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107 Unit 1

Exercise Stress Testing

What is Exercise Testing used to obtain? -Cardiovascular abnormalities not present at rest -Determine the adequancy of cardiac function
What does Exercise Testing used to Determine? -estimate prognosis -Functional capacity -The likelihood and extent of CAD -The effects of therapy
Another Name for Exercise Stress Testing -Graded Exercise Test
What does the Magnitude of Hemodynamic response during exercise depend on? -Severity of the exercise -Amount of muscle mass involved
Amount of mass involed -exercise workload -amount of body surface area being exercised
What happens after the second minute of exercise? -steady-state conditions are reached -heart rate, cardiac output, blood pressure, and pulmonary ventilation are maintained at reasonably constant levels
What happens as Exercise Progress -Skeletal muscle blood flow is increased -Oxygen extraction increases -Total Calculated Peripheral resistance decreases -Systolic BP, Mean Arterial BP increases -Pulse pressure increases -Diastolic blood pressure does not change significantly
Functional Class I > 7 mets -recreation activities -skiing, basketball, sports, jog/walk 5 mph
Functional Class II >5 Mets -garden, rake, wee, roller skates, walk 4 mph on level ground -cannmot complete activities around greater than or equal to & Mets
Functional Class III >2 Mets -make bed, clean windows, walk 2.5 mph, play golf, dress without stopping -cannot do activities requiring equal to or greater than 5 Mets
Functional Class IV -patients cannot perform activities requiring equal to or greater than 2 mets
What does a change from supine to upright posture cause a decrease in? -Venous Return -Left Ventricular end-diastolic volume and pressure -stroke volume
The net effect of exercise performance while in the upright as compared with the supine position 10% increase
3 factors that affect the net effect of exercise Time HR Cardiac Index
3 Main types of Exercise -Static (isometric) -Dynamic (isotonic) -Resistive (both)
what happens 8-12 minutes of continuous progressive exercise? -myocardial oxygen demand is elevated to the patient's maximal level -optimal for diagnostic and prognostic purposes
Static Exercise (Isometric) -exerts muscles at high intensities without movements of the joints -produces a greater blood pressure response than dynamic exercise -increase in HR and BP almost proportional to the force exerted
What the does the patient sustain in an isometric (static) exercise? 20-30% of maximal force for 3-5 minutes
What occurs when heavy dynamic exercise such as lifting weights is performed? -the cardiovascular response is a combination of the responses that occur during both dynamic aerobic exercise and isometric exercise
Dynamic Exercise -keeps joints and muscles moving -swimming, walking, bicycling, weight training
What does dynamic Exercise Improve? -blood circulation -strength -Endurance
Treadmill Protocol -should be consistent with patients physical capacity and purpose of the test -standard bruce protocol
What happens when patients grab the handrails of the treadmill during exercise? -functional capacity can be overestimated by as much as 20%
The Bruce Multistage Maximal treadmill Protocol -3 minute periods to allow achievement of a steady state before workload is increased
Modified Brue Protocol -older individuals -those whose exercise capacity is limited by cardiac disease -modified by two 3-minutes warm-up stages
Warm up Stages of Modified Bruce Protocol -two 3 minute warm-up stages -1.7 mph at 0% grade -1.7 mph at 5% grade
Stage I Bruce Protocol 1.7nmph 10% Class III
Stage II Bruce Protocol 2.5 mph 12% Functional Class I
Stage III Bruce Protocol 3.4 mph 14% Functional Class I
Stage IV Bruce Protocol 4.2 mph 16% Functional Class I
Stage V Bruce Protocol 5 mph 18% Functional Class I
Stage VI Bruce Protocol 5.5 mph 20% Functional Class I
Stage VII Bruce Protocol 6 mph 22% Functional Class I
Naughton and Weber Protocols -use 1-2 minute stages with 1 met increments between stages -more suitable for patients with limited exercise tolerance -patients with compensated heart failure
Arm Ergometry -increment workloads of 10-20 (W) -2-3 minutes stages
What is increased in Arm Ergometry vs Leg exercise? -HR -BP
The most common frequency of Arm Ergometry 50 rpm
Bicycle Ergometry -workloads in W or Kilopond-meters per min (Kpm) -1 W = 6 Kpm -work is determined by force and distance -constant pedaling rate of 60-80 rpm
Electronically Braked Bicycles -provide a constant workload despite changes in pedaling rate and are less dependent on a patients cooperation
Walk Test -older patients -heart failure -orthopedic limitations -
What is recorded form a 6 minute walk test? -total distance walked -symptoms experienced
When should a test not be performed on a patient? Hypertensive (>220/120) Hypotensive (<80 systolic)
the minimum amount of leads that should be displayed continuously throughout the test 3
Electrocardiograph Measurements -Pericardial inflammation -non-shortening of PR, QRS, & QT Intervals -P wave amplitude increase J-Point Depression ST Segment depression ST Segment depression with Inverted T Waves
When the degree of resting ST Segment depression is 0.1 mV/1 mm (ischemia) or greater what happens? -Exercise ECG Becomes less specific -Myocardial imaging modalities should be considered
What does .5 mm in leads V2 and V3 signify? ischemia
Upsloping ST Segments -J point depression is normal during maximal exercise -rapid upsloping segment more than 1 mV/sec -depressed less than 0.15 mV (1.5 mm)
Upsloping ST Segments in patients with a high CAD prevalence -a slow upsloping ST Segment depressed 0.15 mV (1.5 mm) or more than 80 milliseconds (.08 or two small boxes) after the J point -abnormal
ST Segment Elevation -0.10 mV (1 mm) or more of J Point elevation is abnormal -occurs more in patients with anterior myocardial infarctions (MI)
T wave changes -morphology can be influenced by several factors -respiration -drug therapy -ischemia -necrosis
Normal Response of BP -increase systolic BP progressively with increasing workloads to a peak response ranging from 160-200 mmHg
Abnormal BP Response -Failure to increase systolic BP beyond 120 mmHg -sustained decrease greater than 10 mmHg repeatable within 15 seconds -a fall in systolic BP below standing resting values during progressive exercise
Causes of a Fall in Systolic BP below standing resting values during progressive exercise -inadequate elevation of cardiac output -could be due to left ventricular systolic pump dysfunction -excessive reduction in systemic vascular resistance
Maximal Work Capacity -one of the most important prognostic measurements
Influences of Maximal Work Capacity -familiarization with the exercise test equipment -level of training -environmental conditions at the time of testing
What is known or suspected CAD associated with? -increased risk of fatal and nonfatal cardiovascular event regardless of age, gender, race or abdominal adiposity -acute coronary syndromes -stroke
Submaximal Exercise -Max x .85
Maximal Hr 220-age
Who Nondiagnostic Test results are more common with? -peripheral vascular disease -orthopedic limitation -neurologic impairment -patients with poor motivation
Pharmacologic Stress Imaging Studies -Vasodilator nuclear stress testing -Inotrope (increase in HR) Stress Echo
Vasodilator nuclear stress Testing -radioactive substance is added and x rays are taken before and after stress test
Heart Rate Response -Sinus Rate increases progressively with each exercise
Inappropriate Increases in HR -anxiousness -A-fib -Physically deconditioned -hypovolemia -anemia -LV Failure (Marginal LV Function)
Beta-Adrenergic Response -decreased in older patients -decrease in Max HR and cadiac output
Abnormal HRR -relatively slow deceleration of heart rate following exercise cessation -associated with increased abnormal and high-risk myocardial perfusion scans
HRR Peak HR - HR 1 minute later
HRR in upright cool-down position 13 or more is normal
HRR in supine position 19 or more is normal
HRR 2 Minutes into recovery 23 or more is normal
Prognostic Value of abnormal HR independent of exercise level -Beta-blocker usage -Severity of CAD -Left Ventricular Function -Presence of Exercise-Induced Angina -Ischemic electrocardiographic abnormalities
Wht is abnormal HRR associated with? -Increased abnormal and High-risk myocardial perfusion scans
When does exercise-induced chest comfort usually occur? -occurs after the onset of ischemic ST segment abnormalities -may be associated with diastolic hypertension
The most frequent indication for exercise testing coronary artery disease
Patient's Risk Status -aymptomatic population -symptomatic patients -silent myocardial ischemia -acute coronary syndromes -myocardial infarction -CHF
Increased Catecholamine Levels -accelerates the impulse conduction -velocity -shortened myocardial refractory period -increase the slope of phase 4 depolarization of the action potential
Cardiac Rhythm Disturbances -metabolic acidosis -Exercise-Induced myocardial Ischemia
What is Exercise Testing useful for evaluating the effects of? -Ventricular Arrhythmias -Supraventricualr Arrhythmias -Atrial Fibrillation -Sinus Node Dysfunction -Atrioventricular Block -Left Bundle Branch Block -Right Bundle Branch Block -Preexcitation Syndrome -Cardiac Pacemakers and defib devices
Absolute Contraindications to Exercise Testing -recent significant changes in the ECG --significant ischemia --acute cardiac event -acute systemic infection accompanied by fever, body aches -acute MI (within 2 days) -High-risk unstable angina -uncontrolled cardiac arrhythmias
Absolute Contraindications to Exercise Testing -symptomatic severe aortic stenosis -uncontrolled symptomatic heart failure -acute pulmonary embolus or pulmonary infarction -acute myocarditis or pericarditis
Relative Contraindications to Exercise Testing -asymptomatic at rest -left main coronary stenosis -Moderate Stenotic Valvular Heart Disease -Electrolyte Abnormalities -Severe Arterial Hypertension -Tachyarrhythmias or bradyarrhythmias -Mental or phyiscal impairment -High-Degree AV Block
Relative Contraindications to Exercise Testing -uncontrolled endocrine disorder (diabetes, thyroid) -chronic infectious disease (hepatitis, Aids)
Absolute Reasons to Terminate Exercise -Drop in systolic BP >10 mmHg from baseline BP with signs and symptoms -Moderate to severe Angina -Ataxia, Dizziness, near-syncope -cyanosis -techinal difficulties -subject's desire to stop -sustained Vtach -ST elevation above or equal to 1.0 mm
Relative Reasons to Terminate Exercise -asymptomatic -drop in systolic BP >10 mmHg with no evidence of ischemia -ST or QRS Changes -Arrhythmias other than sustained Vtach -fatigue, SOB, wheezing, leg cramps, claudication -devlopment of BBB or intraventricular conduction delays
Relative Reasons to Terminate Exercise -increasing chest pain -hypertensive response (systolic bp at or above 250 mmHg and/or diastolic blood pressure at or above 115 mmHg
Medications available to treat these cardiac arrhythmias in Crash Cart -A-V block -Hypotension -Persistant chest pain
How often are emergency equipment and supplies checked? daily basis
Created by: Mdarrielle09