EXERCISE STRESS

ELECTROCARDIOGRAPHY

Dr.Tahsin N
 EXERCISE PHYSIOLOGY

 Sympathetic activation

 Parasympathetic withdrawal

 Vasoconstriction, except-

 Exercising muscles

 Cerebral circulation

 Coronary circulation

 ↑nor epinephrine and renin

 EXERCISE PHYSIOLOGY

 ↑ventri contractility

 ↑O2 extraction(upto 3)

 ↓peripheral resistance

 ↑SBP,MBP,PP

 DBP –no significant change

 Pulm vasc bed can accommodate 6 fold CO

 CO - ↑ 4-6 times
 EXERCISE PHYSIOLOGY

Isotonic exercise(cardiac output)

 Early phase- SV+HR

 Late phase-HR
↑ Exercise work  ↑ O2 usage 
Person’s max. O2 consumption (VO2max) reached

V02 peak

Oxygen
consumption
(liters/min)

Work rate (watts)

 The slope of the o2–work relationship is a measure of the
biochemical efficiency of exercise

 V o2max is the product of maximal arteriovenous oxygen

difference and cardiac output

 The V o2max depends on

 Age

 Men than in women

 Genetic factors

 Cardiovascular impairment

 Physical inactivity.
 The ability to deliver O2 to muscles and muscle’s
oxidative capacity limit a person’s VO2max. Training 
↑ VO2max

70% V02 max (trained) V02 peak

(trained)

V02 peak
Oxygen (untrained)
consumption
(liters/min) 100% V02 max
(untrained)

175
Work rate (watts)
 Respiration during exercise • During dynamic exercise of
increasing intensity, ventilation
increases linearly over the mild
to moderate range, then more
rapidly in intense exercise

• Workload at which rapid

ventilation occurs is called the
ventilatory breakpoint (together
with lactate threshold)

Lactate acidifies the blood, driving off CO2 and increasing ventilatory rate
BLOOD PRESSURE (BP) ALSO RISES IN EXERCISE
• Systolic pressure (SBP)
goes up to 150-170 mm
Hg during dynamic
exercise; diastolic scarcely
alters

• In isometric (heavy static)

exercise, SBP may exceed
250 mmHg, and diastolic
(DBP) can itself reach 180
 Intense exercise 
Glycolysis>aerobic metabolism 
↑ blood lactate (other organs use some)

Blood
lactic
acid
(mM)

Lactate
threshold;
endurance
estimation
Relative work rate (% V02 max)
 MAXIMUM HR

HR=220 - age in years

 POST EXERCISE PHASE

 Vagal reactivation

Imp cardiac deceleration mech

 ↑in well trained athletes

 Blunted in CCF
 MET

• Metabolic Equivalent Term

• 1 MET = "Basal" aerobic oxygen consumption to stay alive = 3.5 ml O2

/Kg/min

• Differs with thyroid status, post exercise, obesity, disease states

 KEY MET VALUES

1 MET = "Basal" = 3.5 ml O2 /Kg/min

2 METs = 2 mph on level

4 METs = 4 mph on level

< 5METs = Poor prognosis if < 65;

10 METs = same progn with medical thpy as CABG

13 METs = Excell prognosis,

regardless of othr exercise responses

 KEY MET VALUES

3-5 METs:
Raking leaves,light carpentry,golf,3-4 mph
5-7 METs:
Exterior carpentry, singles tennis
>9 METs:
Heavy labour, hand ball, squash, running 6-7 mph
CALCULATION OF METS ON THE TREADMILL

METs = Speed x [0.1 + (Grade x 1.8)] + 3.5

3.5

Calculated automatically by Device!

Note: Speed in meters/minute

conversion = MPH x 26.8
Grade expressed as a fraction
 TREADMILL PROTOCOL

 Bruce protocol

 Naughton protocol

 Weber protocol

 ACIP(asymptomatic cardiac ischemia pilot)

 Modified ACIP
 PROTOCOL DESCRIPTION (BRUCE)

Stage Time (min) M/hr Slope

1 0 1.7 10%
2 3 2.5 12%
3 6 3.4 14%
4 9 4.2 16%
5 12 5.0 18%
6 15 5.5 20%
 PROCEDURE

 Standard 12 lead ECG- leads distally

 Torso ECG + BP

 Supine and Sitting / standing

 HR ,BP ,ECG

 Before, after, stage end

 Onset of ischemic response

 Each minute recovery(5-10 mints)

 PROCEDURE- LEAD SYSTEMS

 Mason-Liker modification

 RAD

 ↑inf lead voltage

 Loss of Q in inf leads

 New Q in AVL
 CONTRAINDICATIONS TO EXERCISE TESTING
Absolute
1) Acute MI (< 2 d)
2) High-risk unstable angina
3) Uncontrolled cardiac arrhythmias causing
symptoms or hemodynamic compromise
4) Symptomatic severe AS
5) Uncontrolled symptomatic CCF
6) Acute pulmonary embolus or pulmonary infarction
7) Acute myocarditis or pericarditis
8) Acute Aortic dissection
 CONTRAINDICATIONS TO EXERCISE TESTING

Relative
1. LMCA stenosis
2. Moderate stenotic valvular heart disease
3. Electrolyte abnormalities
4. Severe HTN
5. Tachyarrhythmias or bradyarrhythmias
6. HOCM and other forms of outflow tract obstruction
7. Mental or physical impairment leading to inability
to exercise adequately
8. High-degree AV block
 Both MI and deaths have been reported and can be
expected to occur at a rate of up to 1 per 2500 tests
 CLASSIFICATION OF CHEST PAIN

 Typical angina
1. Substernal chest discomfort with characterstic quality and
duration
2. Provoked by exertion or emotional stress
3. Relieved by rest or NTG

 Atypical angina
Meets 2 of the above characteristics
 Noncardiac chest pain

Meets one or none of the typical characteristics

BAYES' THEOREM A THEORY OF PROBABILITY

‘The post test probability is proportional to the pretest

probability’
 PRETEST PROBABILITY

 Based on the patient's history ( age, gender, chest pain ), physical

examination and initial testing, and the clinician's experience.

 Typical or definite angina →pretest probability high - test result does

not dramatically change the probability.

 Diagnostic testing is most valuable in intermediate pretest probability

category
 PRE TEST PROBABILITY OF CORONARY DISEASE BY
SYMPTOMS, GENDER AND AGE

Age Gender Typical/Definite Atypical/Probable Non- Asymptomatic

Angina Pectoris Angina Pectoris Anginal
Chest Pain
30-39 Males Intermediate Intermediate low (<10%) Very low (<5%)
30-39 Females Intermediate Very Low (<5%) Very low Very low
40-49 Males High (>90%) Intermediate Intermediate low
40-49 Females Intermediate Low Very low Very low
50-59 Males High (>90%) Intermediate Intermediate Low
50-59 Females Intermediate Intermediate Low Very low
60-69 Males High Intermediate Intermediate Low

60-69 Females High Intermediate Intermediate Low

High = >90% Intermediate = 10-90% Low = <10%

Very Low = <5%
 INDICATIONS
OF EXERCISE TESTING
 TO DIAGNOSE OBSTRUCTIVE CAD

Class I

 Adult patients (including RBBB or <1 mm of resting ST↓) with

intermediate pretest probability of CAD

Class IIa

 Patients with vasospastic angina.

 TO DIAGNOSE OBSTRUCTIVE CAD

Class IIb

1. Patients with a high pretest probability of CAD

2. Patients with a low pretest probability of CAD

3. Patients with <1 mm of baseline ST ↓and on digoxin.

4. Patients with LVH and <1 mm baseline ST ↓.

 TO DIAGNOSE OBSTRUCTIVE CAD

Class III

1. Patients with the following baseline ECG abnormalities:

• Pre-excitation syndrome

• Electronically paced ventricular rhythm

• >1 mm of resting ST depression

• Complete LBBB
 IN ASYMPTOMATIC PERSONS
WITHOUT KNOWN CAD
Class IIa

• Evaluation of asymptomatic T2 DM pts who plan to start vigorous

exercise ( C)

Class IIb

• 1. Evaluation of pts with multiple risk factors as a guide to risk-

reduction therapy.

• 2. Evaluation of asymptomatic men > 45 yrs and women >55 yrs:

• • Plan to start vigorous exercise

• • Involved in occupations which impact public safety

• • High risk for CAD(e.g., PVOD and CRF)

Class III

• Routine screening of asymptomatic

 RISK ASSESSMENT AND PROGNOSIS IN PATIENTS
WITH SYMPTOMS OR A PRIOR HISTORY OF CAD
Class I

• 1. Initial evaluation with susp/known CAD, includingRBBB or <1

mm of resting ST Depression

• 2.Susp/ known CAD, previously evaluated, now significant

change in clinical status.

• 3. Low-risk UA pts >8 to 12 hrs & free of active ischemia/CCF

• 4. Intermed-risk UApts > 2 to 3 days & no active ischemia/ CCF

Class IIa

• Intermed-risk UA pts – initial markers (N),rpt ECG –no signi

change, and markers >6-12 hrs (N) & no other evidence of

ischemia during observation.

 AFTER MYOCARDIAL INFARCTION

Class I

• 1. Before discharge (submaximal --4 to 6 days).

• 2. Early after discharge if the predischarge exercise test was not done
(symptom limited --14 to 21 days).

• 3. Late after discharge if the early exercise test was submaximal

(symptom limited --3 to 6 weeks).

Class IIa

• After discharge as part of cardiac rehabilitation in patients who have

undergone coronary revascularization.
 AFTER MYOCARDIAL INFARCTION

Class IIb

1. Patients with the following ECG abnormalities:

• • Complete LBBB

• • Pre-excitation syndrome

• • LVH

• • Digoxin therapy

• • >1 mm of resting ST-segment depression

• • Electronically paced ventricular rhythm

2. Periodic monitoring in patients who continue to participate in exercise

training or cardiac rehabilitation.
 AFTER MYOCARDIAL INFARCTION

Class III

1. Severe comorbidity likely to limit life expectancy and/or candidacy

for revascularization.

2. At any time to evaluate pts with AMI with uncompensated CCF,

arrhythmia, or noncardiac exercise limiting conditions.

3. Before discharge to evaluate pts who have already been selected

for, or have undergone, cardiac cath.

Although a stress test may be useful before or after cath to

evaluate or identify ischemia in the distribution of a coronary
lesion of borderline severity, stress imaging tests are
recommended.
Submaximal protocols

• Predetermined end point

• Peak HR 120 bpm, or

• 70% predicted max HR or

• Peak MET - 5

Symptom-limited tests

• To continue till signs or symptoms necessitating termination

(i.e., angina, fatigue, ≥ 2 mm of ST↓,ventricular arrhythmias,
or ≥10-mm Hg drop in SBP from the resting blood pressure)
 BEFORE AND AFTER REVASCULARIZATION
Class I

• 1. Demonstration of ischemia before revascularization.

• 2. Evaluating recurrent symps suggesting ischemia after

revascularization.

Class IIa

• After discharge for activity counseling and/or exercise training as part of

rehabilitation in pts aft revascularization.

 BEFORE AND AFTER REVASCULARIZATION

Class IIb

• 1. Detection of restenosis in selected, high-risk asymptomatic pts

< first 12 months aft PCI.

• 2. Periodic monitoring of selected, high-risk asymptomatic ps for

restenosis, graft occlusion, incomplete coronary revascularization,

or disease progression.

Class III

• 1. Localization of ischemia for determining the site of

intervention.

• 2. Routine, periodic monitoring of asymptomatic pts after PCI or

CABG without specific indications.

 STRESS TESTING

Modality Sensitivity Specificity

Exercise test 68% 77%

Nuclear
87-92% 80-85%
Imaging
Stress
80-85% 88-95%
Echo
 INVESTIGATION OF HEART RHYTHM DISORDERS

Class I

• 1. Identification of appropriate settings in pts with rate-

adaptive pacemakers.

• 2. Evaluation of cong CHB in pts considering

↑activity/competitive sports. (C)

Class IIa

• 1. Evaluating known or suspected exercise-induced

arrhythmias.

• 2. Evaluation of medical, surgical, or ablative therapy in

exercise-induced arrhythmias
 INVESTIGATION OF HEART RHYTHM DISORDERS

Class IIb

 1. Isolated VPC in middle-aged pts without other evidence of

CAD.

 2. Prolonged 1˚AV block or type I-2˚AV block , LBBB, RBBB, or

VPC in young pts considering competitive sports. (C)

Class III

 Routine investigation of isolated VPC in young pts.

INTERPRETING TMT
 NORMAL ECG CHANGES DURING EXERCISE

 ↓ PR, QRS, QT

 ↑ P amplitude

 Progressive downsloping PR in inf leads

 j point depression
 THE EXERCISE ECG

1 = Iso-electric ST 60 -- HR > 130/min

2 = J point ST 80 -- HR ≤ 130/min
3 = J + 80 msec
CRITERIA FOR READING ST-SEGMENT CHANGES ON THE
EXERCISE ECG
ST DEPRESSION:

 Measurements made on 3 consecutive ECG complexes

 ST level is measured relative to the P-Q junction

 When J-point is depressed relative to P-Q junction at baseline:

 Net difference from the J junction determines the amount of deviation

 When the J-point is elevated relative to P-Q junction at baseline and

becomes depressed with exercise:

 Magnitude of ST depression is determined from the P-Q junction and

not the resting J point
 Upsloping

J point depression of 2 to 3
mm in leads V4 to V6 with
rapid upsloping ST segments
depressed approximately 1
mm 80 msec after the J point.
The ST segment slope in leads
V4 and V5 is 3.0 mV/sec. This
response should not be
considered abnormal.
 CRITERIA FOR ABNORMAL AND BORDERLINE ST-
SEGMENT DEPRESSION

 ABNORMAL:

 1.0 mm or greater horizontal or downsloping ST depression at

80 msec after J point on 3 consecutive ECG complexes

 BORDERLINE:

 0.5 to 1.0 mm horizontal or downsloping ST depression at 80

msec after J point on 3 consecutive ECG complexes

 2.0 mm or greater upsloping ST depression at 80 msec after J

point on 3 consecutive ECG complexes
Normal

Rapid Upsloping

Minor ST
Depression

Slow Upsloping
Horizontal

Downsloping

Elevation (non Q
lead)

Elevation (Q wave
lead)
• In lead V4 , the
exercise ECG result is
abnormal early in the
test, reaching 0.3 mV
(3 mm) of horizontal
ST segment
depression at the end
of exercise.
• Consistent with a
severe ischemic
response.
•The J point at peak exertion is
depressed 2.5 mm, the ST
segment slope is 1.5 mV/sec,
and the ST segment level at 80
msec after the J point is
depressed 1.6 mm.
•This “slow upsloping” ST
segment at peak exercise
indicates an ischemic pattern
in patients with a high
coronary disease prevalence
pretest.
•A typical ischemic pattern is
seen at 3 minutes of the
recovery phase when the ST
segment is horizontal and 5
minutes after exertion when
the ST segment is
downsloping.
•Becomes abnormal at 9:30
minutes (horizontal arrow
right) of a 12-minute
exercise test and resolves in
the immediate recovery
phase.
•This ECG pattern in which
the ST segment becomes
abnormal only at high
exercise workloads and
returns to baseline in the
immediate recovery phase
may indicate a false-
positive result in an
asymptomatic individual
without atherosclerotic risk
factors.
 ST ELEVATION(LOCALISING)

Abnormal response

– J ↑ ≥0.10mV(1 mm)

– ST 60 ≥0.10mV(1 mm)

– Three consecutive beats

Q wave lead (Past MI)

• Severe RWMA, ↓EF, ↓Prognosis

Non Q wave lead (Past MI)

• Severe ischemic response

Non Q wave lead (No past MI)-1%

• Transmural reversible myocardial ischemia- ----

vasospasm, ↑coronary narrowing
•This type of ECG pattern is usually
associated with a full-thickness, reversible
myocardial perfusion defect in the
corresponding left ventricular myocardial
segments and high-grade intraluminal
narrowing at coronary angiography.
Rarely, coronary vasospasm produces this
result in the absence of significant
intraluminal atherosclerotic narrowing.
 ECG Patterns Indicative of Myocardial Ischaemia

ECG Patterns Not Indicative of Myocardial Ischaemia

ECG CHANGES DURING STRESS TEST
 ST HEART RATE SLOPE

Maximal change in ST with heart rate calculated at the end of each stage

Heart rate adjustment of ST segment depression - improve the sensitivity

Calculation of the maximal ST/heart rate slope in mV/beats/min - linear

regression

An ST/heart rate slope

>2.4 mV/beats/min - abnormal

>6 mV/beats/min - three-vessel CAD.

 THE ST/HEART RATE INDEX

 Average change of ST segment depression with heart rate

throughout the course of the exercise test.

 >1.6 - abnormal
 CONFOUNDERS OF EXERCISE TREADMILL TEST
INTERPRETATION

 Digoxin

 Abnormal ST-segment response to exercise

 In 25% to 40% of healthy subjects

 Related to age.

 Left Ventricular Hypertrophy

 Decreased specificity

 sensitivity is unaffected.

 Resting ST Depression

 Decreased specificity
 CONFOUNDERS OF EXERCISE TREADMILL TEST
INTERPRETATION

 Left Bundle-Branch Block

 Up to 1 cm of ST depression can occur in healthy normal

subjects

 Right Bundle-Branch Block

 Does not reduce the sensitivity, specificity, or predictive value

of the stress ECG

 Beta Blocker Therapy

 Reduced diagnostic or prognostic value because of inadequate

heart rate response
 EARLY REPOLARIZATION AND RESTING ST↑

 Return to the PQ junction is normal

 Hence ST↓ determined from PQ junction

 Not from the elevated J point before exercise

 DUKE TREADMILL SCORE

Treadmill Score=Exercise time

-5X (amount of ST-seg. deviation in mm) - 4X exercise

angina index

(0-no angina, 1 angina, 2 if angina stops test).

High Risk= -11, mortality >5% annually.

Low Risk= +5, mortality 0.5% annually.

Ann Intern Med 1987;106:793.

 ACC/AHA GUIDELINES:

 Patients with a high-risk exercise test result (mortality ≥ 4%/yr),

should be referred for cardiac catheterization.

 Pts. with an intermediate-risk result (mortality of 2% to 3%/yr),

should be referred for additional testing, either cardiac
catheterization, or an exercise imaging study.
 PSEUDO NORMALIZATION PATTERN

No prior MI

 Nondiagnostic finding

Prior MI

 Suggests Reversible myocardial ischemia

 Needs substantiation by rev myo perfusion defect

 R WAVE AMPLITUDE

LVH Voltage criteria

 ST seg – less reliable to ∆ CAD even in the absence of LV

strain pattern

Loss of R wave (MI)

 ↓Sensitivity of ST response in that lead

 U INVERSION

Occasionally in precordial leads at HR<120

 Relatively nonsensitive

 Relatively specific
 ABNORMAL BP RESPONSE

• Failure to ↑SBP >120 mmHg

• Sustained ↓(15 secs) >10mmHg

• ↓SBP below resting BP during progressive exercise

Inadequate ↑ of CO

3VD LMCA disease

Cardiomyopathy Arrhythmias

Vasovagal LVOT obstruction

Hypovolemia Prolonged vigorous exercise

 MAXIMUM WORK CAPACITY

Important prognostic measurement

 Work performed in METs

 Not the no: of minutes of exercise

 EXERCISE CAPACITY

VO2 max = (mph x 26.8) x (0.1 + [% grade X 1.8] + 3.5

1 MET (metabolic equivalent) = 3.5 ml 02 /kg/min

Stage 1 = 5 METS

Stage 2 = 6 - 8 METS

Stage 3 = 8 -10 METS

 EXERCISE CAPACITY

“The strongest predictor of the risk of death among both normal

subjects, and those with cardiovascular disease”.

“Each 1-MET increase in exercise capacity conferred a 12%

improvement in survival”.

NEJM 2002;346:793-801.
For each 1-MET increase in exercise capacity, the survival improved by 12 percent
N Engl J Med 2002
 EXERCISE CAPACITY

 In pts. with CAD > 13 METS (Stage IV) prognosis excellent

regardless of whether medical or surgical therapy is selected.*

 Documented CAD, ≥ 2 mm ST-segment depression. Stage IV had a

100% 5-year survival rate.**

 In the Coronary Artery Surgery Study (CASS), patients with 3-

vessel disease, and high exercise capacity (≥ 10 METS), showed no
benefit from surgery. (JACC 1986;8:741 748)

*Circ 1984;70:226.
**Circ 1982;65:482.
 HEART RATE RESPONSE

Inappropriate ↑ at low work load

 Anxiety (<1minute-transient)

 Persisting several minutes

AF Physically deconditioned

Hypovolemia Anemia

Marginal LV function
 HEART RATE RESPONSE

Chronotropic incompetence

Inability to attain THR OR

Abnormal HR Reserve(<80%)

{%HR Reserve=(HRpeak-HRrest)/(220-age- HRrest)}

Autonomic dysfunction SN dysfuntion,

Drugs Myocardial ischemia

↑long term mortality (not on β blockers)

 CHRONOTROPIC INCOMPETENCE

Framingham Heart Study

Circ 1996;93:1520.
 HEART RATE RECOVERY

 During exercise, HR increases due to withdrawal of vagal tone,

and increase of sympathetic tone.

 During recovery, there is a rapid reactivation of vagal tone

leading to a decrease in heart rate.

 Delayed recovery is a marker of poor outcome

 HEART RATE RECOVERY

Abnormal:

1 minute

TMT (upright) < 12 bpm

TMT (supine) < 18 bpm

An upright value <22 bpm at 2 minutes is abnormal

Poor prognosis independent of other factors
 EXERCISE INDUCED CHEST DISCOMFORT

 Usually after ischemic ST changes

 May be associated with increased DBP

 In some, only chest discomfort

In CSA, CP less freq than ST↓

 Angina with no ST ↓- MPI useful to assess ischemic

severity.
 ANGINA DURING STRESS TEST

Mortality

(+) ve Stress Test with angina 5%/yr.

(+) ve Stress Test, no angina 2.5%/yr.

Circ 1984;70:547-551.
 MARKEDLY POSITIVE STRESS TEST

1. ECG changes in the first three minutes.

2. ECG changes that last through recovery.

3. Hypotensive response.
 ADVERSE PROGNOSIS & MULTIVESSEL CAD

1. Symptom limiting exercise < 5METs

2. Abnormal BP response

3. ST↓≥2mm or downsloping ST↓

<5METs, ≥5 leads, persisting ≥5 mins into reco

4. ST↑

5. Angina at low exercise work loads

6. Reproducible sustained/symptomatic VT
 INDICATIONS FOR TERMINATING EXERCISE TESTING

Absolute indications
1. Drop in systolic BP >10 mm Hg from baseline when
accompanied by other evidence of ischemia
2. Moderate to severe angina
3. ↑ CNS sympts (ataxia, dizziness, or near-syncope)
4. Signs of poor perfusion (cyanosis or pallor)
5. Technical difficulties in monitoring ECG or systolic BP
6. Subject’s desire to stop
7. Sustained VT
8. ST ↑ (≥1.0 mm) in leads without Q-waves (other than V1 or
aVR)
 INDICATIONS FOR TERMINATING EXERCISE TESTING
Relative indications
1. ↓ in systolic BP (≥10 mm Hg) in the absence of other evidence of
ischemia

2. ST or QRS changes such as excessive ST↓ (>2 mm of horizontal or

downsloping ST↓ ) or marked axis shift

3. Arrhythmias other than sustained VT, including multifocal PVCs,

triplets of PVCs, SVT, heart block, or bradyarrhythmias

4. Fatigue, shortness of breath, wheezing, leg cramps, or claudication

5. Development of BBB or IVCD that cannot be distinguished from VT

6. Increasing chest pain

7. Hypertensive response
THANK YOU