II. Efficacy: False Positive Rate

  1. Women: 17%
  2. Men: 11%

III. Preparation

  1. Hold all Beta Blockers 24 hours before test
  2. Hold nitrates (Nitroglycerin) on day of the test

IV. Technique

  1. Typically performed on treadmill (but may be performed on Exercise bike)

V. Indications: Asymptomatic subjects

  1. No absolute indications
  2. Possible indications
    1. Special occupation
      1. Pilot
      2. Police officer
      3. Bus driver
    2. Valvular heart disease: Aortic Regurgitation
    3. Cardiac rhythm disorders
      1. Rate-adaptive Pacemaker assessment
      2. Sports Physical for congenital complete Heart Block
      3. Exercise-induced rhythm disturbance evaluation
    4. Pre-Hypertension Evaluation: Diagnostic criteria
      1. Peak systolic Blood Pressure >214 or
      2. High systolic Blood Pressure >3 minutes in recovery
      3. High diastolic pressure >3 minutes in recovery
    5. Patient with Diabetes Mellitus
      1. Age over 35 years or
      2. Type 2 diabetes >10 years
      3. Type 1 diabetes >15 years
      4. Secondary complications (Neuropathy, retinopathy)
    6. Patient with Cardiac Risks and age >45 years old
      1. Cardiac Risk Factors: 2 or more risk factors
      2. Sedentary patient planning new Exercise program

VI. Indications: Symptomatic subjects

  1. Definite indications
    1. First-line study to assess CAD risk where intermediate risk
      1. See contraindications below
      2. See Angina Diagnosis to determine those with intermediate risk
      3. Requires normal baseline EKG (otherwise requires Stress Imaging)
      4. No prior revascularization procedures such as PTCA, CABG (requires Stress Imaging)
      5. Ability to Exercise at least 5 METS (requires Pharmacologic Stress Testing)
      6. No Diabetes Mellitus (requires Stress Imaging)
    2. Acute Coronary Syndrome Assessment (Low Risk Chest Pain evaluation)
      1. Must have <1 mm resting ST depression
      2. Significant change in clinical status
      3. Atypical symptoms in men or menopausal women
      4. Unstable Angina without active Angina or Congestive Heart Failure
        1. See Acute Coronary Syndrome for risk levels
        2. Low Risk Chest Pain patient after 8-12 hours observation
        3. Intermediate risk and following criteria met
          1. Normal Cardiac Markers at 0 and 6 hours and
          2. No change in serial electorcardiograms and
          3. No evidence of active ischemia
    3. Assess patient with Exercise-induced dysrhythmia
      1. Also see asymptomatic patients above
    4. Known Coronary Artery Disease
      1. Precaution
        1. Do not stress test if recent revascularization procedure
        2. Stress testing is not recommended unless change in function or acute event
        3. In addition, Stress Imaging is preferred if known Coronary Artery Disease
      2. Post-Myocardial Infarction to assess prognosis
        1. Submaximal stress test
          1. Pre-discharge: 4-6 days post-MI or
          2. Post-discharge: 14-21 days post-MI
        2. Symptom-limited stress test at 3-6 weeks post-MI

VII. Contraindications

  1. Aortic Dissection
  2. Critical Aortic Stenosis
  3. Critical Left Ventricular outflow-tract obstruction
    1. Idiopathic Hypertrophic Subaortic Stenosis (IHSS)
  4. Inability to Exercise to adequate level of exertion
    1. Unable to perform 5 minutes on Bruce Protocol
  5. Uninterpretable Electrocardiogram
    1. Left Bundle Branch Block (Adenosine Nuclear needed)
    2. Electronically paced rhythm (Pacemaker)
    3. WPW Syndrome
    4. Abnormal ST segments (>1 mm ST abnormality)
      1. Includes Digoxin
      2. Includes Left Ventricular Hypertrophy
  6. Recent or active cerebral ischemia
  7. Severe, Uncontrolled Hypertension
  8. Uncompensated Congestive Heart Failure
  9. Unstable Angina
  10. Digoxin Use (Class IIB Recommendation)
  11. Cardiac revascularization within last 5 years

VIII. Interpretation: Poor prognostic findings

  1. Low workload
    1. Mets <6.5
    2. Time: < 5-6 minutes on Bruce protocol
  2. Low peak Heart Rate
    1. Pulse < 120 without Beta-Blocker therapy
  3. Systolic Blood Pressure decreased or flat response
    1. Remains under 130 mmHg
  4. ST segment depression >2mm
  5. ST segment depression in multiple leads
  6. Prolonged ST depression after Exercise (>6 min)
  7. ST Elevation without abnormal Q wave
  8. Increase in complex ventricular ectopy
  9. Exercise-induced typical Angina
  10. Frequent ventricular ectopy
    1. Frolkis (2003) N Engl J Med 348:781-90 [PubMed] (or open in [QxMD Read])

IX. Interpretation: Predictors of mortality in women

  1. Decreased peak Exercise capacity
  2. Delayed Heart Rate recovery
  3. ST depression on Exercise was not related to mortality
  4. Mora (2003) JAMA 290:1600-7 [PubMed] (or open in [QxMD Read])

X. Interpretation: Prognostic Duke Treadmill Score

  1. Background
    1. Score developed for patients with median age 49
    2. Alternatively, ability to perform 6 mets on Bruce protocol is as predictive as Duke Score
    3. Not predictive in patients over age 75 years
      1. Kwok (2002) J Am Coll Cardiol 39:1475-81 [PubMed] (or open in [QxMD Read])
  2. Calculation
    1. Start with Exercise Time (minutes)
    2. Subtract (5 x ST segment depression mm)
    3. Subtract (4 x treadmill Angina score)
      1. No Angina: 0
      2. Non-limiting Angina: 1
      3. Limiting Angina: 2
  3. Interpretation
    1. Low death risk: 5 or more
      1. Four-year survival 98-99%
    2. Intermediate Risk: Between -10 and +5
    3. High death risk: Below -10
      1. Four-year survival 71-79%

Images: Related links to external sites (from Google)

Ontology: Exercise stress test (C0015260)

Definition (NCI) A recording of cardiac electrical activity during stress or exercise.
Definition (MSH) Controlled physical activity, more strenuous than at rest, which is performed in order to allow assessment of physiological functions, particularly cardiovascular and pulmonary, but also aerobic capacity. Maximal (most intense) exercise is usually required but submaximal exercise is also used. The intensity of exercise is often graded, using criteria such as rate of work done, oxygen consumption, and heart rate.
Concepts Diagnostic Procedure (T060)
MSH D005080
SnomedCT 142255002, 165085002, 165079009
English Exercise tests, Exercise Test, Test, Exercise, Tests, Exercise, Stress Test, Stress Tests, Test, Stress, Tests, Stress, Exercise Tests, Exercise tolerance test NOS, Exercise stress test, exercise testing, stress test, Stress test, EXERCISE STRESS TEST, Exercise tolerance test NOS (procedure), Stress Electrocardiography, exercise stress testing, exercise stress tests, exercise tests, stress testing, cardiac stress tests, exercise tolerance test, cardiac stress testing, exercise stress test, exercise testings, cardiac stress test, stress tests, Exercise test, Exercise tolerance test, Exercise tolerance test (procedure), exercise test
Dutch stresstest, inspanningstest, Belastingstest, Stresstest, Test, belasting-
French Epreuve d'effort, Épreuve d'effort, Test d'effort, Épreuve d'exercice
German Stresstest, Belastungstest, Streßtest
Portuguese Prova de stress, Prova de esforço, Teste de Esforço
Spanish Prueba de esfuerzo, Exercise tolerance test, prueba de tolerancia al ejercicio (procedimiento), prueba de tolerancia al ejercicio, SAI (procedimiento), prueba de tolerancia al ejercicio, SAI, prueba de tolerancia al ejercicio, prueba de tolerancia al esfuerzo, SAI, Ergometría, Prueba de Esfuerzo, Test de Esfuerzo, Test de Estres, Test del Escalon, Test Ergometrico de Bicicleta, Test Ergometrico del Brazo, Test Ergométrico de Bicicleta, Test Ergométrico del Brazo, Test de Estrés, Test del Escalón, Prueba de Estres, Prueba de Estrés
Japanese ストレス試験, ウンドウシケン, ストレスシケン, トレッドミルテスト, エルゴメーター負荷試験, ステップテスト, 運動負荷, 応力テスト, 二輪車作業計量テスト, 上腕エルゴメトリテスト, 負荷心電図法, 運動負荷試験, 運動試験
Swedish Arbetsprov
Czech zátěžové testy, námahový test, Zátěžový test, Stresový test
Finnish Kuormituskoe
Russian PROBA S NAGRUZKOI, VELOERGOMETRICHESKII TEST, TEST S FIZICHESKOI NAGRUZKOI, FIZICHESKAIA NAGRUZKA, TEST, ВЕЛОЭРГОМЕТРИЧЕСКИЙ ТЕСТ, ПРОБА С НАГРУЗКОЙ, ТЕСТ С ФИЗИЧЕСКОЙ НАГРУЗКОЙ, ФИЗИЧЕСКАЯ НАГРУЗКА, ТЕСТ
Italian Test da sforzo, Prova da sforzo
Croatian TEST OPTEREĆENJA
Polish Próba wysiłkowa
Hungarian Stressz vizsgálat, Terheléses vizsgálat