STRESS TEST
BY:
Jobelyn Delena Tunay, RN
WHAT IS STRESS TESTING?
Tests used in Medicine to measure the heart’s
ability to respond to external stress in a
controlled clinical environment .
TYPES OF STRESS TESTING
*EXERCISE
a. Treadmill
b. Bicycle
*PHARMACOLOGIC
a. Adenosine
b. Dipyridamole
c. Dobutamine
d. Isoproterenol
*OTHER
a. Pacing
INDICATIONS OF EXERCISE TESTING
• Elicit abnormalities not present at rest
• Estimate functional capacity
• Estimate prognosis of CAD
• Likelihood of coronary artery disease
• Extent of coronary artery disease
• Effect of treatment
INDICATIONS OF PHARMACOLOGICAL STRESS TESTING
• Patients inability to exercise adequately because of
physical or psychological limitations.
• The chosen test cannot be performed readily with
exercise (e.g. PET scanning).
METHODS OF DETECTING ISCHEMIA DURING STRESS
TESTING
Electrocardiography
Echocardiography
Myocardial perfusion imaging
Positron emission tomography
Magnetic resonance imaging
ACC/AHA GUIDELINES
(American College of Cardiology/
American Heart Association)
Indications for exercise testing to diagnose obstructive
coronary artery disease
• Adult patients with right bundle branch block or less
than 1mm of resting ST depression with an
intermediate pretest probabilty CAD on the basis of
gender , age and symptoms.
Indications in patients with prior history of coronary heart
disease
• Patients undergoing initial evaluation with suspected or
known CAD, including those with complete right bundle
branch block or less than 1mm of resting ST depression.
• Patients with suspected or known CAD , previously
evaluated , now presenting with significant change in
clinical status .
• Low risk (on pretest probability), unstable angina patients 8 –
12 hours after presentation who have been free of active
ischemia or heart failure symptoms.
• Intermediate risk (on pre test probability),unstable angina
patients 2 to 3 days after presentation who have been free
of active ischemic or heart failure symptoms.
Indications in patients with Valvular heart disease
1. In Chronic Aortic Regurgitation for assessment of
functional capacity and symptomatic responses in
patients with a history of equivocal symptoms.
2. Aortic stenosis – role of exercise testing in
asymptomatic AS patients , with recommendations
that aortic valve replacement be considered in those
with exercise induced symptoms or abnormal blood
pressure response.
Indications in patients with Valvular heart disease
• Mitral stenosis – class 1 reommendation for stress
echocardiography in patients with MS and
discordance between symptoms and stenosis
severity.
• Threshold values proposed for consideration of
intervention: a. Mean transmitral pressure gradient
>15 mm Hg during exercise. b. A peak pulmonary
artery systolic pressure > 60 mm Hg during exercise.
Indications in patients with Valvular heart disease
• Mitral regurgitation – In asymptomatic patients with
severe MR, exercise stress echo helps identify:
a. Patients with subclinical latent LV dysfunction
b. Worsening of MR severity
c. Marked increase in pulmonary arterial pressure
d. Impaired exercise capacity
Indications in patients with Valvular heart disease
• Prosthetic heart valves – Stress echocardiography
used in confirming or excluding the presence of
hemodynamically significant prosthetic valve
stenosis or Patient prosthesis mismatch (PPM).
RHYTHM DISODERS
• Evaluation of congenital complete heart block in
patients considering increased physical activity or
participation in competitive sports .
CONTRAINDICATIONS FOR STRESS TESTING
• Acute myocardial infarction ( within 2 days )
High risk(on pretest probability) unstable angina
• Uncontrolled cardiac arrthymias causing symptoms
or hemodynamic compromise
• Symptomatic severe aortic stenosis Acute
pulmonary embolus or pulmonary infarction Acute
myocarditis or pericarditis
• Acute aortic dissection
EXERCISE PHYSIOLOGY
• Patient position – supine or upright.
• At rest CO and SV more in supine position than in
upright position.
• Change from supine to upright position causes , CO
as a result of in SV and HR.
• The net effect on exercise performance is an
approx. 10 % increase exercise time cardiac index,
heart rate, and rate pressure product at peak exercise
in the upright as compared with the supine position.
The main types of exercise are isotonic or dynamic
exercise, isometric or static exercise, and resistive
(combined isometric and isotonic) exercise.
Isometric
a. Holding a static pushup position;
b. Holding a dumbbell in one hand;
c. Pushing against an immovable object, such as a
wall.
Isotonic
a. Weight lifting
b. Swimming
c. Rock climbing
d. Cycling
CARDIOPULMONARY EXERCISE TESTING
• Involves measurements of respiratory oxygen uptake
(VO₂),carbon dioxide production (VCO₂), and ventilatory
parameters during a symptom-limited exercise test.
• VO₂ max is the product of maximal arterial-venous oxygen
difference and cardiac output and represents the largest
amount of oxygen a person can use while performing
dynamic exercise involving a large part of total muscle mass.
• The VO₂ max decreases with age, is usually less in women
than in men, and diminished by degree of cardio-vascular
impairment and by physical inactivity.
• Peak exercise capacity is decreased when the ratio of
measured to predicted VO₂ max is less than 85 to 90 percent.
METABOLIC EQUIVALENT
• Metabolic equivalent (MET) refers to a unit of oxygen
uptake in a sitting, resting person.
• 1 MET is equivalent to 3.5 VO2 ml 02/kg/min of body
weight. Measured VO2 in ml 02/kg/min divided by 3.5
ml 02/kg/min determines the number of METs
associated with activity.
• Work activities can be calculated in multiples of
METs; this measurement is useful to determine exercise
prescriptions, assess disability, and standardize the
reporting of submaximal and peak exercise workloads
when different protocols are used.
METHODS
General concerns prior to performing an exercise test
include –
• Safety precautions and equipments needs.
• Patient preparation
• Choosing a test type
• Choosing a test protocol
• Patient monitoring
• Reasons to terminate a test
• Post test monitoring
SAFETY PRECAUTIONS AND EQUIPMENT
• The treadmill should have front and side rails for
subjects to steady themselves. It should be calibrated
monthly. An emergency stop button should be readily
available to the staff only.
• Exercise test should be performed under the
supervision of a physician who has been trained to
conduct exercise tests.
TMT ROOM
EMERGENCY
STOP BUTTON
PRETEST PREPARATION
• Any history of light headed or fainted while exercising
sholud be asked.
• The physician should also ask about family history
and general medical history, making note of any
considerations that may increase the risk of sudden
death.
• A brief physical examination should always be
performed prior to testing to rule out significant outflow
obstruction
Preparation for exercise testing include the following
1. The subject should be instructed not to eat or smoke
atleast 2 hours prior to the test .
2. Unusual physical exertion should be avoided before
testing.
3. Specific questioning should determine which drugs are
being taken. The labeled medications should be brought
along so that medications can be identified and recorded.
4. Because of a greater potential for cardiac events with the
sudden cessation of β-blockers , they should not be
automatically stopped prior to testing but done so gradually
under physician guidance, only after consideration of the
purpose of the test.
EXERCISE PROTOCOLS
•Dynamic protocols most frequently are used to assess
cardiovascular reserve, and those suitable for clinical
testing should include a low intensity warm-up phase.
• In general, 6 to 12 minutes of continuous progressive
exercise during which the myocardial oxygen
demand is elevated to the patient's maximal level is
optimal for diagnostic and prognostic purposes. The
protocol should include a suitable recovery or cool-
down period.
VARIOUS PROTOCOLS
• Treadmill protocols
a. Bruce
b. Cornell
c. Balke ware
d. Acip
e. mAcip
f. Naughton
g. Weber
• Bicycle ergometer
TREADMILL PROTOCOL
In healthy individuals, the standard Bruce protocol is
normally used.
The Bruce multistage maximal treadmill protocol has
3-minute periods to allow achievement of a steady
state before work-load is increased for next stage.
In older individuals or those whose exercise capacity
is limited by cardiac disease, the protocol can be
modified by two 3-minute warm -up stages at 1.7 mph
and 0 percent grade and 1.7 mph and 5 percent
grade.
The 6-Minute Walk Test
Used for patients who have marked left ventricular
dysfunction or peripheral arterial occlusive disease
and who cannot perform bicycle or treadmill exercise.
Patients are instructed to walk down a 100-foot
corridor at their own pace, attempting to cover as
much ground as possible in 6 minutes.
At the end of the 6-minute interval, the total distance
walked is determined and the symptoms experienced
by the patient are recorded.
MEASUREMENTS
ECG
Exercise capacity (METS – metabolic equivalent)
Symptoms
Blood pressure
Heart rate response & recovery
Positive test
a. A flat or downsloping depression of the ST segment
> 0.1 mV below baseline (i.e the PR segment ) and
lasting longer than 0.08s
b. Upsloping or junctional ST segment changes are not
considered characteristic of ischemia and do not
constitute a positive test.
Negative test
a. Target heart rate (85% of maximal predicted heart
for age and sex ) is not achieved .
• The normal and rapid upsloping ST segment responses
are normal responses to exercise.
• Minor ST depression can occur occasionally at
submaximal workloads in patients with coronary disease.
• The slow upsloping ST segment pattern often
demonstrates an ischemic response in patients with
known coronary disease or those with a high pretest
clinical risk of coronary disease.
• Downsloping ST segment depression represents a severe
ischemic response.
• ST segment elevation in an infarct territory (Q wave
lead) indicates a severe wall motion abnormality and, in
most cases, is
• False positive : • False negative :
a. In asymptomatic men a. In patients with
< 40 years. obstructive diseases
limited to circumflex
b. In patients taking coronary artery(lateral
cardioactive drugs portion is not well
c. In patients with represented on the
intraventricular conduction surface 12 lead ECG.)
disturbances,ventricul ar
hypertrophy , abnormal
potassium levels.
T WAVE CHANGES
• Influenced by:
• Body position
• Respiration
• Hyperventilation
• Drug Rx
• Myocardial ischaemia
Necrosis Pseudonormalisation of T wave:
• Usually non-diagnostic and consider ancillary
imaging in such cases.
MAXIMAL WORK CAPACITY
• In patients with known or suspected CAD, a limited
exercise capacity is associated with an increased risk
of cardiac events and in general the more severe the
limitation, the worse the CAD extent and prognosis.
• In estimating functional capacity the amount of work
performed (or exercise stage achieved) expressed in
METs and not the number of minutes of exercise,
should be the parameter measured.
• Major reduction in exercise capacity indicates
significant worsening of cardiovascular status.
BLOOD PRESSURE RESPONSE
The normal exercise response is to increase systolic
blood pressure progressively with increasing workloads
to a peak response ranging from 160 to 200mmHg with
the higher range of the scale in older patients with less
compliant vascular systems.
Failure to increase systolic blood pressure beyond
120mmHg or a sustained decrease greater than
10mmHg repeatable within 15 seconds or a fall in
systolic blood pressure below standing resting values
during progressive exercise when the blood pressure
has otherwise been increasing appropriately, is
abnormal .
HEART RATE RESPONSE
Peak HR > 85% of maximal predicted for age
HR recovery >12 bpm (erect)
HR recovery >18 bpm (supine)
LIMITATIONS OF TREADMILL STRESS TEST
• Non-diagnostic ECG change
• Women – false positives
• Elderly – more sensitive/less specific
• Diabetics – autonomic dysfunction
• Hypertension
• Inability to exercise
• Drugs – digoxin; anti-anginals
NON-CORONARY CAUSES OF ST SEGMENT DEPRESSION
• Anaemia • Severe aortic stenosis
• Cardiomyopathy • Severe hypertension
• Digoxin • Severe hypoxia
• Glucose load • Severe volume overload
• Hyperventilation (aortic or mitral rgurgitation)
• Hypokalaemia • Sudden excessive exercise
• Intraventricular conduction disturbance
• Mitral valve prolapse
• Pre-excitation syndrome
• Supraventricular tachycardias
LIMITATIONS OF TREADMILL STRESS TEST
Sensitivity 68%
Specificity 77%
ANCILLARY TECHNIQUES TO ENHANCE CONTENT
Echocardiography
Radionuclide imaging
STRESS ECHOCARDIOGRAPHY
DURING STRESS TEST
• During all types of stress testing, a doctor, nurse, or
technician will always be with you to closely check
your health status.
• Before you start the "stress" part of a stress test, the
nurse will put sticky patches called electrodes on the
skin of your chest, arms, and legs. To help an
electrode stick to the skin, the nurse may have to
shave a patch of hair where the electrode will be
attached.
• The electrodes will be connected to an EKG
(electrocardiogram) machine. This machine records
your heart's electrical activity. It shows how fast your
heart is beating and the heart's rhythm (steady or
irregular). An EKG also records the strength and timing of
electrical signals as they pass through your heart.
• The nurse will put a blood pressure cuff on your arm to
check your blood pressure during the stress test. (The
cuff will feel tight on your arm when it expands every
few minutes.) Also, you might have to breathe into a
special tube so the gases you breathe out can be
measured.
• Next, you'll exercise on a treadmill or stationary bike.
If such exercise poses a problem for you, you might
turn a crank with your arms instead. During the test,
the exercise level will get harder. You can stop
whenever you feel the exercise is too much for you.
• If you can't exercise, medicine might be injected into a vein
in your arm or hand. The medicine will increase blood flow
through your coronary arteries and make your heart beat
fast, as it would during exercise. You can then have the
stress test.
• The medicine may make you flushed and anxious, but the
effects go away as soon as the test is over. The medicine
also may give you a headache.
• While you're exercising or getting medicine to make your
heart work harder, the nurse will ask you how you're feeling.
You should tell him or her if you feel chest pain, short of
breath, or dizzy.
• The exercise or medicine infusion will continue until
you reach a target heart rate, or until you:
• Feel moderate to severe chest pain
• Get too out of breath to continue
• Develop abnormally high or low blood pressure or an
arrhythmia (an irregular heartbeat)
• Become dizzy
• The nurse will continue to check your heart functions
and blood pressure after the test until they return to
normal levels.
• The "stress" part of a stress test (when your heart is
working hard) usually lasts about 15 minutes or less.
• However, there's prep time before the test and
monitoring time afterward. Both extend the total test
time to about an hour for a standard stress test, and
up to 3 hours or more for some imaging stress tests.
After a stress test
• After you stop exercising, you may be asked to stand
still for several seconds and then lie down for a
period of time with the monitors in place. Your
doctor can watch for any abnormalities as your
heart rate and breathing return to normal.
• When your exercise stress test is complete, you may
return to your normal activities unless your doctor
tells you otherwise.
STRESS ECHOCARDIOGRAPHY
Compares pre & post:
• Regional contractility
• Overall systolic function
• Volumes
• Pressure gradients
• Filling pressures
• Pulmonary pressures
• Valvular function
Dipyridamole or Adenosine can be given to create a
coronary "steal" by temporarily increasing flow in
nondiseased segments of the coronary vasculature at
the expense of diseased segments.
Alternatively, a graded incremental infusion of
dobutamine may be administered to increase MVO2
STRESS ECHO - LIMITATIONS
Factors which effect image quality:
• Body habitus
• Lung disease
• Breast implants
NUCLEAR SPECT IMAGING
■Radio-tracer injection
Isotopes:
A) Thallium-201
B) Technetium 99m (sestamibi)
■Myocardial uptake
■Photon emission captured by gamma camera
■Rest & redistribution phases
■Pharmacologic protocols available
■Digital presentation
NUCLEAR STRESS TEST
• A “Nuclear Stress Test” measures blood flow to your
heart muscle both at rest and during stress (exercise).
It provides images that can show areas of low blood
flow to the heart and areas of damaged heart
muscle. A Nuclear Stress Test may be ordered if your
doctor suspects you have coronary artery disease,
other heart problems, have been experiencing chest
pain, shortness of breath, or to guide your medical
treatment.
NUCLEAR STRESS TEST
GENERAL INSTRUCTIONS:
• Do not eat or drink anything but a small amount of water four hours prior to the test
• Do not drink or eat caffeinated or decaffeinated products (this includes coffee, soda,
tea, chocolate or any caffeine-additive drink) 24 hours prior to the test
• Do not use tobacco in any form, or be around others who are smoking, the day of
the test
• Bring all your medications (or list with dosage and frequency) the day of the test
• If you take any medications for your heart (including Nitroglycerine patches or
tablets), blood pressure, breathing or diabetes, please contact your doctor to see if
you need to stop any of the medication prior to the test
• If you use an inhaler, bring it with you the day of the test
• Wear comfortable clothes. If walking on the treadmill, you’ll be required to wear
tennis shoes or other tied shoes. Flip flops or any open back shoes are not
acceptable
NUCLEAR STRESS TEST
ABOUT THE TEST:
• Instruct the pt to be prepared to stay approximately four hours to
complete the test
• An IV will be started and will be given a small amount of a radioactive
tracer called Cardiolite which facilitates obtaining images of heart
when scanned
• A resting scan will be completed and then will undergo one of the
following “exercise tests:”
• The doctor will be present during the exercise part of this test and vital
signs and heart rhythm will be closely monitored
• The doctor will contact you to review your test results
DURING IMAGING STRESS TEST
• For other imaging stress test that uses radioactive dye, the
nurse will inject a small amount of dye into your
bloodstream. This is done through a needle placed in a vein
in your arm or hand.
• You’ll get the dye about a half-hour before you start
exercising or take medicine to make your heart work hard.
The amount of radiation in the dye is considered safe for you
and those around you. However, if you're pregnant, you
shouldn't have this test because of risks it might pose to your
unborn child.
• Pictures will be taken of your heart at least two times:
when it's at rest and when it's working its hardest.
You'll lie down on a table, and a special camera or
scanner that can detect the dye in your
bloodstream will take pictures of your heart.
• Some pictures may not be taken until you lie quietly
for a few hours after the stress test. Some patients
may even be asked to return in a day or so for more
pictures.
THALLIUM- 201 SCAN
• Myocardial perfusion problems are separated from
non viable myocardium by the fact that thallium
eventually washes out of the myocardial cells and
back into the circulation .
• If a defect detected on initial thallium imaging
disappears over a period of 3-24 hours , the area is
presumably viable .
• A persistent defect suggests a myocardial scar.
TECHNETIUM – 99M(sestamibi)
■The technetium – 99m(sestamibi) based agents take
advantage of the shorter half - life ( 6 hours; thallium
201’s is 73 hours)
■This allows for use of a larger dose , which results in
higher energy emissions and higher quality images.
■Technetium 99m’s higher energy emissions scatter
less and are attenuated less by chest wall structures,
reducing the number of artifacts.
TECHNETIUM – 99M(sestamibi)
POSITRON EMISSION TOMOGRAPHY
■Is a technique using tracers that simultaneously emit
two high energy photons .
■A circular array of detectors around the patient can
detect these simultaneous events and accurately
identify their origin in the heart.
■This results in improved spatial resolution , compared
with SPECT .
■PET can be used to assess myocardial perfusion and
myocardial metabolic activity separately by using
different tracers coupled to different molecules.
Agents used:
Oxygen 15(half time 2mins)
Nitrogen -13(half life 10 mins)
Carbon -11(half time 20 mins)
Flourene -18(half 110 mins)
Because Rubidium – 82 with a half life of 75 seconds ,
does not reqiure a cyclotron and can be generated
on site , it is frequently used with PET scanning ,
especially for perfusion images.
LIMITATIONS OF NUCLEAR SPECT IMAGING
• Time-consuming
• Artifacts
• Radiation
Results
• Normal blood flow during exercise and rest. You may not need further
tests.
• Normal blood flow during rest, but not during exercise. Part of your
heart isn't receiving enough blood when you're exerting yourself. This
might mean that you have one or more blocked arteries (coronary
artery disease).
• Low blood flow during rest and exercise. Part of your heart isn't getting
enough blood at all times, which could be due to severe coronary artery
disease or a previous heart attack.
• Lack of radioactive dye in parts of your heart. Areas of your heart that
don't show the radioactive dye have tissue damage from a heart attack.
• If you don't have enough blood flow through your
heart, you may need to undergo coronary
angiography. This test looks directly at the blood
vessels supplying your heart. If you have severe
blockages, you may need a coronary intervention
(angioplasty and stent placement) or open-heart
surgery (coronary artery bypass).
LIMITATIONS OF NUCLEAR SPECT IMAGING
• Risk of iatrogenic malignancy
Consider:
* age
* gender
* background
MRI CARDIAC STRESS TEST
MRI CARDIAC STRESS TEST
Useful for:
Patients unable to exercise
ECG uninterpretable
Unsuitable for DSE
And….
No radiation
But…
Not currently available
COMPLICATIONS OF NUCLEAR STRESS TEST
A nuclear stress test is generally safe, and complications are rare. As with any medical
procedure, there is a risk of complications, including:
• Allergic reaction. Though rare, you could be allergic to the radioactive dye that's injected
during a nuclear stress test.
• Abnormal heart rhythms (arrhythmias). Arrhythmias brought on during a stress test usually
go away shortly after you stop exercising or the medication wears off. Life-threatening
arrhythmias are rare.
• Heart attack (myocardial infarction). Although extremely rare, it's possible that a nuclear
stress test could cause a heart attack.
• Dizziness or chest pain. These symptoms can occur during a stress test. Other possible
signs and symptoms include nausea, shakiness, headache, flushing, shortness of breath
and anxiety. These signs and symptoms are usually mild and brief, but tell your doctor if they
occur.
• Low blood pressure. Blood pressure may drop during or immediately after exercise,
possibly causing you to feel dizzy or faint. The problem should go away after you stop
exercising.
WHAT ARE THE RISKS?
Stress tests pose little risk of serious harm. The chance of these
tests causing a heart attack or death is about 1 in 5,000. More
common, but less serious side effects linked to stress testing
include:
• An arrhythmia (irregular heartbeat). Often, an arrhythmia will
go away quickly once you're at rest. But if it persists, you
may need monitoring or treatment in a hospital.
• Low blood pressure, which can cause you to feel dizzy or
faint. This problem may go away once your heart stops
working hard; it usually doesn't require treatment.
• Jitteriness or discomfort while getting medicine to
make your heart work hard and beat fast (you may
be given medicine if you can’t exercise). These side
effects usually go away shortly after you stop getting
the medicine. Sometimes the symptoms may last a
few hours.
• Also, some of the medicines used for
pharmacological stress tests can cause wheezing,
shortness of breath, and other asthma-like symptoms.
Sometimes these symptoms are severe and require
treatment.
