PROTOCOLSELECTION
- The physician must decide whether the patient needs
a maximal or submaximal test. Most information is
obtained from the maximal test, as a true peak maxi-
mal HR is achieved, rather than an age-predicted max-
imal heart rate. If one chooses a symptom-limited
maximal test, the patient is in control and the most
information is gained. Submaximal testing is gener-
ally reserved for patients being discharged from the
hospital after an MI. Examples of tests include the fol-
lowing:
a. Bruce (most common, each stage changes in both
speed and grade)
b. Modified Bruce (less rigorous)
c. Balke-Ware (smaller workloads, used in cardiac/
older patients)
d. Ramp (most accurate and physiologic in predicting
measured oxygen uptake; slow, continuous increase
in workload)
e. Cycle or arm ergometry (if unable to use treadmill)
RUNNING THETEST
- A pretest checklist should be instituted which includes
an equipment and safety check, consent and pretest
assessment, supine and standing EKGs, blood pressure
measurements, treadmill protocol selection, and indi-
cations for termination. During the exercise test, the
patient should be monitored continuously along with
EKG and BP readings at each stage. The patient
should be alerted to stage changes, and the test should
be terminated when the patient reaches maximal effort
or exhibits clinical signs requiring termination of the
test:
a. Absolute indications for termination of EST- Patient’s request
- Decreasing systolic blood pressure with increased
work - Severe chest pain, vertigo, ataxia, and/or mental
confusion - Serious dysrhythmias (e.g., ventricular tachy-
cardia) - Evidence of an acute MI
- Malfunction of equipment
- Failure of increasing heart-rate response
b. Relative indications for termination of EST - Moderate chest pain, claudication, or dyspnea
- Marked >2-mm horizontal or downsloping ST
depression - Hypertensive BP response >250/115
- BP failing to rise at least 22 mm Hg during the
first 3 stages - Acute onset of bundle branch block
- Less serious dysrhythmias such as supraventric-
ular tachycardia- Recovery includes immediately placing the patient in
the supine position or allowing a “cool-down walk”
and then placing the patient in a chair. Maximal test
sensitivity is achieved with the patient supine post-
exercise. Auscultate for abnormal heart sounds and
obtain BP and EKG every 1 to 2 min. Monitor until
clinically stable and EKG has returned to normal.
- Recovery includes immediately placing the patient in
INTERPRETATION OF THE TEST- Interpreting the exercise test involves much more than
describing whether the test was “positive” or “nega-
tive” for ischemia. The written report should include
the HR and blood pressure response, the presence or
absence of symptoms, any dysrhythmias, the func-
tional aerobic capacity, EKG changes, and the pres-
ence or absence of myocardial ischemia (Evans,
Harris, and Ellestad, 2001).
HEART RATE RESPONSE- An increase in HR occurs with aerobic exercise sec-
ondary to a withdrawal of vagal tone and an increase in
sympathetic tone. The increase is linear and correlates
with workload and oxygen uptake. The maximum HR
should be reported as a percentage of the predicted
maximal HR (220-age). The failure of the HR to ele-
vate above 120 with maximum exercise is defined as
chronotropic incompetence and suggests possible
underlying CAD. Chronotropic incompetence is an
independent predictor of mortality (Ellestad, 1996b;
Lauer et al, 1999). Abnormal HR recovery (HRR),
defined as the failure of the HR to decrease by 12
beats/min during the first minute of recovery, portends
an increased mortality for the patient (Cole et al, 1999).
BLOOD PRESSURE RESPONSE- As work increases, there is a corresponding increase
in the systolic BP that peaks at maximum exercise.
A drop in systolic BP during exercise is very sug-
gestive of associated ischemic dysfunction of the
myocardium (Froelicher and Myers, 2000).
Diastolic BP remains the same or decreases. An
increase in diastolic BP of >10 mmHg is abnormal
and can be considered a hypertensive response to
exercise. The post-exercise systolic BP response
(SBPR) has also been described. A three minute
systolic BP/peak systolic BP > 0.90 is considered
abnormal with a diagnostic accuracy of 75% for
CAD (Taylor and Beller, 1998).
122 SECTION 2 • EVALUATION OF THE INJURED ATHLETE