American College of Cardiology

GIBBONS ET AL., 2002 GUIDELINE UPDATE FOR EXERCISE TESTING
Circulation 2002;106:1883-1892

ACC/AHA 2002 Guideline Update for Exercise Testing—Full Text

A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Excercise Testing Guidelines)

This is a Guideline Update of the 1997 Exercise Testing Guidelines. To highlight the changes, deleted text is indicated by strikeout, and revised text is presented in brown. A clean version of the document, with changes fully incorporated, is available for download and print.

Tables and Figures

Table 1   Contraindications to Exercise Testing

Table 2   Indications for Terminating Exercise Testing

Table 3   Medicare Fees and Volumes of Commonly Used Diagnostic Procedures

Table 4   Pretest Probability of Coronary Artery Disease by Age, Gender, and Symptoms*

Table 5   Definitions and Calculation of the Terms Used to Quantify the Diagnostic Accuracy of a Test

Table 6   Effect of Disease Prevalence on Predictive Value of a Positive Test

Table 7   Meta-Analyses of Exercise Testing ^(25,26)

Table 8   Studies Including Resting ST Depression

Table 9   Studies Excluding Resting ST Depression

Table 10   Studies Including Digitalis

Table 11   Studies Excluding Digitalis

Table 12   Studies Including Left Ventricular Hypertrophy

Table 13   Studies Excluding Left Ventricular Hypertrophy

Table 14   Prognostic Factors for Patients With Coronary Disease

Table 15   Measurements Available From the Exercise Treadmill Test

Table 16   Prognostic Studies of Exercise Testing

Table 17   Short-Term Risk of Death or Nonfatal Infarction in Patients With Unstable Angina

Table 17a   Summary of Studies Using Exercise ECG Testing in Chest Pain Centers

Table 18   Meta-Analyses of Exercise Electrocardiographic Testing After Myocardial Infarction

Table 19   Selected Studies* of Exercise Testing After Myocardial Infarction in the Thrombolytic Era

Table 19a   Estimated Energy Requirements for Various Activities*

Table 20   Classification of Exercise Intensity Based on Oxygen Uptake ⁽¹⁷⁷⁾

Table 21   Classification of Exercise Capacity in Patients With Heart Failure, Based on Peak Oxygen Uptake and Ventilatory Anaerobic Threshold ⁽¹⁸²⁾

Table 22   Guidelines for Peak Exercise Oxygen Uptake as a Criterion for Cardiac Transplantation ⁽¹⁸⁴⁾

Table 23   Sensitivity and Specificity of Exercise Electrocardiography in Women*

Table 24   Prediction of Cardiac Events by Exercise Testing in Studies of >500 Asymptomatic Individuals

Table 25   Predictive Value of Exercise Electrocardiographic Testing for Identification of Restenosis After Percutaneous Transluminal Coronary Angioplasty

Table A1

Table A2

Figures

Figure 1   Clinical context for exercise testing for patients with suspected ischemic heart disease. *Electrocardiogram interpretable unless preexcitation, electronically paced rhythm, left bundle branch block, or resting ST-segment depression >1 mm. See text for discussion of digoxin use, left ventricular hypertrophy, and ST depression <1 mm. **For example, high-risk if Duke treadmill score predicts average annual cardiovascular mortality >3% (see Figure 2 for nomogram). CAD indicates coronary artery disease, ECG, electrocardiogram; MI, myocardial infarction; and rx, treatment.

Figure 2   Nomogram of the prognostic relations embodied in the treadmill score. Prognosis is determined in five steps: (1) The observed amount of exercise-induced ST-segment deviation (the largest elevation or depression after resting changes have been subtracted) is marked on the line for ST-segment deviation during exercise. (2) The observed degree of angina during exercise is marked on the line for angina. (3) The marks for ST-segment deviation and degree of angina are connected with a straight edge. The point where this line intersects the ischemia-reading line is noted. (4) The total number of minutes of exercise in treadmill testing according to the Bruce protocol (or the equivalent in multiples of resting oxygen consumption [METs] from an alternative protocol) is marked on the exercise-duration line. (5) The mark for ischemia is connected with that for exercise duration. The point at which this line intersects the line for prognosis indicates the 5-year cardiovascular survival rate and average annual cardiovascular mortality for patients with these characteristics. Patients with <1 mm of exercise-induced ST-segment depression should be counted as having 0 mm. Angina during exercise refers to typical effort angina or an equivalent exercise-induced symptom that represents the patient's presenting complaint. This nomogram applies to patients with known or suspected coronary artery disease, without prior revascularization or recent myocardial infarction, who undergo exercise testing before coronary angiography. Modified from Mark et al. ⁽¹¹²⁾   

Figure 3   Strategies for exercise test evaluation soon after myocardial infarction. If patients are at high risk for ischemic events, based on clinical criteria, they should undergo invasive evaluation to determine if they are candidates for coronary revascularization procedures (strategy I). For patients initially deemed to be at low risk at the time of discharge after myocardial infarction, two strategies for performing exercise testing can be used. One is a symptom-limited exercise test at 14 to 21 days (strategy II). If the patient is on digoxin or if the baseline electrocardiogram precludes accurate interpretation of ST-segment changes (eg, baseline left bundle branch block or left ventricular hypertrophy), then an initial exercise imaging study could be performed. The results of exercise testing should be stratified to determine the need for additional invasive or exercise perfusion studies. Another strategy (strategy III) is to perform a submaximal exercise test at 4 to 7 days after myocardial infarction or just before hospital discharge. The exercise test results could be stratified using the guidelines in strategy I. If the exercise test studies are negative, a second symptom-limited exercise test could be repeated at 3 to 6 weeks for patients undergoing vigorous activity during leisure time activities, at work, or exercise training as part of cardiac rehabilitation. The extent of reversible ischemia on the exercise imaging study should be considered before proceeding to cardiac catheterization. A small area contiguous to the infarct zone may not necessarily require catheterization. Modified from ACC/AHA guidelines.2  ⁽³⁴⁵⁾ 

Figure 4   Relation of treadmill time (independent of specific protocol) to measured oxygen uptake using a progressive treadmill protocol. From Froelicher et al ⁽¹⁷⁴⁾ with permission.

Figure 5   Relation between measured versus predicted oxygen uptake for the Bruce protocol and progressive ramp protocol in patients with heart failure. Unity is achieved when predicted oxygen uptake is equal to measured oxygen uptake. CHF indicates congestive heart failure. From Froelicher et al ⁽¹⁷⁴⁾ with permission.

Figure 6   Measurements used to determine the gas exchange anaerobic threshold (Atge) using a progressive treadmill protocol. VE indicates minute ventilation; VCO₂, carbon dioxide production; VO₂, oxygen uptake; and FeO₂, fraction of expired air that is oxygen. From Froelicher et al¹⁷⁴ with permission.