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EXERCISE ECG

EXERCISE ECG. NON CORONARY APPLICATIONS. EXERCISE PHYSIOLOGY. Vagal withdrawl-increase HR Symp activation-increase venous return -increase ventilation -incr HR Increase CO Increase BP-b/c of incr CO,though SVR fall.

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EXERCISE ECG

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  1. EXERCISE ECG NON CORONARY APPLICATIONS

  2. EXERCISE PHYSIOLOGY • Vagal withdrawl-increase HR • Symp activation-increase venous return • -increase ventilation • -incr HR • Increase CO • Increase BP-b/c of incr CO,though SVR fall

  3. At fixed work load <AT,steady state of HR,CO,BP and Ventilation occur in 2 mts.Hemodynamics return to normal within mts on stopping

  4. V O2 MAX • O2 consumption of body during max response to exercise • Depends on-Efficiency of lungs, heart,circulatory system and peripheral tissue to extract O2 • Reproducible value,when corrected for Body wt

  5. V O2 MAX • Can be asessed in many ways • V O2= CO x ( CaO2_ Cv O2) • Can be predicted from population values based on body wt • From CP Ex test, breath by breath analysis of PA O2 and PI O2 • VO2=VxWx(.073+OC/100) x 1.8

  6. ANAEROBIC THRESHOLD • Point when muscle switch to anaerobic metabolism as an additional source • Lactate accumulate –CO2 • V CO2 increase, so VE incr • AT occur at 40-60% of VO2 Max

  7. AT • AT can be identified by • disproportionate rise inVCO2 • disproportionate rise in VE • disproportionate rise in ratio of Vco2/Vo2 to Vo2 • Point of intersection of VO2 and VCO2 slopes

  8. Noncoronary indications • CLASS I • Evaluation of Ex capacity & response to Rx in CHF pts for transplant • Differentiate cardiac Vs pulm cause of DOE • Chr AR,-to asess functional status in pts with equivocal symptoms • Evaluate Ex capacty n child with CHD/Post op CHD, Valvular/myocardial diseases

  9. Class I • Child with angina • Appropriate setting in rate adaptive pacemakers • Evaluation of cong CHB in children planning more physical activity/plan to participate in sports

  10. ClassIIa Indications • Asymptomatic DM ,who plan to start vigorous physical activity • Chr AR-evaluation of symptom and functional capacity before participating in sports • Chr AR-prognostic asessment before AVR in minimally symptomatic with LV dysfn

  11. ClassIIa • Exercise induced arrhythmia • Evaluation of medical/surgical/RFA in pts with Ex induced arrhythmia • Evaluation of Ex capacity for medical reasons in pts in whom subjective asessment is not reliable

  12. Valvular heart disease • Objective asessment of atypical symptom • Asess Ex capacity &disability • Elderly-asymptomatic b/c of inactivity • For coexisting CAD

  13. Aortic StenosisSymptomatic sevAS is absolute CI for TMT

  14. AS • Elderly-asympt b/c of inactivity • Cong AS • Lesseffort tolerance,hypotension,ST • depression,increased LVET-sev obstruction • To diff pts with sev AS and Lvdysfn from pts with poor LV function in the setting of mild to mod AS-if trans Ao flow increse with Ex ,primary problem is LVdysfn

  15. AS • Tst to be stopped if Hypotension,VPC,decrease HR occurs • If BP response is abnormal ,pt require a cool down period before attaining supine position, to avoid volume overload. • Ex ST depression.>2mm is asso with >50mm gradient in children

  16. AS • STdepression not correlate with CAD • Supravalvular AS –increase BP in Rt UL

  17. AR • ClassI indication in pts with equivocal symptoms • >1mm ST depression is asso with lower rest and Ex EF,increased wall stress, and greater ESV • Decrease in HR, AT and MVO2 predict LV dysfn

  18. Mitral stenosis • Useful in pts asymptomatic due to inactivity • Abnormal increase in HR, decrease in BP ,chest pain are indicators for early surgery

  19. Mitral regurgitation • Ex and asessing LV function post Ex is useful in documenting occult LV dysfn • MVP without MR- Ex induced MR is asso with subsequent development of MR • ST depression can occur in MVP-causes are pap muscle ischaemia,abnormal coronaries,compression of LAD,spasm,primarycardiomyopathy etc

  20. MR • In pts with CAD undergoing TMT,development of ischaemic MR may be a cause for flat response in syst BP

  21. Pulmonary stenosis • Decrease Ex capacity • ST depression in inf and V1-V3 • May develop cyanosis with Ex,-shunt via PFO

  22. Congenital and Paediatric Uses • Class IIb indications • F/H of SCD • Followup of diseases like Kawasaki’s disease,SLE etc where coronary disease are expected • Long QT syndromes • Asessment of VT in pts with cong CHB

  23. Class IIb indications • Adequacy of Beta Blocker Rx in children • Evaluation of BP response &arm –leg gradient after surgery for Co A. • Asess degree of desaturation in well balanced or palliated cyanotic heart disease

  24. LEFT-RIGHT SHUNTS • Usually no role • Older pts show reduced Ex tolerance • TMT not routinely done to decide operability • Post Ex SaO2<92%&PaO2<80% correlate with PVR>7

  25. Eisenmenger syndrome • Ex is hazardous. Not routinely done • TMT may be done to evaluate response to therapies intented to decrease PAH

  26. TOF • Before Sx,they have,reduced Ex tolerance ,lessVO2,low peak HR,and Ex induced arrhythmia • Post Sx,improvement in Ex capacity occurs • TMT can be used to asess surgical efficacy and to detect residual lesion • Reduced Ex capacity post Sx suggest residual lesion

  27. TOF • If Ex test shows ST depression,less MaxVO2, poor Ex tolerance,ventricular arrhythmia pt should be evaluated for residual lesion/RV dysfn

  28. Other cyanotic heart diseases • TMT is useful in detecting residual lesion, and ventricular arrhythmia post Sx • Post switch Sx, to asess coronary insufficiency

  29. Coarctation • After Sx ,abnormal syst BP elevation may occur normally with Ex • Abnormal dia BP elevation suggest restenosis • Rest A-L Gradient>15 and Ex gradient>35 require angioplasty/Sx • Significant ST depression also suggest significant gradient29

  30. Children with CAD • Ex test is indicated in the following pts prior to participating in sports programme and evaluation of chest pain in them • ALCAPA,Kawasaki’s disease,SLE,Coronary aneurysm, post switch Sx,post TOF Sx with RCA crossing RVOT close to infundibular resection

  31. Supra ventricular arrhythmia • Atrial ectopics –if ectopic has Stdepression more than sinus beat or has tall R than sinus beat it suggest CAD • AF- To detect whether rate is controlled even with Ex • Stdepression in AF s/o CAD

  32. Sick sinus syndrome • To differentiate b/w sss and vagotonia • Chronotropic incompetence s/oSSS(in –ability to attain 85% MPHR • Can also occur in severe CAD with LV dysfn

  33. Ventricular tachycardia • VT may be reproducible with Ex • Varies from 36-80% • RVOT VT reliably reproduced • Also has prognostic value • Also useful in asessing efficacy of Rx

  34. Congenital CHB • Indi cated in child with CHB • If they have effort intolerance –PPI • Also useful in evaluating syncope in them.can demonsrate Torsades

  35. Bundle branch blocks • Rate related BBB-usually occur in asso with CAD • RBBB-reliability of ST depression is debated • ST depression may occur in V1-V3 without CAD • ST depression in V4-V6 s/o CAD

  36. LBBB • Usually not possible to diagnose CAD in presence of LBBB with TMT • Stdepression more than 1.5mm than at rest s/o CAD

  37. WPW SYNDROME • ST depression does not indicate CAD • Ex may bring out delta wave • Ex can cause disappearance of delta wave • Abrupt loss of pre excitation indicate larger refractory period in accessory pathway,. • These pts are unlikely to develop rapid ventricular rate with atrial arrhythmia

  38. LQTS • QTc.440 msec 1mt after Ex s/o LQTS

  39. CHF-Severity • A—VO2>20,AT>8 • B—VO2-16-20,AT 6-8 • C—VO2- 10-16,AT 4-6 • D—VO2 <10 ,AT<4

  40. Timing of transplant • Pts who achieve >50% predicted Max VO2 ,transplant may be defered • Peak VO2>14ml/mt/kgtransplant can be deferred

  41. Evaluation of DOE • Cardiac VE Max does not exceed 50% of MVV • VO2 Max and AT achieved usually • SaO2does not fall below 90%

  42. Resp DOE • VEMax exceeds >50% of MVV • VO2 Max and AT not achieved • Hypoxia occurs

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