cardiac 1

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cardiac 1
2012-09-22 11:06:06
cardiac rehab

cardiac rehab lecture 1
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  1. primary prevention
    manipulating risk factors to decrease the incidence of disease in a population
  2. secondary prevention
    process of helping people who already have a disease change lifestyle and behaviour, reducing risk factors for disease progression so it lessens the impact of the disease on the quality of life, morbidity, and mortality
  3. historic phases of cardiac rehab
    • I - acute period, the initial event, 2-4 weeks in hospital
    • II - convalescent or early outpationt (2nd and 3rd month)
    • III - late outpatient - much less monitoring than in phase II
    • IV - maintenance - solo, in a gym
  4. modern phases of cardiac rehab
    • I:  inpatient - the event
    • II: transitional zone: acute or subacute rehab or homecare
    • III: outpatient - pt must fit specific guidelines of disease and treatment to get accepted here
    • IV: transitional - pt is still monitored, but no longer on tolemetry
    • V: lifetime - gym, changes in ways of life
  5. 3 non modifiable positive risk factors for cardiac disease
    and the details
    family history: a 1st degree male relative who suffered or died from CVD when 55 or younger, or a female rel who did when 65 or younger

    age - fems greater than 45, men greater than 55

    gender - men get it more
  6. 5 modifiable positve risk factors for cardiac disease
    (w/o numbers or details)
    • cigarette smoking
    • hypertension
    • hypercholesterolemia
    • impaired fasting glucose
    • obesity
  7. hypertension numbers for SBP and DBP
    SBP - above or equal to 140

    DBP - above or equal to 90
  8. resting SBP and DBP numbers for the 4 categories of hypertension
    • I:    SBP 140-159    DBP 90-99
    • II:   SBP 160-179    DBP 100-109
    • III:  SBP 180-199    DBP 110-119
    • IV:  SBP >200         DBP >120
  9. resting SBP and DBP at which exercise is contraindicated

    SBP contraindicated exercise for diabetics
    • SBP - 200
    • DBP - 110

    diabetics - SBP - 180
  10. at what numbers is cholesterol hypercholesterolemia and a pos cardiac risk factor (CRF)

    what ratio is low risk? average risk?
    • if total is >200, CRF
    • if total/HDL <3 = low risk ratio
    • if total/HDL 3-5 - averatge risk

    if total is 240 pt has almost twice the risk of if it's 200
  11. If pt has no CVD, cholesterol can be as high as ___ w/o being a risk factor
  12. If pt as CVD, cholestoral is a risk factor if it's not ___.
  13. HDL is a nevative risk factor  if it's ___.
    It's a CRF it's it ___.
    >60 - meaning it reduces your risk

  14. triglicerides are a precursor to diabites when their number is
    >150 mg/dl
  15. fasting glucose numbers for norm, impaired, and diabetes
    • less than or equal to 100  - norm
    • 110-125  - impaired fasting glucose control
    • >125    -  diagnostic for diabetes
  16. ACSM def of physically active
    # steps for intermidate active
    # steps for sedentary
    mod intensity exercise for 30 min / day most days a week

    • at least 10,000 steps/day
    • <5000 = sedentary
  17. BMI = body mass (kg)/ height^2 (meters^2)

    BMI numbers for norm, overweight, and 3 stages of obese
    • <25  - norm
    • 25-29.9 - overweight
    • 30-34.9 - obese stage I
    • 35-39.9 - obese stage II
    • 40 and up - obese stage III
  18. a list of signs and symptoms suggestive of cardiovascular and pulmonary disease
    pain/discomfort in chest, neck, jaw, arms, or elsewhere that may be due to ischemia

    SOB at rest or w mild exertion


    orthopnea or paroxysmal nocturnal dyspnea (ask if pt sleeps w multiple pillows or with bed's head area raised)

    ankle edema

    palpitations or tachycardia

    intermittent claudication (cramping pain when walking)

    known heart murmur

    unusual fatigue or SOB w usual activities
  19. that thing to remember about signs/symptoms and systemic disease, cardiac risk factors, and high risk
    If no systemic disease and no signs/symptoms, then no matter how many CRS, patient's not considered high risk
  20. ACSM's low, mod and high risk qualifications for cardiovascular disease
    low risk - no more than 1 CRF (ex: hypertensive, fat, sedentary, high cholesterol)

    mod risk - 2 or more CRFs

    • high risk - a) systemic disease (diabetes, hypo or hyperthyroidism, kidney disease, etc)       or b) show signs and symptoms
  21. AACVPR's way of rating low, mod, or high risk for cardiac pts using left ventricular ejection fraction (LVEF) and METS

    (she says to know these numbers)
    • Low risk - LVEF > 50% (norm is 55)
    • functional capacity > 7.5 METS

    • Mod risk - LVEF 40-49%
    • functional capacity 5-7.5 METS

    • High risk - LVEF < 40%
    • functional capacity <5 Mets 
  22. American Heart Association's classes A B C D for cardiac patients
    CLass A - apparently healthy

    Class B - documented, stable cardiovascular disease w low risk for vigorous exercise (so you can do sub max or max testing) but slightly greater than Class A folk

    Class C - mod to high risk for cardiac complications during exercise and/or unable to self-regulate activity or to understand recommended activity level (so, should be supervised)

    Class D - unstable disease w activity restriction (only physicians should assign exercise)
  23. low, mod, and high risk - which can do sub max and which can do max testing?
    • low risk - can do both
    • mod risk - can do sub, can't do max unless an MD is on site
    • high risk - can do either only if an MD is on site
  24. exercise intensity training - for low, mod, and high risk pts, who can do mod or mod-high training?
    • low risk can do both
    • mod risk can do mod, can do mod-high w trained HCP on site
    • high can do either w trained HCP on site
  25. foramen ovale
    hoel between R and L atria in fetus so blood can bypass the lungs
  26. ductus arteriosus
    hole from L pulm artery to aorto in fetus to let blood bypass lungs
  27. blood route, from momma to inferior vena cava
    • oxygenated blood enters via umbilical vein
    • half of it bypasses the liver via the ductus venosus
    • then it enters the IVC, then the R atrium
  28. ligamentum arteriosum
    this is what becomes of the ductus arteriosus
  29. patent foramen ovale
    the name for the foramen ovale if it remains after birth
  30. layers of a blood vessel from outside in
    comparison to veins
    • adventitia
    • external elastic lamina
    • tunica media - thickest layer, helps control diameter
    • internal elastic lamina - coronary disease/hardening starts here
    • tunica intima

    veins are similar but with thinner tunica intima, and veins have valves
  31. Left main coronary artery brances into _ and _

    Right main coronary artery becomes _
    • L --> left anterior descending (supplies most of L ventricle) and left circumflex
    • R --> posterior descending
  32. windkessel effect (pr: wine castle)
    arteries expand and contract to creat perfusion pressure to help push blood thru
  33. basic path of blood
    R atrium --> tricuspid valve --> R ventricul --> pulmonic valve --> pulm arteries --> gas exchange --> pulm veins --> L atrium --> mitral/bicuspid valve --> L ventricle --> aortic valve --> systemic + coronary circ
  34. R side of heart - wall thickness and BP comparison to L side
    R side is thinner, and BP is much lower: ~25-30/5-15
  35. annulus fibrosus
    a layer of dense connective tissue which forms a skeleton for the heart and provides support for each valve

    if it loses its structural integrity you lose recoil of the heart

    and it helps slow down electrical flow to give muscle time to contract and relax - it's fibrocartilaginous, and this texture slows the flow
  36. coronary sulcus
    completely encircles the heart and divides the atria from ventricles -- it marks the location of the annulus fibrosus
  37. tricuspid valve
    leaflet valve sperating R atrium from R ventricle
  38. papillary muscles
    pull tri and bicuspid valves open by pulling on the chordae tendinae which connect the muscle to the valves
  39. heart's electrical pathway
    SA node --> internodal pathways -->AV node -->bundle of His -->R + L bundle branches -->Purkinje fibres
  40. HR and ejection volume (stroke volume) are controlled by the ANS. What do parasymp and smyp each do?
    • parasymp: vagus N. sends fibers over surface of heart and to nodal areas to slow HR and decrease SV
    • symp: cervical symp chain and thoracic splanchnic nerves terminate in teh vicinity of SA and AV nodes to increase HR and SV
  41. afferent sensation
    run along symp pathways .. pain is reffered to arm, shoulder, precordium (part of body over heart and lower chest) and sometimes epigastric region (upper central region of abdomen)

    I think this is the same as the anginal pattern (this is unique to each person, but once your anginal pattern is id'ed it'll stay the same for you)
  42. about heart transplant pts and ANS innervation
    they don't have it, so they don't get reflex tachycardia, so when BP changes the heart can't quickly compensate. SO, they need longer to warm up and cool down in the gym.
  43. baroreceptors - where
    they're stretch receptors in the walls of most large arteries
  44. baroreceptors - stimmed by what?
    these stretch receptors in the walls of most large arteries are stimmed at pressures between 60 mmHG and 180 mmHG
  45. 2 effects of baroreceptors that are stimulated
    • 1 - vasodilation vi inhibition of the vasomotor centers of teh medulla
    • 2 - decrease the HR and contractility via vagal stim
  46. why are SA nodes self-exciting?
    there's an inherent "leakiness" of the SA node fibers to sodium ions
  47. SA node characteristics
    • most easily depolarized
    • has automatic rhythmicity (100bpm)
    • electricity goes from here to the AV node via the internodal path
  48. 3 types of channels in the SA node
    fast sodium channels, slow calcium-sodium channels, potassium channels
  49. resting potential fo SA node
    -55 to -60 mV
  50. 4 layers of heart from outside to in
    pericardium, epicardium, myocardium, endocardium
  51. tricuspid valve is between what?
    it's a leaflet valve btwn R atrium and R ventricle
  52. pulmonic valve seperates what? biggest health risk?
    • R vent and pulmonic trunk
    • it's made of cusps which can calcify and then won't open so good
  53. most troublesome valve, most popular for surgery?
    aortic valve - it's a cusp valve
  54. sinuses of vasalva - rel to coronary arteries, aortic valve, and disease
    • coronary arteries arise in here, just above cousp of aortic valve, so if there's a narrowing of aortic valve you'll lose perfusion pressure to coronary arteries.
    • so, if there's severe aortic stenosis, don't exercise until it's addressed
  55. cardiac tamponade
    is pressure on the heart that occurs when blood or fluid builds up in the space between the heart muscle (myocardium) and the outer covering sac of the heart (pericardium)
  56. describe te epicardium
    • visceral serous layer and a variable amount of fat
    • it's in contact w the serous pericardium
  57. myocardium - where does each layer originate?
    on the annulus fibrosus
  58. myocardium - the layers are arranged so they produce what?
    a "wringing" type of effect during contraction which reduces the vol. of the chambers during contraction
  59. myocardial fibers rel to coronary sulcus
    they don't cross it (the sulcus is between the atrias and ventricles)
  60. which layer of the heart is at greatest risk of ischemia? why?
    the endocardium bc it's on the iner lining of the cardiac chambers, therefore furthest from the coronary arteries which are on the pericardium
  61. endocardium description
    • inner lining of cardiac chambers
    • in direct contact w blood
    • smooth, thin endothelium
  62. cardiac myocytes similarities to skeletel muscles
    • similarly striated
    • contain actin and myosin filaments --> cross bridge cycleing results in contraction
  63. intercalated discs  
    do what?
    • between cardiac myocytes
    • they have an electrical resistance 1/400 the resistance of the outer myocyte membrand prmiability = gap junctions, which allow the spread of electrical activity
  64. cool thing about cardiac myocytes
    can beat on their own, so if conducting fibers are damaged, heart can still beat
  65. Bainbridge reflex
    , search

    • The Bainbridge reflex, also called the atrial reflex, is an increase in heart rate due to an increase in central venous pressure. Increased blood volume is detected by stretch receptors located in both atria at the venoatrial junctions.
  66. results of Bainbridge reflex
    • (atrial stretch reflext that causes change in HR)
    • increase HR from baseline
    • decrease HR if heart is beating too fast
    • (initiall causes increase, and if maintained causes decrease)
  67. chemoreceptors effect, changes in sensitivity
    • increase depth and rate of breathing
    • get less sensitive w age
  68. action potential spreads from cell to cell via __ __.It is transmitted to the innermost area fo the cell by way of ___.
    • gap junctions
    • T-tubules
  69. What happens after the action potential, which travels btwn cells via gap junctions, gets to innermost areas of cells via T-tubules?
    the sarcopasmic reticulum releases calcium, which binds to the troponin, which results in teh cross-bridge cycling btwn actin and myosin, ...---> myocardial contraction!
  70. what happens to calcium when the action potential cycle is complete?
    • calcium channels close
    • calcium is reaccumulated in the sarcoplasmic reticulum
    • calcium is also actively removed by specific sodium-calcium pumps in the cell membrane
    • ---> end of the myocardial contraction
  71. excitation-contraction coupling
    basic def
    • turning electrical into mechanical activity
    • In cardiac muscle, the method is dependent on a phenomenon called calcium-induced calcium release, which involves the conduction of calcium ions into the cell triggering further release of ions into the cytoplasm (about 75% of calcium present in the cytoplasm during contraction is released from the sarcoplasmic reticulum).
  72. why is DBP more heavily valued than SBP when pt's at rest?
    • DBP represents the pressure 2/3 of the time
    • with exercise, SBP takes up more time
  73. in which part of BP do coronary arteries get blood? what does this mean about exercise?
    DBP. The % of time spent in DBP decreases as the HR rises (when HR reaces 180, DBP is just 1/3 of the time), s, the higher the HR, the greater the risk of ischemia