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DYNAMIC PROTOCOLS
FOR E.C.G
BY
MINJU
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DEFINITION
: To induce chest pain or discomfort
under controlled conditions in thelaboratories, that can be done by
certain protocols .This is known as
dynamic protocols.
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PURPOSES
Using controlled and carefully supervised
exercise to increase myocardial oxygendemand .
To evaluate the coronary arteries ability to
meet the increased demand successfully. To determine the typical and atypical
chest pain.
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PRINCIPLES
Skeletal muscle function should be proper.
Blood vessels should be patent. Cardiac function should be normal.
Myocardial function should be good.
Coronary perfusion should be clear.
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TYPES OF DYNAMIC PROTOCOLS
. 24 hours monitoring E.C.G. or ambulatory E.C.G.
. Radio Telemetry.. Holter Monitoring.
. Masters Double step technique.
. Bicycle Ergometry.. Stress Test or Tread Mill Test (T.M.T.)
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24 Hours E.C.G. monitoring
We use 3 modified chest leads usually.
Neutral lead placed just below the clavicle. V1 or V2.
Apical.
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PROCEDURE
> Place the electrodes over the chest and
connect the patient to a transmitter.> Ask the patient to perform an activity.
> It will show variations in E.C.G. if there is any
demand-supply mismatch.
> It can perform in I.C.U. only.
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RADIO TELEMETRY
#. A Transmitter is connected to the patient
with modified chest leads.
#. Ask the patient to go for a brisk walk of a radiusof 2 kms.
#. Continuous communication and monitoring of the
patient that will enable to monitor the E.C.G. forany abnormalities.
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HOLTER MONITORING
A Holter monitor is connected to the patient .
Ask the patient to go home and allow him to
do his daily activities.
Patient should maintain a dairy of daily activities
related with time.
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Patient should come back to the hospital after 24
hours.
By correlating the patients activity and abnormal
complexes, helps in identifying coronary
insufficiency.
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MASTERS DOUBLE STEP
Ask the client to climb-up and down in a
two step and do it vigorously,so exertion
is done.
It will be monitored and able to evaluate the
demand-mismatch supply.
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Disadvantage
It is very uncommonly performed because client
can take his own time.
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BICYCLE ERGOMETRY
Ask the client to ride a stationary bicycle
and go on.When examiner increase the resistance for
peddling, as a result of that, the demand
of oxygen and heart work load also be increased.
If heart is able to meet the demand, the heart
function will be normal.
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STRESS TEST OR TREAD MILL TESTDEFINITION:
Disease of the heart frequently are best evaluatedduring an altered state of physiologic stress of
the cardiovascular system.
The most common method of creating that altered
cardiovascular state is an exercise stress test or
tread mill test.
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OBJECTIVES
For the evaluation of chest pain.
To assess the signs and symptoms of
coronary artery disease.
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To evaluate the physiologic response of post-MI.
To evaluate the post revascularisation patients to
exercise.
To evaluate functional capacity for the purpose ofexercise prescription .
INDICATIONS
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To evaluate exercise capacity for the purpose
of work classification (disability evaluation)
and risk stratification (prognosis).
To evaluate the efficacy of medical,surgical,or
pharmacological treatment. To evaluate the presence and severity
of arrhythmias.
The know the preoperative physiological status. To evaluate intermittent claudication.
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CONTRAINDICATIONS
There are 2 types.
1.Absolute contraindication.
2.Relative contraindication.
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A recent change in the resting electrocardiogram
suggesting infarction or other acute cardiac event.
Recent complicated myocardial infarction.
Unstable angina.
Uncontrolled ventricular arrhythmia.
ABSOLUTE
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Uncontrolled atrial arrhythmia that compromises
cardiac function.
Third-degree atrioventricular heart block.
Severe aortic stenosis.
Suspected or unknown Dissecting aneurysm.
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Acute or suspected myocarditis or pericarditis.
Thrombophlebitis or intracardiac thrombi.
Recent systemic or pulmonary embolus.
Acute infection.
Significant emotional distress(psychosis).
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RELATIVE
Resting diastolic B.P.> 115 mm of Hg or
Resting systolic B.P.> 200 mm of Hg.
Moderate valvular heart disease.
Known electrolyte abnormalities (Hypokalemia).
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Fixed rate pacemaker.
Frequent or complex ectopy.
Ventricular Aneursym.
Uncontrolled metabolic disease.
Neuromuscular, musculoskeletal or rheumatoid
disorders that exacerbated by exercise.
Advanced or complicated pregnancy.
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PRE-TEST PREPARATIONS
Take a complete medical history and physical
examination.
Provide a detailed verbal and written
instructions to withhold ingestion of food,alcohol
and caffeine or using tobacco within 3 hoursof testing.
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Patient should be well rested and avoid vigorous
activity the day of the rest.
Wear non-constrictive and comfortable clothing.
Wear rubber-soled, supportive shoes during
testing. Inform the client of the purposes and risks
of exercise testing and obtain a signed consent.
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Record the patients B.P. and pulse.
Record standard 12 lead resting E.C.G.
Obtain a drug history of the patient.
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COMMON DRUGS AND IMPACT ON STRESS TEST
Drug Heart Rate B.P. E.C.G.
Betablockers
Ca channel
blockers
Digoxin
Rest :
Exercise:
Rest :
Exercise:
No change
Rest :Exercise:
Rest :
Exercise:
Rest :
Exercise:
signs ofischemia
signs of
ischemia
signs of
ischemia
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PROCEDURE
There are 3 phases.
1. Preparatory phase.
2. Performance phase.
3. Post exercise recovery period.
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1.PREPARATORY PHASE
Proper skin preparation.
Careful placing of electrodes in proper locationwith tape or a belt.
Examiner must take a baseline resting E.C.G.
before the test.
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Drape lead wires,cables and B.P. cuff to allowmaximum freedom of movement.
Record the patients pulse, B.P. before the test.
Emergency drugs and resuscitation equipments
should be kept ready.
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Target heart rate should be evaluated before test.
TARGET HEART RATE = 220 - AGE OF PATIENT.
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2. PERFORMANCE PHASE
Tread Mill is a motorized device that has an
adjustable conveyer belt.
It has a maximum speed of 1 to 10 miles/hr. The conveyer belt can be adjusted from a
horizontal position to 22% gradient.
It allows the client to walk or run on slopes at alldifferent stages.
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TREAD MILL TEST
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Total duration of T.M.T is 18 mins which
includes 6 stages of 3 mins.
Normal speed of T.M.T is 4 km/hr.
Maximum speed of T.M.T is 7 km/hr.
T.M.T starts with a speed of 2 km/hr.
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PROTOCOLS
: It means that a written plan specifying the
procedures to be followed in giving a particular test.
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There are 3 protocols.
1. Elstends protocol.
2. Balke & Naughton protocol.
3. Modified Bruse protocol.
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ELSTENDS PROTOCOL
Gradient remains constant
&
speed increase in every 3 mins.
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BALKE & NAUGHTON PROTOCOL
Speed remains constant
&
gradient increase in every 3 mins.
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MODIFIED BRUCE PROTOCOL
Both angle of inclination and speed
increase in every 3mins.
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Record the clients B.P, heart rate, rhythm stripand activity level at specified intervals.
Monitor the client for chest pain, arrhythmias, STsegment changes and changes in B.P.
Make frequent observation throughout testingfor any cardiac symptoms include extreme
dyspnea, claudication and vertigo.
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REASON FOR TERMINATION OF TEST
Chest pain.
Severe fatigue.
Greatly increased heart rate a(age related).
20-29 yrs. = 170 Bpm.
30-39 yrs. = 160 Bpm.
40-49 yrs. = 150 Bpm.
50-59 yrs. = 140 Bpm.
60-69 yrs. = 130 Bpm.
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Untoward signs and symptoms of myocardial
ischemia or heart failure.
Failure of systolic B.P. to rise or a drop in B.P.(below resting levels).
Sudden development of bradycardia.
Severe hypertension.
Severe dyspnea.
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ST segment depression (>2-4cm).
A sudden loss of co-ordination(cerebral ischemia).
Serious cardiac dysrhythmia.
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POST- EXERCISE RECOVERY PERIOD
After the procedure, assist the client to a chair or
bed for recovery.
Periodically monitor the clients B.P, heart rate
and rhythm strip for at least 15 mins. After
test completion or until the E.C.G. returnsto base line.
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Ask the patient to inform if he experience any
cardiovascular symptoms ( chest pain, shortness ofbreath or dizziness).
Restrict the patient from taking a hot shower for1 to 2 hrs. following the test.
Patient should be told that they may experience
fatigue and muscle soreness and to avoid heavy
exertion that day.
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DOBUTAMINE STRESS TEST
DEFINITION
:This is also known as chemical stress test which
includes Chemically exercising the heart with
controlled Infusion of dobutamine.
:This is indicated for the patients who is not able to
Perform physical stress test.
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