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Cardiology
Published in Kaji Sritharan, Jonathan Rohrer, Alexandra C Rankin, Sachi Sivananthan, Essential Notes for Medical and Surgical Finals, 2021
Kaji Sritharan, Jonathan Rohrer, Alexandra C Rankin, Sachi Sivananthan
Indications: a diagnostic tool for patients with chest pain of intermediate risk and a prognostic tool in patients with known ischemic heart disease. Limitations: low sensitivity and specificity; not all patients’, e.g. immobile patients, etc. able to perform test. Bruce protocol uses a treadmill with graded levels of exercise, with BP and ECG monitoring. Modified Bruce protocol is used after an episode of acute coronary syndrome/myocardial infarction. Contraindications: acute MI, ACS, uncontrolled arrhythmias, severe AS, symptomatic HF, active endocarditis/myocarditis/pericarditis, aortic dissection. Positive test if BP drops, chest pain, or >2 mm ST depression.
Introduction to specialist investigations
Published in Ian Mann, Christopher Critoph, Caroline Coats, Peter Collins, The Junior Doctor’s Guide to Cardiology, 2017
Ian Mann, Christopher Critoph, Caroline Coats, Peter Collins
The Bruce protocol consists of a standardised seven-stage protocol for cardiac stress testing. Each stage is 3 minutes long, and there is a progressively increasing level of difficulty. The modified Bruce protocol is less demanding and more suitable for the elderly or those with limited mobility. This modified protocol can also be useful for risk-stratifying patients with known ischaemic heart disease who present with troponin and ECG-negative chest pain. A negative test aids the planning of discharge.
Practice Paper 9: Answers
Published in Anthony B. Starr, Hiruni Jayasena, David Capewell, Saran Shantikumar, Get ahead! Medicine, 2016
Anthony B. Starr, Hiruni Jayasena, David Capewell
The resting ECG in patients with suspected ischaemic heart disease (IHD) is often normal and of limited diagnostic value. The exercise ECG was developed to aid in the diagnosis of IHD. The patient is placed on a treadmill and exercised according to a predetermined protocol while their blood pressure, heart rate and ECG are monitored. The most widely used programme is the Bruce protocol, where the speed and incline of the treadmill are increased every 3 minutes through a maximum of seven stages. A positive test is indicated by the development of ischaemic symptoms, ST elevation/depression, arrhythmia and a failure of the blood pressure to rise in response to exercise. The test should be stopped when there is ST elevation >2 mm in any lead, worsening ST depression, chest pain, shortness of breath or arrhythmia. Resuscitation equipment and glyceryl trinitrate spray should always be available when carrying out this investigation.
Greater symptom burden results in reduced exercise tolerance in adolescents following concussion
Published in Brain Injury, 2022
Andrew Fyffe, Michael A. Carron, Rhonda Orr, Maree Cassimatis, Gary Browne
Aerobic capacity and readiness to return to activity/sport were determined via a graded exercise test using a standard Bruce protocol (43,44). The Bruce protocol was chosen over the Buffalo Concussion Treadmill Test for its progressive increase in both speed and incline after each 3-minute stage, enabling participants without previous treadmill experience time to adapt to each stage and in order to reach running speeds that are more comparable to sport-related biomechanics (26). Participants continued until maximal exertion or intolerable symptom exacerbation was reached. A metabolic cart (Ultima Series, MGC Diagnostics, St Paul, Minnesota) together with face mask for oxygen assessment was connected to a BreezeSuite 6.4 program. Heart rate was monitored using a chest-strapped Polar H10 HR Monitor (Polar Electro Oy, Kempele, Finland). To monitor the wellbeing of the participant during the test, the Wong-Baker Faces Pain Rating Scale (WBFPRS) and ratings of perceived exertion (RPE) were used (45,46). The testing protocol was terminated if the participant (1) requested to stop (2); expressed an abnormal heart rate, specifically decrease in heart rate with increased exertion (3); increased >3 on the WBFPRS; or (4) displayed impaired gait or balance. Exercise tolerance determined readiness to return to activity/sport. Participants were given the same exercise test every two to 4 weeks until recovery.
Cardiopulmonary exercise testing in neuromuscular disease: a systematic review
Published in Expert Review of Cardiovascular Therapy, 2021
Gabriela Barroso de Queiroz Davoli, Bart Bartels, Ana Claudia Mattiello-Sverzut, Tim Takken
When an upright cycle ergometer is not available, a treadmill might be an alternative option for assessing aerobic fitness in some subtypes of NMDs. It was the second most frequently used device in the included studies and in those included in the best evidence synthesis [9,62]. The Naughton and the Bruce protocols offered the best evidence for respectively assessing adults and pediatric patients [9,62]. The Bruce protocol is a frequently used protocol [115]; however, it has some disadvantages when assessing children and adolescents with reduced functional capacity. The primary disadvantage is posed by the large and unequal increments that impact the obtained exercise response [115], and a secondary disadvantage is the high metabolic demand in the first stages, requiring an oxygen cost of 17.5 ml/kg/min (5 METS), which represents more than 60% of the mean VO2peak achieved by the young NMD patients on the treadmill. Therefore, the Dubowy protocol, with small and even increments (speed increment: 0.5 km/hr and grade: 3% each 1.5 minute), is more advisable for assessing aerobic fitness in children and adolescents with NMDs.
Cardiopulmonary fitness but not muscular fitness associated with visceral adipose tissue mass
Published in Archives of Physiology and Biochemistry, 2021
Ki-Yong An, Sue Kim, Minsuk Oh, Hye-Sun Lee, Hyuk In Yang, Hyuna Park, Ji-Won Lee, Justin Y. Jeon
Cardiopulmonary fitness was assessed based on maximal oxygen uptake (VO2max) and by using a motorised treadmill (TM65, Quinton, Mortara Instrument Inc., Milwaukee, VA) and a gas analyser (True One 2400, Parvo Medics, Murray, UT). The modified Bruce protocol was used for the test. The rate of perceived exertion (RPE) was monitored every minute, and BP was monitored every 3 min during exercise test and recovery. In addition, heart rate was continuously monitored. The participants were sufficiently aware of the test procedure and precautions before beginning the test. They continued the test until a state of exhaustion or abnormal heart rate and rhythm. The maximum exercise load criteria were as follows: 1) heart rate with ± 5 beats per minute of predicted maximum heart rate, 2) respiratory exchange ratio (RER) of ≥1.15, and 3) plateau in oxygen uptake.