exercise stress ecg. dmo

Exercise stress testingExercise stress testing Dr Shivanand PatilDr Shivanand Patil

General ApplicationsGeneral Applications DiagnosisDiagnosis : Who has coronary artery : Who has coronary artery

diseasedisease

PrognosisPrognosis: Who is high risk? Who needs : Who is high risk? Who needs intervention intervention

Functional assessmentFunctional assessment: Who is : Who is disabled? What activities can be done disabled? What activities can be done safely?safely?

Treatment assessmentTreatment assessment: Is medication : Is medication or intervention effective?or intervention effective?

METABOLIC EQUIVALENTMETABOLIC EQUIVALENT

Unit of sitting , resting O2 uptakeUnit of sitting , resting O2 uptake

1 MET = 3.5 ml O1 MET = 3.5 ml O22 / kg / min / kg / min

Measured VO2 Measured VO2 =NO.Of METS =NO.Of METS 3.5ml O2/Kg/min3.5ml O2/Kg/min

Asses disabilityAsses disabilityStandardize different protocolsStandardize different protocols

ELECTROCARDIOGRAPHIC ELECTROCARDIOGRAPHIC MEASUREMENTSMEASUREMENTS

Mason –Likar Mason –Likar modificationmodification

Extremity electrodes moved to the Extremity electrodes moved to the torso to reduce motion artifacttorso to reduce motion artifact

• Arm electrodesArm electrodes- lateral aspects of - lateral aspects of infraclavicular fossaeinfraclavicular fossae

• Leg electrodesLeg electrodes-above the anterior -above the anterior iliac crest and below the rib cageiliac crest and below the rib cage


It results inIt results in• Right axis shiftRight axis shift• Increased voltage in inferior leadsIncreased voltage in inferior leads• May produce loss of inferior Q waves and May produce loss of inferior Q waves and

development of new Q waves in lead aVLdevelopment of new Q waves in lead aVL Thus, the body torso limb lead Thus, the body torso limb lead

positions positions cannot be used to interpretcannot be used to interpret a diagnostic rest 12-lead ECGa diagnostic rest 12-lead ECG

Baseline Abnormalities - Obscure Baseline Abnormalities - Obscure ECG changes during exerciseECG changes during exercise

Left bundle branch blockLeft bundle branch block LVH with repolarization abnormalityLVH with repolarization abnormality Digitalis TherapyDigitalis Therapy Ventricular paced rhythmVentricular paced rhythm WPW syndromeWPW syndrome ST abnormality associated with SVT (or) AFST abnormality associated with SVT (or) AF ST abnormalities with MVPS and severe ST abnormalities with MVPS and severe

anemiaanemia

Types of ST Segment Types of ST Segment DisplacementDisplacement

In normal personsIn normal persons• The PR, QRS, and QT intervals shorten as The PR, QRS, and QT intervals shorten as

heart rate increasesheart rate increases• P amplitude increasesP amplitude increases• PR segment becomes progressively more PR segment becomes progressively more

downsloping in the inferior leadsdownsloping in the inferior leads• J point or junctional depression will occurJ point or junctional depression will occur

NormalNormal


In patients with myocardial ischemiaIn patients with myocardial ischemia• ST segment usually becomes more ST segment usually becomes more

horizontal (flattens) as the severity of the horizontal (flattens) as the severity of the ischemic response worsens. ischemic response worsens.

• With progressive exercise, the depth of With progressive exercise, the depth of ST segment depression may increase, ST segment depression may increase, involving more ECG leads, and the involving more ECG leads, and the patient may develop anginapatient may develop angina

AbnormalAbnormal

False-positiveFalse-positive


In the immediate postrecovery phaseIn the immediate postrecovery phase• ST segment displacement may persist, with ST segment displacement may persist, with

downsloping ST segments and T wave inversion, downsloping ST segments and T wave inversion, gradually returning to baseline after gradually returning to baseline after 5 to 10 5 to 10 minutesminutes

Ischemic response ---only in the recovery Ischemic response ---only in the recovery phasephase

Occur in Occur in 10 percent10 percent of patients of patients Prevalence is higher in asymptomatic populations Prevalence is higher in asymptomatic populations

compared with those with symptomatic CADcompared with those with symptomatic CAD

Different ECG Different ECG patternspatterns

MEASUREMENT OF ST MEASUREMENT OF ST SEGMENT DISPLACEMENTSEGMENT DISPLACEMENT True isoelectric pointTrue isoelectric point ----TP segment----TP segment• For purposes of interpretation--- For purposes of interpretation--- PQ junctionPQ junction is is

usually chosen as the isoelectric pointusually chosen as the isoelectric point Abnormal responseAbnormal response • The development of The development of 1 mm or greater1 mm or greater of J point of J point

depression depression • with a relatively flat ST segment slope with a relatively flat ST segment slope (<1 (<1

mV/secmV/sec))• depressed greater than or equal to depressed greater than or equal to 0.10 mV 80 0.10 mV 80

msecmsec after the J point (ST 80) in after the J point (ST 80) in three three consecutive beatsconsecutive beats with a stable baseline with a stable baseline

Ischemic exercise-Ischemic exercise-induced ECGinduced ECG

MEASUREMENT OF ST MEASUREMENT OF ST SEGMENT DISPLACEMENTSEGMENT DISPLACEMENT

When the ST 80 measurement is difficult to When the ST 80 measurement is difficult to determine at rapid heart rates (e.g., >130 determine at rapid heart rates (e.g., >130 beats/min), beats/min), the ST 60the ST 60 measurement should be measurement should be used. used.

The ST segment at rest may occasionally be The ST segment at rest may occasionally be depressed. When this occurs, the J point and ST depressed. When this occurs, the J point and ST 60 or ST 80 measurements should be depressed 60 or ST 80 measurements should be depressed an additional 0.10 mV or greater to be consideredan additional 0.10 mV or greater to be considered

When the degree of resting ST segment When the degree of resting ST segment depression is 0.1 mV or greater, the exercise ECG depression is 0.1 mV or greater, the exercise ECG becomes less specific, and myocardial imaging becomes less specific, and myocardial imaging modalities should be consideredmodalities should be considered

MEASUREMENT OF ST MEASUREMENT OF ST SEGMENT DISPLACEMENTSEGMENT DISPLACEMENT

In early repolarizationIn early repolarization • Normal response---Resting ST segment Normal response---Resting ST segment

elevation returns to the PQ junction elevation returns to the PQ junction • Magnitude of exercise-induced ST Magnitude of exercise-induced ST

segment depression should be segment depression should be determined from determined from the PQ junctionthe PQ junction and and not from the elevated position of the J not from the elevated position of the J pointpoint before exercise before exercise

MEASUREMENT OF ST MEASUREMENT OF ST SEGMENT SEGMENT

DISPLACEMENTDISPLACEMENT Localization of site of myocardial Localization of site of myocardial

ischemiaischemia• ST segment depression ST segment depression do not localizedo not localize

the site of myocardial ischemia and the site of myocardial ischemia and which coronary artery is involvedwhich coronary artery is involved

• ST segment elevation is ST segment elevation is relatively relatively specificspecific for the territory of myocardial for the territory of myocardial ischemia and the coronary artery ischemia and the coronary artery involved. involved.

UPSLOPING ST UPSLOPING ST SEGMENTSSEGMENTS

Normal responseNormal response• J point depressionJ point depression• Rapid upslopingRapid upsloping ST segment (>1 mV/sec) ST segment (>1 mV/sec) • depressed depressed less than 1.5 mmless than 1.5 mm after the J-point after the J-point

Abnormal responseAbnormal response

Depression of ST segment > Depression of ST segment > 1.5 mm at ST801.5 mm at ST80 Patients with a high CAD prevalence--- Patients with a high CAD prevalence---

abnormal.abnormal. Asymptomatic or with a low CAD prevalence--- Asymptomatic or with a low CAD prevalence---

less certain. less certain.

ST SEGMENT ST SEGMENT ELEVATIONELEVATION

ST segment elevation may occur inST segment elevation may occur in• an infarct territory where Q waves are an infarct territory where Q waves are

presentpresent• in a noninfarct territory. in a noninfarct territory. Abnormal responseAbnormal response

1 mm1 mm elevation at ST60 for 3 consecutive elevation at ST60 for 3 consecutive beats with a stable baseline. beats with a stable baseline.


ST segment elevation in leads with ST segment elevation in leads with abnormal Q wavesabnormal Q waves

• Occur in Occur in 30%30% of anterior MI & of anterior MI & 15%15% of of inferior MIinferior MI

• Have a lower ejection fractionHave a lower ejection fraction• greater severity of resting wall motion greater severity of resting wall motion

abnormalitiesabnormalities• worse prognosis. worse prognosis. • notnot a marker a marker of more extensive CAD of more extensive CAD • rarely indicatesrarely indicates myocardial ischemia. myocardial ischemia.


ST segment elevation in leads ST segment elevation in leads without Q waveswithout Q waves

Indicates transmural myocardial Indicates transmural myocardial ischemia caused by coronary vasospasm ischemia caused by coronary vasospasm or a high-grade coronary narrowingor a high-grade coronary narrowing

Occurring in a Occurring in a 1 percent1 percent of patients with of patients with obstructive CAD. obstructive CAD.

Site of ST segment elevation is Site of ST segment elevation is relatively relatively specific for the coronary artery involvedspecific for the coronary artery involved

T WAVE CHANGEST WAVE CHANGES

Pseudonormalization of T waves Pseudonormalization of T waves • T-waves inverted at rest and T-waves inverted at rest and

becoming upright with exercisebecoming upright with exercise• Nondiagnostic finding --- in low Nondiagnostic finding --- in low

CAD prevalence populations CAD prevalence populations • In rare instance--- marker for In rare instance--- marker for

myocardial ischemiamyocardial ischemia

Pseudonormalization of T Pseudonormalization of T waveswaves

OTHER ECG MARKERSOTHER ECG MARKERS

Changes in R wave amplitude Changes in R wave amplitude Relatively nonspecific and are related to Relatively nonspecific and are related to

the level of exercise performedthe level of exercise performed In LVH the ST segment response In LVH the ST segment response cannotcannot

be used reliably to diagnose CADbe used reliably to diagnose CAD U wave inversionU wave inversion may occasionally be seen in the may occasionally be seen in the

precordial leads at heart rates of 120 precordial leads at heart rates of 120 beats/minbeats/min

Relatively specific and relatively Relatively specific and relatively insensitive for CADinsensitive for CAD

NONELECTROCARDIOGRAPNONELECTROCARDIOGRAPHIC OBSERVATIONSHIC OBSERVATIONS

Blood PressureBlood Pressure Normal Exercise responseNormal Exercise response • SBP - Increase to 160 to 200 mm HGSBP - Increase to 160 to 200 mm HG• DBP - Does not change significantlyDBP - Does not change significantly In LV dysfunction (or) an excessive In LV dysfunction (or) an excessive

reduction in systemic vascular reduction in systemic vascular resistanceresistance

• Failure to increase SBP> 120 mm HGFailure to increase SBP> 120 mm HG• (or) Sustained decrease > 10 mm HG(or) Sustained decrease > 10 mm HG• (or) Fall in SBP below standing rest values(or) Fall in SBP below standing rest values

Exertional Exertional HypotensionHypotension

Ranges from Ranges from 3 to 9 %3 to 9 % Higher in patients with TVD (or) Left Higher in patients with TVD (or) Left

main CADmain CAD CardiomyopathyCardiomyopathy Cardiac arrhythmiasCardiac arrhythmias Vasovagal reactionsVasovagal reactions LVOT ObstructionLVOT Obstruction On Antihypertensive drugsOn Antihypertensive drugs HypovolemiaHypovolemia Prolonged Vigorous ExerciseProlonged Vigorous Exercise

Work CapacityWork Capacity

Limited work capacityLimited work capacity Associated with increased risk of cardiac Associated with increased risk of cardiac

events in known(or) suspected CADevents in known(or) suspected CAD In estimating functional capacity, the In estimating functional capacity, the

amount of work performed (or exercise amount of work performed (or exercise stage achieved ) should be the stage achieved ) should be the parameter measured and not the parameter measured and not the number of minutes of exercisenumber of minutes of exercise

Sub-Maximal Sub-Maximal ExerciseExercise

APMHR APMHR (Age Predicted Maximum (Age Predicted Maximum Heart Rate) = Heart Rate) = 220 - Age220 - Age

Patient should achieve atleast 85 - 90 % Patient should achieve atleast 85 - 90 % of APMHR to test the cardiac reserveof APMHR to test the cardiac reserve

Non - Diagnostic TestNon - Diagnostic Test• PVDPVD• Orthopedic LimitationOrthopedic Limitation• Neurological ImpairmentNeurological Impairment• Poor MotivationPoor Motivation

Heart Rate Heart Rate ResponseResponse

Inappropriate increase in heart Inappropriate increase in heart rate at low exercise workloadsrate at low exercise workloads• Atrial fibrillationAtrial fibrillation• Physically DeconditionedPhysically Deconditioned• hypovolemichypovolemic• AnaemicAnaemic• Marginal LV functionMarginal LV function

Heart Rate Heart Rate ResponseResponse

Chronotropic incompetenceChronotropic incompetence• Heart rate increment per stage of Heart rate increment per stage of

exercise that is less than normal (or) a exercise that is less than normal (or) a peak rate below predicted at maximal peak rate below predicted at maximal work loadswork loads

Occurs inOccurs in• sinus node diseasesinus node disease• Beta BlockerBeta Blocker• Compensated CCFCompensated CCF• Myocardial ischemic responseMyocardial ischemic response

Rate-Pressure Rate-Pressure ProductProduct

Heart rate x Systolic BP ProductHeart rate x Systolic BP Product Indirect measure of myocardial oxygen Indirect measure of myocardial oxygen

demanddemand increases progressively with exerciseincreases progressively with exercise used to characterize cardiovascular used to characterize cardiovascular

performanceperformance Normal Normal - - 20 to 35 mm HG x beats/m x 20 to 35 mm HG x beats/m x

1010-3-3

In CADIn CAD - < - < 25 mm HG x beats/m x 10 25 mm HG x beats/m x 10-3-3

Chest discomfortChest discomfort It occurs usually after the onset of It occurs usually after the onset of

ischemic ST segment depressionischemic ST segment depression In some patients , it may be the only In some patients , it may be the only

signal of obstructive CADsignal of obstructive CAD In CSA , Chest discomfort occurs In CSA , Chest discomfort occurs

less frequently than ischemic ST less frequently than ischemic ST segment depressionsegment depression

Diagnostic use of Diagnostic use of Exercise testingExercise testing

Sensitivity and Sensitivity and SpecificitySpecificity

Both varies with the population being Both varies with the population being testedtested

Exercise ECG is best used inExercise ECG is best used in• The evaluation of a patient at The evaluation of a patient at

intermediate risk with an atypical history intermediate risk with an atypical history (pre-test probability-30-70%)(pre-test probability-30-70%)

• Patient at Patient at low risk with a typical historylow risk with a typical history

Sensitivity and Sensitivity and SpecificitySpecificity

66%66%

53%53%81%81%

86%86%

Multivessel CADMultivessel CAD

Left main or Left main or TVDTVD

------25-71%25-71%LAD>RCA>LCxLAD>RCA>LCx

SVDSVD

77%77%68%68%In CADIn CAD

(General)(General)

SpecificitySpecificitySensitivitySensitivityPatientsPatients

LimitationsLimitations Bayes theoremBayes theorem• The probability of a positive test result is The probability of a positive test result is

affected by the likelihood affected by the likelihood (conditional (conditional probability)probability) of positive test result among of positive test result among the population that has undergone the test the population that has undergone the test (pretest probability)(pretest probability)

• The higher the probability that a disease The higher the probability that a disease is present in a given individual before a is present in a given individual before a test is ordered, the higher is the test is ordered, the higher is the probability that a test result is true-probability that a test result is true-positive positive

Noncoronary causes of Noncoronary causes of ST segment depressionST segment depression

Severe aortic stenosisSevere aortic stenosis Severe hypertension Severe hypertension CardiomyopathyCardiomyopathy AnemiaAnemia HypokalemiaHypokalemia Severe hypoxia Severe hypoxia Digitalis useDigitalis use Sudden excessive exerciseSudden excessive exercise

Noncoronary causes of Noncoronary causes of ST segment depressionST segment depression

Glucose loadGlucose load Left ventricular hypertrophyLeft ventricular hypertrophy HyperventilationHyperventilation Mitral valve prolapseMitral valve prolapse Interventricular conduction Interventricular conduction

disturbancedisturbance Preexitation syndromePreexitation syndrome Severe volume overload (aortic,mitral Severe volume overload (aortic,mitral

regurgitation)regurgitation) Supraventricular tacyarrhythmiasSupraventricular tacyarrhythmias

Adverse prognosis and Adverse prognosis and multivessel CADmultivessel CAD

Duration of symptom-limiting Duration of symptom-limiting < 6 METS< 6 METS Failure to increase Failure to increase SBP >120 mm hgSBP >120 mm hg, or a , or a

sustained decrease sustained decrease >10 mm hg>10 mm hg, or below , or below rest levels, during progressive exerciserest levels, during progressive exercise

ST segment depression ST segment depression > 2mm> 2mm,, downsloping ST segment, starting at downsloping ST segment, starting at < 6 < 6 METSMETS, involving , involving > 5 leads,> 5 leads, persisting persisting > 5 > 5 minmin into recovery into recovery

Adverse prognosis and Adverse prognosis and multivessel CADmultivessel CAD

Exercise–induced ST segment Exercise–induced ST segment elevation (avr excluded)elevation (avr excluded)

Angina pectoris at low exercise Angina pectoris at low exercise workloadsworkloads

Reproducible sustained (>30 sec) or Reproducible sustained (>30 sec) or symptomatic ventricular tacycardiasymptomatic ventricular tacycardia

Exercise testing in Exercise testing in determining determining

prognosisprognosis

Symptomatic Symptomatic PatientsPatients

TMT should be performed, before TMT should be performed, before coronary Angiography -in patients coronary Angiography -in patients with chronic CADwith chronic CAD

Excellent exercise tolerance ( > 10 Excellent exercise tolerance ( > 10 Mets) usually have an excellent Mets) usually have an excellent prognosis regardless of the prognosis regardless of the anatomical extent of CADanatomical extent of CAD

After Myocardial After Myocardial infarctioninfarction

TMT is useful to determine TMT is useful to determine • Risk stratification and assessment of Risk stratification and assessment of

prognosisprognosis• functional capacity activity prescription functional capacity activity prescription

after hospital dischargeafter hospital discharge• Assessment of adequacy of medical therapyAssessment of adequacy of medical therapy

Cardiac Arrhythmias Cardiac Arrhythmias and conduction and conduction

disturbancesdisturbances

Ventricular Premature Ventricular Premature ContractionContraction

Occurs frequently during exercise Occurs frequently during exercise testing and increase with agetesting and increase with age

not a useful marker of CAD in the not a useful marker of CAD in the absence of ischemic ST segment absence of ischemic ST segment depressiondepression

• In LBBB - Exercised induced ST segment In LBBB - Exercised induced ST segment depression is found in most patients - cannot depression is found in most patients - cannot be used as diagnostic of prognostic indicatorbe used as diagnostic of prognostic indicator

• In RBBB - Exercise induced ST depression in In RBBB - Exercise induced ST depression in leads V1 - V4 is common finding and is non leads V1 - V4 is common finding and is non diagnostic of CADdiagnostic of CAD

Supraventricular Supraventricular ArrhythmiasArrhythmias

Presence of SVT is Presence of SVT is not diagnostic for not diagnostic for CADCAD

Pre-Excitation SyndromePre-Excitation Syndrome Disappearance of delta waves occurs Disappearance of delta waves occurs

while exercise in while exercise in 20 - 50 %20 - 50 % of cases of cases Abrupt disappearanceAbrupt disappearance – Good prognosis – Good prognosis

Presence of WPW syndrome, invalidates Presence of WPW syndrome, invalidates the use of ST segment analysis as a the use of ST segment analysis as a diagnostic method for detecting CADdiagnostic method for detecting CAD

Special Clinical Special Clinical ApplicationsApplications

DigitalisDigitalis - Produce exertional ST - Produce exertional ST depressiondepression

HypokalemiaHypokalemia - associated with ST - associated with ST depression depression

Antischemic therapyAntischemic therapy• prolongs the time of onset of ST depressionprolongs the time of onset of ST depression• Increase exercise toleranceIncrease exercise tolerance• normalize exercise ECG response.(10 to 15 %)normalize exercise ECG response.(10 to 15 %)

Heparin therapyHeparin therapy• increase total exercise durationincrease total exercise duration


In women In women • Sensitivity and specificity are less in women Sensitivity and specificity are less in women

than menthan men

• False positive tests - due to greater release False positive tests - due to greater release of catacholamines during exercise produce of catacholamines during exercise produce vasoconstrictionvasoconstriction

• more common during menses (or) preovulationmore common during menses (or) preovulation


HypertensionHypertension• In normotensive asymptomatic individuals- In normotensive asymptomatic individuals-

increased long term risk is found in increased long term risk is found in • increased SBP > 214 mm HGincreased SBP > 214 mm HG• increased SBP (or) DBP at 3rd minute of increased SBP (or) DBP at 3rd minute of

recoveryrecovery

• Severe systemic hypertension cause Severe systemic hypertension cause exercise induced ST depression in the exercise induced ST depression in the absence of atherosclerosisabsence of atherosclerosis

• Exercise tolerance is decreased in patients Exercise tolerance is decreased in patients with poor blood pressure controlwith poor blood pressure control


In elderly patientsIn elderly patients cardiac arrhythmias , chronotropic cardiac arrhythmias , chronotropic

incompetence and hypertension responses incompetence and hypertension responses are more commonare more common

Diabetes MellitusDiabetes Mellitus• in patients with autonomic dysfunction in patients with autonomic dysfunction

and sensory neuropathy , anginal and sensory neuropathy , anginal threshold may be increased threshold may be increased


After CABGAfter CABG• indicate graft occlusion , stenosis or indicate graft occlusion , stenosis or

progression of CADprogression of CAD After PTCAAfter PTCA

• In asymptomatic patients , 6 months post In asymptomatic patients , 6 months post procedural test allows to diagnose procedural test allows to diagnose restenosis restenosis

Indications for Indications for terminating exercise terminating exercise

testingtesting

CONTRAINDICATIONSCONTRAINDICATIONS

1.1. ABSOLUTEABSOLUTE

2.2. RELATIVERELATIVE

CONTRAINDICATIONS TO EXERCISE CONTRAINDICATIONS TO EXERCISE TESTING (ACC/AHA)TESTING (ACC/AHA)

ABSOLUTE ABSOLUTE

1.1. Acute MI (within 2 d) Acute MI (within 2 d)

2.2. USAP high riskUSAP high risk

3.3. Uncontrolled cardiac arrhythmias causing Uncontrolled cardiac arrhythmias causing symptoms or hemodynamic compromise symptoms or hemodynamic compromise

4.4. Symptomatic severe AS Symptomatic severe AS

CONTRAINDICATIONS TO EXERCISE CONTRAINDICATIONS TO EXERCISE TESTING (ACC/AHA )…TESTING (ACC/AHA )…

ABSOLUTE …ABSOLUTE …

5.5. Uncontrolled symptomatic HF Uncontrolled symptomatic HF

6.6. Acute pulmonary embolus or pulmonary Acute pulmonary embolus or pulmonary infarction infarction

7.7. Acute myocarditis or pericarditis Acute myocarditis or pericarditis

8.8. Acute aortic dissection Acute aortic dissection

CONTRAINDICATIONS TO EXERCISE CONTRAINDICATIONS TO EXERCISE TESTING (ACC/AHA )TESTING (ACC/AHA )

RELATIVERELATIVE

1.1. Left main coronary stenosis Left main coronary stenosis

2.2. Moderate stenotic valvular heart diseaseModerate stenotic valvular heart disease

3.3. Electrolyte abnormalities Electrolyte abnormalities

4.4. Severe arterial hypertension Severe arterial hypertension 200/110 200/110

CONTRAINDICATIONS TO EXERCISE CONTRAINDICATIONS TO EXERCISE TESTING (ACC/AHA )…TESTING (ACC/AHA )…

RELATIVE …RELATIVE …

5.5. Tachyarrhythmias or bradyarrhythmias Tachyarrhythmias or bradyarrhythmias

6.6. Hypertrophic cardiomyopathy and other Hypertrophic cardiomyopathy and other forms of outflow tract obstruction forms of outflow tract obstruction

7.7. Mental or physical impairment leading to Mental or physical impairment leading to an inability to exercise adequately an inability to exercise adequately

8.8. High-degree AV block High-degree AV block

TMT ReportTMT Report Exercise protocol usedExercise protocol used Duration of exerciseDuration of exercise Peak treadmill speed and gradePeak treadmill speed and grade Peak workload in MET or VO2 maxPeak workload in MET or VO2 max Functional Capacity Functional Capacity Maximum heart rate percentage of Maximum heart rate percentage of

APMHRAPMHR Resting and Peak Blood PressureResting and Peak Blood Pressure SymptomsSymptoms ArrhythmiasArrhythmias ECG ChangesECG Changes

Thank YouThank You

Work Capacity in METS-WomenWork Capacity in METS-WomenAge Low Fair Average Good High

20-29 <7.5 8 - 10.3 10.3-12.5 12.5-16 >16

30-39 <7 7-9 9-11 11-15 >15

40-49 <6 6-8 8-10 10-14 >14

50-59 <5 5-7 7-9 9-13 >13

60-69 <4.5 4.5-6 6-8 8-11.5 >11.5

Work Capacity in METS-MenWork Capacity in METS-MenAge Low Fair Average Good High

20-29 <8 8 – 11 11-14 14-17 >17

30-39 <7.5 7.5-10 10-12.5 12.5-16 >16

40-49 <7 7-8.5 8.5-11.5 11.5-15 >15

50-59 <6 6-8 8-11 11-14 >14

60-69 <5.5 5.5-7 7-9.5 9.5-13 >13

Terms-Evalution of test resultsTerms-Evalution of test resultsTrue positive(TP)True positive(TP) = abnormal test results = abnormal test results

in individual with diseasein individual with diseaseFalse positive(FP)False positive(FP) = abnormal test results = abnormal test results

in individual without diseasein individual without diseaseTrue negative(TN)True negative(TN) = normal test result in = normal test result in

individual without diseaseindividual without diseaseLikelihood ratio:Likelihood ratio: odds of a test result odds of a test result

being truebeing true• of an abnormal test:of an abnormal test: sensitivity/(1-specifity) sensitivity/(1-specifity)• Of a normal test:Of a normal test: specificity/(1-Sensitivity) specificity/(1-Sensitivity)

Terms-Evalution of test resultsTerms-Evalution of test resultsSensitivity:Sensitivity: % of patients with CAD who % of patients with CAD who

have an abnormal result= TP/(TP+FN)have an abnormal result= TP/(TP+FN)Specificity:Specificity: % of patients without CAD who % of patients without CAD who

have a normal results =TN/(TN+FP)have a normal results =TN/(TN+FP)Predictive value:Predictive value: % of patients with % of patients with

abnormal result who have CAD= TN/(TN+FN)abnormal result who have CAD= TN/(TN+FN)Test accuracy:Test accuracy: % of true % of true

test=(TP+TN)/total no. of tests performedtest=(TP+TN)/total no. of tests performedRelative risk:Relative risk: Disease rate in persons with Disease rate in persons with

a positive test result/ Negative test resulta positive test result/ Negative test result

Pretest probability of Pretest probability of CADCAD

Age/Age/

SexSexTypical Typical oror

Definite Definite anginaangina

Atypical Atypical oror

Probable Probable anginaangina

NonanginNonanginalal

Chest Chest painpain

AsympAsymptomatitomaticc

30-3930-39

MenMen

WomWomenen

IntermediIntermediateate



Very lowVery low

Low Low

Very lowVery lowVery Very lowlow

Very Very lowlow

40-4940-49

MenMen

WomWomenen

High High



LowLow

IntermediaIntermediatete

Very lowVery low

LowLow

Very Very lowlow

Pretest probability of Pretest probability of CADCAD

Age/Age/

SexSexTypical Typical oror

Definite Definite anginaangina

Atypical Atypical oror

Probable Probable anginaangina

NonangiNonanginalnal

Chest Chest painpain

AsympAsymptomatitomaticc

50-5950-59

MenMen

WomWomenen

HighHigh





LowLow

Low Low

Very Very lowlow

60-6960-69

MenMen

WomWomenen

HighHigh

HighHighIntermediIntermediateate




LowLow

LowLow

Duke treadmill scoreDuke treadmill score

Duke Treadmill ScoreDuke Treadmill ScoreExercise time - ( 5 x ST deviation ) - (4 Exercise time - ( 5 x ST deviation ) - (4

x Treadmill angina index)x Treadmill angina index)used to identify prognostic , intermediate used to identify prognostic , intermediate

- high risk patients in whom coronary - high risk patients in whom coronary angiography would be indicated to define angiography would be indicated to define coronary anatomycoronary anatomy

Low-risk patientsLow-risk patients - scores of - scores of five or higherfive or higher Intermediate riskIntermediate risk -scores between -scores between five five

and –10and –10High riskHigh risk-scores lower than -scores lower than -10-10

PROGNOSTIC SCORESPROGNOSTIC SCORES

DUKE treadmill score - by mark etal in DUKE treadmill score - by mark etal in Exercise time - (5 x max. ST depression) - 4 x 1987, based on 2842 Exercise time - (5 x max. ST depression) - 4 x 1987, based on 2842

patients.patients.

angina index.angina index.

5 YEARS SURVIVAL : 5 YEARS SURVIVAL :

> 5 > 5 - - 97% 97%

- 10 to 4 -- 10 to 4 - 91%91%

< - 10 - 72%< - 10 - 72%

Score contains prognostic information even after clinical and cath Score contains prognostic information even after clinical and cath

data.data.

Prognostic stratifing power greatest in 3 VD and lowest in SVD.Prognostic stratifing power greatest in 3 VD and lowest in SVD.

VETERENS AFFAIRS (VA) SCOREVETERENS AFFAIRS (VA) SCORE H/O CHF / digoxinH/O CHF / digoxin

Change in systolic BP.Change in systolic BP.

METS achieved.METS achieved.

VA score = 5 x (CHF / digoxin) + ST depression + change in VA score = 5 x (CHF / digoxin) + ST depression + change in

SBP - METS.SBP - METS.

< -2 < -2 low risk (annual mortality 1%) low risk (annual mortality 1%)

-2 to 2 moderate risk (annual mortality 7%)-2 to 2 moderate risk (annual mortality 7%)

> 2 high risk (annual mortality 15%)> 2 high risk (annual mortality 15%)

METABOLIC EQUIVALENT…METABOLIC EQUIVALENT…

NYHANYHA METSMETS

II 6-106-10

IIII 4-64-6

IIIIII 2-32-3

IVIV 11

Special applicationsSpecial applications After myocardial infarction/ unstable anginaAfter myocardial infarction/ unstable angina Cardiac rehabilitationCardiac rehabilitation ScreeningScreening Exercise prescriptionExercise prescription Preoperation evaluationPreoperation evaluation DysrhythmiasDysrhythmias Intermittent claudication/Pulmonary diseaseIntermittent claudication/Pulmonary disease

Asymptomatic PopulationAsymptomatic PopulationAbnormal ECGAbnormal ECG

• Prevalance in Men - Prevalance in Men - 5 to 12 %5 to 12 %• Prevalance in Women - Prevalance in Women - 20 to 30 %20 to 30 %• Risk of development of cardiac events - Risk of development of cardiac events -

9 times more than normal 9 times more than normal • Cardiac events over 5 years - Cardiac events over 5 years - 25 %25 %• Most common Cardiac event - AnginaMost common Cardiac event - Angina• Prognostic value of an ST segment shift Prognostic value of an ST segment shift

in women is less than in menin women is less than in men

Ventricular Premature ContractionVentricular Premature Contraction In CAD occurs in In CAD occurs in 20 %20 % of patients of patients In SCD survivors - In SCD survivors - 50 to 75 %50 to 75 % More frequent during recovery phaseMore frequent during recovery phaseSuppressed by B - Blocker therapySuppressed by B - Blocker therapyExercise testing provokes repetitive Exercise testing provokes repetitive

VPC’s in patients with H/O sustained VPC’s in patients with H/O sustained VTVT

exercise stress ecg. dmo

Education

site of st segment elevation

depth of st segment

pr segment

tp segment

af st abnormalities

downsloping st segments

exercise ecg

abnormal q waves