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1TREADMILL EXERCISE TESTING UCSF FELLOWS 1-26-09 UPDATED 1-21-09
TREADMILL EXERCISE TESTING
Nora Goldschlager, M.D.MACP, FACC, FAHA, FHRS
1
SFGH Division of CardiologyUCSF, San Francisco
Disclosures: None
CLINICAL USES OF EXERCISE TESTS• Evaluation of chest pain syndromes
- Effort angina: stable, crescendo- Atypical chest pain, cardiac origin- Atypical chest pain, noncardiac origin
• Assessment of effort toleranceP t di l i f ti
2
- Post-myocardial infarction- Post-revascularization- Valve disease
• Chronotropic competence• Evaluation of rate control in AF• Evaluation of Rx of CAD (medical,
surgical, post-PCI)
CLINICAL USES OF EXERCISE TESTS• Evaluation of blood pressure Rx in
hypertension• Detection of myocardial ischemia in pts at
high risk for CAD• Exercise prescription and risk-
3
stratification post-MI• Detection of exercise arrhythmias
- Due to myocardial ischemia- Symptoms of cerebral hypoperfusion
with exercise• Survivors of out-of-hospital cardiac arrest
2TREADMILL EXERCISE TESTING UCSF FELLOWS 1-26-09 UPDATED 1-21-09
CONTRAINDICATIONS TO MAXIMUM EXERCISE
• Unstable angina pectoris
4
• Baseline uncontrolled ventricular arrhythmias
• ECG suspicious for recent MI
5 6
3TREADMILL EXERCISE TESTING UCSF FELLOWS 1-26-09 UPDATED 1-21-09
ST SEGMENT RESPONSES DURING EXERCISE TESTING: PATHOPHYSIOLOGY
• Primary in myocardial oxygen demand
7
Primary in myocardial oxygen demand (usually produces ST depression)
• Primary in myocardial oxygen supply (can produce ST elevation)
ECG RESPONSES DURING EXERCISE TESTING• ST segment abnormalities
- Depression (downsloping,
8
p ( p g,horizontal, slowly upsloping)
- Elevation- Scooping- Alternans
• ST depression in exercise PVCs
Positional ST-T wave abnormalities
9
4TREADMILL EXERCISE TESTING UCSF FELLOWS 1-26-09 UPDATED 1-21-09
10
Evolution of downsloping ST-T segment response
11
Pseudo-STdepression due to
12
baseline artifact
5TREADMILL EXERCISE TESTING UCSF FELLOWS 1-26-09 UPDATED 1-21-09
Pseudo-ST elevation due to artifact
13 14 15
6TREADMILL EXERCISE TESTING UCSF FELLOWS 1-26-09 UPDATED 1-21-09
16
ST-Talternans
17
PR DEPRESSION WITH PROMINENTTA WAVE
18
7TREADMILL EXERCISE TESTING UCSF FELLOWS 1-26-09 UPDATED 1-21-09
54 y.o. male - recent admission for unstable angina; isordil, -blocker on discharge
19 20 21
8TREADMILL EXERCISE TESTING UCSF FELLOWS 1-26-09 UPDATED 1-21-09
45 y.o. woman with chest pain and hypertension
22 23 24
9TREADMILL EXERCISE TESTING UCSF FELLOWS 1-26-09 UPDATED 1-21-09
ECG RESPONSES DURING EXERCISE TESTING
• T wave abnormalities, isolated- Inversion- Normalization
. Prevalence: pts with CAD = 27%, pts without CAD = 57%
In over 90% of pts with CAD exercise
25
. In over 90% of pts with CAD, exercise test will show evidence of ischemia. In pts without CAD, exercise test will
be normal. T wave normalization does not interfere
with ischemic response. May indicate myocardial viability
- amplitude (“coronary Ts”)
ECG RESPONSES DURING EXERCISE TESTING
• U waves- Inversion- Enhancement
26
• QT dispersion• Axis shifts• Rate dependent bundle branch block• QRS duration changes• in P wave duration (LA) or amplitude
(RA) in II
REST PEAK EFFORT
P ABNORMALITIES WITH EXERCISE
27
10TREADMILL EXERCISE TESTING UCSF FELLOWS 1-26-09 UPDATED 1-21-09
EXERCISE TEST RESPONSES PREDICTING SEVERE CAD
• ST segments: downsloping, elevated• Early onset of ischemic ECG changes
28
y g(1st 3 min)
• Prolonged duration of ischemic ECG changes in recovery (> 7 min)
• Hypotension associated with evidence of ischemia
CORRELATES OF EXERCISE-INDUCED ST SEGMENT ELEVATION
• High-grade proximal obstruction without collaterals
• Viability in infarct area (86% + predictive accuracy) (hibernating myocardium)
• Regional wall-motion abnormality
29
Regional wall motion abnormality, especially anterior wall (large infarction)
• Coronary artery spasm• High incidence of 100% occlusion of an
infarct-related artery (75% of pts) and collateral flow (93% of pts)
• No relationship to extent (number of vessels) of CAD
EXERCISE TEST RESPONSES NOT HELPFUL IN PREDICTING SEVERE
CORONARY ARTERY DISEASE• Inappropriate sinus tachycardia• Failure of heart rate to increase appropriately• Failure of systolic blood pressure to rise
30
• Failure of systolic blood pressure to rise• Rise in diastolic blood pressure• Ischemic ECG changes in exercise vs recovery• Ventricular arrhythmias at high heart rate• Atrial arrhythmias• Bradyarrhythmias
11TREADMILL EXERCISE TESTING UCSF FELLOWS 1-26-09 UPDATED 1-21-09
Inverted U waves during exercise testing
14APeak Ex Recovery 15 sec
31 32
Chikamori et al AJC 3:95
PROMINENT U WAVES IN DETECTION OF LCx OR RCA OBSTRUCTION
Site of prominent Sensitivity Specificity + predictionU-waves (%) (%) (%)Limb leads 19 93 67
33
Right precordial leads 49 89 78
Right and left precordialleads 52 88 77
Chikamori et al , AJC 9.94, N = 311
12TREADMILL EXERCISE TESTING UCSF FELLOWS 1-26-09 UPDATED 1-21-09
FEMALE, ATYPICAL CHEST PAIN,NORMAL CORONARY ARTERIES
34
ABNORMAL EXERCISE ANDRECOVERY SYSTOLIC BP
• Hypotension
35
• Hypotension• Abnormal rise in recovery period
and / or slow decline in recovery
CHRONOTROPIC INCOMPETENCE* AND ABNORMAL CHRONOTROPIC INDEX**
AND PROGNOSIS
Incidence: 15%, 25%Adds independent information (adjusted risk) to:
- Exercise angina
36
- Exercise angina- Abnormal rest and exercise echo (wall
motion score and % ischemic segments)
* ≤ 85% MPHR** % HR reserve/% metabolic reserve < 0.8Elhendy et al (Mayo) JACC 2003; 42:823 -blockers excluded N = 3221
13TREADMILL EXERCISE TESTING UCSF FELLOWS 1-26-09 UPDATED 1-21-09
CHRONOTROPIC INCOMPETENCE* DURING EXERCISE ECHO AND PROGNOSIS
Surv
ival
free
of
CD
and
MI (
%) 100
80 Normal – HR ≥ 85% Normal – HR < 85%Abnormal – HR ≥ 85%Abnormal – HR < 85%
Age-predicted max HR
37
1801 1690 1277 835 491 271259 232 174 101 63 38925 800 590 376 221 123236 186 147 105 69 41
S C 60
* ≤ 85% MPHR -blockers excludedElhendy et al (Mayo) JACC 2003; 42:823
0 1 2 3 4 5
Abnormal HR < 85%
No. at risk Years
CAUSES OF EXERCISE-RELATED HYPOTENSION
• Aortic stenosis• Dilated cardiomyopathy• Severe CAD with poor LV function
38
• Severe CAD with poor LV function• Medications• Vasovagal syndrome• Exhaustive effort• Autonomic insufficiency
Systolic BP ratio =SBP at 3 min recovery
Peak ex SBP
39
NI .90SBP .93 predicts extensive hypoperfusion(sens 64%, spec 76%, + PA 74%)
<>
14TREADMILL EXERCISE TESTING UCSF FELLOWS 1-26-09 UPDATED 1-21-09
CORRELATES OF ABNORMAL SYSTOLIC BLOOD PRESSURE RATIO (SBPR)
• Extent of CAD (angio)• Past MI• Low EF; fall in Ex EF• CHF
E t t f h f i
40
• Extent of hypoperfusion(ischemia + infarction)(scintigraphy)
• Adverse prognosis• Higher Ex SVR• Higher Ex NorEP• Lower work capacity
EXERCISE RESPONSES PREDICTING ADVERSE PROGNOSIS
• Severe ischemic ECG response• Poor effort tolerance (METs, exercise duration)
(true also in 65 y.o.)• Chronotropic incompetence• Hypotension associated with ischemic response
>
41
yp p• Abnormal systolic BP ratio ( 0.9) (3 min SBP:
peak Ex BP) • Abnormal HR recovery
- E.g., peak HR: 1 min recovery HR < 20 bpm; peak HR: 2 min recovery HR < 40 bpm
- criteria not defined• Duke Treadmill score
<
IMPAIRED POST EXERCISE HR RECOVERY• Predicts all cause mortality independent of:
- Gender- Ischemia on ETT or stress echo- Duke treadmill score
42
Duke treadmill score- CAD extent and severity- Functional capacity- -blockers or rate sparing
Ca++ channel blockers• Incidence: 30%
15TREADMILL EXERCISE TESTING UCSF FELLOWS 1-26-09 UPDATED 1-21-09
IMPAIRED POST EXERCISE HR RECOVERY• Relationship to
- Age- HT- DM- Prior MI- Chronotropic incompetence
43
- Severe CAD• Not helpful in predicting presence of any CAD
(sensitivity 30%, specificity 76%)• Mechanism of findings:
- ? Withdrawal of sympathic tone- ? Impairment in reactivation of
parasympathetic nervous system
DUKE TREADMILL SCORE* PERFORMANCE IN PTS WITH NONSPECIFIC
ST-T ABNORMALITIES ON RESTING ECG
Cardiac death
%100
80 Risk group
Cardiac death or nonfatal MI
44
80
60LowIntermediateHigh
0 2 4 6Time (yrs)
* Ex time – (5x ST max) – (4x angina index)Kwok et al JAMA 10.99 N = 906
0 2 4 6
CAUSES OF ISCHEMIC-APPEARING ECG ABNORMALITIES DURING EXERCISE
(“FALSE +” TESTS*)• Hyperventilation (Ds/d vasospasm)• LVH• Abnormal ventricular activation
- WPW- LBBB
45
- RBBB• Syndrome X*• Drugs, electrolytes
- Hypokalemia- Digitalis
• Vasoregulatory abnormalities• Mitral valve prolapse* Gold standard is coronary angiography
16TREADMILL EXERCISE TESTING UCSF FELLOWS 1-26-09 UPDATED 1-21-09
INDICATIONS FOR STRESS SCINTIGRAPHY• Exercise ECG uninterpretable for diagnosis
of ischemia- LBBB - WPW- RBBB - LVH- Baseline ST-T abnormalities
• Exercise ECG of known low sensitivity
46
y- Post myocardial infarction- Single vessel CAD
• Exercise ECG of possible low specificity- Mitral valve prolapse- Vasoregulatory abnormalities- ? Women
• T wave normalization
RBBB: Peak Exercise
47 48
17TREADMILL EXERCISE TESTING UCSF FELLOWS 1-26-09 UPDATED 1-21-09
Rate-dependent LBBB
49 50 51
18TREADMILL EXERCISE TESTING UCSF FELLOWS 1-26-09 UPDATED 1-21-09
52
EXERCISE RELATED ARRHYTHMIAS -ASSOCIATED CONDITIONS
• Normal cardiopulmonary status• Coronary artery disease• Mitral valve prolapse• Cardiomyopathy
Congestive
53
- Congestive- Hypertrophic
• Aortic valvular stenosis• Long QT interval syndromes
- Congenital- Acquired
• Digitalis administration
EXERCISE-INDUCED VENTRICULAR ARRHYTHMIAS AND SURVIVAL
viva
l (%
)
100
95Any (n = 585)
54
Surv
90
85
Follow-up (mo)0 12 24 36 48
Eckart et al AIM 2008; 149:451
y ( )None (n = 2340)LBBB morphology (n = 198)RBBB (n = 250 (LV origin)Multiple morphology (n = 125)
19TREADMILL EXERCISE TESTING UCSF FELLOWS 1-26-09 UPDATED 1-21-09
55
LQTS with TU alternans
56
alternans
0” recovery
57
20TREADMILL EXERCISE TESTING UCSF FELLOWS 1-26-09 UPDATED 1-21-09
2 min recovery
58
PREDICTIVE ACCURACY FOR CAD OF INTRAVENTRICULAR CONDUCTION DELAYS AND SUPRAVENTRICULAR ARRHYTHMIAS IN
AN ASYMPTOMATIC POPULATIONPredictive
Prevalence accuracy
59
RBBB 0.2% 20%LBBB 0.1% 24%AF, other
SV arrhythmias 0.1% 14%
Froelicher, et al AJC 1.77 N = 298
EXERCISE-INDUCEDSUPRAVENTRICULAR ARRHYTHMIAS
IN NORMALS• Prevalence 6%• Relation to age (men)
98% are paroxysmal
60
• 98% are paroxysmal• 16% are > 10 beats• Symptoms in 4%• Most (44%) episodes occur at peak effort
Mauer et al, Baltimore Aging Study, AJC 4.95 843 men, 540 women; FU mean 6 yr
21TREADMILL EXERCISE TESTING UCSF FELLOWS 1-26-09 UPDATED 1-21-09
EXERCISE INDUCED ATRIAL ARRHYTHMIAS
c su
rviv
al (%
) 100
95
90
NoneAF/flutter (0.8%)At i l t (24%)
61
Car
diac 90
85
Bunch et al JACC 2004; 43:1236 Mayo Clinic N = 5375 CAD known/suspected
Atrial ectopy (24%)SVT (3.4%)
0 1 2 3 4 5Years
P = 0.429
EXERCISE INDUCED ATRIAL ARRHYTHMIAS
viva
l fre
e of
AC
E* (%
)
100
90
80NoneAF/fl tt
P = 0.1
62
Surv M 80
70
Bunch et al JACC 2004; 43:1236 Mayo Clinic N = 5375 CAD known/suspected
AF/flutter Atrial ectopy SVT
0 1 2 3 4 5Years
63
22TREADMILL EXERCISE TESTING UCSF FELLOWS 1-26-09 UPDATED 1-21-09
64 65 66
23TREADMILL EXERCISE TESTING UCSF FELLOWS 1-26-09 UPDATED 1-21-09
67 68 69
24TREADMILL EXERCISE TESTING UCSF FELLOWS 1-26-09 UPDATED 1-21-09
BUNDLE BRANCH BLOCK IN TREADMILL TESTING
• Predictive accuracy depends on prevalence of coronary disease in population studied.
+ PA is about 20% in asx subjects• Predictive accuracy of intermittent,
70
rate-dependent and newly acquired BBB is unknown
• Criteria for ischemia apply in lateral leads in RBBB, not in LBBB, although sensitivity is reduced due to the secondary ST-T abnormalities
Rate-dependent LBBB
71 72
25TREADMILL EXERCISE TESTING UCSF FELLOWS 1-26-09 UPDATED 1-21-09
VAGAL BRADYCARDIA DURING TREADMILL EXERCISE
• Uncommon• Usually young, healthy, active individuals• Abrupt bradycardia-hypotension at peak
exercise or during recovery- Often without warning
73
- Often without warning- May be associated with syncope
• Rapid recovery without sequelae• May be related to stimulation of left
ventricular mechanoreceptors• May be reproducible• Does not indicate sinus node dysfunction
35 y.o. asx male with WPW conduction: vagal response to exhaustive exercise
74
EXERCISE-INDUCED AV BLOCK• Occurs in < 1% of all exercise tests• Usually intra-His (QRS normal) or
75
infra-His (BBB at rest)• High (> 90%) rate of progression to
chronic AV block• Cardiac pacing indicated
26TREADMILL EXERCISE TESTING UCSF FELLOWS 1-26-09 UPDATED 1-21-09
56 y.o. male, post-aortocoronary bypass surgery 3 yr prior, developed ill feeling with effort
76
62 y.o. male -trifascicledisease
77 78
27TREADMILL EXERCISE TESTING UCSF FELLOWS 1-26-09 UPDATED 1-21-09
79 80 81
28TREADMILL EXERCISE TESTING UCSF FELLOWS 1-26-09 UPDATED 1-21-09
82
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