Supervision and interpretation of exercise treadmill tests by physician assistants

Two Models to Conduct Nonphysician-led Exercise Stress Testing in Low to Intermediate Risk Patients

BACKGROUND

Exercise stress testing (EST) is a noninvasive procedure that aids the diagnosis and prognosis of a range of cardiac pathologies. Reduced access is recognized as a limiting factor in enabling early access to treatment or safe and appropriate discharge. Increased accessibility can be achieved by utilizing nonphysician health practitioners to supervise tests. To implement nonphysician-led EST in clinical environments, there is a need for the development and administration of feasible and effective models.

OBJECTIVE

Via inpatient and outpatient referral, this article aims to present 2 standardized models of care for patients requiring EST for diagnostic and prognostic evaluation of numerous pathologies.

METHOD

An inpatient and outpatient model was implemented at the Royal Brisbane and Women's Hospital and Logan Hospital in Queensland, Australia between July 2013 and December 2015. Tests were performed by 2 cardiac scientists employed by each hospital. All tests were immediately reported by a cardiology advanced trainee registrar or consultant cardiologist.

RESULTS

A total of 2095 tests were performed via the 2 models. Overall, 73 had a positive result (3.5%), 120 equivocal (5.7%), 129 inconclusive/submaximal (6.2%), and 1773 negative (85.2%). After further testing, 38 of the patients with positive and equivocal results were diagnosed with flow-limiting coronary artery disease. The remaining patients were resolved as negative through further diagnostic testing or lost to follow up.

CONCLUSIONS

After implementation of the 2 models, patient flow was improved for earlier discharge, reduced waiting times, or timely identification of possible cardiac pathologies, thereby optimizing patient care.

Evidence-based risk recommendations for best practices in the training of qualified exercise professionals working with clinical populations

This systematic review examines critically "best practices" in the training of qualified exercise professionals. Particular attention is given to the core competencies and educational requirements needed for working with clinical populations. Relevant information was obtained by a systematic search of 6 electronic databases, cross-referencing, and through the authors' knowledge of the area. The level and grade of the available evidence was established. A total of 52 articles relating to best practices and (or) core competencies in clinical exercise physiology met our eligibility criteria. Overall, current literature supports the need for qualified exercise professionals to possess advanced certification and education in the exercise sciences, particularly when dealing with "at-risk" populations. Current literature also substantiates the safety and effectiveness of exercise physiologist supervised stress testing and training in clinical populations.

Testing of low-risk patients presenting to the emergency department with chest pain: a scientific statement from the American Heart Association

The management of low-risk patients presenting to emergency departments is a common and challenging clinical problem entailing 8 million emergency department visits annually. Although a majority of these patients do not have a life-threatening condition, the clinician must distinguish between those who require urgent treatment of a serious problem and those with more benign entities who do not require admission. Inadvertent discharge of patients with acute coronary syndrome from the emergency department is associated with increased mortality and liability, whereas inappropriate admission of patients without serious disease is neither indicated nor cost-effective. Clinical judgment and basic clinical tools (history, physical examination, and electrocardiogram) remain primary in meeting this challenge and affording early identification of low-risk patients with chest pain. Additionally, established and newer diagnostic methods have extended clinicians' diagnostic capacity in this setting. Low-risk patients presenting with chest pain are increasingly managed in chest pain units in which accelerated diagnostic protocols are performed, comprising serial electrocardiograms and cardiac injury markers to exclude acute coronary syndrome. Patients with negative findings usually complete the accelerated diagnostic protocol with a confirmatory test to exclude ischemia. This is typically an exercise treadmill test or a cardiac imaging study if the exercise treadmill test is not applicable. Rest myocardial perfusion imaging has assumed an important role in this setting. Computed tomography coronary angiography has also shown promise in this setting. A negative accelerated diagnostic protocol evaluation allows discharge, whereas patients with positive findings are admitted. This approach has been found to be safe, accurate, and cost-effective in low-risk patients presenting with chest pain.