心臟康復評定課件

CARDIOVASCULAREVALUATIONDR.LiangQi.CARDIOVASCULAREVALUATIONDR.L1APATIENTCASEEXAMPLE.APATIENTCASEEXAMPLE.21.Whyareyouheretoday?2.Haveyoubeendiagnosedwithacardiacdisorderinthepast?3.Haveyouhadanyspecialteststoexamineyourheartlikeanelectrocardiogram,stresstest,echocardiogram,orcardiaccatheterization?.1.Whyareyouheretoday?.34.Doyouexperienceanginaorshortnessofbreathatrest,onlywithactivity/exercise,orbothatrestandwithactivity/exercise?.4.Doyouexperienceanginaor45.Ifyouexperienceanginaorbecomeshortofbreathduringactivityorexercisecouldyoupleasedescribethetypeofactivityorexercisewhichproducesyouranginaorshortnessofbreath?.5.Ifyouexperienceanginaor56.Canyoudescribeyouranginaorshortnessofbreath?Canyouhelpmeunderstandyouranginaorshortnessofbreathbypointingtothenumbers1through4todescribethelevelofanginayouexperienceatrestandexerciseorbypointingtoyourlevelofshortnessofbreathusingthis10-pointscaleorbymarkingthisvisualanalogscale?.6.Canyoudescribeyourangin67.CouldIfeelyourpulsetodetermineyourheartrateandthestrengthofyourpulse?8.CouldIplacethisfingerprobeonyourindexfingertoobtainanoxygensaturationmeasurement?.7.CouldIfeelyourpulseto79.CouldIplacetheseelectrodesonyourchesttoobtainasimplesingle-leadelectrocardiogram(ECG)?.9.CouldIplacetheseelectr810.CouldItakeyourbloodpressurewhileyouareseatedandthencompareittothebloodpressurewhileyouarelyingdownandthenstanding?Iwouldalsoliketoobserveyourpulse,oxygensaturation,ECG,andsymptomswhenyouarelyingdownandstanding..10.CouldItakeyourbloodpr911.CouldIlistentoyourheartandlungswithmystethoscope?WhileIdothisIwillconcentrateonwatchingyourECGsothatIcanidentifyyourheartsoundsandanychangesintheECGwhileyouarebreathingdeeplywhenlisteningtoyourlungs..11.CouldIlistentoyourhea1012.CouldIplace1ofmyhandsonyourstomachand1handonyourupperchesttodeterminehowyoubreathe?13.CouldIplacemyhandsonthelowermostribsoneachsideofyourchesttodeterminehowyoubreathe?14.CouldIplacemyhandsonyourbacktodeterminehowyoubreathe?15.CouldIwrapmytapemeasurearoundyourchestatseveraldifferentsitestodeterminehowyoubreathe?.12.CouldIplace1ofmyhand1116.NowthatIunderstandsomeverybasicinformationaboutthemannerinwhichyoubreathecouldyoupleasebreatheinthemannerIinstructyouviasoundsImake,pressurefrommyhands,methodsIshowtoyou,ordifferentbodypositions?IwilloccasionallyplacemyhandsonyourchestandwrapmytapemeasurearoundyourchesttodeterminehowyoubreatheduringthesesimpletestsandIwillaskyoutoidentifyyourlevelofshortnessofbreathusingthe10-pointscaleorvisualanalogscale—Isthisokwithyou?.16.NowthatIunderstandsome1217.CouldImeasurethestrengthofyourbreathingmusclebyhavingyouplacethismouthpieceinyourmouthandbreatheinandoutasdeeplyandasforcefullyasyouareable?.17.CouldImeasurethestreng1318.Iwouldlikeyoutonowperformtheactivityorexercisewhichproducesyouranginaorshortnessofbreath.Couldyoupleasedothisnow?.18.Iwouldlikeyoutonowpe14Thankyouforgivingmethechancetoexamineyoutoday.Iwillcallyourphysiciantogetsomemoreinformationaboutyoulikeelectrocardiogram,echocardiogramandpulmonaryfunctionteststhatyousaidwereperformedlastweekaswellasthearterialbloodgasresults,chestX-ray,andexercisetestresults..Thankyouforgivingmethech15PhysicalTherapyExaminationMedicalInformationandRiskFactorAnalysis

listeningtothepatientspasthistoryandprimarycomplaintsiscriticalintheexaminationprocess.

.PhysicalTherapyExaminationM16ExaminationsofPatientAppearancecategorizedbyspecificsignsandsymptoms.ExaminationsofPatientAppear17Angina-MethodsToEvaluateAnginafromNonanginalPainIfasuspectedanginalpainchanges(increasesordecreases)withbreathing,palpationinthepainfularea,ormovementofajoint(ie,shoulderflexionandabduction)itisverylikelythatthepainisNOTangina..Angina-MethodsToEvaluateAng18Angina-MethodsToEvaluateAnginafromNonanginalPainitcanbeworsenedbyphysicalexerciseoractivity.Therefore,ifthesuspectedanginalpainisunchangedwiththepreviouslycitedmaneuversandthepainoccurredwithexertion,itisSUSPECTforangina.Ifthesuspectedanginalpainisunchangedbythesemaneuvers,ifthepainoccurredwithexertion,andifthepaindecreasesorsubsideswithrest,itisverylikelythatthepainISangina.Finally,ifthesuspectedpaindecreasesorsubsideswithnitroglycerin,itisevenmorelikelythatthepainISangina..Angina-MethodsToEvaluateAng19..20"Other"SymptomsofHeartDiseasedyspneaFatigueDizzinessLightheadednessPalpitationsasenseofimpendingdoom."Other"SymptomsofHeartDise21..22ExaminationsofPatientAppearanceskincoloroftheperipheralextremities.Paleorcyanoticskininthelegs,feet,arms,andfingersisassociatedwithpoorcardiovascularfunction..ExaminationsofPatientAppear23ExaminationsofPatientAppearanceDiagonalearlobecrease.Thisphenomenonhasbeeninvestigatedformanyyearsandrecentlywasonceagainfoundtobehighlypredictiveofheartdisease.ExaminationsofPatientAppear24AnthropometricmeasurementsbodyweightfingerpressureonanedematousareaGirthmeasurementsskin-foldcalipermeasurementscalculationofthebodymassindexmeasurethepercentageofbodyfatandleanmusclemass.Anthropometricmeasurementsbod25Jugularvenousdistensionitisoftenduetoright-sidedheartfailure..Jugularvenousdistensionitis26..27..28PalpationoftheRadialPulsePalpationoftheradialpulsecanprovideimportantinformationaboutthestatusofthecardiovascularsystem.MeasurementoftheSystolicBloodPressureandPulseDuringBreathingandSimplePerturbationsoftheBreathingCycle.PalpationoftheRadialPulseP29MeasurementoftheSystolicandDiastolicBloodPressureandPulseinDifferentBodyPositions.MeasurementoftheSystolic30

ToDeterminetheStatusoftheCardiovascularSystem

observationofadecreaseinsystolicanddiastolicbloodpressurewithoutasubsequentincreaseinheartratewhenchangingbodypositionfromsupinetostandingisconsideredapositivesignforautonomicnervoussystemdysfunction...

ToDeterminetheStatusofth31ToDeterminethe

HealthoftheCardiovascularSystemAcardiovascularsystemthatrespondsrapidlytobodypositionchangeislikelyinabetterstateofhealththanacardiovascularsystemthatrespondssluggishly.Bothanunchangedordecreasedheartrateafterstandingfor30seconds(comparedtotheheartrateat15seconds)issuggestiveofautonomicdysfunction..ToDeterminethe

Healthofthe32asluggishorhypoadaptive(lessthannormal)heartrateandbloodpressureresponseduringachangeinbodypositionsupinetostandingshouldbeconsideredabnormalandsuggestiveofanunhealthycardiovascularsystem..asluggishorhypoadaptive(le33amoreadaptiverapidincreaseinheartrateandbloodpressureaftermovingfromasupinetostandingposition(approximately30seconds)islikelyassociatedwithahealthiercardiovascularsystem.amoreadaptiverapidincrease34ExaminationofthePulseandArterialBloodPressure

DuringFunctionalTasksandExerciseFrequentmonitoringoftheheartrateandbloodpressuremaybethebestwaytoexaminethesafetyofexerciseandhelptoestablishguidelinesandproceduresforfunctionalorexercisetraining..ExaminationofthePulseandA35anincreaseinthediastolicbloodpressurewhenthediastolicbloodpressureshouldbedecreased(orlow)isastrongindicatorofcardiovasculardysfunction...anincreaseinthediastolicb36PotentialindirectmeasuresofcardiacfunctionSymptomsandfunctionalclassificationCold,pale,andpossiblycyanoticextremitiesJugularvenousdistensionandperipheraledemaHeartsoundsPulseElectrocardiographyBloodpressure.Potentialindirectmeasuresof37StandardmeasurementofcardiacfunctionCardiaccatheterizationEchocardiographySwan-GanscatheterizationCentralvenouspressureCardiacenzymesANPandBNPRadiologicevidence.Standardmeasurementofcardia38ExerciseTesting.ExerciseTesting.39IndicationsforExerciseTesting:DiagnosisofCoronaryArteryDiseaseAssessmentofPrognosisinCoronaryArteryDiseaseEvaluationofFunctionalCapacityEvaluationofTherapyforCoronaryDiseaseDeterminationofExercisePrescription.IndicationsforExerciseTesti40AbsoluteContraindicationstoExerciseTestingAcuteMI(within2days)High-riskunstableanginaUncontrolledcardiacarrhythmiasActiveEndocarditisSevereaorticstenosisDecompensatedheartfailureAcutepulmonaryembolusorinfarction,DVTAcutenoncardiacdisorderaffectingoraggravatedbyexerciseAcutemyocarditis,pericarditisPhysicaldisabilityprecludessafeandadequatetestInabilitytoobtainconsent.AbsoluteContraindicationsto41RelativeContraindicationstoExerciseTestingLeftmaincoronarystenosisorequivalentModerateaorticvalvularstenosis(?)ElectrolytedisorderTachyarrhythmiasorBradyarrhythmiasAtrialfibrillationwithuncontrolledventricularresponseHypertrophicCardiomyopathy(?gradient)MentalimpairmentleadingtoinabilitytocooperateHigh-degreeAVblock.RelativeContraindicationsto42ECGLeadPlacementfor

ExerciseTesting.ECGLeadPlacementfor

Exerci43ProtocolsforExerciseTesting.ProtocolsforExerciseTesting44BloodPressureResponses:

ExerciseTestingDependencyoncardiacoutputandperipheralresistanceNormalresponses:IncreaseinSBP(>20-30mmHg)NochangeorfallinDBPInadequateriseinSBP:Myocardialischemia,severeLVsystolicdysfunction,aorticorLVOTobstruction,drugtherapy(?-blockers)Exercise-InducedHypotension(>10mmHgbelowbaseline)Severemyocardialischemia(50%positivepredictivevalueforleftmainor3-vesseldisease),valvularheartdisease,cardiomyopathynoevidenceofclinicallysignificantheartdisease(dehydration,antihypertensivetherapy,prolongedstrenuousexercise).BloodPressureResponses:

Exe45HeartRateResponsetoExerciseTestingAcceleratedHeartRateResponse:Deconditioning,prolongedbedrest,anemia,metabolicdisorders,conditionsassociatedwithdecreasedbloodvolumeorlowsystemicvascularresistance,autonomicinsufficencyChronotropicincompetence:Inadequateexerciseeffort,drugtherapy(?-blockers),PrognosticSignificance:(PeakHR-RestingHR)/(220-age-RestingHR)<0.80(Lauer,1999)PeakHR<130bpm(Ellestad).HeartRateResponsetoExercis46EvaluationofExerciseEffortduringExerciseTesting:TheBorgPerceivedExertionScale.EvaluationofExerciseEffort47ExerciseCapacity-ExerciseTestingMETcapacity1MET=3.5ml/kg/minO2consumptionFunctionalAerobicImpairment(FAI) (BruceProtocolspecific)PredictedMETlevel(nomograms)PredictedVO2(ACSMformulae)PracticalAspects:LackofassociationbetweenLVEFandexercisecapacityPrognosticvalueofdecreasedexercisecapacityandactiveCADPredictorofpatient’sdisability.ExerciseCapacity-ExerciseT48ExerciseTesting-ComplicationsMIordeath:Upto10per10,000tests(1per2,500)Lifethreateningventriculararrhythmias:0-5per100,000Cardiac:Bradyarrhythmias,tachyarrhythmias,acutecoronarysyndromes,heartfailure,hypotension,syncope,deathNoncardiac:Musculoskeletaltrauma,soft-tissueinjuryMiscellaneous:Severefatigue,dizziness,myalgias.ExerciseTesting-Complicatio49AbsoluteIndicationsforTerminationofExerciseTestST-segmentelevation(>1.0mm)inleadswithoutQ-waves(otherthanV1oraVR)Dropinsystolicbloodpressure>10mmHg(persistentlybelowbaseline)despiteanincreaseinworkload,whenaccompaniedbyanyotherevidenceofischemiaModeratetosevereangina(grades3-4)Centralnervoussystemsymptoms(ataxia,dizziness,nearsyncope)Signsofpoorperfusion(cyanosisorpallor)SustainedventriculartachycardiaTechnicaldifficultiesmonitoringtheECGorsystolicBPPatient’srequesttostop.AbsoluteIndicationsforTermi50RelativeIndicationsforTerminationofanExerciseTestSTchanges(horizontalordownsloping>2mm)ormarkedaxisshiftDropinsystolicbloodpressure>10mmHg(persistentlybelowbaseline)despiteanincreaseinworkload,intheabsenceofotherevidenceofischemiaandnopresyncopalsymptomsIncreasingchestpainFatigue,shortnessofbreath,wheezing,legcramps,orclaudicationHypertensiveresponse(SBP>250mmHgand/orDBP>115mmHg)Developmentofbundle-branchblock(LBBB)thatcannotbedistinguishedfromventriculartachycardia;?EvidenceofanteriorischemiaArrhythmiasotherthansustainedventriculartachycardia(frequentmultifocalPVC’s,ventriculartriplets,SVT,heartblock,orbradyarrhythmias)GeneralAppearance(diaphoresis,peripheralcyanosis).RelativeIndicationsforTermi51CriteriaforReadingST-SegmentChangesontheExerciseECGSTDEPRESSION:Measurementsmadeon3consecutiveECGcomplexes!STlevelismeasuredrelativetotheP-Qjunction3keymeasurements(P-Qjunction,J-point,60-80msecafterJ-point-use60msecforHR>130bpmWhenJ-pointisdepressedrelativetoP-Qjunctionatbaseline:NetdifferencefromtheJjunctiondeterminestheamountofdeviationWhentheJ-pointiselevatedrelativetoP-Qjunctionatbaselineandbecomesdepressedwithexercise:MagnitudeofSTdepressionisdeterminedfromtheP-QjunctionandnottherestingJpoint.CriteriaforReadingST-Segmen52CriteriaforReadingST-SegmentChangesontheExerciseECGSTELEVATION:60msecafterJpointin3consecutiveECGcomplexes.CriteriaforReadingST-Segmen53CriteriaforAbnormalandBorderlineST-SegmentDepressionontheExerciseECGABNORMAL:1.0mmorgreaterhorizontalordownslopingSTdepressionat60msecafterJpointon3consecutiveECGcomplexesBORDERLINE:0.5to1.0mmhorizontalordownslopingSTdepressionat60msecafterJpointon3consecutiveECGcomplexes2.0mmorgreaterupslopingSTdepressionat60msecafterJpointon3consecutiveECGcomplexes.CriteriaforAbnormalandBord54MorphologyofST-SegmentDeviation

duringExerciseTesting.MorphologyofST-SegmentDevia55ValueofRight-SidedECGLeadsduringExerciseTestingfortheDiagnosisofCAD.ValueofRight-SidedECGLeads56HorizontalST-segmentDepressionduringExerciseTesting.HorizontalST-segmentDepressi57DownslopingST-SegmentDepressionduringExerciseTesting.DownslopingST-SegmentDepress58ST-SegmentDepressioninEarlyRecoveryPeriodafterExerciseTesting.ST-SegmentDepressioninEarly59UpslopingST-SegmentDepressionduringExerciseTesting.UpslopingST-SegmentDepressio60MorphologyofST-SegmentDepressionPredictsSeverityofCoronaryArteryDisease

(Goldschlager,1976).MorphologyofST-SegmentDepre61Exercise-InducedST-SegmentElevationwithPriorAnteriorMyocardialInfarction.Exercise-InducedST-SegmentEl62Exercise-InducedST-SegmentElevationintheSettingofPriorInferolateralMI.Exercise-InducedST-SegmentEl63Exercise-InducedAnteriorST-SegmentElevationasReflectionofLADIschemia.Exercise-InducedAnteriorST-S64Indicationsfor

ExerciseTestingintheDiagnosisofObstructiveCoronaryDiseaseCLASSI:Adultpatients(includingthosewithRBBBorlessthan1mmorrestingST-depression)withanintermediatepretestprobabilityofCAD,basedongender,age,andsymptomsCLASSIIa:PatientswithvasospasticanginaCLASSIIb:PatientswithahighpretestprobabilityofCADbyage,symptoms,andgenderPatientswithalowpretestprobabilityofCADbyage,symptoms,andgenderPatientswithlessthan1mmofbaselineSTdepressionandtakingdigoxinPatientswithECGcriteriaofLVHandlessthan1mmSt-depression.IndicationsforExerciseTesti65Pre-testProbabilityofCAD

byAge,Gender,andSymptomsTypical/DefiniteAnginaPectorisAge30-39 Men Intermediate(10-90%)Women IntermediateAge40-49 Men High(>90%)Women IntermediateAge50-59 Men HighWomen IntermediateAge60-69Men HighWomen High.Pre-testProbabilityofCAD

b66Pre-testProbabilityofCAD

byAge,Gender,andSymptomsAtypical/PossibleAnginaPectoris:Age30-39Men Intermediate Women VeryLow(<5%)Age40-49 Men Intermediate Women Low(<10%)Age50-50 Men Intermediate Women IntermediateAge60-69 Men Intermediate Women Intermediate.Pre-testProbabilityofCAD

b67Pre-testProbabilityofCAD

byAge,Gender,andSymptomsNonanginalChestPain:Age30-39 Men Low Women VeryLowAge40-49 Men Intermediate Women VeryLowAge50-59 Men Intermediate Women LowAge60-69 Men Intermediate Women Intermediate

.Pre-testProbabilityofCAD

b68Pre-testProbabilityofCAD

byAge,Gender,andSymptomsAsymptomatic:Age30-39Men VeryLow Women VeryLowAge40-49Men Low Women VeryLowAge50-59Men Low Women VeryLowAge60-69Men Low Women Low.Pre-testProbabilityofCAD

b69Indicationsfor

ExerciseTestingintheDiagnosisofObstructiveCoronaryDiseaseClassIII:PatientswiththefollowingECGabnormalities:WPWsyndrome,electronicallypacedventricularrhythm,greaterthan1mmrestingST-depression,completeLBBBPatientswithadocumentedMIorpriorcoronaryangiographydemonstratingsignificantCADhaveanestablisheddiagnosis(?ischemia,prognosis).IndicationsforExerciseTesti70ExerciseTesting;SensitivityandSpecificityfortheDiagnosisofCADSensitivity=[Truepositives/truepositives+falsenegatives]x100Specificity=[Truenegatives/falsepositives+truenegatives]x100StandardExerciseTest(mostlymen)*Sensitivity=68% Specificity=77%PredictiveAccuracy=73%*Basedon1.0mmST-segmentdepression.ExerciseTesting;Sensitivity71ExerciseTestingintheDiagnosisofCoronaryArteryDiseaseinWomenECGAnalysisalone:Sensitivity: 46-79%Specificity: 48-86%UseofDukePrognosticScore:LowRiskscore:19.1%CAD>75%stenosis, 3.5%3-vesselorleftmaindiseaseIntermediateRiskscore:34.9%CAD>75%stenosis,12.4%3-vesselorleftmaindiseaseHighRiskScore:89.2%CAD>75%stenosis,46%3-vesselorleftmaindisease.ExerciseTestingintheDiagno72RiskAssessmentandPrognosiswithExerciseTestinginPatientswithSymptomsandPriorHistoryofCADClassI:PatientundergoinginitialevaluationwithsuspectedorknownCADincludingthosewithcompleteRBBBandlessthan1mmofrestingECG(exceptions-ClassIIb)PatientswithsuspectedorknowCADpreviouslyevaluated,nowpresentingwithsignificantchangeinclinicalstatusLow-riskacutecoronarysyndromepatients8-12hoursafterpresentationwhohavebeenfreeofactiveischemiaorheartfailuresymptoms(LevelofEvidence=B)Intermediate-riskacutecoronarysyndromepatients2-3daysafterpresentationwhohavebeenfreeofactiveischemiaorheartfailuresymptoms(LevelofEvidence=B).RiskAssessmentandPrognosis73RiskAssessmentandPrognosiswithExerciseTestinginPatientswithSymptomsandPriorHistoryofCADClassIIa:Intermediate-riskacutecoronarysyndromepatientswhohaveinitialcardiacmarkersthatarenormal,arepeatECGwithoutsignificantchange,andcardiacmarkers6-12hoursaftertheonsetofsymptomsthatarenormalandnootherevidenceofischemiabyobservation(LevelofEvidence=B)ClassIIb:PatientswiththefollowingECGabnormalities:WPWsyndrome,electronicallypacedventricularrhythm,1mmormoreofrestingST-depression,completeLBBBorIVCDwithaQRSduration>120msecPatientswithastableclinicalcoursewhoundergoperiodicmonitoringtoguidetreatment.RiskAssessmentandPrognosis74RiskAssessmentandPrognosiswithExerciseTestinginPatientswithSymptomsandPriorHistoryofCADClassIII:Patientswithsevereco-morbiditylikelytolimitlifeexpectancyand/orcandidacyforrevascularizationHigh-riskacutecoronarysyndromepatients(LevelofEvidence=c).RiskAssessmentandPrognosis75Short-termRiskAssessmentforDeathorNonfatalMIinPatientswithAcuteCoronarySyndrome

HIGHRISK(atleastoneofthefollowingfeatures):CharacterofPain: Prolongedongoing(>20min)restchestpainClinicalFeatures:Pulmonaryedema,neworworseningMR,S3ornew/worseningrales,hypotension,bradycardia,tachycardia,age>75yrsECGFindings:AnginaatrestwithtransientSTchanges>0.05mV,BBB(neworpresumednew),sustainedventriculartachycardiaBiochemicalMarkers:Elevatedtroponin-I.Short-termRiskAssessmentfor76Short-termRiskAssessmentforDeathorNonfatalMIinPatientswithAcuteCoronarySyndromeINTERMEDIATERISK:Nohigh-riskfeaturebutmusthaveoneofthefollowing:History:PriorMI,peripheralorcerebrovasculardisease,CABGorprolongedaspirinuseCharacterofPain:Prolonged(>20min)restangina,nowresolved,withmoderatetohighlikelihoodofCADRestangina(<20min)orrelievedbysublingualNTGClinicalFindings:age>70yrsECGFindings:T-waveinversionsgreaterthan0.2mV,pathologicalQ-wavesBiochemicalMarkers:Borderlineelevatedtroponin-I.Short-termRiskAssessmentfor77Short-termRiskAssessmentforDeathorNonfatalMIinPatientswithAcuteCoronarySyndromeLOWRISK:Nohighorintermediateriskfeaturesbutanyofthefollowing:CharacterofPain:

New-onsetorprogressiveCCSCIIIorIVanginainpast2weekswithmoderatetohighlikelihoodofCADECGFindings:

NormalorunchangedECGduringanepisodeofchestdiscomfortBiochemicalMarkers:

Normal.Short-termRiskAssessmentfor78PrognosticFactorsfromExerciseTestingElectrocardiographic:MaximumST-depressionMaximumST-elevationST-depressionslope(morphology)NumberofleadsshowingSTchangesDurationofSTdeviationintorecoveryST/HRindexesExercise-inducedventriculararrhythmiasTimetoonsetofSTdeviation.PrognosticFactorsfromExerci79PrognosticFactorsfromExerciseTestingHemodynamic:MaximumexerciseheartrateMaximumexerciseSBPMaximumexercisedoubleproduct(HRxSBP)Totalexerciseduration(functionalcapacity)ExertionalhypotensionChronotropicincompetenceAbnormalheartraterecovery.PrognosticFactorsfromExerci80HeartRateRecoveryAfterExerciseTestingPredictsOutcomeinCAD

.HeartRateRecoveryAfterExer81PrognosticFactorsfromExerciseTestingSymptomatic:Exercise-inducedanginaExercise-inducedsymptoms(SOB,dizziness)Timetoonsetofangina.PrognosticFactorsfromExerci82PrognosticScoreinAssessmentofCardiacEventRiskduringExerciseTestingDukePrognosticScore:TreadmillScore=exercisetimex5(amountofST-segmentdeviation)-4xexerciseanginaindex(0=none,1=presentbutnotlimiting,2=reasontostopthetest)HighRisk:<-11 (5%annualmortality)LowRisk:>+5 (0.5%annualmortality)InformationadditivetocoronaryanatomyandLVEF.PrognosticScoreinAssessment83DukePrognosticScoreNomogram.DukePrognosticScoreNomogram84CombinedPrognosticFactorsIncreasePredictiveValueofExerciseTestingDatainCAD.CombinedPrognosticFactorsIn85IndicationsforExerciseTestingafterMyocardialInfarctionClassI:Beforedischargeforprognosticassessment,activityprescription,evaluationofmedicaltherapy(submaximalversusmaximal,submaximal4-6days)Earlyafterdischargeforprognosticassessment,activityprescription,evaluationofmedicaltherapy,andcardiacrehabilitationifpre-dischargeexercisetestwasnotdone(symptom-limited,about14-21days)Lateafterdischargeforprognosticassessment,activityprescription,evaluationofmedicaltherapy,andcardiacrehabilitationiftheearlyexercisetestwassubmaximal(symptom-limited3-6weeks).IndicationsforExerciseTesti86IndicationsforExerciseTestingafterMyocardialInfarctionClassIIa:Afterdischargeforactivitycounselingand/orexercisetrainingaspartofcardiacrehabilitationinpatientswhohaveundergonecardiacrevascularizationClassIIb:PatientswiththefollowingECGabnormalities:CompleteLBBB,Pre-excitationsyndrome,LVH,Digoxintherapy,greaterthan1mmofrestingST-depression,electronicallypacedventricularrhythmPeriodicmonitoringinpatientswhocontinuetoparticipateinexercisetrainingorcardiacrehabilitation.IndicationsforExerciseTesti87IndicationsforExerciseTestingafterMyocardialInfarctionClassIII:Severecomorbiditylikelytolimitlifeexpectancyand/orcandidacyforrevascularizationAtanytimetoevaluatepatientswithacutemyocardialinfarctionwhohavedecompensatedheartfailure,cardiacarrhythmias,ornoncardiacconditionsthatseverelylimittheirabilitytoexercise(LevelofEvidence=C)Beforedischargetoevaluatepatientswhohavealreadybeenselectedfor,orhaveundergone,cardiaccatheterization.Althoughastresstestmaybeusefulbeforeoraftercatheterizationtoevaluateoridentifyischemiainthedistributionofacoronarylesionofborderlineseverity,stressimagingtestsarerecommended..IndicationsforExerciseTesti88IndicationsforExerciseTestinginAsymptomaticPersonswithoutKnownCADClassI:NoneClassIIa:Evaluationofasymptomaticpersonswithdiabetesmellituswhoplantostartvigorousexercise(LevelofEvidence=C)ClassIIb:Evaluationofpersonswithmultipleriskfactorsasaguidetoriskreductiontherapy(moderateFraminghamriskscore,stronglypositivefamilyhistoryofprematureCAD,?Calciumscore)Evaluationofasymptomaticmen>45yrsandwomen>55yrsWhoplantostartvigorousexercise(especiallyifsedentary)orWhoareinvolvedinoccupationsinwhichimpairmentmightimpactpublicsafety,orWhoareathighriskforCADduetootherdiseases(PAD,ChronicRenalFailure).IndicationsforExerciseTesti89IndicationsforExerciseTestinginAsymptomaticPersonswithoutKnownCADClassIII:RoutinescreeningofasymptomaticmenorwomenNoscientificbasisforthe“e