EKG certification Certification EKG Stress Testing & Holter Monitoring 1 — Questions and Answers
Question 1: During a treadmill stress test, which EKG change is considered a positive finding indicating myocardial ischemia?
- T-wave inversion of 1 mm in V1
- ST-segment depression of 2 mm that is horizontal or downsloping (Correct answer)
- Sinus tachycardia reaching 85% of the maximum predicted heart rate
- Occasional premature atrial contractions during peak exercise
Correct answer: ST-segment depression of 2 mm that is horizontal or downsloping
Horizontal or downsloping ST-segment depression of ≥1 mm (and especially ≥2 mm) during exercise is the classic EKG sign of exercise-induced myocardial ischemia, reflecting subendocardial oxygen demand that outpaces supply.
Question 2: A Holter monitor records continuously for 24–48 hours. What is the main clinical advantage of this extended recording period compared to a standard resting 12-lead EKG?
- It provides higher voltage sensitivity for detecting bundle branch blocks
- It captures intermittent arrhythmias that may not occur during a brief office visit (Correct answer)
- It measures beat-to-beat blood pressure changes alongside rhythm
- It eliminates baseline artifact caused by patient movement
Correct answer: It captures intermittent arrhythmias that may not occur during a brief office visit
Many arrhythmias — such as paroxysmal atrial fibrillation or nonsustained ventricular tachycardia — occur sporadically. A 24–48 hour Holter recording vastly increases the chance of capturing these transient events that a short resting EKG would miss.
Question 3: A patient's Holter monitor diary shows she noted 'chest tightness' at 10:42 AM. The technician reviews the corresponding strip and finds no arrhythmia but sees 1.5 mm ST depression. What does this correlation most likely represent?
- Artifact from electrode movement during activity
- Silent atrial flutter with variable block
- Symptomatic myocardial ischemia without an arrhythmia (Correct answer)
- Normal physiologic response to increased activity
Correct answer: Symptomatic myocardial ischemia without an arrhythmia
When a patient's symptom diary timestamp aligns with ST depression on the Holter recording, it strongly suggests that the chest tightness was caused by ischemia rather than an arrhythmia, even in the absence of rhythm disturbances.
Question 4: Which of the following best describes the Bruce Protocol used in exercise stress testing?
- A pharmacologic stress test using adenosine infused at a fixed rate
- A treadmill protocol with stages that increase speed and incline every 3 minutes (Correct answer)
- A bicycle ergometer test that increases pedaling resistance every 2 minutes
- A supine leg-press protocol designed for patients who cannot walk
Correct answer: A treadmill protocol with stages that increase speed and incline every 3 minutes
The Bruce Protocol is the most widely used treadmill exercise stress test, consisting of successive 3-minute stages where both belt speed and incline (grade) increase, progressively raising the patient's workload and heart rate.
Question 5: What is the most appropriate action when a patient's systolic blood pressure drops by more than 10 mmHg from baseline during an exercise stress test despite increasing workload?
- Increase the treadmill speed to push the patient to target heart rate
- Continue monitoring and document the finding for the interpreting physician
- Immediately terminate the stress test as this is an absolute indication to stop (Correct answer)
- Administer sublingual nitroglycerin and continue the test at the same stage
Correct answer: Immediately terminate the stress test as this is an absolute indication to stop
A drop in systolic blood pressure of ≥10 mmHg from baseline during increasing exercise — known as exertional hypotension — is an absolute indication to stop the stress test immediately, as it may signal severe left ventricular dysfunction or hemodynamic instability.
Question 6: After completing a 48-hour Holter recording, the patient returns the device. The technician notices the electrode in lead V5 position had poor skin contact for the last 12 hours, producing significant artifact. What is the most appropriate next step?
- Report the full 48 hours of data as valid since two leads remained clean
- Discard the entire recording and repeat the Holter immediately
- Note the artifact in the report, analyze the remaining clean lead data, and flag the affected time period for the interpreting physician (Correct answer)
- Re-apply the electrode and extend the recording by another 12 hours to compensate
Correct answer: Note the artifact in the report, analyze the remaining clean lead data, and flag the affected time period for the interpreting physician
Partial artifact does not invalidate an entire Holter study. The technician should document which channels and time periods were affected by poor contact, analyze the usable data from the remaining leads, and clearly communicate these limitations to the interpreting physician.
EKG certification Certification EKG Stress Testing & Holter Monitoring 1
During a treadmill stress test, which EKG change is considered a positive finding indicating myocardial ischemia?