Cover
Contributors
Preface
Abbreviations
1 Introduction
1. Introduction
2. Pathophysiologic Considerations
3. Preparations and Precautions
4. Methodology
5. Endpoints to Terminate Exercise ECG Stress Tests
6. Indications Versus Contraindications (see Chapters 3 and 4)
7. Interpretations of the ECG Stress Test
8. Clinical Values of the Exercise ECG Test
9. Cardiac Arrhythmias and the Exercise ECG Test (Chapter 12)
10. Hemodynamic Responses to Exercise
11. Complications and Potential Risks (Chapters 12 and 21)
12. References
2 Preparations and Precautions
1. Introduction
2. Preparations and Precautions
3. History Taking and Physical Examination
4. 12‐Lead Electrocardiogram
5. Blood Pressure (BP) Monitoring
6. Premature Test Termination
7. References
3 Indications
1. Introduction
2. Indications
3. References
4 Contraindications to Stress Testing
1. Introduction
2. Absolute Contraindications
3. Relative Contraindications
4. References
5 Exercise Stress ECG Test Protocols
1. Introduction
2. General Testing Procedures
3. Exercise ECG Testing Protocols
4. References
6 Stress ECG Testing with Nuclear Myocardial Perfusion Imaging Techniques
1. Introduction
2. Nuclear Perfusion Agents
3. Stress Test and Radiotracer Protocols
4. Image Interpretation
5. Clinical Application of Nuclear Myocardial Imaging
6. References
7 Stress Echocardiography
1. Introduction
2. Exercise Stress Echocardiography
3. Dobutamine Stress Echocardiography
4. Other Methods of Stress Echocardiography
5. References
8 Pharmacological Stress Testing
1. Introduction
2. Vasodilator Agents
3. Beta‐Adrenergic Agonist
4. References
9 Cardiopulmonary Exercise Testing
1. Introduction
2. Physiology
3. Procedural Aspects of CPX Testing
4. Measurements
5. Applications in Clinical Practice
6. Reporting
7. References
10 Stress Testing After Acute Coronary Syndromes
1. Introduction
2. Guidelines for Stress Testing After ACS
3. Exercise ECG Protocols After ACS
4. Myocardial Imaging
5. References
11 Proper Selection of the Mode of Stress Testing
1. Introduction
2. General Comments
3. Selection of Mode Stress Testing (see Figure 11.2)
4. References
12 Exercise‐induced Cardiac Arrhythmias
1. Introduction
2. Equipment
3. Electrophysiologic Effects of Exercise
4. Value of Exercise Stress Testing in Diagnosing and Managing Arrhythmias
5. Cardiac Arrhythmias and Termination of Exercise Testing
6. Classification, Diagnosis, and Clinical Significance of Exercise‐Induced Arrhythmias
7. References
13 Complications
1. Introduction
2. Cardiac Complications
3. Noncardiac Complications
4. Ill‐Defined and Miscellaneous Complications
5. References
14 Interpretation
1. Introduction
2. Physiologic Responses to Exercise
3. Abnormal Responses to Exercise
4. Electrocardiographic Changes
5. Hemodynamic Changes
6. Symptoms and Signs
7. Clinical Implications
8. Reporting
9. References
15 False‐Positive and False‐Negative Exercise ECG Test Results
1. Introduction
2. False‐Positive Exercise ECG Responses
3. False‐Negative Exercise ECG Responses
4. References
16 Pediatric Exercise Testing
1. Introduction
2. Indications for Exercise Testing of Children
3. Children’s Responses to Exercise
4. Performing Exercise Testing in Children
5. References
17 Follow‐up Care and Management
1. Introduction
2. General Principles and Goals of Exercise Stress Testing
3. Large Scale Studies Assessing Predictive Implications of Exercise ECG Stress Testing
4. Exercise ECG Parameters Associated with Prognosis
5. Prognostic Value of Myocardial Imaging
6. References
18 Value of Exercise (Stress) ECG Testing Before Engaging in Exercise Programs or Competitive Sports
1. Introduction
2. Proper Interpretation
3. Asymptomatic Patients
4. Prior to Vigorous Exercise or Competitive Sports
5. References
19 Exercise Prescriptions for Healthy Individuals and Cardiac Patients
1. Introduction
2. Physiology of Exercise
3. Exercise Prescription for Healthy Subjects
4. Exercise Prescription for the Cardiac Patient
5. References
20 Computer Technology in the Field of Exercise ECG Stress Testing
1. Introduction
2. Computer‐Driven Automated Performance of the Exercise ECG Test
3. Data Processing
4. Computerized Analysis of ST‐Segment Response to Stress
5. Computer Applications to Estimate Post‐Test Probability of CAD
6. References
21 Medicolegal Aspects of Stress ECG Testing
1. Introduction
2. The Stress Laboratory
3. Medical Personnel
4. Test Preparation (see Chapters 2 and 3)
5. Test Performance
6. Proper Emergency Equipment and Drugs
7. Medico‐legal Aspects as they Pertain to Stress ECG Testing
8. References
22 Educational Guide for Patients and Families
1. Introduction
2. Exercise ECG (Treadmill) Stress Test
3. Exercise‐Myocardial Perfusion Imaging (“Nuclear”) Scan
4. Vasodilator (Adenosine, Dipyridamole, or Regadenoson) Cardiac Perfusion Test
5. Dobutamine Myocardial Perfusion Imaging (“Nuclear”) Stress Test
6. Exercise Treadmill Test or Dobutamine Test with Echocardiography (“Stress Echocardiography”)
7. Important for All Tests
8. Delays
Index
End User License Agreement

List of Tables

Chapter 2
1. Table 2.1 Emergency equipment, medications, and fluids.
2. Table 2.2 Sample exercise ECG laboratory consent form.
Chapter 3
1. Table 3.1 Indications for exercise ECG testing.
2. Table 3.2 Approximate metabolic costs of activities (includes resting metabolic ...
3. Table 3.3 New York Heart Association (NYHA) functional classification and corresp...
Chapter 4
1. Table 4.1 Absolute and relative contraindications to exercise testing.
2. Table 4.2 Conditions known to interfere with ECG interpretation.
Chapter 5
1. Table 5.1 Parameters to be observed and assessed during testing.
2. Table 5.2 Indications for terminating exercise testing.
3. Table 5.3 Bruce protocol.
4. Table 5.4 Modified Bruce protocol.
5. Table 5.5 Naughton protocol.
6. Table 5.6 Ellestad protocol.
7. Table 5.7 McHenry protocol.
Chapter 6
1. Table 6.1 Pre‐existing ECG abnormalities affecting repolarization.
2. Table 6.2 Properties of clinically used myocardial perfusion agents.
Chapter 7
1. Table 7.1 Interpretation of responses to stress echocardiography.
2. Table 7.2 Low‐dose dobutamine protocol for suspected low‐flow, low‐gradient aort...
Chapter 8
1. Table 8.1 Indications for pharmacologic stress testing.
2. Table 8.2 Methylxanthine derivatives and caffeine‐containing products.
3. Table 8.3 Endpoints of dobutamine infusion.
4. Table 8.4 Comparison of available pharmacologic stress agents.
Chapter 9
1. Table 9.1 Respiratory measurements duringcardiopulmonary exercise test (CPX) tes...
2. Table 9.2 Cardiopulmonary exercise test (CPX) findings in cardiovascular and pulm...
Chapter 11
1. Table 11.1 Pretest probability ofcoronary artery disease (CAD) according to age,...
Chapter 13
1. Table 13.1 Complications of exercise ECG stress testing.
Chapter 14
1. Table 14.1 Factors influencing the results of the exercise ECG stress test.
2. Table 14.2 Expected physiologic responses to exercise.
3. Table 14.3 Abnormal responses to exercise.
4. Table 14.4 Factors that may result in false‐positive exercise ECG tests.
5. Table 14.5 Factors that may result in false‐negative exercise ECG tests.
6. Table 14.6 Criteria for positive exercise ECG stress test.
Chapter 15
1. Table 15.1 Causes of False‐Positive and False‐Negative Exercise ECG Results.
Chapter 16
1. Table 16.1 Modified Balke treadmill protocol.
2. Table 16.2 Cycle ergometer protocols for children.
3. Table 16.3 Relative risks for stress testing.
Chapter 17
1. Table 17.1 Survival among patients with ≥2 mm ST‐segment depression during exerc...
2. Table 17.2 Exercise ECG stress test variables associated with increased risk of ...
Chapter 19
1. Table 19.1 Normal values for maximal oxygen consumption according to age and gen...
2. Table 19.2 Energy requirements of various activities inmetabolic equivalents (ME...
3. Table 19.3 Rate of perceived exertion (RPE).
4. Table 19.4 Risk classification for exercise training.
5. Table 19.5 Indications for termination of a symptom‐limited exercise test.
Chapter 20
1. Table 20.1 Sources of noise associated with the Exercise (Stress) ECG.
Chapter 21
1. Table 21.1 Complications of stress testing.
2. Table 21.2 Procedure consent form for non‐treadmill stress ECG test.
3. Table 21.3 Contents of code blue crash cart for stress ECG laboratory.

List of Illustrations

Chapter 6
1. Figure 6.1 Schematic representation of single photon emission computed tomogra...
2. Figure 6.2 Stress and delayed SPECT myocardial perfusion images in the short‐a...
3. Figure 6.3 Stress and delayed SPECT myocardial perfusion images in the short‐a...
4. Figure 6.4 Stress and delayed (rest) SPECT myocardial perfusion images in the ...
Chapter 7
1. Figure 7.1 Diagram of the 17‐segment model of the left ventricle (LV) used for...
2. Figure 7.2 Diagram of regional wall segments and corresponding typical distrib...
Chapter 8
1. Figure 8.1 Time‐line diagrams for pharmacological agent‐myocardial perfusion i...
Chapter 9
1. Figure 9.1 Abnormal patterns of responses from cardiopulmonary exercise test (...
Chapter 11
1. Figure 11.1 Application of Bayes’ theorem to estimate the post exercise test p...
2. Figure 11.2 An algorithm for selecting of a particular type of stress test for...
Chapter 12
1. Figure 12.1 Baseline ECG taken in a 68‐year‐old man with sinus bradycardia wit...
2. Figure 12.2 Exercise ECG in the same 68‐year‐old man. Note an atrial premature...
3. Figure 12.3 Baseline ECG in a 72‐year‐old woman with resting sinus bradycardia...
4. Figure 12.4 Exercise ECG in the same 72‐year‐old woman who developed AF during...
5. Figure 12.5 Baseline ECG demonstrating unifocal ventricular premature contract...
6. Figure 12.6 Recovery ECG in the same 75‐year‐old male with known coronary arte...
7. Figure 12.7 Baseline ECG in a 32‐year‐old woman with WPW syndrome. Note the sh...
8. Figure 12.8 Peak exercise ECG racing in the same 32‐year‐old woman with WPW sy...
9. Figure 12.9 Baseline ECG in a 54‐year‐old woman undergoing an ETT for evaluati...
10. Figure 12.10 Exercise ECG in the same 54‐year‐old woman demonstrating non‐sust...
11. Figure 12.11 Baseline ECG in a 78‐year‐old man with exertional dyspnea demonst...
12. Figure 12.12 Exercise ECG in the same 78‐year‐old man. Note the inappropriate ...
13. Figure 12.13 Baseline ECG in a 62 year‐old man who developed left bundle branc...
14. Figure 12.14 Peak exercise ECG in the same 61‐year‐old male who developed LBBB...
15. Figure 12.15 Recovery ECG in the same 61‐year‐old male. Note the transition ba...
16. Figure 12.16 Baseline ECG in a 26 year‐old‐woman with WPW syndrome. Note the s...
17. Figure 12.17 Recovery ECG in the same 26 year‐old‐woman. Note the persistent S...
Chapter 14
1. Figure 14.1 Types of ST depression seen during exercise.
2. Figure 14.2 Exercise ECG in a 64‐year‐old male referred for exercise testing f...
3. Figure 14.3 Exercise ECG in a 58‐year‐old male referred for exercise ECG testi...
4. Figure 14.4 Early recovery ECG in the same 58‐year‐old male. Note that the ups...
5. Figure 14.5 Exercise ECG in a 38‐year‐old woman with atypical chest pain. Note...
6. Figure 14.6 Recovery ECG in a 75‐year‐old male with known coronary artery dise...
7. Figure 14.7 Exercise ECG in a 70‐year‐old woman with chest pain and dyspnea. N...
8. Figure 14.8 Exercise ECG in a 70‐year‐old male with known anteroseptal infarct...
9. Figure 14.9 Baseline ECG in a 38‐year‐old woman referred for exercise testing ...
10. Figure 14.10 Exercise ECG in the same 38‐year‐old woman. Note the persistent S...
11. Figure 14.11 Baseline ECG in a 57‐year‐old male referred for exercise testing ...
12. Figure 14.12 Recovery ECG in the same 57‐year‐old male. Note the marked diffus...
13. Figure 14.13 Baseline ECG in a 66‐year‐old woman with aortic stenosis demonstr...
14. Figure 14.14 Exercise ECG in the same 66‐year‐old woman with aortic stenosis. ...
15. Figure 14.15 Baseline ECG demonstrating right bundle branch block (RBBB) in a ...
16. Figure 14.16 Exercise ECG in the same 56‐year‐old male. Note the persistent ST...
Chapter 15
1. Figure 15.1 Resting ECG showing sinus rhythm with short PR interval and ventri...
2. Figure 15.2 Peak stress ECG showing 1‐2 mm horizontal ST depression consistent...
3. Figure 15.3 Recovery ECG showing persistent horizontal ST depression and ventr...
Chapter 19
1. Figure 19.1 Exercise prescription health screening algorithm.

This edition first published 2020 © 2020 by John Wiley & Sons Ltd.
Edition History [1e, 1997]

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Library of Congress Cataloging‐in‐Publication Data

Names: Tighe, Dennis A., editor. | Gentile, Bryon A., II, editor. | Prededed by (work): Chung, Edward K. Pocket guide to stress testing.
Title: Pocket guide to stress testing / edited by Dennis A. Tighe, Bryon A. Gentile, II.
Description: Second edition. | Hoboken, NJ: Wiley, 2020. | Preceded by Pocket guide to stress testing / Edward K. Chung, Dennis A. Tighe. c1997. | Includes bibliographical references and index.
Identifiers: LCCN 2019024458 | ISBN 9781119481775 (paperback) | ISBN 9781119481799 (adobe pdf) | ISBN 9781119481751 (epub)
Subjects: | MESH: Exercise Test | Electrocardiography | Heart Diseases–diagnosis | Handbook
Classification: LCC RC683.5.S77 | NLM WG 39 | DDC 616.1/207543–dc23
LC record available at https://lccn.loc.gov/2019024458

Cover Design: Wiley
Cover Image: © Bryon Gentile

Preface

Since the first edition of the Pocket Guide was published, the role of stress testing in evaluating patients with suspected cardiovascular disease has been affirmed and new indications have emerged. In addition, new information on the application of stress testing in specific patient populations and the role of myocardial imaging in conjunction with stress testing has continued to evolve. Thus, the impetus for this second edition was to update the reader on the proper application, performance, and interpretation of the various stress testing modalities used in the contemporary stress laboratory. Each chapter has been revised to reflect the most up‐to‐date information available.

Although abundant information and expansive texts on stress testing are available, we believe that the success of the first edition of the Pocket Guide stemmed from its focused content, emphasis on key points, and inclusion of informative illustrations and tables. Therefore, in the second edition we intentionally continued using a format that is bulleted and focused, and makes extensive use of tables and illustrations to present the essential information without over‐emphasizing esoteric points. We also include a list of key references in the field at the end of each chapter, so that the reader requiring more detailed information can explore topics of interest in greater depth.

As indications and applications for stress testing have evolved, so has the number of non‐physician healthcare professionals involved in the assessment of patients prior to stress testing, during actual performance and monitoring of the test, and issuing of preliminary interpretation of test results. Given the subject matter and practical information included, this edition of the Pocket Guide should prove to be a valuable resource to both physicians and non‐physicians involved in the care of these patients.

I would like to acknowledge the contributions of my colleagues, who have provided insightful and up‐to‐date information. My co‐author, Bryon A. Gentile, II, deserves special recognition for his contribution of many valuable and highly informative chapters; without his efforts this edition of the Pocket Guide would not have been possible. I wish to acknowledge the staff of Wiley Publishers for their support and cooperation during the process of bringing this project to fruition.

Finally, I wish to pay special recognition posthumously to my mentor, teacher, co‐author, and friend, Edward K. Chung, MD. Dr. Chung was an internationally recognized author and leader in the field of electrocardiography and all its applications. He was a generous teacher who demanded excellence and influenced a generation of learners in the heart station at the Thomas Jefferson University Hospital. I was particularly fortunate to have known him and learned from him. It was my distinct privilege to have co‐authored the first edition of the Pocket Guide with him. I will be forever grateful to him for his wisdom and encouragement.

Dennis A. Tighe, MD

Worcester, MA, USA