Post on 22-Dec-2015
Stress TestingDaymar College
Lisa H. Young, RN, BSN, MA Ed.
Kattus or Stress Testing
Diagnostic Procedure
•Chest Pain•Determine function capacity of the heart after surgery or MI•Screen for heart disease (CAD)•Set limitations for exercise program•Abnormal heart rhythms•Effectiveness of heart medications•Post angioplasty•Family history of heart disease
http://www.youtube.com/watch?v=Z8nJgg59JsM&list=PL510FBA78000A7A05 & http://www.youtube.com/watch?v=W9mxeMp7zHg
Absolute Contraindications • Acute or Recent MI• Unstable angina or angina at rest• Rapid atrial or ventricular rhythms• Severe aortic stenosis• Dissecting aneurysm• 2 or 3 degree heart block• Inflammation surrounding the heart• Severe anemia• Uncontrolled Hypertension• CHF
Relative Contraindications
• Uncontrolled rapid supraventricular rhythms
• Frequent PVCs
• Uncontrolled hypertension
• Mild or moderate aortic stenosis
Educating the Patient• Possible complications and safety measures• Reason for the test• Explain the procedure• “Informed Consent”• Clothing• Medications
Preparing for the Stress Test
• Equipment check• Supplies• Emergency supplies• Physician’s order• Complete medical history, vital signs, EKG• Informed consent• Safety equipment• Test protocol• Belt length X cycles/minute (RPM) = speed
Post Stress Test Procedure
• Monitor and observe patient• Collect supplies• Avoid tobacco, caffeine and alcohol• Avoid extreme temperature changes• Rest• Results in approximately 10 days• Documentation
12 Lead Electrode Placement for
Ambulatory Monitoring/ Stress Test
Arm Ergometer
Leg Ergometer
Metabolic Equivalents
• Reflection of oxygen consumption
• 1 MET = person at rest/ 3.5 ml oxygen/kg/min
• 3 – 6 METs = moderate physical activity
• 4 METs = possible ischemia with CAD patient
Bruce and Modified Bruce Protocol
Naughton Protocol
Double Product
• Determine the level of exercise achieved
• HR X SBP = DP
• Exampled: SBP = 118 HR = 88 DP = 10384
Target or Maximum Heart Rate
• 220 minus age
• At least 85% of THR is achieved
• Example: pt age 60 220 --- 60 = 160 85% of 160 = 136• 70% post MI
Termination of Stress Test
• ST segment elevation/ ST depression > 3mm• Sustained Ventricular tachycardia or frequent
PVCs• Chest pain/ pale and diaphoretic• Drop in blood pressure or failure of the BP to rise
with exercise/ elevation of 240mmHg or diastolic BP above 120 mmHg
• Bradycardia, especially development of AV block• Pt voices inability to continue; symptoms
Stress Test Expected EKG Changes
• Shortened PR interval , RT interval & QT interval• Decreased R wave amplitude (lower voltage
QRS)• Tall P waves; increased amplitude• Rightward axis shift• T wave may become taller or inverted• Increased heart rate (shorter R-R intervals)• Increased ectopic activity with maximum
exercise Chronotropic reserve Chronotropic incompetence
Expected Clinical Symptoms• Vasodilation decreasing systemic vascular
resistance• Increased respiratory rate• Sweating• Fatigue• Muscle cramping • J point depression• Increased systolic blood pressure and slight (5 – 10 mmHg) increase in diastolic pressure Inotropic reserve / inotropic incompetence
Positive Stress Test• ST segment depression or elevation of 1 mm or
more
• U wave inversion or new appearance• Increased R wave amplitude in multiple leads• QT interval lengthens with exercise with CAD
Reliability of Stress Test
• Angiogram
• Sensitivity Positive
• Specificity Negative
Categories of Stress Test
• True Positive
• False Positive
• True Negative
• False Negative
Bayes’s Theorem
• Accuracy
• Patient’s probability of disease
• Risk assessment
Factors Affecting Interpretation
• Assess the equipment and settings
• Patient characteristics: activity level medical problems medications
• Interpretation of ECG strip: heart rate regularity
ST segment changes
Post Stress Test
• “Cooling down” 10 – 15 minutes• Rest • Avoid extreme temperature changes• Avoid stimulants for at least 3 hours• Do not take a hot shower / bath• Results in about 10 days• Discuss results with physician
Poor Prognostic Findings• Low workload
• Less than 6.5 METs
• Less than 5 – 6 minutes
• Low peak heart rate
• Low systolic blood pressure
• Significant ST segment depression or prolonged ST segment depression
Nuclear Stress Test
• Radioactive substance (radiotracer)
• Noninvasive procedure/ 4- 6 hours
• Depict how the heart muscle is working
• Resting portion and exercise portion
Exercise Echo or Stress Echo
• Combines echocardiogram with exercise• Diagnose coronary heart disease, assess results of
coronary procedures, certain types of heart muscle or heart valve disease
• Performed at rest, then during and after exercise test• 3 phases: resting echo images, exercise, & second
echo images
• http://www.youtube.com/watch?v=87XWZTIr-Xc
Pharmacologic Stress Test
• Physical limitations
• IV dose of medicationo Cardiolyteo Dobutamineo Dipyridamoleo Adenosine
http://www.youtube.com/watch?v=wY347r1gFSg
Homer Heart Attack
Lexiscan
• Regadenoson• IV dose 5 ml (0.4 mg)• Not given with second or third degree AV blocks
or sinus node dysfunction (pacemaker)• No caffeine for 12 hours before test• Monitor for hypersensitivity
Dobutamine Stress Test
• Most commonly used medication
• Adrenergic agonist• Increased blood pressure and heart rate• Increased workload of the
heart
http://www.youtube.com/watch?v=tqfwdzgB9cU
Dipyridamole or Persantine Stress Test
• Antiplatelet agent
• Dilates coronary vessels
• Accumulation adenosine
• http://www.youtube.com/watch?v=PZKScVAUEsk
Cardiolyte Stress Test
• Radioactive technetium
• Exercise and rest
• With a pharmacologic stress test
• Labels red blood cells
• http://www.youtube.com/watch?v=g9LtAyJ4gZw
Adenosine or Cardiac Stress Test
http://www.youtube.com/watch?v=4tU9DC5ueio
Thallium Stress Test
• Myocardial perfusion
• Thallium 201
• “cold spot” vs “hot spot”
• Side effects
• http://www.youtube.com/watch?v=fmtG4hx5F0Q
Tilt Table Test
http://www.youtube.com/watch?v=5H5FZTAic7c&list=PLjjz5qBEvYVXc8yyflUWJcTC7NsEr_SAR
Tilt Table Procedure
• Supine position on table (feet flush to edge)• Strap patient to table• BP and 6 lead EKG• Tilt table 80 degrees for 30- 45 minutes• Isuprel infusion started• Alternate tilting table and increasing isuprel• Positive vs. Negative results• Recovery
Cardiac Scoring
• Test to assess risk of heart disease
• High-speed CT scanner
• 10 minutes
• Images of hardening arteries
• http://www.youtube.com/watch?v=HFeQZA0Ygrg
MUGA Stress Test
Echocardiogram: TE
Transthoracic echocardiogram• Ultrasonic waves• Diagnosis heart problems• Doppler
http://www.youtube.com/watch?v=ZpGTq0vuO7Ehttp://www.youtube.com/watch?v=yVZ7jvsgyU4
Transesophageal Echocardiogram
• Scope with ultrasound transducer
• Passed into esophagus• Diagnose heart damage• Valve damage
http://www.youtube.com/watch?v=42vaOjNdErQhttp://www.youtube.com/watch?v=VB4kDng3Frg
Intravascular Ultrasound
http://www.youtube.com/watch?v=N9Za6K2HyIQ
Positron Emission Tomography
http://www.youtube.com/watch?v=ltesoTEu7JE
CT Scanner/ CTA
http://www.youtube.com/watch?v=D3WynbxwTuI
Life Vest
http://www.bing.com/videos/search?q=lifevest+video&FORM=VIRE12#view=detail&mid=9F37968281C2800935AF9F37968281C2800935AF