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    Duke Treadmill Score

    Diagnoses and prognoses suspected CAD based on the treadmill exercise test.
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    When to Use
    Pearls/Pitfalls
    Why Use

    Patients without known coronary artery disease undergoing treadmill EKG testing.

    • Originally created using minutes of exercise under Bruce protocol.
    • Should be used with caution in patients undergoing testing with other protocols.
      • If alternative protocol used, consider equivalent in multiples of resting oxygen consumption (METs) instead of minutes of exercise.
    • Provides independent prognostic information in addition to coronary anatomy, left ventricular ejection fraction, and clinical data.
    • Unclear utility if any of the following are present: significant valvular or congenital heart disease, previous cardiac surgery, uninterpretable EKG due to left bundle branch block, ST-segment elevation in leads with pathologic Q waves.
    • Does not consider clinical variables such as age, heart rate, or blood pressure, which are known risk factors for CAD.

    Can provide diagnostic and prognostic information for patients with suspected coronary artery disease based on the treadmill exercise test.

    min
    mm
    No angina during exercise
    0
    Non-limiting angina
    +1
    Patient stops exercising because of angina
    +2

    Result:

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    Next Steps
    Evidence
    Creator Insights

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    Formula

    Duke Treadmill Score = duration of exercise, minutes – (5 × maximal net ST-segment deviation during or after exercise*, millimeters) – (4 × treadmill angina index)

    *except in lead aVR

    Where angina index is as follows:

    Feature

    Angina index

    No angina during exercise

    0

    Non-limiting angina

    1

    Patient stops exercising because of angina

    2

    Facts & Figures

    Interpretation:

    Duke Treadmill Score

    Risk group

    5-year survival*

    ≥+5

    Low

    99%

    -10 to +4

    Medium

    95%

    <-10

    High

    79%

    *For outpatients. From Mark 1991.

    The data from the treadmill exercise test can be plotted on a nomogram to derive an estimate of five-year survival or average annual mortality.

    Prognosis is determined in five steps:

    1. The observed amount of exercise-induced ST-segment deviation (the largest elevation or depression after resting changes have been subtracted) is marked on the line for ST-segment deviation during exercise.
    2. The observed degree of angina during exercise is marked on the line for angina.
    3. The marks for ST-segment deviation and degree of angina are connected with a straight edge. The point where this line intersects the ischemia-reading line is noted.
    4. The total number of minutes of exercise in treadmill testing according to the Bruce protocol (or the equivalent in multiples of resting oxygen consumption [METs] from an alternative protocol) is marked on the exercise-duration line.
    5. The mark for ischemia is connected with that for exercise duration. The point at which this line intersects the line for prognosis indicates the five-year survival rate and average annual mortality for patients with these characteristics.

    Evidence Appraisal

    Derivation study, Mark 1987:

    • 2,842 patients referred to Duke University Medical Center between 1969 and 1980 with chest pain who had an exercise treadmill test (Bruce protocol) within 6 weeks of cardiac catheterization.
    • Population randomly divided into two groups of equal size; Cox regression model was used in one to create the treadmill score that was validated in the other group.
    • Exclusion: significant valvular or congenital heart disease, previous cardiac surgery, uninterpretable EKG due to LBBB, ST-segment elevation in leads with pathologic Q waves.
    • The DTS adds independent prognostic information in addition to coronary anatomy, left ventricular ejection fraction, and clinical data.
    • The treadmill score was useful to stratify prognosis in suspected coronary artery disease.

    Validation study, Mark 1991:

    • 613 outpatients.
    • Prospective study.
    • Predicted outcomes based on the Duke Treadmill Score agreed closely with observed outcomes at four years of follow-up.

    Literature

    Clinical Practice Guidelines

    Research PaperGibbons RJ, Balady GJ, Beasley JW, Bricker JT, Duvernoy WF, Froelicher VF, Mark DB, Marwick TH, McCallister BD, Thompson PD Jr, Winters WL, Yanowitz FG, Ritchie JL, Gibbons RJ, Cheitlin MD, Eagle KA, Gardner TJ, Garson A Jr, Lewis RP, O'Rourke RA, Ryan TJ. ACC/AHA Guidelines for Exercise Testing. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing). J Am Coll Cardiol. 1997 Jul;30(1):260-311.Research PaperGibbons RJ, Balady GJ, Bricker JT, Chaitman BR, Fletcher GF, Froelicher VF, Mark DB, McCallister BD, Mooss AN, O'Reilly MG, Winters WL, Gibbons RJ, Antman EM, Alpert JS, Faxon DP, Fuster V, Gregoratos G, Hiratzka LF, Jacobs AK, Russell RO, Smith SC; American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Committee to Update the 1997 Exercise Testing Guidelines. ACC/AHA 2002 guideline update for exercise testing: summary article. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines). J Am Coll Cardiol. 2002 Oct 16;40(8):1531-40.Research PaperFihn SD, Gardin JM, Abrams J, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation. 2012;126(25):e354-471.
    Dr. Daniel B. Mark

    About the Creator

    Daniel B. Mark, MD, MPH, is a cardiologist and tenured professor of medicine at Duke University Medical Center. He is the vice chief for academic affairs in the division of cardiology and the director of outcomes research at the Duke Clinical Research Institute. Dr. Mark's primary research interests include medical economics and quality of life outcomes.

    To view Dr. Daniel B. Mark's publications, visit PubMed

    Content Contributors
    • Sean Kotkin, MD
    • Rajesh Vedanthan, MD
    About the Creator
    Dr. Daniel B. Mark
    Guidelines
    Content Contributors
    • Sean Kotkin, MD
    • Rajesh Vedanthan, MD