心电图运动试验

运动终点 Exercise End Points
达到预期目标心率 reach predicted heart rate 2002年ACC/AHA指南推荐终止运动试验的指征 2002年ACC/AHA指南推荐终止运动试验的指征 一、绝对指征 Absolute indications 二、相对指征 Relative indications
Evaluation of asymptomatic persons with diabetes mellitus who plan to start vigorous exercise (Level of Evidence: C)
Class IIb
1. Evaluation of persons with multiple risk factors as a guide to risk-reduction therapy. 2. Evaluation of asymptomatic men older than 45 years and women older than 55 years: • Who plan to start vigorous exercise or • Who are involved in occupations in which impairment might impact public safety or • Who are at high risk for CAD due to other diseases
2. Patients with a documented myocardial infarction or prior coronary angiography; however, ischemia and risk can be determined by testing
Pretest Probability of Coronary Artery Disease by Age, Gender, and Symptoms
• Acute myocardial infarction (within 2 d) • High-risk unstable angina • Uncontrolled cardiac arrhythmias causing symptoms or hemodynamic compromise • Symptomatic severe aortic stenosis • Uncontrolled symptomatic heart failure • Acute pulmonary embolus or pulmonary infarction • Acute myocarditis or pericarditis • Acute aortic dissection
Class III
Routine screening of asymptomatic men or women.
Contraindications to Exercise Testing
Absolute contraindications Relative contraindications
Absolute
Cl源自文库ss III
1. Patients with the following baseline ECG abnormalities: • Pre-excitation (Wolff-Parkinson-White) syndrome • Electronically paced ventricular rhythm • Greater than 1 mm of resting ST depression • Complete left bundle-branch block
Relative
• Left main coronary stenosis • Moderate stenotic valvular heart disease • Electrolyte abnormalities • Severe arterial hypertension • Tachyarrhythmias or bradyarrhythmias • Hypertrophic cardiomyopathy and other forms of outflow tract obstruction • Mental or physical impairment leading
Class I Adult patients with an intermediate pretest probability of CAD on the basis of gender, age, and symptoms. Class IIa Patients with vasospastic angina.
Relative indications
• Drop in systolic blood pressure ≥10 mm Hg, in the absence of other evidence of ischemia • ST or QRS changes such as excessive ST depression or marked axis shift
主要内容
运动试验的方法 运动量 运动终点 运动试验的结果判 2002年运动试验的指南 2002年运动试验的指南
运动试验的方法
双倍二级梯运动试验 踏车运动试验 活动平板试验
运动量
极量运动试验 目标心率=220目标心率=220-年龄 次极量运动试验 目标心率=195目标心率=195-年龄 症状限制性运动试验 心绞痛、全身乏力、气短、ST压低大于0.3、血压 心绞痛、全身乏力、气短、ST压低大于0.3、血压 下降大于10mmHg、PVC大于连续3 下降大于10mmHg、PVC大于连续3个
High indicates >90%; intermediate, 10%–90%; low, <10%; and very low, <5%.
Exercise Testing in Asymptomatic Persons Without Known CAD
Class I
None.
Class IIa
Class IIb 1. Patients with a high pretest probability of CAD by age, symptoms, and gender. 2. Patients with a low pretest probability of CAD by age, symptoms, and gender. 3. Patients with less than 1 mm of baseline ST depression and taking digoxin. 4. Patients with electrocardiographic criteria for left ventricular hypertrophy (LVH) and less than 1 mm of baseline ST depression.
• Arrhythmias other than sustained ventricular tachycardia • Fatigue, shortness of breath, wheezing, leg cramps, or claudication • Development of bundle-branch block or IVCD • Increasing chest pain • Hypertensive response
• Signs of poor perfusion (cyanosis or pallor) • Technical difficulties in monitoring ECG or systolic blood pressure • Subjects desire to stop • Sustained ventricular tachycardia • ST elevation (≥1.0 mm) in leads without diagnostic Q-waves (other than V1 or aVR)
心电图运动试验 Exercise Testing
王随峰
历史事件
1902年 荷兰的Einthoven以弦线型心电图计描记出 1902年 荷兰的Einthoven以弦线型心电图计描记出 第一份心电图 1909年 Nicolai和Slmons描记出首例心绞痛患者运 1909年 Nicolai和Slmons描记出首例心绞痛患者运 动后的心电图 1932年 Goldhammer开始将运动试验用于冠心病的 1932年 Goldhammer开始将运动试验用于冠心病的 诊断 1986年 ACC/AHA发表第一个运动试验指南 1986年 ACC/AHA发表第一个运动试验指南
单支病变，敏感性0.37单支病变，敏感性0.37-0.60 前降支病变，敏感性0.77 前降支病变，敏感性0.77 双支，敏感性0.67双支，敏感性0.67-0.91 三支病变，敏感性0.86三支病变，敏感性0.86-1
EXERCISE TESTING TO DIAGNOSE OBSTRUCTIVE CAD
运动试验的结果判断
阳性指标 出现典型心绞痛、ST压低、运动中血压下降 出现典型心绞痛、ST压低、运动中血压下降 阴性指标 达到目标心率，ST段无压低，或压低小于0.1 达到目标心率，ST段无压低，或压低小于0.1
假阳性，其他非冠心病的原因 假阴性，抗心绞痛药物（Beta-Blocker 、CCB、硝 假阴性，抗心绞痛药物（ CCB、硝 酸酯类），陈旧性心梗，单支病变，运动量不足、 心率反常增快但是不是心肌缺血所致
Absolute indications
• Drop in systolic blood pressure of >10mmHg, accompanied by other evidence of ischemia • Moderate to severe angina • Increasing nervous system symptoms