Dr. Shashank Tiwari.

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