Sports Medicine: Just the Facts

CHAPTER 20 • EXERCISE TESTING 121

• Moderate risk: Older individuals (men ≥age 45
  years; women ≥age 55 years) or those individuals
  with ≥2 risk factors from Table 20-1.


• High risk: Individuals with one or more signs/symp-
  toms from Table 20-2 or known cardiovascular, pul-
  monary, or metabolic disease.


• In addition, level of activity is divided into moderate
  (3–6 METS or 40–60% of VO2 max) and vigorous
  (>6 METS or >60% of VO2 max) exercise. Clinicians use
  these factors to recommend which patients need a stress
  test (American College of Sports Medicine, 2000a):
  a. Low risk individuals do not need an EST regard-
  less of level of activity.
  b. Moderate risk individuals should have a stress test
  prior to beginning vigorous exercise only.
  c. High risk individuals need a stress test before any
  moderate or vigorous activity.
  •Risk stratification of patients for diagnosis of CAD
  divides patients into those with typical angina, atypi-
  cal angina, nonanginal chest pain, or no chest pain.
  There are also special disease groups (e.g., diabetes
  mellitus) that have specific indications for testing
  (American Diabetes Association, 2003).

CONTRAINDICATIONS

• In some individuals there may be contraindications to
  performing the procedure.

ABSOLUTECONTRAINDICATIONS
a. Acute MI
b. A recent significant change in EKG
c. Unstable angina
d. Rapid ventricular or atrial arrhythmias
e. History suggesting medicine toxicity
f. Severe aortic stenosis
g. Uncontrolled congestive heart failure(CHF)
h. Suspected dissecting aortic aneurysm

i. Active myocarditis or pericarditis

j. Active thrombophlebitis

k. Recent embolism

l. Active infection

m. Uncooperative patient

RELATIVECONTRAINDICATIONS

• Risks of performing procedure may outweigh bene-
  fits.
  a. Uncontrolled tachyarrhythmias or bradyarrhyth-
  mias
  b. Frequent ventricular ectopic activity
  c. Untreated pulmonary hypertension
  d. Systemic blood pressure(BP) >200/110
  e. Ventricular aneurysm
  f. Moderate aortic stenosis/ Hypertrophic cardiomy-
  opathy
  g. Marked cardiac enlargement
  h. Uncontrolled metabolic disease
  i. Chronic infectious disease
  j. Known left main artery disease
  k. Electrolyte abnormalities
  l. Neuromuscular, musculoskeletal disorders that
  prohibit exercise or are exacerbated by exercise

SPECIAL CONSIDERATIONS

• There are special situations in which the physician
  must evaluate the patient carefully before doing an
  EST. These patients are usually put into one of three
  groups: conduction disturbances (AV blocks, LBBB,
  WPW), medication effects (beta blockers, calcium
  channel blockers), and special clinical situations
  (unstable hypertension, previous MI, known CAD). In
  these situations, consultation with a cardiologist
  and/or referral for an imaging study may be warranted
  (White and Evans, 2001).

PHYSICIAN RESPONSIBILITIES

• During exercise testing, the physician’s responsibili-
  ties include the following:

PRETESTPATIENTEVALUATION ANDCLEARANCE

a. Review of medical history

b. Performance of a cardiac exam to evaluate for

murmurs or gallops

c. Clarification of EST indications and exclusion of

those with contraindications

d. Consent of patient and documentation of risks

versus benefits

e. Obtaining a resting baseline EKG and evaluation

for abnormalities

TABLE 20-2 Major Signs/Symptoms Suggestive
of Cardiovascular and Pulmonary Disease

1. Pain or discomfort (or other anginal equivalent) in the chest, neck,
   jaw, arms, or other areas that may be caused by ischemia.


2. Dizziness, near-syncope or syncope


3. Palpitations or tachycardia


4. Shortness of breath at rest or with exertion


5. Orthopnea or paroxysmal nocturnal dyspnea


6. Ankle edema


7. Unusual fatigue with usual activities


8. Known heart murmur


9. Intermittent claudication

SOURCE: American College of Sports Medicine: Guidelines for Exercise
Testing and Prescription, 6th ed. Baltimore, MD, Lippincott Williams &
Wilkins, 2000, p 25.