Introduction
Exercise testing is a useful diagnostic
procedure performed by appropriately trained primary care physicians.
The three major cardiopulmonary reasons for doing exercise testing
relate to diagnosis, prognosis, and therapeutic prescription. The
predictive value of the exercise test is greatest when test results are
combined with family history, current symptoms, and underlying risk
factors. This consensus approach of combining clinical information with
exercise test data yields 94% sensitivity and 92%
specificity. Exercise testing allows the clinician to assess the
severity of previously diagnosed disease and to predict the
patient 's future risk of cardiac events, including death.
Following exercise testing a therapeutic exercise program can be
prescribed and later assessed for its benefits.
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Exercise testing can be utilized in
assessing physical fitness, determining functional capacity, diagnosing
cardiac disease, defining the prognosis of known cardiac disease,
determining an exercise prescription, and guiding cardiac
rehabilitation.
To deal with possible complications, one
must be trained in advanced cardiac life support (ACLS) protocols. ACLS
equipment, including proper medications and a defibrillator, should be
available at all times. The most important safety precaution is careful
pretest patient evaluation and selection of the proper protocol. The
overall risk of a significant cardiac event during an exercise stress
test is 0.8 per 10,000 tests. The risk of infarction is 3.5 per 10,000
tests, with a mortality rate of 0.5 to 1.0 in a high-risk
population.
Equipment
- Exercise treadmill
device - Echocardiogram (ECG)
machine - Monitor
- Defibrillator and ACLS
equipment (not shown)
Indications
- Evaluating patients with
chest pain - Screening for latent
coronary artery disease - Determining functional
capacity - Evaluating
dysrhythmias - Early detection of labile
hypertension - Generating an exercise
prescription - Evaluating individual
training programs for athletes - Establishing the
severity/prognosis of coronary artery disease - Evaluating antianginal or
antihypertensive therapy - Evaluating arrhythmias or
antiarrhythmia therapy - Evaluating patients with
congestive heart failure - Evaluating congenital
heart disease and valvular dysfunction - Evaluating the patient
after myocardial infarction for risk stratification
Contraindications
Absolute Contraindications
- A recent
significant change in the resting ECG, suggesting
significant ischemia or other recent cardiac event - Recent
myocardial infarction (within 2 days) or other acute cardiac
event - Unstable
angina - Uncontrolled
arrhythmias, causing symptoms or hemodynamic changes - Severe aortic
stenosis - Uncompensated
congestive heart failure - Acute pulmonary
embolus or pulmonary infarction (within 3 months) - Suspected or
confirmed dissecting aneurysm - Acute
infections - Acute
myocarditis or pericarditis - Uncooperative
patients
Relative Contraindications
- Known left main
artery stenosis - Moderately
stenotic valvular heart disease - Electrolyte
abnormalities (e.g., hypokalemia, hypomagnesemia) - Severe systemic
hypertension (systolic pressure >200 mm Hg or
diastolic pressure >110 mm Hg) - Uncontrolled
tachyarrhythmias or bradyarrhythmias - Hypertrophic
cardiomyopathy or other forms of outflow tract
obstruction - Neuromuscular,
musculoskeletal, or rheumatoid disorders that prohibit
exercise or are exacerbated by exercise - Chronic
infectious disease (e.g., mononucleosis, hepatitis,
AIDS) - High degree of
atrioventricular block (second-degree Mobitz II or
third-degree block) - Ventricular
aneurysm - Uncontrolled
metabolic disease (e.g., diabetes mellitus, thyrotoxicosis,
or myxedema)
The Procedure
Step 1
Following informed consent,
the ECG leads are placed for the exercise test as follows:
- V1 " fourth
intercostal space right side of the sternum - V2 " fourth
intercostal space left side of the sternum - V3 " midway
between V2 and V4 (usually overlying the fourth rib) - V4 " fifth
intercostal space in the midclavicular line (usually below
the left nipple) - V5 " fifth
intercostal space in the anterior axillary line - V6 " fifth
intercostal space in the midaxillary line - Right arm
lead " right infraclavicular fossa - Left arm
lead " left infraclavicular fossa - Right lower
extremity lead " lower abdomen - Left lower
extremity lead " midback or left lower side - PITFALL: Check leads V5 and V6 carefully
because often they are not positioned correctly. - Pearl: Reapply brassiere in women to help
maintain proper position of leads during the procedure.
Step 1 View Original Step 1 View Original
Step 2
A baseline ECG is obtained in
the supine position and compared with a previous baseline ECG prior
to initiating the procedure.
- PITFALL: Any change from the previous
resting ECG may indicate unstable angina or a recent
myocardial event, including infarction, and may be cause to
abort the procedure.
Step 2 View Original Step 2 View Original
Step 3
Initiate the test according
to the specified protocol. The modified Bruce protocol allows the
patient to become accustomed to the treadmill speed and to smaller
increment changes in the inclination or grade prior to starting the
more aggressive Bruce protocol. Total exercise time is 8 to 12
minutes for a physiologic response. Each stage is 3 minutes in
length. Blood pressure and pulse are recorded with a Borg score
(perceived exertion) at the end of each stage (see Table 15-1).
Table 15-1.Modified Bruce (Gray Cells) and Bruce ProtocolsView LargeTable 15-1.Modified Bruce (Gray Cells) and Bruce Protocols Stage Speed (mph) Grade (%) 0 1.7 0 1/2 1.7 5 1 1.7 10 2 2.5 12 3 3.4 14 4 4.2 16 5 5.0 18 6 5.5 20
Continue the procedure until
the patient reaches peak exercise or develops complications (e.g.,
arrhythmias, chest pain). If the patient achieves <85%
of his maximum predicted heart rate (MPHR) and no abnormalities are
found, the results are inconclusive. (MPHR ¢ ¼ 220 - age
± 12 beats for 95% confidence limits. This derived
value has an extremely wide range and is not specific for the
individual patient.)
- PITFALL: Observe the monitor for any
cardiac abnormalities. - PITFALL: Observe the patient for signs of
distress " difficulty maintaining speed and grade,
difficulty breathing, or gait abnormalities. - PITFALL: Record any other parameters
(e.g., Wright peak flow, pulse oximetry) with each stage of
the procedure. - PITFALL: Information is valid and more
predictable if the patient achieves his personal maximum
heart rate determined by high work load (METs), exertional
fatigue (Borg scale), and plateau of heart rate (failure of
heart rate to increase in response to an increasing
workload).
Step 3 View Original Step 3 View Original
Step 4
The test is terminated, and
the patient is put into the recovery (cool-down) period for 1 to 2
minutes. Heart rate and blood pressure are determined at 1 minute.
Systolic blood pressure at 3 minutes is divided by the systolic
blood pressure at peak exercise. If this ratio is ≥0.91, this
parameter a marker for heart disease. Monitoring in the recovery
period is continued for 9 minutes or until the patient has returned
to baseline blood pressure and heart rate. The leads are then
removed from the patient, the test results are carefully reviewed,
and a written report is made. Inform the patient of the results.
- PITFALL: ECG abnormalities including
electrocardiographic wave (ST)-segment changes may occur
only in recovery and not during the exercise period. These
"recovery-only ST-segment changes " indicate
heart disease. - PITFALL: A failure to reduce the heart
rate at 1 minute in recovery by at least 12 beats, compared
to the maximum exercise heart rate, indicates heart
disease.
Step 4 View Original Step 4 View Original
Step 5
Interpretation
Myocardial ischemia is
defined by ST-segment changes with exercise. The most common
findings are a normal response followed by the abnormal responses of
upsloping ST-segment depression, horizontal ST-segment depression,
and downsloping ST-segment depression.
- Upsloping
ST-segment depression: ST-segment depression that is
>1.5 mm at 80 msec past the J-point. - Horizontal
ST-segment depression: ST-segment depression that is
>1 mm at 60 msec past the J-point. - Downsloping
ST-segment depression: ST-segment depression that is
>1 mm at 60 msec past the J-point. - ST-segment
elevation (very rare): ST-segment elevation (with J-point
elevation) >1 mm at 60 msec past the J-point. - PITFALL: ST-segment depression represents
subendocardial ischemia and may not correspond to the
anatomic site of pathology (diseased vessel), whereas
ST-segment elevation represents transmural ischemia and does
correspond with the pathologic anatomic site.
Step 5 View Original Step 5 View Original
Complications
- Hypotension
- Congestive heart
failure - Accidental physical
trauma (e.g., falls) - Acute central nervous
system events (e.g., syncope, stroke) - Severe cardiac
dysrhythmias - Acute myocardial
infarction - Cardiac arrest
- Death
Pediatric Considerations
The clinical reasons for pediatric
exercise stress testing include (i) evaluating signs or symptoms induced
or accentuated by exercise; (ii) assessing or identifying abnormal
responses to exercise in children with known cardiac, pulmonary, or
other organ disorders, including myocardial ischemia and arrhythmias;
(iii) assessing efficacy of medical or surgical therapies; (iv)
assessing functional capacity for recreational, athletic, or vocational
activities; (v) establishing baseline data for institution of cardiac,
pulmonary, or musculoskeletal rehabilitation; (vi) evaluating prognosis
of specific disease states, including serial testing measurements; and
(vii) evaluating specific disease states or diagnoses.
These specific disease states or
diagnoses include (i) exercise-related symptoms in a child with normal
ECG and cardiovascular examination; (ii) exercise-induced bronchospasm
studies; (iii) evaluation for long-QTc syndrome; (iv) asymptomatic
ventricular ectopy with a normal structural heart; (v) patients with
unrepaired or residual congenital cardiac disease who are asymptomatic
at rest; (vi) evaluation of patients at risk for myocardial ischemia
(e.g., Kawasaki 's disease, anomalous left coronary artery
circulation, and previous myocardial infarction); (vii) monitoring of
heart transplant patients; (viii) patients with hemodynamically stable
supraventricular tachycardia (SVT); (ix) patients with stable dilated
cardiomyopathy; (x) testing of patients with Marfan 's syndrome;
and (xi) unexplained syncope with exercise.
Exercise treadmill protocols for
pediatric patients are similar to those for adults. Often the Bruce
protocol is utilized and then continued into adulthood. This choice
permits following the patient on a longitudinal basis over many years
with the same protocol. The Balke protocol is also used in pediatric
patients, and in some testing centers the cycle ergometer is
utilized.
Postprocedure Instructions
The postprocedure written report
should include the (i) the heart rate and blood pressure response
(include double product); (ii) any dysrhythmias; (iii) the functional
aerobic capacity; (iv) ECG changes, especially the ST-segment; (v)
results of any other testing parameters (e.g., Wright peak flow
measurements, pulse oximetry, glucose determinations); (vi) the presence
or absence or myocardial ischemia (probability statement); and (vii)
prognosis (based on the Duke treadmill score).
Coding Information and Supply Sources
View Large CPT Code Description 2008 Average 50th Percentile Fee Global Period 93000 ECG with interpretation and report $77.00 XXX 93005 ECG, without interpretation and report $54.00 XXX 93010 ECG interpretation and report only $45.00 XXX 93015 CV stress test with supervision, interpretation, and
report $407.00 XXX 93016 CV stress test supervision only $189.00 XXX 93017 CV stress test supervision only $110.00 XXX 93018 CV stress test interpretation and report only $131.00 XXX 94760 Pulse oximetry, single determination $36.00 XXX 94761 Pulse oximetry, multiple determination $64.00 XXX 94620 Pulmonary stress testing with pre- and postspirometry and
oximetry $248.00 XXX XXX, global concept does not apply.2008
average 50th Percentile Fees are provided
courtesy of 2008 MMH-SI 's copyrighted
Physicians ' Fees and Coding Guide.
ICD-9 Codes
View Large 401.1 to 429.9 Includes hypertension, coronary artery disease, angina,
aneurysm of heart and coronary vessels, cardiomyopathy,
atrial fibrillation, and heart failure 780.2 Syncope and collapse 786.05 Shortness of breath 786.06 Tachypnea 786.07 Wheezing 786.50 Chest pain, unspecified 786.51 Precordial pain 786.59 Chest pain, other V71.7 Observation for suspected cardiovascular disease
Suppliers
- GE Marquette
CASE Stress System, Milwaukee, WI. Web site: www.gehealthcare.com. - Medgraphics
Cardio Perfect Stress System, St. Paul, MN. Web site: www.medgraphics.com. - Quinton Q-Stress
Cardiac Stress System, Bothell, WA. Web site: www.quinton.com. - Spacelabs
Burdick Quest Stress Test System, Deerfield, WI. Web site: www.spacelabsburdick.com. - Welch Allyn PCE
PC-Based Exercise ECG System, Skaneateles Falls, NY. Web
site: www.welchallyn.com.
Bibliography
1Ellestad M.
Stress Testing: Principles and
Practices. 5th ed.
New York:
Oxford University Press;
2003. 2Froelicher VF, Myers J.
Exercise and the
Heart. 5th ed.
Philadelphia:
Sanders-Elsevier;
2006. 3Gibbons RJ, Balady GJ, Bricker JTACC/AHA 2002 guideline
update for exercise testing: summary article: a report of
the American College of Cardiology/American Heart
Association Task Force on Practice Guidelines (Committee to
Update the 1997 Exercise Testing
Guidelines).
Circulation.
2002;106:1883 " 1892. [View Abstract] 4Lane JR, Ben-Schachar G.
Myocardial infarction in healthy
adolescents.
Pediatrics.
2007;120:938 " 943. 5Paridon SM, Alpert BS, Boas SRClinical stress testing
in the pediatric age group: a statement from the American
Heart Association Council on Cardiovascular Disease in the
Young, Committee on Atherosclerosis, Hypertension, and
Obesity in Youth.
Circulation. 2006;113:1905 " 1920. [View Abstract] 6Price DE, Elder K, White RD.
Exercise testing. In: O '
Connor FG, Sallis R, Wilder R,
et al., eds. Sports Medicine " Just the
Facts. New
York:
McGraw-Hill;
2004:118 " 126. 72008 MAG Mutual Healthcare
Solutions,
Inc. 'sPhysicians '
Fee and Coding Guide. Duluth,
Georgia. MAG Mutual
Healthcare Solutions,
Inc.2007.