Skip to main content
Log in

Ramp Exercise Protocols for Clinical and Cardiopulmonary Exercise Testing

Sports Medicine Aims and scope Submit manuscript

Abstract

Historically, the protocol used for exercise testing has been based on tradition, convenience or both. In the 1990s, a considerable amount of research has focused on the effect of the exercise protocol on test performance, including exercise tolerance, diagnostic accuracy, gas exchange patterns and the accuracy with which oxygen uptake (V̇O2) is predicted from the work rate. Studies have suggested that protocols which contain large and/or unequal increments in work cause a disruption in the normal linear relation between V̇O2 and work rate, leading to an overprediction of metabolic equivalents. Other studies have demonstrated that such protocols can mask the salutary effects of an intervention, and some have suggested that the protocol design can influence the diagnostic performance of the test. Guidelines published by major organisations have therefore suggested that the protocol be individualised based on the patient being tested and the purpose of the test. The ramp approach to exercise testing has recently been advocated because it facilitates recommendations made in these guidelines. This article reviews these issues and discusses the evolution of ramp testing which has occurred in the 1990s.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Table I
Table II
Fig. 2
Table III
Fig. 3

References

  1. Froelicher VF, Myers J. Exercise and the heart. 4th ed. Philadelphia (PA): W.B. Saunders, 2000

    Google Scholar 

  2. Gibbons RJ, Balady GJ, Beasley JW, et al. 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: 260–315

    Article  PubMed  CAS  Google Scholar 

  3. American College of Sports Medicine. Guidelines for exercise testing and exercise prescription. 6th ed. Philadelphia (PA): Lippencott, Williams & Wilkins, 2000

    Google Scholar 

  4. Myers J, Buchanan N, Walsh D, et al. Comparison of the ramp versus standard exercise protocols. J Am Coll Cardiol 1991; 17: 1334–42

    Article  PubMed  CAS  Google Scholar 

  5. Tamesis B, Stelken A, Byers S, et al. Comparison of the asymptomatic cardiac ischemia pilot and modified asymptomatic cardiac ischemia pilot versus Bruce and Cornell exercise protocols. Am J Cardiol 1993; 72: 715–20

    Article  PubMed  CAS  Google Scholar 

  6. Panza JA, Quyyumi AA, Diodati JG, et al. Prediction of the frequency of ambulatory myocardial ischemia in patients with stable coronary artery disease by determination of the ischemic threshold from exercise testing: importance of the exercise protocol. J Am Coll Cardiol 1991; 17: 657–63

    Article  PubMed  CAS  Google Scholar 

  7. Myers J, Buchanan N, Smith D, et al. Individualized ramp treadmill: observations on a new protocol. Chest 1992; 101: 2305–415

    Google Scholar 

  8. Kaminsky L, Whaley M. Evaluation of a new standardized ramp protocol: the BSU/Bruce ramp protocol. J Cardiopulm Rehabil 1998; 18: 438–44

    Article  PubMed  CAS  Google Scholar 

  9. Okin PM, Kligfield P. Effect of exercise protocol and lead selection on the accuracy of heart rate-adjusted indices of ST segment depression for detection of three-vessel coronary disease. J Electrocardiol 1989; 22: 187–94

    Article  PubMed  CAS  Google Scholar 

  10. Myers J, Froelicher VF. Optimizing the exercise test for pharmacologic studies in patients with angina pectoris. In: Ardissino D, Savonitto S, Opie LH, editors. Drug evaluation in angina pectoris. Pavia: Kluwer Academic, 1994: 41–52

    Chapter  Google Scholar 

  11. Balke B, Ware RW. An experimental study of physical fitness of Air Force personnel. U S Armed Forces Med J 1959; 10: 675–88

    PubMed  CAS  Google Scholar 

  12. Åstrand PO, Rodahl K. Textbook of work physiology. 3rd ed. New York (NY): McGraw-Hill, 1986

    Google Scholar 

  13. Bruce RA. Exercise testing of patients with coronary heart disease. Ann Clin Res 1971; 3: 323–30

    PubMed  CAS  Google Scholar 

  14. Ellestad M. Stress testing: principles and practice. 4th ed. Philadelphia (PA): F.A. Davis, 1997

    Google Scholar 

  15. Naughton JP, Haiden R. Methods of exercise testing. In: Naughton JP, Hellerstein HK, Mohler LC, editors. Exercise testing and exercise training in coronary heart disease. New York (NY): Academic Press, 1973; 79–91

    Google Scholar 

  16. Buchfuhrer MJ, Hansen JE, Robinson TE, et al. Optimizing the exercise protocol for cardiopulmonary assessment. J Appl Physiol 1983; 55: 1558–64

    PubMed  CAS  Google Scholar 

  17. Webster MWI, Sharpe DN. Exercise testing in angina pectoris: the importance of protocol design in clinical trials. Am Heart J 1989; 117: 505–8

    Article  PubMed  CAS  Google Scholar 

  18. Redwood DR, Rosing DR, Goldstein RE, et al. Importance of the design of an exercise protocol in the evaluation of patients with angina pectoris. Circulation 1971; 43: 618–28

    Article  PubMed  CAS  Google Scholar 

  19. Weiner DA, Ryan TJ, McCabe CH, et al. Value of exercise testing in determining the risk classification and the response to coronary artery bypass grafting in three-vessel coronary artery disease: a report from the Coronary Artery Surgery Study (CASS) registry. Am J Cardiol 1987; 60: 262–6

    Article  PubMed  CAS  Google Scholar 

  20. Mark DB, Hlatky MA, Harell FE, et al. Exercise treadmill score for predicting prognosis in coronary artery disease. Ann Intern Med 1987; 106: 793–800

    PubMed  CAS  Google Scholar 

  21. Chang JA, Froelicher VF. Clinical and exercise test markers of prognosis in patients with stable coronary artery disease. Curr Probl Cardiol 1994; 19: 533–8

    Article  PubMed  CAS  Google Scholar 

  22. Morris CK, Ueshima K, Kawaguchi T, et al. The prognostic value of exercise capacity: a review of the literature. Am Heart J 1991; 122: 1423–31

    Article  PubMed  CAS  Google Scholar 

  23. Whipp BJ, Davis JA, Torres F, et al. A test to determine parameters of aerobic function during exercise. J Appl Physiol 1981; 50: 217–21

    PubMed  CAS  Google Scholar 

  24. Bhadha K, Walter J, DiMarzio D, et al. Comparison of the Bruce and ramp protocols in the assessment of left ventricular performance during exercise in healthy women. Am J Cardiol 1995; 75: 963–6

    Article  PubMed  CAS  Google Scholar 

  25. McInnis K, Bader D, Pierce G, et al. Comparison of cardiopulmonary responses in obese women using ramp versus step treadmill protocols. Am J Cardiol 1999; 83: 289–91

    Article  PubMed  CAS  Google Scholar 

  26. Bader D, Maguire T, Balady G. Comparison of ramp versus step protocols for exercise testing in patients ≥60 years of age. Am J Cardiol 1999; 83: 11–4

    Article  PubMed  CAS  Google Scholar 

  27. Hlatky MA, Boineau RE, Higginbotham MB, et al. A brief self-administered questionnaire to determine functional capacity (the Duke activity status index). Am J Cardiol 1989; 64: 651–6

    Article  PubMed  CAS  Google Scholar 

  28. Rankin S, Briffa T, Morton A, et al. A specific activity questionnaire to measure the functional capacity of cardiac patients. Am J Cardiol 1996; 77: 1120–223

    Article  Google Scholar 

  29. Myers J, Do D, Herbert W, et al. A nomogram to predict exercise capacity from a specific activity questionnaire and clinical data. Am J Cardiol 1994; 73: 591–6

    Article  PubMed  CAS  Google Scholar 

  30. The Criteria Committee of the New York Heart Association. 1994 revision to classification of functional class and objective assessment of patients with disease of the heart. Circulation 1994; 92: 644–5

    Google Scholar 

  31. Campeau L. Grading of angina pectoris. Circulation 1976; 54: 522–3

    PubMed  CAS  Google Scholar 

  32. Goldman L, Hashimoto B, Cook EF, et al. Comparative reproducibility and validity of systems for assessing cardiovascular functional class: advantages of a new specific activity scale. Circulation 1981; 64: 1227–34

    Article  PubMed  CAS  Google Scholar 

  33. Myers J, Gullestad L. The role of exercise testing and gas-exchange measurement in the prognostic assessment of patients with heart failure. Curr Opin Cardiol 1998; 13: 145–55

    PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Jonathan Myers.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Myers, J., Bellin, D. Ramp Exercise Protocols for Clinical and Cardiopulmonary Exercise Testing. Sports Med 30, 23–29 (2000). https://doi.org/10.2165/00007256-200030010-00003

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.2165/00007256-200030010-00003

Keywords

Navigation