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In normal subjects, this is not a Dynamic isotonic exercise, which causes movement of the limiting determinant of peak exercise capacity. A nor- endowment and level of training. mal systolic blood pressure response to progressive exercise is dependent on both sex higher in males and age higher with HR Response advancing age. cise is an increase in HR that is attributable to a decrease in After maximum exercise, systolic blood pressure usu- vagal tone, followed by an increase in sympathetic outflow.

This postexercise hemodynamic response highlights degree of variability exists among subjects of identical age the importance of an active cool-down period when possible.

Moreover, the HR eterization to obtain coronary arterial and venous oxygen content. response is generally continuous with increasing workload. An However, myocardial oxygen uptake can be estimated during accelerated HR response to standardized submaximal workloads clinical exercise testing by the product of HR and systolic blood is observed after prolonged bed rest, indicating that physical pressure double product or rate—pressure product and ranges conditioning also plays a role in the HR response, which from the 10th percentile value of 25 to a 90th percentile value also can change in response to anemia, metabolic disorders, of 40 at peak exercise.

A linear relationship exists between variable vascular volume or peripheral resistance, or ventricular myocardial oxygen uptake and coronary blood flow. During dysfunction. These conditions themselves do not appear to affect exercise, coronary blood flow increases as much as 5-fold above maximal HR unless capacity for exercise intensity becomes the resting value. A subject with obstructive CAD often cannot limited.

Conversely, a lower-than-expected incremental rise in provide adequate coronary blood flow to the affected myocardial HR during a progressive exercise test could be attributed to an tissue to meet the metabolic demands of the myocardium during enhanced level of fitness and left ventricular LV function.

As exercise; consequently, myocardial ischemia occurs. Myocardial will be discussed in detail, inadequate HR response to exercise ischemia usually occurs at the same rate—pressure product rather can be a marker not only for sinus node dysfunction but also for than at the same external workload eg, exercise test stage.

It is considered the best measure of cardiovascular fitness the cardiac response to exercise. Other factors that can influence and exercise capacity. The decline of HR myocardial ischemia, and associated symptomatology. has consistently demonstrated prognostic value. Submaximal oxygen uptake is most frequently vascular resistance. whereas diastolic pressure usually remains about the same or To meet the metabolic demand of dynamic exercise, oxygen is moderately decreased because of vasodilatation of the vas- uptake quickly increases, achieving steady state, as previ- cular bed.

In addition, the development of In most cases, the ventilatory threshold is highly reproducible, signs or symptoms associated with the need for exercise test although it might not be achieved or readily identified in some termination, such as angina pectoris, hypertension, or cardiac patients, particularly those with very poor exercise capacity.

be compared with average normal values by age and sex. exercise habits, heredity, and cardiovascular clinical status. Vo2max is equal to the product of maximum cardiac output Absolute and Relative Contraindications to Exercise and maximum arteriovenous oxygen difference. Assessment of this balance oxygen difference at peak exercise.

Because the arteriovenous requires knowledge of the purpose of the test for the individ- oxygen difference at peak exercise reaches a physiological limit ual subject or patient and what symptom or sign end points and usually varies little across a wide spectrum of cardiovascular will be for the individual test.

function, most of the clinical variation in the oxygen pulse at Absolute Contraindications peak exercise is therefore attributable to variation in the forward stroke volume at peak exercise. Reprinted from Fleg JL et al. for the test is not clear, the referring provider should be con- be instructed to resume medication if rebound phenomena tacted for further information. Routine medications may be taken with small amounts correlation with test findings.

of water. Subjects with a history of worsening the nature of the progressive exercise, symptom and sign unstable angina or decompensated heart failure should not end points, and possible complications. undergo exercise testing until their condition stabilizes.

pressure responses to exercise. If ischemia does not occur, A resting supine standard lead ECG should be obtained the diagnostic value of the test for detection of CAD is before exercise to compare to previously obtained standard limited. No formal guidelines for tapering or holding ECGs to determine if changes have occurred over time. importantly from the preexercise standard ECG.

The torso Electrocardiographic Leads for Exercise Testing ECG is not equivalent to a standard ECG because the torso ECG Because a high-quality standard lead ECG with electrodes can shift the frontal plane axis to the right, increasing voltage placed on the limbs cannot be obtained during exercise, elec- in the inferior leads.

waves in a patient with a documented previous Q-wave inferior Multiple leads improve test sensitivity. Most of the change between these do alter QRS and T-wave morphology, they are nonethe- supine limb-lead standard electrocardiographic recordings and less valid for interpretation of heart rhythm and are generally upright torso electrocardiographic recordings is attributable to similar to the standard ECG for detecting ST-segment devia- electrode position and not to the positional change.

If for the leg leads , as shown in Figure 2. Nonstandard elec- torso-lead tracings will be taken in the supine position during trode placement should be documented on the tracing.

recovery, a supine torso-lead tracing also should be obtained in the control period. Blood pressures in the upright position Bipolar CM5. A useful bipolar chest lead, not present in the should be recorded before beginning exercise. Hyperventilation standard lead ECG, can be constructed by using an elec- at rest could produce nonspecific ST-segment changes in some trode placed over the manubrium just below the sternal notch otherwise normal subjects, and these also might occur during that is paired with precordial lead V5 in its standard position exercise as false-positive responses for the identification of midway between V4 and V6 in the anterior axillary line.

The ischemia. the LV cavity from base to apex and also from the high lead strength of the electrode pair in this position. Electrocardiographic Recording Skin Preparation Lead —aVR in Exercise Testing. Lead aVR, when inverted, An important factor governing the recording quality of an takes its place in the frontal plane halfway between standard exercise ECG is the interface between electrode and skin.

bipolar leads I and II. Because this axis also aligns with the Removal of the superficial oils and layer of skin by gentle general axis of the left ventricle, —aVR inverted aVR is abrasion significantly lowers resistance, thus improving the widely used in routine electrocardiography in other countries signal-to-noise ratio.

The areas for electrode application are and also has been endorsed for routine use in resting elec- first shaved and then rubbed with alcohol-saturated gauze. as ST elevation in standard-lead aVR. Recognition of ST depression in aVR as a useful Disposable electrodes used in exercise testing are generally finding in some cases of ST-elevation infarction has prompted silver—silver chloride combinations with adherent gel.

Contact its reevaluation in general exercise testing. Several studies between electrodes and the skin generally improves with sev- have highlighted its usefulness for the detection of demand eral minutes of application time and with the moisture that ischemia during exercise and for the recognition of left main occurs with sweating during exercise, although excess sweat- and proximal left anterior descending stenoses.

Wrapping the torso with a 6-inch elastic bandage or tionship of the derived lead to the axis of the left ventricle as with a fitted torso net can reduce noise produced by electrode a result of torso placement of the electrodes which actually and cable movement, especially in obese patients.

Electrode makes a torso-based —aVR somewhat similar to CM5 in axis. placement for signal stability in large-breasted women can be It should be noted that the spatial diagnostic information con- difficult, sometimes requiring tradeoff of variable location and tained in aVR cannot exceed that of the other routine electro- motion artifact.

cardiographic leads because it is mathematically dependent on Hard-wired connecting cables between the electrodes and and calculated from any 2 bipolar limb leads. standing, the clinical value of aVR —aVR appears promising. Most available commercial exercise cables are constructed to lessen motion artifact by digitizing the electrocardiographic Electrocardiographic Mapping During Exercise. Multiple waveform at the cable box proximal to the attachment to the electrodes in excess of the standard 10 can be used to derive electrocardiograph recorder itself.

Cables generally have a body surface potential maps at rest and during exercise, life span of about 1 year and eventually must be replaced to which can provide additional insight into exercise-related reduce acquired electrical interference and discontinuity.

It is ischemia. Placement of the limb leads on the torso is necessary for reduction of noise in the ECG during exercise, whereas precordial lead placement is unchanged. Waveforms of activity-compatible torso-lead ECGs differ from those derived from standard lead ECGs, but ST-segment shifts with torso electrodes are valid.

The manubrial electrode can be paired with standard lead V5 to produce bipolar CM5. From the figure, it can be seen that —aVR inverted aVR using the torso electrode positions to produce the central terminal has spatial orientation that is similar in orientation to CM5. See text for further details on these leads. LA indicates left arm; LL, left leg; RA, right arm; and RL, right leg.

Reproduced with permission from Fletcher et al. used for clinical exercise test purposes. Details are beyond the of the PR segment, as occur when the reliable point is actu- scope of the present statement. ally on the descending limb of a P wave with a shortened PR interval during exercise, will confound the baseline used for Relative Sensitivity of Leads.

In general, more electrodes lead measurement of ST-segment shift and will result in incorrect to greater test sensitivity. As is true with automated algorithms for emphasized the general individual sensitivity of CM5 and the interpretation of resting ECGs, the computer should be an — aVR, both of which are in the general vector direction adjunct to, not a substitute for, human interpretation.

of the standard lateral precordial leads. Unlike ST elevation during acute MI, ST depression during demand-induced Exercise Equipment subendocardial ischemia during exercise does not localize the Details on exercise testing equipment and exercise testing lab- area of myocardium that is involved.

Treadmill testing is resentative complexes for each lead. Having both exer- to reduce random noise and to reduce beat-to-beat variability cise modes available is advantageous, given that some individ- caused by respiration and movement.

Automated measure- uals have difficulty with treadmill ambulation for reasons that ment of ST-segment shifts based on individual representative include imbalance and orthopedic limitations, whereas other complexes has the potential to increase precision of the mag- individuals develop earlier exercise fatigue using the bicycle.

nitude of repolarization deviation,41 but this is true only when reliable points determining baseline, QRS onset, and QRS Treadmill offset for determining the J-point and ST-segment levels at The treadmill should have front rails, side rails, or both to aid any specified time after the J point are selected accurately in subject stability.

However, subjects should be encouraged not by the computer algorithm. At faster HRs, there invariably is to tightly grasp the front or side rails because this action sup- merging of the end of the T wave with the P wave in patients ports body weight and thus reduces the workload at any given in sinus rhythm, making the standard T—P baseline unusable stage, leading to the potential for a significant overestimation of during exercise for most patients.

For this reason, the end of oxygen uptake. It can be helpful if subjects remove their hands the PR segment is used as a compromise isoelectric baseline from the rails, close their fists, and place one finger of each hand by automated algorithms. Completion of Stage 4 of the Bruce protocol 4. Functional class refers to New York Heart Association class. walking on the treadmill. The treadmill should have variable period again at low workload. Several different treadmill pro- speed and grade capability and must be accurately calibrated.

tocols are in general use and are seen in detail in Figure 3. Standard tables can be used to convert treadmill standard Bruce protocol include its use in many published grade and speed into estimated MET levels. Some Electrically braked cycles vary the resistance to the pedaling subjects, especially those who are elderly, obese, or have gait speed rate-independent ergometers , thereby permitting bet- difficulties, are forced to stop exercising prematurely because ter power output control, because it is common for subjects of musculoskeletal discomfort or an inability to tolerate the who are fatigued or unable to cooperate to decrease their ped- high workload increments.

Initial zero or one-half stages 1. Cycle ergometers are promised exercise capacities. Because exercise on a workload changes between stages of the standard Bruce proto- cycle ergometer is not weight bearing, kiloponds or watts can col by reducing stage duration to 2 minutes while interpolating be converted to oxygen uptake in milliliters per minute.

METs additional half stages. are useful choices for elderly, deconditioned patients. A com- The cycle ergometer is usually less expensive, occupies less plete set of protocols can be found in the American College of space, and is less noisy than a treadmill. Upper body motion is Sports Medicine guide for exercise prescription and testing. Care must be taken to pre- speed, which is increased gradually until the patient has a good vent isometric or resistance exercise of the arms while grasping stride.

In this type of protocol, treadmill testing in those not accustomed to cycling. Exercise protocols should be individual- Exercise Protocols ized according to the type of subject being tested. A 9-minute Protocols for clinical exercise testing generally include an ini- targeted ramp protocol that increases in small steps has many tial warm-up period at low workload , followed by progressive advantages, including more accurate estimates of MET level. If arm available during all exercise tests.

For additional details about ergometry is substituted for cycle ergometry, a similar protocol supervision and interpretation of exercise tests, reference is may be used, except that initial power output and incremental made to the document on clinical competence in stress testing increases are lower.

Two-minute stages are most popular with from the ACCF, AHA, and American College of Physicians. The undergo pharmacological stress testing with imaging. physician or senior medical healthcare professional conduct- The 6-minute walk test is a functional test that can be used ing the test must be trained in advanced cardiopulmonary resus- to evaluate submaximal exercise capacity. This assessment citation.

A defibrillator and appropriate medications also should has frequently been used in patients with chronic disease, be immediately available. Surveys suggest that 0 to 6 deaths or such as heart failure, chronic obstructive pulmonary disease, cardiac arrests per 10 tests and 2 to 10 MIs per 10 tests and peripheral arterial occlusive disease.

tested population. Detailed guidelines describing the administration of rare in clinically normal subjects. Table 1 lists several classes of the 6-minute walk test are available. As an alternative to using HR alone to clinically thus limiting its diagnostic value for ischemia or arrhythmia. determine intensity of exercise, the 6-to Borg scale of per- Exercise Test Supervision ceived exertion62 is useful Table 2. Special verbal and writ- Exercise testing should be performed under the supervision ten explanations about the rating of perceived exertion RPE of a qualified health professional who is appropriately trained are available for subjects.

Although there is some variation to administer exercise tests. Thus, the Borg scale can for exercise testing. Absolute and relative contraindications to exercise testing performed maximal exercise, and values higher than 15 to 16 are subsequently discussed. In any procedure with a risk of suggest that the ventilatory threshold has been exceeded.

complications, the test administrator should be certain that the Angina Characteristics and Scale subject understands the risks and benefits of the test, and writ- Levels of anginal discomfort in those with known or suspected ten informed consent should be obtained. Good communica- CAD are also excellent subjective end points. Whether typi- tion with the patient about testing is mandatory.

cal angina occurs with exercise or is the reason for termina- The physician should be responsible for ensuring that the tion of the test is an important observation in evaluation of the exercise laboratory is properly equipped and that exercise test- exercise test, and it is an important factor in calculation of the ing personnel are appropriately trained. Exercise testing should Duke Treadmill Score. Complications Secondary to Exercise Testing The degree of subject supervision needed during a test can be Cardiac Bradyarrhythmias determined by the clinical status of the subject being tested.

Recent recommendations permit additional Miscellaneous Severe fatigue malaise , sometimes persisting for flexibility with regard to supervision personnel. Even when no abnormalities occur Reprinted from Borg with permission of the at peak exercise, postexercise attention is necessary because publisher. during the recovery period. Mechanical dysfunction and elec- trophysiological abnormalities in the ischemic ventricle after Indications for Termination of Exercise Testing exercise can persist for minutes to hours.

Monitoring of blood The decision to terminate exercise is an important function of pressure should continue during recovery because abnormal test supervision that is generally determined by the purpose responses could occur, particularly hypotension, and arrhyth- of testing in individual subjects. Symptom-limited testing is mias also might be present in the recovery period. desirable for general evaluation, but this recommendation could be modified in several situations.

Scales for each of these symptoms are provided in the present statement and other documents. arterial hypertension. Currently, CPX is test. Signs of poor perfusion, such as cyanosis or pallor, and common in clinical practice for patients with heart failure increasing nervous system symptoms, such as ataxia, dizzi- who are being considered for transplantation and for those ness, and vertigo, serve as absolute test termination criteria.

P-wave duration is generally those at increased risk for CVD, and virtually all patient popu- unchanged or is minimally longer.

uted to atrial repolarization the Ta wave and can cause appar- Maximal work capacity achieved during an exercise test, which ent ST-segment depression when the negative Ta wave persists frequently is used to estimate aerobic capacity, is influenced by into the early ventricular repolarization period. Age- and sex-predicted peak MET levels workloads.

To provide the most into a QRS score for diagnostic purposes. Moreover, The J junction, also known as the J point representing the a conservative exercise test protocol, with smaller workload time—voltage coordinate of the end of the QRS complex and adjustments from one stage to the next, is preferable in patients the beginning of the ST segment can be depressed at maxi- with a diminished functional capacity.

Upsloping ST depression at peak exercise might performed to assess therapeutic efficacy or disease progression. The magnitude quent sections greatly improves the reliability of key variables of ST depression should be measured 60 to 80 ms after the J obtained from the exercise test.

or mouthpiece. When combined with traditional testing pro- T Wave cedures, this assessment is commonly referred to as cardio- A general decrease in T-wave amplitude is observed during pulmonary exercise testing CPX.

Commercially available ventilatory expired gas systems are also commonly capable U Wave of performing pulmonary function tests. Equivocal test tials shorten as HR increases with exercise, and the resulting responses are a major reason for the reduced sensitivity of the QT interval of the ECG is further affected by neurohumoral exercise ECG. However, if upsloping ST depression were con- changes that accompany effort. Other recognized causes of false negative some subjects more commonly women there can be a para- test responses include inadequate effort and anatomically mild doxical absolute QT prolongation in the early minutes of the disease; test sensitivity rises markedly with increasing sever- test.

The then decrease as rates increase at higher exercise workloads. and Recovery in Ischemia The lower the workload and rate—pressure product at which it occurs, the worse is the prognosis and the more likely the pres- ST-Segment Deviation ence of multivessel disease; the duration of ST depression in Changes in the level of the ST segment comprise the earliest the recovery phase also can be related to the severity of CAD.

The ST level Waves. Exercise-induced elevation can occur in an infarct area is measured relative to the end of the PR segment the P—Q where prior Q waves are present. Three or the J point is considered an abnormal response. In the presence more consecutive beats in the same lead with a stable base- of prior Q-wave MI, this could represent reversible ischemia in line should be identified and the average magnitude and tan- the peri-infarct area or ventricular dyskinesis or akinetic LV seg- gent direction of displacement at 60 to 80 ms after the J point mental wall motion.

The changes could result in reciprocal ST-segment depres- ST-Segment Depression. ST-segment depression is the tra- sion that simulates myocardial ischemia in other leads. However, ditional manifestation of exercise-induced myocardial isch- ST-segment elevation and ST-segment depression in the same emia. Myocardial imaging represents the magnitude and direction of electrical gradients techniques can help distinguish the concomitant presence of a generated by ischemic vectors across the endocardium and new myocardial ischemic zone from reciprocal changes induced epicardium, as well as the location of the recording electrodes.

by ST-segment elevation in Q-wave leads. Upsloping, horizontal, and downsloping types of ST-segment ST-Segment Elevation in Subjects Without Prior Infarction. depression are illustrated in Figure 4. Demand ischemia dur- In subjects without previous infarction absence of Q waves ing exercise is limited primarily to the endocardium, with on the resting ECG , ST-segment elevation during exercise reductions in phase 2 plateau amplitude and also less nega- frequently localizes the site of severe transient combined tive phase 4 resting membrane potentials contributing to ST endocardial and subepicardial ischemia resulting from sig- depression on the surface ECG.

When coronary arteries, but this is uncommon. In the presence of resting coronary spasm in otherwise unobstructed arteries. ST-segment elevation at 60 to 80 ms after the J point because of early repolarization, only ST-segment changes below the ST-Segment Normalization P-Q baseline should be used for analysis. patients with angina,98 and increased area of the time integral Normalization of the ST segment during exercise might be of upsloping ST depression might be associated with increased related to cancellation effects of oppositely directed forces risk of future coronary events in higher-risk men.

It is usual for young subjects myocardial ischemia in general populations. Definition of ST-segment depression changes during exercise. HR Adjustment of ST-Segment Depression. As the HR the sensitivity of the exercise test with preservation of test slows during early recovery from peak exercise, the recovery specificity, primarily from improved classification of patients phase behavior of the depressed ST segment as it returns to with equivocal test responses attributable to upsloping ST normal differs in normal subjects and patients with ischemia.

After 1 minute of recovery, ST and from technical differences in methodology. The methods depression attributable to ischemia is generally greater than are not accurate in the early phase after Q-wave infarction in it was at the same HR during exercise, whereas in normal patients with resting abnormalities of repolarization, but they subjects it is less.

It is emphasized that prospective evaluation of infarction has been associated with reversible ischemia during these criteria in larger, multicenter populations is required dobutamine stress echocardiography but also has been asso- for clarification of their value and limitations. Exercise-induced U-wave inversion in sub- in relevant populations is needed if further progress is to be jects with a normal resting ECG can be a marker of myocardial made in exercise ECG.

ischemia in up to one quarter of patients with single-vessel left anterior descending disease. Among patients with chest pain both exercise treadmill testing and by isoproterenol infusion, evaluated by myocardial perfusion imaging, exercise-related but not atrial pacing, was found to prolong the QT interval, P-wave duration and terminal P-wave amplitude in V1 have with U-wave enlargement in subjects with some types of con- been reported to be greater in patients with reversible isch- genital long-QT syndrome.

Absence of QT interval emia. An increase in P-wave duration by signal-averaging has shortening at peak exercise as generally rate-corrected by also been associated with ischemia. However, differences in peak HR between R-Wave Amplitude Changes.

The average response in nor- patients with and without ischemia and problems with inac- mal subjects is an increase in R-wave amplitude during sub- curacy of the Bazett correction at the faster rates that occur maximal exercise, with a decrease at maximum exercise. An during exercise have limited the applicability of peak- increase in R wave at peak exercise has been associated with exercise QT interval alone as an electrocardiographic cri- myocardial ischemia,, perhaps as a correlate of LV isch- terion for ischemia.

Careful measurement of QRS duration dur- length rather than time. Disorders of impulse for- CAD, particularly in women and in some situations with oth- mation include supraventricular and ventricular arrhythmias.

erwise false-positive ST-segment responses. Because exercise increases myocardial oxygen demand, in the presence of CAD, exercise-induced myocardial ischemia could High-Frequency QRS Fragmentation. Reduction of root predispose the subject to ectopic activity. It seems that isch- mean square and peak amplitudes of signal-averaged high- emia with ST depression is not as arrhythmogenic as ischemia frequency QRS complexes and occurrence of reduced high- with ST elevation.

Exercise-induced arrhythmias are generated frequency amplitude zones have been found to have useful test by enhanced sympathetic tone, increased myocardial oxygen performance characteristics for the detection of CAD. The period immediately after exercise is par- These techniques require special filtering methodology.

ticularly dangerous because of the high catecholamine levels QRS Score. An index based on exercise-induced changes in that are associated with generalized vasodilation. Peripheral amplitudes of Q, R, and S waves was introduced as the Athens arterial dilation induced by exercise and reduced cardiac out- QRS score89 and has been related to the extent of CAD and put, resulting from diminished venous return secondary to sud- to the anatomic extent of myocardial ischemia.

The increased sympathetic tone in the myocardium can stimulate ectopic Purkinje pacemaker activity by accelerat- T-Wave Changes. An increase in precordial T-wave amplitude ing phase 4 of the action potential, which provokes spontane- has been associated with the localized onset of apical asynergy ous discharge and leads to increased automaticity. during dobutamine stress electrocardiography. In patient populations with a low CAD prevalence, normal- cardia that is caused by exercise-induced vagal withdrawal and ization of inverted T waves with exercise is a nondiagnostic increased sympathetic stimulation.

Exercise-induced sinus finding. In patients with CAD, findings have varied. Sinus arrhythmias with peri- limited to these precordial leads alone is rare in myocardial ods of sinus bradycardia and wandering atrial pacemaker ischemia, the usual diagnostic criteria can be applied in the are relatively common during early exercise and the imme- remaining inferolateral leads.

The development of right bundle- diate recovery phase. Paroxysmal AV junctional tachycardia is observed a recent study, and rate-dependency of the right bundle in less during exercise only rarely. Exercise-induced supraventricular selected populations could limit predictive value. arrhythmias alone are not usually related to CAD but are more AV Conduction.

Shortening of the PR interval by as much often related to older age, pulmonary disease, recent alcohol as 0.

increases is normal, probably because of increased sym- Ventricular Arrhythmias. Ectopic ventricular beats are the pathetic tone and vagal withdrawal. This usually occurs in most frequent cardiac arrhythmia during exercise. Their prev- young, healthy individuals. In FIRST-DEGREE AV BLOCK. First-degree AV block occurs occa- general, ectopic ventricular beats are of concern in subjects sionally at the end of exercise or during the recovery phase, with a family history of sudden death or a personal history particularly in the presence of occult AV node disease.

Medi- of cardiomyopathy, valvular heart disease, or severe myo- cations or conditions that can produce prolonged AV conduc- cardial ischemia.

with arrhythmogenic right ventricular dysplasia. The diag- nostic and prognostic values of patterns of ventricular ectopy SECOND-DEGREE AV BLOCK. The occurrence of Wenckebach- during and after exercise have been variable. Recent studies type Mobitz type I AV block during exercise is rare because have suggested that frequent or complex repetitive ventricular vagal tone is reduced during exercise, whereas sympathetic activity during exercise, and particularly ventricular ectopy in neurohumoral tone increases.

The clinical significance of the recovery period after exercise, can be independent predic- exercise-induced Mobitz type II AV block generally is related tive markers for death. Disorders of impulse con- rate-related phenomenon that appears as the sinus rate is accel- duction include abnormalities of normal impulse initiation erated beyond a critical level. block develops during exercise, the test should be terminated. Bundle-Branch and Fascicular Blocks.

Intracardiac conduction THIRD-DEGREE COMPLETE AV BLOCK. Acquired advanced or blocks can exist before exercise, develop during exercise, or dis- complete AV block at rest is a relative contraindication to exer- appear during exercise. Rate-dependent intraventricular blocks cise testing because increasing sympathetic drive without effec- that develop during exercise often precede the appearance of tive rate increase can result in complex ventricular arrhythmias.

chronic blocks that develop later at rest. The development of ECG is usually impossible when left bundle-branch block is complete block during exercise testing is uncommon, but it can present. There can be a marked degree of exercise-induced ST- be related to transient ischemia.

 
 

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