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Stress Testing by TreadmillTreadmill protocolExercise capacity is reported in terms of estimated metabolic equivalents of task (METs). The MET unit reflects the resting volume oxygen consumption per minute (VO2) for a 70-kg, 40-year-old man, with 1 MET equivalent to 3.5 mL/min/kg of body weight. In the standard Bruce protocol, the starting point (ie, stage 1) is 1.7 mph at a 10% grade (5 METs). Stage 2 is 2.5 mph at a 12% grade (7 METs). Stage 3 is 3.4 mph at a 14% grade (9 METs). This protocol includes 3-minute periods to allow achievement of a steady state before workload is increased. The modified Bruce protocol has 2 warmup stages, each lasting 3 minutes. The first is at 1.7 mph and a 0% grade, and the second is at 1.7 mph and a 5% grade. This protocol it is most often used in older individuals or those whose exercise capacity is limited by cardiac disease. The Bruce protocol has larger increments between stages than do other protocols, such as the Naughton, Weber, and Asymptomatic Cardiac Ischemia Pilot (ACIP) study protocols, all of which start with less than 2 METs at 2 mph and increase in 1- to 1.5-MET increments between stages. Other exercise protocols include bicycle and arm ergometry, both of which are used less often in North America than treadmill stress testing is. The bicycle ergometer has the advantage of requiring less space than a treadmill. It is quieter, permits sensitive precordial measurements without much motion artifact, and is generally safer because the risk of falling from the machine is lower. Indications for termination of exercise testingThe American College of Cardiology (ACC)/American Heart Association (AHA) guidelines also specify indications for termination of exercise testing. Absolute indications for termination of testing include the following:
Relative indications for termination include the following:
Interpretation of test findingsInterpretation should include exercise capacity and clinical, hemodynamic, and ECG response. The occurrence of ischemic chest pain consistent with angina is important, particularly if it forces termination of the test. The classic criteria for visual interpretation of positive stress test findings include the following:
Noncoronary causes of ST-segment depression include the following:
 Author Specialty Editor Board Yasmine S Ali, MD, MSCI, FACC, FACP Assistant Clinical Professor of Medicine, Vanderbilt University School of Medicine; President, LastSky Writing, LLC Yasmine S Ali, MD, MSCI, FACC, FACP is a member of the following medical societies: American College of Cardiology, American College of Physicians, American Heart Association, American Medical Association, American Medical Writers Association, National Lipid Association, Tennessee Medical Association Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: LastSky Writing;Philips Healthcare;M Health;Athena Health;PeerView Institute;Verywell Health; HealthCentral;MedEdicus;Pharmaceutical Training Institute;Elsevier;MedStudy;North American Thrombosis Forum;WellnessVerge;Prose Media; AKH, Inc.<br/>Serve(d) as a speaker or a member of a speakers bureau for: North American Thrombosis Forum. Chief Editor Eric H Yang, MD Associate Professor of Medicine, Director of Cardiac Catherization Laboratory and Interventional Cardiology, Mayo Clinic ArizonA Eric H Yang, MD is a member of the following medical societies: Alpha Omega Alpha Disclosure: Nothing to disclose. Acknowledgements Javier M Gonzalez, MD Consulting Staff, Department of Cardiology, Citrus Cardiology Consultants Javier M Gonzalez, MD is a member of the following medical societies: American College of Cardiology and American Medical Association Disclosure: Nothing to disclose. Ronald J Oudiz, MD, FACP, FACC, FCCP Professor of Medicine, University of California, Los Angeles, David Geffen School of Medicine; Director, Liu Center for Pulmonary Hypertension, Division of Cardiology, LA Biomedical Research Institute at Harbor-UCLA Medical Center Ronald J Oudiz, MD, FACP, FACC, FCCP is a member of the following medical societies: American College of Cardiology, American College of Chest Physicians, American College of Physicians, American Heart Association, and American Thoracic Society Disclosure: Actelion Grant/research funds Clinical Trials + honoraria; Encysive Grant/research funds Clinical Trials + honoraria; Gilead Grant/research funds Clinical Trials + honoraria; Pfizer Grant/research funds Clinical Trials + honoraria; United Therapeutics Grant/research funds Clinical Trials + honoraria; Lilly Grant/research funds Clinical Trials + honoraria; LungRx Clinical Trials + honoraria; Bayer Grant/research funds Consulting Justin D Pearlman, MD, ME, PhD, FACC, MA Chief, Division of Cardiology, Director of Cardiology Consultative Service, Director of Cardiology Clinic Service, Director of Cardiology Non-Invasive Laboratory, Director of Cardiology Quality Program KMC, Dartmouth-Hitchcock Medical Center, Dartmouth Medical School Justin D Pearlman, MD, ME, PhD, FACC, MA is a member of the following medical societies: American College of Cardiology, American College of Physicians, American Federation for Medical Research, International Society for Magnetic Resonance in Medicine, and Radiological Society of North America Disclosure: Nothing to disclose. Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Medscape Salary Employment What are absolute indications for terminating an exercise test?The following are the absolute indications for termination of testing:. A drop in systolic blood pressure of greater than 10 mmHg from baseline when accompanied by other indications of ischemia.. Moderate-to-severe angina.. Increasing neurologic symptoms, such as ataxia, dizziness, near-syncope.. When should you terminate exercise?The exercise test should be terminated in each of the following scenarios: ≥10 mmHg drop in systolic blood pressure in presence of other signs suggestive of myocardial ischemia. Systolic blood pressure >280 mmHg. This limit is lower if the patient has an increased risk of bleeding (e.g patients on anticoagulants).
Which of the following are general indications for stopping an exercise test during a maximal graded exercise test?Absolute Indications. Suspicion of a myocardial infarction or acute myocardial infarction (heart attack). Onset of moderate-to-severe angina (chest pain). Drop in systolic blood pressure (SBP) below standing resting pressure or drop in SBP with increasing workload accompanied by signs or symptoms.. Why would an exercise tolerance test be discontinued?ETT might be prematurely stopped for any of the following: development of chest pain, presence of ST elevation, very deep, 2 mm or more ST depression, arrhythmias, hypotension or if the patient becomes tired and is unable to continue.
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Which of the following are absolute indications for terminating an exercise test?
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