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Microsoft project 2016 set baseline free download. Untitled — Windows 10 guest account does not work…
The baseline may also represent a contractual obligation for the project. Baseline information that consistently differs from current data may indicate that your original plan is no longer accurate, possibly because the scope needs review or because the nature of the project has changed. If project stakeholders agree that the difference warrants it, you can modify or rework the baseline at any time during the project. You may find that setting multiple baselines is especially useful for long projects or for projects in which the baseline is rendered irrelevant by significant changes to scheduled tasks or costs.
An interim plan, on the other hand, is a set of current project data that you save after the project begins and that you can compare against the baseline to assess project progress. An interim plan saves only two kinds of information:. You can set up to 10 interim plans for a project.
If you need to keep records of extensive project data during the planning phase, it is a good idea to set multiple baselines instead of using interim plans. For example, you may want to set a baseline at each major planning milestone. Then, if you need to save only task start dates and finish dates after the project begins, you can set multiple interim plans. For example, you may want to set an interim plan on a monthly or quarterly basis. If you are setting a baseline for specific tasks, select the tasks, including subtasks and summary tasks, that you want to include in your baseline plan.
If you are setting a baseline for the entire project, skip this step. To select nonadjacent tasks, hold down CTRL, and then click each task that you want. You can select up to 10 tasks at one time. Click the Project tab. To set the baseline for only the tasks that you selected in the Gantt Chart view, click Selected tasks. To all summary tasks Select this check box if you want updated baseline data for the selected tasks to be rolled up to the corresponding summary tasks.
Otherwise, baseline data for summary tasks may not accurately reflect subtask baseline data. From subtasks into selected summary task s Select this check box if you want baseline data for selected summary tasks to be updated to reflect both deletions of subtasks and added tasks for which you previously saved baseline values.
Note: If you selected both subtasks and their summary tasks, select both check boxes. In the Copy box, click the start and finish or baseline values that you want to save.
The current start and finish, and baseline values are not numbered. In the Into box, click the name of the interim plan into which you want to copy the values. Interim plans are stored in the start and finish fields. Note: If you select one baseline in the Copy box and another baseline in the Into box, you will save a baseline, rather than an interim plan.
All baseline data will be copied. If you select a baseline in the Copy box, and a start and finish interim plan in the Into box, only the start date and finish date from the baseline will be copied to the interim plan. Click Entire project or Selected tasks to save the portion of the schedule that you want. If changes to your initial plan occur after you set a baseline or an interim plan, you can update the saved data.
Tip: If changes to your plan occur while your project is underway, you may find it helpful to save a second set of baseline or interim data, rather than updating your existing saved data. In the Task Name field, select the tasks, including subtasks and summary tasks, that have baseline or interim data that you want to update.
If you are updating baseline or interim data for the entire project, skip this step. If you are updating a baseline, click Set baseline , and then select the baseline that you want to update. If you are updating an interim plan, click Set interim plan.
In the Copy list, select the data that you are copying. In the Into list, click the interim plan that you want to update. To update the baseline or interim data for the entire project, click Entire Project. To update the baseline or interim data for only the tasks that you selected in the Gantt Chart view, click Selected tasks.
Under Roll up baselines , select how you want the updated baseline data to be rolled up:. From subtasks into selected summary task s Select this check box if you want baseline data for selected summary tasks to be updated to reflect both the deletions of subtasks and added tasks for which you previously saved baseline values.
After you set baseline or interim data, you can compare it with the scheduled and actual data to see how your project is tracking against your initial goals. After you set a baseline for the entire project, you can view the baseline data side-by-side with the current planned data, the actual data, and the variance.
On the Project tab, in the Properties group, click Project Information. To view variance information in a sheet view, click the View tab.
In the Data group, click Tables , and then Variance. To view variance information graphically, click the View tab. The Variance table shows start and finish dates for both scheduled information and baseline information, making it possible to evaluate your prediction of how the project would progress baseline by comparing that prediction with how the project is in fact progressing actual. If the variance in your project doesn’t show the values that you expect, there are several possible explanations:.
You might not have set a baseline. The variance is the baseline value compared with the actual value for a field. If there is no baseline, Project calculates this difference by using a 0 value for the baseline fields, resulting in variances that are as large as the scheduled field itself. You might have set multiple baselines, but Project uses only the initial baseline values that is, the values for the Baseline field, and not the values for Baseline1 through Baseline10 when calculating variance.
In this case, you might see information in variance fields, but the information might seem to be outdated and possibly too large. You might have added new tasks to a project but not added them to the baseline plan.
In this case, you might see variances that are equal to the scheduled values. You might not have updated actual values for those tasks that are completed or in progress. In this case, variances might be equal to the scheduled values, or otherwise larger than you expect. See text for further details on these leads. LA indicates left arm; LL, left leg; RA, right arm; and RL, right leg. Reproduced with permission from Fletcher et al.
used for clinical exercise test purposes. Details are beyond the of the PR segment, as occur when the reliable point is actu- scope of the present statement. ally on the descending limb of a P wave with a shortened PR interval during exercise, will confound the baseline used for Relative Sensitivity of Leads.
In general, more electrodes lead measurement of ST-segment shift and will result in incorrect to greater test sensitivity. As is true with automated algorithms for emphasized the general individual sensitivity of CM5 and the interpretation of resting ECGs, the computer should be an — aVR, both of which are in the general vector direction adjunct to, not a substitute for, human interpretation.
of the standard lateral precordial leads. Unlike ST elevation during acute MI, ST depression during demand-induced Exercise Equipment subendocardial ischemia during exercise does not localize the Details on exercise testing equipment and exercise testing lab- area of myocardium that is involved. Treadmill testing is resentative complexes for each lead.
Having both exer- to reduce random noise and to reduce beat-to-beat variability cise modes available is advantageous, given that some individ- caused by respiration and movement. Automated measure- uals have difficulty with treadmill ambulation for reasons that ment of ST-segment shifts based on individual representative include imbalance and orthopedic limitations, whereas other complexes has the potential to increase precision of the mag- individuals develop earlier exercise fatigue using the bicycle.
nitude of repolarization deviation,41 but this is true only when reliable points determining baseline, QRS onset, and QRS Treadmill offset for determining the J-point and ST-segment levels at The treadmill should have front rails, side rails, or both to aid any specified time after the J point are selected accurately in subject stability. However, subjects should be encouraged not by the computer algorithm. At faster HRs, there invariably is to tightly grasp the front or side rails because this action sup- merging of the end of the T wave with the P wave in patients ports body weight and thus reduces the workload at any given in sinus rhythm, making the standard T—P baseline unusable stage, leading to the potential for a significant overestimation of during exercise for most patients.
For this reason, the end of oxygen uptake. It can be helpful if subjects remove their hands the PR segment is used as a compromise isoelectric baseline from the rails, close their fists, and place one finger of each hand by automated algorithms. Completion of Stage 4 of the Bruce protocol 4.
Functional class refers to New York Heart Association class. walking on the treadmill. The treadmill should have variable period again at low workload. Several different treadmill pro- speed and grade capability and must be accurately calibrated. tocols are in general use and are seen in detail in Figure 3. Standard tables can be used to convert treadmill standard Bruce protocol include its use in many published grade and speed into estimated MET levels.
Some Electrically braked cycles vary the resistance to the pedaling subjects, especially those who are elderly, obese, or have gait speed rate-independent ergometers , thereby permitting bet- difficulties, are forced to stop exercising prematurely because ter power output control, because it is common for subjects of musculoskeletal discomfort or an inability to tolerate the who are fatigued or unable to cooperate to decrease their ped- high workload increments.
Initial zero or one-half stages 1. Cycle ergometers are promised exercise capacities. Because exercise on a workload changes between stages of the standard Bruce proto- cycle ergometer is not weight bearing, kiloponds or watts can col by reducing stage duration to 2 minutes while interpolating be converted to oxygen uptake in milliliters per minute.
METs additional half stages. are useful choices for elderly, deconditioned patients. A com- The cycle ergometer is usually less expensive, occupies less plete set of protocols can be found in the American College of space, and is less noisy than a treadmill. Upper body motion is Sports Medicine guide for exercise prescription and testing. Care must be taken to pre- speed, which is increased gradually until the patient has a good vent isometric or resistance exercise of the arms while grasping stride.
In this type of protocol, treadmill testing in those not accustomed to cycling. Exercise protocols should be individual- Exercise Protocols ized according to the type of subject being tested.
A 9-minute Protocols for clinical exercise testing generally include an ini- targeted ramp protocol that increases in small steps has many tial warm-up period at low workload , followed by progressive advantages, including more accurate estimates of MET level. If arm available during all exercise tests. For additional details about ergometry is substituted for cycle ergometry, a similar protocol supervision and interpretation of exercise tests, reference is may be used, except that initial power output and incremental made to the document on clinical competence in stress testing increases are lower.
Two-minute stages are most popular with from the ACCF, AHA, and American College of Physicians. The undergo pharmacological stress testing with imaging. physician or senior medical healthcare professional conduct- The 6-minute walk test is a functional test that can be used ing the test must be trained in advanced cardiopulmonary resus- to evaluate submaximal exercise capacity. This assessment citation. A defibrillator and appropriate medications also should has frequently been used in patients with chronic disease, be immediately available.
Surveys suggest that 0 to 6 deaths or such as heart failure, chronic obstructive pulmonary disease, cardiac arrests per 10 tests and 2 to 10 MIs per 10 tests and peripheral arterial occlusive disease. tested population. Detailed guidelines describing the administration of rare in clinically normal subjects. Table 1 lists several classes of the 6-minute walk test are available. As an alternative to using HR alone to clinically thus limiting its diagnostic value for ischemia or arrhythmia.
determine intensity of exercise, the 6-to Borg scale of per- Exercise Test Supervision ceived exertion62 is useful Table 2. Special verbal and writ- Exercise testing should be performed under the supervision ten explanations about the rating of perceived exertion RPE of a qualified health professional who is appropriately trained are available for subjects. Although there is some variation to administer exercise tests. Thus, the Borg scale can for exercise testing.
Absolute and relative contraindications to exercise testing performed maximal exercise, and values higher than 15 to 16 are subsequently discussed. In any procedure with a risk of suggest that the ventilatory threshold has been exceeded. complications, the test administrator should be certain that the Angina Characteristics and Scale subject understands the risks and benefits of the test, and writ- Levels of anginal discomfort in those with known or suspected ten informed consent should be obtained.
Good communica- CAD are also excellent subjective end points. Whether typi- tion with the patient about testing is mandatory. cal angina occurs with exercise or is the reason for termina- The physician should be responsible for ensuring that the tion of the test is an important observation in evaluation of the exercise laboratory is properly equipped and that exercise test- exercise test, and it is an important factor in calculation of the ing personnel are appropriately trained.
Exercise testing should Duke Treadmill Score. Complications Secondary to Exercise Testing The degree of subject supervision needed during a test can be Cardiac Bradyarrhythmias determined by the clinical status of the subject being tested. Recent recommendations permit additional Miscellaneous Severe fatigue malaise , sometimes persisting for flexibility with regard to supervision personnel.
Even when no abnormalities occur Reprinted from Borg with permission of the at peak exercise, postexercise attention is necessary because publisher. during the recovery period. Mechanical dysfunction and elec- trophysiological abnormalities in the ischemic ventricle after Indications for Termination of Exercise Testing exercise can persist for minutes to hours.
Monitoring of blood The decision to terminate exercise is an important function of pressure should continue during recovery because abnormal test supervision that is generally determined by the purpose responses could occur, particularly hypotension, and arrhyth- of testing in individual subjects. Symptom-limited testing is mias also might be present in the recovery period. desirable for general evaluation, but this recommendation could be modified in several situations.
Scales for each of these symptoms are provided in the present statement and other documents. arterial hypertension. Currently, CPX is test. Signs of poor perfusion, such as cyanosis or pallor, and common in clinical practice for patients with heart failure increasing nervous system symptoms, such as ataxia, dizzi- who are being considered for transplantation and for those ness, and vertigo, serve as absolute test termination criteria.
P-wave duration is generally those at increased risk for CVD, and virtually all patient popu- unchanged or is minimally longer.
uted to atrial repolarization the Ta wave and can cause appar- Maximal work capacity achieved during an exercise test, which ent ST-segment depression when the negative Ta wave persists frequently is used to estimate aerobic capacity, is influenced by into the early ventricular repolarization period. Age- and sex-predicted peak MET levels workloads.
To provide the most into a QRS score for diagnostic purposes. Moreover, The J junction, also known as the J point representing the a conservative exercise test protocol, with smaller workload time—voltage coordinate of the end of the QRS complex and adjustments from one stage to the next, is preferable in patients the beginning of the ST segment can be depressed at maxi- with a diminished functional capacity.
Upsloping ST depression at peak exercise might performed to assess therapeutic efficacy or disease progression. The magnitude quent sections greatly improves the reliability of key variables of ST depression should be measured 60 to 80 ms after the J obtained from the exercise test.
or mouthpiece. When combined with traditional testing pro- T Wave cedures, this assessment is commonly referred to as cardio- A general decrease in T-wave amplitude is observed during pulmonary exercise testing CPX. Commercially available ventilatory expired gas systems are also commonly capable U Wave of performing pulmonary function tests.
Equivocal test tials shorten as HR increases with exercise, and the resulting responses are a major reason for the reduced sensitivity of the QT interval of the ECG is further affected by neurohumoral exercise ECG. However, if upsloping ST depression were con- changes that accompany effort. Other recognized causes of false negative some subjects more commonly women there can be a para- test responses include inadequate effort and anatomically mild doxical absolute QT prolongation in the early minutes of the disease; test sensitivity rises markedly with increasing sever- test.
The then decrease as rates increase at higher exercise workloads. and Recovery in Ischemia The lower the workload and rate—pressure product at which it occurs, the worse is the prognosis and the more likely the pres- ST-Segment Deviation ence of multivessel disease; the duration of ST depression in Changes in the level of the ST segment comprise the earliest the recovery phase also can be related to the severity of CAD.
The ST level Waves. Exercise-induced elevation can occur in an infarct area is measured relative to the end of the PR segment the P—Q where prior Q waves are present. Three or the J point is considered an abnormal response. In the presence more consecutive beats in the same lead with a stable base- of prior Q-wave MI, this could represent reversible ischemia in line should be identified and the average magnitude and tan- the peri-infarct area or ventricular dyskinesis or akinetic LV seg- gent direction of displacement at 60 to 80 ms after the J point mental wall motion.
The changes could result in reciprocal ST-segment depres- ST-Segment Depression. ST-segment depression is the tra- sion that simulates myocardial ischemia in other leads. However, ditional manifestation of exercise-induced myocardial isch- ST-segment elevation and ST-segment depression in the same emia. Myocardial imaging represents the magnitude and direction of electrical gradients techniques can help distinguish the concomitant presence of a generated by ischemic vectors across the endocardium and new myocardial ischemic zone from reciprocal changes induced epicardium, as well as the location of the recording electrodes.
by ST-segment elevation in Q-wave leads. Upsloping, horizontal, and downsloping types of ST-segment ST-Segment Elevation in Subjects Without Prior Infarction. depression are illustrated in Figure 4. Demand ischemia dur- In subjects without previous infarction absence of Q waves ing exercise is limited primarily to the endocardium, with on the resting ECG , ST-segment elevation during exercise reductions in phase 2 plateau amplitude and also less nega- frequently localizes the site of severe transient combined tive phase 4 resting membrane potentials contributing to ST endocardial and subepicardial ischemia resulting from sig- depression on the surface ECG.
When coronary arteries, but this is uncommon. In the presence of resting coronary spasm in otherwise unobstructed arteries. ST-segment elevation at 60 to 80 ms after the J point because of early repolarization, only ST-segment changes below the ST-Segment Normalization P-Q baseline should be used for analysis. patients with angina,98 and increased area of the time integral Normalization of the ST segment during exercise might be of upsloping ST depression might be associated with increased related to cancellation effects of oppositely directed forces risk of future coronary events in higher-risk men.
It is usual for young subjects myocardial ischemia in general populations. Definition of ST-segment depression changes during exercise. HR Adjustment of ST-Segment Depression. As the HR the sensitivity of the exercise test with preservation of test slows during early recovery from peak exercise, the recovery specificity, primarily from improved classification of patients phase behavior of the depressed ST segment as it returns to with equivocal test responses attributable to upsloping ST normal differs in normal subjects and patients with ischemia.
After 1 minute of recovery, ST and from technical differences in methodology. The methods depression attributable to ischemia is generally greater than are not accurate in the early phase after Q-wave infarction in it was at the same HR during exercise, whereas in normal patients with resting abnormalities of repolarization, but they subjects it is less.
It is emphasized that prospective evaluation of infarction has been associated with reversible ischemia during these criteria in larger, multicenter populations is required dobutamine stress echocardiography but also has been asso- for clarification of their value and limitations. Exercise-induced U-wave inversion in sub- in relevant populations is needed if further progress is to be jects with a normal resting ECG can be a marker of myocardial made in exercise ECG. ischemia in up to one quarter of patients with single-vessel left anterior descending disease.
Among patients with chest pain both exercise treadmill testing and by isoproterenol infusion, evaluated by myocardial perfusion imaging, exercise-related but not atrial pacing, was found to prolong the QT interval, P-wave duration and terminal P-wave amplitude in V1 have with U-wave enlargement in subjects with some types of con- been reported to be greater in patients with reversible isch- genital long-QT syndrome. Absence of QT interval emia.
An increase in P-wave duration by signal-averaging has shortening at peak exercise as generally rate-corrected by also been associated with ischemia.
However, differences in peak HR between R-Wave Amplitude Changes. The average response in nor- patients with and without ischemia and problems with inac- mal subjects is an increase in R-wave amplitude during sub- curacy of the Bazett correction at the faster rates that occur maximal exercise, with a decrease at maximum exercise.
An during exercise have limited the applicability of peak- increase in R wave at peak exercise has been associated with exercise QT interval alone as an electrocardiographic cri- myocardial ischemia,, perhaps as a correlate of LV isch- terion for ischemia. Careful measurement of QRS duration dur- length rather than time.
Disorders of impulse for- CAD, particularly in women and in some situations with oth- mation include supraventricular and ventricular arrhythmias. erwise false-positive ST-segment responses. Because exercise increases myocardial oxygen demand, in the presence of CAD, exercise-induced myocardial ischemia could High-Frequency QRS Fragmentation.
Reduction of root predispose the subject to ectopic activity. It seems that isch- mean square and peak amplitudes of signal-averaged high- emia with ST depression is not as arrhythmogenic as ischemia frequency QRS complexes and occurrence of reduced high- with ST elevation.
Exercise-induced arrhythmias are generated frequency amplitude zones have been found to have useful test by enhanced sympathetic tone, increased myocardial oxygen performance characteristics for the detection of CAD. The period immediately after exercise is par- These techniques require special filtering methodology.
ticularly dangerous because of the high catecholamine levels QRS Score. An index based on exercise-induced changes in that are associated with generalized vasodilation. Peripheral amplitudes of Q, R, and S waves was introduced as the Athens arterial dilation induced by exercise and reduced cardiac out- QRS score89 and has been related to the extent of CAD and put, resulting from diminished venous return secondary to sud- to the anatomic extent of myocardial ischemia. The increased sympathetic tone in the myocardium can stimulate ectopic Purkinje pacemaker activity by accelerat- T-Wave Changes.
An increase in precordial T-wave amplitude ing phase 4 of the action potential, which provokes spontane- has been associated with the localized onset of apical asynergy ous discharge and leads to increased automaticity. during dobutamine stress electrocardiography. In patient populations with a low CAD prevalence, normal- cardia that is caused by exercise-induced vagal withdrawal and ization of inverted T waves with exercise is a nondiagnostic increased sympathetic stimulation.
Exercise-induced sinus finding. In patients with CAD, findings have varied. Sinus arrhythmias with peri- limited to these precordial leads alone is rare in myocardial ods of sinus bradycardia and wandering atrial pacemaker ischemia, the usual diagnostic criteria can be applied in the are relatively common during early exercise and the imme- remaining inferolateral leads. The development of right bundle- diate recovery phase.
Paroxysmal AV junctional tachycardia is observed a recent study, and rate-dependency of the right bundle in less during exercise only rarely. Exercise-induced supraventricular selected populations could limit predictive value. arrhythmias alone are not usually related to CAD but are more AV Conduction. Shortening of the PR interval by as much often related to older age, pulmonary disease, recent alcohol as 0. increases is normal, probably because of increased sym- Ventricular Arrhythmias.
Ectopic ventricular beats are the pathetic tone and vagal withdrawal. This usually occurs in most frequent cardiac arrhythmia during exercise. Their prev- young, healthy individuals. In FIRST-DEGREE AV BLOCK. First-degree AV block occurs occa- general, ectopic ventricular beats are of concern in subjects sionally at the end of exercise or during the recovery phase, with a family history of sudden death or a personal history particularly in the presence of occult AV node disease.
Medi- of cardiomyopathy, valvular heart disease, or severe myo- cations or conditions that can produce prolonged AV conduc- cardial ischemia. with arrhythmogenic right ventricular dysplasia. The diag- nostic and prognostic values of patterns of ventricular ectopy SECOND-DEGREE AV BLOCK.
The occurrence of Wenckebach- during and after exercise have been variable. Recent studies type Mobitz type I AV block during exercise is rare because have suggested that frequent or complex repetitive ventricular vagal tone is reduced during exercise, whereas sympathetic activity during exercise, and particularly ventricular ectopy in neurohumoral tone increases.
The clinical significance of the recovery period after exercise, can be independent predic- exercise-induced Mobitz type II AV block generally is related tive markers for death.
Disorders of impulse con- rate-related phenomenon that appears as the sinus rate is accel- duction include abnormalities of normal impulse initiation erated beyond a critical level. block develops during exercise, the test should be terminated. Bundle-Branch and Fascicular Blocks. Intracardiac conduction THIRD-DEGREE COMPLETE AV BLOCK. Acquired advanced or blocks can exist before exercise, develop during exercise, or dis- complete AV block at rest is a relative contraindication to exer- appear during exercise.
Rate-dependent intraventricular blocks cise testing because increasing sympathetic drive without effec- that develop during exercise often precede the appearance of tive rate increase can result in complex ventricular arrhythmias. chronic blocks that develop later at rest.
The development of ECG is usually impossible when left bundle-branch block is complete block during exercise testing is uncommon, but it can present. There can be a marked degree of exercise-induced ST- be related to transient ischemia.
subjects with left bundle-branch block, and there is no clear dif- ference in ST-segment response to exercise between those with Exercise and Preexcitation Syndromes. Exercise can pro- and those without myocardial ischemia. Left bundle-branch voke, abolish, or have no effect on ventricular preexcitation block that develops during exercise might or might not be asso- in individuals with known WPW syndrome.
In the pres- of intraventricular blocks that are present at rest is rare. Although precordial leads V1, V2, and V3 , where ST depression is fre- exercise has been considered a predisposing factor to initiate quently present at baseline and increases with exercise even in tachyarrhythmia in WPW syndrome, prevalence of tachyar- the absence of coronary obstruction.
test, as described in the sections that follow. Sensitivity is the percentage study. Sensitivity is influenced by disease severity, effort level, those with an abnormal resting ECG, including bundle-branch and anti-ischemic drugs.
Specificity is the percentage of those block, resting ST-T-wave abnormalities, or LV hypertrophy. without the disease who will have normal test results, and it Positive and Negative Predictive Values can be affected by drugs such as digoxin, by baseline electro- Predictive values help define the diagnostic value of a test. cardiographic patterns, and by LV hypertrophy. Sensitivity and The predictive value of a test is greatly influenced by the specificity are inversely related; when sensitivity is the high- prevalence of disease in the group or individual being tested.
est, specificity is lowest, and vice versa. As in a high-prevalence population; conversely, a higher negative a graphical tool, a receiver operating characteristic plot dis- predictive value and lower positive predictive value occur in a plays the test sensitivity on the y-axis against 1 minus the test lower-prevalence population.
For example, an exercise ECG specificity on the x-axis for varying values of the diagnostic that demonstrates ST depression in an elderly person with cut point. The area under the curve provides a summary mea- typical anginal symptoms is most likely a true positive result, sure that averages the diagnostic accuracy across the range of whereas that in a young asymptomatic person without cardiac test values.
It equals 1. curve corresponds to random chance. Thus, the closer the area Pretest and Posttest Probability of Disease is to 1. On the basis of individual like- most data are derived from studies in which patients under- lihood of disease and the performance characteristics of the went both exercise testing and cardiac catheterization.
Because outcome on exercise ECG, the posttest likelihood of obstruc- patients selected for coronary arteriography are more likely to tive CAD can be estimated for a given individual. have obstructive CAD, these data are subject to a workup bias that inflates the estimated sensitivity and deflates the specific- Assessment of Anatomic and Functional Extent of CAD ity. The diagnostic accuracy of a test also will be influenced by Exercise-induced ST-segment depression does not provide a criteria that are used to determine whether an adequate level reliable assessment of the specific coronary vessel s involved.
of stress has been achieved. There are can be localized by the leads involved: Leads V2 through V4 reflect shortcomings to using this calculation for diagnostic purposes, left anterior descending artery disease; lateral leads reflect left and it should not be used as a sole reason to terminate the test.
ECG, HR, and of CAD include the degree, time of appearance, duration, and blood pressure are monitored during each stage. number of leads with ST-segment depression or elevation. Intravenous ble but nonobstructive plaque. Complications of dobutamine infu- and should be done with consideration of several non—ST-seg- sion include nausea, headache, tremor, anxiety, angina and ment variables, as discussed in the later section on prognosis.
diographic testing alone. Imaging provides information on Selective A2a Adenosine Receptor Agonists and Adenosine the location and amount of ischemic myocardium and on LV Vasodilators such as adenosine, dipyridamole, and regadenoson function. Exercise or pharmacological stress imaging stud- cause coronary vasodilation in normal epicardial arteries.
vasodilators are given. The relative lack of increased perfusion The Ischemic Cascade during vasodilation can be visualized with nuclear myocardial The limitation of coronary flow reserve by hemodynamically perfusion agents.
The acute metabolic dobutamine may serve as an alternative to exercise. consequences of this mismatch include decreased production Nuclear perfusion imaging with vasodilator agents is use- of adenosine triphosphate and increased production of lactate, ful particularly for the diagnosis of CAD in patients with left and they result in alterations of the electrical properties and bundle-branch block on resting ECG, because artifactual mechanical function of the myocardium.
These alterations perfusion defects can occur in patients with normal coronary occur in rapid succession in a characteristic sequence termed arteries and left bundle-branch block with exercise or dobuta- ischemic cascade and include, in typical order, reduced LV mine stress.
Side effects of vasodilator agents include flush- compliance, regional wall motion abnormalities attributable ing, chest pain, headache, nausea, dyspnea, and AV block, to decreased myocardial contractility, increased LV end- which can be reversed with aminophylline.
Adenosine and dipyr- pectoris often occurs last, if at all. idamole should not be used in patients with second- or third- Pharmacological stress imaging identifies the relative lack degree block who do not have permanent pacemakers in place or in patients with severe asthma or chronic obstructive lung of increase in perfusion in myocardial territories supplied by a disease. or functional consequences of the mismatch between oxygen supply and demand resulting from exercise-induced ischemia.
Nuclear Myocardial Perfusion Imaging Stress myocardial perfusion imaging can be performed as Pharmacological Stress Testing and Agents single-photon emission computed tomography SPECT or In patients unable to exercise for reasons such as deconditioning, positron emission tomography PET.
SPECT uses commercially available tracers demand and supply in lieu of physical exercise or to unmask such as technetium Tc m sestamibi, Tcm-tetrofosmin, locally limited capacity for coronary vasodilatation. Medications and, less commonly, thallium PET uses myocardial perfu- used for pharmacological stress testing include dobutamine, sion imaging agents with very short half-lives, of which rubid- selective A2a adenosine receptor agonists, and adenosine.
ium Rb can be produced with a generator, whereas N Dobutamine ammonia requires a local cyclotron. Compared with SPECT, Adrenergic agents such as dobutamine increase myocardial PET typically has higher spatial and temporal resolution, has oxygen demand by increasing myocardial contractility, HR, a lower effective radiation dose, allows quantitative measure- and blood pressure.
Dobutamine is infused intravenously at ment of myocardial perfusion, and can be performed faster. Nonetheless, retically ideally suited for quantitative myocardial perfusion cumulative radiation is a factor in serial perfusion imaging. measurements, but technical limitations, including radiation SPECT and N ammonia PET can be performed with exer- dose to patients, have limited its development. An increasing cise and pharmacological stress, whereas R PET imaging can number of clinical reports on vasodilator stress myocardial be performed only with pharmacological stress because of the perfusion imaging with computed tomography are being pub- extremely short tracer half-life.
The radioisotope is injected, and lished at the time of this writing. Myocardial perfusion images at rest CAD in symptomatic patients with chest pain, determining and during stress are displayed as tomographic slices in 3 dif- myocardial viability before revascularization, assessing ferent views to visualize all myocardial segments without over- prognosis after MI or in patients with chronic angina, and lap. Details at rest indicate myocardial ischemia.
Perfusion defects that are about exercise and stress testing with cardiac imaging present during exercise and persist at rest suggest previous MI. The ACCF and AHA now include these procedural With exercise stress, echocardiographic images in several guidelines in the ongoing updates of disease-based guidelines, views are obtained with electrocardiographic gating ie, syn- such as those for stable ischemic heart disease, acute coronary chronized to the QRS complex at rest and while the patient syndromes, heart failure, and other conditions.
performs stationary cycling or immediately after treadmill The ACCF, along with the AHA and other specialty and exercise. of patients with known or suspected CVD. Appropriate use With pharmacological stress, images are obtained at baseline, criteria can be periodically updated. These documents reflect with low-dose and peak dobutamine infusion, and during an ongoing effort by the ACCF to critically and systematically recovery. Echocardiography by itself has no known risks, and create, review, and categorize clinical situations in which such serial testing has no known cumulative effects.
procedures may be used. Although it is recognized that levels The images obtained during different phases of the stress test of evidence supporting test appropriateness will vary, practical are compared side by side.
Myocardial contractility normally consensus is required where conclusive evidence is lacking. It increases with exercise, whereas ischemia causes hypokinesis, is anticipated that appropriate use criteria will have an impact akinesis, or dyskinesis of the affected segments. An exercise or on physician decision making, test performance, and reim- stress echocardiogram is considered positive if regional wall bursement policy and will guide future research.
Appropriate motion abnormalities develop with exercise in previously normal use criteria for stress cardiac nuclear imaging and stress echo- segments or become more severe in already abnormal segments. cardiography are outlined in detail elsewhere. gauge prognosis regardless of whether CAD is present. In fact, although reliance on exercise testing for CAD diagno- Cardiac Magnetic Resonance Imaging and Computed sis increasingly is challenged by alternative diagnostic strate- Tomography gies eg, imaging modalities, serologic markers , application Technological advances in magnetic resonance imaging and of exercise electrocardiographic testing to assess prognosis is computed tomography have resulted in increasing use of these increasing3, and often serves as a complementary perspec- modalities for cardiac imaging.
Standard exercise equipment tive for management decisions. Multiple in many experienced centers. tive to age- and sex-based standards. Still, even this stratifica- Nonetheless, several procedural issues must be addressed tion is only an approximation because differences in height, in the assessment of maximal exercise capacity.
Many regard weight, and mode of exercise all modify exercise potential and CPX as a superior means to assess exercise performance ideally should be incorporated into stratifications of age and because gas exchange measurements provide detailed informa- sex standards. protocol is a powerful predictor of prognosis in patients with Abnormal Chronotropic Response to Exercise known or suspected CVD. Nevertheless, there are consider- Chronotropic incompetence is the inability of the HR to ations that help optimize the value of standard exercise test- increase commensurate with increased activity or demand.
ing to assess exercise capacity and prognosis. The widely used An intact HR response is vital for matching cardiac out- Bruce protocol was developed as an efficient diagnostic test for put to metabolic demands during exertion.
Investigations in middle-aged men; however, it might not be the optimal proto- population-based and clinical cohorts demonstrated that an col to assess exercise capacity in heterogeneous populations, impaired chronotropic response is predictive of cardiac events particularly in elderly, obese, and deconditioned individuals.
In and all-cause death. The simplest approach is to report change of exercise with the Bruce protocol because of physical limi- in HR with exercise relative to peak HR. Because peak HR tations instead of physiological exhaustion, thereby diminish- decreases with age, age-predicted maximal HR is often deter- ing the prognostic implications of low exercise performance.
mined as minus age in years. However, baseline functional ments in energy requirements between stages are available that capacity and resting HR also have bearing on chronotropic could be better suited to measure exercise capacity in elderly responses.
Therefore, an alternative method to determine and deconditioned individuals. chronotropic incompetence entails assessment of the propor- A related limitation of routine prognostic assessment based tion of HR reserve used at peak exercise, defined by the differ- on exercise capacity is that many stress testing laboratories use ence between age-predicted maximal HR and resting HR.
This value is often referred of the maximally predicted HR, a threshold assumed sufficient to as the chronotropic index or the proportion of HR reserve for sensitive diagnosis of CAD. With imaging as the priority, used during exercise.
Furthermore, exercise capacity often is reported merely in —0. minute after cessation of the exercise test, while in the upright Whereas absolute METs achieved by a year-old man might position, is most frequently used to define an abnormal HR be greater than those achieved by a year-old woman, he recovery response.
Numerous investigations have demonstrated that a predict death than ectopy originating from the right ventricu- decreased HR recovery is a strong adverse prognostic marker lar outflow tract or other relatively benign variants.
sistencies in the literature have led to some uncertainty about Advantages of imaging include the opportunity to characterize this index. Some HR recovery protocols entail active cool- ejection fraction, extent and distribution of ischemia, presence down. Initial reports of HR recovery were based on patients of coronary calcification, and, in some cases, even the intrinsic who underwent an upright cool-down protocol with a slow structure of stenoses, all of which are powerful risk predictors walk for 2 minutes immediately after exercise.
With this pro- for both death and cardiovascular events. In standard exercise prognostic electrocardiographic testing. When different protocols are even when SPECT imaging is available, and relatively little used, HR recovery cut points have tended to be higher, but additional prognostic insight is gained by adding SPECT the implications of attenuated HR deceleration were similar.
Adults who are older, deconditioned, female, or ischemia or other known heart disease. Exercise-induced hypotension consistently has been for exercise stress to determine prognosis in situations in shown to be a marker of increased risk for adverse events. with subthreshold HR. The component of the Duke for future hypertension, LV hypertrophy, and cardiovascular Treadmill Score that has been consistently validated for inde- events.
Some reports indicate that can be used as a multivariate score to predict risk. First devel- ventricular ectopy during exercise testing heralds increased oped as a score to improve the sensitivity of the exercise test risk of death, whereas others do not.
Other studies indicate for the diagnosis of CAD in men and later also in women, increased risk of death in those demonstrating increased ven- the Morise score was subsequently applied to the prediction tricular ectopy in recovery. sured directly by CPX have been used as criteria for disability by the Social Security Administration. Additional Uses of Exercise Testing Evaluation of Perioperative Risk for Noncardiac Surgery Exercise Prescription In most ambulatory patients, exercise testing with electro- Although the indications for exercise testing are varied, the cardiographic monitoring provides both an estimate of assessment of exercise response and determination of func- functional capacity and the detection of myocardial ischemia tional capacity are particularly useful in the development of through changes in the ECG and hemodynamic response.
the exercise plan or prescription. However, pharmacological stress imaging to the healthy population. In addition, training results in increased a higher relative risk of future events such as angina pectoris, exercise time and workload to provocation of symptoms pre- MI, and sudden death, the absolute risk of cardiac events in viously identified during submaximal exercise, such as angina these populations remains low.
Measurable dictive value of any test in low-risk populations must be low. improvements, or lack thereof, provide the basis for updates It is also acknowledged that prospective, multicenter studies in the exercise prescription and determination of subsequent to demonstrate that interventions based on exercise electro- strategies for patient care. cardiographic findings alone can favorably alter clinical out- Response to Medication comes in asymptomatic subjects are wanting. Management of medication prescribed to control exercise- Even so, several exercise electrocardiographic findings related symptoms or various inappropriate cardiorespira- have been related to future risk and have potential importance tory responses also can be evaluated with exercise testing.
for risk management. However, the positive predictive value was risk factors. A concomitant abnormal exercise thallium tions based on the following considerations. Most acute cardiac beats did not have significant prognostic value in this popu- events are attributable to plaque rupture of minor stenoses lation. Although abnormal HR-adjusted ST-segment findings, but not standard extensive obstruction makes unstable plaque more likely and ST-depression criteria alone, identified increased 4-year risk might be more readily identified by exercise testing, it is not of coronary heart disease events.
With regard to subjects who are asymptomatic but have risk Prediction of exercise-related MI and sudden death by exercise factors for CAD, exercise testing could have greater predic- testing is therefore limited by the same factors that reduce tive value. Exercise testing was of no predictive value asymptomatic low-risk younger subjects.
However, there are in the group with no risk factors. Interestingly, a positive test was not significantly management, particularly when functional test findings such associated with nonfatal MI. Furthermore, asymptomatic from CAD among men with an abnormal test response and patients at higher risk for obstructive CAD could benefit suggested that the exercise ECG might serve to identify high- from the reassurance provided by a normal test, which risk men who do benefit from interventions targeting risk fac- might facilitate prescription of and compliance with more tor reduction.
Exercise testing is well. in individuals with chest pain or with dyspnea on exertion, with or without known CAD, to evaluate whether vigorous Before Participation in Vigorous Exercise exercise is appropriate for such an individual, to establish Vigorous physical exertion, usually defined as exercise requir- training limits, and to develop an exercise prescription.
However, individual risk of adverse events is reduced Education Program. Whether exercise testing should be performed in asymp- www. tomatic adult subjects before beginning vigorous exercise has been controversial—even more so for routine screening of Exercise Electrocardiographic Testing in Women young people before engaging in athletics. Exercise testing has similar diagnostic and prognostic value in Exercise testing before beginning an exercise program has women as it does for men.
Exercise capacity but no evidence of coronary disease on an angiography. Although a study of women who underwent stress testing and sub- overall prognosis in these women is better than in those with sequent angiography, exercise capacity was among the best obstructive coronary disease, syndrome X is nonetheless stress testing variables for predicting the presence of CAD, associated with an increased rate of cardiovascular mortality, and it improved the sensitivity and specificity of exercise test- including sudden cardiac death, MI, and heart failure.
no significant ischemia detected. The prognostic value of exercise capacity has been shown in The Pediatric Population both asymptomatic women73, and symptomatic women. It is also asymptomatic women, exercise capacity was an independent sometimes necessary to modify protocols.
Low ramp rates are predictor of death as well, where for each additional MET needed for small children performing cycle ergometry. In contrast, for many capacity was lower for women than for men.
They of symptomatic women referred for exercise testing and tend to generate unrealistically low values for small children, angiography, the presence of CAD correlated with the Duke especially boys. In terms of progno- be used in these calculations. study, exercise agree well with the results of these tests. Although myocardial with interpretable ECGs and good effort capacity. Even in conditions where there percentage of their maximal capacity at specific submaximal is a potential for impaired coronary perfusion eg, congenital exercise loads than that exerted by younger people.
The systolic blood pressure response to both maximal monitoring. For patients with known or suspected CAD, stress and submaximal aerobic exercise also is increased with age. If, on the women. Because of its poor diagnostic accu- attributable to LV stiffness and decreased compliance. An exercise test with pre- and postexercise spirometry and ejection fraction responses to maximal aerobic exercise is a might be a worthwhile study if this condition is suspected.
Some disorders, such as PAD and chronic obstruc- Measurements at peak exercise are particularly helpful in this tive lung disease, frequently coexist with CAD because of regard. However, for peak exercise data to be reliable and repro- shared risk factors. Degenerative arthritis of weight-bearing ducible, it is important to ascertain that the patient expends a joints is the most prevalent chronic disorder in older adults.
maximal or near-maximal effort. Exercise laboratory person- Additionally, mental health issues and cognitive impairment nel should therefore be familiar with effective techniques for can also affect the ability to perform exercise testing in the motivating children to expend adequate efforts.
During CPX older adult. Moreover, unfamiliarity with vigorous exercise testing, patients should be encouraged to continue exercising and fear of exercise testing equipment can intimidate older until the respiratory exchange ratio exceeds 1. In prepu- patients, resulting in submaximal test results. When added to bescent children, anaerobic metabolic pathways might not be the effects of comorbid ailments, the end result could be a expressed to the extent seen in older individuals, and a respi- symptom-limited test of only a few minutes.
ratory exchange ratio of 1. Large autopsy studies have dem- chronotropic defects and cannot achieve normal peak HRs. In general, exacerbation dramatically with age. In patients bank, and other series have documented an age-associated with structurally normal hearts, the suppression of ectopy increase in CAD severity.
The age differences in the prevalence and severity of CAD and treadmill is preferred in older subjects who do not have signif- comorbid conditions be considered.
with stable CAD. The use of use in apparently healthy older adults, exercise testing has also smaller, more frequent increments in work rate is preferable to demonstrated prognostic significance in such a population. For either over 8 years of median follow-up. These pretest score based on a 4-point dyskinesis ranking in each of 16 maneuvers will help alleviate the anxiety of the older patient segments from rest to peak exercise was a potent independent and reduce the risk of musculoskeletal injury and falls.
National surveys of exercise laboratories have docu- respectively, and an earlier study of patients whose mean age mented very low overall risks of MI or cardiac death, and was 72 years. prognostic utility in this age group. been observed. The supervising clinician should be aware that Hypertension myocardial ischemia or MI in the older adult can present as Hypertension per se is not an indication for exercise testing, but marked dyspnea, extreme fatigue, or chest pressure, rather it is very often present in individuals who are referred for test- than as typical chest discomfort or pain.
The test should be postponed if resting systolic blood pres- Exercise testing is well established as a useful tool for sure exceeds mm Hg or if diastolic exceeds mm Hg. assessing the progress of patients with stable CAD and those Antihypertensive medications generally should not be withheld who have had MI. Available data in the older adult, although before testing. Hypertensive individuals often have an exagger- more limited, suggest similar prognostic value in this age ated pressure response to exercise even if resting levels are con- group.
As in the general post-MI population, inability to per- trolled. In the latter group, 1-year mortality rate was best capacity in people with hypertension and normal systolic LV predicted by the magnitude of systolic blood pressure rise dur- function. In contrast, ST-segment depression and diovascular outcomes in otherwise healthy people with hyper- ventricular arrhythmia predicted recurrent MI and need for tension, as is true in normotensive individuals.
coronary revascularization but not death. In older patients with stable CAD, exercise testing also has Obesity diagnostic and prognostic utility. For many obese patients, particularly the morbidly obese, Exercise testing has several potential uses in patients with this is related to gait instability, low functional capacity, coex- PAD. First, it is the most objective method of quantifying isting orthopedic impairments, and uneven body weight dis- walking capacity in those with exercise-induced claudication tribution.
In one study, 25 obese women mean BMI of 40 or suspected PAD. Given the high Bruce protocols on the basis of a pretest activity question- prevalence of CAD in patients with PAD, exercise testing is naire. Despite a longer time to reach fatigue when the ramp also indicated to detect CAD. different between tests. In another study, obese subjects with The specific exercise test variables used to assess PAD CAD were assigned to 2 severe energy-deficient study groups functional severity are distance or time to onset of claudica- one with exercise and the other by diet plus a control group.
tion pain and peak exercise distance or time. In conclu- Measurement of ankle—brachial index immediately after exer- sion, these 2 studies and clinical experience reveal that obese cise testing can help diagnose PAD in difficult cases and also subjects can have exercise tests effectively performed with a can determine the extent of circulatory impairment.
Because variety of protocols. Low-impact walking protocols, starting the pressure distal to an obstructive arterial lesion falls during at low work rates with small increments between stages, are exercise as a result of dilation of distal arterioles, the ankle— preferred in this patient population.
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You will find a link in the last few pages of your eBook that directs you to the media files. Helpful tips: If you are able to search the book. Score: 5. Adobe Premiere Pro CS6 Classroom in a Book Author : Adobe Creative Team Publisher : Adobe Press Release Date : Genre: Computers Pages : ISBN 10 : GET BOOK Adobe Premiere Pro CS6 Classroom in a Book Book Description : Those creative professionals seeking the fastest, easiest, most comprehensive way to learn Adobe Premiere Pro CS6 choose Adobe Premiere Pro CS6 Classroom in a Book from the Adobe Creative Team at Adobe Press.
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The 6 project-based lessons show readers step-by-step the key techniques for working with the applications in det Creative Suite. Readers learn what they need to know to create engaging layouts for print or web publishing. You will need a web-enabled device or computer in order to access the media files that accompany this ebook.
Entering the URL supplied into a computer accounting using software xero web access will allow you to get to the files. Depending on your device, it is possible that your display settings will cut off взято отсюда of the URL.
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