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

MRI Scanner

http://www.youtube.com/watch?v=xeRyGuwpxWs

Life Vest

http://www.bing.com/videos/search?q=lifevest+video&FORM=VIRE12#view=detail&mid=9F37968281C2800935AF9F37968281C2800935AF