: Survival of the fittest: A new look at cardiac exercise test

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??????????????Survival of the fittest A new
look at cardiac exercise test
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• 2007???????????
• ????????????
• ??????????????????

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• ????????(cardiac ex test,CET)???????????????????
  
• ????????????????????????????????,?????
• ?????????????????
• ???????????????

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Cardiac exercise test CET
Cardiac pulmonary exercise test CPET
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• ??the discovery that exercise in pt with
  coronary disease produced ST segment depression
• Feil Siegel (1928) exercised pt with angina to
  bring about pain.
• They performed stress test by sit-ups.
• Master(1929) published paper using pulse and BP
  to evaluate the cardiac capacity. (His
  contribution exercise protocol rather than use
  of ECG. )

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• Goldhammer Scherf (1932) ST depression was
  present in 75 pt with angina and proposed the
  use of exercise to confirm the diagnosis of
  coronary ischemia.
• Katz Landt (1935) lead 5 is better in terms of
  discrimination than lead 4. Use of anoxia to
  bring changes in ST segment.

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• Missal (1938) having pt run up 3-6 flights of
  stairs and he might be the first to use a max
  stress test and to the point of pain and
  emphasized the necessity of taking the recording
  as quickly as possible thereafter.

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• Riseman et al (1940) the first to use continuous
  monitoring and discovered that ST depression
  appeared before the onset of pain and persisted
  for a time after the pain subsided.
• They concluded that exercise was of little value
  because of its poor discrimination between the
  normal and the abnormal subjects.

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• Johnson et al (1942) developed Harvard Step
  Test. Use pulse counts during recovery and
  provide an index of physical fitness.
• Hellerstein katz (1949) ST depression is
  primarily a diastolic injury current manifested
  during the TQ interval.

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• Wood et al Push the pt to the max level of
  their capacity
• The amount of work should not be fixed, but
  adjusted to the individual
• The more strenuous work would produce a higher
  percentage of positive tests
• Recommend the use of the stress test to uncover
  latent myocardial ischemia.

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• Bruce (1956) work test performed on a treadmill
  and established guideline that would more or less
  group pt into the NYHDC I through IV
• Astrand Ryhming max oxygen uptake could be
  predicted by the HR at submax exercise

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• Blackburn (1969)90 of the ischemic changes
  could be demonstrated in the CM5 or V5 lead. So
  spread the use of test outside the research lab.
• Conventional exercise test, done with a
  treadmill, is being supplemented by many other
  techniques to improve the disgnostic certainty
  and help localize the disease vessels.

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• ???(functional capacity)???????????????
• ????????????????????
• ??????(chronotropic imcompetence)??????(heart
  rate reserve)???????

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• Greater fitness results in longer survival (Myers
  et al, NEJM 2002)
• 3679 men with CVD V.S. 2534 men without CVD on
  treadmill max ET
• After adjusting for age, peak exercise capacity
  measured in METs is the strongest predictor of
  the risk of death in both groups.
• Absolute peak ex ca is a stronger predictor than
  age-predicted value achieved.
• Risk of death doubled among those MET less then 5
  when compared to whose MET more than 8

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• Exercise capacity is a more powerful predictor of
  mortality among men than other established risk
  factors for CV disease

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• Abnormal heart rate recovery and risk of death
• HRR after ex as a predictor of mortality(Cole et
  al, NEJM 1999)
• Slow HRR after ex is associated with carotid
  atherosclerosis (Jae et al, Atherosclerosis)
• Prognostic value of HRR in pt with HF (Arena, Am
  H J )
• HRR after ex is a predictor of mortality,
  independent of the angiographic severity of CD
  (Vivekananthan et al, J Am Col Cardio)
• HRR improved as a result of ex training during CR
  (MacMillan et al, Heart Lung)

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Cole et al, NEJM 1999
12 bpm, 26 abnormal HRR, No further improvement
for value above 20
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A strong association between ? ex ca and ab HRR
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• Chronotropic incompetence(??????)????????????????
  ??
• Peak HR is related to age referred as CI when
  lt85 of the age-predicted HR is achieved.
• HR reserve(?????, HRR)???????????
• Azarbal et al found that failure to reach 85 of
  the age-predicted maximum HR was predictive of
  death but that failure to use 80of HRR was a
  stronger predictor of risk.

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• The prognostic value of a normogram for ex ca in
  women (Gulati et al, NEJM 2005)
• Ex ca an independent predictor of mortality
• 5721 asymptomatic women underwent a
  symptom-limited max ex test.
• A nomogram established on the basis of age and ex
  ca
• Use the nomogram to determine the of original
  women and another 4471 women with CVD

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? 14.7-(0.13age) ? 14.7-(0.11age)
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Active ?17.9-(0.16age) Sedentary ?
14.7-(0.12age)
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• HR reserve approach should be used when
  assessing HR to ex
• The ex test provides critical prognostic
  information beyond that provided by nuclear
  imaging
• Azarbal et al also found that chronotropic
  response predicts outcome over and above
  functional capacity, one of the most powerful
  predictors of all-cause and cardiac death.

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??CET V.S. ??CET
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??CET V.S. ??CET
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• ?????????????,???????????????????????
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  ?
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• Cole et al 19992428 subjects without HD history
  undergoing symptom-limited ex test. Heart rate
  recovery (HRR) was defined as the reduction in
  the HR from the peak ex to one min after the
  cessation of ex
• An abnormal HRR was found using log-rank
  chi-square test statistic. HRRlt12 beats per min
  is considered abnormal

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• ???????????????????????,???????????
• Rapid HRR is due to high vagal tone associated
  with fitness and good health
• HRR is prognostic usually at 1 or 2 min after ex
  in populations related to ex test
• Vivekananthan et al HRR predicts mortality,
  independent of the angiographic severity of CD

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• ??????????????????????
• ???????(autonomic imbalance)?????????????????????
  ????
• ???????,??????,????????
• ???baroreflex sensitivity, heart rate
  variability, and heart rate recovery

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• ??????????,???????????????????(????????????????)
• ?????????????(Mona Lisa Hypothesis most
  obesities known are low in sympathetic activity)
• ??????????????????
• ??????,??????????????????

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• ?????????????????????????????
• ????? symptom-limited maximal treadmill
  exercise(Bruce protocol),?90 age-predicted
  maximal heart rate reserve?????????
• ?????????????????????3??

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• ?????????(two way ANOVA)?????? ??( BMI body mass
  index)????????
• ?????below average(BA), average (A), above
  average (AA) ??
• ????NOR(BMIlt25), OW(25 ? BMI lt30 ), OB(BMI?30)??
  
• ????????????????????????????????????????,??HRR1,
  HRR3, HRR5

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• ????????
• ????????(F (2,45) 3.66, plt.05)
  ,LSD??????AA??A??HRR1? HRR3????BA?
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• ??????????, ?????????,?????????, ???????????,
  ??????

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• ????????????????????????
• ????????????,????????????
• ????????????BMI, ???BMI?????????????
• ??????, ????????????????, ???????????????
• ?????, ????????

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• ??????????????????, ????????, ?90 ????????????,
  ??????????????????
• ???BMI????????, ??????????????????????
• ????????????????????????????, ????????????????????
  ??

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• The amount, intensity, and duration of physical
  activity required to reduce the risk of coronary
  heart disease is debated.
• Harvard Alumni Study no further reduction in
  events associated with CAD in men with an energy
  expenditure of more than 2000 Kcal per week.
• Either a threshold effect or a progressive
  decline with progressive activity, possibly
  because of differences in the range of activity
  in the populations.

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• ????????????6MET?????,???????????????50????????
• ???????????????????,?????????????????????
• ACSM?????????,???????????More vigorous exercise
  is probably more beneficial, but also carries a
  cardiovascular risk, especially for those who are
  usually inactive.

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Survival of the fittest????

• Cardiorespiratory fitness enables a person to
  perform physical activity and is influenced by
  several other factors, including age, sex,
  heredity, and medical status.
• A nearly linear reduction in mortality was
  observed as fitness levels increased, and each
  increase of 1MET in exercise capacity conferred a
  12 improvement in survival.

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• The lowest threshold for a dose and an intensity
  that would confer specific survival and
  cardiovascular benefits is not known.
• To compel the clinician to go beyond the
  identification of risk to the initiation of
  interventions, such as the prescription of
  increased physical activity and exercise to
  modify risk, particularly in patients with low
  levels of fitness.

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• ????????,????????????????????????,??????????HDL??
  ????????????