treadmill testing

1. EXERCISE TESTING
PRESENTER-
Ms. Anshu
M.Sc. Nursing
KGMU Institute of Nursing

2. EXERCISE TESTING
• Exercise test are used to assess a patients
ability to tolerate increased physical activity
while electrocardiographic, hemodynamic and
symptomatic responses are monitored in a
controlled environment.

3. INDICATIONS
• physiologic response of post MI and post
revascularization patients to exercise.
• Functional capacity for the purpose of exercise
prescription
• Exercise capacity for the purpose of work classification
and risk stratification.
• The efficacy of medical, surgical or pharmacologic
treatment.
• The presence and severity of arrhythmias
• Preoperative physiologic status.
• Intermittent claudication.

4. CONTRAINDICATION
• A recent change in the resting ECG suggesting
infarction or other acute cardiac event.
• Recent complicated MI.
• Unstable angina.
• Uncontrolled ventricular arrhythmias
• 3rd degree AV block
• Acute congestive HF.
• Severe aortic stenosis

5. CONTI…
• Suspected or known dissecting aneurysm
• Active or suspected myocarditis or
pericarditis.
• Thrombophlebitis
• Recent systemic or pulmonary embolism
• Acute infection
• Significant emotional distress.

6. PRETEST CONSIDERATIONS
• All patient should undergo a complete medical
history and a physical examination to identify
contraindications to exercise testing.
• Detailed verbal and written instruction,
provided to the patient in advance, it include
refrain from ingesting food, alcohol, and
caffeine or using tobacco products within 3
hrs of testing.

7. Conti….
• Patient should be well rested and avoid vigorous
activity the day of the test.
• Clothing should be comfortable and provide
freedom of movement as well as allow access for
electrode and blood pressure cuff placement.
• Properly fitting shoes with rubber soles should be
worn to ensure good traction, particularly if a
treadmill is the mode of testing.
• Provide written and verbal informed consent.

8. PREPARATION FOR ECG
• Sites of ECG electrode placement should be
rubbed with alcohol pad to remove skin oil.
• Place the electrode after applying conducting
gel.
• Mason-Likar limb lead placement is the
standard configuration clinically because it
provides a 12 lead ECG with fewer artifact and
less restriction to movement than the
standard lead placement.

10. EXERCISES PROTOCOL
• Bruce treadmill protocol
• Balke treadmill protocol
• Naughton treadmill protocol
• Ramp testing
• Stress testing

11. 1. Bruce treadmill
• It has 3 min period to allow achievement of a
steady state before workload is increased.
• For Individuals with limited exercise capacity,
Bruce’s protocol can be modified by 2-3 min
warm up stages at 1.7 mph and 0% grade and
1.7mph with 5% grade and speed gradually
increased upto 5.5mph in stages.
• There are total 7 stages in Bruce protocal.

13. • Limitation:-
• Large increase in O2 between stages and
traditional energy cost of running as
compared with walking at stages in excess of
Bruce’s stage III.

14. 2. BALKE TREADMILL
• The Balke protocol and modifications of it,
has been widely used for clinical exercise
testing.
• It uses constant walking speeds (2 or 3mph)
and modest increments in grade (2.5% or 5%)
and it has been used particularly often in
studies assessing angina responses.

15. Conti…
• One modification, developed by the United
States School of Aerospace Medicine(Balke
ware) consist of 5% grade increases every
2min and a constant brisk walking speed of
3.3mph(after an initial warmup of 2mph),
which has been considerd the most efficient
speed for walking.

16. 3. NAUGHTON TREADMILL
• It is a low level test that has become common
for multicenter trials in patients with chronic
heart failure.
• The test begins with 2 min stages at 1 and
2mph and 0%grade, then continually increases
grade in approximately 1 MET increaments at
a constant speed of 2mph for the next 8min.

17. Conti…
• Speed then increase to 3mph with a slight
drop in grade, followed by increases in grade
equivalent to approximately 1 MET.
• This protocol has been used extensively in
patient with congestive heart failure.

18. 4. RAMP TESTING
• It uses a constant and continuous increase in
metabolic demand that replaces the “staging”
used in conventional exercise test.
• The uniform increase in work allows for a
steady rise in cardiopulmonary responses and
permits a more accurate estimation of oxygen
uptake.

19. 5. PHARMACOLOGIC STRESS
TECHNIQUE
• Used for patients Who are unable to do exercise
on a treadmill or cycle ergometer to and
adequate level.
This includes patients having:-
• Orthopedic limitation
• Peripheral vascular disease
• COPD
• Elderly patient with low functional capacity
• DM patient with severe neuropathy
• Patient with neuromuscular

20. Two types of pharmacologic stress agents have
been used:-
• Those that increase coronary blood flow
through coronary vasodilation.
• Those that increase myocardial oxygen
demand by increasing heart rate.

21. 1.increase coronary blood flow
through coronary vasodilation.
• The commonly used coronary vasodilators are
adenosine and dipyridamole (persantine),
where as dobutamine is used to increase
myocardial oxygen demand.
• The vasodilator cause greatly increased
endocardial and epicardial blood flow in
normal coronary arteries but not in stenotic
segment.

22. 2.increase myocardial oxygen demand
by increasing heart rate.
• Dobutamine is used which can create an
imbalance between myocardial oxygen supply
and demand by increasing heart rate and
contractility.

23. • These drugs are administered IV and when
associated with an imaging technique such as
thallium-201 scintigraphy, sestamibi or
echocardiography, can provide important
information about coronary artery stenosis.

24. INTERPRETATION OF EXERCISE
TESTING
Heart rate:-
• Heart rate increases linearly with oxygen
uptake during exercise.
• The inability to appropriately increase heart
rate during exercise has been associated with
the presence of heart disease.

25. Blood pressure:-
• Assess the BP at rest and during exercise.
• BP should be assessed during last minute of
each exercise stage and more frequently if
hypotensive or hypertensive responses are
observed.
• Systolic > 250 mmHg and diastolic >115mmHg
is an indication of termination of exercise.
• A decrease in systolic BP with progressive
exercise suggest that cardiac output is unable
to increase in accordance with the work rate
and is reflection of ischemia.

26. Exercise capacity:-
• Exercise capacity is expressed in METs
(metabolic equivalents).
• MET value can be ascribed to any speed and
grade on a trademill or workload achieved on
a cycle ergometer; therefore exercise capacity
can be compared uniformly between protocol.
• MET refers to a unit of O2 uptake. 1MET is
3.5mlO2/Kg/min of body wt.

27. ECG responses:-
ECG should be repeated every 3 min.
In CAD cases exercise can cause an imbalance
between myocardial O2 demand which can
result in alteration in ST segment.

28. Subjective responses:-
• Angina and dyspnea are the subjective
responses.
• Angina and dyspnea are carefully explained to
patient.

29. ANGINA SCALE:-
• 1+ onset of discomfort.
• 2+ moderate
• 3+ moderately severe
• 4+ severe

30. DYSPNEA SCALE:-
• 1+ mild, noticeable to patient but not to
observer.
• 2+ mild, some difficulty, noticeable to
observer
• 3+ moderate difficulty, but can continue
• 4+ severe difficulty, patient cannot continue.

31. TEST TERMINATION
• Drop in systolic BP>10 mmHg from baseline.
• Moderate to severe angina
• Increasing symptoms of ataxia, dizziness or
syncope.
• Subject desire to stop
• Sustained VT
• ST elevation (1mm) without diagnostic Q wave.

32. RECOVERY PERIOD
• Active recovery consist of walking on the
treadmill at a speed of 1.5 – 2mph.
• An active recovery decreases the risk of
hypotension and dysrhythmias.
• A passive standing recovery should be avoided
because of potential complication of venous
pooling.
• Patient should be monitored for 6-8min after
exercise.

33. • BP, ECG and other symptoms should be
monitored and recorded at 2min intervals .
• Recovery period can be extended to resolve
the symptoms.

34. INSTRUCTIONS
• Avoid long standing, hot showers.
• Patient may experience fatigue and muscle
soreness
• Avoid heavy exertion on same day.
• Any discomfort or pain day after test should
be reported.