Exercise Treadmill Stress Testing

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  • Evaluate for myocardial ischemia
  • Evaluate for exercise-induced arrhythmia
  • Evaluate exercise tolerance
  • Baseline ECG findings that limit interpretation (LBBB, LVH with strain, digoxin abnormality, significant resting ST-T wave abnormalities)
  • Mental or physical impairment that renders the patient unable to perform exercise stress test
  • Ongoing acute coronary syndrome or acute myocardial infarction within 48 hours
  • High-risk unstable angina
  • Uncontrolled arrhythmia
  • Severe aortic stenosis
  • Symptomatic congestive heart failure
  • Severe arterial hypertension (systolic blood pressure (SBP) > 200 mm Hg)
  • Left bundle branch block (consider pharmacologic myocardial perfusion study)
  • Treadmill
  • ECG machine and BP Monitor
  • Oxygen delivery nasal cannula and wall oxygen on hand
  • Resuscitation capability: crash cart/defibrillator with emergency pharmaceuticals


Interpretation of the ECG is dependent on reproducible and standardized positioning of the cardiac electrodes. It is important to be familiar with proper placement of ECG electrodes for ETT. Four limb leads are placed either on the patient’s limbs or on the torso near the patient’s limbs. A standardized color scheme is used to designate limb leads:

  • White: Right upper extremity or right upper torso (shoulder)
  • Green: Right lower extremity or right lower torso (hip)
  • Black: Left upper extremity or left upper torso (shoulder)
  • Red: Left lower extremity or left lower torso (hip)

Precordial leads (standard ECG includes 6 leads, termed V1 through V6) are placed across the chest wall.

V1: Right sternal margin, 4th intercostal space
V2: Left sternal margin, 4th intercostal space
V3: Midway between V2 and V4
V4: Left midclavicular line, 5th intercostal space
V5: Left anterior axillary line, same horizontal plane as V4
V6: Left midaxillary line, same horizontal plane as V4


  • Requisition form is reviewed by nurse or physician.
  • Provide patient instruction and determine appropriateness of study on basis of clinical history and current status.
  • Instruct patient to hold beta-blockers, calcium channel blockers, and long-acting nitrates 24 hours before test.
  • Instruct patient to wear comfortable clothing and comfortable, stable shoes for treadmill use.
  • Instruct patient to not eat or drink for 3 hours before the test.

Sample excerpt does not include step-by-step text instructions for performing this procedure
The full content of this section includes:
  • Step-by-step text instructions for performing the procedure
  • Clinical pearls providing practical clinical tips from medical experts
  • Patient safety guidelines consistent with Joint Commission and OHSA standards
  • Links to medical evidence and related procedures

  • Answer any questions for the patient and discuss follow-up plans.
  • Physician and sonographer complete reporting and finalize report.
  • There are no absolute contraindications for stress echocardiography.
  • Patients may experience angina, dyspnea, palpitations during the study.

Risk stratification of CAD via the Duke Treadmill Score: A high-risk treadmill score ( ≤ –11) is associated with a 3% annual mortality rate, an intermediate-risk score (–11 to 5) is associated with an annual mortality of 1% to 3%, and a low-risk score (>5) is associated with an annual mortality of less than 1%.

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