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The occurrence of Wenckebach- during and after exercise have been variable. Recent studies type Mobitz type I AV block during exercise is rare because have suggested that frequent or complex repetitive ventricular vagal tone is reduced during exercise, whereas sympathetic activity during exercise, and particularly ventricular ectopy in neurohumoral tone increases.

The clinical significance of the recovery period after exercise, can be independent predic- exercise-induced Mobitz type II AV block generally is related tive markers for death. Disorders of impulse con- rate-related phenomenon that appears as the sinus rate is accel- duction include abnormalities of normal impulse initiation erated beyond a critical level.

block develops during exercise, the test should be terminated. Bundle-Branch and Fascicular Blocks. Intracardiac conduction THIRD-DEGREE COMPLETE AV BLOCK. Acquired advanced or blocks can exist before exercise, develop during exercise, or dis- complete AV block at rest is a relative contraindication to exer- appear during exercise. Rate-dependent intraventricular blocks cise testing because increasing sympathetic drive without effec- that develop during exercise often precede the appearance of tive rate increase can result in complex ventricular arrhythmias.

chronic blocks that develop later at rest. The development of ECG is usually impossible when left bundle-branch block is complete block during exercise testing is uncommon, but it can present.

There can be a marked degree of exercise-induced ST- be related to transient ischemia. subjects with left bundle-branch block, and there is no clear dif- ference in ST-segment response to exercise between those with Exercise and Preexcitation Syndromes. Exercise can pro- and those without myocardial ischemia. Left bundle-branch voke, abolish, or have no effect on ventricular preexcitation block that develops during exercise might or might not be asso- in individuals with known WPW syndrome.

In the pres- of intraventricular blocks that are present at rest is rare. Although precordial leads V1, V2, and V3 , where ST depression is fre- exercise has been considered a predisposing factor to initiate quently present at baseline and increases with exercise even in tachyarrhythmia in WPW syndrome, prevalence of tachyar- the absence of coronary obstruction. test, as described in the sections that follow. Sensitivity is the percentage study.

Sensitivity is influenced by disease severity, effort level, those with an abnormal resting ECG, including bundle-branch and anti-ischemic drugs. Specificity is the percentage of those block, resting ST-T-wave abnormalities, or LV hypertrophy. without the disease who will have normal test results, and it Positive and Negative Predictive Values can be affected by drugs such as digoxin, by baseline electro- Predictive values help define the diagnostic value of a test.

cardiographic patterns, and by LV hypertrophy. Sensitivity and The predictive value of a test is greatly influenced by the specificity are inversely related; when sensitivity is the high- prevalence of disease in the group or individual being tested. est, specificity is lowest, and vice versa.

As in a high-prevalence population; conversely, a higher negative a graphical tool, a receiver operating characteristic plot dis- predictive value and lower positive predictive value occur in a plays the test sensitivity on the y-axis against 1 minus the test lower-prevalence population. For example, an exercise ECG specificity on the x-axis for varying values of the diagnostic that demonstrates ST depression in an elderly person with cut point.

The area under the curve provides a summary mea- typical anginal symptoms is most likely a true positive result, sure that averages the diagnostic accuracy across the range of whereas that in a young asymptomatic person without cardiac test values.

It equals 1. curve corresponds to random chance. Thus, the closer the area Pretest and Posttest Probability of Disease is to 1. On the basis of individual like- most data are derived from studies in which patients under- lihood of disease and the performance characteristics of the went both exercise testing and cardiac catheterization.

Because outcome on exercise ECG, the posttest likelihood of obstruc- patients selected for coronary arteriography are more likely to tive CAD can be estimated for a given individual. have obstructive CAD, these data are subject to a workup bias that inflates the estimated sensitivity and deflates the specific- Assessment of Anatomic and Functional Extent of CAD ity.

The diagnostic accuracy of a test also will be influenced by Exercise-induced ST-segment depression does not provide a criteria that are used to determine whether an adequate level reliable assessment of the specific coronary vessel s involved. of stress has been achieved. There are can be localized by the leads involved: Leads V2 through V4 reflect shortcomings to using this calculation for diagnostic purposes, left anterior descending artery disease; lateral leads reflect left and it should not be used as a sole reason to terminate the test.

ECG, HR, and of CAD include the degree, time of appearance, duration, and blood pressure are monitored during each stage. number of leads with ST-segment depression or elevation. Intravenous ble but nonobstructive plaque. Complications of dobutamine infu- and should be done with consideration of several non—ST-seg- sion include nausea, headache, tremor, anxiety, angina and ment variables, as discussed in the later section on prognosis. diographic testing alone. Imaging provides information on Selective A2a Adenosine Receptor Agonists and Adenosine the location and amount of ischemic myocardium and on LV Vasodilators such as adenosine, dipyridamole, and regadenoson function.

Exercise or pharmacological stress imaging stud- cause coronary vasodilation in normal epicardial arteries. vasodilators are given.

The relative lack of increased perfusion The Ischemic Cascade during vasodilation can be visualized with nuclear myocardial The limitation of coronary flow reserve by hemodynamically perfusion agents. The acute metabolic dobutamine may serve as an alternative to exercise. consequences of this mismatch include decreased production Nuclear perfusion imaging with vasodilator agents is use- of adenosine triphosphate and increased production of lactate, ful particularly for the diagnosis of CAD in patients with left and they result in alterations of the electrical properties and bundle-branch block on resting ECG, because artifactual mechanical function of the myocardium.

These alterations perfusion defects can occur in patients with normal coronary occur in rapid succession in a characteristic sequence termed arteries and left bundle-branch block with exercise or dobuta- ischemic cascade and include, in typical order, reduced LV mine stress. Side effects of vasodilator agents include flush- compliance, regional wall motion abnormalities attributable ing, chest pain, headache, nausea, dyspnea, and AV block, to decreased myocardial contractility, increased LV end- which can be reversed with aminophylline.

Adenosine and dipyr- pectoris often occurs last, if at all. idamole should not be used in patients with second- or third- Pharmacological stress imaging identifies the relative lack degree block who do not have permanent pacemakers in place or in patients with severe asthma or chronic obstructive lung of increase in perfusion in myocardial territories supplied by a disease.

or functional consequences of the mismatch between oxygen supply and demand resulting from exercise-induced ischemia. Nuclear Myocardial Perfusion Imaging Stress myocardial perfusion imaging can be performed as Pharmacological Stress Testing and Agents single-photon emission computed tomography SPECT or In patients unable to exercise for reasons such as deconditioning, positron emission tomography PET. SPECT uses commercially available tracers demand and supply in lieu of physical exercise or to unmask such as technetium Tc m sestamibi, Tcm-tetrofosmin, locally limited capacity for coronary vasodilatation.

Medications and, less commonly, thallium PET uses myocardial perfu- used for pharmacological stress testing include dobutamine, sion imaging agents with very short half-lives, of which rubid- selective A2a adenosine receptor agonists, and adenosine. ium Rb can be produced with a generator, whereas N Dobutamine ammonia requires a local cyclotron.

Compared with SPECT, Adrenergic agents such as dobutamine increase myocardial PET typically has higher spatial and temporal resolution, has oxygen demand by increasing myocardial contractility, HR, a lower effective radiation dose, allows quantitative measure- and blood pressure. Dobutamine is infused intravenously at ment of myocardial perfusion, and can be performed faster.

Nonetheless, retically ideally suited for quantitative myocardial perfusion cumulative radiation is a factor in serial perfusion imaging. measurements, but technical limitations, including radiation SPECT and N ammonia PET can be performed with exer- dose to patients, have limited its development.

An increasing cise and pharmacological stress, whereas R PET imaging can number of clinical reports on vasodilator stress myocardial be performed only with pharmacological stress because of the perfusion imaging with computed tomography are being pub- extremely short tracer half-life.

The radioisotope is injected, and lished at the time of this writing. Myocardial perfusion images at rest CAD in symptomatic patients with chest pain, determining and during stress are displayed as tomographic slices in 3 dif- myocardial viability before revascularization, assessing ferent views to visualize all myocardial segments without over- prognosis after MI or in patients with chronic angina, and lap.

Details at rest indicate myocardial ischemia. Perfusion defects that are about exercise and stress testing with cardiac imaging present during exercise and persist at rest suggest previous MI. The ACCF and AHA now include these procedural With exercise stress, echocardiographic images in several guidelines in the ongoing updates of disease-based guidelines, views are obtained with electrocardiographic gating ie, syn- such as those for stable ischemic heart disease, acute coronary chronized to the QRS complex at rest and while the patient syndromes, heart failure, and other conditions.

performs stationary cycling or immediately after treadmill The ACCF, along with the AHA and other specialty and exercise. of patients with known or suspected CVD. Appropriate use With pharmacological stress, images are obtained at baseline, criteria can be periodically updated.

These documents reflect with low-dose and peak dobutamine infusion, and during an ongoing effort by the ACCF to critically and systematically recovery. Echocardiography by itself has no known risks, and create, review, and categorize clinical situations in which such serial testing has no known cumulative effects.

procedures may be used. Although it is recognized that levels The images obtained during different phases of the stress test of evidence supporting test appropriateness will vary, practical are compared side by side. Myocardial contractility normally consensus is required where conclusive evidence is lacking. It increases with exercise, whereas ischemia causes hypokinesis, is anticipated that appropriate use criteria will have an impact akinesis, or dyskinesis of the affected segments.

An exercise or on physician decision making, test performance, and reim- stress echocardiogram is considered positive if regional wall bursement policy and will guide future research. Appropriate motion abnormalities develop with exercise in previously normal use criteria for stress cardiac nuclear imaging and stress echo- segments or become more severe in already abnormal segments. cardiography are outlined in detail elsewhere. gauge prognosis regardless of whether CAD is present.

In fact, although reliance on exercise testing for CAD diagno- Cardiac Magnetic Resonance Imaging and Computed sis increasingly is challenged by alternative diagnostic strate- Tomography gies eg, imaging modalities, serologic markers , application Technological advances in magnetic resonance imaging and of exercise electrocardiographic testing to assess prognosis is computed tomography have resulted in increasing use of these increasing3, and often serves as a complementary perspec- modalities for cardiac imaging.

Standard exercise equipment tive for management decisions. Multiple in many experienced centers. tive to age- and sex-based standards.

Still, even this stratifica- Nonetheless, several procedural issues must be addressed tion is only an approximation because differences in height, in the assessment of maximal exercise capacity. Many regard weight, and mode of exercise all modify exercise potential and CPX as a superior means to assess exercise performance ideally should be incorporated into stratifications of age and because gas exchange measurements provide detailed informa- sex standards.

protocol is a powerful predictor of prognosis in patients with Abnormal Chronotropic Response to Exercise known or suspected CVD. Nevertheless, there are consider- Chronotropic incompetence is the inability of the HR to ations that help optimize the value of standard exercise test- increase commensurate with increased activity or demand. ing to assess exercise capacity and prognosis. The widely used An intact HR response is vital for matching cardiac out- Bruce protocol was developed as an efficient diagnostic test for put to metabolic demands during exertion.

Investigations in middle-aged men; however, it might not be the optimal proto- population-based and clinical cohorts demonstrated that an col to assess exercise capacity in heterogeneous populations, impaired chronotropic response is predictive of cardiac events particularly in elderly, obese, and deconditioned individuals. In and all-cause death. The simplest approach is to report change of exercise with the Bruce protocol because of physical limi- in HR with exercise relative to peak HR.

Because peak HR tations instead of physiological exhaustion, thereby diminish- decreases with age, age-predicted maximal HR is often deter- ing the prognostic implications of low exercise performance. mined as minus age in years. However, baseline functional ments in energy requirements between stages are available that capacity and resting HR also have bearing on chronotropic could be better suited to measure exercise capacity in elderly responses. Therefore, an alternative method to determine and deconditioned individuals.

chronotropic incompetence entails assessment of the propor- A related limitation of routine prognostic assessment based tion of HR reserve used at peak exercise, defined by the differ- on exercise capacity is that many stress testing laboratories use ence between age-predicted maximal HR and resting HR.

This value is often referred of the maximally predicted HR, a threshold assumed sufficient to as the chronotropic index or the proportion of HR reserve for sensitive diagnosis of CAD. With imaging as the priority, used during exercise. Furthermore, exercise capacity often is reported merely in —0. minute after cessation of the exercise test, while in the upright Whereas absolute METs achieved by a year-old man might position, is most frequently used to define an abnormal HR be greater than those achieved by a year-old woman, he recovery response.

Numerous investigations have demonstrated that a predict death than ectopy originating from the right ventricu- decreased HR recovery is a strong adverse prognostic marker lar outflow tract or other relatively benign variants. sistencies in the literature have led to some uncertainty about Advantages of imaging include the opportunity to characterize this index.

Some HR recovery protocols entail active cool- ejection fraction, extent and distribution of ischemia, presence down. Initial reports of HR recovery were based on patients of coronary calcification, and, in some cases, even the intrinsic who underwent an upright cool-down protocol with a slow structure of stenoses, all of which are powerful risk predictors walk for 2 minutes immediately after exercise.

With this pro- for both death and cardiovascular events. In standard exercise prognostic electrocardiographic testing. When different protocols are even when SPECT imaging is available, and relatively little used, HR recovery cut points have tended to be higher, but additional prognostic insight is gained by adding SPECT the implications of attenuated HR deceleration were similar.

Adults who are older, deconditioned, female, or ischemia or other known heart disease. Exercise-induced hypotension consistently has been for exercise stress to determine prognosis in situations in shown to be a marker of increased risk for adverse events. with subthreshold HR. The component of the Duke for future hypertension, LV hypertrophy, and cardiovascular Treadmill Score that has been consistently validated for inde- events.

Some reports indicate that can be used as a multivariate score to predict risk. First devel- ventricular ectopy during exercise testing heralds increased oped as a score to improve the sensitivity of the exercise test risk of death, whereas others do not.

Other studies indicate for the diagnosis of CAD in men and later also in women, increased risk of death in those demonstrating increased ven- the Morise score was subsequently applied to the prediction tricular ectopy in recovery.

sured directly by CPX have been used as criteria for disability by the Social Security Administration. Additional Uses of Exercise Testing Evaluation of Perioperative Risk for Noncardiac Surgery Exercise Prescription In most ambulatory patients, exercise testing with electro- Although the indications for exercise testing are varied, the cardiographic monitoring provides both an estimate of assessment of exercise response and determination of func- functional capacity and the detection of myocardial ischemia tional capacity are particularly useful in the development of through changes in the ECG and hemodynamic response.

the exercise plan or prescription. However, pharmacological stress imaging to the healthy population. In addition, training results in increased a higher relative risk of future events such as angina pectoris, exercise time and workload to provocation of symptoms pre- MI, and sudden death, the absolute risk of cardiac events in viously identified during submaximal exercise, such as angina these populations remains low.

Measurable dictive value of any test in low-risk populations must be low. improvements, or lack thereof, provide the basis for updates It is also acknowledged that prospective, multicenter studies in the exercise prescription and determination of subsequent to demonstrate that interventions based on exercise electro- strategies for patient care.

cardiographic findings alone can favorably alter clinical out- Response to Medication comes in asymptomatic subjects are wanting. Management of medication prescribed to control exercise- Even so, several exercise electrocardiographic findings related symptoms or various inappropriate cardiorespira- have been related to future risk and have potential importance tory responses also can be evaluated with exercise testing.

for risk management. However, the positive predictive value was risk factors. A concomitant abnormal exercise thallium tions based on the following considerations. Most acute cardiac beats did not have significant prognostic value in this popu- events are attributable to plaque rupture of minor stenoses lation.

Although abnormal HR-adjusted ST-segment findings, but not standard extensive obstruction makes unstable plaque more likely and ST-depression criteria alone, identified increased 4-year risk might be more readily identified by exercise testing, it is not of coronary heart disease events. With regard to subjects who are asymptomatic but have risk Prediction of exercise-related MI and sudden death by exercise factors for CAD, exercise testing could have greater predic- testing is therefore limited by the same factors that reduce tive value.

Exercise testing was of no predictive value asymptomatic low-risk younger subjects. However, there are in the group with no risk factors. Interestingly, a positive test was not significantly management, particularly when functional test findings such associated with nonfatal MI.

Furthermore, asymptomatic from CAD among men with an abnormal test response and patients at higher risk for obstructive CAD could benefit suggested that the exercise ECG might serve to identify high- from the reassurance provided by a normal test, which risk men who do benefit from interventions targeting risk fac- might facilitate prescription of and compliance with more tor reduction. Exercise testing is well. in individuals with chest pain or with dyspnea on exertion, with or without known CAD, to evaluate whether vigorous Before Participation in Vigorous Exercise exercise is appropriate for such an individual, to establish Vigorous physical exertion, usually defined as exercise requir- training limits, and to develop an exercise prescription.

However, individual risk of adverse events is reduced Education Program. Whether exercise testing should be performed in asymp- www. tomatic adult subjects before beginning vigorous exercise has been controversial—even more so for routine screening of Exercise Electrocardiographic Testing in Women young people before engaging in athletics. Exercise testing has similar diagnostic and prognostic value in Exercise testing before beginning an exercise program has women as it does for men.

Exercise capacity but no evidence of coronary disease on an angiography. Although a study of women who underwent stress testing and sub- overall prognosis in these women is better than in those with sequent angiography, exercise capacity was among the best obstructive coronary disease, syndrome X is nonetheless stress testing variables for predicting the presence of CAD, associated with an increased rate of cardiovascular mortality, and it improved the sensitivity and specificity of exercise test- including sudden cardiac death, MI, and heart failure.

no significant ischemia detected. The prognostic value of exercise capacity has been shown in The Pediatric Population both asymptomatic women73, and symptomatic women. It is also asymptomatic women, exercise capacity was an independent sometimes necessary to modify protocols. Low ramp rates are predictor of death as well, where for each additional MET needed for small children performing cycle ergometry.

In contrast, for many capacity was lower for women than for men. They of symptomatic women referred for exercise testing and tend to generate unrealistically low values for small children, angiography, the presence of CAD correlated with the Duke especially boys. In terms of progno- be used in these calculations. study, exercise agree well with the results of these tests. Although myocardial with interpretable ECGs and good effort capacity.

Even in conditions where there percentage of their maximal capacity at specific submaximal is a potential for impaired coronary perfusion eg, congenital exercise loads than that exerted by younger people.

The systolic blood pressure response to both maximal monitoring. For patients with known or suspected CAD, stress and submaximal aerobic exercise also is increased with age.

If, on the women. Because of its poor diagnostic accu- attributable to LV stiffness and decreased compliance. An exercise test with pre- and postexercise spirometry and ejection fraction responses to maximal aerobic exercise is a might be a worthwhile study if this condition is suspected.

Some disorders, such as PAD and chronic obstruc- Measurements at peak exercise are particularly helpful in this tive lung disease, frequently coexist with CAD because of regard. However, for peak exercise data to be reliable and repro- shared risk factors. Degenerative arthritis of weight-bearing ducible, it is important to ascertain that the patient expends a joints is the most prevalent chronic disorder in older adults.

maximal or near-maximal effort. Exercise laboratory person- Additionally, mental health issues and cognitive impairment nel should therefore be familiar with effective techniques for can also affect the ability to perform exercise testing in the motivating children to expend adequate efforts.

During CPX older adult. Moreover, unfamiliarity with vigorous exercise testing, patients should be encouraged to continue exercising and fear of exercise testing equipment can intimidate older until the respiratory exchange ratio exceeds 1. In prepu- patients, resulting in submaximal test results. When added to bescent children, anaerobic metabolic pathways might not be the effects of comorbid ailments, the end result could be a expressed to the extent seen in older individuals, and a respi- symptom-limited test of only a few minutes.

ratory exchange ratio of 1. Large autopsy studies have dem- chronotropic defects and cannot achieve normal peak HRs. In general, exacerbation dramatically with age. In patients bank, and other series have documented an age-associated with structurally normal hearts, the suppression of ectopy increase in CAD severity. The age differences in the prevalence and severity of CAD and treadmill is preferred in older subjects who do not have signif- comorbid conditions be considered.

with stable CAD. The use of use in apparently healthy older adults, exercise testing has also smaller, more frequent increments in work rate is preferable to demonstrated prognostic significance in such a population. For either over 8 years of median follow-up. These pretest score based on a 4-point dyskinesis ranking in each of 16 maneuvers will help alleviate the anxiety of the older patient segments from rest to peak exercise was a potent independent and reduce the risk of musculoskeletal injury and falls.

National surveys of exercise laboratories have docu- respectively, and an earlier study of patients whose mean age mented very low overall risks of MI or cardiac death, and was 72 years. prognostic utility in this age group. been observed.

The supervising clinician should be aware that Hypertension myocardial ischemia or MI in the older adult can present as Hypertension per se is not an indication for exercise testing, but marked dyspnea, extreme fatigue, or chest pressure, rather it is very often present in individuals who are referred for test- than as typical chest discomfort or pain.

The test should be postponed if resting systolic blood pres- Exercise testing is well established as a useful tool for sure exceeds mm Hg or if diastolic exceeds mm Hg.

assessing the progress of patients with stable CAD and those Antihypertensive medications generally should not be withheld who have had MI. Available data in the older adult, although before testing. Hypertensive individuals often have an exagger- more limited, suggest similar prognostic value in this age ated pressure response to exercise even if resting levels are con- group. As in the general post-MI population, inability to per- trolled.

In the latter group, 1-year mortality rate was best capacity in people with hypertension and normal systolic LV predicted by the magnitude of systolic blood pressure rise dur- function. In contrast, ST-segment depression and diovascular outcomes in otherwise healthy people with hyper- ventricular arrhythmia predicted recurrent MI and need for tension, as is true in normotensive individuals. coronary revascularization but not death. In older patients with stable CAD, exercise testing also has Obesity diagnostic and prognostic utility.

For many obese patients, particularly the morbidly obese, Exercise testing has several potential uses in patients with this is related to gait instability, low functional capacity, coex- PAD. First, it is the most objective method of quantifying isting orthopedic impairments, and uneven body weight dis- walking capacity in those with exercise-induced claudication tribution. In one study, 25 obese women mean BMI of 40 or suspected PAD. Given the high Bruce protocols on the basis of a pretest activity question- prevalence of CAD in patients with PAD, exercise testing is naire.

Despite a longer time to reach fatigue when the ramp also indicated to detect CAD. different between tests. In another study, obese subjects with The specific exercise test variables used to assess PAD CAD were assigned to 2 severe energy-deficient study groups functional severity are distance or time to onset of claudica- one with exercise and the other by diet plus a control group.

tion pain and peak exercise distance or time. In conclu- Measurement of ankle—brachial index immediately after exer- sion, these 2 studies and clinical experience reveal that obese cise testing can help diagnose PAD in difficult cases and also subjects can have exercise tests effectively performed with a can determine the extent of circulatory impairment.

Because variety of protocols. Low-impact walking protocols, starting the pressure distal to an obstructive arterial lesion falls during at low work rates with small increments between stages, are exercise as a result of dilation of distal arterioles, the ankle— preferred in this patient population.

In asymptomatic individuals who have diabetes mellitus and in such patients, both shorter treadmill exercise time and lower assessing prognosis. Asymptomatic individuals who have dia- 6-minute walk distance have been correlated with greater betes mellitus generally show reduced aerobic capacity relative superficial femoral artery plaque burden. Arm exercise testing often fails to elicit ischemic ST-segment Such individuals were at increased risk for total mortality, MI, depression or angina because the patient is limited by fatigue.

Many testing protocols use arm cycle higher risk of death over a mean follow-up of 7. asymptomatic patients who have diabetes mellitus with exer- Safe and effective testing can be performed by most of these cise ECG or pharmacological myocardial perfusion imaging subjects. If arm ergometry is considered, the protocol should could identify substantial numbers of individuals with induc- begin at a resistance of 20 W and be increased by 10 W per ible myocardial ischemia, the recent Detection of Ischemia in stage.

Electronically braked ergometers allow for constant Asymptomatic Diabetics DIAD and Do You Need to Assess workloads at various cranking revolutions per minute. Each Myocardial Ischemia in Type-2 diabetes DYNAMIT trials stage should last 2 consecutive minutes, with a 1-minute rest showed no significant benefit of such screening on hard clinical period before beginning the next stage. In accord with Bayesian principles, the angiography performed well for predicting absence of acute greatest incremental diagnostic value occurs in intermediate- coronary syndrome in an observational cohort study and could risk clinical patient subsets.

Exercise treadmill testing should become an important triage alternative to traditional exercise be considered in patients who present to the ED with symptoms testing in ED patients with acute chest pain syndromes. In response to tachycardia. Exercise testing is considered useful, most studies, it is performed soon after presentation after an Class IIa, for evaluating the response to medical or ablation acute coronary syndrome has been excluded.

Acute coronary treatment in patients with known exercise-induced ventricu- syndromes are ruled out by an accelerated diagnostic protocol, lar arrhythmias.

Class IIb recommendations include patients which is usually performed within a 6- to hour interval with with arrhythmias but a low probability of CAD and for the serial cardiac serum markers and ECGs.

Both methods have thus far been shown to be safe, by the 6-minute walk test was considered more accurate than informative, and cost-effective, although experience with the clinical variables such as functional classification for the pre- latter is considerably more limited than with the former. diction of death and sudden death in chronic heart failure. No adverse documented VT, pacemakers, and T-wave alternans. Class effects of exercise testing were reported. Class IIa indications include and at 5-month follow-up.

Compared with patients with a arrhythmia provocation in patients with known or suspected positive test, those with negative tests had equivalent, or exercise-induced arrhythmias, including evaluation of medi- fewer readmissions at 1 to 6 months.

Substantial cost savings cal, surgical, or catheter ablation therapy in such individuals; also have been demonstrated with an accelerated management evaluation of ventricular rate response and suspected myocar- protocol that included exercise testing. normal, near-normal, or unchanged ECGs. The prototype for such arrhyth- adverse effects of exercise testing. structural heart disease. In patients with patient population, given their association with pulmonary long-QT interval syndrome, exercise testing may elicit QT ventilation—perfusion mismatching, a primary consequence of prolongation, which can be useful in risk stratification.

Initial evidence indicates that T-wave alternans represents macroscopic or measurable these CPX variables are both prognostic and gauge therapeutic microscopic alternation in electrocardiographic T-wave ampli- efficacy in patients with pulmonary arterial hypertension. T-wave alternans testing performed in conjunction could become a secondary consequence, such as in heart with exercise testing can be useful in identifying patients at failure, HCM, chronic obstructive lung disease, and interstitial risk for developing life-threatening ventricular arrhythmias.

Adults with congenital heart disease usually have cardiovas- In patients with rate-adaptive pacemakers, exercise testing cular issues that are distinct from those encountered among can help to optimize the HR response and increase exercise other adult cardiology patients.

The role of exercise testing in capacity. adult cardiology patients. In general, the primary goal of exer- Patients with atrial fibrillation not uncommonly demon- cise testing in adults with congenital heart disease is not the strate exaggerated ventricular rate responses to low-level exer- detection or evaluation of CAD. Rather, purposes of the test cise even when resting HR appears well controlled.

functional capacity, the exercise test protocol should typically The validity of these data depends on adequate effort expendi- be conservative in nature. In addition, tic efficacy. found to be an independent predictor of death or hospitaliza- Pulmonary Hypertension tion in a variety of congenital heart defects, including tetral- The role of CPX in assessing pulmonary hemodynamics is a ogy of Fallot, repair of transposition of the great arteries, rapidly emerging field demonstrating a great deal of clinical and Fontan physiology.

Perhaps years. Thus, it is unclear whether the low peak HR was of end-tidal CO2 during exercise, reflect the degree of elevation an independent risk factor for death or merely a marker for a in pulmonary arterial pressure and therefore disease severity.

history of serious arrhythmias. The abnormal pressure impairment is likely attributable to an impaired chronotropic response appears to be mediated by a decrease in stroke response, reflected by a depressed peak HR, or an impaired volume attributable to systolic dysfunction.

stroke volume response, reflected by a low oxygen pulse at Although nonsustained VT NSVT during ambulatory peak exercise. It also should be noted that in the presence of electrocardiographic monitoring is associated with increased significant chronotropic impairment there should be a com- risk of sudden cardiac death in patients with HCM, the role of pensatory increase in stroke volume and oxygen pulse, solely exercise-induced NSVT in predicting adverse outcomes is less on the basis of the Frank-Starling mechanism.

Under these clear. On multivariate analysis, useful in patients with congenital heart disease. In 1 study of monary artery stenoses. tetralogy patient and a strong, negative impact on prognosis. great arteries. cise in patients, and no patients experienced syncope. to pulmonary blood flow maldistribution and ventilation— The reduced stroke volume is secondary to blunting of pre- perfusion mismatch secondary to the absence of a pulmonary load reserve, the end-diastolic volume.

The sensitivity of the exercise ECG for detect- response to exercise, a provocable LVOT gradient, or exercise- ing myocardial ischemia is also very low in this population. Blood pressure, line electrocardiographic abnormalities and LV hypertrophy. HR, and electrocardiographic responses are usually normal. Aortic Stenosis Subjects with severe mitral regurgitation do not necessarily Effort syncope in subjects with aortic stenosis is an important have a decreased cardiac output and limited exercise capacity.

and well-appreciated symptom. In asymptomatic patients with severe an absolute contraindication for testing because of concern mitral regurgitation and preserved LV function, exercise test- about syncope and cardiac arrest. Proposed mechanisms for ing with Doppler echocardiography is reasonable to assess exercise-induced syncope in subjects with aortic stenosis exercise capacity and the effect of exercise on pulmonary include carotid hyperactivity, LV failure, arrhythmia, and LV artery pressure.

In such patients, mitral valve surgery should baroreceptor stimulation. be considered if pulmonary artery systolic pressure exceeds Exercise testing might be useful, however, in asymptomatic 60 mm Hg during exercise. Testing should be ter- translate into a reduction in diagnostic accuracy.

Maximum minated if angina, dizziness, decrease in systolic blood pres- HR—systolic blood pressure product likely would be reduced. In the presence of an abnormal blood pres- before testing should be recorded. A normal QT interval is Subjects with aortic regurgitation usually maintain a normal associated with digitalis-induced ST changes, whereas pro- exercise capacity for a longer time than those with aortic ste- longed QT intervals occur with ischemia, other type 1 anti- nosis.

During exercise, the decreases in diastolic duration and arrhythmic drugs, electrolyte imbalance, and other medical regurgitation volume favor forward output.

As the myocardium problems. Exercise-induced ST-segment depression can persist fails, peak HR tends to slow, and ejection fraction and stroke for 2 weeks after some preparations of digitalis are discontinued. volume decrease. Exercise testing can be useful in patients with Diuretics asymptomatic severe aortic regurgitation to assess functional Most diuretics have little influence on HR and cardiac perfor- capacity and symptom response.

Surgery is usually indicated if mance but do decrease plasma volume, peripheral resistance, unequivocal symptoms are elicited at a low workload. Diuretics can cause hypokalemia, which Mitral Stenosis can result in muscle fatigue, ventricular ectopy, and, rarely, Subjects with mitral stenosis can show either a normal or ST-segment depression. an excessive increase in HR during exercise.

Because stroke Hormones volume cannot be significantly increased, the normal rise of cardiac output is attenuated, and cardiac output eventually Menstrual Cycle can fall during exercise; this is frequently accompanied by Research on the impact of the menstrual cycle on various exercise-induced hypotension.

Resting, exercise, and mittent anovulatory cycles, which might not be apparent on recovery HRs and blood pressures should be tabulated accord- the basis of bleeding pattern. The available literature suggests ing to stages, and peak exercise values should be stated. There that there are probably no major differences in muscle con- should be a specific statement with regard to the presence or tractile characteristics, maximum oxygen uptake, or substrate absence of chest pain at peak exercise and whether this was the utilization during exercise between phases of the menstrual reason for termination of the test.

Patient effort can be defined cycle, but it has been suggested that the elevated body temper- by percent maximum predicted HR achieved or by use of a ature during the luteal phase of the cycle could limit exercise chronotropic index.

Additionally, it is useful to describe effort in hot environments. One study reported shorter time to ST-segment depression and the test should be defined as positive, negative, or equivo- more frequently during the menstrual and preovulatory phases cal according to standard ST-segment criteria.

Several princi- phase. supplemented with estrogen and amelioration of postexer- The goal of this section on exercise training is to provide an cise ST-segment depression among men supplemented with evidence base for the medical benefits of long-term physical testosterone. Care is taken to merge the public health benefits ST-segment depression between postmenopausal women on of exercise with the medical model, such that medical evalu- and not on hormone replacement did not quite reach statistical ation is not set up as a barrier to exercise, yet selected higher- significance.

estrogen monotherapy. Changes in vasomotor tone, changes in auto- hemodynamic function, autonomic nervous system function, nomic tone, and a digitalis-like effect have been proposed. Collectively, these adaptations result in an The Exercise Electrocardiographic Test Report exercise training effect, which allows an individual to exercise The exercise test report should describe information relevant longer, to higher peak workloads, with lower HRs at submaxi- to diagnosis and prognosis.

This would include the reason for mal levels of exercise. testing, a higher cardiac output after training is usually brought During exercise, baroreflex function is reset to operate around about by an increase in stroke volume because maximal HR the higher blood pressures achieved during physical activity. Parasympathetic tone also can be increased and, with sympa- Central Hemodynamic Changes thetic adjustments, could account for the slower HR and lower Although a greater maximal cardiac output can be achieved as arterial blood pressures seen after training.

a result of exercise training, values at fixed submaximal exter- Preventive Value of Regular Physical Activity nal workloads are unchanged or slightly diminished. Thus, physical inactivity is considered a treatable or modifiable Peripheral Muscular, Vascular, and Autonomic Changes coronary risk factor. Skeletal muscle changes after exercise training insufficient physical activity for deriving health benefits. betes mellitus, insulin resistance, and thrombogenic factors. Each of these adaptations contrib- provide the primary basis documenting the inverse relation- utes to greater capacity to use oxygen and improve endurance.

ship between physical activity and risk of CAD. This is reflected either by the ability to exercise fatal MI. Furthermore, the results of these adap- fewer than 10 studies included women.

Few studies involve tations increase the anaerobic threshold the point at which racial and ethnic minority groups. Meta-analyses reveal that blood lactate begins to accumulate. Adaptation to submaxi- the sedentary participants in these studies generally had about mal exercise is also associated with a lower HR—systolic blood twice the incidence of death from CAD of their more active pressure product for a given exercise task, reflecting reduced counterparts.

respiratory fitness by exercise testing have almost uniformly Vascular. Exercise training directly affects arterial shear stress, shown an inverse relationship between fitness and risk of a stimulus to antiatherogenic adaptations in vascular function CAD and total mortality in both men and women. reached that a minimum of 30 minutes of moderate-intensity The mechanisms for these responses appear to be endothelium physical activity continuous or in minute increments is and nitric oxide dependent.

That is, pursuant to the repeated required on most preferably all days of the week to opti- increases in arterial wall stress with repeated bouts of exercise, mally reduce the risk of CAD events. These mechanisms are reviewed in lipid levels.

increases in HDL cholesterol for every 10 minutes of exercise duration. Cross-sectional on lipids and lipoproteins in specific populations in a series of studies show that greater physical activity and fitness cor- meta-analyses. Benefits of exercise on lipoproteins extended to relate with lower total and low-density lipoprotein LDL older individuals and women, whereas among overweight cholesterol levels, higher high-density lipoprotein HDL and obese individuals, only decreases in triglycerides reached cholesterol levels, and lower triglyceride levels throughout statistical significance.

In the Coronary Artery Risk Development in Young Adults CARDIA study, Exercise Training and Hypertension. After early seminal changes in physical fitness and activity were only weakly cor- observations,, the inverse relationship between physical related with lipid levels, whereas changes in body weight were activity, physical fitness, and incident hypertension has been more strongly associated with lipid changes.

In Atherosclerosis Risk in Communities study, increases in the ARIC study, leisure-time physical activity among middle- physical activity level over 9 years of follow-up were asso- aged adults was strongly associated with incident hyperten- ciated with increases in HDL cholesterol among white and sion in white males but not in women or in blacks.

Among young adults enrolled in the CARDIA study, women. among whites and blacks and in both sexes. who remained vigorously active and were increased in those A meta-analysis of 48 clinical trials of exercise-based cardiac whose vigorous activity declined over time. A meta-analysis of 54 trials of aerobic exercise to —0. In the Training Level Comparison Study, a 1-year Moderate-intensity resistance training leads to blood pres- randomized trial in men with coronary heart disease that sure reductions of similar magnitude.

surable benefit. In individu- reported a weighted mean difference in systolic blood pressure als with established type 2 diabetes mellitus, a meta-analysis of —3. Overweight and obesity and reduces visceral adipose tissue and plasma triglycerides, have reached epidemic proportions in the United States, with but not plasma cholesterol, in people with type 2 diabetes mel- recent data from the National Health and Nutrition Exami- litus, even without weight loss.

Current high rates of obesity are and less use of glucose-lowering medications, compared with determined by both a high rate of physical inactivity and an usual care. This acute-phase response, which appears to be pro- the best predictor of successful long-term weight loss mainte- portional to the amount of activity and extent of muscle injury, nance is the presence of an ongoing exercise program with a tends to abate within a few days and is less pronounced in high level of caloric expenditure.

High-caloric-expenditure exercise daily longer- activity. Physical activity are more limited but suggest that exercise training both aero- has beneficial effects on both glucose metabolism and insulin bic and resistance training can favorably affect hs-CRP levels sensitivity, including increased sensitivity to insulin, decreased and other inflammatory markers both in healthy populations production of glucose by the liver, a larger number of muscle and among individuals with metabolic disorders such as dia- cells that use more glucose than adipose tissue, and reduced betes mellitus.

The effect of exercise on insulin sensitivity matory markers are unknown. Aging, even in healthy adults, is accompanied compared with a control group, over 2.

vasodilation and myocardial blood flow. Endurance training in adults induces remodeling of conduit Antiarrhythmic Effects of Exercise Training arteries, resulting in reduced wall thickness and increased A risk of ventricular fibrillation or sudden cardiac death during lumen diameter. The effects of exercise train- ing. ing mobility, exercise training is a logical intervention to reduce Exercise Training and Autonomic Function or prevent age-associated disability.

In a systematic review The balance between sympathetic and parasympathetic activ- of exercise interventions, it was found that trials that offered ity modulates cardiovascular activity. Enhanced sympathetic a multicomponent exercise program involving endurance, nervous system activity is associated with an increased risk of strength, flexibility, and balance training generally reported cardiac events, particularly in patients with known heart dis- significant reductions in disability.

A reduction of HR variability HRV has been reported intervention and follow-up and interventions in more function- in several cardiac conditions, such as after MI, in heart failure, ally limited individuals were associated with greater likelihood and in diabetic neuropathy.

The ongoing multicenter men reported higher parasympathetic activity among those Lifestyle Interventions for Independence in Elders LIFE who were physically trained and fit than among those who study will provide additional information on this topic. In the were not. Because the rate—pressure product is a or absence of established CVD. Healthy adults who wish to major determinant of myocardial oxygen demand, the reduced undertake a low- to moderate-intensity walking program or rate—pressure product resulting from training will substantially equivalent moderate-intensity exercise generally do not need lower oxygen demand, mimicking the anti-ischemic effects of a formal medical screening.

In addition, exercise training enhances arterial nitric oxide part of daily activities. If an asymptomatic individual does not undergo an in broad, healthy populations of adults has not been proven to exercise test before beginning training, he or she should fol- be useful and could serve as a barrier to undertaking healthful low the activity guidelines outlined in Table 3. If the history or exercise. These are extenuating circumstances, such as a family history of will prompt referral for medical evaluation by a healthcare sudden death at a young age, or poorly controlled cardiac professional when indicated.

risk factors. ning— and at 1 death per 67 participants during tri- This should include a medical history, a physical exami- athlons, with almost all triathlon deaths occurring during the nation, and a risk factor profile. For most, an electrocar- swim portion. This classification is tory of familial CAD or heart failure; presence of valvular provided in detail in Tables 3 through 6, which are used to heart disease, stable or unstable angina, congenital heart determine the need for subsequent supervision and the level disease, stroke, sudden death, history of pulmonary disease of monitoring required.

ie, chronic obstructive pulmonary disease or asthma ; pres- ence of symptoms including chest discomfort, dizziness, and shortness of breath at rest or with activities of daily Exercise Training Techniques living and leg discomfort claudication suggesting cardio- Elements of an Exercise Training Session vascular or pulmonary disease; changes in balance or gait; Exercise training sessions are typically arranged with brief presence of orthopedic problems including joint concerns periods of warm-up and cool-down low-intensity aerobic and swelling , arthritis, or changes in mobility; medication use stretching movements before and after a more intense and and use of caffeine or alcohol; and prior exercise habits.

Of prolonged phase of conditioning of either endurance or resis- particular interest are data in the history that indicate that tance training Table ,a. Often, endurance training is unsupervised exercise could be hazardous.

Table 3. Risk Classification for Exercise Training: Class A: The physical examination should include vital signs and Apparently Healthy Individuals examination of the cardiovascular and pulmonary systems, including evaluation of abnormal heart sounds or murmurs; This classification includes: 1.

If the test is abnormal, further exercise test before engaging in vigorous exercise. Reproduced with permission work-up should follow, according to symptoms and estimates from Fletcher et al. Risk Classification for Exercise Training: Class flexibility. After the conditioning phase, cool-down facili- B: Presence of Known, Stable CVD With Low Risk for tates a gradual transition to exercise cessation, modulating Complications With Vigorous Exercise, But Slightly Greater the effects of vasodilation, high catecholamines, and potential Than for Apparently Healthy Individuals ischemia.

Cool-down helps the HR and blood pressure transi- This classification includes individuals with any of the following diagnoses: tion to normal levels, reducing the likelihood for hypotension 1. 中小企業向け Microsoft 大企業向け Microsoft 大企業向け Office Microsoft Dynamics ビジネス向け Windows Microsoft SQL Server. Operations Management Suite. System Center. IoT 向け Windows Azure Cognitive Services. Enterprise Mobility. Office モビリティ.

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exe ファイル」をクリックします。. 既知の問題と詳細なトラブルシューティングのリストについては、「 Adobe Reader インストールのトラブルシューティング Windows 」を参照してください。 他のユーザーに同様なダウンロードおよびインストールの問題が発生していないかを確認するには、 Acrobat Reader ユーザーフォーラム を参照してください。問題をフォーラムに投稿して、対話式のトラブルシューティングを試してみてください。フォーラムに投稿する場合、ご使用のオペレーティングシステムおよび製品バージョン番号を含めます。. その他の関連ヘルプ Acrobat Reader ダウンロードのトラブルシューティング 競合するプロセスまたはアプリケーションを閉じる Acrobat および Reader のアップデートをインストールする エラーとフリーズのトラブルシュート Reader Windows 既知の問題 Acrobat DC、Reader DC.

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Microsoft Project is a project management software program created for businesses and freelance professionals to help better manage individual projects that occur within companies. Although no project management software should be used to replace project management techniques or adequate training of management and staff, Project can and will improve the efficiency, organization, and sometimes even the speed of which a project is completed. Both the beginner and seasoned Project user can benefit from this course, starting with the basics of the program including navigation and continuing on to more advanced features.

You do not need to have access to Project to take or successfully complete this course. However, it is recommended. A 60 day free trial for Project is available on the Microsoft website. Open Main Menu. Browse Courses My Classes.

Sign In Subscribe Course Catalog. Both the beginner and seasoned Project user can benefit from this course. Students have taken this course. Course Description. Courses Frequently Bought Together:. Lesson 1: Introduction to MS Project xlsx Lesson discussions: Reasons for Taking this Course Complete: Assignment 1 Assessment: Exam 1. When you open Project for the first time, you have a few choices in how you want to get started. Additional lesson topics: Microsoft Project Demonstration; Microsoft Project Tutorial 11 Total Points Lesson 2 Video Complete: Assignment 2 Assessment: Exam 2.

Although the purpose of this course is to teach you how to use Project , Project can only manage the information about the project that you give it. Being able to enter tasks is critical, not only to your project, but to being able to use Project successfully. xlsx Complete: Assignment 4 Complete Assignment: Project 1 Assessment: Exam 4. Additional lesson topics: Split a view 11 Total Points Lesson 5 Video Complete: Assignment 5 Assessment: Exam 5.

In Project , the calendar shows the various hours in a workday, the days in a work week, holidays, and nonworking days on which a project schedule is based. Additional lesson topics: Add a calendar to a task 11 Total Points Lesson 6 Video Complete: Assignment 6 Assessment: Exam 6. Taking the time to organize your tasks will make managing them easier - and improve the efficiency of your team while working on the project.

Additional lesson topics: Create and work with subtasks and summary tasks; Project management goal: Create a new project schedule 11 Total Points Lesson 7 Video Complete: Assignment 7 Assessment: Exam 7. Lesson 8: Working with Task Duration, Constraints, and Deadlines. Whenever you create a task, you have to set the duration for the task, or how long it will take to complete.

Additional lesson topics: Types of task links; Link and Unlink Tasks 16 Total Points Lesson 8 Video Complete: Assignment 8 Complete Assignment: Project 2 Assessment: Exam 8. A dependency in Project is defined as a timing relationship between two tasks in a project - or tasks that are a predecessor-successor pair.

In this lesson, we are going to learn about resources in Project and how to apply them to your project. Additional lesson topics: How to Add Resources to Tasks; Enter costs for resources 11 Total Points Lesson 10 Video Complete: Assignment 10 Assessment: Exam The key to successful projects and excellent project management is finding the right resources.

Additional lesson topics: Resource Management Engagements; Understanding Resource Engagements in Microsoft Project ; Project Online: Resource Management and Capacity Planning 11 Total Points Lesson 11 Video Complete: Assignment 11 Assessment: Exam When you want to track the progress being made on a project, you must enter different kinds of information. Additional lesson topics: Actual Work fields; Show the Time in MS Project Start and End Date Fields 16 Total Points Lesson 12 Video Complete: Assignment 12 Complete Assignment: Project 3 Assessment: Exam It is important that you map out what information you need to track as the project commences and advances.

Additional lesson topics: Project collaboration and communication with Sway 11 Total Points Lesson 13 Video Complete: Assignment 13 Assessment: Exam By definition, a baseline is the detailed project against which actual work is tracked. Additional lesson topics: Set and save a baseline 11 Total Points Lesson 14 Video Complete: Assignment 14 Assessment: Exam In this lesson, we are going to show you how to format elements of the Project screen, as well as teach you to create customized templates.

Additional lesson topics: How to Format a Gantt Chart; File formats supported by Project 11 Total Points Lesson 15 Video Complete: Assignment 15 Assessment: Exam Reports show how costs are accumulating, what tasks are in progress, and which ones still need to start.

In this lesson, we are going to teach you how to print in Project. Describe what MS Project is and what its capabilities are. Define and create projects. Describe entering and scheduling tasks. Describe Project views. Demonstrate organizing tasks. Demonstrate working with task duration, constraints, and deadlines. Describe dependencies. Summarize resource management. Identify tracking work in project. Summarize communication and progress updates. Describe using baselines.

Describe customizing and formatting your project. Describe running reports. Describe consolidating projects and resources. Summarize printing project information. Additional Course Information. Document Your Lifelong Learning Achievements Earn an Official Certificate Documenting Course Hours and CEUs Verify Your Certificate with a Unique Serial Number Online.

Course Title: Microsoft Project Languages: English - United States, Canada and other English speaking countries. Category: UniversalClass. CEU Value: 0. CE Accreditation: Universal Class, Inc. has been accredited as an Authorized Provider by the International Association for Continuing Education and Training IACET. Instructor: UniversalClass Instructional Team. Choose Your Subscription Plan. Add to Cart. Platinum Yearly. Start Now. Student Testimonials. Explore Sign In Pricing Course Catalog Group Discounts CEU Verification Gift Certificates FAQ.

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クイック アクセス. Remove From My Forums. Archived Forums. Office and Office ProPlus - IT Pro General Discussions. This IT Professional forum is for general questions, feedback, or anything else related to the RTM release versions of Office and Office ProPlus. aspx 0 2. 回答としてマーク Office Support - MSFT 年6月17日 Here is the output from the thread you sent. All rights reserved.

REMAINING GRACE: 25 days minute s before expiring Last 5 characters of installed product key: GVGXT DNS auto-discovery: KMS name not available KMS machine registry override defined: No Key Management Service KMS could be contacted.

Please see the Application Event Log for additional information. To view the activation event history run: cscript ospp. プロファイル 個人情報 の管理 お問い合わせ先 TechNet の情報を無料ニュースレターで入手 日本での個人情報の取り扱い サイトマップ 特商法に基づく表示 使用条件 商標 プライバシー. This update is no longer available. To fix the issues that are described in this article, install the latest Microsoft Office update from the following Microsoft Docs article:. Latest updates for versions of Office that use Windows Installer MSI.

This article describes update for Microsoft PowerPoint and Office Home and Student RT that was released on December 10, The download links for this update are also included here. This update provides the latest fixes for PowerPoint It also includes stability and performance improvements.

For Office Click-to-Run edition, an Update Options item is displayed. For MSI-based Office edition, the Update Options item is not displayed. For more information about how to download Microsoft support files, click the following article number to view the article in the Microsoft Knowledge Base:.

Microsoft used the most current virus-detection software that was available on the date that the file was posted. The file is stored on security-enhanced servers that help prevent any unauthorized changes to the file.

This update contains the files that are Listed in the following tables. msp file information. Office Home and Student RT Powerpoint-x-none. Swipe in from the right edge of the screen, and then tap Search. If you are using a mouse, point to the lower-right corner of the screen, and then click Search. Type windows update, tap or click Settings , and then tap or click View installed updates in the search results. In the List of updates, locate and then tap or click update , and then tap or click Uninstall.

In the List of updates, locate and then click update , and then click Uninstall. The Office System TechCenter contains the latest administrative updates and strategic deployment resources for all Versions of Office. For more information about the Office System TechCenter, go to the following Microsoft website:. IT support and resources for Microsoft Office. Notice This update is no longer available. To fix the issues that are described in this article, install the latest Microsoft Office update from the following Microsoft Docs article: Latest updates for versions of Office that use Windows Installer MSI.

Start an Office application such as Microsoft Word On the File menu, click Account. Office Click-to-Run edition MSI-based Office edition. msp file information File name File version File size Date Time Microsoft.

dll exe manifest Not Applicable 3, Nov Ppcore. msp file information File name File version File size Date Time Ppintl. olb dll Not Applicable 1,, Nov Pptico. potx Not Applicable , Nov Previewtemplate2.

potx Not Applicable , Nov Windows 8 Swipe in from the right edge of the screen, and then tap Search. Windows 7 Click Start , and then click Run. Type Appwiz. cpl, and then click OK. Click View installed updates. RSS フィードを購読する. はい いいえ. サポートに役立つご意見をお聞かせください。 改善にご協力いただけますか? Home » Windows » Windows For all kinds of devices like desktop PC, Laptop PC, handphones, tablets, and much more. It uses the same software on all platforms and servers for both home and business activities.

Unlike its predecessor, it runs developed apps on all Windows 10 devices, and universal apps. It can be run in normal windows as normal software applications. Windows 10 the seventh updated version was published on May 21, It was preceded by the version An awesome version with packed features that bring an outstanding change in the operating system.

As a mixture of windows 7 and windows 8, windows 10 is very easy and simple to use. You can run it on PC, Tablet, Smartphone, Xbox One, Surface Hub, and Holo lens. Some old features with a new touch, the software is a whole changed version, to experience more flexibly and smoothly.

Two user interfaces, one with a keyboard and mouse. And the other is for the touch screen is very simple and easy to use. You can change the size of the screen which is a mixture of Windows 7 and Windows 8.

Existing of all apps on the screen, easily run them together. The taskbar menu helps you to open multiple apps as well as create a fresh virtual desktop. On the welcome screen, several eye-catching themes for an exciting experience. The phone users can enjoy the changing of colors on the screen. The new edition of Windows 10 has been removed some old features like Windows Media Center, Windows DVD player, One Drive Sync-Client, choice of updating Windows by the user himself.

Windows 10 introduces several editions for users of different lifestyles. Some areas following are given. Home Edition supports 4 GB RAM for the bit version and GB RAM for the bit version. It is the basic version for home PC and tablet with new features like Cortana, Edge Browser, Mobile Management Facility, and Taskbar with a virtual desktop, and few others. Pro Edition for PC and tablets is especially designed for home users, professionals, and small business activities.

It is consists of all Home Edition features with some extra such as BitLocker, Joining Windows domain, Hyper-V, Windows To Go, and few business-related features. It supports 2 TB RAM. Enterprise Edition is a packed feature program of security, hardware, software.


年半期チャネル (対象指定) リリースのアーカイブ済みリリース ノート - Office release notes | Microsoft Docs - Question Info

To set a baseline, on the Project tab, in the Schedule group, click Set Baseline. In the dialog box, click Set Baseline. Select the baseline you want—Baseline or Baseline 1 through Baseline Setting a baseline copies all currently scheduled fields for tasks into the corresponding baseline fields. Mar 08,  · Less. This article describes update KB for Microsoft Project , which was released on March 8, This update has a prerequisite. Be aware that the update on the Microsoft Download Center applies to the Microsoft Installer .msi)-based edition of Office It doesn't apply to the Office Click-to-Run editions, such as. Jun 28,  · To start the download, click the Download button and then do one of the following, or select another language from Change Language and then click Change.. Click Run to start the installation immediately.; Click Save to copy the download to your computer for installation at a later time; IT professional resources IT professional working in managed environments can find complete resources Category: Update.


- Untitled — Windows 10 guest account does not work

We tested this on a number of failed machines and they all took the servicing upgrade successfully. Home » Windows » Windows For all kinds of devices like desktop PC, Laptop PC, handphones, tablets, and much more. Operations Manager How do I create a performance monitor to monitor if a performance counter sample exceeds a threshold? Because of its poor diagnostic accu- attributable to LV stiffness and decreased compliance. Windows 10 guest account does not work microsoft project 2016 set baseline free download. who remained vigorously active and were increased in those A meta-analysis of 48 clinical trials of exercise-based cardiac whose vigorous activity declined over time.


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