Description
Exercise stress test is a method used to evaluate the cardiovascular response to physical stress. It is helpful in assessing cardiovascular disease and defining limits for exercise programs.
Indications for Exercise Stress test
- To detect the presence and location of coronary artery disease.
- To identify myocardial risk stratification.
- As preoperative evaluation.
- For evaluating the physiologic significance of known or suspected coronary artery stenosis for revascularization procedures or medical management.
- To determine the prognosis after myocardial infarction.
- To evaluate the efficacy of therapeutic interventions in patients with known coronary artery disease.
- To monitor the effects of revascularization and medical therapy.
Contraindications and precautions for Exercise Stress test
- Unstable angina with recent (48 hours) angina episode.
- Acute myocardial infarction.
- Uncontrolled systemic hypertension (systolic >200 mm Hg or diastolic >100 mm Hg) or pulmonary hypertension.
- Untreated arrhythmias causing symptoms or hemodynamic compromise.
- Untreated congestive heart failure (CHF).
- Recent pulmonary embolism.
- History of aortic dissection.
- Known left main coronary stenosis.
- Electrolyte abnormalities.
- Tachyarrhythmias or bradyarrhythmias.
- Second-or third-degree atrioventricular (AV) block.
- Severe pulmonary hypertension.
- Acute myocarditis.
- Acute pericarditis.
- Moderate mitral or aortic stenosis.
- Moderate obstructive cardiomyopathy.
- Acute systemic illness.
- Mental or physical impairment leading to inability to exercise adequately.
Specific patient instruction before performing Exercise Stress test
The procedure is performed on outpatient basis. Nurse needs to instruct patient regarding the following:
- Inform patient not to eat or drink for 3 hours prior to the procedure. This reduces the likelihood of nausea that may accompany strenuous exercise after a heavy meal. Diabetics, particularly those who use insulin, will need special instruction from the physician’s office.
- Inform patient not to smoke or use tobacco, alcohol, or caffeine on the day of test.
- Inform patient that specific heart medicines may need to be stopped for 1 or 2 days prior to the test (e.g., digoxin, beta blockers and calcium channel blockers). Instructions regarding this should be obtained from physician.
- Instruct patient to wear comfortable, loose clothing and shoes that are suitable for exercise. (Hospital gown may be provided in some centers.)
Preparation of the Patient for Exercise Stress test
Preparing a patient and assisting with an Exercise Stress Test involves several important steps to ensure accurate results and patient safety.
- Fasting:
- Avoid eating or drinking for 3 hours before the test.
- Avoid caffeine, alcohol, nicotine, and cannabis products before the test.
- Medication Adjustments:
- Some medications may need to be stopped 24-48 hours before the test. Consult your doctor.
- Bring a list of all medications, including names and doses.
- Clothing and Accessories:
- Wear comfortable clothing and walking/running shoes (avoid boots, flip-flops, or heels).
- Do not apply lotions, creams, or powders to the chest area.
- Consent and Communication:
- Explain the procedure to the patient, addressing any concerns or questions.
- Obtain informed consent before proceeding.
Procedures for Exercise Stress test
| Nursing actions | Rationale | |
| 1. | Before procedure Provide explanation/demonstration about test and obtain informed consent. | Promotes patient’s understanding and cooperation during the test. |
| 2. | Inform patient to remove jewellery and handover to relatives. | Presence of jewellery hinders placement of leads and may produce artifacts. |
| 3. | During procedure Obtain baseline pulse and blood pressure measurements and pulse oximetry readings. | Helps for comparison. |
| 4. | Assist patient to undress up to waist. Provide hospital gown/shirt for female patients. | Helps for correct placement of ECG leads. |
| 5. | Prepare electrode sites with “Nu Prep” (solution for skin preparation) and alcohol. If hair is present, the site should be shaved. | Helps in better contact of leads with skin and less artifacts on ECG. |
| 6. | Attach electrodes to the chest and shoulder and connect to the ECG portion of the stress test machine. Record baseline 12-lead ECG. | Baseline ECG helps making comparisons after the test. |
| 7. | Physician determines suitable treadmill protocol for patient (protocols Bruce, modified Bruce, or Naughton). | |
| 8. | Start treadmill and have patient begin walking as naturally as possible taking long steps and keeping to the front of the treadmill. | Helps patient to warm up. |
| 9. | Physician presses “start exercise” on the console. The ECG and the presence of any symptoms are monitored continuously during the test. | Continuous monitoring helps to tailor the exercise to the client’s tolerance level. |
| 10. | Records of ECG and heart rate are obtained every minute, and blood pressure should be obtained at the second minute of every stage. | Systolic BP may normally rise to 200 mm Hg at peak exercise. At the same time, the diastolic BP remains unchanged or falls to a slight degree. In patients with hypertension, there will be rise of both systolic and diastolic readings. |
| 11. | Exercise termination is symptom limited, with patients achieving at least 85% or greater of their age predicted maximum heart rate. | |
| 12. | The test may be stopped prior to achievement of the target heart rate if the patient develops untoward symptoms. | |
| 13. | On reaching the desired heart rate for a particular patient, physician presses “Stop Exercise” on console. | |
| 14. | Inform patient that the speed and elevation of treadmill will reduce gradually. Ask patient to cool down for 1 minute by walking at a slow pace on the treadmill with no elevation. | Keeps patient informed. Helps to cool down after exercising. |
| 15. | After procedure Monitor patient for 5 minutes after completion of the test. An ECG should be obtained every minute, and the blood pressure and symptoms should be obtained every other minute. | Helps detect changes in ECG. |
| 16. | Continue to monitor if patient continues to have symptoms or ECG changes. | |
| 17. | Physician interprets and provides a written report of the test. | |
| 18. | Remove chest leads and clean sites with paper tissues. Assist patient to change on termination of the test. |
Exercise Stress test endpoint
- Patient requests to stop.
- Drop in systolic blood pressure of (SBP) >20 mm Hg from baseline blood pressure despite an increase in workload, when accompanied by other evidence of ischemia.
- Moderate to severe angina.
- Marked dyspnea or fatigue.
- Increasing nervous system symptoms (e.g., ataxia, dizziness, or near syncope).
- Signs of poor perfusion (cyanosis or pallor).
- Technical difficulties in monitoring ECG or systolic BP.
- Sustained ventricular tachycardia or supraventricular tachycardia.
- ST elevation (>1.0 mm) in leads without diagnostic Q-waves (other than V1 or AVR).
- ST or QRS changes, such as excessive ST depression (>3 mm of horizontal or downs loping ST-segment depression) or marked axis shift.
- Arrhythmias [multifocal premature ventricular contractions (PVCs), triplets of PVCs, heart block, and bradyarrhythmias in the presence of clinical signs and symptoms).
- Fatigue, shortness of breath, wheezing, leg cramps, or claudication.
- Development of bundle and arch block or intraventricular conduction defect (IVCD) that cannot be distinguished from ventricular tachycardia.
- Increasing chest pain.
- Hypertensive response [SBP >220 mm Hg and diastolic blood pressure (DBP) >110 mm Hg].
- About 85% maximum predicted heart rate (MPHR).
Treadmill protocols for patients
- Bruce
| Stage | Time (minute) | Speed (mph) | Elevation (%) | Metabolic Equivalents (METS) |
| 1 | 3 | 1.7 | 10 | 4 |
| 2 | 3 | 2.5 | 12 | 7 |
| 3 | 3 | 3.4 | 14 | 10 |
| 4 | 3 | 4.2 | 16 | 13 |
| 5 | 3 | 5.0 | 18 | 17 |
| 6 | 3 | 5.5 | 20 | 20 |
| 7 | 3 | 6.0 | 22 | 23 |
- Modified bruce
| Stage | Time (minute) | Speed (mph) | Elevation (%) | Metabolic Equivalents (METS) |
| 1 | 3 | 1.7 | 0 | 1.7 |
| 2 | 3 | 1.7 | 5 | 2.8 |
| 3 | 3 | 1.7 | 10 | 5 |
| 4 | 3 | 2.5 | 12 | 7 |
| 5 | 3 | 3.4 | 14 | 9-10 |
| 6 | 3 | 4.2 | 16 | 13-14 |
| 7 | 3 | 5.0 | 18 | 16.7 |
| 8 | 3 | 5.5 | 20 | 19-20 |
| 9 | 3 | 6.0 | 22 | 23 |
- Naughton
| Stage | Time (minute) | Speed (mph) | Elevation (%) | Metabolic Equivalents (METS) |
| 1 | 2 | 1.0 | 0 | 1.6 |
| 2 | 2 | 2.0 | 0 | 2.0 |
| 3 | 2 | 2.0 | 3.5 | 3.0 |
| 4 | 2 | 2.0 | 7.0 | 4.0 |
| 5 | 2 | 2.0 | 10.5 | 5.0 |
| 6 | 2 | 2.0 | 14 | 6.0 |
| 7 | 2 | 2.0 | 17.5 | 7.0 |
Treatment of adverse reactions
Life support instruments and emergency drugs must be immediately available. In addition, an advanced cardiac life support (ACLS) trained nurse must be available to supervise the procedure.
Minor Adverse Events
- Mild chest pain: Stop exercise, have patient sit down, oxygen 2-4 L/min, sublingual nitroglycerin, consider aspirin 160-325 mg.
- Shortness of breath: Stop exercise, have patient sit down, consider oxygen 2-4 L/min.
- Hypotension/dizziness: Stop exercise, have patient lie down, elevate feet.
- Hypertension: Stop exercise, have patient lie down.
Special Consideration
- Confirm the patient’s medical history, including heart conditions, hypertension, or respiratory issues.
- Ensure the patient has followed pre-test instructions, such as fasting and avoiding caffeine.
- Verify if the patient is on medications that may affect heart rate or blood pressure.
- Adjust medications as per the healthcare provider’s instructions.
- Explain the procedure to the patient, addressing any concerns or questions.
- Obtain informed consent and reassure the patient to reduce anxiety.
- Continuously monitor heart rate, blood pressure, and ECG readings.
- Have emergency equipment, such as a defibrillator and oxygen supply, readily available.
- Be prepared to stop the test if the patient experiences severe symptoms.
- Ensure the patient maintains a steady pace and follows instructions during the test.
- Encourage the patient to report any unusual symptoms immediately.
- Allow the patient to recover for 5-10 minutes after the test.
- Monitor for delayed complications, such as chest pain or excessive fatigue.
REFERENCES
- Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
- Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
- Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwers, ISBN-13:978-9388313285
- Adrianne Dill Linton, Medical-Surgical Nursing, 8th Edition, 2023, Elsevier Publications, ISBN: 978-0323826716
- Donna Ignatavicius, Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care, 11th Edition ,2024, Elsevier Publications, ISBN: 978-0323878265
- Lewis’s Medical-Surgical Nursing, 12th Edition,2024, Elsevier Publications, ISBN: 978-0323789615
- AACN Essentials of Critical Care Nursing, 5th Ed. Sarah. Delgado, 2023, Published by American Association of Critical-Care Nurses ISBN: 978-1264269884
- Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2024. PART IV, NURSING PROCESS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK610818/
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