Stress training_运动平板

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1、Selling Stress运动平板培训,GE Marquette Medical Systems,运动心电图的应用范围 冠心病的辅助诊断 多支血管病变的病人确定犯罪血管 从冠心病人中选择高危病人进行PTCA和CABG 心肌梗死病人有无存活心肌或缺血心肌 心肌梗死病人出院前运动处方的制定 冠心病人介入治疗或CABG后再狭窄的判定 评估冠心病病人预后 心脏病内外科治疗疗效评定 评定心脏功能，安排病人活动量 体育疗法运动处方的制定 运动员体力状态的鉴定 飞行员体检,运动试验的原理,运动测试心电图用于 冠心病诊断未能确认 确认病人的身体状况 测验会记录运动及药物对心脏影响过程中的心电图 评估的指标

2、传统上采用ST段的压低或抬高（预示心肌缺血） 运动前的危险因素和最大运动级量也是强有力的诊断依据 运动级量由以下参数来体现: 最大运动时间，最大负荷，最大代谢当量（MET）或最大心率及心率和血压的乘积,运动试验的类型,标准运动试验-跑台试验 运动超声心动图( Stress Echo) 用心脏超声显示心脏壁的运动 核医学运动测试（Nuclear stress testing） 核医学影像扫描确认血流的特点 铊, Cardiolite 药物学平板试验 潘生丁，腺苷，多巴酚安,运动试验检测CAD机制 通过运动提高心率增加心肌耗氧量，检测冠状动脉供血情况，如冠状动脉明显狭窄，运动达到一定负荷量时，冠状

3、血流量不能相应增加，既发生心肌缺血反映。,运动试验阳性心电图改变解释 ST段下降：代表心内膜下心肌损伤 ST段抬高：冠脉血流暂时中断 T波高耸：内膜下心肌缺血 强阳性（ST段下降0.20mV），多支病变。,阳性标准 运动中或运动后发作心绞痛 运动中或运动后发生缺血型ST段下降0.10mV, 1mm。 运动中或运动后发生ST段急性损伤型抬高0.20mV。 运动中或运动后发生AMI。 运动诱发缺血型T波高耸。 运动诱发血压急剧下降。,运动试验终止相对指征 发生缺血型ST段下降0.10mV 胸痛加重 血压显著升高或下降 快速心律失常，如AVRT、PSVT、AF、Af 出现束支阻滞、W-P-W, 不能

4、区分真、假阳性 突然发生缓慢窦性心律失常、传导阻滞、停搏,运动试验终止绝对指征 发作心绞痛，急性冠脉闭塞 达到目标心率 心电图出现阳性指征 血压下降伴全身反应、面色苍白、出冷汗 病人要求终止试验 严重心律失常如室速、室颤 仪器设备故障,假阳性发生的主要原因 高血压患者 左心室肥厚 左束支阻滞 植物神经紊乱综合症 处于更年期的人群（女性更为突出） 冠状动脉心肌桥 预激综合征,运动试验的技术及程序,运动试验的阶段 运动前阶段 皮肤处理及电极贴放 运动前ECG 协议 运动阶段 运动协议 恢复阶段 运动舒缓阶段 连续实时ECG 监护 最后报告阶段 最后报告的准备、确认、及发出,病人准备,正确的皮肤处理

5、=好的测试 高质量的皮肤处理及电极放置的目的是获得好的信噪比（阻抗） 高质量的皮肤处理 减少肌颤伪差 减少基线漂移 确保高质量的打印输出及数据,噪声 :运动试验- 一个多噪音的 环境,噪音的类型 低频噪音 : 基线漂移 高频噪音: 肌电伪差 50-Hz 噪音: 来自电源,解决方案 高质量的预处理及电极放置; 立方曲线校正 渐量修正技术去除肌电伪差 高质量的预处理及电极放置;无扶手; 屏幕及记录仪滤波 直接数字采集; 消除电源干扰,运动前阶段,手动控制阶段 ECG 协议 典型阶段 仰卧位 站位 深呼吸 目的:获得静息基线ECG 数据, 与运动ECGs 作比较,运动阶段,自动运行运动协议, 增加跑

6、台的速度及梯度. 运动系统预先设置标准的运动协议: Bruce (modified Bruce) Balke Naughton Ramp protocols Drug protocols,运动阶段,临床医生观察 ST 改变, 心律失常 (异常事件), 最大心率, 血压, 以及运动终止时的生命体征,恢复阶段,手动控制恢复阶段, 监护12-lead ECGs 约 8-10 分钟,观察心率失常及 ST段的变化. 终止运动的根据: 身体状态 ECG 变化 达到最大目标心率 HR 和 BP 异常,最后报告阶段,最后报告阶段包括: 回顾全部运动过程 总结 ST 段变化 趋势 心律失常回顾 存储诊断数据,最

7、后报告的诊断,心率: 最大 HR, 最大预测HR, 目标 HR 血压 (收缩压升高) 率压积 (HR x 收缩压) 功能性 (运动负荷的承受能力)- 由于运动量大小和氧耗量成平行关系,故氧耗量可作运动量的计量单位.用METS 代谢当量评估氧耗量. 1个 MET= 每公斤体重每分钟耗氧 3.5毫升(静息状态下). 限制型病人 - 6 METS or 更低 无症状病人 - 7 to 11 METS 健康型病人 - 12 to 15 METS 耐久性运动员- 16 to 20 METS,最后报告的诊断,生命体征及症状 ECG 反应 - ST 段的变化 ST 段水平或下斜型压低1.0 毫米或更多 非正

8、常 四种类型的有关冠状动脉疾病的ST段改变 ST 段抬高 缓慢上斜型ST段压低 水平 ST段压低 下斜型ST段压低,目前市场上的平板种类,GE Marquette - Case 8000, Max-1, Max-Personal, T2000 treadmill, Cardiosys Quinton - Q4500, Q710, Q55/65 and ST 65/55 Schiller CS-200, AT-10 and 60; Burdick Quest Other - Cambridge Heart , Mortara, Esaote, Siemens,平板客户关心的问题,内科医师/临床医

9、生(心脏病专家, 内科医生) 首先考虑病人的安全 , 可信赖的平板试验及精确的报告 报告格式 测量的准确度 临床标准 心电信号描记质量,平板客户关心的问题?,技术员(平板技术员, 心电图技术员, 护士) Interface with the patient and equipment. Features to make their job easier and faster. Ease-of-use Throughput Familiarity with equipment they currently use Final reports the way the physician wants

10、 them.,平板客户关心的问题?,Cardiology Manager, Administrator Interface with the other hospital departments. Clinical issues remain a priority. However, information access and department efficiencies are becoming a priority. Process efficiencies Clinical decision support Information access, electronic patient

11、 record.,平板客户关心的问题?,IS/HIS Administrators In the networked health care systems, the IS administrator is looking for ease of integration into the network and all resultant benefits Complete patient medical record Data integration into enterprise-network information system Device connectivity into inf

12、ormation system,What is the Exercise Testing System Sale?,The stress sale can often be a REPLACEMENT SALE. Two types of stress sales in the hospital market Sale to a long-time GE Marquette stress customer Sale to a current Quinton customer or Schiller user Strategy - profile what stress equipment is

13、 currently in the account, and replace it with the appropriate GE Marquette stress device.,MAX Personal - Fundamental System Designed for Modularity,12SL Analysis - Adult/Pediatric, with battery operation MUSE CV compatible via modem transmission Remote Query to MUSE CV Full variety of final reports

14、, editing in Recovery, Linked Medians report Cubic Spline, Incremental Updating AM 5 digital acquisition module, InterLead design Automatic arrhythmia detection,MAX Personal - Fundamental System Designed for Modularity,Price - System $9,050-$9,450 - Ergometer $9,800 - Treadmill, Cart Price - Options

15、 $0 - 12SL $1,000 -Computer-Assist -12SL $1,500- Computer-Assist-12SL-Cubic Spline Introduced - Winter 1995,MAX 1- Intuitive Technology for Diverse Requirements,12SL Analysis - Adult/Pediatric MUSE CV compatible via diskette Pharmacologic Report Option Full variety of final reports, editing in Recov

16、ery, Linked Medians report Cubic Spline, Incremental Updating AM 5 digital acquisition module, InterLead design Automatic arrhythmia detection Full interfacing to peripheral devices,MAX 1- Intuitive Technology for Diverse Requirements,Price - System $11,900 - Basic $12,900 - Dual Floppy-MUSE Price -

17、 Options $750 - 12SL $250 -Pharmacologic $1,000 - Combined Introduced - Spring 1989,Clinical Decision Support - FRF algorithm - accuracy of interpretation Waterfall Display - quick, ischemic assessment Stress Serial Presentation - confirm clinical changes 15 lead stress, ST/HR Index, arrhythmia anal

18、ysis Workflow Efficiency - Getting Started CBT Tips Tutorial, Competency List Reporting, Post-Test Review Tools,CASE 8000 - Cardiac Assessment System for Exercise -,Outcomes , Information Access - Bi-Directional MUSE connectivity - network connectivity, Web-enabled for complete cardiovascular MUSE r

19、ecord at point-of-care ADT, orders download Remote, WAN access,CASE 8000 - Cardiac Assessment System for Exercise,Price - System $17,500 - 15 “ Monitor Price - Options 12SL - $750 Full Disclosure- $1,000 Remote Viewing- $800 Storage to Local Network -$200 MUSE Network Installation - $1,000 Introduce

20、d - Spring 1999,CASE 8000 - Cardiac Assessment System for Exercise,2020/9/3,Selling Stress EMEA 98,36,Clinical ExpertiseExercise ECG Algorithms - Today,12 SL ECG Analysis Program Incremental Median Updating Cubic Spline ST Measurements Direct Digital Acquisition Arrhythmia Analysis,12 SL ECG Analysi

21、s Program,What is it? Computer program for analyzing simultaneously acquired 12-lead ECGs. acquired on 12 leads, sampled 500Hz, 50/60 adapaive filters, incremental median updatng,accurate QRS measurements, interpretive program for rhythm and morphology. Benefits? Experts: saves time, second opinion,

22、 reduces variability of readings Less experienced: second opinion, educational feedback, added readability,Incremental Median Updating,Also called Representative Beat Determination Signal Averaging What is it? 1976 CASE - noise-rejection, signal enhancing algorithm for ECGs QRS detection for dominan

23、t template Beat Alignment - matches incoming /dominant beat Correlation - 80% accept; less 80% reject ectopic Median Update- incremental revision 10mv/1/16 Benefits Maintains accurate median morphology Real-time, beat-by-beat median updating,Cubic Spline,What is it? enhanced algorithm for removing b

24、aseline roll in ECG tracings. mathematical program that uses 3 beats to estimate baseline roll, which is subsequently subtracted to yield straigthened ECG with no waveform phase distortion. Benefits? Straigthens baseline, cleans ECG even with artifact Uses no aggressive filtering , so full fideltity

25、 QRS Eliminates errors in measurements from more aggressive filtering.,ST Segment Measurements,What is it? Electronic ST segment measurement using traditional clinical approach Establish Epoint (onset), J point (latest offset) and user-selected post-J point then electronically measure. Benefits? Avo

26、ics errors of fixed-time interval measurements Enhances accuracy of ST measurements User-adjusted post-J location,Direct Digital Acquisition,What is it? Active patient cable does analog-to-digital conversion at the patient. Benefits? Eliminates analog cable noise from cable movement and gives cleane

27、r signal regardless of cable length Allows for modular patient cable design. easy disconnect lower cost cable replacement,Quinton Q 4500 - Features and Claims,Tilt-and swivel monitor Muscle artifact and baseline wander filters Oversize soft-touch exercise device controls “Customize” in-test and fina

28、l reports Pre-edit during recovery Q412 automatic BP Quick-prep “gun”,Quinton Q 4500 - Takeaways,No interpretive resting ECG analysis No 12-leads in final report: tabular summary, average beat, worst case medians, canned statements, interpretation Challenge to program Doesnt show worst case lead on

29、the screen Difficult to use; several menus deep,Quinton Q 4500 - vs. MAX-1,Push 12SL interpretive ECG Analysis program Present variety of final reports - preview report Focus on ease-of-use Point to comparative median complexes;scan for worst case ST Push Cubic spline, incremental median updating, L

30、inked Medians Pre-edit in Recovery MUSE connectivity,Quinton Q 710 Exercise invalidates final report. only 3 seconds ECG data on screen with no median complexes. not mechanically robust no auto arrhythmia documentation. Can be replaced by Q4500 when customer has problems,Quinton Q 710 - vs. MAX-PE,1

31、2SL gives best analysis and measurement algorithm techniques in both resting ECG and stress ECG applications-consistency of data and interpretation Ease -of -use of interface MUSE connectivity and Remote Query full 8 second display with median complexes,Quinton MedTrack ST 55 ,ST 65- Features and Cl

32、aims,New Hyperdrive System ,brushless motor New soft start Quiet throughout test Weight capacity 400 lbs 0.8 to 9.6 mph and up to 25% grade,Quinton MedTrack ST 55 ,ST 65- vs. Marquette T2000,Brushless DC motor 0 mph start Quiet throughout test Weight capacity 450 lbs 0 to 13.5 mph and up to 25% grad

33、e Emergency Stop Button and front/side rails standard 60 length Better value,Burdick Quest - Features and Claims,Reports: 12-lead, summary, median, ectopic summary Disconnect patient module. PCCMCIA card for upgrades T-600 Treadmill Diskette storage (10 reports),Burdick Quest - Features passive cabl

34、e with processing in chassis T-600 treadmill ordinary Redesigning writer; had been swap-out from Eclipse carts Third party service,Burdick Quest - vs. Max- 1,12SL ECG Analysis program - resting and stress ECG application. Easy-to-use functional keys to go through phases. Ease of trim knob control -

35、No errors in stress test sequence. Full complement of final reports Interlead and Active front end.,Schiller Cardiovit AT-10,Laptop design Full size reports Custom screens and reports Spirometry option Free lifetime software updates ST segment 12-lead bar graph Full disclosure resting ECG $12,995-$1

36、3,400 package,Schiller Cardiovit AT-60,Hospital grade Custom screens and reports Vectorcardiography option Internal floppy drive option Spirometry option Free lifetime software updates 12-channel report printing $15,995-$16,95 package,Schiller Cardiovit AT-10/60 - Takeaways,No worst case ST scan Nee

37、d top screen; alptop screen impossible to read Pretest stage only 1 minute; so pretest stages done prior to starting test No VE counter Average complex and J-point difficult to change Service is difficult; send to factory,Schiller Selling Strategies,Push value of the system - 12-lead ECG, cart, remo

38、te screen, treadmill , etc. all for $12,995 Size and ease of transportability - take AT-10 in car to different offices and plug in for resting and stress ECG Reliability and performance of “Swiss-made” equipment. “Exec Software” for free to get median beat /12-lead bar graph,Schiller and Trackmaster

39、 Treadmills,Treadmills can be basic or additional $500 for hospital-grade upgrade Sold as package for best value to customer,Cambridge Heart - CH 2000 Features dedicated function keys an done-level menus Total recall-full disclosure reports and storage (500 Mb drive),CH 2000 - Features and Claims,Cl

40、ear diagnostic display 1 mm red-grid for real-time interpretation all 12-leads displayed throughout test Alternans trend report displays alternanas levels vs. heart rate for entire study,Cambridge Heart - CH 2000 Takeaways,Accuracy for detection of Arrhythmia Vulnerability a “coin flip”at HR 120 Accuracy dependent on HR and noise levels No proof of efficacy with treadmills; requires bicycle ergometry Requires 70% HR target yielding submaximal stress test,