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PubMed1996

Exercise testing and prescription. Practical recommendations for the sedentary.

A sedentary lifestyle is prevalent in most industrialised societies. Persuasive evidence allows us to demonstrate that a physically active lifestyle protects against the development and progression of many chronic diseases. The assessment of sedentary individuals for the purpose of exercise testing and or exercise prescription should always culminate in the determination of the relative risk of the individual for traumatic events which may be precipitated by participation in moderate physical activity. Sedentary individuals may be categorised in a low to high risk stratification as apparently healthy (Class I), higher risk (Class II), or known coronary heart disease and/or symptomatic of chronic disease (Class III). An expanded role for allied health professionals, such as a clinical exercise physiologist, may enhance and extend the services of physicians and nurses as they relate to exercise testing, exercise prescription and preventative healthcare in general. Risk stratification will determine the type of exercise test, the exercise prescription and the exercise environment (low to high levels of supervision). The exercise prescription may include a determination of mode, duration, frequency, intensity, and progression of activity. Although target heart rate remains one of the most effective instruments for monitoring exercise intensity, the rate of perceived exertion should be incorporated especially in the titration of exercise prescriptions for those on beta-blockade therapy. Finally the benefits of an exercise programme, derived from a foundation of proper assessment, are numerous and include improvements in cardiovascular fitness, body composition, blood lipid profile and retention of essential muscle mass during the course of the life-cycle. A considerable public health benefit will result if sedentary individuals become regularly more physically active.

Adrenergic beta-Antagonists↗
PubMed1978

[Hyperventilation test in coronary disease: a comparison with a bicycle ergometer exercise test. Report of 100 cases].

A hundred cases have been studied and divided into three categories:--60 normal subjects;--30 coronary subjects with a positive exercise test;--10 subjects with defective nervous control of the circulation; using the exercise test, we studied the effects of hyperventilation on repolarisation of the ventricle. In the normal subjects there was no ischaemic depression of the ST segment, but there were minor changes in repolarisation which affected the T wave in 73% of subjects and were essentially posterior in distribution. In the coronary subjects, we found three with ischaemic depression of the ST segment and one with ST elevation of 2.5 mm (6.7% of the coronary subjects). This last finding is evidence against the commonly held hypothesis that reproduction of ST depression by hyperventilation during the exercise test indicates a false positive test. In the patients with defective nervous control of the circulation, 9 had an ischaemic type of ST depression, either as a new feature or as a more severe one compared with that found at rest. The mechanism by which these depressions are produced has not been totally explained:--in the cases with defective nervous control of the circulation, it appears that latent increased sympathetic activity is increased by the hyperventilation;--in the coronary subjects, it may be caused by true ischaemia or by an associated defect in nervous control of the circulation.

Adult↗
PubMed1988

Serial exercise testing in pulmonary embolism.

A patient underwent exercise testing during evaluation for unexplained dyspnea. Evidence of ventilation-perfusion mismatch was noted and subsequent testing revealed multiple pulmonary emboli. Ventilation perfusion parameters by serial exercise testing progressively improved during the course of the patient's illness but did not totally normalize. A discussion of the utility of exercise testing in the evaluation of the patient with unexplained dyspnea is provided and the potential value of serial exercise testing in the management of patients with pulmonary emboli is discussed.

Adult↗
PubMed1992

Symptom-limited versus low level exercise testing before hospital discharge after myocardial infarction.

OBJECTIVE: This study was undertaken to compare a low level and a symptom-limited test performed before hospital discharge after an uncomplicated myocardial infarction. BACKGROUND: Exercise testing after myocardial infarction provides useful prognostic information. Usually either a low level test is performed before hospital discharge or a symptom-limited test is performed at 3 weeks. METHODS: The study group comprised 202 patients with an uncomplicated myocardial infarction; 58 patients had a non-Q wave infarction and 115 patients had received thrombolytic therapy. Both a low level and a symptom-limited exercise test were performed in 200 of the 202 study patients in randomized order on consecutive days, a mean of 7.4 +/- 2.3 days after infarction. RESULTS: The symptom-limited test required a considerably greater effort than the low level test: exercise duration was 554 +/- 209 versus 389 +/- 125 s (p less than 0.0001), and peak work load was 5.7 +/- 1.8 versus 4.2 +/- 1.1 METs (p less than 0.0001). The peak heart rate was higher during the symptom-limited test (121 +/- 20 vs. 108 +/- 14 beats/min, p less than 0.0001), as was the rate-pressure product. The number of patients who developed ST segment depression greater than or equal to 1 mm increased from 56 during the low level test to 89 during the symptom-limited test (p less than 0.0001). ST segment depression greater than or equal to 2 mm occurred in 22 patients during the low level test and in 41 patients during the symptom-limited test, an 86% increase (p less than 0.0001). The number of patients with either angina or ST depression greater than or equal to 1 mm increased from 66 to 105 (p less than 0.0001) with the symptom-limited test. Exercise test results were similar for patients with a Q wave or a non-Q wave infarction. Exercise duration was longer and exercise-induced ST depression less frequent in patients who had received thrombolytic therapy. CONCLUSIONS: A symptom-limited exercise test performed before hospital discharge after uncomplicated myocardial infarction provides a significantly greater cardiovascular stress than does a low level test and is associated with an ischemic response nearly twice as frequently. The prognostic significance of a positive response at higher work loads has not been defined.

Angina Pectoris↗
PubMed1990

Autonomic dysfunction and silent myocardial ischaemia on exercise testing in diabetes mellitus.

The incidence and mechanism of painless myocardial ischaemia on exercise testing in diabetic patients is not clear. Therefore, two studies were performed. Retrospectively, all exercise tests carried out in our hospital during the past 5 years were reviewed for silent ischaemia. Prospectively, diabetic patients with known or suspected coronary artery disease underwent autonomic function testing and a second exercise test. Of 1653 exercise tests reviewed, 247 were positive (ST depression greater than 0.1 mV). Of the 29 diabetic patients with positive tests 20 (69%) had painless ST depression, compared with 77 (35%) of the 218 non-diabetic patients (p less than 0.001). The diabetic patients with painful and painless ST depression were comparable for age, sex, therapy, but the 20 with no pain on exercise testing had a longer duration of diabetes and a higher incidence of microvascular complications than the 9 with pain (70 vs 22%, p less than 0.05). In the prospective study, 12 of 30 diabetic patients with positive exercise tests had pain in association with ST depression and 18 had no pain. Six patients had mild and 12 severe autonomic neuropathy on formal testing. Twelve had no autonomic dysfunction. Eleven (92%) of 12 patients with severe neuropathy had painless ST depression, compared with 7 (39%) of 18 without severe neuropathy (p less than 0.01). Thus, silent myocardial ischaemia on exercise testing is common among patients with diabetes mellitus and is associated with severe autonomic dysfunction.

Aged↗
PubMed1985

Exercise testing.

In the athletic horse, an exercise test may be required to measure the adaptation of the animal to a specific training program; to modify the training program in response to the progress achieved; to investigate the reasons for failure to perform at the expected level; and to form part of an overall clinical examination of a horse with a specific disability. This article includes information on the scope and form of an exercise test, the parameters measured during the test and their interpretation, treadmill and track tests, and the clinical applications of exercise tests.

Animals↗
PubMed2002

[Prevalence and clinical background of exercise-induced ventricular tachycardia during exercise testing].

OBJECTIVES: This study assessed the prevalence and clinical background of exercise-induced ventricular tachycardia during exercise testing. METHODS: Complications during exercise testing were reviewed in 25,075 consecutive patients, 14,037 men and 11,038 women, who underwent a total of 47,656 maximal treadmill or bicycle exercise tests between April 1985 and March 1999. The mean age of the patients was 53.3 +/- 8.8 (mean +/- SD) years. Non-sustained ventricular tachycardia was defined as 8 or more consecutive ventricular ectopic beats at > 100 beats/min. A total of 126 patients undergoing exercise testing to evaluate the efficacy of pharmacotherapy for ventricular tachycardia were excluded. RESULTS: The major reasons for the exercise test were chest pain (27.0%) and screening (20.3%). Twenty patients (0.08%) had exercise-induced ventricular tachycardia. Six patients had ischemic heart disease, two had cardiomyopathy, five had other cardiac diseases, and seven patients showed no clinical evidence of heart disease. The incidence of ventricular tachycardia in patients with cardiomyopathy (2/109) was higher than in other patients, but the number of patients with ventricular tachycardia was small. Ventricular tachycardia was documented at heart rates of more than 80% of predicted maximal heart rate in 12 of the 20 patients. CONCLUSIONS: These results suggest that the exercise testing can be done safely when the end-point criteria are properly applied.

Adult↗
PubMed1998

Evaluation of chest pain in low-risk patients presenting to the emergency department: the role of immediate exercise testing.

STUDY OBJECTIVES: To determine the safety and utility of immediate exercise testing in the evaluation of low-risk patients presenting to the emergency department with chest pain and its applicability to a heterogeneous population of men and women. METHODS: We conducted a prospective study of the safety and utility of immediate exercise testing in low-risk patients, as indicated by clinical and ECG criteria. The study group was large, heterogeneous, and included patients with a history of coronary artery disease. The patients were treated at a large, university medical center. Exercise testing (immediate exercise treadmill testing) was performed by internists, and cardiac serum enzyme levels were not measured before the exercise test. RESULTS: A total of 212 patients (121 men, 91 women) underwent exercise testing with no adverse effects. Twenty-eight (13%) patients had positive results on exercise ECGs. Twenty-three of the latter had further evaluation that revealed evidence of coronary artery disease in 13 (57%). Fifty-nine percent (125/212) of patients had negative exercise test results and 28% (59/212) had nondiagnostic tests. All patients with negative test results and 93% with nondiagnostic test results were discharged directly from the ED. Thirty-day follow-up was achieved in 201 (95%) patients and revealed no mortality in any of the patients in the three groups. One patient with a positive exercise test result returned to the ED within 30 days with mild congestive heart failure. CONCLUSION: Our results in this patient population support the safety and utility of immediate exercise testing of low-risk patients who present to the ED.

Adult↗
PubMed1983

[Early exercise test after myocardial infarct: prognostic stratification].

Exercise testing in myocardial infarction before discharge has been used for treatment and exercise prescription in the post-hospital phase. Aim of this study was to investigate the prognostic significance, within one year after the infarction, of submaximal exercise testing before discharge. 428 patients performed the test 14.5 days after the acute episode and were followed for 12 months. The following variables were examined: heart rate, blood pressure, rate-pressure product at maximum exercise, total work and reasons for stopping the test (fatigue, submaximal HR, BP greater than or equal to 200/110, hypotension, ischemic or arrhythmic response). Two events were considered: 1) non fatal reinfarction; 2) cardiac death. Two methods of multivariate analysis (Cox's model regression analysis and discriminant analysis) were used. None of the considered variables was found to be predictive of non fatal reinfarction. According to Cox's model total performed work and hypertensive response were found to be predictive of cardiac death, while using discriminant analysis only total work had a predictive value (discriminant function: L = 0.00094 X total work performed + 1.48643; p less than 0.01). In detail, the higher the total work, the better the probabilities of survival, while in patients who stopped the test because of hypertension, the probabilities of cardiac death were lower. Exercise testing performed in uncomplicated myocardial infarction before hospital discharge provides, the basis for a more rational management of patients in the post-infarction phase, and contributes to identify a subset of high-risk patients.

Aged↗
PubMed1992

[Hypertensive reaction to exercise. Retrospective studies of 1363 consecutive exercise tests].

OBJECTIVE: To study exercise hypertensive reaction and its relation with rest blood pressure, hypertension type and hypertensive cardiac disease. DESIGN: Retrospective study of treadmill exercise testes (ET) performed from January/89 to June/91: (n: 1703). SETTING: Stress tests Laboratory of Cardiology Service of a Military Hospital. METHODS: 1363 consecutive ET of male subjects, performing at least the 3rd stage of the Bruce protocol, were studied. From each ET record were obtained general data, including the reason for test, medication and the rest and exercise blood pressure. Exercise hypertensive reaction was defined as a Bruce protocol 3rd stage systolic blood pressure above 187 mmHg, which corresponds to mean +2SD of 130 normal male subjects previously studied. The Echocardiograms of non-treated hypertensives, obtained less than a month from ET, were reviewed. The diagnosis of borderline or moderate hypertension was base on the clinical records. RESULTS: 1) The 1363 ET included 132 (9.7%) ET to study hypertensive subjects, and 68 of these had hypertensive reaction. 86 ET were performed by non-treated hypertensive subjects, of whom 73 had Echocardiogram. 43 (3.5%) from 1231 ET performed by non-hypertensive subjects also had exercise hypertensive reaction. 2) The left ventricular (LV) mass index of non-treated hypertensive patients had a positive correlation with exercise systolic pressure (r: 0.45; p < 0.001), more important than with rest blood pressure or exercise systolic pressure response; there was a relation with LV wall thickness, but not with internal ventricular dimensions, that was only observed in hypertensive subjects that also had hypertensive reaction to exercise. 3) Exercise systolic blood pressure was usually normal in borderline and elevated in moderate hypertensives (Qui2: 27.249; p < 0.001). 4) Subjects with exercise hypertensive reaction, but not previously diagnosed as hypertensives, were usually true hypertensives. CONCLUSIONS: 1) Hypertensive peaks seem to be an important determinant factor in LV hypertrophy of hypertension, but its influence is felt only above a certain blood pressure threshold; it results on LV concentric type hypertrophy. 2) Exercise systolic blood pressure had a discrimination power of about 80% to separate borderline and moderate hypertensive subjects. 3) All subjects having an exercise hypertensive reaction must be carefully observed, even if their blood pressure at rest is normal, because most of them are true hypertensive patients.

Adult↗
PubMed1995

[Value of the exercise test in the study of arrhythmia].

Exercise testing may be used to assess symptoms occurring on effort, to search for and evaluate arrhythmias or conduction defects, antiarrhythmic drugs, pacemakers or implantable cardioverter defibrillators. Interpretation of exercise testing is difficult because of the complexity of the factors in play. Exercise itself induces changes in myocardial metabolism and the autonomic nervous system, the nature and importance of which are influenced by the underlying cardiac disease and the presence of cardiac failure or myocardial ischaemia. This is particularly true when studying the behaviour of arrhythmias on effort, which depends on many parameters, in that they may appear or disappear during exercise, irrespective of their relationship to autonomic nervous system activation. The main problem lies in the interpretation of changes in the heart rate before the onset of an arrhythmia. The sinus rhythm is both a passive indicator of the vago-sympathetic equilibrium and one of the determining factor of the arrhythmia (relationship to the rate), but it is, itself, dependent on the presence of myocardial dysfunction, a source of arrhythmias, and its changes then become difficult to interpret. These reasons explain why exercise testing is certainly a valuable tool in assessing arrhythmias but the poor reproducibility, especially in the evaluation of ventricular arrhythmias, advises prudence in the interpretation of results.

Arrhythmias, Cardiac↗
PubMed1992

[Effect of beta adrenergic blocking drugs on the prognostic value of ST-segment depression during exercise electrocardiogram testing].

Exercise testing has been shown to be predictive for future cardiac events in patients with established diagnosis of coronary heart disease. Exercise test parameters associated with poor prognosis may be unreliable if patient is receiving beta adrenergic agents. The purpose of this study was: 1) to compare the results of exercise testing performed before and during beta blocking therapy, and 2) to determine the role of beta blockers in the prognostic significance of the ST-segment response recorded during exercise testing. The study population consisted of 518 patients (mean age 52 +/- 7 years) with coronary heart disease. The diagnosis was based on the presence of one of the following three criteria: 1) typical history and significant ST-segment depression on resting or exercise electrocardiogram, 2) history of myocardial infarction, 3) significant coronary angiographic abnormalities. In all patients symptom-limited exercise test was performed before and two weeks after the onset of beta blocker therapy. The data from the first and second tests were estimated for significance of differences between the mean values with following results: maximal heart rate--135 +/- 21 and 123 +/- 19 bpm (p less than 0.001), maximal work load achieved--98 +/- 43 and 109 +/- 44 W (p less than 0.001), maximal systolic blood pressure--171 +/- 28 and 163 +/- 26 mmHg (p less than 0.001). Occurrence of characteristic ST-segment depression was more frequent during the first than during the second test (p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Adrenergic beta-Antagonists↗
PubMedDate not supplied

Exercise testing, training and arm ergometry.

Standard exercise testing and training methods require leg work, but alternative methods involving arm work appear to be particularly applicable for selected subjects. An understanding of the physiology of upper extremity exercise and of the implications for arm exercise testing and training will assist in the diagnostic and functional evaluation and prescription of exercise. The cardiorespiratory and haemodynamic responses to submaximal and maximal arm and leg exercise are reviewed and practical information and guidelines for the recommendation of arm exercise testing and training in wheelchair-confined individuals, normal subjects, and patients with coronary heart disease are provided.

Adult↗
PubMed1990

"Recovery only" ST-segment depression and the predictive accuracy of the exercise test.

STUDY OBJECTIVE: To clarify the predictive value of exercise-induced ST-segment depression occurring in recovery only, and to determine whether the addition of recovery data improves the interpretation of the exercise test. DESIGN: Retrospective analysis of data collected during exercise testing and coronary angiography. SETTING: A 1000-bed Veterans Affairs Medical Center. PARTICIPANTS: The study included 328 male patients who had had both a sign- or symptom-limited treadmill test and coronary angiography. MEASUREMENTS AND MAIN RESULTS: Of the 168 patients who had abnormal ST-segment responses, 26 had such responses only during recovery. The positive predictive value of this pattern for significant angiographic disease (84%) was not statistically different from the predictive value of ST depression occurring during exercise (87%). Inclusion of ST depression during recovery significantly increased the sensitivity of the exercise test from 50% to 59% (P = 0.01) without a change in predictive value. In addition, ST-segment depression occurring only during exercise is usually associated with less-severe angiographic coronary artery disease. CONCLUSION: The occurrence of ST-segment depression during the recovery period only, does not generally represent a "false-positive" response. The inclusion of findings from this period increases the diagnostic yield of the exercise test. Previously proposed exercise test scores, as well as exercise electrocardiography (ECG) analysis done in conjunction with scintigraphy, have a falsely lowered sensitivity that could be increased by considering ST-segment changes occurring in recovery.

Aged↗
PubMed2005

Applications of cardiopulmonary exercise testing in the management of cardiovascular and pulmonary disease.

A growing body of literature has underscored the value of ventilatory gas exchange techniques during exercise testing (commonly termed cardiopulmonary exercise testing) and their applications in the management of patients with cardiovascular and pulmonary disease. Once limited to the domain of research physiologists and pulmonary medicine, the test is now widely used in clinical practice; guidelines on exercise testing from major organizations list specific indications for the use of cardiopulmonary exercise testing. The added precision provided by this technology is useful in terms of quantifying the response to therapy, evaluating disability, assessing the mechanism of exercise intolerance, making activity recommendations to patients, and quantifying the response to training. Importantly, a significant body of data published in recent years has documented the prognostic utility of cardiopulmonary exercise testing. A cardiopulmonary exercise test can supplement other clinical and exercise test information when precision is important, when the patient's symptoms are mixed, or when it is unclear why the patient was referred for exercise testing. Information from the test can also be used to support the important recommendation that the patient engage in an exercise program.

Anaerobic Threshold↗
PubMed1983

Serial exercise testing up to 6 years after coronary bypass surgery: behavior of exercise parameters in groups with different degrees of revascularization determined by postoperative angiography.

To evaluate the behavior of exercise parameters in patients with different angiographically defined degrees of revascularization, serial exercise tests were analyzed in 435 patients 1 to 6 years after coronary artery bypass grafting (CABG). All patients had undergone postoperative angiography 2 to 12 months after CABG to determine the degree of revascularization achieved. Revascularization was complete in 182 patients (all significantly stenosed arteries had patent grafts), sufficient in 176 patients (at least the dominant artery supplying the left ventricle had a patent graft) and incomplete in 57 patients (the dominant artery supplying the left ventricle had a closed graft). Twenty patients had all grafts occluded. Exercise tolerance, angina-free exercise tolerance (angina threshold), maximal double product, prevalence of greater than or equal to 0.1 mV exercise-induced S-T segment depression, and the prevalence of the combination of S-T segment depression plus angina pectoris were determined in serial exercise tests (average of 3.0 postoperative exercise tests per patient for a mean follow up of 3.5 years). Patients with complete, sufficient, and incomplete revascularization showed improvement of all exercise parameters for 6, 4, and 1 year after CABG, respectively. Patients with all grafts occluded had improvement of only some exercise parameters. Five years after CABG, exercise tolerance was improved by 24 W (p less than 0.0005) and 21 W (p less than 0.005) in patients with complete and sufficient revascularization, respectively, and not improved in patients with incomplete revascularization or with all grafts occluded. The angiographically determined completeness of revascularization correlates with the extent and the duration of improvement of exercise parameters after CABG.

Angina Pectoris↗
PubMed2004

Exercise testing and training in German CF centers.

Physical exercise is increasingly recognized as a valuable diagnostic and therapeutic modality for patients with cystic fibrosis (CF). We sought to characterize the use of exercise testing and training as well as the attitude toward both issues through a national survey. A questionnaire was sent to 107 specialized CF centers (caring for a total of 5,231 patients) and 7 inpatient rehabilitation institutions. Answers were available from 62 specialized centers caring for 3,580 patients and from 4 rehabilitation centers with 520 treatment episodes per year. Sixty percent of specialized centers performed some sort of exercise testing at an average frequency of 1 in 2.3 years for patients aged 8 and above. However, protocols and indication criteria were often unstandardized or not specified at all. Equipment availability was no major problem, and the majority of tests were conducted by a physician alone. Nineteen centers had adopted exercise testing as part of their diagnostic routine. Two thirds of caregivers advised their patients to engage in physical activity, but failed to discuss specific modalities and potential hazards. Nevertheless, physical exercise was viewed as "extremely important" or "very important" by 87%. In a rehabilitation setting, an exercise test was conducted 1.1 times per patient stay, and a training program offered in 100% of cases. In conclusion, standardized exercise testing and training programs appear to be underused in German CF centers, despite a high degree of interest in the topic. Supplementary material for this article can be found on the Pediatric Pulmonology website (http//www.interscience.wiley.com/jpages/8755-6863/suppmat).

Adult↗
PubMed1996

Clinical exercise testing in chronic airflow limitation.

Exercise testing has become an essential tool in the management of patients with CAL. In addition to its ability to assess exercise limitation objectively, it has usefulness in detecting the presence or absence of associated disease processes, in assessing the response to therapies, in allowing assessment of the importance of psychological factors in exercise limitation, and in guiding prescription for exercise rehabilitation programs. Although much is known about the clinical usefulness of exercise testing in this disease, and much has been learned about how this disease functionally impairs the exercise capacity of the patient, additional study is necessary to appreciate fully the physiologic abnormalities demonstrated by patients with CAL during exercise.

Cardiac Output↗