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Exercise Testing

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Referral Form (DD3163)

The paediatric exercise referral form (DD3163) must be completed and faxed to the cardiac physiology department, phone 24301. You can access  the latest pdf of the referral form here to print out and complete.

Any queries regarding making acute bookings can be made to the ECG technician (for paediatric exercise testing) on 93-7089 or to the ECG technician (for adult exercise testing) on 93-4232.

Prior to commencing the test

The supervisor must:

  1. Know the indication for testing.
  2. Know whether this is a standard cardiac exercise test or a cardiopulmonary test, and whether the treadmill or cycle ergometer will be used.
  3. Recognise relative contraindications or features which make vigorous exercise inappropriate.
  4. Confirm endpoints for stopping the test.
  5. Examine a resting ECG and confirm it is appropriate to proceed with exercise testing.
  6. Confirm the patient knows why the test is being performed and what is involved.
  7. In the case of technician/house surgeon supervision, confirm that a cardiologist or cardiology registrar is immediately available if required.
  8. Confirm that a defibrillator is available and know what steps to take in the event of a cardiac arrest or other emergency.

Indications for testing

1 Assessment of exercise tolerance in congenital heart disease
2 Diagnosis of chest-pain syndromes
3 Provocation of exercise related arrhythmias / evaluation of QT intervals 
4 Assessment of disease severity and risk in patients with ischaemic heart disease
5 Blood pressure response in Hypertrophic Cardiomyopathy (HCM) 

Contraindications*

  1. Episodes of anginal pain at rest. Chest pain thought not to be due to myocardial ischaemia is not a contra-indication but careful observation is needed.
  2. Uncontrolled heart-failure.
  3. Resting systolic BP> 200mm Hg.
  4. Severe aortic stenosis
  5. Acute myocardial infarction < 5 days previously.
  6. Uncontrolled ventricular arrhythmia.

*Exercise testing will not be performed by technician supervisor unless personally advised by a consultant - see safety requirements

Protocol

For most subjects use the Bruce Protocol
For subjects with suspected low exercise capacity, use the modified Bruce Protocol
For cardiopulmonary testing / VO2 use the Steep protocol
It is necessary to stop anti-angina medications before exercise testing 

Stopping the exercise test

Exercise should usually be symptom limited. Diagnostic information increases with the amount of exercise performed, but high levels of exercise should be avoided in patients with poor left ventricular function or other major cardiac disease. Achieving 85% of predicted maximum heart rate is a guide to achieving a satisfactory level of exercise, but this alone should not determine the termination decision.

The test should be stopped if:

  1. The patient requests. This is usually pre-empted by careful monitoring of the patient's progress and symptoms.
  2. For obvious distress including excessive breathlessness, non-cardiac pain (e.g. claudication, arthritic) or dizziness.
  3. For exercise-related chest pain. Symptoms suggesting myocardial ischaemia are an indication for stopping the test without ECG changes necessarily being present. When uncertain of the nature of the chest pain a 12 lead ECG looking for ST depression is useful. The test should always be stopped for persistent or increasing chest pain regardless of the ECG appearances.
  4. For ST segment depression or elevation of > 2mm compared to baseline in one or more ECG leads irrespective of symptoms.
  5. For cardiac arrhythmias: 3 beats VT, 2 or single VPB's > every fourth beat, new atrial fibrillation, bradycardia or AV block.
  6. Systolic BP is > 240mmHg.
  7. There is a sustained fall in blood pressure of > 20mmHg compared to baseline.

Safety requirements

  1.  Every patient exercised by a supervising technician/physician must have a nominated cardiologist or senior cardiology registrar immediately available if required.
  2. Standard hospital procedure should be followed in the event of a cardiac arrest.
  3. Before the test standard checks include adequacy of the display monitor, availability of the nominated cardiologist and normal function of the defibrillator.
  4. The patient should be shown how to stop the treadmill in an emergency.
  5. Trinitrin spray must be available for persisting chest pain after exercise.
  6. Patients should not leave the exercise room without regaining their baseline state unless authorised by the supervising doctor.

Observation during exercise

  1. Ask the patient to report chest discomfort or other symptoms during exercise. Record the timing and severity of symptoms.
  2. Watch the video monitor for heart rate, ST segment changes and arrhythmias. Record a rhythm strip of significant arrhythmias including those in the recovery phase.
  3. Record the blood pressure at lease once during each stage of exercise and more often if the patient is breathless or dizzy.
  4. Record the 12 lead ECG towards the end of each 3 minute stage and more frequently if symptoms or ECG changes are observed. Continue recording the ECG each minute for at least 6 minutes after exercise or until the ECG has returned to the baseline level.

Report

A written report for each case is done and must include:

1 The duration of the test, indication for stopping
2 Heart rate and Blood pressure response 
3 Evidence of ischaemia -duration of test 
4 Evidence of arrhythmia 
5 QT intervals (if this is the reason for the assessment. Report at rest, at peak Heart rate, and at 3 and 6 minutes (QT, R-R intervals and calculate QTc) 
6 Symptoms if present
7 Maximum oxygen uptake (VO2, max), VE/VCO2 slope etc for cardiopulmonary testing

Information for Families

See parent information sheet on exercise testing

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Document Control

  • Date last published: 02 November 2015
  • Document type: Clinical Guideline
  • Services responsible: Paediatric Cardiology
  • Owner: Tim Hornung
  • Editor: Marion Hamer