Box 2.2 American Association of

Box 2.2 American Association of

Cardiovascular and Pulmonary

Rehabilitation (AACVPR) Risk

Stratification Criteria for Patients with

Cardiovascular Disease

Nonexercise Testing Findings

• Resting ejection fraction ≥50%

• Uncomplicated myocardial infarction or revascularization procedure • Absence of complicated ventricular dysrhythmias at rest

• Absence of congestive heart failure

• Absence of signs or symptoms of postevent/postprocedure ischemia • Absence of clinical depression

Box 2.2 American Association of

Cardiovascular and Pulmonary

Rehabilitation (AACVPR) Risk

Stratification Criteria for Patients with

Cardiovascular Disease

Characteristics of patients at moderate risk for exercise participation (any one or combination of these findings places a patient at moderate risk)

• Presence of angina or other significant symptoms (e.g., unusual shortness of breath, light-headedness, or dizziness occurring only at high levels of exertion [≥7 METs]) • Mild to moderate level of silent ischemia during exercise testing or recovery

(ST-segment depression <2 mm from baseline) • Functional capacity <5 METs

Nonexercise Testing Findings

• Rest ejection fraction 40% to 49%

Box 2.2 American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) Risk Stratification Criteria for Patients with Cardiovascular Disease

Characteristics of patients at high risk for exercise participation (any one or combination of these findings places a patient at high risk)

• Presence of complex ventricular dysrhythmias during exercise testing or recovery • Presence of angina or other significant symptoms (e.g., unusual shortness of breath,

light-headedness, or dizziness at low levels of exertion [<5 METs] or during recovery) • High level of silent ischemia (ST-segment depression ≥2 mm from baseline) during

exercise testing or recovery

• Presence of abnormal hemodynamics with exercise testing (i.e., chronotropic

incompetence or flat or decreasing systolic BP with increasing workloads) or recovery (i.e., severe postexercise hypotension)

Box 2.2 American Association of Cardiovascular and Pulmonary

Rehabilitation (AACVPR) Risk Stratification Criteria for Patients

with Cardiovascular Disease

Nonexercise Testing Findings

• Rest ejection fraction <40%

• History of cardiac arrest or sudden death • Complex dysrhythmias at rest

• Complicated myocardial infarction or revascularization procedure • Presence of congestive heart failure

• Presence of signs or symptoms of postevent/postprocedure ischemia • Presence of clinical depression

Reprinted from (32), with permission from Elsevier.

Chapter 5

Introduction

• Clinical exercise testing has been part of the differential diagnosis of patients with

suspected ischemic heart disease (IHD) for more than 50 yr.

• Although there are several indications for clinical exercise testing, most tests are likely

performed as part of the diagnosis and evaluation of IHD.

• There are several evidence-based statements from professional organizations related to

the conduct and application of clinical exercise testing.

Indications for a Clinical Exercise Test

• Indications for clinical exercise testing encompass

three general categories: (a) diagnosis (e.g.,

presence of disease or abnormal physiologic

response), (b) prognosis (e.g., risk for an adverse

event), and (c) evaluation of the physiologic

response to exercise (e.g., blood pressure [BP] and

peak exercise capacity).

Indications for a Clinical Exercise Test (Cont.)

• The clinical utility of exercise testing is described in

several evidence-based guideline statements

aimed at specific cardiac diagnoses (Box 5.1).

• In addition to indications listed in Box 5.1, an

Conducting the Clinical Exercise Test

• When administering clinical exercise tests, it is

important to consider contraindications, the

exercise test protocol and mode, test endpoint

indicators, safety, medications, and staff and facility

emergency preparedness

Conducting the Clinical Exercise

Test (cont.)

• Testing Staff

• Over the past several decades, there has been a transition in many

exercise testing laboratories from tests being administered by

physicians to nonphysician allied health professionals, such as clinical

exercise physiologists, nurses, physical therapists, and physician

assistants.

• According to the ACC and AHA, the nonphysician allied health care

professional who administers clinical exercise tests should have

Conducting the Clinical Exercise Test

(cont.)

• Testing Mode and Protocol

• The mode selected for the exercise test can impact the results and

should be selected based on the test purpose and patient preference

• Treadmill

• Cycle ergometer

• Other exercise testing modes may be considered

Conducting the Clinical Exercise Test

(cont.)

• Monitoring and Test Termination

• Variables that are typically monitored during clinical exercise testing

include HR; ECG; cardiac rhythm; BP; perceived exertion; and clinical

signs and patient-reported symptoms suggestive of myocardial

ischemia, inadequate blood perfusion, inadequate gas diffusion, and

limitations in pulmonary ventilation

Conducting the Clinical Exercise Test

(cont.)

• Monitoring and Test Termination (Cont.)

• The analysis of expired gas during a CPET overcomes the potential inaccuracies

associated with estimating exercise capacity from peak workload (e.g., treadmill

speed and grade). The direct measurement of

VO

is the most accurate measure of

exercise capacity and is a useful index of overall cardiopulmonary health

• Exertional dyspnea

• SpO

• Termination criteria-When the goal is a symptom-limited