Absolute Contraindications to Exercise Testing - ANSWER • A recent significant change in the resting ECG suggesting significant ischemia, recent MI (within 2 d), or other acute cardiac event • Unstable angina • Uncontrolled cardiac dysrhythmias causing symptoms or hemodynamic compromise • Symptomatic severe aortic stenosis • Uncontrolled symptomatic heart failure • Acute pulmonary embolus or pulmonary infarction • Acute myocarditis or pericarditis • Suspected or known dissecting aneurysm • Acute systemic infection, accompanied by fever, body aches, or swollen lymph glands Relative Contraindications to Exercise Testing - ANSWER • Left main coronary stenosis • Moderate stenotic valvular heart disease • Electrolyte abnormalities (hypokalemia or hypomagnesemia) • Severe arterial hypertension (SBP>200 mmHg and/or DBP >110 mmHg) at rest • Tachydysrhythmia or bradydysrhythmia • Hypertrophic cardiomyopathy and other forms of outflow tract obstruction • Neuromotor, musculoskeletal, or rheumatoid disorders that are exacerbated by exercise • High-degree AV block • Ventricular aneurysm • Uncontrolled metabolic disease (diabetes, thyrotoxicosis, or myxedema) • Chronic infectious disease (e.g. HIV) • Mental or physical impairment leading to inability to exercise adequately General Indications for Stopping an Exercise Test - ANSWER • Onset of angina or angina-like symptoms • Drop in SBP of ≥10 mmHg with an increase in work rate or if SBP decreases below the value obtained in the same position prior to testing • Excessive rise in BP: SBP>250 mmHg and/or DBP>115 mmHg • Shortness of breath, wheezing, leg cramps, or claudication • Signs of poor perfusion: light-headedness, confusion, ataxia (loss of full control of bodily movements), (pallor) unhealthy pale appearance, cyanosis (bluish skin color), nausea, or cold and clammy skin • Failure of HR to increase with increased exercise intensity • Noticeable change in heart rhythm by palpation or auscultation • Subject requests to stop • Physical or verbal manifestations of severe fatigue • Failure of the testing equipment Absolute Indications for stopping an exercise test - ANSWER • Drop in SBP ≥10 mmHg with an increase in work rate, or if SBP decreases below the value obtained in the same position prior to testing when accompanied by other evidence of ischemia • Moderately severe angina (defined as 3 on standard scale) • Increasing nervous system symptoms (e.g. ataxia, dizziness, or near syncope) • Signs of poor perfusion (cyanosis or pallor) • Technical difficulties monitoring the ECG or SBP • Subject's desire to stop • Sustained ventricular tachycardia • ST elevation (+1.0 mm) in leads without diagnostic Q waves (other than V1 or aVR) Relative Indications for stopping an exercise test - ANSWER • Drop in SBP ≥10 mmHg with an increase in work rate, or if SBP below the value obtained in the same position prior to testing • ST or QRS changes such as excessive ST depression (>2 mm horizontal or down sloping ST-segment depression) or marked axis shift • Arrhythmias other than sustained V Tach, including multifocal PVCs, triplets of PVCs, SVT, heart block, or bradyarrhythmias • Fatigue, shortness of breath, wheezing, leg cramps, or claudication • Development of bundle-branch block or intraventricular conduction delay that cannot be distinguished from V Tach • Increasing chest pain • Hypertensive response (SBP>250 mmHg and/or DBP>115 mmHg) ST segment depression - ANSWER ≥1 mm of horizontal or down sloping ST↓ 60-80 ms beyond the J point suggesting myocardial ischemia Chronotropic incompetence - ANSWER 1. Peak exercise HR about 20 BPM below the age predicted HRmax or an inability to achieve > 85% of the age predicted HRmax for subjects limited by volitional fatigue. 2. Chronotropic index <.8 Heart Rate Recovery - ANSWER less than or equal to 12 BPM at 1 minute for walking, or less than or equal to 22 BPM at 2 mins for supine position Sensitivity - ANSWER % of pts. tested with known CVD who demonstrate significant ST segment changes. Exercise EKG sensitivity usually requires greater than or equal to 70% stenosis True Positive - ANSWER Horizontal or down sloping ST segment depression of ≥1.0 mm and correctly identifies a patient with CVD False Negative - ANSWER test shows no or non-diagnostic ECG changes and fails to identify patients with underlying CVD