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Heart Education Awareness Resource and Training through E-learning

03: Stable Coronary Artery Disease: Case 2 Mary

Exercise Treadmill Testing

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  1. Frances: Hi Richard, my name's Frances I"m the cardiology nurse consultant. Your GP sent you up to the clinic this morning to have an Exercise Tolerance Test done. You"ve obviously been complaining of some chest pain, is that right?
  2. Richard: Yes, mostly in the centre of my chest, some tightness. Probably for the last couple of weeks to a month.
  3. Frances: That tight feeling, does it go anywhere else, down your arms or up your jaw?
  4. Richard: No, it just seems to stay across the centre part of my chest.
  5. Frances: OK, does it make you feel breathless or sick?
  6. Richard: No I feel slightly warmer, maybe a bit sweaty. But I don"t feel breathless or sick.
  7. Frances: And you"re not aware of your heart beating fast in your chest or anything like that?
  8. Richard: No, I don"t think so no.
  9. Frances: Not at all. And you say you can get it when you"re exercising, but you can also get when you"re at rest as well.
  1. Debbie: And the next thing I"m going to do is just bring some cables across, "cos obviously we need to attach up all these. So we can have a look at your initial heart tracing.
  2. Debbie: So we"ll just wire you up to this little lot now (here you go). Have you been on a treadmill before at all?
  3. Richard: I have yeah, I"ve used a treadmill before.
  4. Debbie: At the gym or somewhere like that?
  5. Richard: Yeah, at the gym.
  6. Debbie: So you"ve got a rough idea of what we"re going to do you today. The idea is we"re going send you for a walk, up a bit of a hill.
  7. Richard: OK.
  8. Debbie: The most important thing is you"ll let us know straightaway if you start to feel any of that chest discomfort, or any problems at all (that you"re having).
  9. Richard: OK.
  10. Debbie: Now obviously Frances and I will be with you the whole time. And we"ll be monitoring your blood pressure and your heart rate very closely. As well as some other things. But please let us know if there's any changes that worry you.
  11. Richard: OK.
  12. Debbie: OK, we"re just going to pop the belt around your waist, which will keep everything attached to you during the test (thanks, that's great). Lovely, great. So that's you. We"ll get you down from there now and we"ll show you what to do and get you on our treadmill.
  1. Frances: Richard I"m just going to put this blood pressure cuff on your arm. I will record your blood pressure a few times throughout the test.
  2. Frances: You will hear a bleep in the machine, don"t worry about that, that's just to remind me to take a blood pressure. Your blood pressure will go up through the test and your heart rate will go up through the test. But that's a natural response to exercise and that's what we"re looking for.
  3. Richard: OK.
  4. Debbie: Just before we get started, I"ve a last set of instructions for you. When the belt starts moving what we want you to do is start walking straightaway, keeping up to the top half of the treadmill all the time here.
  5. Debbie: Once you get comfortable you"re gonna go up a small gradient into level one. And that's gonna be you for the first few minutes of the test, so I want you to really relax and take your time with that.
  6. Debbie: Importantly, like we were saying earlier, let us know straightaway if you feel any of this chest discomfort you"ve been getting or anything symptoms that's bothering you, alright, you just let us know.
  7. Richard: OK, no bother.
  8. Debbie: OK, we"re gonna get started with the test now, so if you can take a long slow stride, right up to the top of the treadmill for us.
  9. Debbie: That's the way, good. And now I"m gonna put you up the small hill, and that's just gonna get you into level one, OK. Good stuff, if you can just take your time with that. First three minutes, if you can let us know if there's any problems. How you feeling at that?
  10. Richard: Yeah, that's fine, no problem.
  11. Debbie: Great.
  • ((treadmill whirring))
  1. Debbie: OK Richard, you still feeling fine there at the moment?
  2. Richard: OK, I"m quite warm, but I"m OK yup.
  3. Debbie: Good, well we"re gonna get you into level two. Which means slightly faster and slightly steeper. Now it's just gonna change over in five seconds alright, you"re gonna hear it moving up a gear. Right, now. That's you up in level two. How you finding that?
  4. Richard: It's OK.
  5. Debbie: Great, good.
  6. Richard: You"ve no chest pain at the moment Richard?
  7. Frances: No, I feel fine. Good.
  • ((treadmill whirring))
  1. Debbie: OK that's you finished level two now. So we"re gonna make it a little bit faster and steeper again provided you"re feeling OK still.
  2. Richard: Yeah, I feel fine thanks.
  3. Debbie: None of that discomfort at all?
  4. Richard: Nothing.
  5. Debbie: OK, it's about to get faster and steeper for you... now. It's quite hard work this one, bit more of a quicker walk for you.
  6. Richard: (OK).
  • ((treadmill whirring))
  1. Debbie: That's you finished the test there, so we"re gonna just start slowing things down now. If you can keep walking straight to the top, until it comes to a halt.
  2. Debbie: Now when it does stop, you might feel a little bit lightheaded and giddy. Don"t want you to worry about that, it's quite normal, alright.
  3. Debbie: We"re just gonna start slowing things down now. If you could just keep walking to the top and we"ll bring you to a halt now, OK. Great, that's you. Well done.
  1. Frances: Hi Richard. I"ve got the result of your exercise test and it's looking good.
  2. Richard: (Good).
  3. Frances: You did nine minutes on the test, you had no symptoms while you were on the test and your (ECG"s) trace and your ECG's actually looking fine. There's no abnormalities in it that we would be concerned about.
  4. Richard: (Good, OK).
  5. Frances: So thinking about your symptoms, you presented with a rather atypical presentation for angina. And your treadmill test is very good. So what we would be saying is, this is certainly not angina.
  6. Frances: What I"ll do now is, is write to your GP, tell him that you have been up to the clinic, you"ve done your treadmill test and everything looks fine.
  7. Frances: How do you feel about that?
  8. Richard: Quite relieved, it's obviously not related to my heart or angina. So yeah, quite happy. I obviously didn"t experience any signs or symptoms when I was on the test, so, yeah pretty relieved. (OK).

The treadmill test (also known as exercise tolerance test) shown in the video clip is not Mary´s case but a snapshot of a patient undergoing an ETT at RACPC.

For more information about ETT see modules 1 and 4.

Remember the ETT like any other test is not 100% conclusive and you can get false positive tests and false negative tests. This is why the history and investigation go hand in hand when making a diagnosis.

Low pre-test prob - atypical, young, female N=1000: 120 ve of which 95 will be false ve tests.

High pre-test prob - typical, 65 yr male with HBP Pre-test prob. 90%, ve ETT = 98% prob., -ve ETT = 83% prob

Intermediate pre-test prob: atypical, 50yr female, smokes Pre-test prob. 50%, ve ETT 83%, -ve ETT 36% prob

Still is a useful test but be aware of its limitations A –ve test does not exclude significant/ symptomatic IHD in “intermediate-high likelihood groups”

The Society for Cardiological Science & Technology: Recommendations for Clinical Exercise Tolerance Testing [.pdf]

Diagnosis by exercise testing

Module name: Coronary Artery Disease

Map name: 03: Stable Coronary Artery Disease: Case 2 Mary

Map ID: 1563

Node ID: 41566