CLINICAL EXERCISE TESTING

1. CLINICAL EXERCISE TESTING • To evaluate person’s ability to tolerate increasing levels of work output • parameters measured include but are not limited to • ECG • hemodynamic response • symptomatic ischemia • electrical abnomralities • exertion related problems

2. APPLICATIONS • Diagnostic, Prognostic and Therapeutic • Exercise Prescription • Occupation • Activities of daily living

3. DIAGNOSTIC TESTING • Not appropriate for the general population • Age, gender, risk factors , symptoms and vigor of exercise will determine test necessity • Geared toward individuals with a higher probability of disease

4. TESTING FOR DISEASE SEVERITY (PROGNOSIS) • Symptoms, functional capacity and ischemia during exercise are evaluated • Magnitude of ischemic response and at what replicable point does it occurr • Double-Product --SBP x HR= myocardial oxygen consumption

5. TESTING AFTER AN INSULT • Prior to hospital discharge • Submax tests may be used • Symptom limited tests done 4 day post MI • Use to gage activity level and therapy

6. FUNCTIONAL TESTING • Used for exercise prescription, activity counseling, or disability limitations • Usually described in terms of a percentage of “normal” in units of METS

7. CLINICAL TEST MODALITIES • Treadmill--yields the highest VO2 and HR • Hand rails--needs and purposes • Stop belt--Stop exercise • Additional directions for the novice like???

8. MORE • Cycle ergometers--lower VO2 (5-25%) and HR • Better HR and BP measures • Less expensive, less noise, less space • Driven by patient motivation • Localized fatigue • Arm ergometery-lower VO2 (20-30%)

9. PROTOCOLS • Based on purpose of test, desired outcomes and the individual • Bruce, Ellestad--larger incremental changes-for healthy • Naughton, Balke-Ware, USAFSAM--smaller incremental changes--for older and deconditioned • Submax tests-used for individuals that are too unstable or high risk to take to max

10. PROTOCOLS • Submax tests are usually terminated based on a predetermined end point like 120 bpm or a MET level of 5 • Even so, most end points are patient specific • Ramp Protocol-- increasingly popular--based on constant and continuous increase in workload-seemingly more accurate in estimations and more individualized

11. TESTING FOR RETURN TO WORK POST INSULT • 15-20% of MI survivors do not return to work • Medical and nonmedical factors contribute to outcome • Job demands, timelines for return to work, rehab based on job demands, and to determine special work related needs • GXT can provide necessary info but specialized tests can be used also

12. SPECIALIZED TESTS • Weight carrying tests-evaluates tolerance for dynamic and static lifting • Repetitive lifting--evaluates tolerance to bouts of lifting

13. MEASURES DURING TESTS • Pretest--ECG, HR, BP, RPE--supine, sitting, standing • Exercise--3-lead ECG every min., 12-lead ECG last 15 sec, of each stage, BP last min. of each stage, RPE last min. of each stage--BP, 12-lead ECG, and RPE at MAX • Posttest--same as during the exercise portion

14. MEASURING EXPIRED GASES • The most accurate way of determining VO2, functional capacity and VT • Not necessary for all clinical testing • Most appropriate for: evaluating a therapeutic intervention, in research, when cause of exercise limitation is uncertain, evaluation for prognosis and need for transplantation, and exercise prescription for cardiac rehab

15. ECG MONITORING • Quality of ECG very important • Skin prep is essential • shave • alcohol • abrasion • Electrode placement in supine position • 10 electrodes for 12 lead

16. SUBJECTIVE RATINGS • RPE- 0-10 or 6-20 scale • Note instructions on p. 105-6 • Symptomatic scales are different • rating for angina • rating for leg pain • rating for dyspnea

17. POST EXERCISE PERIOD • Healthy individuals do an active and passive recovery • Symptomatic individuals may require supine recovery • Test termination based on absolute or relative indications

18. EXERCISE TESTING WITH IMAGING • Used to determine extent or distribution of disease • An additional confirmation when ECG changes are hard to interpret • Echocardiography-cheaper than nuclear testing but operator dependent • identifies wall abnormalities for ischemia

19. Nuclear Imaging • -limitations include exposure to radiation, additional equipment and personnel and physician training in nuclear medicine and interpretation • advantages include sharper and improved images over 180 degrees rotation--depicts heart in 3 dimensions so multiple myocardial segments can be viewed separately

20. PHARMACOLOGIC TESTING • For patients not able to do an exercise test--to establish diagnosis of CAD or evaluating efficacy of CABG • Dobutamine and Thallium are the most used tests • Images obtained are similar to echocardiography

21. CONSIDERATIONS FOR PULMONARY PATIENT • Degree of dyspnea • Cause of dyspnea • Distinguish between cardiac or pulmonary limitations • Deconditioning factors such as obesity, anxiety • Exercise induced oxygen desaturation

22. TESTING SUPERVISION • Physician supervision • Physician in the immediate vicinity • Paramedical personnel • Expertise versus physician presence • Implications for Costs