tress Test

The Gale Encyclopedia of Medicine. 5th ed. 2015.

COPYRIGHT 2015 Gale, Cengage Learning

Definition
A stress test is primarily used to identify coronary artery disease. Consequently, it is also
sometimes called a cardiac stress test or cardiac diagnostic test. The stress test measures the
ability of the heart to react to exercise while being monitored in a controlled environment. The
test measures the heart at rest and while it is under the stress of exercise. It requires patients to
exercise on a treadmill or exercise bicycle while their heart rate, blood pressure,
electrocardiogram (ECG), and any symptoms that occur during the test are monitored. The result
shows the general physical condition of their circulatory system and, specifically, may show when
an abnormal flow of blood is going into or out of the heart. Besides helping to diagnose heart
disease, it also provides prognoses after heart attacks.

Purpose
The body requires more oxygen during exercise than when it is at rest. To deliver more oxygen
during exercise, the heart has to pump more oxygen-rich blood. Because of the increased stress
on the heart, exercise can reveal coronary problems that are not apparent when the body is at
rest. This is why the stress test, though not perfect, remains the best initial, noninvasive, practical
coronary test.

The stress test is particularly useful for detecting ischemia (inadequate supply of blood to the
heart muscle) caused by blocked coronary arteries. Less commonly, it is used to determine safe
levels of exercise in people with existing coronary artery disease. A stress test may also be given
when the following conditions are suspected or present:

 acute chest pain

 acute coronary syndrome (ACS)
 angina
 atypical or non-cardiac chest pain
 cardiac disease (if undergoing emergency non-cardiac surgery)
 coronary artery disease (if disease status changes)
 past coronary revascularization
 newly diagnosed heart failure or cardiomyopathy
 select arrhythmias
 valvular heart disease

Description
A technician affixes electrodes to the patient’s chest, using adhesive patches with a special gel
that conducts electrical impulses. Typically, electrodes are placed under each collarbone and
each bottom rib, and six electrodes are placed across the chest in a rough outline of the heart.
Wires from the electrodes are connected to an ECG, which records the electrical activity picked
up by the electrodes.
The technician performs resting ECG tests while the patient is lying down, then standing up, and
then breathing heavily for half a minute. These baseline tests can later be compared with the
ECG tests performed while the patient is exercising. The patient’s blood pressure is taken and
the blood pressure cuff is left in place so that blood pressure can be measured periodically
throughout the test.

The patient begins riding a stationary bicycle or walking on a treadmill. Gradually the intensity of
the exercise is increased. For example, if the patient is walking on a treadmill, then the speed of
the treadmill increases and the treadmill is tilted upward to simulate an incline. If the patient is on
an exercise bicycle, then the resistance or “drag” is gradually increased. The patient continues
exercising at increasing intensity until reaching the target heart rate (generally set at a minimum
of 85% of the maximal predicted heart rate based on the patient’s age) or experiencing severe
fatigue, dizziness, or chest pain. During the test, the patient’s heart rate, ECG, and blood
pressure are monitored.

Sometimes other tests, such as echocardiography or thallium scanning, are used in conjunction
with the exercise stress test. This is partly because studies suggest that women have a high rate
of false negatives (results showing no problem when one exists) and false positives (results
showing a problem when one does not exist) with the stress test. They may benefit from another
test, such as exercise echocardiography. People who are unable to exercise may be injected
with drugs, such as adenosine, which mimic the effects of exercise on the heart, and then they
are given a thallium scan. The thallium scan and echocardiogram are particularly useful when the
patient’s resting ECG is abnormal. In such cases, interpretation of exercise-induced ECG
abnormalities is difficult.

An echocardiogram stress test is performed in a similar fashion to an ECG stress test (the
subject rides a bike or walks on a treadmill in both tests). However, in an echocardiogram, sound
waves create a moving image of the heart. The image is more detailed than the one produced
with an x-ray scan and does not require radiation. The type of echocardiogram that is most often
used is a transthoracic echocardiogram (TTE). In the TTE process, a transducer is positioned
above or around the heart so that when high-frequency sound waves are emitted, the transducer
receives back the sound waves as they bounce off the heart. The waves are transmitted as
electrical impulses to the echocardiograph machine, which converts these impulses into two-
dimensional or three-dimensional images of the heart. In addition to this, a Doppler
echocardiogram records the motion of blood as it passes through the heart.

Radionuclide myocardial perfusion imaging (rMPI) is a nuclear procedure used in medicine that
shows the function of the heart muscle. This imaging scan is the most common nuclear medicine
procedure used for heart analyses. The scan is performed after a small amount of radioactive
material such as thallium (chemical symbol Tl) or technetium (Tc) is injected into a vein of the
patient. The radioactive material passes into the patient’s heart muscle and images are taken
with a special camera to obtain a three-dimensional image. In order to detect coronary heart
disease, a stress test is performed along with the scan. The overall test requires two sets of
images of the heart and usually two sets of injections. One set of images is obtained immediately
after a patient exercises on a treadmill or after stressing the heart with a medication, and the
other is taken while the heart is at rest.

The use of rMPI with single-photon emission computed tomography (SPECT) or positron
emission tomography (PET) is well established for the diagnosis of coronary heart disease.
SPECT is a nuclear medicine tomographic imaging technique that uses gamma rays to detect
the functioning of the heart. In SPECT, a three-dimensional image is produced, one that consists
of cross-sectional slices of an organ. PET, also a nuclear medicine tomographic technique,
produces three-dimensional images by detecting pairs of gamma rays emitted indirectly by a
radionuclide (called a tracer) that gives off tiny positively charged particles (positrons). A camera
records the positrons and converts the recording into images on a computer. The tracer is
introduced into the body at the beginning of the test. The PET scan is especially useful for
determining the flow of blood in and around the heart.
Although exercise stress testing is generally preferred when evaluating the heart, an alternative
means of evaluation is sometimes used in patients who cannot properly exercise for the test. The
pharmacologic stress test is the evaluation method that does not use exercise as part of its
method. It is most often used when patients cannot exercise to an adequate level, which is
defined as at least 80% of the workload necessary for their gender and age, or 85% or more of
their maximum heart rate for their gender and age.

Preparation
Patients are usually instructed not to eat or smoke for several hours before the test. They should
be advised to inform the physician about any medications they are taking, and to wear
comfortable sneakers and exercise clothing.

Patients should understand the purpose of the test and the signs and symptoms that indicate the
test should be stopped. Physicians, nurses, and ECG technicians can ensure patients are safe
by encouraging them to immediately communicate discomfort at any time during the stress test.

Aftercare
After the test, patients should rest until their blood pressure and heart rate return to normal. If all
goes well, and there are no signs of distress, patients may return to their normal daily activities.

Risks
There is a very slight risk of myocardial infarction (a heart attack) from the exercise, as well as
cardiac arrhythmia (irregular heartbeat), angina, or cardiac arrest (about one in 100,000). For this
reason, exercise stress tests should be attended by healthcare professionals with immediate
access to defibrillators and other emergency equipment.

Patients are cautioned to stop the test should they develop any of the following symptoms:

 unsteady gait
 confusion
 skin that is grayish or cold and clammy
 dizziness or fainting
 a drop in blood pressure
 angina (chest pain)
 cardiac arrhythmia (irregular heartbeat)

Results
A normal result of an exercise stress test shows normal electrocardiogram tracings and heart
rate, blood pressure within the normal range, and no angina, unusual dizziness, or shortness of
breath.

A number of abnormalities may appear on an exercise stress test. Examples of exercise-induced

ECG abnormalities are ST segment depression or heart rhythm disturbances. These ECG
abnormalities may indicate deprivation of blood to the heart muscle (ischemia) caused by
narrowed or blocked coronary arteries. Stress test abnormalities generally require further
diagnostic evaluation and therapy.
The Duke Treadmill Score (DTS) is a common prognostic scoring system used for finding a
result from a stress test in which a patient has chest pain and is undergoing a treadmill stress
test. It predicts coronary heart disease, but is not applicable for patients who already have
coronary heart disease. The DTS is a weighted index that incorporates exercise duration,
symptoms, and ECG changes based on the following:

 Treadmill Exercise Time (Ex Time): amount of time for treadmill exercise, using the
standard Bruce protocol, in minutes, usually from 0 to 15 minutes
 Maximum net ST segment deviation (Max ST): taking into account depression or
elevation, in millimeters after 80 milliseconds from the J-Point; usually 0 to 7 millimeters;
the ST segment on an electrocardiogram connects the QRS complex and the T wave,
and has a duration of 0.080 seconds to 0.120 seconds
 Exercise-induced Treadmill Angina Index (Angina Index): 0 (no angina during exercise),
1 (non-limiting), or 2 (exercise-limiting)

The scoring for DTS consists of the following equation: (treadmill exercise time) minus (five times
maximum net ST deviation) minus (four times treadmill angina index); or (Ex Time) − (5 × Max
ST) − (4 × Angina Index). A range of scores for the DTS is from −25 to −11 (for highest risk of
coronary heart disease), −10 to +4 (moderate risk), and +5 to +15 (lowest risk).

Adam, Andy, Adrian K. Dixon, Ronald G. Grainger, and David J.

Allison. Grainger & Allison’s Diagnostic Radiology: A Textbook of Medical
Imaging. 5th ed. Philadelphia: Churchill Livingstone/Elsevier, 2008.

Bonow, Robert O., et al., eds. Braunwald’s Heart Disease: A Textbook of

Cardiovascular Medicine. 9th ed. Philadelphia: Elsevier Saunders, 2012.

Mettler, Fred A., Jr. Essentials of Radiology. 3rd ed. Philadelphia:

Elsevier/Saunders, 2014.

Websites

A.D.A.M. Medical Encyclopedia. “Echocardiogram.”

MedlinePlus. http://www.nlm.nih.gov/medlineplus/ency/article/003869.htm (ac
cessed September 18, 2013).

A.D.A.M. Medical Encyclopedia. “Nuclear Stress Test.”

MedlinePlus. http://www.nlm.nih.gov/medlineplus/ency/article/007201.htm (ac
cessed September 18, 2013).

Canadian Society of Echocardiography. “Duke Treadmill

Score.” http://www.csecho.ca/cardiomath/?eqnHD=
stress&eqnDisp=duketsc (accessed September 18, 2013).

Heller, Gary V., Justin B. Lundbye, and Athanasios Kapetanopoulos.

“Vasodilator Stress Radionuclide Myocardial Perfusion Imaging: Testing
Methodologies and Safety.” UpToDate.com. (March 8,
2013). http://www.uptodate.com/contents/vasodilator-stress-radio nuclide-
myocardial-perfusion-imaging-testing-method ologies-and-safety (accessed
September 18, 2013).
 Mayo Clinic staff. “Stress Test.”
MayoClinic.com. http://www.mayoclinic.com/health/stress-
test/MY00977 (accessed September 18, 2013).

Society of Nuclear Medicine and Molecular Imaging. “Radionuclide Perfusion

Imaging of the
Heart.” http://www.snm.org/docs/PET_PROS/Heart%20Disease%20Fact%20
Sheet.pdf (accessed September 18, 2013).

WebMD. “Heart Disease and Stress Tests.” http://www.webmd.com/heart-

disease/guide/stress-test(accessed September 18, 2013).

Zunis Foundation. “Duke Treadmill Score: Prediction Of Coronary Heart

Disease in a Patient with Chest Pain Undergoing a Treadmill Stress
Test.” http://www. zunis.org/Duke%20Treadmill%20Score%20-%20
CAD%20Predictor.htm (accessed September 18, 2013).

Organizations

American Heart Association Street 7272 Greenville

Ave. Dallas TX 75231 Free (800) AHA-USA-1 (242-8721) http://www.heart.org

National Heart, Lung, and Blood Institute Information Center Street PO Box
30105 Bethesda MD20824-0105 Phone (301) 592-8573 Fax (240) 629-
3246 nhlbiinfo@ nhlbi.nih.govhttp://www.nhlbi.nih.gov

Sangkalan: Informasi ini bukan alat untuk melakukan swa-diagnosis maupun menggantikan tindakan
pemeliharaan profesional.
Kutipan Sumber (Edisi ke-8 MLA)

Wexler, Barbara, et al. "Stress test." The Gale Encyclopedia of Medicine, edited by Jacqueline L.
Longe, 5th ed., Gale, 2015. Health & Wellness Resource
Center, http://link.galegroup.com/apps/doc/TDJSCX606742361/HWRC?u=iddepkes&sid=HWRC&xid
=9d2c49e5. Accessed 11 Aug. 2018.

Stress Test

Abstract
Translate [unavailable for this document]

The effects of child abuse can last a lifetime. Neglected or abused children have a higher risk of
developing all sorts of ailments as adults, including mental illnesses such as depression but also
physical ones like cancer and stroke. In fact, the effects may last even longer. Emerging
evidence suggests that the consequences of mistreatment in childhood may persist down the
generations, affecting a victim's children or grand-children, even if they have experienced no
abuse themselves. Here, the effects of childhood trauma are discussed.
Full Text
Translate [unavailable for this document]

Headnote

Genetics

The effects of childhood trauma maybe passed on through sperm

THE effects of child abuse can last a lifetime. Neglected or abused children have a higher risk of
developing all sorts of ailments as adults, including mental illnesses such as depression but also
physical ones like cancer and stroke. In fact, the effects may last even longer. Emerging
evidence suggests that the consequences of mistreatment in childhood may persist down the
generations, affecting a victim's children or grand-children, even if they have experienced no
abuse themselves.

Exactly how this happens is not well understood. Rigorous experiments on human subjects are
difficult. Scientists have therefore turned to rats and mice. But now Larry Feig of Tufts University
and his colleagues have shown that psychological stress seems to cause similar changes in the
sperm of both mice and men. Their study is published this week in Translational Psychiatry.

Biologists know that traits are carried down the generations by genes. Genes encode proteins,
and proteins make up organisms. That is still true. But it has recently become clear that it is not
the whole story. Organisms regulate the activity of their genes throughout their lives, switching
different genes on and off as circumstances require. It is possible that such "epigenetic"
phenomena can be passed, along with the genes themselves, to an animal's descendants. They
offer a mechanism by which an animal's life experiences can have effects on its offspring.

Hunting for signs of this, Dr Feig and his colleagues asked 28 male volunteers to complete a
questionnaire assessing the severity of any trauma they had experienced as youngsters. They
also asked their volunteers to provide sperm samples. They then looked for evidence for a
common epigenetic mechanism involving small molecules called micro-RNAs. Their job is to bind
to another molecule called messenger RNA, whose task in turn is to ferry information read from a
gene to the cellular factories that create the required protein. Micro-RNA renders messenger rna
inactive, reducing the activity of the gene in question-and it can travel in sperm alongside DNA.

Sure enough, upon screening the men's sperm, the researchers found that concentrations of two
types of micro-RNAs, miR-34 and miR-449, were as much as 100 times lower in samples from
abused men.

The team then turned to their mice. A standard way to stress mice is to move them to new cages,
with new mice, from time to time until they reach adulthood. When the team did this they found
that the stressed males had lower levels of miR-34 and miR-449 in their sperm. They mated
these males with unstressed females. The resulting embryos also had low levels of the two
micro-RNAs. And so in turn did sperm produced by the male offspring of these unions.

Dr Feig and others have shown that the female offspring of stressed male mice tend to be more
anxious and less sociable. Furthermore, the sons of stressed fathers themselves produce
stressed daughters. The effects of cage-shuffling, in other words, seem to last for at least three
generations. The researchers have not demonstrated conclusively that miR-34 and miR-449 are
responsible. But their results are suggestive.

To try to nail their case, the researchers plan to carry out a bigger study. This time, they will give
questionnaires to their human subjects' fathers, to tease out whether any epigenetic changes
they observe arise from the childhood experiences of the subject or his father. Sisters and
daughters may be included in the study, too. That is an ambitious goal. It is also a worthy one.
Unless genetic engineering can one day be perfected, changes in genes are hard-wired. But
epigenetic effects might be treatable, by boosting levels of particular micro-RNAsin sperm, for
example. That could mean the legacy of abuse is no longer passed to future generations. ?

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Copyright The Economist Intelligence Unit N.A., Incorporated May 26, 2018