Exercise ECG

• Involves graded exercise until physical fatigue, limiting chest pain (or discomfort), marked ischemia, or a drop in blood pressure occurs.¹
• Candidates for exercise ECG are those:¹
  • without disabling comorbidity (e.g., frailty, marked obesity (BMI >40 kg/m2), PAD, COPD, or orthopedic limitations) and capable of performing ADLs or able to achieve ≥5 METs and
  • without resting ST-T abnormalities (e.g., >0.5-mm ST depression, LVH, paced rhythm, LBBB, Wolff-Parkinson-White (WPW) pattern, or digoxin use).
• Contraindications
  • Abnormal ST changes on resting ECG, digoxin, LBBB, Wolff-Parkinson- White pattern, ventricular paced rhythm (unless test is performed to establish exercise capacity and not for diagnosis of ischemia)
  • Unable to achieve ≥5 METs or unsafe to exercise
  • High-risk unstable angina or AMI (<2 d) i.e., active ACS
  • Uncontrolled HF
  • Significant cardiac arrhythmias (e.g., VT, complete atrioventricular block) or high risk for arrhythmias caused by QT prolongation
  • Severe symptomatic aortic stenosis
  • Severe systemic arterial hypertension (e.g., ≥200/110 mm Hg)
  • Acute illness (e.g., acute PE, acute myocarditis/pericarditis, acute aortic dissection)
• Widely available and inexpensive
• Interpretable ECG
• Requires ability to exercise to an adequate level
• Who should you test?
  • Intermediate-risk ASx adults (including considering starting a vigorous exercise program), particularly when attention is paid to exercise capacity
• Limited diagnostic accuracy
  • sensitivity ~60% & specificity ~70%
• Avoid if pre-existing ECG abnormalities
• What are you looking for?
  • See slide
• Prognostic importance of functional capacity
  • Once > 10 METS your prognosis, regardless of whether you have CAD or not, is quite good)
  • 
    • Figure source: 📄 Myers J, Prakash M, Froelicher V, Do D, Partington S, Atwood JE. Exercise Capacity and Mortality among Men Referred for Exercise Testing. New England Journal of Medicine. 2002;346(11):793-801. doi:10.1056/nejmoa011858
• Value add of Coronary Artery Calcium (CAC) Score
  • See 📄 Chang SM, Nabi F, Xu J, et al. Value of CACS Compared With ETT and Myocardial Perfusion Imaging for Predicting Long-Term Cardiac Outcome in Asymptomatic and Symptomatic Patients at Low Risk for Coronary Disease. JACC: Cardiovascular Imaging. 2015;8(2):134-144. doi:10.1016/j.jcmg.2014.11.008
  • 

Stress ECG Interpretation

Footnotes

1. Gulati M, Levy PD, Mukherjee D, et al. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain. Journal of the American College of Cardiology. 2021;78(22):e187-e285. doi:10.1016/j.jacc.2021.07.053 ↩ ↩²