• Signs of poor perfusion (cyanosis or pallor)
• Sustained ventricular tachycardia (VT) or other arrhythmia, including
second- or third-degree atrioventricular (AV) block, that interferes with
normal maintenance of cardiac output during exercise
• Technical difficulties in monitoring the ECG or systolic blood pressure
• The subject’s request to stop

30. Relative Indications
• Marked ST displacement (horizontal or
downsloping of >2 mm, measured 60 to 80 ms
after the J point [the end of the QRS complex])
in a patient with suspected ischemia
• Drop in systolic blood pressure >10 mmHg
(persistently below baseline) despite an
increase in workload, in the absence of other
evidence of ischemia
• Increasing chest pain

31. • Fatigue, shortness of breath, wheezing, leg cramps, or
claudication
• Arrhythmias other than sustained VT, including
multifocal ectopy, ventricular triplets, supraventricular
tachycardia, and bradyarrhythmias that have the
potential to become more complex or to interfere with
hemodynamic stability
• Exaggerated hypertensive response (systolic blood
pressure >250 mmHg or diastolic blood pressure >115
mmHg)
• Development of bundle-branch block that cannot
immediately be distinguished from VT

32. TREADMILL PROTOCOLS

33. BRUCE PROTOCOL

34. • The modified Bruce protocol employs 2 initial low level
3-minutes stages at a speed of 1.7 mph and grades 0 % and
5%,respectively, and then continues into the full Bruce protocol
• During treadmill exercise, patients should be encouraged to walk
freely and use the handrails for balance only when necessary.
• Excessive handrail gripping and support alter the BP response and
decrease the oxygen requirement (METs) per given workload,
thereby resulting in an overestimation of exercise capacity and an
inaccurate HR- and BP-to-workload relationship

35. Other protocols
• The Naughton protocol is good for older or
debilitated persons and allows a gradual increase
in workload.
• The Balke protocol is good for younger, fit
persons. It maintains a speed of 3, 3.5, or 4 mph
(4.8, 5.6, or 6.4 km/h, respectively) and increases
the grade every 2 minutes.
• The Cornell protocol allows for a gradual increase
in grade and speed and may be started at 0%, 5%,
or 10% grade, depending on fitness level

36. • 1 MET being resting energy expenditure and
defined as approximately 3.5 mL O2/kg body
weight/min
• V
̇ O2 is equal to the product of cardiac output
and oxygen extraction
• V
̇ O2max is the peak oxygen uptake achieved
during performance of the highest level of
dynamic exercise

37. • Myocardial oxygen demand is related to heart rate
(HR), blood pressure (BP), left ventricular (LV)
contractility (myocardial shortening per beat), and
LV wall stress.
• Changes in any of these interdependent factors
can affect myocardial need for oxygenated blood.
• The product of HR and systolic BP, termed the
RATE-PRESSURE PRODUCT, is a reliable index of
myocardial oxygen demand

38. DATA

39. • Electrocardiographic data.
• Age-predicted maximum heart rate (APMHR).
• Rating of perceived exertion (RPE)
• Blood pressure monitoring
• Symptoms
• Functional capacity

40. Electrocardiographic data
• ST-SEGMENT CHANGES
• Measurement of the ST-segment- it is measured 60 ms
past the J point
• ST-segment changes - measured from the isoelectric
baseline, which can be determined from the PR interval.
• If the ST-segment is elevated at rest, any depression that
occurs with exercise is still measured from the isoelectric
line;
• Early repolarization of the ST-segment at rest is normal.
• If the ST-segment is depressed at rest, any further
depression should be measured from the baseline
ST-segment

41. • ST-DEPRESSION - does not localize the area of
ischemia.
• ST-depression of at least 1 mm that is horizontal
or downsloping is abnormal, as is upsloping
ST-depression of at least 2.0 mm.
• Baseline ST-abnormalities are less likely to
represent exercise-induced myocardial ischemia,
and the baseline ST-depression should be
subtracted from the peak ST-depression

42. • NORMAL RESPONSE-
• During exercise, there is
depression of the J junction that is maximal at
peak exercise and returns to baseline during
recovery. This normal depression is upsloping
and typically <1 mm below the isoelectric line
80 ms after the J point.

43. Baseline Abnormalities That May Obscure
Electrocardiographic Changes during
Exercise
• Left bundle branch block
• Left ventricular hypertrophy with repolarization
abnormality
• Digitalis therapy
• Ventricular paced rhythm
• Wolff–Parkinson–White syndrome
• ST abnormality associated with supraventricular
tachycardia or atrial fibrillation
• ST-abnormalities with mitral valve prolapse and
severe anemia

44. Criteria that increase the probability of
ischemia
• The number of leads involved (i.e., more leads increase the
probability of ischemia),
• Workload at which the ST-depression occurs (i.e., lower workload
increases the probability)
• The angle of the slope (i.e., a downsloping angle has a higher
probability than a horizontal one)
• ST-segment adjustment relative to heart rate (ST/HR index)
• The amount of time in recovery before normalization of the
ST-segment (i.e., longer recovery increases the probability)
• The magnitude of the depression.
• Changes in the lateral leads, particularly V5, are more specific than
in any of the other leads.
• Changes in the inferior leads alone are likely to be a false-positive
result

45. ST-elevation
• A) ST-segment elevation with Q-waves of prior MI is a common
finding among patients who have had MI.
• It occurs among up to 50% of patients with anterior MI and 15% of
patients with previous inferior MI, and it is not caused by
ischemia.
• There may even be reciprocal ST-segment depression. Patients
with more extensive Q-waves have more pronounced
ST-elevation. These patients typically have a lower ejection
fraction than those without elevated ST-segment with a Q-wave.
• These changes do not imply ischemia (although they may imply
viability) and should be interpreted as normal.
• B) ST-segment elevation without Q-waves of prior MI represents
marked transmural myocardial ischemia. STelevation may also
indicate the location of the ischemia. This finding should be
interpreted as abnormal.

46. • ST-NORMALIZATION, or the lack of ST-changes
during exercise, may be a sign of ischemia.
• This phenomenon occurs when ischemic
ST-depression and ST-elevation cancel one
another.
• It should be considered in tests of patients
with no electrocardiographic changes but with
a high likelihood of CAD.

47. • Time to resolution of changes- the longer into
recovery time it takes for electrocardiographic
changes to resolve, the higher is the probability
that they are important.
• Rapid recovery (<1 minute) indicates less
likelihood of disease and that disease if present is
less severe.
• Bundle branch block or conduction delay-
Exercise-induced left bundle branch block is
predictive of a worse outcome

48. Age-predicted maximum heart rate
(APMHR)
• APMHR . HR(max) = 220 – Age
• Newer equation

49. • If MHR does not exceed 85% of APMHR during
testing and there are no substantial
electrocardiographic changes, the test is
usually read as nondiagnostic.
• If there are substantial electrocardiographic
changes, the test is read as abnormal,
regardless of the heart rate achieved.

50. CHRONOTROPIC RESPONSE INDEX
• The chronotropic response index (CRI) is a
measure of MHR in relation to chronotropic
reserve.
• A normal response is defined as a CRI of >0.8
(0.62 for patients on β-blockers)

51. BLOOD PRESSURE MONITORING
• It should be checked in each walking stage.
• Systolic blood pressure, Pulse pressure, HR-BP product
(Double Product), and Double-product Reserve (change in
double product from peak to rest) all increase steadily as
workload increases.
• A failure of SBP to rise with increasing workload or a drop in
SBP usually indicates the presence of CAD and is an
indication to terminate testing.
• Diastolic blood pressure decreases with exercise and may be
audible down to 0 during vigorous activity. Unlike SBP,
diastolic blood pressure is not useful in diagnosis.

52. SYMPTOMS
• The presence or absence of symptoms and
their change over time are included in the
final report

53. Exercise-Induced Symptoms
• Are the symptoms reported during the test
the same or similar to the reported historical
symptoms that prompted the exercise test?
• Exercise-induced angina is an important
clinical predictor of the presence and severity
of CAD, equal to or greater than ST-segment
depression

54. • Exercise-induced angina predicts an adverse
prognosis regardless of the ST-segment
response or the exercise capacity.
• Typical angina at the exercise test was a
predictor of adverse events,including death,
nonfatal MI, and revascularization
,irrespective of the absence of a positive
ST-segment response or good exercise
capacity.

55. Functional capacity
• Functional capacity- is a powerful marker for
prognosis.
• Strong predictor of mortality and nonfatal
cardiovascular outcomes in both men and
women with and without CAD

57. Postexercise recovery
• The length of the cool-down period may vary from
30 seconds to several minutes, depending on the
person.
• A general rule is to allow enough time for the
heart rate to drop to <110 beats/min.
• The exception to observing a cool-down period
may be made for exercise echocardiography, in
which it is important to image the subject when
he or she is as close as possible to MHR

58. Prognosis
• . The Duke nomogram is a simple chart that
factors in ST-segment deviation, amount of
angina during exercise, and exercise capacity
to give an estimate of a 5-year survival and
average annual mortality.
• The Duke treadmill score (DTS) is a numeric
form of the nomogram is an important
predictor of mortality

61. HEART RATE RECOVERY
• The heart rate recovery, defined as the difference in
heart rate at peak exercise and at 1 minute after
cessation of exercise.
• A heart rate recovery of 12 beats/min or less is
considered abnormal during an upright cool-down
period.
• For patients assuming an immediate supine position,
such as during exercise echocardiography, a value of
<18 beats/min is considered abnormal.
• Abnormal HRR is associated with an increase in
all-cause mortality in both asymptomatic individuals
and patients with established heart disease.

62. VENTRICULAR ECTOPY
• Ventricular ectopy in recovery from exercise,
including frequent ventricular ectopics
(>7/min), couplets, bigeminy, trigeminy,
ventricular tachycardia, and ventricular
fibrillation, has been shown to be predictive of
all-cause mortality.
• These findings in recovery are a better
predictor of death than ventricular ectopy
during exercise

63. THE EXERCISE ELECTROCARDIOGRAPHIC
TEST REPORT

64. EXERCISE TEST REPORT
• Exercise protocol used, duration of exercise, peak treadmill
speed and grade, maximum heart rate and percentage of
APMHR achieved, resting and peak blood pressure, and
symptoms
• Negative/positive/equivocal standard ST-segment response
to exercise
• “The ST/HR index of ≤1.6 µV/beats/min is consistent with
the absence of obstructive coronary disease and makes
anatomically, functionally, and prognostically important
coronary disease unlikely”; “The ST/HR index >1.6
µV/beats/min is consistent with the presence of obstructive
coronary disease and predicts increased cardiovascular risk

65. • The estimated functional capacity of (x METs) predicts
(high/low) risk of all-cause mortality The Duke treadmill
score of (x) predicts a cardiac mortality of (x%) per year over
the next 5 y. This implies a (low/intermediate/high) risk
• The chronotropic response index of (0.xx) predicts an
(increased/decreased) risk of death compared with the
Duke treadmill score. For patients not on β-blockers, a value
≤0.80 raises concerns; for patients on β-blockers, a value
≤0.62 is abnormal
• The heart rate recovery of (x beats/min) further predicts an
(increased/decreased) risk of death The presence/absence
of frequent ventricular ectopy during recovery further
increases/decreases predicted risk of deat