Dr R.V.S.N. Sarma., M.D.

,
M.Sc.,

Consultant Physician and

Chest Specialist

To my beloved mother

Slowly progressive CAD

CSA to USA to NSTEMI to STEMI
and CVM
Warning ++ long duration
Collateral CBF good
ECG / TMT evidence +
CAG will confirm CAD
Prognosis is good; Older
Non vulnerable plaques
Flow limiting narrowing
Form only 30 % of MI cases

Group with sudden MACE

Give no time to act
SCD or Massive MI
No previous CSA or USA
No warning; Short duration
No time for collateral CBF
TMT/ CAG -ve before MACE
Prognosis is poor; Younger
Vulnerable ruptured plaques
Focus on factors causing rupture
Contribute to 70% of MI cases

1. Routine Treadmill (ECG only) ETT or

TMT
2. Stress Echocardiography
Dobutamine Echocardiography (CSE)
Exercise Stress Echocardiography (ESE)

3. Nuclear Imaging Chemical Stress - MPI

Dobutamine Nuclear Stress
Adenosine Nuclear Stress
Persantine Nuclear Stress

 Exercise testing is a well-established procedure

It is in widespread clinical use for many
decades
The how-to is beyond the scope of this talk
Although ETT is generally a safe procedure,
both MI and death have been reported
Occur at a rate of up to 1 per 2500 tests
(0.04%)
It is essential to screen and choose the pt for
ETT

 Perfect Lead contact shaving the chest area in men

Should be supervised by a well trained physician,
who should be available immediately for
emergencies
Careful monitoring & recording in each stage of
exercise

The electrocardiogram (ECG)

Heart rate
Blood pressure
And during ST-segment abnormalities and chest pain.

The patient should be monitored continuously

For transient rhythm disturbances, ST-segment changes
and
ECG manifestations of myocardial ischemia.

Bicycle Ergo meter

Treadmill Test

 Cycle Ergo meters are generally

Less expensive and smaller

Less noisy than treadmills
ECG disturbances are minimum
But, produce less motion of the upper part of
body
The fatigue of the quadriceps muscles is a
major limitation

Treadmills are much more commonly used

Supine stress testing is not routinely used

Diagnostic Test
Age
utility
Gender
Most in
Angina
intermediate
H/o previous
probability
MI
Least in high or
Q waves in ECG
low probability
Typical Angina
Resting ST-T
Sub-sternal
changes
location
Diabetes
Provoked by
Dyslipidemia
exertion or

Use a computer model or

Use the probability table

Absolute
Acute myocardial infarction (within 2 days)
High-risk unstable angina
Uncontrolled cardiac arrhythmias
Symptomatic severe aortic stenosis
Uncontrolled symptomatic heart failure
Acute pulmonary embolus or pulmonary
infarction
Acute myocarditis or pericarditis
Acute aortic dissection

Relative
Left main coronary stenosis
Moderate stenotic valvular heart
disease
Electrolyte abnormalities
Severe arterial hypertension
Tachy or Brady arrhythmias
HOCM and other outflow obstructions
Mental or physical impairment
High-degree atrio-ventricular block

Absolute indications
Drop in SBP of >10 mm Hg from baseline BP with
accompanying evidence of ischemia
Moderate to severe angina
Increasing nervous system symptoms ataxia,
dizziness
Signs of poor perfusion (cyanosis or pallor)
Technical difficulties in monitoring ECG or SBP
Subjects desire to stop; Sustained ventricular
tachycardia
ST elevation (1.0 mm) in leads without diagnostic Q

Relative indications
Drop in SBP of 10 mm Hg BP without ischemia
ST or QRS changes - ST depression (>2 mm of
horizontal
or down sloping ST-segment ) or axis
shift
Arrhythmias VT, multifocal PVCs, triplets of PVCs,
SVT,
Heart block or brady arrhythmias, BBB or IVCD
Fatigue, shortness of breath, wheezing, leg cramps, IC
Increasing chest pain; Hypertensive response >
250/115

 Only Manual SBP measurement for safety

Adjust to clinical history (couch potatoes)
Age predicted Heart Rate Targets ? ?
The BORG Scale of Perceived Exertion
METs - not Minutes have to be used
Use standard ECG analysis + 3 minute
recovery
Use scores, ST/HR Index, Heart rate
recovery
ST segment changes alone will not suffice

o Metabolic Equivalent Term

o 1 MET = "Basal" aerobic oxygen consumption
to stay alive = 3.5 ml O2 /Kg/min -70 kg, 40
yr man
o Actually differs with thyroid status, post
exercise,
obesity, disease states
o By convention just divide ml O2/Kg/min by 3.5
METs =

Speed x [0.1 + (Grade x 1.8)] + 3.5

3.5

Calculated automatically by Device!

 Total of 1+6 (Seven 3 minute stages) (3+18 min)

Each minute exercise is approximately 1 MET
Pretest plain walking + 6 Stages of graded exercise
In each stage there is increase in speed and
gradient
Initial 1.7 mph with 10% gradient (upward inclination)
Maximum 5.5 mph with 20% gradient

Modified Bruce 2 warm up stages (1.7 mph 0%,

5%)
For elderly and patients with reduced exercise capacity

o 1 MET = "Basal" = 3.5 ml

O2 /Kg/min

o 2 METs =
2 mph on level
o 4 METs =
4 mph on level
o < 5METs = Poor prognosis if
< 65 years

o10 METs =

Medical Rx as
good as CABG

o 13 METs = Excellent
prognosis

o 16 METs = Aerobic master

 Lead V5 alone consistently outperforms other leads

False + ves are high with the inferior leads
Without prior MI and with normal resting ECGs, the
precordial leads alone are a reliable marker for
CAD.
Exercise-induced ST-segment only in inferior
leads is not significant for CAD.
Down sloping or horizontal ST-segment is a
stronger predictor of CAD but not up sloping ST

J point depression of 2
to 3 mm in leads V4 to
V6 with rapid up
sloping ST segments
depressed
approximately 1 mm 80
m sec after the J point.
This response should
not be considered
abnormal.

In lead V4 , the exercise

ECG result is abnormal
early in the test, reaching
0.3 mV (3 mm) of
horizontal ST segment
depression at the end of
exercise.
Consistent with a severe
ischemic response.

This slow up sloping ST

segment at peak exercise
indicates an ischemic
pattern with a high
coronary disease
prevalence pretest.
A typical ischemic pattern
is seen at 3 minutes of the
recovery phase when the
ST segment is horizontal
and 5 minutes after
exertion when the ST
segment is down sloping.
This is typical ischemic

 Early repolarization is a common resting

pattern of ST in normal persons.
Exercise-induced ST-segment is always
considered from the baseline ST level.
ST is seen after a Q-wave infarction, but
ST in leads without Q waves occurs in
only 1 of 1000 (0.1%) patients of ETT.
ST is very arrhythmogenic and localizes
the IHD

 MACE : Sudden Cardiac Death (SCD), AMI and USA

Ruptures of high-risk or vulnerable plaques
Inner plaque material is exposed to blood and
initiates formation of a platelet-fibrin thrombus on
the rupture.
The rupture may seal without detectable sequelae or
The patient may experience ACS or SCD.
Majority of the vulnerable plaques appear
insignificant on
the CAG ,before rupture (less than
75% stenosis)
Majority of the stenosis > 75% have no vulnerable
plaques

LV Functional Damage

Severity of CAD

Modifiable factors

H/o Prior MI, ECG Path Qs

Anatomic - SVD, DVD, TVD

DM, HT, Dyslipidemia

CHF, Cardiomegaly in CXR

Degree of stenosis and extent Excess weight, Smoking

EF (<40%) and ESV

Transient IHD on Holter

Other co-morbidities

LV -RWMA on Echocardio

ETT induced ST deviations

Other Metabolic factors

Conduction disturbances

Progressive symptoms of IHD Ventricular arrhythmias

MR, Exercise tolerance

Increasing age

Systolic Blood Pressure x HR = Double

Product
Example: SBP 170 x HR 160 = 27, 200
Double product must be at least: 20, 000
SBP should rise > 40 mmHg
Diastolic BP may decline by 10 mm
Drop of > 10 mm in SBP is ominous
(Exertional Hypotension)

 Age Predicted Maximum HR (PrMHR) = (220

Age in years)
Example: For a 55 years pt Pr MHR = (220-55)
= 165
THR = 90% of Pr MHR of 165 = 148
Chronotropic Incompetence = < 85% of Pr
MHR
In this case 85% of 165 (Pr MHR) = < 140 BPM
Chronotropic Index (CI)= of less than 0.8 is
very significant
(HRpeak HR rest) (PrMHR HRrest)
If this pt achieved HRpeak of 130 from HRrest

Abnormal
If the HR is not reduced by at
least 22 BPM
from peak exercise heart rate to
heart rate
measured after 2 minutes.
It is strongly predictive of allcause mortality.

 Duke score = Exercise time 5 (ST-segment

deviation in mm) 4 Exercise Angina Index (EAI)
Exercise time is based on a standard Bruce protocol
ST deviation is < 1 mm, is taken as 0.
ST deviation = Max exercise ST Base line ST
E A I value: 0 if no exercise angina
1 if exercise angina occurred
2 if angina severe enough to stop
ETT
Interpretation contd

 High-risk group: The Duke score of 11

13% of patients fall in this group.
Average annual CV mortality 5%.
Intermediate risk : The Duke score of + 4 to
10
53% of all patients fall in this group
Annual CV mortality 0.5% to 4%
Low-risk group: The Duke score of + 5
34% of patients fall in this group.
Average annual CV mortality < 0.5%
For Duke treadmill score Nomogram. See next
slide

This nomogram applies to patients with known or suspected coronary

artery disease, without prior revascularization or recent myocardial
infarction, who undergo exercise testing before coronary angiography.

Variable
Maximal Heart
Rate

Circle response

Poin
ts

Less than 100 bpm

= 30
100 to 129 bpm =
24
130 to 159 bpm =18
160 to 189 bpm =12
190 to 220 bpm =06

Exercise ST
Depression

1-2mm =15
> 2mm =25

Age

>55 yrs =20

40 to 55 yrs = 12

Angina History

Definite/Typical = 5
Probable/atypical
=3
Non-cardiac pain =1

Hypercholesterol
emia?

Yes=5

Choose only
one per
group

<40: Low
probability

40-60:
Intermediate
probability
>60: High
probability

Variable
Maximal Heart
Rate

Circle response Poin

ts
Less than 100 bpm
= 20
100 to 129 bpm =
16
130 to 159 bpm =12
160 to 189 bpm =08
190 to 220 bpm =04

Exercise ST
Depression

1-2mm =06
> 2mm =10

Age

>65 yrs =25

50 to 65 yrs = 15

Angina History

Definite/Typical =
10
Probable/atypical
=6
Non-cardiac pain =2

Estrogen status

Positive = -5;
Negative = +5

Choose only
one per
group

<37: Low
probability

37-57:
Intermediate
probability
>57: High
probability

 954 patients - clinical/TMT

reports
Sent to 44 expert
cardiologists,
40 cardiologists and 30 MD
physicians
Scores did always better
than all three

SCORE = (1=yes, 0=no)

METs<5 + Age>65 + History of
CHF + History of MI or Q wave
a=0, b=1, c=2, d=more than 2

ETT Result
Low risk
Intermediate
High risk
Co morbidity +

CAD Prob Average Mortality

40%

1% per year

40 to 60% 2 3 % per year

60%

4% per year

Any prob. Any level risk

Recommend
Medical Rx.
Imaging/CAG
CAG soon
Medical Rx.

GOLD STANDARD
CAD
by CAG

No CAD
by CAG

True Positives False Positives

a
b

TMT VE

False Negative True Negatives

c
d

TEST

TMT + VE

SnNOUT
(Minimum FN)
Sensitivity
is

True positives
a
Total CAD
Specificity is
a+c
True Negatives
d
Total No CAD

Total CAD
a+c

Total No CAD
b+d

b SpPIN
+ d (Minimum FP)

GOLD STANDARD
CAD
by CAG

No CAD
by CAG

True Positives False Positives

60
60

TMT VE

False Negative True Negatives

40
240

TEST

TMT + VE

SnNOUT
(Rules out 60%)
Sensitivity
is

True positives
60
Total CAD
Specificity is
100
True Negatives
240
Total No CAD

Total CAD
100

Total No CAD
300

300
SpPIN (Confirms 80%)

SnNout

Gianrossi R, Detrano R,
Mulvihill D, et al.
Exercise-induced ST
depression in the
diagnosis of coronary
artery disease.
Circulation 1989; 80:8798.
Meta-analysis of 147
consecutive studies
involving 24,074 patients

SpPin

78
76
74
72
70
68
66
64
62
SENSITIVITY

SPECIFICITY

 Sensitivity of ETT is as low as 30 % v/s

62% in men
Stress imaging is not the first alternative
in women
Just as in men Exercise ECG testing is the
first test
Multiple CV risk factors, Severe long
standing DM, PVD, CKD are indications for
ETT
Routinely in asymptomatic men/women
without any CV Risk factors ETT is not
indicated

 Risk stratification and assessment of

prognosis
Functional capacity for activity level
after discharge
Assessment of adequacy of medical
therapy
To decide on diagnostic or treatment
options.
ETT after MI is safe but after 2 to 3
weeks
Fatal Re MI and cardiac rupture 0.03%

 The two types of patients Implications

for testing
Sensitivity (SnNout) : 62%; Specificity
(SpPin) : 78%
Pretest probability : If intermediate ETT is
very useful
METs < 5; 5-10; >10, > 13 ; Bruce
protocol - minutes
Max SBP at least 40 mm more; THR
90% of MHR
Drop in SBP ominous, Chronotropic
Incompetence

www.cardiology.org for all the calculators

http://www.emedicine.com/med/topic2961.htm
http://www.aafp.org/afp/990115ap/401.html
http://www.acc.org/clinical/guidelines/exercise
http://www.annals.org/cgi/content/full/118/2/81
http://www.webmd.com/heart-disease/exerciseelectrocardiogram
http://circ.ahajournals.org/cgi/content/full/96/1/345#T
1
http://www.mssm.edu/medicine/generalmedicine/ebm/CPR/CAD.html