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CLINICAL POLICY
Exercise Stress Testing Policy
A. EFFECTIVE DATE :
April 7, 2021
B. PURPOSE :
To define policy information for performing regular exercise stress tests. Relies 100% on EKG tracing and patient
symptoms to diagnose heart disease.
C. POLICY :
Cardiology will operate an Exercise Stress testing service to evaluate potential cardiac disease and/or to detect
abnormalities in electrocardiographic tracings.
D. SCOPE :
INDICATIONS:
1. Diagnosis of myocardial ischemia.
2. Identification of severity of CAD.
3. Risk stratification after acute MI or after revascularization procedure.
4. Preoperative evaluation for major non-cardiac surgical procedure.
5. Evaluate for ischemia as cause for cardiomyopathy.
CONTRAINDICATIONS:
Absolute
1. Acute myocardial infarction (within 2 days)
2. High-risk unstable angina*
3. Uncontrolled cardiac arrhythmias causing symptoms or hemodynamic compromise
4. Symptomatic severe aortic stenosis
5. Uncontrolled symptomatic heart failure
6. Acute pulmonary embolus or pulmonary infarction
7. Acute myocarditis or pericarditis
8. Acute aortic dissection
Relative
1. Left main coronary artery disease
2. Moderate stenotic valvular heart disease
3. Electrolyte abnormalities
4. Severe arterial hypertension
5. Tachyarrhythmias or bradyarrhythmias
6. Hypertrophic cardiomyopathy and or other forms of outflow tract obstruction
7. Mental or physical impairment leading to inability to exercise adequately
8. High-degree atrioventricular block
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INDICATIONS FOR TERMINATING EXERCISE TESTING
Absolute:
1. Drop in systolic blood pressure of >10mmHg from baseline blood pressure despite an increase in workload,
when accompanies by other evidence of ischemia
2. Moderate to severe angina
3. Increasing nervous system symptoms (e.g. ataxia, dizziness, or near-syncope)
4. Signs of poor perfusion (cyanosis or pallor)
5. Technical difficulties in monitoring ECG (electrocardiogram) or systolic blood pressure
6. Subject’s desire to stop
7. Sustained ventricular tachycardia
8. ST elevation (> 1.0mm) in leads without diagnostic Q-waves (other than V1 or a VR)
Relative
1. Drop in systolic blood pressure of > 10mmHG from baseline blood pressure despite an increase in workload,
in the absence of other evidence of ischemia
2. ST or QRS changes such as excessive ST depression (> 2mm of horizontal or downsloping ST-segment
depression) or marked axis shift
3. Arrhythmias other than sustained ventricular tachycardia, including multifocal PVCs, triplets of PVCs
(premature ventricular contractions), supraventricular tachycardia, heart block, or bradyarrythmias
4. Fatigue, shortness of breath, wheezing, leg cramps, or claudication
5. Development of bundle-branch block or IVCD (intraventricular conduction delay) that cannot be
distinguished from ventricular tachycardia
6. Increasing chest pain
7. Hypertensive response (systolic blood pressure of > 250mmHG and/or a diastolic blood pressure of >
115mmHg)
MISCELLANEOUS
1. Except under unusual circumstances, all tests are maximal stress tests, that is symptom-limited: due to
symptoms or concerning cardiovascular signs (see Indications for Terminating Exercise Testing)
2. Minimal standard for diagnostic test: symptom limited or 85% of MPHR (Maximal Predicated Heart Rate)
and double product of 25K or greater.
3. Test supervisor will notify attending cardiologist of any critical end points.
4. Attending cardiologist will notify referring (ordering) physician within one hour of being notified of critical
test results.
5. A patient’s condition may require the need to be seen by attending cardiologist or have more definitive care
in the Emergency Department for critical end points. The test supervisor will accompany the patient to the
ED. The test supervisor will give a report to the ED nurse/physician with appropriate documentation and a
copy of the EKG.
6. Critical Test results (defined by attached) will be communicated to referring (ordering) provider by
supervising cardiology within one hour of interpretation and documented accordingly in formal final report.
E. DEFINITIONS:
None
F. MATERIAL(S) NEEDED :
Electrodes, treadmill or exercise bike, emergency medication and crash cart, CASE machine
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G. PROCEDURE :
1. Patient is properly identified via hospital policy for patient identification.
2. Informed consent should be signed and dated, with time for signing indicated.
3. The patient is brought into the stress testing laboratory. The test is explained, questions are answered, and
informed consent for the test is signed.
4. After skin preparation, ten electrodes are placed on specific areas of the chest (RA, RL, LA, LL, V1-V6).
Electrodes should be placed on patient while he/she is standing in order to standardize procedure.
5. Resting heart rate, blood pressure, and electrocardiogram are obtained, both supine and standing.
6. All data obtained during the test will be entered in the stress testing computer system.
7. An assessment is completed by the test supervisor which may include, but is not limited to: reason for
testing, history of present illness, current medications and whether they were taken on the day of the test,
past medical history, allergies to medication, presence of risk factors for cardiovascular disease, cardiac
history, history of asthma or other pulmonary problems, presence of any orthopedic or neurological
problems that may prohibit walking on the treadmill and how the patient is feeling on the day of the test.
8. A focused physical examination may be done which may include, but is not limited to: heart and lungs
auscultation.
9. Appropriate lab data is reviewed on inpatients/ED patients to verify two (2) negative sets of cardiac
enzymes.
10. The order is reviewed for completeness and appropriateness of test.
11. After evaluating the above data, the test supervisor determines whether to proceed with testing. If testing
is determined inappropriate, unsafe, or clinically not indicated, the test supervisor will notify referring
provider. The test supervisor may change an exercise stress test to a pharmacologic stress test per protocol
if the patient is deemed to be mentally or physically unable to exercise or if the patient refuses to exercise.
12. Test supervisor chooses the appropriate protocol. Standard Bruce Protocol is recommended or, if indicated,
modified Bruce protocol or Naughton protocol.
13. Patient exercises on the treadmill with the amount of exertion gradually increasing per protocol. Heart rate
and heart rhythm, as well as subjecting and objective signs of test tolerance, are continuously monitored.
Blood pressure is intermittently monitored.
14. The treadmill is stopped when the patient can no longer exercise, there are concerning symptoms that
appear, or changes that occur in the EKG, heart rate, heart rhythm, or blood pressure (including
hypotension: >20mmHg decrease compared to the previous stage in the setting of clinical evidence of
ischemia).
15. There is a minimal five-minute recovery period where the heart rate and rhythm are continuously
monitored and blood pressure is monitored minimally every two minutes.
16. The test is completed when the blood pressure, heart rate and rhythm are stable and any symptoms, EKG
changes or arrhythmias have resolved.
17. Test supervisor will interpret the stress test, incorporating all clinical variables (workload, EKG changes, HR,
and BP response) and prepare a preliminary report.
18. Critical test results, as defined under separate cover, are communicated to attending cardiologist. Attending
cardiologist will notify ordering physician within one hour of test interpretation and document on final
report.
19. The patient is disconnected from the stress testing equipment; all but three (3) precordial electrodes are
removed.
H. ATTACHMENTS :
None
I. REFERENCES :
ACC/AHA Guidelines for Exercise Testing.
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J. SEARCH WORDS :
Stress testing, exercise study
K. ENFORCEMENT:
Violations of this policy or associated procedures may result in appropriate disciplinary measures in accordance with
University By-Laws, General Rules of Conduct for All University Employees, applicable collective bargaining
agreements, the University of Connecticut Student Code, other applicable University Policies, or as outlined in any
procedures document related to this policy.
L. STAKEHOLDER APPROVALS :
On File
M. COMMITTEE APPROVALS :
None
N. FINAL APPROVAL :
1. Andrew Agwunobi (Signed) 04/16/2021
Andrew Agwunobi, MD, MBA Date
UConn Health Chief Executive Officer
2. Anne Horbatuck (Signed) 04/16/2021
Anne D. Horbatuck, RN, BSN, MBA Date
Clinical Policy Committee Co-Chair
3. Scott Allen (Signed) 04/15/2021
Scott Allen, MD Date
Clinical Policy Committee Co-Chair
4. Caryl Ryan (Signed) 04/13/2021
Caryl Ryan, MS, BSN, RN Date
VP Quality and Patient Service & Chief Nursing Officer
O. REVISION HISTORY :
Date Issued: 1/2009
Date Revised: 3/2021
Date Reviewed: 01/2005, 12/2006, 01/2008, 01/2009, 09/2012, 10/02/2014, 02/06/2015, 11/30/2017, 07/2020
