ekg 운동심전도-추출
TRANSCRIPT
![Page 1: Ekg 운동심전도-추출](https://reader034.vdocuments.site/reader034/viewer/2022042907/587bb0731a28abb8258b4615/html5/thumbnails/1.jpg)
Exercise stress EKG운동 심전도 , 운동부하 심전도
![Page 2: Ekg 운동심전도-추출](https://reader034.vdocuments.site/reader034/viewer/2022042907/587bb0731a28abb8258b4615/html5/thumbnails/2.jpg)
Pathophysiology
• At rest- adequate coronary blood flow
• with exercise-supply\demand mismatch -ST segment changes
• 70-80%occlusion - detection by EST
• Sign CAD can exist with a -VE Exercise Stress Test.
![Page 3: Ekg 운동심전도-추출](https://reader034.vdocuments.site/reader034/viewer/2022042907/587bb0731a28abb8258b4615/html5/thumbnails/3.jpg)
Treadmill protocol
• Bruce protocol• Naughton protocol• Weber protocol• ACIP(asymptomatic cardiac ischemia pilot)• Modified ACIP
![Page 4: Ekg 운동심전도-추출](https://reader034.vdocuments.site/reader034/viewer/2022042907/587bb0731a28abb8258b4615/html5/thumbnails/4.jpg)
The Bruce protocol• 1949 by Robert A. Bruce,
considered the “father of ex-ercise physiology”.
• Published as a standardized protocol in 1963.
• gold-standard for detection of myocardial ischemia when risk stratification is necessary.
![Page 5: Ekg 운동심전도-추출](https://reader034.vdocuments.site/reader034/viewer/2022042907/587bb0731a28abb8258b4615/html5/thumbnails/5.jpg)
BRUCE Protocol
Stage Time (min) M/hr Slope
1 0 1.7 10%
2 3 2.5 12%
3 6 3.4 14%
4 9 4.2 16%
5 12 5.0 18%
6 15 5.5 20%
![Page 6: Ekg 운동심전도-추출](https://reader034.vdocuments.site/reader034/viewer/2022042907/587bb0731a28abb8258b4615/html5/thumbnails/6.jpg)
Peak Vo2 is the same regardless of the protocol useddiff – rate at which it is achieved
PROTOCOL USES COMMENTS
BRUCE Normally used large↑Vo2 bet stages\running≥st 3
NAUGHTON&WEBER Limited ex tolerance-CCF 1-2 min stages\1 MET increment
ACIP Established CAD 2 min stages\> linear ↑ in HR & Vo2
MOD-ACIP Short elderly individuals
![Page 7: Ekg 운동심전도-추출](https://reader034.vdocuments.site/reader034/viewer/2022042907/587bb0731a28abb8258b4615/html5/thumbnails/7.jpg)
Procedure
• Standard 12 lead ECG- leads
• Torso ECG + BP• Supine and Sitting / standing
• HR ,BP ,ECG• Before,after,stage • Onset of ischemic response• Each min recovery(5-10 mints)
![Page 8: Ekg 운동심전도-추출](https://reader034.vdocuments.site/reader034/viewer/2022042907/587bb0731a28abb8258b4615/html5/thumbnails/8.jpg)
Procedure- Lead systems
• Mason-Liker modification-extremity electrodes moved to torso 2 ↓ motion artifacts
• RAD• ↑inf lead voltage• Loss of inf lead q• New Q in AVL
![Page 9: Ekg 운동심전도-추출](https://reader034.vdocuments.site/reader034/viewer/2022042907/587bb0731a28abb8258b4615/html5/thumbnails/9.jpg)
Contraindications to Exercise Testing
Absolute• A/c MI (< 2 d)• High-risk unstable angina• Uncontrolled cardiac arrhythmias causing symp-
toms or hemo compromise• Symptomatic severe AS• Uncontrolled symptomatic CCF• Acute pulmonary embolus or pulmonary infarc-
tion• A/c myocarditis or pericarditis• A/c Ao dissection
![Page 10: Ekg 운동심전도-추출](https://reader034.vdocuments.site/reader034/viewer/2022042907/587bb0731a28abb8258b4615/html5/thumbnails/10.jpg)
Contraindications to Exercise Testing
Relative• LMCA stenosis• Mod- stenotic VHD• Electrolyte abnormalities• Sev HTN• Tachyarrhythmias or bradyarrhythmias• HOCM and other outflow tract obstructions• Mental or physical impairment leading to inabil-
ity to exercise adequately• High-degree AV block
![Page 11: Ekg 운동심전도-추출](https://reader034.vdocuments.site/reader034/viewer/2022042907/587bb0731a28abb8258b4615/html5/thumbnails/11.jpg)
SAFETY & RISKS
In nonselected pat pop-mortality- .01% -morbidity-.05%In k/c CAD- 1 C.arrest/59000 person hours -AMI in 1.4 / 10000 testsArrythmias-AF-Mc-9/10,000 tests -VT-6/10,000 tests -VF- .6/10,000 tests
Deaths& MI estimated occur in 1 of 25000 tests
![Page 12: Ekg 운동심전도-추출](https://reader034.vdocuments.site/reader034/viewer/2022042907/587bb0731a28abb8258b4615/html5/thumbnails/12.jpg)
The post test probability is proportional to the pretest probability
To diagnose, test sensitivity ,specificity& prevalence in the population being tested req
Bayes' theorem A theory of probability
![Page 13: Ekg 운동심전도-추출](https://reader034.vdocuments.site/reader034/viewer/2022042907/587bb0731a28abb8258b4615/html5/thumbnails/13.jpg)
• Sensitivity- a person with the disease having a pos-itive test.
• Specificity-person without the disease having a negative test.
• Prevalence- % in the population having disease.
![Page 14: Ekg 운동심전도-추출](https://reader034.vdocuments.site/reader034/viewer/2022042907/587bb0731a28abb8258b4615/html5/thumbnails/14.jpg)
Pretest Probability
• Based on the pat's h/o ( age, gender, chest pain ), phy ex and initial testing, and the clinician's experience.
• Typical or definite angina →pretest probability high - test result does not dramatically change the probability.
• Diag power maximal when the pretest probability is in-termediate-30-70%
![Page 15: Ekg 운동심전도-추출](https://reader034.vdocuments.site/reader034/viewer/2022042907/587bb0731a28abb8258b4615/html5/thumbnails/15.jpg)
Classification of chest pain
• Typical angina1. Substernal chest discomfort with characterstic quality and
duration2. Provoked by exertion or emotional stress3. Relieved by rest or NTG
• Atypical angina• Meets 2 of the above characteristics
• Noncardiac chest pain• Meets one or none of the typical characteristics
![Page 16: Ekg 운동심전도-추출](https://reader034.vdocuments.site/reader034/viewer/2022042907/587bb0731a28abb8258b4615/html5/thumbnails/16.jpg)
Pre Test Probability of Coronary Disease by Symptoms, Gender and Age
Age Gender Typical/DefiniteAngina Pectoris
Atypical/ProbableAngina Pectoris
Non-Anginal
Chest Pain
Asymptomatic
30-39 Males Intermediate Intermediate low (<10%) Very low (<5%)30-39 Females Intermediate Very Low (<5%) Very low Very low
40-49 Males High (>90%) Intermediate Intermediate low
40-49 Females Intermediate Low Very low Very low
50-59 Males High (>90%) Intermediate Intermediate Low
50-59 Females Intermediate Intermediate Low Very low
60-69 Males High Intermediate Intermediate Low
60-69 Females High Intermediate Intermediate Low
High = >90% Intermediate = 10-90% Low = <10% Very Low = <5%
![Page 17: Ekg 운동심전도-추출](https://reader034.vdocuments.site/reader034/viewer/2022042907/587bb0731a28abb8258b4615/html5/thumbnails/17.jpg)
INTERMEDIATE CATEGORYAGE GROUP GENDER & SYMPTOMS
30-39 YEARS M& F + TYPICAL ANGINA M + ATYPICAL/ PROBABLE ANGINA
40-49 YEARS F + TYPICAL ANGINAM + ATYPICAL/ NON ANGINAL CP
50-59 YEARS F+ TYPICAL ANGINAM&F + ATYPICAL NAGINAM+ NON ACP
60-69 YEARS M& F+ ATYPICAL/PROB ANGINAM&F + NACP
![Page 18: Ekg 운동심전도-추출](https://reader034.vdocuments.site/reader034/viewer/2022042907/587bb0731a28abb8258b4615/html5/thumbnails/18.jpg)
E T TO DIAGNOSE OBSTRUCTIVE CAD
Class I• Adult (including RBBB or <1 mm of resting ST↓) with
intermed pretest probability of CAD Class IIa• Patients with vasospastic angina.
![Page 19: Ekg 운동심전도-추출](https://reader034.vdocuments.site/reader034/viewer/2022042907/587bb0731a28abb8258b4615/html5/thumbnails/19.jpg)
E T TO DIAGNOSE OBSTRUCTIVE CAD
Class IIb1. Patients - high pretest probability of CAD 2. Patients - low pretest probability of CAD 3. Patients with <1 mm of baseline ST ↓and on digoxin.4. Patients with LVH and <1 mm baseline ST ↓.
Class III1. Patients with the following baseline ECG abnormalities:
• Pre-excitation syndrome• Electronically paced ventricular rhythm• >1 mm of resting ST depression• Complete LBBB
![Page 20: Ekg 운동심전도-추출](https://reader034.vdocuments.site/reader034/viewer/2022042907/587bb0731a28abb8258b4615/html5/thumbnails/20.jpg)
EST SENSITIVITY SPECIFICITY
OVERALL 68% 77%
SVD(LAD>RAD>LCX) 25-71%
MULTIVESSEL DIS 81% 66%
LMCA/3-VD 86% 53%
![Page 21: Ekg 운동심전도-추출](https://reader034.vdocuments.site/reader034/viewer/2022042907/587bb0731a28abb8258b4615/html5/thumbnails/21.jpg)
Exercise Testing in Asymptomatic PersonsWithout Known CAD
Class I • None.
Class IIa• Evaluation of asymP DM pts - plan to start vigorous exercise ( C)
Class IIb• 1. Eval of pts with multiple risk factors - guide to risk-reduction therapy.• 2. Eval of asymptomatic men > 45 yrs and women >55 yrs: Plan to start vigorous exercise Involved in occupations which impact public safety High risk for CAD(e.g., PVOD and CRF)Class III• Routine screening of asymptomatic
![Page 22: Ekg 운동심전도-추출](https://reader034.vdocuments.site/reader034/viewer/2022042907/587bb0731a28abb8258b4615/html5/thumbnails/22.jpg)
RISK ASSESS AND PROG IN PAT WITH SYMP OR A PRIOR HIS-TORY OF CAD
Class I
1. Initial evalu with susp/known CAD +/- RBBB or <1 mm of resting ST Depression
2.Susp/ known CAD, previously evaluated-+ signi change in clinical status nw
3. Low-risk UA pts >8 to 12 hrs & free of active ischemia/CCF
4. Intermed-risk UApts > 2 to 3 days & no active is-chemia/ CCF
Class IIa
Intermed-risk UA pts – initial markers (N),rpt ECG –no signi change, and markers >6-12 hrs (N) & no other evi-dence of ischemia during observation.