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edu uses cookies to nicrosoft content, tailor ads and improve the user experience. By using our site, you agree to our collection of information through the use of cookies.

To learn more, view our Privacy Policy. edu no longer supports Internet Explorer. To browse Academia. edu and the wider internet faster and more securely, please take a few seconds to upgrade your browser. Log in with Facebook Log in with Google. Remember me on this computer. Enter the email address you signed up with downloadd we’ll email you a reset link. Need an account? Click here to sign up. Download Free PDF. Exercise Standards for Testing and Training A Scientific Statement From the American Heart Association.

Ross Arena. Download Download PDF Full PDF Package Download Full PDF Package This Paper. A short summary of this paper. Download Download PDF. Download Full PDF Package. Translate PDF. AHA Scientific Statement Exercise Standards for Testing and Training A Scientific Statement From the American Heart Association Gerald F.

Fletcher, MD, FAHA, Microsofh Philip A. Ades, MD, Co-Chair; Paul Kligfield, MD, FAHA, Co-Chair; Ross Arena, PhD, PT, FAHA; Gary J. Balady, MD, FAHA; Vera A. Bittner, MD, MSPH, FAHA; Lola A. Coke, PhD, ACNS, FAHA; Jerome L.

Profesional, MD; Daniel E. Forman, MD, FAHA; Thomas C. Gerber, MD, Downloaf, FAHA; Martha Gulati, MD, MS, FAHA; Kushal Ofvice, PhD, PT; Jonathan Rhodes, MD; Paul D. Thompson, MD; Mark A. Williams, PhD; on behalf of the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee of the Council on Clinical Cardiology, Council on Nutrition, Physical Activity and Metabolism, Council on Cardiovascular and Stroke Nursing, and Council 20016 Epidemiology and Prevention Table of Microsoft office professional plus 2016 error 1317 free download Evaluation and Exercise Prescription in Exercise Testing.

These exercise standards are intended for Drugs and Electrolytes in Exercise Testing. Because professionall an Exercise and Health. The revision deals ertor basic Healthy Individuals. The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a pluz, professional, or business interest of a member of the writing panel.

Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest. This statement was approved by the American Heart Association Science Advisory and Coordinating Committee on February 1, To purchase additional reprints, call or e-mail kelle.

ramsay wolterskluwer. The American Heart Association requests that this document be cited as follows: Fletcher GF, Ades PA, Kligfield P, Arena R, Balady GJ, Bittner VA, Coke LA, Fleg JL, Forman DE, Gerber TC, Gulati M, Madan K, Rhodes J, Thompson PD, Williams MA; on behalf of the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee of the Council on Clinical Cardiology, Council on Nutrition, Physical Activity and Metabolism, Council on Cardiovascular and Stroke Nursing, and Council on Epidemiology and Prevention.

Exercise standards for testing and training: a scientific statement from the American Heart Association. Expert peer review of AHA Scientific Statements is conducted by the AHA Office of Science Operations.

org DOI: Static provide justification for certain consensus recommendations isometric exercise results in no movement microspft the microsoft office professional plus 2016 error 1317 free download. The based on expert opinion. metabolic classification refers primarily to the availability of With regard to a literature pkus for this revision, no spe- oxygen for the contraction process and includes aerobic oxygen cific strategy or formal data quality assessment was used.

Each available or anaerobic without oxygen processes. Microsoft office professional plus 2016 error 1317 free download, references were and anaerobic metabolism, and depending on the efror selected by the group on the basis of personal experience or plys each, the physiological responses can be significantly readily available publications and databases. The cited refer- different. Current clinical exercise testing procedures manifest a ences represent a consensus of the writing group.

predominant dynamic—aerobic endurance component. allows the test supervisor to determine appropriate methodol- Maximum arteriovenous oxygen difference has a physiologi- ogy and to select test end points that maximize test safety and cal limit of 15 to 17 mL O2 per mL blood. As a pous obtain needed diagnostic and prognostic information.

increasingly on assessment of cardiovascular risk, not sim- At fixed, mild-to-moderate submaximal workloads below ply detection of coronary obstruction. beyond which muscles cannot derive all required energy from oxygen utilizationsteady-state conditions usually are reached within 3 to 5 minutes after the onset offife exercise, and subse- Physiology of Exercise Testing quently, HR, cardiac output, blood pressure, and pulmonary Aerobic exercise, progressively increasing to maximal ventilation are maintained at reasonably constant levels.

However, in addition to exercise, the cardiovascular vasoconstriction in most circulatory body systems, except in response to physiological stress is also commonly evaluated exercising muscle and in the microsoft office professional plus 2016 error 1317 free download and coronary circulations. through the use of pharmacological stress agents. Total calculated this term no longer remains precise. The following section peripheral resistance decreases, while systolic blood pressure, will focus specifically on exercise as a means to provoke mean arterial pressure, and pulse pressure usually increase.

cardiovascular and pulmonary stress. Diastolic blood pressure can microsoft office professional plus 2016 error 1317 free download unchanged or decrease to profexsional small degree, each of which is considered a normal response.

Types of Exercise The pulmonary vascular bed can accommodate as much as a Exercise involves muscle activity that has both mechanical 6-fold increase in cardiac output without a significant increase dynamic, static and metabolic aerobic, anaerobic properties. in transpulmonary gradient. In normal subjects, this is not a Microsoft office professional plus 2016 error 1317 free download profsssional exercise, which causes movement of the limiting determinant of peak exercise capacity.

P,us nor- endowment and level of training. mal systolic blood pressure response to progressive exercise is dependent on both sex microskft in males and age diwnload with HR Response advancing age. cise is an increase in HR that is attributable to a profsesional in After maximum exercise, systolic blood pressure usu- vagal tone, followed by an increase in microwoft outflow.

This postexercise hemodynamic response highlights degree of variability exists among subjects of identical age the importance of an active cool-down period when possible. Moreover, the HR eterization to obtain coronary arterial and venous oxygen content.

response microsooft generally continuous with increasing workload. An However, myocardial oxygen uptake can be estimated during accelerated HR response to standardized submaximal workloads clinical exercise testing by the product of HR and systolic blood is observed after prolonged bed rest, indicating that physical pressure double product or rate—pressure product and ranges conditioning also plays a role in microsoft office professional plus 2016 error 1317 free download HR response, which from the 10th percentile value of 25 to a 90th percentile value also can change in response to anemia, metabolic disorders, of 40 at peak exercise.

A linear relationship exists between variable vascular volume or peripheral resistance, or ventricular myocardial oxygen uptake and coronary microdoft flow. During dysfunction. These conditions themselves do not appear to affect exercise, coronary blood mifrosoft increases as much as 5-fold above maximal HR unless capacity приведенная ссылка exercise pofessional becomes the resting value.

A subject with obstructive CAD often cannot limited. Conversely, a lower-than-expected incremental rise in provide adequate coronary blood flow to the affected myocardial HR during a progressive exercise test could be attributed to an tissue to meet the metabolic demands of the myocardium during enhanced level of fitness and left ventricular LV function.

As exercise; consequently, myocardial ischemia occurs. Myocardial will be discussed in detail, inadequate HR response to exercise ischemia usually occurs at the same rate—pressure product rather can be a marker not only for sinus downolad dysfunction profeseional also for than at the same external workload eg, exercise test stage.

It is considered the best measure of cardiovascular fitness the cardiac response to exercise. Other factors that professionsl influence and exercise capacity. The decline of HR myocardial ischemia, and associated symptomatology. microsoft office professional plus 2016 error 1317 free download cownload demonstrated prognostic value. Submaximal oxygen uptake is по этому сообщению frequently vascular resistance.

whereas diastolic pressure usually remains about the same or To meet the metabolic demand of dynamic exercise, oxygen is moderately decreased because of microsoft office professional plus 2016 error 1317 free download of the vas- uptake quickly increases, achieving steady state, as previ- cular bed. In addition, the development of In most cases, the ventilatory threshold is highly reproducible, signs or symptoms associated with the need for exercise test although it might not be achieved or readily identified in some termination, such as angina pectoris, hypertension, or cardiac patients, particularly those with very poor exercise capacity.

be compared with average normal values by age and sex. exercise habits, heredity, and cardiovascular clinical status. Vo2max is equal to the product of maximum cardiac output Absolute and Relative Contraindications to Exercise and maximum arteriovenous oxygen difference. Assessment of this balance oxygen difference at peak exercise. Because the arteriovenous requires knowledge of the purpose of the test for the individ- oxygen difference at peak exercise reaches a physiological limit ual subject or patient and what symptom or sign end points and usually varies little across a wide spectrum of cardiovascular download crack sketchup pro 2016 32 bit free download be for the individual test.

function, most of the clinical variation in the oxygen pulse at Absolute Contraindications peak exercise is therefore attributable to variation in the forward stroke volume at peak exercise. Reprinted from Fleg JL et al. for the test is not clear, the referring provider should be con- be instructed to resume medication if rebound phenomena tacted for further information.

Routine medications may be taken with small amounts correlation with test findings. of water. Subjects with a history of worsening the nature /28181.txt the progressive exercise, symptom and sign unstable angina or decompensated heart failure should not end points, and possible complications. undergo exercise testing until their condition stabilizes.

pressure free dc add image download adobe signature pro acrobat to exercise. If ischemia does not occur, A resting supine ofrice lead ECG should be obtained microsof diagnostic value of the test for detection of CAD is before exercise to compare to previously obtained standard limited. No formal guidelines for tapering or holding ECGs to determine if changes have occurred over time.

 
 

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normal, near-normal, or unchanged ECGs. The prototype for such arrhyth- adverse effects of exercise testing. structural heart disease. In patients with patient population, given their association with pulmonary long-QT interval syndrome, exercise testing may elicit QT ventilation—perfusion mismatching, a primary consequence of prolongation, which can be useful in risk stratification.

Initial evidence indicates that T-wave alternans represents macroscopic or measurable these CPX variables are both prognostic and gauge therapeutic microscopic alternation in electrocardiographic T-wave ampli- efficacy in patients with pulmonary arterial hypertension. T-wave alternans testing performed in conjunction could become a secondary consequence, such as in heart with exercise testing can be useful in identifying patients at failure, HCM, chronic obstructive lung disease, and interstitial risk for developing life-threatening ventricular arrhythmias.

Adults with congenital heart disease usually have cardiovas- In patients with rate-adaptive pacemakers, exercise testing cular issues that are distinct from those encountered among can help to optimize the HR response and increase exercise other adult cardiology patients. The role of exercise testing in capacity. adult cardiology patients. In general, the primary goal of exer- Patients with atrial fibrillation not uncommonly demon- cise testing in adults with congenital heart disease is not the strate exaggerated ventricular rate responses to low-level exer- detection or evaluation of CAD.

Rather, purposes of the test cise even when resting HR appears well controlled. functional capacity, the exercise test protocol should typically The validity of these data depends on adequate effort expendi- be conservative in nature. In addition, tic efficacy. found to be an independent predictor of death or hospitaliza- Pulmonary Hypertension tion in a variety of congenital heart defects, including tetral- The role of CPX in assessing pulmonary hemodynamics is a ogy of Fallot, repair of transposition of the great arteries, rapidly emerging field demonstrating a great deal of clinical and Fontan physiology.

Perhaps years. Thus, it is unclear whether the low peak HR was of end-tidal CO2 during exercise, reflect the degree of elevation an independent risk factor for death or merely a marker for a in pulmonary arterial pressure and therefore disease severity.

history of serious arrhythmias. The abnormal pressure impairment is likely attributable to an impaired chronotropic response appears to be mediated by a decrease in stroke response, reflected by a depressed peak HR, or an impaired volume attributable to systolic dysfunction. stroke volume response, reflected by a low oxygen pulse at Although nonsustained VT NSVT during ambulatory peak exercise. It also should be noted that in the presence of electrocardiographic monitoring is associated with increased significant chronotropic impairment there should be a com- risk of sudden cardiac death in patients with HCM, the role of pensatory increase in stroke volume and oxygen pulse, solely exercise-induced NSVT in predicting adverse outcomes is less on the basis of the Frank-Starling mechanism.

Under these clear. On multivariate analysis, useful in patients with congenital heart disease. In 1 study of monary artery stenoses. tetralogy patient and a strong, negative impact on prognosis. great arteries. cise in patients, and no patients experienced syncope. to pulmonary blood flow maldistribution and ventilation— The reduced stroke volume is secondary to blunting of pre- perfusion mismatch secondary to the absence of a pulmonary load reserve, the end-diastolic volume. The sensitivity of the exercise ECG for detect- response to exercise, a provocable LVOT gradient, or exercise- ing myocardial ischemia is also very low in this population.

Blood pressure, line electrocardiographic abnormalities and LV hypertrophy. HR, and electrocardiographic responses are usually normal. Aortic Stenosis Subjects with severe mitral regurgitation do not necessarily Effort syncope in subjects with aortic stenosis is an important have a decreased cardiac output and limited exercise capacity.

and well-appreciated symptom. In asymptomatic patients with severe an absolute contraindication for testing because of concern mitral regurgitation and preserved LV function, exercise test- about syncope and cardiac arrest. Proposed mechanisms for ing with Doppler echocardiography is reasonable to assess exercise-induced syncope in subjects with aortic stenosis exercise capacity and the effect of exercise on pulmonary include carotid hyperactivity, LV failure, arrhythmia, and LV artery pressure.

In such patients, mitral valve surgery should baroreceptor stimulation. be considered if pulmonary artery systolic pressure exceeds Exercise testing might be useful, however, in asymptomatic 60 mm Hg during exercise. Testing should be ter- translate into a reduction in diagnostic accuracy.

Maximum minated if angina, dizziness, decrease in systolic blood pres- HR—systolic blood pressure product likely would be reduced.

In the presence of an abnormal blood pres- before testing should be recorded. A normal QT interval is Subjects with aortic regurgitation usually maintain a normal associated with digitalis-induced ST changes, whereas pro- exercise capacity for a longer time than those with aortic ste- longed QT intervals occur with ischemia, other type 1 anti- nosis.

During exercise, the decreases in diastolic duration and arrhythmic drugs, electrolyte imbalance, and other medical regurgitation volume favor forward output. As the myocardium problems. Exercise-induced ST-segment depression can persist fails, peak HR tends to slow, and ejection fraction and stroke for 2 weeks after some preparations of digitalis are discontinued.

volume decrease. Exercise testing can be useful in patients with Diuretics asymptomatic severe aortic regurgitation to assess functional Most diuretics have little influence on HR and cardiac perfor- capacity and symptom response.

Surgery is usually indicated if mance but do decrease plasma volume, peripheral resistance, unequivocal symptoms are elicited at a low workload. Diuretics can cause hypokalemia, which Mitral Stenosis can result in muscle fatigue, ventricular ectopy, and, rarely, Subjects with mitral stenosis can show either a normal or ST-segment depression.

an excessive increase in HR during exercise. Because stroke Hormones volume cannot be significantly increased, the normal rise of cardiac output is attenuated, and cardiac output eventually Menstrual Cycle can fall during exercise; this is frequently accompanied by Research on the impact of the menstrual cycle on various exercise-induced hypotension. Resting, exercise, and mittent anovulatory cycles, which might not be apparent on recovery HRs and blood pressures should be tabulated accord- the basis of bleeding pattern.

The available literature suggests ing to stages, and peak exercise values should be stated. There that there are probably no major differences in muscle con- should be a specific statement with regard to the presence or tractile characteristics, maximum oxygen uptake, or substrate absence of chest pain at peak exercise and whether this was the utilization during exercise between phases of the menstrual reason for termination of the test.

Patient effort can be defined cycle, but it has been suggested that the elevated body temper- by percent maximum predicted HR achieved or by use of a ature during the luteal phase of the cycle could limit exercise chronotropic index. Additionally, it is useful to describe effort in hot environments. One study reported shorter time to ST-segment depression and the test should be defined as positive, negative, or equivo- more frequently during the menstrual and preovulatory phases cal according to standard ST-segment criteria.

Several princi- phase. supplemented with estrogen and amelioration of postexer- The goal of this section on exercise training is to provide an cise ST-segment depression among men supplemented with evidence base for the medical benefits of long-term physical testosterone.

Care is taken to merge the public health benefits ST-segment depression between postmenopausal women on of exercise with the medical model, such that medical evalu- and not on hormone replacement did not quite reach statistical ation is not set up as a barrier to exercise, yet selected higher- significance. estrogen monotherapy.

Changes in vasomotor tone, changes in auto- hemodynamic function, autonomic nervous system function, nomic tone, and a digitalis-like effect have been proposed. Collectively, these adaptations result in an The Exercise Electrocardiographic Test Report exercise training effect, which allows an individual to exercise The exercise test report should describe information relevant longer, to higher peak workloads, with lower HRs at submaxi- to diagnosis and prognosis.

This would include the reason for mal levels of exercise. testing, a higher cardiac output after training is usually brought During exercise, baroreflex function is reset to operate around about by an increase in stroke volume because maximal HR the higher blood pressures achieved during physical activity. Parasympathetic tone also can be increased and, with sympa- Central Hemodynamic Changes thetic adjustments, could account for the slower HR and lower Although a greater maximal cardiac output can be achieved as arterial blood pressures seen after training.

a result of exercise training, values at fixed submaximal exter- Preventive Value of Regular Physical Activity nal workloads are unchanged or slightly diminished. Thus, physical inactivity is considered a treatable or modifiable Peripheral Muscular, Vascular, and Autonomic Changes coronary risk factor. Skeletal muscle changes after exercise training insufficient physical activity for deriving health benefits.

betes mellitus, insulin resistance, and thrombogenic factors. Each of these adaptations contrib- provide the primary basis documenting the inverse relation- utes to greater capacity to use oxygen and improve endurance. ship between physical activity and risk of CAD. This is reflected either by the ability to exercise fatal MI.

Furthermore, the results of these adap- fewer than 10 studies included women. Few studies involve tations increase the anaerobic threshold the point at which racial and ethnic minority groups.

Meta-analyses reveal that blood lactate begins to accumulate. Adaptation to submaxi- the sedentary participants in these studies generally had about mal exercise is also associated with a lower HR—systolic blood twice the incidence of death from CAD of their more active pressure product for a given exercise task, reflecting reduced counterparts. respiratory fitness by exercise testing have almost uniformly Vascular. Exercise training directly affects arterial shear stress, shown an inverse relationship between fitness and risk of a stimulus to antiatherogenic adaptations in vascular function CAD and total mortality in both men and women.

reached that a minimum of 30 minutes of moderate-intensity The mechanisms for these responses appear to be endothelium physical activity continuous or in minute increments is and nitric oxide dependent. That is, pursuant to the repeated required on most preferably all days of the week to opti- increases in arterial wall stress with repeated bouts of exercise, mally reduce the risk of CAD events. These mechanisms are reviewed in lipid levels. increases in HDL cholesterol for every 10 minutes of exercise duration.

Cross-sectional on lipids and lipoproteins in specific populations in a series of studies show that greater physical activity and fitness cor- meta-analyses. Benefits of exercise on lipoproteins extended to relate with lower total and low-density lipoprotein LDL older individuals and women, whereas among overweight cholesterol levels, higher high-density lipoprotein HDL and obese individuals, only decreases in triglycerides reached cholesterol levels, and lower triglyceride levels throughout statistical significance.

In the Coronary Artery Risk Development in Young Adults CARDIA study, Exercise Training and Hypertension. After early seminal changes in physical fitness and activity were only weakly cor- observations,, the inverse relationship between physical related with lipid levels, whereas changes in body weight were activity, physical fitness, and incident hypertension has been more strongly associated with lipid changes.

In Atherosclerosis Risk in Communities study, increases in the ARIC study, leisure-time physical activity among middle- physical activity level over 9 years of follow-up were asso- aged adults was strongly associated with incident hyperten- ciated with increases in HDL cholesterol among white and sion in white males but not in women or in blacks. Among young adults enrolled in the CARDIA study, women. among whites and blacks and in both sexes. who remained vigorously active and were increased in those A meta-analysis of 48 clinical trials of exercise-based cardiac whose vigorous activity declined over time.

A meta-analysis of 54 trials of aerobic exercise to —0. In the Training Level Comparison Study, a 1-year Moderate-intensity resistance training leads to blood pres- randomized trial in men with coronary heart disease that sure reductions of similar magnitude.

surable benefit. In individu- reported a weighted mean difference in systolic blood pressure als with established type 2 diabetes mellitus, a meta-analysis of —3. Overweight and obesity and reduces visceral adipose tissue and plasma triglycerides, have reached epidemic proportions in the United States, with but not plasma cholesterol, in people with type 2 diabetes mel- recent data from the National Health and Nutrition Exami- litus, even without weight loss.

Current high rates of obesity are and less use of glucose-lowering medications, compared with determined by both a high rate of physical inactivity and an usual care. This acute-phase response, which appears to be pro- the best predictor of successful long-term weight loss mainte- portional to the amount of activity and extent of muscle injury, nance is the presence of an ongoing exercise program with a tends to abate within a few days and is less pronounced in high level of caloric expenditure.

High-caloric-expenditure exercise daily longer- activity. Physical activity are more limited but suggest that exercise training both aero- has beneficial effects on both glucose metabolism and insulin bic and resistance training can favorably affect hs-CRP levels sensitivity, including increased sensitivity to insulin, decreased and other inflammatory markers both in healthy populations production of glucose by the liver, a larger number of muscle and among individuals with metabolic disorders such as dia- cells that use more glucose than adipose tissue, and reduced betes mellitus.

The effect of exercise on insulin sensitivity matory markers are unknown. Aging, even in healthy adults, is accompanied compared with a control group, over 2. vasodilation and myocardial blood flow. Endurance training in adults induces remodeling of conduit Antiarrhythmic Effects of Exercise Training arteries, resulting in reduced wall thickness and increased A risk of ventricular fibrillation or sudden cardiac death during lumen diameter.

The effects of exercise train- ing. ing mobility, exercise training is a logical intervention to reduce Exercise Training and Autonomic Function or prevent age-associated disability. In a systematic review The balance between sympathetic and parasympathetic activ- of exercise interventions, it was found that trials that offered ity modulates cardiovascular activity. Enhanced sympathetic a multicomponent exercise program involving endurance, nervous system activity is associated with an increased risk of strength, flexibility, and balance training generally reported cardiac events, particularly in patients with known heart dis- significant reductions in disability.

A reduction of HR variability HRV has been reported intervention and follow-up and interventions in more function- in several cardiac conditions, such as after MI, in heart failure, ally limited individuals were associated with greater likelihood and in diabetic neuropathy. The ongoing multicenter men reported higher parasympathetic activity among those Lifestyle Interventions for Independence in Elders LIFE who were physically trained and fit than among those who study will provide additional information on this topic.

In the were not. Because the rate—pressure product is a or absence of established CVD. Healthy adults who wish to major determinant of myocardial oxygen demand, the reduced undertake a low- to moderate-intensity walking program or rate—pressure product resulting from training will substantially equivalent moderate-intensity exercise generally do not need lower oxygen demand, mimicking the anti-ischemic effects of a formal medical screening.

In addition, exercise training enhances arterial nitric oxide part of daily activities. If an asymptomatic individual does not undergo an in broad, healthy populations of adults has not been proven to exercise test before beginning training, he or she should fol- be useful and could serve as a barrier to undertaking healthful low the activity guidelines outlined in Table 3.

If the history or exercise. These are extenuating circumstances, such as a family history of will prompt referral for medical evaluation by a healthcare sudden death at a young age, or poorly controlled cardiac professional when indicated. risk factors. ning— and at 1 death per 67 participants during tri- This should include a medical history, a physical exami- athlons, with almost all triathlon deaths occurring during the nation, and a risk factor profile.

For most, an electrocar- swim portion. This classification is tory of familial CAD or heart failure; presence of valvular provided in detail in Tables 3 through 6, which are used to heart disease, stable or unstable angina, congenital heart determine the need for subsequent supervision and the level disease, stroke, sudden death, history of pulmonary disease of monitoring required.

ie, chronic obstructive pulmonary disease or asthma ; pres- ence of symptoms including chest discomfort, dizziness, and shortness of breath at rest or with activities of daily Exercise Training Techniques living and leg discomfort claudication suggesting cardio- Elements of an Exercise Training Session vascular or pulmonary disease; changes in balance or gait; Exercise training sessions are typically arranged with brief presence of orthopedic problems including joint concerns periods of warm-up and cool-down low-intensity aerobic and swelling , arthritis, or changes in mobility; medication use stretching movements before and after a more intense and and use of caffeine or alcohol; and prior exercise habits.

Of prolonged phase of conditioning of either endurance or resis- particular interest are data in the history that indicate that tance training Table ,a.

Often, endurance training is unsupervised exercise could be hazardous. Table 3. Risk Classification for Exercise Training: Class A: The physical examination should include vital signs and Apparently Healthy Individuals examination of the cardiovascular and pulmonary systems, including evaluation of abnormal heart sounds or murmurs; This classification includes: 1.

If the test is abnormal, further exercise test before engaging in vigorous exercise. Reproduced with permission work-up should follow, according to symptoms and estimates from Fletcher et al. Risk Classification for Exercise Training: Class flexibility. After the conditioning phase, cool-down facili- B: Presence of Known, Stable CVD With Low Risk for tates a gradual transition to exercise cessation, modulating Complications With Vigorous Exercise, But Slightly Greater the effects of vasodilation, high catecholamines, and potential Than for Apparently Healthy Individuals ischemia.

Cool-down helps the HR and blood pressure transi- This classification includes individuals with any of the following diagnoses: tion to normal levels, reducing the likelihood for hypotension 1. CAD MI, coronary artery bypass graft, percutaneous transluminal and ventricular ectopy.

Body heat, lactic acid, and adrenaline coronary angioplasty, angina pectoris, abnormal exercise test, are dissipated with gradual restoration to baseline levels. and abnormal coronary angiograms ; includes patients whose condition is stable and who have the clinical characteristics Flexibility Exercise outlined below Flexibility training preserves or progressively increases ROM 2.

Valvular heart disease, excluding severe valvular stenosis or of joints over time. Flexibility goals usually are tailored to regurgitation, with the clinical characteristics as outlined below capacities and needs of each patient, but a well-rounded 3. Congenital heart disease; risk stratification for patients with program generally includes at least one stretching exercise congenital heart disease should be guided by the 27th Bethesda for each major muscle group ie, lower back, hips, posterior Conference recommendations thighs, and legs.

Just as with endurance and resistance train- 4. In the case of flexibility not HCM or recent myocarditis exercise, this entails stretching muscle beyond its normal rest- 5. Exercise test abnormalities that do not meet any of the high-risk ing length but not to the point of pain or injury. New York Heart Association class I or II onds. May 15, The actual, full implementation in the context of an example app is available making it perfect for sensor-based or Internet of Things IoT use cases.

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Exercise-induced supraventricular selected populations could limit predictive value. arrhythmias alone are not usually related to CAD but are more AV Conduction.

Shortening of the PR interval by as much often related to older age, pulmonary disease, recent alcohol as 0. increases is normal, probably because of increased sym- Ventricular Arrhythmias.

Ectopic ventricular beats are the pathetic tone and vagal withdrawal. This usually occurs in most frequent cardiac arrhythmia during exercise. Their prev- young, healthy individuals. In FIRST-DEGREE AV BLOCK. First-degree AV block occurs occa- general, ectopic ventricular beats are of concern in subjects sionally at the end of exercise or during the recovery phase, with a family history of sudden death or a personal history particularly in the presence of occult AV node disease.

Medi- of cardiomyopathy, valvular heart disease, or severe myo- cations or conditions that can produce prolonged AV conduc- cardial ischemia. with arrhythmogenic right ventricular dysplasia. The diag- nostic and prognostic values of patterns of ventricular ectopy SECOND-DEGREE AV BLOCK.

The occurrence of Wenckebach- during and after exercise have been variable. Recent studies type Mobitz type I AV block during exercise is rare because have suggested that frequent or complex repetitive ventricular vagal tone is reduced during exercise, whereas sympathetic activity during exercise, and particularly ventricular ectopy in neurohumoral tone increases. The clinical significance of the recovery period after exercise, can be independent predic- exercise-induced Mobitz type II AV block generally is related tive markers for death.

Disorders of impulse con- rate-related phenomenon that appears as the sinus rate is accel- duction include abnormalities of normal impulse initiation erated beyond a critical level. block develops during exercise, the test should be terminated. Bundle-Branch and Fascicular Blocks.

Intracardiac conduction THIRD-DEGREE COMPLETE AV BLOCK. Acquired advanced or blocks can exist before exercise, develop during exercise, or dis- complete AV block at rest is a relative contraindication to exer- appear during exercise. Rate-dependent intraventricular blocks cise testing because increasing sympathetic drive without effec- that develop during exercise often precede the appearance of tive rate increase can result in complex ventricular arrhythmias.

chronic blocks that develop later at rest. The development of ECG is usually impossible when left bundle-branch block is complete block during exercise testing is uncommon, but it can present. There can be a marked degree of exercise-induced ST- be related to transient ischemia. subjects with left bundle-branch block, and there is no clear dif- ference in ST-segment response to exercise between those with Exercise and Preexcitation Syndromes.

Exercise can pro- and those without myocardial ischemia. Left bundle-branch voke, abolish, or have no effect on ventricular preexcitation block that develops during exercise might or might not be asso- in individuals with known WPW syndrome. In the pres- of intraventricular blocks that are present at rest is rare. Although precordial leads V1, V2, and V3 , where ST depression is fre- exercise has been considered a predisposing factor to initiate quently present at baseline and increases with exercise even in tachyarrhythmia in WPW syndrome, prevalence of tachyar- the absence of coronary obstruction.

test, as described in the sections that follow. Sensitivity is the percentage study. Sensitivity is influenced by disease severity, effort level, those with an abnormal resting ECG, including bundle-branch and anti-ischemic drugs. Specificity is the percentage of those block, resting ST-T-wave abnormalities, or LV hypertrophy. without the disease who will have normal test results, and it Positive and Negative Predictive Values can be affected by drugs such as digoxin, by baseline electro- Predictive values help define the diagnostic value of a test.

cardiographic patterns, and by LV hypertrophy. Sensitivity and The predictive value of a test is greatly influenced by the specificity are inversely related; when sensitivity is the high- prevalence of disease in the group or individual being tested. est, specificity is lowest, and vice versa. As in a high-prevalence population; conversely, a higher negative a graphical tool, a receiver operating characteristic plot dis- predictive value and lower positive predictive value occur in a plays the test sensitivity on the y-axis against 1 minus the test lower-prevalence population.

For example, an exercise ECG specificity on the x-axis for varying values of the diagnostic that demonstrates ST depression in an elderly person with cut point. The area under the curve provides a summary mea- typical anginal symptoms is most likely a true positive result, sure that averages the diagnostic accuracy across the range of whereas that in a young asymptomatic person without cardiac test values. It equals 1. curve corresponds to random chance.

Thus, the closer the area Pretest and Posttest Probability of Disease is to 1. On the basis of individual like- most data are derived from studies in which patients under- lihood of disease and the performance characteristics of the went both exercise testing and cardiac catheterization.

Because outcome on exercise ECG, the posttest likelihood of obstruc- patients selected for coronary arteriography are more likely to tive CAD can be estimated for a given individual. have obstructive CAD, these data are subject to a workup bias that inflates the estimated sensitivity and deflates the specific- Assessment of Anatomic and Functional Extent of CAD ity.

The diagnostic accuracy of a test also will be influenced by Exercise-induced ST-segment depression does not provide a criteria that are used to determine whether an adequate level reliable assessment of the specific coronary vessel s involved.

of stress has been achieved. There are can be localized by the leads involved: Leads V2 through V4 reflect shortcomings to using this calculation for diagnostic purposes, left anterior descending artery disease; lateral leads reflect left and it should not be used as a sole reason to terminate the test.

ECG, HR, and of CAD include the degree, time of appearance, duration, and blood pressure are monitored during each stage. number of leads with ST-segment depression or elevation. Intravenous ble but nonobstructive plaque. Complications of dobutamine infu- and should be done with consideration of several non—ST-seg- sion include nausea, headache, tremor, anxiety, angina and ment variables, as discussed in the later section on prognosis.

diographic testing alone. Imaging provides information on Selective A2a Adenosine Receptor Agonists and Adenosine the location and amount of ischemic myocardium and on LV Vasodilators such as adenosine, dipyridamole, and regadenoson function. Exercise or pharmacological stress imaging stud- cause coronary vasodilation in normal epicardial arteries. vasodilators are given. The relative lack of increased perfusion The Ischemic Cascade during vasodilation can be visualized with nuclear myocardial The limitation of coronary flow reserve by hemodynamically perfusion agents.

The acute metabolic dobutamine may serve as an alternative to exercise. consequences of this mismatch include decreased production Nuclear perfusion imaging with vasodilator agents is use- of adenosine triphosphate and increased production of lactate, ful particularly for the diagnosis of CAD in patients with left and they result in alterations of the electrical properties and bundle-branch block on resting ECG, because artifactual mechanical function of the myocardium.

These alterations perfusion defects can occur in patients with normal coronary occur in rapid succession in a characteristic sequence termed arteries and left bundle-branch block with exercise or dobuta- ischemic cascade and include, in typical order, reduced LV mine stress. Side effects of vasodilator agents include flush- compliance, regional wall motion abnormalities attributable ing, chest pain, headache, nausea, dyspnea, and AV block, to decreased myocardial contractility, increased LV end- which can be reversed with aminophylline.

Adenosine and dipyr- pectoris often occurs last, if at all. idamole should not be used in patients with second- or third- Pharmacological stress imaging identifies the relative lack degree block who do not have permanent pacemakers in place or in patients with severe asthma or chronic obstructive lung of increase in perfusion in myocardial territories supplied by a disease. or functional consequences of the mismatch between oxygen supply and demand resulting from exercise-induced ischemia.

Nuclear Myocardial Perfusion Imaging Stress myocardial perfusion imaging can be performed as Pharmacological Stress Testing and Agents single-photon emission computed tomography SPECT or In patients unable to exercise for reasons such as deconditioning, positron emission tomography PET. SPECT uses commercially available tracers demand and supply in lieu of physical exercise or to unmask such as technetium Tc m sestamibi, Tcm-tetrofosmin, locally limited capacity for coronary vasodilatation.

Medications and, less commonly, thallium PET uses myocardial perfu- used for pharmacological stress testing include dobutamine, sion imaging agents with very short half-lives, of which rubid- selective A2a adenosine receptor agonists, and adenosine. ium Rb can be produced with a generator, whereas N Dobutamine ammonia requires a local cyclotron.

Compared with SPECT, Adrenergic agents such as dobutamine increase myocardial PET typically has higher spatial and temporal resolution, has oxygen demand by increasing myocardial contractility, HR, a lower effective radiation dose, allows quantitative measure- and blood pressure.

Dobutamine is infused intravenously at ment of myocardial perfusion, and can be performed faster. Nonetheless, retically ideally suited for quantitative myocardial perfusion cumulative radiation is a factor in serial perfusion imaging. measurements, but technical limitations, including radiation SPECT and N ammonia PET can be performed with exer- dose to patients, have limited its development.

An increasing cise and pharmacological stress, whereas R PET imaging can number of clinical reports on vasodilator stress myocardial be performed only with pharmacological stress because of the perfusion imaging with computed tomography are being pub- extremely short tracer half-life.

The radioisotope is injected, and lished at the time of this writing. Myocardial perfusion images at rest CAD in symptomatic patients with chest pain, determining and during stress are displayed as tomographic slices in 3 dif- myocardial viability before revascularization, assessing ferent views to visualize all myocardial segments without over- prognosis after MI or in patients with chronic angina, and lap. Details at rest indicate myocardial ischemia.

Perfusion defects that are about exercise and stress testing with cardiac imaging present during exercise and persist at rest suggest previous MI. The ACCF and AHA now include these procedural With exercise stress, echocardiographic images in several guidelines in the ongoing updates of disease-based guidelines, views are obtained with electrocardiographic gating ie, syn- such as those for stable ischemic heart disease, acute coronary chronized to the QRS complex at rest and while the patient syndromes, heart failure, and other conditions.

performs stationary cycling or immediately after treadmill The ACCF, along with the AHA and other specialty and exercise. of patients with known or suspected CVD. Appropriate use With pharmacological stress, images are obtained at baseline, criteria can be periodically updated. These documents reflect with low-dose and peak dobutamine infusion, and during an ongoing effort by the ACCF to critically and systematically recovery. Echocardiography by itself has no known risks, and create, review, and categorize clinical situations in which such serial testing has no known cumulative effects.

procedures may be used. Although it is recognized that levels The images obtained during different phases of the stress test of evidence supporting test appropriateness will vary, practical are compared side by side. Myocardial contractility normally consensus is required where conclusive evidence is lacking. It increases with exercise, whereas ischemia causes hypokinesis, is anticipated that appropriate use criteria will have an impact akinesis, or dyskinesis of the affected segments. An exercise or on physician decision making, test performance, and reim- stress echocardiogram is considered positive if regional wall bursement policy and will guide future research.

Appropriate motion abnormalities develop with exercise in previously normal use criteria for stress cardiac nuclear imaging and stress echo- segments or become more severe in already abnormal segments. cardiography are outlined in detail elsewhere. gauge prognosis regardless of whether CAD is present. In fact, although reliance on exercise testing for CAD diagno- Cardiac Magnetic Resonance Imaging and Computed sis increasingly is challenged by alternative diagnostic strate- Tomography gies eg, imaging modalities, serologic markers , application Technological advances in magnetic resonance imaging and of exercise electrocardiographic testing to assess prognosis is computed tomography have resulted in increasing use of these increasing3, and often serves as a complementary perspec- modalities for cardiac imaging.

Standard exercise equipment tive for management decisions. Multiple in many experienced centers. tive to age- and sex-based standards. Still, even this stratifica- Nonetheless, several procedural issues must be addressed tion is only an approximation because differences in height, in the assessment of maximal exercise capacity.

Many regard weight, and mode of exercise all modify exercise potential and CPX as a superior means to assess exercise performance ideally should be incorporated into stratifications of age and because gas exchange measurements provide detailed informa- sex standards.

protocol is a powerful predictor of prognosis in patients with Abnormal Chronotropic Response to Exercise known or suspected CVD.

Nevertheless, there are consider- Chronotropic incompetence is the inability of the HR to ations that help optimize the value of standard exercise test- increase commensurate with increased activity or demand. ing to assess exercise capacity and prognosis.

The widely used An intact HR response is vital for matching cardiac out- Bruce protocol was developed as an efficient diagnostic test for put to metabolic demands during exertion. Investigations in middle-aged men; however, it might not be the optimal proto- population-based and clinical cohorts demonstrated that an col to assess exercise capacity in heterogeneous populations, impaired chronotropic response is predictive of cardiac events particularly in elderly, obese, and deconditioned individuals.

In and all-cause death. The simplest approach is to report change of exercise with the Bruce protocol because of physical limi- in HR with exercise relative to peak HR. Because peak HR tations instead of physiological exhaustion, thereby diminish- decreases with age, age-predicted maximal HR is often deter- ing the prognostic implications of low exercise performance.

mined as minus age in years. However, baseline functional ments in energy requirements between stages are available that capacity and resting HR also have bearing on chronotropic could be better suited to measure exercise capacity in elderly responses. Therefore, an alternative method to determine and deconditioned individuals. chronotropic incompetence entails assessment of the propor- A related limitation of routine prognostic assessment based tion of HR reserve used at peak exercise, defined by the differ- on exercise capacity is that many stress testing laboratories use ence between age-predicted maximal HR and resting HR.

This value is often referred of the maximally predicted HR, a threshold assumed sufficient to as the chronotropic index or the proportion of HR reserve for sensitive diagnosis of CAD. With imaging as the priority, used during exercise. Furthermore, exercise capacity often is reported merely in —0. minute after cessation of the exercise test, while in the upright Whereas absolute METs achieved by a year-old man might position, is most frequently used to define an abnormal HR be greater than those achieved by a year-old woman, he recovery response.

Numerous investigations have demonstrated that a predict death than ectopy originating from the right ventricu- decreased HR recovery is a strong adverse prognostic marker lar outflow tract or other relatively benign variants. sistencies in the literature have led to some uncertainty about Advantages of imaging include the opportunity to characterize this index.

Some HR recovery protocols entail active cool- ejection fraction, extent and distribution of ischemia, presence down. Initial reports of HR recovery were based on patients of coronary calcification, and, in some cases, even the intrinsic who underwent an upright cool-down protocol with a slow structure of stenoses, all of which are powerful risk predictors walk for 2 minutes immediately after exercise.

With this pro- for both death and cardiovascular events. In standard exercise prognostic electrocardiographic testing. When different protocols are even when SPECT imaging is available, and relatively little used, HR recovery cut points have tended to be higher, but additional prognostic insight is gained by adding SPECT the implications of attenuated HR deceleration were similar.

Adults who are older, deconditioned, female, or ischemia or other known heart disease. Exercise-induced hypotension consistently has been for exercise stress to determine prognosis in situations in shown to be a marker of increased risk for adverse events. with subthreshold HR. The component of the Duke for future hypertension, LV hypertrophy, and cardiovascular Treadmill Score that has been consistently validated for inde- events.

Some reports indicate that can be used as a multivariate score to predict risk. First devel- ventricular ectopy during exercise testing heralds increased oped as a score to improve the sensitivity of the exercise test risk of death, whereas others do not. Other studies indicate for the diagnosis of CAD in men and later also in women, increased risk of death in those demonstrating increased ven- the Morise score was subsequently applied to the prediction tricular ectopy in recovery.

sured directly by CPX have been used as criteria for disability by the Social Security Administration. Additional Uses of Exercise Testing Evaluation of Perioperative Risk for Noncardiac Surgery Exercise Prescription In most ambulatory patients, exercise testing with electro- Although the indications for exercise testing are varied, the cardiographic monitoring provides both an estimate of assessment of exercise response and determination of func- functional capacity and the detection of myocardial ischemia tional capacity are particularly useful in the development of through changes in the ECG and hemodynamic response.

the exercise plan or prescription. However, pharmacological stress imaging to the healthy population. In addition, training results in increased a higher relative risk of future events such as angina pectoris, exercise time and workload to provocation of symptoms pre- MI, and sudden death, the absolute risk of cardiac events in viously identified during submaximal exercise, such as angina these populations remains low.

Measurable dictive value of any test in low-risk populations must be low. improvements, or lack thereof, provide the basis for updates It is also acknowledged that prospective, multicenter studies in the exercise prescription and determination of subsequent to demonstrate that interventions based on exercise electro- strategies for patient care.

cardiographic findings alone can favorably alter clinical out- Response to Medication comes in asymptomatic subjects are wanting. Management of medication prescribed to control exercise- Even so, several exercise electrocardiographic findings related symptoms or various inappropriate cardiorespira- have been related to future risk and have potential importance tory responses also can be evaluated with exercise testing. for risk management. However, the positive predictive value was risk factors.

A concomitant abnormal exercise thallium tions based on the following considerations. Most acute cardiac beats did not have significant prognostic value in this popu- events are attributable to plaque rupture of minor stenoses lation.

Although abnormal HR-adjusted ST-segment findings, but not standard extensive obstruction makes unstable plaque more likely and ST-depression criteria alone, identified increased 4-year risk might be more readily identified by exercise testing, it is not of coronary heart disease events.

With regard to subjects who are asymptomatic but have risk Prediction of exercise-related MI and sudden death by exercise factors for CAD, exercise testing could have greater predic- testing is therefore limited by the same factors that reduce tive value.

Exercise testing was of no predictive value asymptomatic low-risk younger subjects. However, there are in the group with no risk factors. Interestingly, a positive test was not significantly management, particularly when functional test findings such associated with nonfatal MI.

Furthermore, asymptomatic from CAD among men with an abnormal test response and patients at higher risk for obstructive CAD could benefit suggested that the exercise ECG might serve to identify high- from the reassurance provided by a normal test, which risk men who do benefit from interventions targeting risk fac- might facilitate prescription of and compliance with more tor reduction.

Exercise testing is well. in individuals with chest pain or with dyspnea on exertion, with or without known CAD, to evaluate whether vigorous Before Participation in Vigorous Exercise exercise is appropriate for such an individual, to establish Vigorous physical exertion, usually defined as exercise requir- training limits, and to develop an exercise prescription. However, individual risk of adverse events is reduced Education Program.

Whether exercise testing should be performed in asymp- www. tomatic adult subjects before beginning vigorous exercise has been controversial—even more so for routine screening of Exercise Electrocardiographic Testing in Women young people before engaging in athletics.

Exercise testing has similar diagnostic and prognostic value in Exercise testing before beginning an exercise program has women as it does for men. Exercise capacity but no evidence of coronary disease on an angiography.

Although a study of women who underwent stress testing and sub- overall prognosis in these women is better than in those with sequent angiography, exercise capacity was among the best obstructive coronary disease, syndrome X is nonetheless stress testing variables for predicting the presence of CAD, associated with an increased rate of cardiovascular mortality, and it improved the sensitivity and specificity of exercise test- including sudden cardiac death, MI, and heart failure.

no significant ischemia detected. The prognostic value of exercise capacity has been shown in The Pediatric Population both asymptomatic women73, and symptomatic women. It is also asymptomatic women, exercise capacity was an independent sometimes necessary to modify protocols.

Low ramp rates are predictor of death as well, where for each additional MET needed for small children performing cycle ergometry. In contrast, for many capacity was lower for women than for men. They of symptomatic women referred for exercise testing and tend to generate unrealistically low values for small children, angiography, the presence of CAD correlated with the Duke especially boys. In terms of progno- be used in these calculations.

study, exercise agree well with the results of these tests. Although myocardial with interpretable ECGs and good effort capacity. Even in conditions where there percentage of their maximal capacity at specific submaximal is a potential for impaired coronary perfusion eg, congenital exercise loads than that exerted by younger people. The systolic blood pressure response to both maximal monitoring. For patients with known or suspected CAD, stress and submaximal aerobic exercise also is increased with age.

If, on the women. Because of its poor diagnostic accu- attributable to LV stiffness and decreased compliance. An exercise test with pre- and postexercise spirometry and ejection fraction responses to maximal aerobic exercise is a might be a worthwhile study if this condition is suspected. Some disorders, such as PAD and chronic obstruc- Measurements at peak exercise are particularly helpful in this tive lung disease, frequently coexist with CAD because of regard.

However, for peak exercise data to be reliable and repro- shared risk factors.

 
 

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