Treadmill Exercise Stress Echo Procedure

Treadmill Exercise Stress Echocardiography Procedure

Purpose

To outline a standard process and provide information to ensure best practice is followed.

Procedure

Pre-test:  Prior to study date, patient will be notified by phone or mail with the date and time of test, instructions to wear comfortable clothing and shoes, and a reminder to have someone available to drive them home.  On arrival, after introductions and patient identification confirmed, patient will receive a full explanation of the test procedure and potential risks, with the opportunity to ask questions.  A verbal and/ written consent must be obtained to continue.

Test:  Ensure patient is wearing comfortable shoes to walk in.  Patient will be required to disrobe from the waist up and don a gown open in the front.  Documentation of patient height, weight, age, resting B/P and current medications.  A cardiac history is taken and recorded for the reading cardiologist.  12-lead ECG is attached ensuring a good signal with appropriate prep to the skin.  The technologist will take standing and supine ECGs at rest for baseline.  Use tissue harmonics (reduces near field artifact, improves resolution, enhances myocardium, and improves endocardial border definition).  Decide early in the process the need for a contrast agent, used with each acquisition.  The sonographer acquires digital loops of the imaging views Apical 4ch, 2ch, ALAX, PLAX and PSAX at rest. The machine preset should have a continuous capture or stacking function.  Choose either the Bruce or the Modified protocol.  Reinforce instructions and explanation of treadmill format immediately prior to starting the test.  Remind patient to speak up if having any symptoms or concerns while on the treadmill.  Remind patient of increase in incline and speed about 10 seconds before it occurs.  Encourage patient to stay on treadmill to reach or surpass the target heart rate.  Check patient B/P at each stage and document.  Continually watch 12-lead ECG for arrhythmias and ST changes.  Stop treadmill when test end point has been reached.  Assist patient back onto bed in a left lateral position so the sonographer can acquire peak images while heart rate is at its maximum.  Continue to monitor B/P and any symptoms.  Complete the test with post imaging when heart rate is below 100 beats/minute and document.

Test End Points:  Reached or surpassed target heart rate.  Drop in systolic blood pressure from baseline despite an increase in workload.  ST segment or QRS changes such as excessive ST depression (> 2 mm of horizontal or down-sloping).  ST elevation > 1 mm in leads without diagnostic Q waves (other than V1 or AVR).  Arrhythmias: ventricular tachycardia, multifocal frequent PVCs, heart block.  Severe symptoms: moderate to severe angina, presyncope, ataxia, pallor.  Machine technical difficulties—patient safety is a priority.  Patient refuses to continue.

Policy

 Respect patient’s modesty and privacy by draping the patient throughout the test.  Respect patient’s right to refuse test or stop upon request.  Ensure proper test supervision by physician, location and availability prior to starting the test.  Patient’s ability to walk on treadmill should be assessed by staff as early as possible. Need to change test type should be discussed and approved by the supervising physician.  Ensure requisition filled out and appropriateness of test indication.  Confidentiality: test results are not to be given to patient by the sonographer in a preliminary format.  Use contrast if unable to see any of the walls of the myocardium to ensure a complete study.  Medications and equipment available to treat and monitor if patient has symptoms.  Crash cart is in close proximity and staff aware of emergency response protocols.  Appropriate room size and current equipment, to ensure patient safety in an emergency situation.  Preprinted order forms preferred for the use of contrast, oxygen, nitroglycerine and written instructions for administration.

Treatment of Symptoms:  Moderate or severe angina: stop test, return patient to the bed, do an immediate blood pressure, apply oxygen—notify physician for assessment of 12 lead ECG and vitals, and give Nitroglycerine if ordered.  ST depression of > 2 mm or elevation > 1 mm: stop test and return patient to bed, perform immediate images, and monitor vitals and symptoms.  Presyncope, dizziness, unwell feeling: stop test, return to bed and monitor vitals.