ATS Pulmonary Function Laboratory Manual

chapter  19

Patient Safety 1. Monitored exercise testing is considered relatively safe with a reported complication rate of < 1 to 5 per 10,000 tests (14–19), and death has occurred in approximately 0.5 per 10,000 tests. 2. Criteria for immediately stopping the exercise test (9, 13): In the vast majority of CPETs, patients should be verbally encouraged before and during the test, to give a maximal effort with the goal of achieving physiologic limitation. Exceeding a preset heart rate criterion is not a useful criterion for stopping exercise. Absolute indications for exercise termination are: 2.1. Moderate to severe angina 2.2. ST-segment elevation (>1.0 mm) in leads without preexisting Q waves because of prior MI 2.3. Central nervous system symptoms (e.g., ataxia, dizziness, near syncope) 2.4. Signs of poor perfusion (cyanosis or pallor) 2.5. Fall in systolic blood pressure >10 mm Hg, despite an increase in workload, when accompanied by any other evidence of ischemia 2.6. Severe desaturation: Sp O 2 ≤ 80% when accompanied by symptoms and signs of severe hypoxemia 2.7. Sustained ventricular tachycardia or other arrhythmia, including second or third degree atrioven- tricular block, that interferes with normal maintenance of cardiac output during exercise 2.8. Technical difficulties in monitoring the ECG or systolic blood pressure 2.9. Patient’s request to stop 2.10. Exaggerated hypertensive response (e.g., for adults, systolic blood pressure >250 mm Hg or diastolic blood pressure > 115 mm Hg) In situations in which the exercise is terminated because of the above criteria, the patient should be observed until the patient is stable and physiologic variables have returned to baseline conditions. Table 19.2 Contraindications for Performing the CPET (2, 9–13) (However, this List Should not Replace Good Clinical Judgment) Absolute contraindications • Acute myocardial infarction, within past 2 days • Symptomatic severe aortic stenosis • Ongoing unstable angina • Uncontrolled cardiac arrhythmias with hemodynamic compromise • Acute pulmonary embolism, pulmonary infarction, or deep vein thrombosis • Active endocarditis • Decompensated heart failure • Acute myocarditis or pericarditis • Acute aortic dissection • Physical disability that precludes safe and adequate testing Relative contraindications • Resting hypertension. Resting systolic >200 mm Hg, diastolic >110 mm Hg • Tachyarrhythmias • Known obstructive left main coronary artery stenosis • Moderate to severe aortic stenosis with uncertain relation to symptoms • Acquired advanced or complete heart block • Known electrolyte abnormalities (e.g., hypokalemia and hypomagnesemia) • Recent stroke or transient ischemic attack • Hypertrophic obstructive cardiomyopathy with severe resting gradient • Uncorrected medical conditions, such as significant anemia, important electrolyte imbalance, and hyperthyroidism

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