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Stress Testing

To detect coronary artery disease, physicians often record an electrocardiogram (ECG), but at rest, many disease sufferers have a normal ECG. To increase demands on the heart and coronary circulation, an ECG is performed while the patient walks on a treadmill or rides a stationary bicycle. It is sometimes called a stress test.

Exercise increases the heart rate and the systemic arterial blood pressure. These changes increase cardiac work and the demand for coronary blood flow. In many patients, coronary blood flow is adequate at rest, but because of coronary arterial blockage, cannot rise sufficiently to meet the increased demands of exercise. During a stress test, specific ECG changes can indicate that cardiac muscle is not receiving sufficient blood flow and oxygen delivery.

As heart rate increases during exercise, the distance between any portion of the ECG (for example, the R wave) on the ECG becomes shorter (Fig. 30.A and 30.B). In patients suffering from ischemic heart disease, however, other changes occur. Most common is an abnormal depression between the S and T waves, known as ST segment depression (see Fig. 30.B). Depression of the ST segment arises from changes in cardiac muscle electrical activity secondary to lack of blood flow and oxygen delivery.

During the stress test, the ECG is continuously analyzed for changes while blood pressure and arterial blood oxygen saturation are monitored. At the start of the test, the exercise load is mild. The load is increased at regular intervals, and the test ends when the patient becomes exhausted, the heart rate safely reaches a maximum, significant pain occurs, or abnormal ECG changes are noted. With proper supervision, the stress test is a safe method for detecting coronary artery disease. Because the exercise load is gradually increased, the test can be stopped at the first sign of problems.

Effect of exercise on the electrocardiogram (ECG) in a patient with ischemic heart disease. 1, The ECG is normal at rest. 2, During exercise, the interval between R waves is reduced, and the ECG segment between the S and T waves is depressed.

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