Treadmill testing (TMT) is a widely used test to evaluate cardiovascular disease. It was initially developed to detect coronary artery disease but is now also used to assess other conditions and predict prognosis. TMT measures total body oxygen uptake during exercise to estimate energy requirements. It provides a common form of physical stress and patients are more likely to reach high exertion levels than with stationary cycling. While exercise testing carries some risk, complications are low at less than 1% for events like heart attack and 0.5% for death. Supervision depends on a patient's risk level but a physician should be available. TMT can help diagnose conditions, stratify post-heart attack risk, and guide management of chest pain.

1. Value of TMT

2. Exercise testing
• It is better known as Exercise electrocardiographic testing.
• It most fundamental and widely used tests for the evaluation of
patients with cardiovascular disease (CVD).

3. • Initially developed to detect the presence of myocardial ischemia
secondary to coronary artery disease (CAD)
• Now recognized for its power in predicting prognosis.

4. Other uses
• Valvular heart disease
• Congenital heart disease
• Genetic cardiovascular conditions.
• Arrhythmias.
• Peripheral arterial disease (PAD).

5. Physiology of exercise testing
TOTAL BODY OXYGEN UPTAKE:
• Energy requirements at rest and for any given amount of physical
activity (work rate) can be estimated from measurements of total-
body oxygen uptake (V O2).
• VO2 is equal to the product of cardiac output and oxygen extraction
at the periphery.
• VO2 is easily expressed in multiples of resting oxygen requirements
(metabolic equivalents [METs].

6. • 1 MET being resting energy expenditure and defined as approximately
3.5 mL oxygen/kg body weight/min.
• Therefore, 5-MET activity requires five times the energy expenditure
at rest.
• VO2max is the peak oxygen uptake achieved during performance of
the highest level of dynamic exercise involving large muscle groups.

8. Patients assessment:

9. Contraindications:

10. Exercise Test Modality and Protocols
• Patient’s estimated functional capacity based on age, estimated
physical fitness from the patient’s history, and underlying disease.
• Treadmill and stationary cycle ergometers.
• use stepped or continuous ramp protocols

11. • Work rate increments (stages) during stepped protocols can vary from
1 to 2.5 METs.
• Ramp protocols are designed with stages that are no longer than 1
minute and for the patient to attain peak effort within 8 to 12
minutes.
• Ramp protocols must be individualized and selected to accommodate
the patient’s estimated exercise capacity.

12. • Submaximal tests are used in patients early after myocardial
infarction before discharge from the hospital because they can
provide prognostic information to guide management.
• They are useful in the evaluation of a patient’s ability to engage in
daily activities after discharge and in addition serve as a baseline for
cardiac rehabilitative exercise therapy

13. TMT
• Treadmill testing provides a more common form of physiologic stress
(i.e., walking) in which
• In this subjects are more likely to attain a higher oxygen uptake and
peak heart rate than during stationary cycling
• The most frequently used stepped treadmill protocols are the Bruce
protocol.

15. • Patients should be encouraged to walk freely and use the handrails
for balance only when necessary.
• This will prevent overestimation of exercise capacity and an
inaccurate heart rate– and blood pressure–to-workload relationship.
• Exercise capacity (peak METs) can be reasonably estimated for
treadmill exercise

16. Stationary Cycle
• Cycle ergometer is smaller, quieter, and less expensive than a
treadmill.
• Quality electrocardiographic recordings and blood pressure
measurements are easier to obtain.
• Involves cycling at a given pace against an external force and is
generally independent of the patient’s body weight, which is
supported by the seat.

17. Cardiopulmonary Exercise Testing.
• It uses ventilatory gas exchange analysis during exercise to provide a
more reliable and reproducible measure of VO2.
• Peak VO2 is the most accurate measure of exercise capacity and is a
useful reflection of overall cardiopulmonary health.

18. Exercise test supervision
• Patients be screened before exercise testing to assess their risk for an
exercise-related adverse event.
• Personal supervision requires a physician’s presence in the room only
if the screening has labelled high risk for TMT.
• It is supervised by nonphysician staff members but physician should
be available to attend emergency.

19. Risk of exercise testing
• It has an increased risk for an adverse cardiovascular event.
• Recent myocardial infarction, reduced left ventricular systolic
function, exertion-induced myocardial ischemia, and serious
ventricular arrhythmias are at highest risk.
• Safety of exercise testing is well documented and the overall risk for
adverse events is quite low.

20. • Major complications (including myocardial infarction and other events
requiring hospitalization) was less than 1 to as high as 5 per 10,000
tests.
• The rate of death was less than 0.5 per 10,000 tests.

21. Monitoring during the test:

22. Indication for terminating the test

23. Diagnostic utility:
• Pre test probability
• Prognostic utilization
• Acute coronary syndrome
• Post MI risk stratification
• Role in chest pain unit

26. • Thank you