Exercise Stress Test: Beyond the ST segment

Estimated Functional Capacity Relative to Age and Sex:

Importance of Estimated Functional Capacity as a Predictor of All-Cause Mortality. Claire E Snader et al. Journal of the American College of Cardiology Jul 1997, 30 (3) 641-648


Stress test:

  1. *** exercise tolerance for age and gender
  2. Chest pain did not*** occur during the test
  3. There is no electrocardiographic*** or echocardiographic evidence of ischemia
  4. *** Occasional PVCs noticed during exercise
  5. *** Low risk study

Baseline echocardiogram:

  1. Normal biventricular size and systolic function
  2. Screening 2D and Doppler is negative for significant valvular abnormalities

Pre-test Probability of CAD:

R. J. Gibbons, et al.ACC/AHA 2002guideline update for exercise testing: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines). Circulation 106 (14), 1883-1892

Risk Stratification:

ACCF/SCAI/STS/AATS/AHA/ASNC 2009 Appropriateness Criteria for Coronary Revascularization. Manesh R. Patel, Gregory J. Dehmer, John W. Hirshfeld, Peter K. Smith, John A. Spertus. Journal of the American College of Cardiology Feb 2009, 53 (6) 530-553; DOI: 10.1016/j.jacc.2008.10.005

Predicted Exercise Capacity for Age:

Exercise Electrocardiogram Testing: Beyond the ST Segment. Paul Kligfield and Michael S. Lauer. Circulation. 2006;114:2070-2082

New Equation for Age-Predicted Maximum Heart Rate:

  • Men: Max HR = 208 – (0.7 x Age)
  • Women: Max HR = 206 – (0.88 x Age)
  • CAD with beta-blockers: Max HR = 164 – (0.7 x Age)


Chronotropic Index Calculator:

[(HR max – HR rest) x 100]  /   [(220 – Age) – HR rest]

    • Index < 80 % defines chronotropic incompetence
    • With significant doses of beta-blockers, index < 62 % is considered chronotropic incompetence

Abnormal Heart Rate Recovery:

  • With post-exercise cool down: Heart rate decrease by less than 12 beats/min after one minute
  • With immediate exercise cessation: Heart rate decrease by less than 18 beats/min after one minute and less than 42 beats/min after 2 minutes


Blood Pressure Response:

  • Exaggerated systolic pressure response: > 210 mmHg in men and > 190 mmHg in women
  • Exercise-induced hypotension: Reduction of blood pressure below initial resting systolic pressure (or > 20 mmHg drop)
  • Pseudo-exercise-induced hypotension: When the resting blood pressure is high and comes down with exercise
  • Low systolic pressure peak: when peak blood pressure < 140 mmHg or < 10 mmHg rise in blood pressure with exercise
  • Double-product reserve: Difference between resting and peak double-product is less than 10, 000