The New York Mets: A Team Effort
their marketing game, the Mets stepped up to the plate – and the game was on The Team Ethic In a game situation, teamwork is essential As a member of the Mets behind-the-scenes team, the Xerox Graphic Communications Marketing group offered to lead and fund the 1:1 Lab program test Xerox brought in the Pente Corporation, an experienced
MET Levels of Common Recreational Activities
MODERATE 5–6 3 0–6 0 METs Noticeable increase Feels fairly easy to somewhat hard (e g , brisk walking) VIGOROUS 7–8 Greater than 6 0 METs Large increase in breathing & heart rate but not out-of-breath Feels somewhat hard to hard (e g , jogging, vigorous sports) *Intensity scale: On a scale of 0–10 where 0 = sitting and 10 = all-out effort
Non-Invasive Cardiac Stress Testing
Achieving ≥ 10 METS: Medical therapy as good as CABG no matter how bad the CAD 2 13 METS = Excellent prognosis, regardless of exercise response 1 Myers J, Prakash M, Froelicher V, Do D, Partington S, Atwood JE Exercise capacity and mortality among men referred for exercise testing N Engl J Med Mar 14 2002;346(11):793-801 2
Understanding and Interpreting an FCE
3 Effort Metrics Definitions •Consistency of Effort = Reproducibility - or the likelihood that an effort may be copied, duplicated, or produced as a close imitation, in a series of trials •Quality of Effort = Degree - or the extent, level, or scope of a subject's volitional exertion in maximal or repetitive testing
EPREUVES D’ EFFORT
Segmentation de l’épreuve d’effort Sujet sédentaire •P max Théorique 300 watts (302 W) •13 minutes d ’effort ( 8 à 20 min d’effort ) : • 3 min d’échauffement à 20 PMT : 60 Watts • 10 paliers de 1 minute • Incrément de 25 W ( 300W – 60w ) / 10min
Peut-on interpréter un test d’effort sous-maximal
test ’effort “sousmaximal” c’est e saoir s’il est vraiment sous-maximal On parlera de test sous-maximal lorsque l’effort a été interrompu précocement soit par l’opérateur soit par manque e motiation u suet et non pas en raison de signes cliniques ou ECG imposant l’arrêt e test ’effort oit être maximal ou limité par les smp
TREADMILL EXERCISE TESTING
common test used to assess cardiorespiratory fitness, especially in clini-cal settings The test is administered in three-minute stages until the client achieves 85 of his or her age-predicted maximum heart rate (MHR) In a clinical setting, the test is typically performed to maximal effort, to evaluate both fitness and cardiac function
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Non-Invasive Cardiac Stress Testing:
Choosing the Most Appropriate Test to Get the Most Diagnostic Benefit for Your PatientJENNIFER BALLARD-HERNANDEZ
DNP, FNP/GNP/CVNP-BC, CCRN, CHFN, AACC, FAHA
CARDIOLOGY NURSE PRACTITIONER
VA LONG BEACH
Disclosures
program/presentation.Objectives
modalities testing agents assessment, diagnosis, clinical management and prognosis7RGM\·V $JHQGM
What we will be reviewing:
Chest Pain
emergency department2 can lead to substantial consequences2 imperative1.Hsiao CJ, Cherry DK, Beatty PC, Rechtsteiner EA. National ambulatory medical care survey: 2007 summary. Natl Health Stat Report. 2010; (27):1-32.
2.Bonow RO, Braunwald E. Braunwald's heart disease : a textbook of cardiovascular medicine. 9th ed. Philadelphia: Saunders; 2012.
Purpose of Stress Testing
potential symptom equivalents device therapyPotential Complications
ventricular arrhythmia, and death) has been estimated to be about 1 in 250011. Gibbons RJ, et al. ACC/AHA 2002 guideline update for exercise testing: summary article. A report of the American College of Cardiology/American Heart Association Task Force on
Practice Guidelines. J. Am. Coll. Cardiol. Oct 16 2002;40(8):1531-1540.When performing the chest pain work up,
You must have a method to your madness!
Step 1: Assess the Clinical Classification of Chest PainStep 2: Determine Pretest Probability of CADStep 3: Determine the Most Appropriate
Stress Test Modality
Step 1: Assess the Clinical Classification of Chest PainSubsternal chest discomfort
Provoked by exertion or emotion stress
Relieved by rest or NTGTypical Angina
(definite) Meets 2 of the above characteristicsAtypical Angina (probable)Meets 1 or none of the typical anginal
characteristicsNoncardiacChest Pain
J Am Coll Cardiol. 2012;60(24):2564-2603. doi:10.1016/j.jacc.2012.07.012 Step 2: Determine the Pre Test Probability of Coronary DiseaseGibbons RJ, et al. ACC/AHA 2002 guideline update for exercise testing: summary article. A report of the American College of Cardiology/American Heart Association Task Force on
Practice Guidelines. J. Am. Coll. Cardiol. Oct 16 2002;40(8):1531-1540.Pretest Likelihood of CAD in Symptomatic Patients
According to Age and Sex* (Combined Diamond/Forrester and CASS Data) Diagnostic power of stress testing is maximal when the pre-test probability is intermediateLow CAD
ProbabilityHigh CAD
ProbabilityIntermediate
CAD Probability
High False
Positive RateOptimalHigh False
Negative Rate
Step 3: Determine Stress Test Modality
Choice of stress testing modality depends on many factors, including but not limited to:Step 3: Determine Stress Test Modality
EXERCISE STRESS TESTING
Exercise Stress Testing
supply of oxygenated blood to myocardial cells is inadequate to meet demands increasing to maximal tolerance, can elicit cardiovascular abnormalities not present at rest, while aiding in the determination of the adequacy of cardiac function 11.Fletcher G et al. Circulation 2013;128:873-934Photo source: Ballard-+HUQMQGH]·V SHUVRQMO SORPR ŃROOHŃPLRQ
Exercise Stress Testing
all-cause death1. Gibbons RJ, et al. ACC/AHA 2002 guideline update for exercise testing: summary article. A report of the American College of Cardiology/American Heart
Association Task Force on Practice Guidelines. J. Am. Coll. Cardiol. Oct 16 2002;40(8):1531-1540. Absolute Contraindications to Exercise Stress Testing with hemodynamic compromise stenosis or DVT safe and adequate testing Relative Contraindications to Exercise Stress TestingBaseline Abnormalities That May Obscure ECG
Changes During Exercise
Measurements During Exercise Stress Testing
Maximal Heart Rate
MHR = 220 ²age (in years)
Metabolic Equivalents (METs)
activitiesPhysical activityMET
Light intensity activities< 3
sleeping0.9 watching television1.0 walking, 1.7mph (2.7km/h), level ground, strolling, very slow2.3Moderate intensity activities3 to 6
bicycling, stationary, 50 watts, very light effort3.0Vigorous intensity activities> 6
jogging, general7.0 rope jumping10.0The Importance of Functional Capacity
population matter how bad the CAD 2 response1. Myers J, Prakash M, Froelicher V, Do D, Partington S, Atwood JE. Exercise capacity and mortality among men referred for exercise testing. N.
Engl. J. Med. Mar 14 2002;346(11):793-801.
2. Weiner, D. A., Ryan, T. J., McCabe, C. H., Chaitman, B. R., Sheffield, L. T., Fisher, L. D., et al. (1986). The role of exercise testing in identifying
patients with improved survival after coronary artery bypass surgery.Journal of the American College of Cardiology, 8(4), 741-748
Exercise capacity is a more powerful predictor of mortality among men than other established risk factors for CV disease Myers J, Prakash M, Froelicher V, Do D, Partington S, Atwood JE. Exercise capacity and mortality among men referred for exercise testing. N. Engl. J. Med. Mar 14 2002;346(11):793-801.Exercise Stress Test Preprocedure Preparation
voltage in inferior leads1 1Which Protocol to use?
The test protocol should be selected according to the purpose of testing and the individual patientExercise protocols
Normal electrocardiographic changes during
exerciseIndications for Terminating Exercise Testing:
Absolute
Indications for Terminating Exercise Testing:
Relative
Clinical Pearls for Exercise Stress Testing
exercise adequately, who have an interpretable ECG, and do not have any contraindications depression observed in multiple lead systems 1 does not localize the area of myocardium that is involved such as it does inSTEMI. 1 ,2
12Bonow RO, Braunwald E. Braunwald's heart disease : a textbook of cardiovascular medicine.
9th ed. Philadelphia: Saunders; 2012.
Duke Treadmill Score (DTS)
DTS = exercise time -(5x max ST deviation in mm) -(4 x treadmill angina index) refer patients for further evaluation or intervention patients classified as high or low risk. prognosis: No further evaluation is generally unnecessary prognosis and should be referred for angiographyfor another imaging modality (MPI)1Mark DB, Hlatky MA, Harrell FE, Lee KL, Califf RM, Pryor DB. Exercise treadmill score for predicting prognosis
in coronary artery disease. Ann Intern Med. 1987;106:793-800.2Mark DB, Shaw L, Harrell FE, et al. Prognostic value of a treadmill exercise score in outpatients with
suspected coronary artery disease. N Engl J Med. 1991;325:849-853.http://www.zunis.org/Duke%20Treadmill%20Score%20-
%20CAD%20Predictor.htm