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Exercise Testing Exercise Testing ProtocolProtocol

HazzaaHazzaa M. AlM. Al--HazzaaHazzaa,, PhPh D, FACSMD, FACSMProfessor & DirectorProfessor & Director

Exercise Physiology LaboratoryExercise Physiology LaboratoryKing Saud UniversityKing Saud UniversityTel (office): Tel (office): 46784114678411

Lab: Lab: 46784064678406http://faculty.ksu.edu.sa/hazzaahttp://faculty.ksu.edu.sa/hazzaa

514 RHS 514 RHS -- Fall 2010Fall 2010

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Clinical Exercise TestingClinical Exercise Testing

Routine Treadmill /Bike Routine Treadmill /Bike ((ECG & BP onlyECG & BP only//Gas ExchangeGas Exchange))..

Exercise EchocardiographyExercise Echocardiography

Exercise Nuclear StressExercise Nuclear Stress

DobutamineDobutamine EchocardiographyEchocardiography

DobutamineDobutamine Nuclear StressNuclear Stress

Adenosine Nuclear Stress Adenosine Nuclear Stress

PersantinePersantine Nuclear StressNuclear Stress

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Exercise Testing ProtocolExercise Testing Protocol

Exercise ModeExercise Mode-- Treadmill versus Bicycle.Treadmill versus Bicycle.

Continuous versus discontinuous exercise test Continuous versus discontinuous exercise test protocol.protocol.

Some exercise protocols are designed for Some exercise protocols are designed for clinical exercise testing and others for functional clinical exercise testing and others for functional capacity or capacity or cardiorespiratorycardiorespiratory fitness.fitness.

Maximal versus Maximal versus submaximalsubmaximal exercise.exercise.

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Common Graded Common Graded Exercise Testing Exercise Testing

ProtocolProtocol

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O2

Upt

ake

(ml/k

g.m

in)

Bruce Protocol

0

10

20

30

40

50

60

70

80

3 6 9 12 15 18 21

1122

33

44

55

6677

5577

10101313

16.516.52020

2222

StagesStages

Time (min)

9.68.886.85.542.7Speed(km/h)

22201816141210Grade (%)7654321Stage

METMET

Common Graded Exercise Protocols

StageMinSpeedKm/h

Grade%

MinSpeedKm/h

Grade%

MinSpeedKm/h

Grade%

124.8031.6032.710224.82.532.4024.810324.8533.2026.410424.87.533.23.53810524.81033.27624.812.534.85724.81534.87.5824.817.534.810924.82034.812.51024.822.534.815

Balke Protocol 2Naughton ProtocolEllestad Protocol

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ناتن)Naughton(

بلكي)Bulke(

بروس المعدل)Modified Bruce(

بروس)Bruce(

المرحلة)Stage(

1.83.62.34.613.54.53.57.024.55.04.610.235.45.57.012.146.45.910.214.957.46.412.117.068.36.914.919.37

Heyward V, Advanced Fitness Assessment & Exercise Prescription, 2002

MET Values during Common Exercise Protocols

Bicycle Ergometer Protocol

Approximately 10 -12 minutes of duration

Pedaling frequency of 60 rpm

1-3 minutes resting data

1-3 minutes unloaded pedaling

Interval period of 2-3 minutes (for each stage)

Increase by 5-30 W/minute

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Exercise Testing Protocol

Time (min)

Wor

k L

oad

(wat

t)

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Incremental Incremental versusversus Ramp Ramp

ProtocolProtocol

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Incremental Protocol

0

30

60

90

120

150

180

3 6 9 12 15 18 21Time (min)

Wor

k L

oad

(wat

t)

Incremental increases in load

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Wor

k L

oad

(wat

t)

0

30

60

90

120

150

180

3 6 9 12 15 18 21

Time (min)

Ramp Protocol

Load increases in a constant and continuous manner

Why Ramp Protocol?

With ramp protocol, there is linear increase in heart rate.

Improved prediction of METs

It is an Individualized test using prior test, history or questionnaire.

Test duration is nine-minute for most patients.

Terminating the Exercise Test

All treadmill stress tests should be completed to a symptom-limited endpoint, if possible.

85% of maximal predicted heart rate is required to identify a test as adequate.

Chronotropic Incompetencev Peak heart rate less than 120 BPM.

v Failure to achieve 85% of age-predicted maximum.

Safety of Exercise Stress Testing

The risk of death during or immediately after an exercise test is less than or equal to 0.01%.

The risk of an acute MI during or immediately after an exercise test is less than or equal to 0.04%.

The risk of a complication requiring hospitalization is less than or equal to 0.2%.

ACSM, 2000Gordon & Khol, JCR, 1993

+

Na+ / K+ Na+ / K+ Ions Ions

ImbalanceImbalance

CatecholaminesCatecholamines

In Case of CAD

During ExerciseRight after Exercise

Increased Increased Sympathetic ActSympathetic Act

Reduced Reduced VagusVagus ToneTone

IncresedIncresed HRHRIncreased BPIncreased BP

Increased Myocardial Increased Myocardial OO22 DemandsDemands

Cardiac IschemiaCardiac IschemiaChanges in the Changes in the Conduction of Conduction of

the Heartthe HeartVentricular Ventricular EctopiesEctopies

Changes in Changes in DepoDepo//RepolarizationRepolarization

of Cardiac Cellsof Cardiac Cells

Myocardial Myocardial ExcitationExcitation

Stop of muscle Stop of muscle contractioncontraction

Venous Venous DilationDilation

Reduced Reduced Venous ReturnVenous Return

Reduced BPReduced BP

Reduced COReduced CO

Reduced Heart Reduced Heart PerfusionPerfusion

Anaerobic Anaerobic ThresholdThreshold

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Definition of Anaerobic Threshold Definition of Anaerobic Threshold (AT)(AT)

The exercise VOThe exercise VO22 (& work rate) above which (& work rate) above which anaerobic energy production starts to progressively anaerobic energy production starts to progressively increase, with consequential increase in increase, with consequential increase in lactate/lactate/pyruvatepyruvate ratio, and a net increase in lactate ratio, and a net increase in lactate production at the site of production at the site of anaerobiosisanaerobiosis..

Wasserman et al., Wasserman et al., 19991999

Gas exchange is also affected by increases in Gas exchange is also affected by increases in COCO22 output & minute ventilation as a result of output & minute ventilation as a result of HCOHCO33-- buffering of lactic acid.buffering of lactic acid.

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VOVO22 & HR responses during steady state treadmill & HR responses during steady state treadmill test for a young athlete (test for a young athlete (21 21 yearyear--old) old)

Al-Hazzaa, 1993

0

10

20

30

40

50

60

0 1 2 3 4 5 6 7 8 9 10

10 12 14 16

Time (min)

Speed (km/h)

160

142130117

VO2 max = 69 ml/kg.min (18 Kcalori/min)

b/min189= HR max

HR

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Aerobic MetabolismAerobic Metabolism (Cellular Respiration)(Cellular Respiration)

AdiposeTissues

MuscleGlycogen

Glucose

Skeletal Muscle

Liver

Mitochondria

Glycogen

Glycerol

FFA

ATP

GlycolysisGlycolysisتحلل الجلیكوجین والجلوكوزتحلل الجلیكوجین والجلوكوز

حمض البیروفیك

حمض اللبنیك

الجلوكوزالجلیكوجین

فوسفات - 6جلوكوز

عملیات األكسدة

Aerobicھوائي

Anaerobicھوائي ال

حمض البیروفیك

حمض LDHاللبنیك

H + + HCO3 - H2 CO3 CO2 + H2O

Ventilatory Thresholdعتبة التھویة الرئویة

H+

VE

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Anaerobic Threshold Determination by Anaerobic Threshold Determination by the Vthe V--Slope MethodSlope Method

VO2

VC

O2 AT

SS11

SS22

S1 = < 1S2 = > 1

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Maximal Graded Ergometer Test for a Healthy Saudi MaleMaximal Graded Ergometer Test for a Healthy Saudi MaleAge = Age = 23 23 yrs; Wt = yrs; Wt = 7171..3 3 kg; Ht = kg; Ht = 171 171 cm cm

0

0.5

1

1.5

2

2.5

3

3.5

Rest 2 4 6 8 10

VO2 VCO2

Time Time (min)(min)

Data from: Exercise Physiology Laboratory, KSUData from: Exercise Physiology Laboratory, KSU

L/m

inL

/min

BikeBike

RER >RER >11

AT determined by An Increase in AT determined by An Increase in VentilatoryVentilatory Equivalent Equivalent of Oof O22 (VEVO(VEVO2 2 without an increase in VECOwithout an increase in VECO22

AT determined by An Increase in AT determined by An Increase in VentilatoryVentilatory Equivalent Equivalent of Oof O22 (VEVO(VEVO2 2 without an increase in VECOwithout an increase in VECO22

VOVO22 & VCO& VCO22 ResponsesResponsesAbove & Below ATAbove & Below AT COCO22

3030

60609090

120120

150150

180180

210210

PowerPower((WW))

Casaburi, et al, JAP, Casaburi, et al, JAP, 19891989

COCO22

Mean and lower Confidence Limits for PredictedMean and lower Confidence Limits for PredictedAT/Predicted Peak VOAT/Predicted Peak VO2 2 in adults (%)in adults (%)

Lower 95% CLAnaerobic Threshold (%)

Age (years)

424253532043435454304444555540454556565046465757604747585870

Wasserman, et al.,1999, p.154

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AT Determination is problematic in:AT Determination is problematic in:

Chronic hyperventilation syndrome. Chronic hyperventilation syndrome.

Progressive exerciseProgressive exercise--induced hypoxemia.induced hypoxemia.

Impaired peripheral chemosensitivity with Impaired peripheral chemosensitivity with an associated high airway resistance.an associated high airway resistance.

Wasserman et al., Wasserman et al., 19991999

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Factors affecting Anaerobic Threshold

Physical TrainingNutrition

Muscle Fiber TypesUsed Protocol

Health Status:• Affecting blood carrying capacity.• Blood flow to the muscles.

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What are the reasons for AT Improvement after What are the reasons for AT Improvement after TrainingTraining

Increased blood flow in the muscles after training. Increased blood flow in the muscles after training.

Increased muscle’s ability to oxidized Increased muscle’s ability to oxidized pyruvatepyruvateand FFA.and FFA.

Delay of the fast twitch muscle fibers recruitment.Delay of the fast twitch muscle fibers recruitment.

Wasserman et al., Wasserman et al., 19991999

All these factors are related to muscle metabolism(Local/peripheral factors)

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Oxygen Uptake: Oxygen Uptake: from Rest to Maximal Exercisefrom Rest to Maximal Exercise

VOVO22 increases from increases from 250 250 ml/min at rest to ml/min at rest to 22..55--3 3 l/min l/min at maximal exercise (at maximal exercise (1010--12 12 fold increase). fold increase).

CO increases from about CO increases from about 5 5 l/min at rest to l/min at rest to 2020--25 25 l/min l/min at max exercise (at max exercise (44--5 5 fold increase) .fold increase) .

Explain how is this happening?Explain how is this happening?

What accounts for the differences?.What accounts for the differences?.