Doctor123.org

Exercise Treadmill Testing

Doctor123.org

Exercise Treadmill Testing

Introduction

Equipment

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

Following exercise testing a therapeutic exercise program can be

prescribed and later assessed for its benefits.

assessing physical fitness, determining functional capacity, diagnosing

To deal with possible complications, one

must be trained in advanced cardiac life support (ACLS) protocols. ACLS

available at all times. The most important safety precaution is careful

pretest patient evaluation and selection of the proper protocol. The

test is 0.8 per 10,000 tests. The risk of infarction is 3.5 per 10,000

the ECG leads are placed for the exercise test as follows:

Step 1 View Original Step 1 View Original

A baseline ECG is obtained in

the supine position and compared with a previous baseline ECG prior

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.,

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

the patient is put into the recovery (cool-down) period for 1 to 2

parameter a marker for heart disease. Monitoring in the recovery

period is continued for 9 minutes or until the patient has returned

removed from the patient, the test results are carefully reviewed,

and a written report is made. Inform the patient of the results.

defined by ST-segment changes with exercise. The most common

findings are a normal response followed by the abnormal responses of

exercise stress testing include (i) evaluating signs or symptoms induced

or accentuated by exercise; (ii) assessing or identifying abnormal

(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,

of specific disease states, including serial testing measurements; and

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

(e.g., Kawasaki 's disease, anomalous left coronary artery

heart transplant patients; (viii) patients with hemodynamically stable

supraventricular tachycardia (SVT); (ix) patients with stable dilated

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

(include double product); (ii) any dysrhythmias; (iii) the functional

aerobic capacity; (iv) ECG changes, especially the ST-segment; (v)

measurements, pulse oximetry, glucose determinations); (vi) the presence

or absence or myocardial ischemia (probability statement); and (vii)

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

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

2003. 2Froelicher VF, Myers J.

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

2002;106:1883 " 1892. [View Abstract] 4Lane JR, Ben-Schachar G.

2007;120:938 " 943. 5Paridon SM, Alpert BS, Boas SRClinical stress testing

Young, Committee on Atherosclerosis, Hypertension, and

Circulation. 2006;113:1905 " 1920. [View Abstract] 6Price DE, Elder K, White RD.

Connor FG, Sallis R, Wilder R,

et al., eds. Sports Medicine " Just the

2004:118 " 126. 72008 MAG Mutual Healthcare

Fee and Coding Guide. Duluth,

  • 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

  • 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
  • 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

  • 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.
  • 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.
  • 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).
  • 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.
  • 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.

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

Postprocedure Instructions

Coding Information and Supply Sources

  • 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