Stress Testing by Treadmill

Treadmill protocol
Exercise 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-yearold 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 testing

The 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:
Drop in systolic blood pressure (SBP) of more than 10 mm Hg from baseline, despite an
increase in workload, when accompanied by other evidence of ischemia
Moderate-to-severe angina
Increasing nervous system symptoms (eg, ataxia, dizziness, near-syncope)
Signs of poor perfusion (cyanosis or pallor)
Technical difficulties in monitoring electrocardiographic (ECG) tracings or SBP
Subjects desire to stop
Sustained ventricular tachycardia
ST elevation (> 1 mm) in leads without diagnostic Q waves (other than V 1 or aVR)
Relative indications for termination include the following:
Drop in SBP of 10 mm Hg or more from baseline, despite an increase in workload, in the
absence of other evidence of ischemia
ST or QRS changes such as excessive ST depression (horizontal or downsloping STsegment depression >2 mm) or marked axis shift
Arrhythmias other than sustained ventricular tachycardia, including multifocal premature
ventricular contractions (PVCs), triplets of PVCs, supraventricular tachycardia, heart block, or
bradyarrhythmias
Fatigue, shortness of breath, wheezing, leg cramps, or claudication
Development of bundle branch block or intraventricular conduction delay that cannot be
distinguished from ventricular tachycardia

Increasing chest pain

Hypertensive response (SBP of 250 mm Hg, diastolic blood pressure [DBP] higher than
115 mm Hg, or both)

Interpretation of test findings

Interpretation 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:
J point This is defined as the junction of the point of onset of the ST-T wave; it is
normally at or near the isoelectric baseline of the ECG
ST80 This is defined as the point that is 80 msec from the J point
Depression of 0.1 mV (1 mm) or more
ST-segment slope within the range of 1 mV/sec in 3 consecutive beats

Noncoronary causes of ST-segment depression include the following:

Severe hypertension
Severe aortic stenosis
Cardiomyopathy
Anemia
Hypokalemia
Severe hypoxia
Digitalis
Sudden excessive exercise
Glucose load
Left ventricular hypertrophy
Hyperventilation
Mitral valve prolapse
Intraventricular conduction delay
Preexcitation syndrome ( Wolff-Parkinson-White [WPW] syndrome)
Severe volume overload (aortic, mitral regurgitation)
Supraventricular tachyarrhythmias

General Formula for Calculating Oxygen Consumption and METs on Treadmills

Oxygen utilization (ml/kg/min) = (mph x 2.68) + (1.8 x 26.82 x mph x grade/100) + 3.5
1 MET is 3.5 ml O2/kg/min

For example, consider Bruce Stage II at 2.5 mph, 12% grade:

Oxygen utilization = -(2.5 x 2.68) + (1.8 x 26.82 x 2.5 x 12/100) + 3.5 = 6.70 + 14.48 + 3.5 = 24.68 ml

O2/kg/min.
Since 1 MET is 3.5 ml O2/kg/min, the METs used in the example would be 24.68/3.5 = 7.05 METs.