Usefulness of the Duke Activity Status Index to Select an Optimal Cardiovascular Exercise Stress Test Protocol

Published:January 31, 2021DOI:
      Exercise testing represents the preferred stress modality for individuals undergoing evaluation of suspected myocardial ischemia. Patients with limited functional status may be unable to achieve an adequate exercise stress, thus influencing the diagnostic sensitivity of the results. The Duke Activity Status Index (DASI) is a clinically applicable tool to estimate exercise capacity. The purpose of the current study was to assess the utility of the DASI to identify patients unable to achieve an adequate exercise stress result. Patients referred for exercise stress testing were administered the DASI pre-exercise. Baseline characteristics and exercise variables were evaluated including DASI-metabolic equivalents (DASI-METs), peak METs, exercise time (ET), and %-predicted maximal heart rate (%PMHR). Criteria for determining adequate exercise stress was defined as ≥85%PMHR or ≥ 5-METs at peak exercise. In 608 cardiovascular stress tests performed during the study period; 314 were exercise stress. The median DASI-METs (8.4 [interquartile range; 6.7 to 9.9]) was associated with estimated peak exercise METs (R=0.50, p <0.001), ET (R=0.29, p <0.001), and %PMHR (R=0.19, p = 0.003). DASI-METs were different between those with < or ≥85%PMHR (7.9 [6.6-9.0] vs. 8.9 [7.1-9.9], P=0.025) and those with < or ≥5-METs (5.8 [4.6 to 6.6] versus 8.9 [7.3-9.9], p <0.001). Receiver operating characteristic curve analysis identified a DASI-MET threshold of ≤/>7.4 to optimally predict adequate exercise stress (sensitivity=93%, specificity=71%). In conclusion, the DASI correlates with peak METs, ET, and %PMHR among patients referred for exercise testing and can be used to identify patients with an increased likelihood of an inadequate stress test result.
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        • Fihn SD
        • Gardin JM
        • Abrams J
        • Berra K
        • Blankenship JC
        • Dallas AP
        • Douglas PS
        • Foody JM
        • Gerber TC
        • Hinderliter AL
        • 3rd King SB
        • Kligfield PD
        • Krumholz HM
        • Kwong RY
        • Lim MJ
        • Linderbaum JA
        • Mack MJ
        • Munger MA
        • Prager RL
        • Sabik JF
        • Shaw LJ
        • Sikkema JD
        • Smith Jr., CR
        • Smith Jr., SC
        • Spertus JA
        • Williams SV
        American College of Cardiology Foundation; American Heart Association Task Force on Practice Guidelines; American College of Physicians; American Association for Thoracic Surgery; Preventive Cardiovascular Nurses Association; Society for Cardiovascular Angiography and Interventions; Society of Thoracic Surgeons. 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.
        J Am Coll Cardiol. 2012; 60: e44-e164
        • Bourque JM
        • Beller GA.
        Value of exercise ecg for risk stratification in suspected or known CAD in the era of advanced imaging technologies.
        JACC Cardiovasc Imaging. 2015; 8: 1309-1321
        • Fletcher GF
        • Ades PA
        • Kligfield P
        • Arena R
        • Balady GJ
        • Bittner VA
        • Coke LA
        • Fleg JL
        • Forman DE
        • Gerber TC
        • Gulati M
        • Madan K
        • Rhodes J
        • Thompson PD
        • Williams MA
        American Heart Association Exercise CR and PC of the C on CC, Council on Nutrition PA and M, Council on Cardiovascular and Stroke Nursing, and Council on Epidemiology and Prevention. Exercise standards for testing and training: a scientific statement from the American Heart Association.
        Circulation. 2013; 128: 873-934
        • Jain M
        • Nkonde C
        • Lin BA
        • Walker A
        • Wackers FJT.
        85% of maximal age-predicted heart rate is not a valid endpoint for exercise treadmill testing.
        J Nucl Cardiol. 2011; 18: 1026-1035
        • Pinkstaff S
        • Peberdy MA
        • Kontos MC
        • Finucane S
        • Arena R.
        Quantifying exertion level during exercise stress testing using percentage of age-predicted maximal heart rate, rate pressure product, and perceived exertion.
        Mayo Clin Proc. 2010; 85: 1095-1100
        • Myers J
        • Voodi L
        • Umann T
        • Froelicher VF.
        A survey of exercise testing: methods, utilization, interpretation, and safety in the VAHCS.
        J Cardiopulm Rehabil. 2000; 20: 251-258
        • Hlatky MA
        • Boineau RE
        • Higginbotham MB
        • Lee KL
        • Mark DB
        • Califf RM
        • Cobb FR
        • Pryor DB.
        A brief self-administered questionnaire to determine functional capacity (the Duke Activity Status Index).
        Am J Cardiol. 1989; 64: 651-654
        • Arena R
        • Humphrey R
        • Peberdy MA
        • Madigan M.
        Predicting peak oxygen consumption during a conservative ramping protocol: implications for the heart failure population.
        J Cardiopulm Rehabil. 2003; 23: 183-189
        • Henzlova MJ
        • Duvall WL
        • Einstein AJ
        • Travin MI
        • Verberne HJ.
        ASNC imaging guidelines for SPECT nuclear cardiology procedures: Stress, protocols, and tracers.
        J Nucl Cardiol. 2016; 23: 606-639
        • Lancellotti P
        • Pellikka PA
        • Budts W
        • Chaudhry FA
        • Donal E
        • Dulgheru R
        • Edvardsen T
        • Garbi M
        • Ha JW
        • Kane GC
        • Kreeger J
        • Mertens L
        • Pibarot P
        • Picano E
        • Ryan T
        • Tsutsui JM
        • Varga A
        The clinical use of stress echocardiography in non-ischaemic heart disease: recommendations from the European Association of Cardiovascular Imaging and the American Society of Echocardiography.
        J Am Soc Echocardiogr. 2017; 30: 101-138
        • Kligfield P
        • Lauer MS.
        Exercise electrocardiogram testing: beyond the ST segment.
        Circulation. 2006; 114: 2070-2082
        • Ross R
        • Blair SN
        • Arena R
        • Church TS
        • Després J-P
        • Franklin BA
        • Haskell WL
        • Kaminsky LA
        • Levine BD
        • Lavie CJ
        • Myers J
        • Niebauer J
        • Sallis R
        • Sawada SS
        • Sui X
        • Wisløff U.
        Importance of assessing cardiorespiratory fitness in clinical practice: a case for fitness as a clinical vital sign: a scientific statement from the American Heart Association.
        Circulation. 2016; 134: e653-e699
        • Myers J
        • Buchanan N
        • Walsh D
        • Kraemer M
        • McAuley P
        • Hamilton-Wessler M
        • Froelicher VF.
        Comparison of the ramp versus standard exercise protocols.
        J Am Coll Cardiol. 1991; 17: 1334-1342
        • Pinkstaff S
        • Peberdy MA
        • Kontos MC
        • Fabiato A
        • Finucane S
        • Arena R.
        Overestimation of aerobic capacity with the bruce treadmill protocol in patients being assessed for suspected myocardial ischemia.
        J Cardiopulm Rehabil Prev. 2011; 31: 254-260
        • Kaminsky LA
        • Whaley MH.
        Evaluation of a new standardized ramp protocol: The BSU/Bruce Ramp protocol.
        J Cardiopulm Rehabil. 1998; 18: 438-444
      1. American College of Sports Medicine. ACSM's Guidelines for Exercise Testing and Prescription. 9th ed. (Pescatello L, Arena R, Riebe D, Thompson PD, eds.). Philadelphia: Wolters Kluwer/ Lippincott Williams & Wilkins; 2014.

        • Gibbons RJ
        • Balady GJ
        • Beasley JW
        • Bricker JT
        • Duvernoy WF
        • Froelicher VF
        • Mark DB
        • Marwick TH
        • McCallister BD
        • Thompson PDJ
        • Winters WL
        • Yanowitz FG
        • Ritchie JL
        • Gibbons RJ
        • Cheitlin MD
        • Eagle KA
        • Gardner TJ
        • Garson AJ
        • 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; 30: 260-311
        • Myers J
        • Froelicher VF.
        Exercise testing. Procedures and implementation.
        Cardiol Clin. 1993; 11: 199-213
        • Shaw LJ
        • Olson MB
        • Kip K
        • Kelsey SF
        • Johnson BD
        • Mark DB
        • Reis SE
        • Mankad S
        • Rogers WJ
        • Pohost GM
        • Arant CB
        • Wessel TR
        • Chaitman BR
        • Sopko G
        • Handberg E
        • Pepine CJ
        • Bairey Merz CN
        The value of estimated functional capacity in estimating outcome: results from the NHBLI-Sponsored Women's Ischemia Syndrome Evaluation (WISE) Study.
        J Am Coll Cardiol. 2006; 47: S36-S43
        • Morey MC
        • Pieper CF
        • Cornoni-Huntley J.
        Is there a threshold between peak oxygen uptake and self-reported physical functioning in older adults?.
        Med Sci Sport Exerc. 1998; 30: 1223-1229
        • Kozlov S
        • Caprnda M
        • Chernova O
        • Matveeva M
        • Alekseeva I
        • Gazdikova K
        • Gaspar L
        • Kruzliak P
        • Filipova S
        • Gabbasov Z.
        Peak responses during exercise treadmill testing using individualized ramp protocol and modified bruce protocol in elderly patients.
        Folia Med (Plovdiv). 2020; 62: 76-81
        • Phillips L
        • Wang JW
        • Pfeffer B
        • Gianos E
        • Fisher D
        • Shaw LJ
        • Mieres JH.
        Clinical role of the Duke Activity Status Index in the selection of the optimal type of stress myocardial perfusion imaging study in patients with known or suspected ischemic heart disease.
        J Nucl Cardiol. 2011; 18: 1015-1020
        • Bairey Merz CN
        • Olson M
        • McGorray S
        • Pakstis DL
        • Zell K
        • Rickens CR
        • Kelsey SF
        • Bittner V
        • Sharaf BL
        • Sopko G.
        Physical activity and functional capacity measurement in women: a report from the NHLBI-sponsored WISE study.
        J Womens Health Gend Based Med. 2000; 9: 769-777
        • Gulati M
        • Pandey DK
        • Arnsdorf MF
        • Lauderdale DS
        • Thisted RA
        • Wicklund RH
        • Al-Hani AJ
        • Black HR.
        Exercise capacity and the risk of death in women: The St James Women Take Heart Project.
        Circulation. 2003; 108: 1554-1559
        • Lauer MS
        • Pothier CE
        • Magid DJ
        • Smith SS
        • Kattan MW.
        An externally validated model for predicting long-term survival after exercise treadmill testing in patients with suspected coronary artery disease and a normal electrocardiogram.
        Ann Intern Med. 2007; 147: 821-828
        • Riedel B
        • Li MH-G
        • Lee CHA
        • Ismail H
        • Cuthbertson BH
        • Wijeysundera DN
        • Ho KM.
        A simplified (modified) Duke Activity Status Index (M-DASI) to characterise functional capacity: a secondary analysis of the Measurement of Exercise Tolerance before Surgery (METS) study.
        Br J Anaesth. 2021; 126: 181-190