What Are The Specific Adjustments I Should Make To The Bruce Protocol During An Exercise Electrocardiogram For A 65-year-old Patient With Known Coronary Artery Disease And A Resting Heart Rate Of 80 Beats Per Minute, Considering The Patient's Concomitant Beta-blocker Therapy And Chronic Obstructive Pulmonary Disease?

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To adjust the Bruce protocol for a 65-year-old patient with coronary artery disease (CAD), a resting heart rate of 80 bpm, on beta-blocker therapy, and with chronic obstructive pulmonary disease (COPD), consider the following modifications:

  1. Starting Point: Begin with a lower intensity, such as 1.0 mph at 0% grade, to accommodate the patient's CAD and COPD.

  2. Progression: Modify the progression by increasing the incline while keeping the speed lower or increasing speed more gradually. Consider using a modified Bruce protocol which starts at a lower intensity.

  3. Stage Duration: Maintain the standard 3-minute stages but be prepared to adjust based on the patient's tolerance and symptoms.

  4. Heart Rate Target: Set a lower target heart rate, considering beta-blockade. Aim for 120-130 bpm instead of the usual 155 bpm (220 - age).

  5. Monitoring: Focus on symptoms such as chest pain, shortness of breath, and ECG changes, as heart rate response may be blunted. Use tools like the Borg scale for perceived exertion.

  6. Termination: Be prepared to stop the test early if the patient experiences distress, considering both cardiac and respiratory symptoms.

  7. Cool Down: Ensure a proper cool-down period post-exercise to prevent complications.

By implementing these adjustments, the test can be conducted safely while accounting for the patient's medical conditions and medications.