How treadmill test is performed by a cardiologist

TREADMILL TEST (TMT TEST)

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WHAT IS A TREADMILL TEST (TMT)?

A treadmill test is a cardiac stress test where you will be asked to walk on a treadmill in a controlled environment while your ECG or EKG is continuously monitored. The test helps diagnose coronary artery disease (CAD), a condition often missed when a person
is resting. This test also helps your doctor determine how well your heart handles the workload of exercise. In that way, your doctor knows the kind and level of physical activity that’s right for you before starting any exercise regimen.

What is necessary for a TMT  or stress test when ECG and 2d echo are normal?

Oxygen is essential for the heart to do it function properly. Oxygen reaches your heart through vessels called coronary arteries.
(supply). The heart requires around 1ml/min/gm of blood at resting (demand). This increases to 6 ml/min/gm during strenuous exercise (increased demand).   The narrowing of coronary arteries is called coronary artery disease. Even if you have narrowing in your coronary arteries (i.e., even if you have coronary artery disease), the blood supply to your heart may be sufficient at rest (supply = demand). ECG and 2d echo are commonly done while you are resting. So they can be normal despite the presence of blockages in coronary arteries (CAD)
principle of treadmill test
ADVANTAGES OF TREADMILL TEST OVER ECG AND 2D CHO
While doing exercise, as in the treadmill test, your heart demands more blood (up to 6ml/min/gm) that may not be supplied due to narrowing in your coronary arteries  (demand-supply mismatch). This deprives your heart of sufficient oxygen during the treadmill test (called ischemia) that may cause certain changes to occur in your ECG. These changes are identified by your doctor, who may diagnose you have coronary artery disease. This is the reason why you may be asked by your doctor to do TMT even if you have a normal ECG and 2d ECHO.
Oxygen supply demand mismatch is the principle behind the tmt test

 

So TMT test checks whether your heart is receiving optimum oxygen when it requires it the most i.e., when you exercise.

 

Why does my doctor advise TMT for me?

Doctors use exercise stress tests to determine whether you have coronary artery disease.
  • 1. If your symptoms (such as chest pain or difficulty breathing) suggest coronary artery disease, but your ECG and 2d echo are normal, you may need TMT to rule out coronary artery disease. It is a poor man’s angiogram.
  • 2. This test also helps your doctor to tell you how hard you can safely exercise when you are joining a cardiac rehabilitation program or starting an exercise program.
  • 3. Sometimes helps your doctor know if treatments you have received for your heart disease are working.

Do I need to do anything to prepare for a stress test?

Tell your heart doctor about any medicines (including over-the-counter, herbs, and vitamins) you take. They may ask you not to
take some of them before the test. Certain drugs that decrease your heart rates, such as beta-blockers, calcium channel blockers, and ivabradine, must be stopped before the test. Please don’t stop taking them unless the doctor says to. You can take other medication as usual
·You may be asked not to eat or drink for two to four hours before the test. You  are told to avoid smoke for 12 hours
·Wear comfortable, loose-fitting clothing and walking shoes with rubber soles. Shorts or sweatpants and jogging or tennis shoes are good choices.

What happens during the TMT  test?

You’re hooked up to equipment to monitor your heart. The electrocardiography machine will record your heartbeat and heat waves in an electrocardiogram (ECG). Wires or electrodes will be hooked up to your chest, arms, or shoulders. The cables are connected to the ECG machine.
HOW TREADMILL TEST IS PERFORMED
You will be taken resting ECG and baseline blood pressure before the test in the supine position. The test has different stages (usually 6 to 7 stages) with increasing speed and grade of tilt (incline). Each phase lasts around 3 minutes (a commonly used protocol called Bruce protocol, but your doctor may prescribe other protocols that suit you well).
You are requested to step onto the treadmill once electrodes and bp cuff are hooked. At the initial stage, the speed is kept at a minimum. This is stage 1 of the test. It lasts around 3 minutes. But, slowly, the speed and grade (incline) is increased. It tilts so you feel like you’re going up a small hill and changes speed to make you walk faster when you reach stage 2. It lists further, and speeds increase further in stages 3, 4, 5, 6, and 7. You are connected to the computer throughout the test, where your ECG during exercise is continuously recorded.
Your doctor measures your blood pressure at the end of each stage. You can stop the test at any time if you need to, or your doctor may ask you to stop the test if he feels he got sufficient information. After slowing down for a few minutes, you’ll sit or lie down, and your heart and blood pressure will be again checked. ECG will be taken immediately after completion of the test, 3 minutes after completion of the test. Your entire data will be stored and analyzed by a computer or your doctor after completing the test.
WHAT TO EXPECT DURING TREADMILL TEST

What is monitored during the test?

  1. ·Your heart rate utilizing ECG
  2. ·Your blood pressure by a mean of BP cuff
  3. ·Your electrocardiogram (ECG or EKG)

 

Is there a risk with the stress treadmill test?

As it will be performed under controlled and monitored conditions, it carries much less risk than running 10 k on the street. There’s very little risk, provided your doctor followed the indication and contraindication of the test properly. Medical professionals are on hand in case anything unusual happens during the test.

Few complications that can occur during or after a treadmill test are

  1. heart attack or myocardial infarction
  2. Sudden cardiac arrest
  3. Ventricular tachycardia
  4. Ventricular fibrillation
  5. Accidental fall

How much time will it takes for the report to come?

It takes around 5 to 10 minutes for the tmt test report to share with you.

 

What will my doctor advise after the TMT test?

If the TMT test is negative for coronary artery disease, it is assurance that you may not need further tests. If the test turns out to be positive, you may need further tests depending on the type of problem identified. A coronary angiogram or CAG is one of a heart specialist’s most common follow-up tests.

 

Can my TMT be abnormal despite having no coronary artery disease?

Yes. You can have abnormal TMT test results despite having no coronary artery disease. This is called false positive TMT. It can happen in as high as 20% of cases. Some false-positive TMT causes are low hemoglobin (anemia), having left ventricular hypertrophy, taking certain medications like digoxin, and having certain resting ECG abnormalities like WPW syndrome.
Causes for false positive tmt test like anaemia, digoxin use, hypokalemia, hypertension, aortic stenosis
Causes of positive TMT without coronary artery disease

 

My TMT results are inconclusive. What does it mean?
A treadmill test is declared inconclusive if you don’t achieve your target heart rate. Your doctor can not rule out CAD in such cases. One cause for unable to achieve the target heart rate is taking some BP medication. You may have to repeat the test again or may need to undergo an alternative test.

 

When are you not supposed to do TMT?

You should not perform TMT if you have certain conditions. You will be at risk if you do it. Some examples are given below.
Following people should not perform tmt test or stress test due to risk of complications
1. recent heart attack
2. Ongoing chest pain or heart pain or angina pectoris
3. Pericarditis
4. Myocarditis
5. Severe uncontrolled blood pressure
6. Severe symptomatic aortic valve stenosis
7. Symptomatic hypertrophic obstructive cardiomyopathy
8. Heart failure
9. Ongoing Cardiac arrhythmia
WHO CAN NOT PERFORM TMT TEST LIKE RECENT MI, HEART FAILURE, AS, HOCM, PERICARDITIS, MYOCARDITIS

 

I can’t do TMT. What should I do to know if I have coronary artery disease?

 

Some people may not be in a position to do the treadmill. Some examples where patients cannot do TMT are those with severe
joint problems in their legs or fractures of the leg. In such a case, your cardiologist may advise you of alternative tests like stress 2d echo or angiogram.
WHO CAN NOT PERFORM TMT TEST -KNEE PAIN, LEG BONE FRACTURE, LEG PAIN

What are alternative tests for the treadmill test or stress ECG test?

Alternative tests for treadmills are needed when a patient should not perform a treadmill test because of their medical condition.

  1. Coronary angiogram or CAG
  2. CT Coronary angiogram

Alternative tests for treadmills are needed when a patient can not perform a treadmill test because of their physical inability.

  1. Stress echo test
  2. Nuclear stress test
  3. Coronary angiogram or CAG
  4. CT Coronary angiogram

 TMT versus 2d echo: which is better for heart diseases?

 

TMT test and 2d echo test are based on different principles. The purpose of the study is different. Hence, they are not comparable. 2d echo test is an imaging test of the heart that can take live pictures and videos of the beating heart. 2d echo test is for the anatomy of the heart like the size of the chambers, the thickness of the chambers, mass in the chambers, infection in the chambers, fluid around the chambers, etc. Doppler facility can be used to study the function of the heart valves like the mitral valve, aortic valve, pulmonary valve, and tricuspid valve. It is limited in chronic stable angina unless stress echo is used.

TMT test is, on the other way, a test that records the electrical activity of the heart on a graph paper before, during, and after exercise. It is mainly used to diagnose coronary artery diseases. It can not be used to diagnose valvular heart disease, congenital heart disease, pericardial heart disease, cardiomyopathies, and heart infections.

Can I have a normal angiogram with an abnormal TMT test?

The specificity of the tmt test is about 70 %. There is a 30% chance of having a normal angiogram or angiogram with mild abnormalities. This percentage can reach even up to 50 % if you have

  1. anemia
  2. concentric left ventricular hypertrophy
  3. age less than 40 years
  4. No risk factors for heart diseases like hypertension, diabetes, and smoking
  5. No symptoms of heart disease

Can I have an abnormal angiogram with a normal TMT test?

 

The sensitivity of the exercise stress test or stress ECG test is just 60 to 70%. Around 30 percent of patients with CAD on angiogram can have normal tmt reports.

Which stress test is better for the detection of coronary artery disease?

We have three main stress tests for diagnosing CAD. They are

  1. stress ECG test or tmt test
  2. stress echo test
  3. nuclear stress test

TMT test is the fastest test to perform among the three. Among them, the stress echo test or dobutamine stress test is the most accurate. However, the stress ECG or tmt test gained popularity because it is inexpensive, widely available, and needs less technical expertise.

I can not run fast. Is there any alternative?

For patients with low fitness levels, the tmt test got other protocols apart from standard protocol. In those protocols, the speed and tilt of the treadmill increase slowly.

What stage should I reach to complete the tmt test?

Reaching a particular stage is not a target in the treadmill test. Target during the tmt test is to get a target heart rate that depends on your age. Few people reach the target heart rate in the first stage itself. Few patients take stage 5 or 6 to complete the test. Most patients complete the tmt test in 2 to 4 stages.

What happens if I stop the test prematurely?

Your cardiologist gives the tmt report as inconclusive. You have to do the tmt test again after a few days or go for an alternative test.

When should I stop the tmt test?

 

You should stop the tmt test if you experience the following symptoms

  1. chest pain
  2. severe shortness of breath
  3. Giddiness
  4. Wheezing
  5. Leg cramps.

 

To stop the tmt test. you can either press the knob or inform your cardiologist

What is the cost of the tmt test in India?

TMT is an inexpensive test among all stress tests. It is called poor mans angiogram. The cost can range anywhere from 1000 Indian rupees to 3000 Indian rupees. Price varies based on the city and center of the tmt test. TMT test is included in health packages also. You can get it in the package at a cheaper rate. It does not cover under insurance.

Is it compulsory to undergo an angiogram after an abnormal tmt test?

It is better to undergo a coronary angiogram after a positive treadmill test. Many people avoid it for many reasons. Affordability is the most common cause. Do not panic. You will not get a heart attack immediately if you get a tmt test positive. Your doctor may prescribe medicines for CAD like blood thinners and drugs to reduce angina. You should use them without fail; If you get improvement with medications, an angiogram can be postponed. If symptoms do not improve, an angiogram should be done.

 

 

 

 

Contact the DM heart care clinic if you want to undergo a TMT test in Hyderabad, India.

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