Everything to do with Graded Exercise Tests (GXT's) A. Factors that determine the dept ? of GXT scan 1. age 2. health status 3. type of test ( max ) 4. exercise plan (vigorous or sedentary) B. Importance of screening prior to exercise testing 1. safety a. the majority of safety occurs here 2. choosing appropriate exercise testing 3. ID needs for more comprehensive medical evaluations 4. prescribing appropriate exercise programs a. nature of the exercise programs C. Purposes for testing 1. assess the safety in terms of starting or changing an exercise program 2. aid in the diagnosis of heart disease 3. prescribing an appropriate exercise program 4. to follow the progress of known coronary or pulmonary disease 5. to determine effectiveness of medical or surgical procedures involving medication 6. to develop a repoir with an indiv. 7. to assess the CV or Pul. capacity of both the app. healthy and the diseased 8. To determine when to intervene a. put in a new valve D. Three categories to undergo exercise testing 1. apparently healthy a. no major coronary risk factors 2. high risk a. symptoms suggest CV, Pul., or metabolic prob's; or al least one major coronary risk factor 3. Individual's with known diseases E. Major Coronary risk factors 1. High BP - 145 / 95 2. Total Cholesterol / HDL's > 5.0 3. Cig. smoking 4. Abnormal resting ECG a. is indirect evidence of an old myocardial infarct, l-ventricular hypertrophy, ischemia, conduction defects, or disrhythmias 5. Family history of coronary or other atherosclerosis prior to age 50 6. Diabetes Mellitus F. Metabolic Diseases 1. Diabetes 2. thyroid disorder 3. renal disease 4. liver disease 5. other smaller diseases G. Classify individuals 1. Give a medical questionnaire 2. Then put them in one of the above three categories H. Apparently healthy 1. If < age 45 a. no need to exercise test prior to beginning an exercise program 2. if 45 or older a. give a max exercise test before beginning or changing the exercise program (1) all max exercise tests after age 35 should be done with a physician present (2) a sub max test at any age will not require a physician (3) it is valuable to giving a safe exercise prescription I. Individuals at risk 1. GXT max is desireable at any age a. esp. with symptoms (1) physician should be there 2. without symptoms and less than 35 a. no physician necessary 3. Sub-max tests a. little diagnostic value b. lead to determination of heart disease c. functional test tests fitness 4. Symptomatic at any age a. need a physician supervised max test J. Diseased 1. Need a physician supervised max test 2. Purpose a. to determine the safety of the exercise b. to determine functional capacity ** TEST QUESTION ** FILL IN YES / NO FOR THE TABLE ON PAGE 7 K. Complications and potential risks of GXT's 1. Extremely low risk of morbidity both max and sub- max a. deaths are not related to severity b. deaths are 1 / 10,000 2. the complication rate is 8 / 10,000 3. ventric. arry's or MI = 4 / 10,000 ** The risks appear acceptable a. each case is evaluated separately as to the benefits vs. the risk ( exp. with the old and diseased ) L. The PAR-Q 1. is used as a bare minimum 2. will ID those to whom exercise may be harmful 3. contains 6 questions a. learn them !!!!! b. if answer yes, then should not exercise until cleared by a physician M. Depth of the evaluation 1. in addition to the others previously given ( age, health status, type of test, and exercise plan ) a. be familiar with this on page 4-6, they are the complications evaluated prior to exercise testing (1) medical history (a) is the most important (2) physical exam. (3) lab tests N. What do GXT's do 1. Yield sig. data on the status of heart and lung fcl capacities 2. detects myocardial ischemia - not CAD O. Purposes of GXT's 1. Functional 2. diagnostic 3. Prognostic a. health, life length P. GXT Pathophysiology considerations 1. Angina Pectoralis a. ecg changes, etc b. because 70% of the O2 is extracted from the art's at rest, it takes 85% occlusion before angina pectoralis occurs c. with exercise, it only has to be 50% 2. Blood Pressure a. the least understood b. the least measured (1) need to measure SBP max Q. Conditions for a GXT 1. Continuous or non-continuous a. children use non-cont b. a ramp protocol is a continuous one 2. Single load or multi-staged 3. supine or upright 4. modality 5. max or a sub-max 6. nature of recovery a. cool down (1) not needed with cardiac patients if looking at recovery (2) if not enough time (over 10 min.) have them lie down and elevate the feet 7. Type of protocol a. diseased status b. activity status c. age (1) more likely to get a false positive than a true positive (a) myocardium irritability increases with age 8. orthopedic considerations R. GXT preparations 1. Patient preparation a. food, clothing, etc. 2. Complete medical history and any lab tests 3. Consider the indications and the contraindications to testing a. recent MI is a definite contraindication b. recent illness is also (1) will get a false positive 4. consideration of the factors leading to a false positive or negative a. sub-max tests => false negatives (1) did not get high enough intensity (2) more likely in the females (big breasted ones esp., and the old) 5. consideration of drug effects and electrolyte imbalance a. are they on drugs b. diuretics effect the electrolyte imbalance 6. obtain the informed consent S. Subject preparation 1. Avoid strenuous activity on the day of the test, esp. 2-4 hr before a. if testing athletes, have them rest the day before 2. have an overnight fast, or four hours past a heavy meal or 2 hours past a light meal 3. avoid caffeine 2-4 hrs before a. they increase the PVC's and HR 4. no alcohol or cigs 2-4 hrs before, esp. just before a. alcohol can both increase and decrease HR 5. free of any illness or discomfort 6. dressed comf. with light shoes 7. 68-74 deg. F., with a 40 - 60 % humidity 8. rest comf. in a supine position 10 min. prior T. Informed consent (would not hold up in court) 1. absolute necessity- though not universally recognized 2. ACSM - states they should sign prior to exercise 3. the exact value of the medical viewpoint is not clear a. people cannot waive their right to sue 4. PURPOSE - to make certain the participant is aware of the risk a. if a subject asks excessive questions, this person is likely to sue if something goes wrong U. Specifics of an informed consent 1. Immediately prior to exercise, the partic. must receive 2. Should contain a. explanation of the procedures, purpose, risks, discomfort, and benefits b. offer to fully answer any questions c. both the person and the test administrator should sign should sign (1) if a minor, then both parents and the minor should sign d. a brief demonstration of the test procedures