ET test 4
•METABOLIC GRADED EXERCISE TESTING IS BEST SUITED (AND SHOULD BE REQUIRED) FOR PATIENTS WITH:
-COPD and other lung diseases. -CHF. -Unexplained dyspnea. -Cardiac transplant potential. -Lung transplant potential.
Describe monitoring signs specifically
-Clinical signs of cardiopulmonary exercise intolerance (e.g., ECG changes, drop in BP, pallor)
what are Common variables assessed during clinical exercise testing?
-Heart rate (HR) -Electrocardiogram (ECG) -Blood pressure (BP) -Subjective ratings (RPE/Dyspnea/Angina/OMNI Scales) -Signs and symptoms -Oxygen saturation levels (e.g., SpO2) -Expired gases and ventilatory responses -Blood gases via venipuncture (e.g., PaO2)
Can only physicians conduct exercise tests?
-Over the past several decades, there has been a transition in many exercise testing laboratories from tests being administered by physicians to nonphysician allied health professionals, such as clinical exercise physiologists (CEPS), nurses, physical therapists, and physician assistants. -According to the ACC and AHA, the nonphysician allied health care professional who administers clinical exercise tests should have cognitive skills similar to, although not as extensive as, the physician who provides the final interpretation
Describe monitoring ECG specifically
-Particularly ST-segment displacement and supraventricular and ventricular dysrhythmias
describe three points regarding clinical exercise physiologist and registered clinical exercise physiologist
-Soon to be combined into one certification and BS candidates can take this -Proper training in the field -Proper certifications - BLS and Advanced Cardiac Life Support Certification
Describe the ramp protocol advantages
-avoidance of large and unequal increments in workload, -uniform increase in hemodynamic and physiologic responses, -more accurate estimates of exercise capacity and ventilatory threshold, -individualized test protocol (ramp rate), and -targeted test duration (individualized ramp protocols).
Describe when and why exercise testing is used after a myocardial infarction (important)
-before or soon after hospital discharge for prognostic assessment, -for exercise prescription, -for evaluation of further medical therapy, and -for interventions including coronary revascularization.
Why is functional fitness testing valuable?
-physical activity counseling, -exercise prescription, -disability assessment, -helping to estimate prognosis, and -return to work evaluation (if occupation requires aerobic activity).
What should exercise testing do for asymptomatic individuals?
-reflect general health, -identify normal and abnormal physiologic responses to physical exertion, -provide information to more precisely design the exercise prescription (Ex Rx), and -provide prognostic insight, especially among those with multiple CVD risk factors.
The protocol employed during an exercise test should consider what three things?
-the purpose of the evaluation, -the specific outcomes desired, and -the characteristics of the individual being tested (e.g., age, symptomatology).
Why test high risk individuals during exercise test?
-to assess residual myocardial ischemia, -to assess threatening ventricular arrhythmias, and -for prognosis rather than for diagnostic purposes.
Describe the The Modified Costill/Fox Protocol
•Best for trained endurance runners -Low-risk, endurance-trained individuals •Faster speeds and lower elevations •Monitoring of ECG/BP is difficult, therefore of limited clinical value •Speed continues until the subject reports a RPE of 13. At that point, the grade increases by 2% every 2' until exhaustion.
Which treadmill protocols did verrill list in powerpoint
•Bruce •Modified Bruce •BSU Ramp •Balke-Ware •USAFSAM •ACIP (Asymptomatic Cardiac Ischemia Pilot) •Modified Naughton •Modified Costill/Fox
What are common protocols to include during cycle test
•Commonly used incremental protocol: -Oftentimes 2-minute stages -Work-rate increments of 150 kg . m . min-1 •Higher initial workload or larger increments may be used for larger clients
What are the 4 reasons for wide variability of sub max tests
•Age-predicted maximal HR (± 10-20 bpm) •Mechanical efficiency of client on the ergometer (± 20-30 bpm) •Variability in sub-maximal HR at the same work rate on different days •Break in linearity of HR and O2 as maximum exercise is approached
Describe the emergency stop on a treadmill
•An emergency stop button should be readily visible and available to both the subject undergoing testing and supervising staff.
Describe when the arm test is used, and what type of people use this test for arm ergometry
•Arm ergometer tests can be used for physical activity counseling and exercise prescription for certain disabled populations (e.g., spinal cord injury). •Arm ergometer tests can be used by individuals who perform primarily dynamic upper body work during occupational or leisure time activities.
Describe arm ergometry, when it should be used, muscle mass involved, and what it has been replaced by
•Arm ergometry is an alternative method of exercise testing for patients who cannot perform leg exercise. •Because a smaller muscle mass is used during arm ergometry, maximal oxygen consumption during arm exercise is generally 20%-30% lower than that obtained during treadmill testing. •Although this test has diagnostic use, it has been largely replaced by the non-exercise pharmacologic stress techniques.
Describe ST segment elevation as a response to an exercise test
ST ↑ in leads displaying a previous Q wave MI almost always reflects an aneurysm or wall motion abnormality. In the absence of significant Q waves, exercise-induced ST ↑ often is associated with a fixed high-grade coronary artery stenosis.
What are ABSOLUTE INDICATIONS to stop a test
ST-segment elevation (>1.0 mm) in leads without preexisting Q waves because of prior MI (other than aVR, aVL, or V1 ) Drop in systolic BP of >10 mm Hg, despite an increase in workload, when accompanied by other evidence of ischemia Moderate-to-severe angina Central nervous system symptoms (e.g., ataxia, dizziness, or near syncope) Signs of poor perfusion (cyanosis or pallor) Sustained ventricular tachycardia or other arrhythmia, including 2nd or 3rd degree AV block, that interferes with normal maintenance of Q during exercise Technical difficulties monitoring the ECG or systolic BP The subject's request to stop
Describe the quote for personnel that administer exercise test, what they should be trained in
"In all situations where exercise testing is performed, site personnel should at least be certified at a level of basic life support (CPR) and have automated external defibrillator (AED) training. Preferably, one or more staff members should also be certified in first aid and advanced cardiac life support (ACLS)."
Describe monitoring symptoms specifically
- Chest pain, dizziness, syncope, etc.
Describe monitoring hemodynamics specifically
-Assessed by the heart rate and systolic and diastolic blood pressure responses
Describe the Bayes theorem
-Bayes' theorem states that the post-test probability of having a disease is determined by the disease probability before the test and the probability that the test will provide a true result. -The probability of a patient having a disease before the test is most importantly related to the presence of symptoms (particularly chest pain characteristics), in addition to the patient's age, sex, and the presence of major CVD risk factors.
•WHICH TYPE OF CLIENT WOULD LIKELY PERFORM AN ARM ERGOMETER TEST INSTEAD OF A TREADMILL TEST?
someone has lower extremity issues, nuero problems, no lower half, and obese
Describe ST segment depression as a response to a stress test
An abnormal ECG response is defined as ≥1 mm of horizontal or downsloping ST ↓ 60-80 milliseconds (.06 to .08 seconds) beyond the J-point, suggesting myocardial ischemia.
What is the modified bord scale good for?
We can also estimate one's perception of shortness of breath, or dyspnea. The greater the exercise intensity, the greater the level of dyspnea and dyspnea ratings. This scale is used extensively in cancer and pulmonary rehabilitation programs.
•WOULD THERE BE ANY TYPES OF ATHLETES WHO WOULD HAVE A HIGHER MAXIMAL OXYGEN CONSUMPTION ON ARM ERGOMETER TEST COMPARED TO A MAXIMAL TREADMILL TEST?
Wheel chair athletes!
Glance over bruce protocol vs ACIP protocol
Bruce has higher met level
Describe the bruce vs balke protocol for treadmill test
Bruce is much more vigorous
Describe the stage increases of the bruce treadmill test
Increases 2-3 METS per stage Via both speed and grade Stages are 3 minutes in duration Most often used by physicians due to time constraints! MET level increments technically too great per stage for diseased populations—better protocols available Not appropriate in most cardiac, pulmonary, or cancer
List the 4 purposes of stress tests
Diagnostic, prognostic, therapeutic and Goal setting
Look at these three scales and become comfortable with them
Dyspena, claudulation and angina
Describe the 5 things to monitor during a stress test according to ACSM
ECG, BP, RPE, HR , S&S
Describe 4 factors for selecting the protocol
Ease of assessment and comparison of test results Population being tested (e.g., cardiac vs. healthy) Ability to achieve maximal effort in 6-15 minutes - Ideally 8-12 minutes (sources may vary on this...) Treadmill work rate increases: -By incline only or via speed and incline -In stages or gradual consistent increases (ramps)
What 5 things do we monitor during a stress test according to Mr. Verrill
Hemodynamics, ECG Waves, signs, symptoms, ventilatory gas exchange
Describe Arterial Blood Gas Assessment During Exercise (IV access)
In patients who present with unexplained exertional dyspnea, pulmonary disease should be considered as a potential underlying cause. It is important to quantify gas partial pressures in these patients because oxygen desaturation may occur during exertion. You cannot rely on the pulse oximeters by themselves!
What are sources of error during BP assessment during an exercise test
Inaccurate sphygmomanometer Improper cuff size cuff and sphygmomanometer not at heart level Auditory acuity of technician Rate of inflation or deflation of cuff pressure Experience of technician Reaction time of technician Faulty equipment Improper stethoscope placement or pressure Background noise Allowing patient to hold treadmill handrails or flex elbow Certain physiologic abnormalities (e.g., damaged brachial artery, subclavian steal syndrome, arteriovenous fistula)
Describe the cycle work rates and arm movement of a cycle ergometer test
Incremental work rates on an electronically braked cycle ergometer are more sensitive than mechanically braked ergometers because the work rate can be maintained over a wide range of pedal rates. Because there is less movement of the patient's arms and thorax during cycling, it is easier to obtain better quality ECG recordings, blood pressure measurements and blood draws.
look over the modified bruce protocol chart
Modified is less strenuous
Should a person hang onto the hand rails of treadmill during test
NO! improves results •The treadmill should have handrails for balance and stability; but given the negative impact tight gripping of the handrails can have on both the accuracy of estimated exercise capacity (estimated VO2peak with handrail gripping is greater than measured VO2peak) and the quality of the ECG recording, handrail use should be discouraged or minimized to the lowest level possible when maintaining balance is a concern.
Describe monitoring ventilatory gas exchange specifically
O2 and Co2 percentages and how they change during the test
What type of treadmill is most expensive?
Ones that can bear more weight, may be wider
What are major signs and symptoms of cardiovascular, pulmonary, or metabolic disease.
Pain or discomfort "Heaviness"
Glance over this risk chart for different tests
Pretty darn safe
How do you take a patient BP during test if they have fistulas in both arms?
Take blood pressure somewhere else!!!!
What does a patient self report during a stress test?
The measurement of perceptual responses during exercise testing can provide useful clinical information. Somatic ratings of perceived exertion (RPE) (see Chapters 4,7, and 10) and/or specific symptomatic complaints include:
Describe the main points regarding the bruce treadmill protocol
The most common maximal exercise test protocol Substantial data are available regarding typical responses Starts at approximately 4.5 METs -pretty vigorous
How do you determine if you are going to do a max rest or a submax test?
Time required Expense Personnel Equipment and facilities required and available Risk level of client Medical supervision available Cardiac or pulmonary pathology Patient's medications
Describe the therapeutic purpose of stress tests
To gauge the impact of a given intervention
Describe the goal setting purpose of stress tests
To help design an exercise prescription and for physical activity counseling
Describe the diagnostic purpose of stress tests
To identify abnormal physiologic responses
Describe the prognostic purpose of stress tests
To identify adverse events
what is increased risk synonymous with?
• increased Risk = increased level of risk stratification
Who can administer exercise tests?
•ACSM Certified Clinical Exercise Physiologist (CCEP) or Registered Clinical Exercise Physiologist (RCEP)
Describe the duke nomogram for stress tests
can be used to predict angina severity and their chance of dying in that year
In the clinical setting (e.g., a fully staffed and monitored cardiology ECG lab), would you rather have your patients walk during cool-down, or immediately lie down after the test?
lay down for abnormal responses, to help doctor. Normally would walk but not in this case
What is subjectively self reported during test
degree of chest pain, burning, and discomfort; degree of dyspnea; light-headedness; and leg discomfort or pain.
Describe the commonality of cycle ergometers, the expenses, and what they must include
•Cycle ergometers are the most common exercise testing modes used in many European countries. •Cycle ergometry is less expensive and requires less space than treadmill testing and is a viable alternative to treadmill testing in individuals with obesity and those who have orthopedic, peripheral vascular, and/or neurologic limitations. •The cycle ergometer must include handlebars and an adjustable seat, allowing for the knee to be flexed ~25 degrees of full extension in a given subject.
Describe a VO2 max estimation
•Estimation of VO2max from peak workload -Not a desirable method, but 2nd best option -Metabolic calculation equations were developed for steady-state submaximal work rates -Sometimes used for cycle testing or other treadmill protocols without prediction equations based on time -Due to the lack of availability of metabolic testing in many rehab programs, we often (most of the time) use prediction equations to estimate VO2max -This also helps greatly formulating the exercise prescription (e.g., target exercise METS or kcal)
For patients with a recent MI, what is proportional to their increased chance of survival?
•For every 1 MET in exercise capacity, there is a 12% improvement in survival.
Describe gold standard tests
•Gold standard tests will assess O2 with a metabolic measurement system
Describe normal cardiovascular responses to a graded exercise test
•Heart Rate—increases with exercise unless certain drugs or poor pump (CHF) •Systolic Blood Pressure— increases with exercise unless certain drugs or poor pump (CHF) •Diastolic Blood Pressure—remains about the same or decreases slightly •SaO2—may decrease slightly, but not significantly (> 94-95%)
Describe HR and BP during testing
•Heart rate and blood pressure responses should be measured before, during, and after the GXT. •A standardized procedure should be adopted for each laboratory so that baseline measures can be assessed more accurately when repeat testing is performed.
How do you determine when it's ok to implement a exercise test after a MI?
•Low risk -Submaximal test 4 - 6 days post event -Symptom-limiting test 14 - 21 days post-discharge -Normally 3-6 weeks post hospital discharge -Note: Varies widely depending upon preference of cardiologist
Describe the standard, balke-ware protocol
•Major distinguishing factor: Fixed speed •Small incremental increases of 1/2 MET •Stage duration is 3 minutes, but constantly increasing each min. •Test designed to be longer •Test used exclusively at the Cooper Institute in Dallas, TX
What are relative indications to stop an exercise test
•Marked ST displacement (horizontal or downsloping of > 2 mm, measured 60-80 ms after the J point in a patient with suspected ischemia) •Drop in systolic BP of > 10 mm Hg (persistently below baseline) despite an increase in workload, in the absence of other evidence of ischemia • •Increasing chest pain • •Fatigue, shortness of breath, wheezing, leg cramps, or claudication •Arrhythmias other than sustained ventricular tachycardia, including multifocal ectopy, ventricular triplets, supraventricular tachycardia, and bradyarrhythmias that have the potential to become more complex or interfere with hemodynamic stability •Exaggerated hypertensive response (SBP >250 mm Hg and/or a DBP > 115 mm Hg) •Development of a bundle-branch block that cannot be distinguished from ventricular tachycardia •SpO2 < 80%
Describe standard cycle protocol
•Non-weight bearing with external resistance •Ability to push resistance is related to muscle mass Ramp protocols are popular
Describe diagnostic exercise testing and what it's used to assess
•Patients with a high probability of disease (e.g., typical angina, prior coronary revascularization, myocardial infarction) are tested: -to assess residual myocardial ischemia, -to assess threatening ventricular arrhythmias, and -for prognosis rather than for diagnostic purposes.
Describe what should be recorded post exercise
•Patients with a high probability of disease (e.g., typical angina, prior coronary revascularization, myocardial infarction) are tested: -to assess residual myocardial ischemia, -to assess threatening ventricular arrhythmias, and -for prognosis rather than for diagnostic purposes.
Describe the bruce-ramp protcol
•Patterned after the Bruce protocol -Same speed and grade at each 3-minute time period •Difference: increases work rate every 20 seconds with speed and grade settings •Allows for a longer walking time -11 minutes vs. 9 minutes on the standard Bruce protocol •Most subjects prefer this vs. standard Bruce •Better from a physiological perspective for attaining true HRmax and VO2max
Where should physicians be during exercise test?
•Physicians (nearby in the area—NOT necessarily in the GXT room)
Describe 3 points reguarding vo2 max tests
•Provide measures of exercise ventilation and expired concentrations of O2 and CO2 to derive O2 •Expense, maintenance, and expertise needed for operation of metabolic systems limit their use •Methods have been developed to predict O2 from measures taken during maximal exercise tests
What should be done post exercise in terms of monitoring
•Regardless of the postexercise procedures (active vs. passive recovery), monitoring should continue for at least 6 minutes after exercise or until ECG changes return to baseline and significant signs and symptoms resolve. •ST-segment changes that occur only during the post-exercise period are currently recognized to be an important diagnostic part of the test.
Describe errors during VO2 max testing
•Remember that errors can easily occur with metabolic testing!
Describe risk of an exercise test
•Risk increases with the intensity of exercise and increasing client risk stratification levels •Comorbidities and risk factors are "cumulative"
What test should be considered to use for a patient who recently had MI?
•Submaximal Exercise Testing provides sufficient data to assess the effectiveness of: a) current pharmacologic management (see Appendix A) b) activities of daily living (ADLs), and c) early ambulatory exercise therapy recommendations. •Symptom-limited Graded Exercise Tests are considered safe and appropriate early after discharge (~14-21 d) for: a) exercise prescription, b) physical activity counseling and c) further assessment of pharmacologic management efficacy.
Describe GXT supervision
•The ideal health professional to supervise the maximal GXT for all healthy and clinical populations is the clinical exercise physiologist (CEP). •Unfortunately, many hospitals still employ ECG technicians and nurses to perform GXT duties. •These hospital staff members are not best suited to perform GXTs, as they typically have had no exercise physiology training of what happens to the healthy and diseased body during maximal exertion.
What is the magnitude of ischemia inversely and directly proportional to?
•The magnitude of ischemia caused by a coronary lesion (clot or blockage) is generally: -directly proportional to a) the degree of ST-segment depression, b) the number of ECG leads involved, and c) the duration of ST-segment depression in recovery; and -inversely proportional to the a) the ST slope, b) the rate pressure product (RPP) at which the ST-segment depression occurs, and c) the maximal HR, SBP, and METS achieved.
Describe the treadmill test specifically, cost etc
•The treadmill is the most common exercise testing mode used in the United States. •Many models available—must pay $6-10K for a "laboratory grade" TM Treadmills in clinical exercise laboratories should be electronically driven, allow for a wide range of speed (1-8 mph or 1.61-12.8 km ∙ h−1) and grade (0%-20%), and be able to support a body weight of at least 350 lb (159.1 kg) with heavier TM's around
List and describe 3 common modes of exercise testing
•Treadmill—the default mode for most facilities due to its similarity to daily activities and uses more muscle mass, therefore typically the highest VO2max •Cycle ergometer—good for obese, disabled, children and older individuals (as well as those who specialize in cycling) •Arm ergometer—necessary for individuals who have lower body disabilities or neuromuscular issues
Describe the criteria for determining if a subject hit a vo2 max
•VO2 plateaus (< 2 ml/kg/min variation at peak) •RER > 1.15 (debatable) •HR within 10 beats of age-predicted max •Blood lactate is > 8 mmol/L •RPE > 17
Describe vo2 peak vs vo2 max
•VO2peak: The highest VO2 obtained during a particular test. For example, you could have a VO2peak higher on a test such as a treadmill test compared to a VO2peak on an arm ergometer test. •VO2max: Your maximal oxygen consumption observed during a graded exercise test. This is usually the highest value recorded during the test and is your true maximal oxygen consumption (or functional capacity). For example, your VO2peak on a cycle ergometer test could be significantly lower than your VO2max on a treadmill test.
