Exercise Stress

Electrocardiography
Dr Bijilesh.U

Exercise is a common physiological stress used to elicit

cardiovascular abnormalities not present at rest and to
determine adequacy of cardiac function.
Exercise ecg - one of the most frequent noninvasive
modalities used to assess patients with suspected or
proven cardiovascular disease.

Estimate likelihood & extent of CAD , the prognosis ,

determine functional capacity & effects of therapy.

Exercise physiology
Exercise protocols
Electrocardiographic measurements
Nonelectrocardiographic observations
Exercise test indications
Specific Clinical Applications
Safety and risks of exercise testing
Termination of exercise

EXERCISE PHYSIOLOGY
Exercise - body's most common physiologic stress

places major demands on CVS

Exercise considered most practical test of cardiac
perfusion and function
Fundamentally involves the measurement of work
Common biologic measure of total body work is oxygen
uptake
Cardiac output can increase as much as six-fold

EXERCISE PHYSIOLOGY
Acceleration of HR by vagal withdrawal
Increase in alveolar ventilation
Increased venous return- sympathetic
venoconstriction.

Early phases - cardiac output increased by

augmentation in stroke volume and heart rate
Later phases by sympathetic-mediated increase
in HR

 During strenuous exertion, sympathetic discharge is

maximal and parasympathetic stimulation is
withdrawn
Vasoconstriction of most circulatory body systems except in exercising muscle , cerebral and
coronary circulations
Catecholamine release enhances ventricular
contractility

 As exercise progresses
skeletal muscle blood flow is increased
O2 extraction increases by as much as threefold
total calculated peripheral resistance decreases
systolic blood pressure, mean arterial pressure, and pulse pressure increase

Diastolic blood pressure does not change significantly.

V O2
Total body or ventilatory O2 uptake - amount of O2
extracted from air as the body performs work

Determinants of VO2
- cardiac output
- peripheral AV oxygen difference

Maximal AV difference is constant 15 to 17 mL/dL

Vo2 - estimate of maximal cardiac output.

V O2 can be estimated from treadmill speed and

grade

Vo2 = (MPH 2.68 ) [.1 + ( Grade 1.8) ] + 3.5

Vo2 can be converted to METS by dividing by

3.5.

M O2
Myocardial oxygen uptake is the amount of oxygen
consumed by the heart muscle

Determinants of M O2 Intramyocardial wall tension

- Contractility & HR

Mo2 - estimated by - HR & SBP (double product).

Exercise-induced angina often occurs at the same Mo2
Higher double product - better myocardial perfusion

Maximum heart rate

Maximum heart rate (MHR) : 220 age
Overestimate maximum heart rate in females
MHR = 206 0.88 (age in years)
MHR decreased in older persons

Age-predicted maximum heart rate is a useful

measurement for safety reasons

 Post exercise phase - hemodynamics return to

baseline within minutes
Vagal reactivation - important cardiac deceleration
mechanism after exercise
Accelerated in athletes but blunted in chronic
heart failure

Metabolic Equivalent
Refers to a unit of oxygen uptake in a sitting,
resting person
Common biologic measure of total body work is
the oxygen uptake
One MET is equated with the resting metabolic
rate (3.5 mL of O2/kg/min)
MET value achieved from an exercise test is a
multiple of the resting metabolic rate

 METS associated with activity = Measured Vo2 /

3.5 (both in mL O2/kg/min)

Measured directly (as oxygen uptake) or

estimated from the maximal workload achieved using standardized equations

Calculation of METs on the Treadmill

METs = Speed x [0.1 + (Grade x 1.8)] + 3.5
3.5
Calculated automatically by Device!

Clinically Significant Metabolic Equivalents for Maximum Exercise

1 MET

Resting

2 METs

Level walking at 2 mph

4 METs

Level walking at 4 mph

<5 METs

Poor prognosis; peak cost of basic activities of daily living

10 METs

13 METs

Prognosis with medical therapy as good as coronary artery

bypass surgery; unlikely to exhibit significant nuclear perfusion
defect
Excellent prognosis regardless of other exercise responses

18 METs

Elite endurance athletes

20 METs

World-class athletes

Exercise Test Modalities

Isometric, dynamic, and a combination of the two.

Isometric exercise - constant muscular contraction without
movement

Moderate increase in cardiac output and only a small increase

in vo2 - insufficient to generate an ischemic response.

Dynamic exercise - rhythmic muscular activity resulting in

movement

Exercise Protocols
Dynamic protocols are most frequently used to
assess cardiovascular reserve

Should include a low-intensity warm-up and a

recovery or cool-down period

Optimal for diagnostic and prognostic purposes

- Approximately 8 to 12 minutes of continuous progressive
exercise

- myocardial oxygen demand elevated to patient's maximum

Arm Ergometry
Bicycle Ergometry
Treadmill Protocol
Walk Test

Arm Ergometry
Involve arm cranking at incremental workloads of
10 to 20 watts for 2- or 3-minute stages
HR & BP responses to a
given workload > leg exercise
Peak vo2 and peak HR
- 70% of leg testing

Bicycle Ergometry
Involve incremental workloads
starting at 25 50 watts
Lower maximal VO2 than the treadmill

Treadmill Protocol s

Bruce
Modified Bruce
Naughton and Weber
ACIP (Asymptomatic cardiac ischemia pilot trial)
Modified ACIP

Tread mill protocol

Bruce multistage maximal treadmill protocol

3 minutes periods to achieve steady state

before workload is increased
Limitation - relatively large increase in
vo2 between stages
Modified Bruce protocol - Older individuals or
those whose exercise capacity is limited
Modified by two 3 min warm up stages at
1.7mph % 0 % grade and 1.7mph % 5%grade.

 Naughton and Weber protocols use 1-2min

stages with 1-MET increments between
stages
Asymptomatic cardiac ischemia pilot trial
and modified ACIP protocols use 2min
stages with 1.5mets increments between
stages - after two 1min warm up
Functional capacity overestimated by 20% -if
handrail support is permitted

Walk Test
A 6-minute walk test or a long-distance corridor walk
Provide an estimate of functional capacity in patients who
cannot perform bicycle or treadmill exercise

Older patients ,heart failure, claudication, or orthopedic

limitations

Walk down a 100-foot corridor at their own pace - cover as

much ground as possible in 6 minutes

Total distance walked is determined and the symptoms

experienced by the patient are recorded.

Cardiopulmonary Exercise Testing

Involves measurements of respiratory oxygen
uptake (vo2) , carbon dioxide production ( vco2 )
and ventilatory parameters during a symptomlimited exercise test

Patient wears a nose clip and breathes through a

nonrebreathing valve

Technique
No caffeinated beverages or smoke 3hr before
Wear comfortable shoes and clothes.
Unusual physical exertion should be avoided
Brief history & physical examination performed
Explain risks and benefits
Informed consent is taken

12 lead ECG is recorded with electrodes at the

distal extremities
Torso ECG is obtained in supine & standing position
If false +ve test is suspected, hyperventilation
should be performed

Room temp should be 18 24 C & humidity < 60%

Walking should be demonstrated to the patient
HR, BP & ECG recorded at end of each stage.
Resuscitator cart, defibrillator and appropriate
cardioactive drugs should be available

Optimal patient position

in the recovery phase

? supine

Sitting position, less space is required and patients

are more comfortable

Supine position increases end-diastolic volume

and has the potential to augment ST-segment
changes

 Electrocardiographic
Measurements

Lead system

Mason-Likar modification

Modification of the standard 12-lead ECG

Extremity electrodes moved to torso to reduce motion
artefact
Results in
right axis shift
increased voltage in inferior leads
loss of inferior Q waves
new Q waves in lead aVL

Types of ST-Segment Displacement

J point, or junctional, depression - normal finding in exercise
In myocardial ischemia, ST segment becomes horizontal,
With progressive exercise depth of ST segment may increase
In immediate post recovery phase ST segment displacement
may persist with down sloping ST segments and T wave
inversion - returning to baseline after 5-10 min

In 10% , ischemic response may appear in recovery phase

Measurement of ST-Segment
Displacement
PQ junction is chosen as isoelectric point
TP segment is true isoelectric point but impractical choice
Abnormal ST depression
0.1mv (1mm) or > ST depression from PQ junction
with a flat ST segment slope ( <0.7-1mv /sec)
80 msec after J point (ST 80)
in 3 consecutive beats with a stable base line

When ST 80 measurement difficult at rapid heart

rates > 130/mt measure at ST 60
When ST is depressed at rest- additional 0.1mv or
more during exercise is considered abnormal

1.PQ JUNCTION
2. J POINT
3.ST 80

Upsloping ST segment

Rapid upsloping ST segment (more than 1 mV/sec) depressed

less than 1.5 mm after the J point - normal

Slow upsloping ST segment

at peak exercise

In patients with high CAD

prevalence, slow up sloping ST
,depressed > 1.5mm ST 80 is
considered abnormal

Horizontal ST-segment
depression

 ST segment elevation

0.1mv ( 1mm) or greater of ST elevation, at ST

60 in 3 consecutive beats - abnormal response.

More frequently with AWMI - early after event decreases in frequency by 6 weeks

ST elevation is relatively specific for territory of

ischemia

 In leads with abnormal Q waves - not a marker

of more extensive CAD and rarely indicates
ischemia.

When it occurs in non q wave lead in a patient

without previous MI - transmural ischemia

In a patient who has regenerated embryonic R

waves after AMI - significance similar

Eight typical exercise ecg

patterns at rest and at
peak exertion

T Wave Changes

Transient conversion of a negative T wave

at rest to positive T wave in exercise
pseudonormalisation
Nonspecific finding in
patients without prior MI
Does not enhance
diagnostic or prognostic
content of test

Nonelectrocardiographic Observations

Blood pressure
Maximal Work Capacity
Heart rate response
Heart Rate Recovery
Chest discomfort
Rate-Pressure Product

Blood pressure
Normal exercise response - increase SBP progressively
with increasing workloads.
Range from 160 to 200 - higher range in older patients
with less compliant vessels
Abnormal
Failure to increase SBP > 120 mm Hg
Sustained decrease greater than 10 mm Hg
Fall in SBP below resting values
Diastolic BP doesnt change significantly

 Conditions other than myocardial ischemia associated with

abnormal BP response
Cardiomyopathy
Cardiac arrhythmias
LVOT obstruction
Antihypertensive drugs
Hypovolemia

An exaggerated BP increase with exercise - increased risk

of future hypertension

Maximal Work Capacity

Important prognostic measurement of exercise test
Limited exercise capacity - increased risk of fatal
and nonfatal cardiovascular events

In one series - adjusted risk of death reduced by

13% for each 1-MET increase in exercise capacity
Estimates of peak functional capacity for age and
gender - known for most protocols

Heart rate response

Sinus rate increases progressively with exercise.
Inappropriate increase in heart rate at low work
loads Atrial fibrillation
Physically deconditioned
Hypovolumic
Anemia
Marginal left ventricular function

Chronotropic incompetence
Decreased heart rate sensitivity to the normal
increase in sympathetic tone during exercise
Inability to increase heart rate to at least 85%of
age predicted maximum.
Associated with adverse prognosis

Heart Rate Recovery(HRR)

Abnormal HRR refers to a relatively slow
deceleration of heart rate following exercise
cessation

Reflects decreased vagal tone - associated with

increased mortality
Value of 12 beats/min or less - abnormal

Chest discomfort
Development of typical angina during exercise can
be a useful diagnostic finding
Chest discomfort usually occurs after the onset of
ST segment abnormality
Exercise-induced angina and a normal ECG requires
assessment using a myocardial imaging

Rate-Pressure Product
Heart rate SBP product - indirect measure of myocardial
oxygen demand
Increases progressively with exercise

Normal individuals develop a peak rate pressure product

of 20 to 35 mm Hg beats/min 103
With significant CAD rate-pressure product< 25

Cardio active drug significantly influences this

Diagnostic Use of Exercise Testing

In patients with CAD - Sensitivity 68% &
specificity - 77%
In SVD -- sensitivity is 25-71%
In multivessel CAD-- sensitivity is 81%, specificity
is 66%
Left main or 3vd -- sensitivity is 86%, specificity is
53%

INDICATION FOR EXERCICE

ECG FOR DIAGNOSIS

Guidelines 2002

.
ACC/AHA

Patients with intermediate pretest probability of CAD based on age, gender, and
I symptoms, including those with complete RBBB or <1 mm of ST-segment
depression at rest
IIa
Patients with suspected vasospastic angina

iii 1.Patients with baseline electrocardiographic abnormalities:

a.Preexcitation (Wolff-Parkinson-White) syndrome
b.Electronically paced ventricular rhythm
c.>1 mm of ST-segment depression at rest
d.Complete left bundle branch block

2.Patients established diagnosis of CAD because of prior MI or CAG; however,

testing can assess functional capacity and prognosis

Noncoronary Causes of ST-Segment Depression

Anaemia
Cardiomyopathy
Digitalis use
Hyperventilation
Hypokalemia
IVCD

LVH
MVP
Severe AS
Severe HTN
Severe hypoxia

Brody effect
As exercise progress R wave amplitude increase
normally till HR around 130 , after that amplitude
decrease
Indicates normal or minimal LV dysfunction and is
associated with normal CAG
Increase R wave amplitude in post exercise period
indicates ischemia and LV dysfunction
May be related to an increase in LV end-diastolic
volume due to exercise-induced LV dysfunction.

Bayes Theorem
Incorporates pretest risk of disease & sensitivity
and specificity of test to calculate post-test
probability of CAD

Clinical information and exercise test results are

used to make final estimate about probability of
CAD

Diagnostic power maximal when pretest

probability of CAD is intermediate (30% to 70%)

PRETEST PROBABILITY
AGE (yr)

GENDER

30-39

Men

TYPICAL
ATYPICAL NONANGINAL ASYMPTOMATIC
CHEST PAIN
ANGINA
ANGINA
Intermediate Intermediate Low
Very low

Women

Intermediate Very low

Men

High

Women

Intermediate Low

Men

High

Women

Intermediate Intermediate Low

Men

High

Intermediate Intermediate Low

Women

High

Intermediate Intermediate Low

40-49
50-59
60-69

Very low

Very low

Intermediate Intermediate Low

Very low

Very low

Intermediate Intermediate Low

Very low

EXERCISE PARAMETERS ASSOCIATED WITH

MULTIVESSEL CAD

Duration of symptom-limiting exercise < 5 METs

Abnormal BP response
Angina pectoris at low exercise workloads
ST-depression 2 mm - starting at <5 METs
down sloping ST

- involving 5 leads,
- 5 min into recovery

Exercise-induced ST- elevation (aVR excluded)

Reproducible sustained or symptomatic VT

. Exercise Testing in Determining Prognosis

Asymptomatic population

Prevalence of abnormal TMT in asymptomatic

middle aged men - 5-12%.
Risk of developing a cardiac event- approximately
nine times when test abnormal
Future risk of cardiac events is greatest if test
strongly positive or with multiple risk factors
Appropriate asymptomatic subjects for test estimated annual risk > 1 or 2% per year

Symptomatic patients

Exercise ECG should be routinely performed in

patients with chronic CAD before CAG

Patients with good effort tolerance (>10

METS) have excellent prognosis regardless of
anatomical extent of CAD.

Provides an estimate of functional significance

of CAG documented coronary stenoses

RISK ASSESSMENT AND PROGNOSIS in PATIENTS

WITH SYMPTOMS OR PRIOR HISTORY OF CAD
CLASS

INDICATION

ACC/AHAGuidelines 2002

1.Patients undergoing initial evaluation

Exceptions
a.Preexcitation syndrome
b.Electronically paced ventricular rhythm
c.>1 mm of ST-segment depression at rest
d.Complete left bundle branch block

2.Patients after a significant change in cardiac symptoms

3. Low-risk unstable angina patients 8 to 12 hr after presentation who have
been free of active ischemic or heart failure symptoms
4. Intermediate-risk unstable angina patients 2 to 3 days after presentation
who have been free of active ischemic or heart failure symptoms

III

Patients with severe comorbidity likely to limit life expectancy or prevent

revascularization

Duke tread mill score

Developed by Mark and co-workers
Provide survival estimates based on results from
exercise test
Provides accurate prognostic & diagnostic
information

Adds independent prognostic information to that

provided by clinical data & coronary anatomy

Less effective in estimating risk in subjects > 75

Duke tread mill score

Exercise time - (5 ST deviation) - (4 treadmill
angina index)

Angina index
0-if no angina
1-if typical angina occurs during exercise
2-if angina was the reason pt stopped exercise

Duke tread mill score - RISK

Score

Risk

5 yr survival %

CAD

>5

Low risk

97

Nil / SVD

- 10 to +4

Moderate risk

91

< -11

High risk

72

TVD/LMCA

SPECIFIC CLINICAL
APPLICATIONS

After MI
Exercise testing is useful to determine
Risk stratification
Functional capacity for activity prescription
Assessment of adequacy of medical therapy
Incidence cardiac events with test after MI is low
Slightly greater for symptom-limited protocols

Risk Stratification Before Discharge after MI : Class I Recommendations for

exercise test
ACC/AHA Guidelines
For low-risk patients who have been free of ischemia at rest or with low-level activity
and of HF for a minimum of 12 to 24 hr

For patients at intermediate risk who have been free of ischemia at rest or with lowlevel activity and of HF for a minimum of 12 to 24 hr

SUBMAXIMAL TEST
Performed within 3 to 4 days in uncomplicated
patients
Low-level exercise test
achievement of 5 to 6 METs
70% to 80% of age-predicted maximum HR

A 3- to 6-week test - for clearing patients to return to

work in occupations with higher MET expenditure

Preoperative Risk Stratification before

Noncardiac Surgery
Provides an objective measurement of functional
capacity
Identify likelihood of perioperative myocardial
ischemia
Perioperative cardiac events - significantly
increased with abnormal test at low workloads

Consider CAG with revascularization before high

risk surgery in such patients

Cardiac arrhythmias & conduction

disturbances
VPCs are common during exercise test & increase with
age.
Occur in 0-5% of asymptomatic subjects - no increased
risk of cardiac death
Suppression of VPCs during exercise is nonspecific.
In patients with recent MI, presence of repetitive VPC is
associated with increased risk of cardiac events.

Ventricular arrhythmia
Exercise testing provokes VPCs in most patients
with h/o sustained ventricular tachyarrhythmia.
VPC in early post exercise phase is associated
with worse long term prognosis

RBBB morphology was associated with increased

2-year mortality rate than LBBB

Supraventricular arrhythmias

Premature beats are seen in 4-10%of normal persons &

40%of patients with heart disease.
Sustained arrhythmia occur in 1-2%.

Atrial fibrillation
Rapid ventricular response is seen in initial stages of
exercise
Effect of digitalis & beta-blockers on attenuating this
can be assessed by exercise testing

Sinus node dysfunction

Lower heart rate response may be seen at submaximal
and maximal workloads

Atrioventricular block
In congenital AV block, exercise induced heart rate is low
In acquired diseases, exercise can elicit advanced AV
block

LBBB
Exercise-induced ST
depression is seen in
patients with LBBB &
cant be used as diagnostic indicator.
New development of LBBB - 0.4%
Relative risk of death or other major cardiac events
with new exercise-induced LBBB - increased three fold.

RBBB

Indicators CAD in RBBB

1.new onset ST depression in V5 & V6, or L II or avF
2.reduced exercise capacity
3.inability to adequately increase systolic BP

Exercise induced ST depression leads V1-V4

common with RBBB -non-diagnostic

Preexcitation syndrome

WPW syndrome invalidates use of ST segment

analysis as a diagnostic method.
False +ve ischemic changes are seen
Exercise may normalise QRS complex with
disappearance of delta waves in 20-50%
more frequent with left sided than right sided
pathway

Exercise Testing in Heart Rhythm Disorders

Class I
Adults with ventricular arrhythmias with
intermediate or greater probability of CAD

In patients with known or suspected exerciseinduced ventricular arrhythmias

Class IIa
For evaluating response to medical or ablation
therapy in exercise-induced ventricular arrhythmias

Cardiac pacemakers

To assess performance following CRT in patients

with heart failure and ventricular conduction delay
Ideal pacemaker should normalize the heart rate
response to exercise

ICD
When testing patients with ICD program detection
interval of the device should be known
If ICD is implanted for VF or fast VT rate will
normally exceed that attainable during sinus
tachycardia
Test terminated as the HR approaches 10 beats/min below
the detection interval

With slower detection rates, ICD reprogrammed to

a faster rate - avoid accidental discharge during exercise testing
Can be temporarily deactivated by a magnet.

Influence of drugs and other factors

Smoking reduces ischemic response threshold.

Hypokalemia & digoxin - exertional ST depression

Nitrates, beta blockers, CCB

Prolong the time to onset of ST depression
Increase exercise tolerance

Women

Diagnostic accuracy is less in women due to lower

prevalence of CAD.

False +ve results are common during menses or

preovulation, & in postmenopausal women on
estrogen therapy

Elderly patients
Started at slowest speed with 0% grade and adjusted
according patients ability
Frequency of abnormal results is more and risk of
cardiac events also more
Subjects > 75 years Duke treadmill scoring system is
less useful
Diabetes mellitus
In patients with autonomic dysfunction and sensory
neuropathy anginal threshold is increased and
abnormal HR and BP response is common

Valvular heart disease

Provide information on timing of operative
intervention and estimate degree of incapacitation
Aortic stenosis
With moderate to severe AS exercise testing can
be safely performed with appropriate protocols

Hypotension during test in asymptomatic patients

with AS is sufficient to consider for valve
replacement

 In the young adult with AS with - mean gradient >

30 mm Hg or a peak velocity > 3.5 m/sec - before
athletic participation - Class IIa

Increase in mean gradient by 18 , ecg changes,

blunted BP response predict cardiac events

Symptomatic patients with AS - Class III

MS
In patients with MS,
Excessive HR response to low levels of
exercise
Exercise-induced hypotension & chest pain
- Favor earlier valve repair

HOCM

To determine exercise capability, symptoms, ECG

changes or arrhythmias, or increase in LVOT
gradient - Class IIa

Inability to increase BP by 20 mm Hg during exercise

is associated with adverse prognosis

High resting gradients ,NYHA class III or IV

symptoms, h/o ventricular arrhythmias - not tested.

Coronary bypass grafting

ST depression may persist when

revascularisation is incomplete
Also in 5% of persons with complete
revascularisation
After CABG Stress imaging better than exercise
ECG
Late abnormal exercise response may indicate
graft occlusion or stenosis

Percutaneous coronary intervention

Low detection rate of restenosis in the early

phase (< 1month)
Early abnormal result
Suboptimal result
Impaired coronary vascular reserve in a successfully
dilated vessel
Incomplete revascularization

6-12 month post procedure test detect

restenosis
Initial normal test to an abnormal result in the
initial 6 months usually associated with restenosis

Cardiac transplantation
Maximal O2 uptake & work capacity
improved as compared with pre-operative findings.
Abnormalities that may be seen are
1.resting tachycardia
2.slow HR response during mild to moderate exercise
3.more prolonged time for HR to return to baseline during
recovery

Safety and risks of TMT

Mortality is < 0.01%, morbidity is <0.05%

Risk of major complication is twice when
symptom limited protocol is used
Risk is greater when test is performed soon after
an acute event.

Early postinfarction phase risk of fatal

complication during symptom-limited testing 0.03%.

Absolute Contraindications to
Exercise Testing

ACC/AHA Guidelines:

Recent significant change in the rest electrocardiogram

Acute myocardial infarction (within 2 days)
High-risk unstable angina
Uncontrolled cardiac arrhythmias causing symptoms or hemodynamic compromise
Symptomatic severe aortic stenosis
Uncontrolled symptomatic heart failure
Acute pulmonary embolus or pulmonary infarction
Acute myocarditis or pericarditis
Acute aortic dissection

Relative Contraindications to
Exercise Testing

ACC/AHA Guidelines:

Left main coronary stenosis

Severe arterial hypertension (systolic blood pressure > 200 mm Hg and/or diastolic blood
pressure > 110 mm Hg)
Tachyarrhythmias or bradyarrhythmias
Hypertrophic cardiomyopathy and other forms of outflow tract obstruction
High-degree atrioventricular block
Neuromuscular, musculoskeletal, or rheumatoid disorders
Ventricular aneurysm

TERMINATION OF EXERCISE
Absolute indications
Moderate to severe angina
Increasing nervous system symptoms (eg, ataxia, dizziness, or near-syncope)
Technical difficulties in monitoring ECG or systolic blood pressure
Subject's desire to stop
Sustained ventricular tachycardia
ST-segment elevation (1.0 mm) in leads without diagnostic Q waves (other than V 1 or aVR)
Relative indications
Drop in systolic blood pressure of 10 mm Hg from baseline blood pressure
ST-segment depression (> 3 mm of horizontal or downsloping)
Other arrhythmias - multifocal PVCs, triplets of PVCs, SVT, heart block, or bradyarrhythmias
Fatigue, shortness of breath, wheezing, leg cramps, or claudication
Development of bundle branch block or IVCD indistinguishable from VT
Hypertensive response

( SBP > 250 mm Hg and/or a diastolic BP > 115 mm Hg)

THANK YOU