ACSM-EP Clinical Exercise Testing — Questions and Answers
Question 1: Which finding during a graded exercise test is an ABSOLUTE indication to terminate the test?
- Drop in systolic BP of more than 10 mmHg despite an increase in work rate (Correct answer)
- Systolic BP of 190 mmHg at 6 METs
- Onset of mild leg fatigue at 85% of age-predicted maximal HR
- RPE of 17 on the 6-20 scale in an otherwise asymptomatic adult
Correct answer: Drop in systolic BP of more than 10 mmHg despite an increase in work rate
A fall in systolic BP of more than 10 mmHg as work rate increases signals inadequate cardiac output or ischemia and requires stopping the test.
ACSM lists absolute termination criteria that include SBP falling more than 10 mmHg with increasing work rate, moderate-to-severe angina, central nervous system symptoms, signs of poor perfusion, sustained ventricular tachycardia, and ST elevation above 1 mm in leads without Q waves. Normal rising SBP of 190 mmHg at 6 METs, mild leg fatigue, and a high RPE near end of a maximal test are expected and are not reasons to stop. A falling SBP is dangerous because normally SBP rises about 10 mmHg per MET.
Question 2: What are the speed and grade of Stage 1 of the standard Bruce treadmill protocol?
- 1.7 mph and 0% grade
- 2.5 mph and 12% grade
- 1.7 mph and 10% grade (Correct answer)
- 3.4 mph and 14% grade
Correct answer: 1.7 mph and 10% grade
Stage 1 of the Bruce protocol is 1.7 mph at 10% grade; speed and grade both increase every 3 minutes.
The Bruce protocol uses 3-minute stages: Stage 1 is 1.7 mph/10%, Stage 2 is 2.5 mph/12%, and Stage 3 is 3.4 mph/14%. The 0% grade option describes a modified Bruce first stage (1.7 mph at 0%), used for deconditioned or cardiac patients. The large increments between stages are why ramp or modified protocols are preferred in frail patients. Stage 1 corresponds to about 4.6 METs.
Question 3: A 70-year-old patient walks Stage 1 of the Bruce protocol (1.7 mph, 10% grade). Using the ACSM walking equation, what is the estimated VO2 in mL/kg/min?
- 8.1
- 12.4
- 21.9
- 16.3 (Correct answer)
Correct answer: 16.3
Speed is 1.7 x 26.8 = 45.6 m/min, so VO2 = 0.1(45.6) + 1.8(45.6)(0.10) + 3.5 = 16.3 mL/kg/min.
Convert speed: 1.7 mph x 26.8 = 45.56 m/min. Horizontal component = 0.1 x 45.56 = 4.56; vertical component = 1.8 x 45.56 x 0.10 = 8.20; resting component = 3.5. Total = 4.56 + 8.20 + 3.5 = 16.3 mL/kg/min, or about 4.7 METs. The answer 8.1 results from leaving out the grade term, and entering grade as 10 instead of 0.10 would give an absurdly high value.
Question 4: Which of the following is an absolute contraindication to performing a maximal graded exercise test?
- Resting blood pressure of 150/92 mmHg
- Known stable coronary artery disease taking a beta-blocker
- Acute myocardial infarction within the previous 2 days (Correct answer)
- Resting heart rate of 92 bpm
Correct answer: Acute myocardial infarction within the previous 2 days
A recent acute myocardial infarction (within 2 days) is an absolute contraindication because exercise stress could provoke serious ischemia or arrhythmia.
ACSM absolute contraindications to exercise testing include acute MI within 2 days, ongoing unstable angina, uncontrolled arrhythmia causing symptoms or hemodynamic compromise, active endocarditis, symptomatic severe aortic stenosis, decompensated heart failure, acute pulmonary embolism, acute myocarditis or pericarditis, and acute aortic dissection. Stable CAD on a beta-blocker is a common population for testing. A resting BP of 150/92 or a resting HR of 92 bpm do not preclude testing; relative contraindications start at resting SBP above 200 or DBP above 110 mmHg.
Question 5: At peak exercise a patient has a heart rate of 150 bpm and a systolic BP of 180 mmHg. What is the rate-pressure product?
- 330
- 2,700
- 27,000 (Correct answer)
- 270,000
Correct answer: 27,000
Rate-pressure product = HR x SBP = 150 x 180 = 27,000, an index of myocardial oxygen demand.
Rate-pressure product (double product) is HR multiplied by systolic BP: 150 x 180 = 27,000. It is a noninvasive estimate of myocardial oxygen demand. In patients with angina, the RPP at which symptoms or ST depression appear (the ischemic threshold) is used to set the safe exercise intensity. The other values result from addition (330) or misplacing the decimal.
Question 6: Which exercise ECG response is the standard criterion for a positive (ischemic) test?
- 0.5 mm of upsloping ST depression at the J point
- T-wave flattening at peak heart rate
- Isolated premature atrial contractions
- 1 mm or more of horizontal or downsloping ST depression, measured 60-80 ms after the J point (Correct answer)
Correct answer: 1 mm or more of horizontal or downsloping ST depression, measured 60-80 ms after the J point
Horizontal or downsloping ST depression of at least 1 mm (0.1 mV) measured 60-80 ms after the J point is the standard ischemic criterion.
The classic positive exercise ECG is at least 1 mm (0.1 mV) of horizontal or downsloping ST depression 60-80 ms after the J point, in three consecutive beats. Upsloping ST depression is common in healthy people at high heart rates and is usually considered a normal response. Isolated atrial ectopy and T-wave flattening are nonspecific. Resting ECG abnormalities such as LVH with repolarization changes, digoxin use, or LBBB reduce the accuracy of ST analysis.
