{"title":"Blood Pressure Measurements during Exercise Testing","authors":"G. Thomas, M. Ellestad","doi":"10.1093/MED/9780190225483.003.0006","DOIUrl":"https://doi.org/10.1093/MED/9780190225483.003.0006","url":null,"abstract":"``The chapter Blood Pressure Measurement During Exercise reviews the 3 methods of sphygmomanometry to measure blood pressure and normal and abnormal blood pressure responses to exercise. Mercury, aneroid, and oscillometric assessment of Korotkoff sounds provide accurate measurement. Periodic calibration is important for aneroid and oscillometric devices. With verification, automated oscillometric measurements during exercise can be accurate. The normal blood pressure response to exercise testing is an incremental increase in systolic blood pressure with minimal change in diastolic blood pressure. Exercise induced hypotension, particularly early in exercise, is predictive of severe coronary artery disease (CAD). Its occurrence at peak exercise at a high level of exertion may occur in normal individuals secondary to exhaustion. An exaggerated systolic response to exercise is modestly predictive of future hypertension. A slow decrease is systolic blood pressure during recovery is suggestive of CAD, likely secondary to less vagal tone, analogous to a slow decrease in heart rate during recovery.","PeriodicalId":368036,"journal":{"name":"Ellestad's Stress Testing","volume":"18 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"126946684","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Heart Rate Response to Exercise","authors":"G. Thomas","doi":"10.1093/MED/9780190225483.003.0022","DOIUrl":"https://doi.org/10.1093/MED/9780190225483.003.0022","url":null,"abstract":"The chapter Heart Rate Response to Exercise reviews the studies performed to estimate a patient’s maximum predicted heart rate. While the commonly used formula (220 – age), developed in 1971, is easy to remember, it underestimates the actual maximum heart rate in older persons. Studies of large sample size have found the maximum heart rate to be relatively independent of sex and physical fitness but to incrementally decline with age. The decrease with age is less than 1 beat per minute per year, however. A more accurate and recommended formula is [(208) – (0.7)(age)] as developed by Tanaka and colleagues.","PeriodicalId":368036,"journal":{"name":"Ellestad's Stress Testing","volume":"39 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"131445150","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Cardiovascular and Pulmonary Responses to Exercise","authors":"Fiona Sylvies, M. Ellestad","doi":"10.1093/MED/9780190225483.003.0020","DOIUrl":"https://doi.org/10.1093/MED/9780190225483.003.0020","url":null,"abstract":"The chapter Cardiovascular and Pulmonary Responses to Exercise reviews the changes in cardiac function when called upon to increase its output of oxygenated blood during exercise. A deep understanding of exercise physiology enhances one’s ability to understand the pathophysiology of ischemia and coronary artery disease (CAD) inherent in the performance of stress testing. With the onset of exercise, the body exhibits an almost immediate response through alterations in heart rate, preload, contractility, stroke volume, and coronary blood flow, all to compensate for augmented metabolic demands. Individual characteristics such as age, sex, and fitness impact a person’s physiological response to exertion. Differences in exercise modality, duration, intensity, and frequency will provoke unique responses, which can be utilized to design exercise prescriptions specific to a patient’s goals and medical needs.","PeriodicalId":368036,"journal":{"name":"Ellestad's Stress Testing","volume":"47 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"127061235","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Stress Cardiac Magnetic Resonance Imaging","authors":"Y. Yoon, L. Wann","doi":"10.1093/MED/9780190225483.003.0017","DOIUrl":"https://doi.org/10.1093/MED/9780190225483.003.0017","url":null,"abstract":"The chapter Stress Cardiac Magnetic Resonance Imaging reviews how cardiovascular magnetic resonance imaging (CMR) has become a gold standard for evaluating stress induced wall motion abnormalities based on regional endocardial excursion and myocardial thickening. The high spatial and temporal resolution of CMR without limitations imposed by body habitus and acoustic windows allows outstanding visualization of myocardial function. CMR can also be combined with vasodilator stress to perform dynamic first-pass myocardial perfusion imaging. The addition of late gadolinium enhancement allows the accurate of nonviable scar tissue in combination with wall motion and myocardial perfusion assessment. Case studies highlight the opportunity provided by stress CMR.","PeriodicalId":368036,"journal":{"name":"Ellestad's Stress Testing","volume":"15 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"115338983","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Rhythm and Conduction Disturbances in Stress Testing","authors":"G. Thomas, M. Balouch","doi":"10.1093/MED/9780190225483.003.0010","DOIUrl":"https://doi.org/10.1093/MED/9780190225483.003.0010","url":null,"abstract":"The chapter Rhythm and Conduction Disturbances in Stress Testing reviews the frequency and significance of arrhythmias and conduction abnormalities precipitated by exercise. Case examples are provided. PVCs occurring prior to, during exercise, or during recovery all modestly increase the risk of all-cause mortality in patients with and without known coronary artery disease (CAD). Ventricular tachycardia and premature ventricular complexes are often not reproducible on a subsequent exercise test. Exercise induced left bundle branch block (LBBB) predicts increased risk of the presence of CAD, all cause mortality, and often permanent LBBB. Differentiating wide complex tachycardia during exercise testing between supraventricular tachycardia and ventricular tachycardia can be challenging. The Wellens, Brugada, and Vereckei algorithms to distinguish between these arrhythmias are detailed and compared.","PeriodicalId":368036,"journal":{"name":"Ellestad's Stress Testing","volume":"5 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"122281422","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Perspectives on the Future of Stress Testing","authors":"L. Wann, G. Thomas","doi":"10.1093/MED/9780190225483.003.0029","DOIUrl":"https://doi.org/10.1093/MED/9780190225483.003.0029","url":null,"abstract":"The chapter Perspectives on the Future of Stress Testing forecasts changes in the ability to detect atherosclerosis in the form of obstructive and non-obstructive coronary artery disease and ischemia. These will continue to include low cost and widely available exercise testing as well as embracing new technology such as mobile sensors, biomarkers, and genetic testing. Continued advancements in positron emission tomography, cardiac computed tomography, and cardiac magnetic resonance imaging will create new opportunities for better definition of myocardial blood flow and prediction of prognosis. While we will continue to expand our ability to measure greater detail of aspects of cardiac structure, function and metabolism, the humanity of a clinician being at the side of the treadmill while our whole patients exercise to their individual capacity remains a valuable diagnostic, educational and bonding opportunity","PeriodicalId":368036,"journal":{"name":"Ellestad's Stress Testing","volume":"38 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"121809899","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Sports Medicine and Cardiac Rehabilitation for Coronary and Peripheral Artery Disease Patients","authors":"G. Thomas, M. Ellestad","doi":"10.1093/med/9780190225483.003.0026","DOIUrl":"https://doi.org/10.1093/med/9780190225483.003.0026","url":null,"abstract":"The chapter Sports Medicine and Cardiac Rehabilitation for Coronary and Peripheral Artery Disease (CAD) reviews the benefits and potential risks of physical activity and the opportunity for particular benefit in patients with coronary artery disease and peripheral artery disease (PAD). Longitudinal studies of large populations have found a benefit to habitual exercise on cardiovascular health, including decreasing cardiovascular mortality. A physiologic training effect is not required for benefit. Mild exercise is better than inactivity and increasing activity provides even greater benefit. Athletic training induces expected electrocardiographic changes at rest in athletes. Prescribing exercise with or without an exercise test is discussed in asymptomatic individuals as well as prior to participation in traditional cardiac rehabilitation or a supervised exercise program for patients with peripheral artery disease. PAD patients often do not have classic intermittent claudication yet are able to benefit from exercise therapy.","PeriodicalId":368036,"journal":{"name":"Ellestad's Stress Testing","volume":"58 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"131219088","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Nuclear Cardiology","authors":"G. Thomas, L. Wann","doi":"10.1093/med/9780190225483.003.0015","DOIUrl":"https://doi.org/10.1093/med/9780190225483.003.0015","url":null,"abstract":"The Nuclear Cardiology chapter reviews the opportunity to increase sensitivity and specificity of stress testing for the diagnosis of coronary artery disease with exercise or pharmacologic myocardial perfusion imaging (MPI). Case presentations highlight the concepts presented. Based on the extraction fraction of thallium-201 and technetium-99m sestamibi and tetrofosmin, optimal timing of radioisotope injection at near peak exercise is reviewed. The importance of achieving ≥85% of maximal heart rate or an ischemic endpoint and when to convert to vasodilator testing is discussed. Multiple well-tested protocols are reviewed to add exercise to adenosine or regadenoson to minimize adverse effects and improve imaging quality and throughput. Data from the 1,147 patient EXERRT study are reviewed demonstrating that a technetium-99m radioisotope dose ratio of 1:3 is too low for 1-day low-dose rest/high-dose stress MPI secondary to shine through of the resting study into the stress study. A dose ratio minimum of 1:4 is recommended for 1-day low-dose rest/high-dose stress protocols.","PeriodicalId":368036,"journal":{"name":"Ellestad's Stress Testing","volume":"10 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"115661161","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Parameters to Be Measured during Exercise","authors":"G. Thomas, M. Ellestad","doi":"10.1093/MED/9780190225483.003.0005","DOIUrl":"https://doi.org/10.1093/MED/9780190225483.003.0005","url":null,"abstract":"The chapter Parameters to be Measured During Exercise reviews the physiologic changes with exercise which indicate health and disease. Key parameters include blood pressure, heart rate, electrocardiographic changes, exercise duration, maximum oxygen uptake (VO2max), and anaerobic threshold. An in-depth review and consensus estimate is provided to estimate metabolic equivalents (METs) achieved based on exercise duration on the Bruce and Ellestad protocols. Use of bipolar leads for detection of exercise induced myocardial ischemia is discussed, typified by CM5 which captures up to 90% of patients with an electrocardiographic manifestation of ischemia. Changes in murmurs that occur with exercise are reviewed; walk-through angina and chronotropic incompetence.","PeriodicalId":368036,"journal":{"name":"Ellestad's Stress Testing","volume":"29 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"125035186","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Combining Coronary Artery Calcium Scanning and Treadmill Exercise in the Assessment of Coronary Artery Disease","authors":"James R. Adams","doi":"10.1093/med/9780190225483.003.0019","DOIUrl":"https://doi.org/10.1093/med/9780190225483.003.0019","url":null,"abstract":"Coronary calcium scoring (CAC) by noncontrast computed tomography is a powerful predictor of coronary artery disease (CAD) prognosis. Exercise testing is a powerful predictor of CAD severe enough to cause ischemia. Both tests predict CAD in a graded incremental fashion. The higher the CAC score, the greater than chance of a coronary event or all cause mortality. The greater the ST depression and the shorter the exercise duration of an exercise test, the greater the cardiac event rate. Both tests are inexpensive and provide incremental information. In 2013, Alan Rozanski and colleagues suggested combining the tests, calling it a “Treadmill Calcium Test.” Such a test can inform the patient and physician with a measure of atherosclerosis with CAC and a measure of ischemia and fitness with an exercise test. CAC can also provide incremental information when combined with an exercise imaging study such as myocardial perfusion imaging or stress echocardiography.","PeriodicalId":368036,"journal":{"name":"Ellestad's Stress Testing","volume":"39 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"125633622","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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