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PubMed1987

Graded exercise testing.

The graded exercise test can be used for both diagnosis and functional assessment. Indications for diagnostic testing include pain, palpitation, elevated systemic blood pressure and potential problem. Functional testing is performed to determine prognosis, progression of cardiac disease, post-therapy status and physical fitness. For the diagnostic study, medications other than sublingual nitroglycerin should be avoided. For the functional study, the patient's medication should usually be continued.

Arrhythmias, Cardiac↗
PubMed1992

[Exercise tests in pneumology. C.R.E.D.O].

Exercise tests have proved very useful in numerous areas such as sports medicine, research, clinical medicine and rehabilitation to exercise and therapeutic trials. It is not always easy for a pneumologist to decide what sort of effort and which protocol to use. There is also the question of which parameter to use and the relationship between parameters and which are the most pertinent as a function of the aim of the research. Above all the exercise test should be adaptable in view of the diversity of the objectives. In routine pneumology the exercise test using a bicycle ergometer and a triangular type of protocol are recommended for numerous reasons. The usual parameters (ventilation, oxygen consumption, production of carbonic dioxide, cardiac rate and blood gases) and their derivatives all have a value in the domain of cardiorespiratory physiology. It is important in clinical practice not to give too great an emphasis to the exact relationship expressed as a function of the workload, because the cycloergometer is practically never calibrated or even checked by the user. Dyspnoea was the major symptom leading the patient to seek a consultation and it is of primary importance that all effort tests include an estimation of the sensation of breathlessness.

Blood Gas Analysis↗
PubMed1986

[Early exercise test after myocardial infarction].

Exercise tests of coronary function at the tenth day of an uncomplicated myocardial infarction offer objective evaluation of short-term benefits of an early accelerated physical retraining program. They also allow better individual adaptation of exercises prescribed at the start of convalescence at home. Exercise test results show significant correlation with clinical data and bicycle ergometer tests carried out two months after infarction, with respect to physical aptitude, reasons for discontinuation of test and lethality risk two months after infarction. This suggests that exercise tests performed after the acute phase of myocardial infarction are of diagnostic and prognostic value.

Aged↗
PubMed1987

Current review of exercise testing: application and interpretation.

Exercise testing has changed dramatically in scope over the past 50 years. While initially used to assess functional capacity, it is now also utilized to detect the presence and severity of coronary artery disease (CAD), to evaluate postmyocardial infarction patients at risk for future cardiac events, to screen certain asymptomatic populations for CAD, and to evaluate dysrhythmias, peripheral vascular disease, and lung disease. Dynamic exercise in continuous multistage protocols is most popularly employed because of the more easily measured workload. The safety of exercise testing, its contraindications and termination end points are summarized. The sensitivity of exercise testing ranges between 60 and 70% while specificity has been reported between 85 and 90%. Both sensitivity and specificity are enhanced through use of radionuclide exercise thallium imaging and ventricular angiography.

Coronary Disease↗
PubMed1987

Comparison of exercise-positive with recovery-positive treadmill graded exercise tests.

A treadmill exercise test response may become positive because a diagnostic electrocardiographic ST-segment shift occurred during exercise, or, less often, because it occurred only during the recovery period after exercise had been completed. Factors that may be related to these 2 different responses in subjects enrolled in the Program of Surgical Control of Hyperlipidemia were investigated. No differences were found with regard to age, sex, level or location of Minnesota electrocardiographic Q-QS codes, number of narrowed coronary arteries, presence of collateral coronary artery circulation, ejection fraction, number of abnormally moving left ventricular wall segments, heart rate, systolic and diastolic blood pressure, double product, total exercise time, exercise-induced angina, or maximally achieved exercise heart rate or double product. Thus, the same significance should be attributed to a recovery-positive as to an exercise-positive treadmill test, and electrocardiographic, hemodynamic and angiocardiographic variables do not distinguish between subjects who exhibit these 2 different responses.

Adult↗
PubMed1989

[The integrative cardiorespiratory exercise test: 2. Response to maximal exercise in heart and lung diseases].

Physiological measurements during integrative cardiorespiratory progressive exercise in different cardiovascular and respiratory disorders help discern and describe the characteristic exercise response patterns of different disorders. Cardiovascular limitation to exercise is characterized by reduced maximal exercise capacity and reduced anaerobic threshold and oxygen utilization. On the other hand, respiratory limitation of exercise is characterized by reduced breathing reserve with high ventilatory equivalents for a given metabolic load but with a normal cardiovascular response. Combined cardiovascular and respiratory disorders demonstrate both cardiovascular and respiratory types of limitation of exercise. We present 2 patients with cardiovascular disorders, 2 with respiratory, and 2 with combined cardiovascular and respiratory disorders. The interpretation of the physiological data of the progressive cardiorespiratory exercise test increased the accuracy of clinical evaluation and treatment. We therefore think the test will gain wide use in the clinical evaluation of patients with cardiovascular and respiratory disorders.

Cardiovascular Diseases↗
PubMed1985

Exercise testing in suspected coronary artery disease.

The interpretation and selection of exercise tests depends on the pretest probability of CAD. Imperfect tests (like exercise tests) provide probability estimates, not definite statements (such as "the patient has CAD" or "the patient does not have CAD"). In patients with a low pretest probability of CAD (asymptomatic persons or men and women with nonanginal chest pain), abnormal exercise test results provide probability estimates that are much too low to conclude that the patient has CAD. In patients with anginal pain and normal exercise tests, the probability of CAD is too high to conclude that the patient has a normal coronary circulation. Exercise tests are not useful for trying to rule out CAD in patients with anginal pain. In patients with an intermediate pretest probability of CAD (men and women with atypical angina and women with typical angina), abnormal exercise tests (particularly the myocardial scintiscan) provide probability estimates that are high enough to justify starting treatment for CAD. Exercise tests are most useful in this group, a conclusion that has been reached by other methods of analysis. The myocardial scintiscan is much more useful than the exercise ECG in women. When CAD is strongly suspected, exercise tests have relatively little diagnostic value but may be useful for prognosis. However, clinical evidence of poor ventricular function may alone suffice to select patients with angina pectoris for coronary arteriography. Conversely, when clinical indicators of congestive heart failure are absent, the prognosis in chronic stable angina is so favorable that any further testing may be unnecessary. Screening asymptomatic persons for CAD is a very low yield practice. Patients who have no cardiac risk factors (hypercholesterolemia, family history of CAD, cigarette smoking, and hypertension) are at especially low risk of a primary cardiac event. Older men with stable typical angina are particularly likely to have left main coronary artery stenosis or three-vessel disease with poor ventricular function. The exercise ECG can identify groups of older men with a relatively high risk of having left main coronary artery stenosis. Physicians should be cautious when applying these recommendations to a primary care practice. The foregoing analysis is based on data obtained from patients who had been selected for coronary arteriography. There are two principal effects of biased selection of study patients: The pretest probability of CAD in clinical subgroups is probably lower than as shown here.(ABSTRACT TRUNCATED AT 400 WORDS)

Adult↗
PubMed1988

Do data from a previous exercise test influence the prognostic information given by a second routine exercise ECG test? A 13 1/2-year follow-up study in apparently healthy middle aged men.

A positive exercise ECG test in a middle-aged man without confounding disease is a strong indicator of occult coronary heart disease. In the years following a positive test mortality, but CHD events vary considerably compared with subjects having normal exercise tests. If a second exercise test is positive in the same subjects years later, this signifies a disease which is prone to progress in a very severe way in the ensuing years. A first normal test followed by a second pathologic test has an intermediate prognostic significance compared with two normal tests years apart. The clinical course indicates that preventive measures should be taken after observing a positive exercise test, and even more importantly if two positive tests are observed years apart.

Adult↗
PubMed1990

The estimation of post-test probability of coronary disease following exercise testing using the sequential application of two Bayesian methods.

Recent studies have revealed that Bayesian methods to estimate post-test probability following exercise testing differ in their sensitivity and specificity across the range of post-test probability. To take advantage of the relative strengths of each method, we combined two of these methods into a single method (DUAL BAYES) and compared it with the two original methods in 436 patients who underwent stress testing followed within 2 months by coronary arteriography. All patients had post-test probabilities determined using CADENZA (better sensitivity). Those CADENZA-derived probabilities greater than or equal to 50% were substituted with post-test probabilities determined by Diamond and Forrester's original TABULAR method (better specificity). Mean post-test probabilities were as follows: TABULAR 34, CADENZA 48, DUAL BAYES 37 (actual incidence 38%). Comparison of sensitivity and specificity at every fifth percentile of post-test probability revealed that the sensitivity of DUAL BAYES was better than that of TABULAR and equal to that of CADENZA at thresholds less than or equal to 10 and that the specificity was better than that of CADENZA and equal to that of TABULAR at thresholds greater than or equal to 60. Therefore using both methods as indicated above was better than using either method alone.

Algorithms↗
PubMed1990

[Evaluation of exercise test reproducibility in patients with ischemic cardiopathy].

We evaluated the repeatability of some measurements taken during the bicycle ergometer exercise test (exercise duration, heart rate and pressure rate product at angina and ST segment depression times) in 166 consecutive non-selected ambulatory patients with proven ischemic heart disease. One hundred and sixty-six patients with history of angina and/or myocardial infarction performed three exercise tests within seven days of wash-out. Eighty-six (58.1%) of these experienced angina and ischemic ST segment depression during all three tests (group 1), and 80 (48.2%) finished at least one test without angina or ST segment depression (group 2). The degree of angina (according to Canadian Cardiovascular Society classification) was higher in the first group than in the second one; on the contrary, exercise duration as well as pressure rate product at ischemic threshold, heart rate and pressure rate product at the onset of angina were significantly lower (0.001 less than p less than 0.05) in the former group. In group 1, we analyzed ergometric parameter measurement "repeatability" during the three consecutive exercise tests. The analysis of variance for repeated measurements showed that exercise duration and pressure rate product values at ischemic threshold did not vary significantly in the three tests, while other ergometric parameters showed a greater variability (0.001 less than p less than 0.05). Age, previous myocardial infarction or rest angina, the number of critically stenotic coronary vessels and the ejection fraction did not condition the repeatability of the test. In conclusion, in our population of non-selected ischemic patients only 52% developed angina and ischemic ST segment depression during all three exercise tests performed.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1979

Maximal exercise testing--Bruce protocol.

Maximal treadmill exercise testing is feasible for the family physician's office especially in a group setting. The Bruce Exercise Test is described in detail and is helpful in the diagnosis of asymptomatic coronary heart disease, following the course of coronary heart disease, diagnosis of other cardiac disease, and in preventive testing and exercise prescription. Sensitivity and specificity of ST changes may be improved by recognizing factors which cause false positive and negative ST responses. The Bruce Test is safe when the procedure is followed meticulously. There have been 2,490 tests performed in the laboratory of three family physicians without serious morbidity. The screening exercise test with preventive exercise prescription is particularly pertinent to the present day concepts of family practice.

Adult↗
PubMed1990

Progressive exercise testing in closed head-injured subjects: comparison of exercise apparatus in assessment of a physical conditioning program.

Progressive exercise tests were performed on 12 closed head-injured subjects to determine 1) whether results differ when tests are performed on a treadmill, a bicycle ergometer, or mechanical stairs and 2) whether a 3-month general physical conditioning program results in an improvement in exercise performance. The subjects performed progressive exercise tests on each apparatus on entry into a residential transitional rehabilitation program and approximately 3 months later following participation in a physical conditioning program. On both the initial and 3-month exercise tests, maximal oxygen consumption (VO2 max) was significantly greater on the treadmill and the mechanical stairs than on the bicycle ergometer. The mean VO2 max was 74% of the predicted value on the initial exercise test and rose to 85% of the predicted value after the 3-month physical conditioning program. Oxygen consumption per kilogram of body weight at a given power output on a given apparatus showed no statistically significant difference between the initial and 3-month tests, indicating no change in exercise efficiency. On the 3-month test, a statistically significant decrease was noted in heart rate at rest and after the 4-minute period of recovery from maximal exercise on any given apparatus. The data obtained in this study indicate that 1) the treadmill and mechanical stairs are more suitable than the bicycle ergometer for assessing maximal exercise performance and 2) improved physical fitness following a physical conditioning program is associated with an improvement in cardiovascular function.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1979

Exercise testing in congenital aortic stenosis.

Treadmill exercise testing was performed on 23 patients with isolated congenital aortic stenosis. It was found that eight patients, with a negative exercise test and a normal rise in systolic blood pressure on exercise, had gradients less than 45 mmHg. Fifteen patients with gradients greater than 50 mmHg had positive exercise tests and their systolic blood pressure did not rise normally. It is suggested that the left heart studies to measure aortic valve gradients can safely be postponed if an exercise test is negative. Serial exercise testing of such patients will give an indication when left heart catheterization should be considered.

Adolescent↗
PubMed1986

Use of maximal bicycle exercise testing with respiratory gas analysis to assess exercise performance in patients with congestive heart failure secondary to coronary artery disease or to idiopathic dilated cardiomyopathy.

Analysis of respiratory gases during maximal treadmill exercise testing has been used in patients with congestive heart failure (CHF) to detect the lactate threshold, presumed to reflect the onset of skeletal muscle underperfusion, and maximal oxygen consumption (VO2), the point at which VO2 plateaus with increasing work due to exhaustion of peripheral oxygen delivery capacity. To determine if this approach is also useful during maximal bicycle exercise testing, ventilatory, hemodynamic and systemic lactate responses to bicycle exercise were measured in 48 patients with CHF. Ventilatory responses also were assessed in 12 normal subjects. Exercise increased VO2 to 24.8 +/- 3.9 ml/min/kg in normal subjects and 13.9 +/- 3.7 ml/min/kg in patients with CHF (p less than 0.001). In all but 1 patient the VO2 increment over the last 3 minutes of exercise was comparable to that in normal subjects exercising over identical work times, suggesting that maximal VO2 was not achieved. Moreover, in patients who exercised for less than 6 minutes, a ventilatory lactate threshold could not be identified. In the 33 patients who exercised longer, a ventilatory lactate threshold was identified in 31 and correlated well (r = 0.81) with blood lactate threshold, as defined by the VO2 at which lactate increased 5 mg/dl over rest levels. However, the 95% confidence limit for predicting blood lactate threshold from ventilatory data was +/- 200 ml/min, a large range relative to the measured ventilatory threshold (570 +/- 132 ml/min). These data suggest that in patients with CHF, respiratory gas analysis during maximal bicycle exercise cannot be used to measure maximal VO2 and provides only a general index of blood lactate behavior.

Cardiac Output↗
PubMed1988

The prognostic value of the exercise test.

Numerous investigators have demonstrated that responses to exercise testing enable prediction of the severity of underlying coronary disease and the patient's prognosis. However, exercise testing cannot predict angiographic findings or a poor prognosis with absolute certainty. Because survival can only be improved in specific clinical subsets of patients, it is important to carefully select for catheterization those in whom intervention can improve both quality and quantity of life. To deliver cost-effective health care, an effort has been made to use decision analysis to select those who should undergo cardiac catheterization. Decision analysis depends on reliable information regarding the predictive accuracy of the exercise test. Thus, this review is timely. Recent studies investigating the prognostic value of the exercise test are reviewed in this monograph. Patients include those recovering from a recent myocardial infarction (MI), those with stable coronary heart disease (including studies that have considered coronary angiographic findings, cardiac end points, and/or improved survival with coronary artery bypass surgery), and apparently healthy individuals. From this review, we conclude that silent ischemia induced by exercise testing in apparently healthy men is not as predictive of a poor outcome as once thought. Also, the use of the exercise test for screening is even more misleading than previously appreciated because of the higher rate of false positive results. Review of the 24 available studies of exercise testing in post-MI patients demonstrates that clinical judgment can be used to identify the high-risk patients, and that ST-segment shifts are not as predictive of high risk as an abnormal systolic blood pressure response or a poor exercise capacity. In patients with stable coronary heart disease, studies considering angiographic findings, cardiac events, and the differential outcome of coronary artery bypass surgery as compared with medical therapy have shown the exercise test to have prognostic power. From this perspective, it is obvious that there is much information supporting the use of exercise testing as the first noninvasive step after the history, physical examination, and resting electrocardiogram in the prognostic evaluation of patients with coronary artery disease. It accomplishes both purposes of prognostic testing: to provide information regarding the patient's status, and to help make recommendations for optimal management. The exercise test results help us make reasonable decisions for selection of patients who should undergo coronary angiography-including quality-of-life issues.(ABSTRACT TRUNCATED AT 400 WORDS)

Aged↗