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Leading cause of death
1 in 3 have one or more types of it.
Underlying pathologies of CVD?
- altered myocardial muscle mechanics
- valvular dysfunction
Location of heart
- L thoracic cavity
- between 2nd and 5th rib
- base is superior
- apex is inferior
Layers of pericardium surrounding the heart
- pericardial fluid
- parietal layer
layers of myocardium:
purpose of the coronary arteries
blood supply to myocardium happens during ventricular relaxation
Left Coronary artery branch supplies blood where?
to the left anterior descending and circumflex
right coronary artery supplies blood where?
to the posterior descending
how can the lumen be altered?
- by athersclerotic lesions
- smooth muscle contraction within the walls
what is occurring during systole?
what is occurring during diastole?
what is occurring during the normal heart sound, S1?
mitral and tricuspid valves closing
What is occurring during the normal heart sound, S2?
aortic and pulmonary valves closing
abnormal heart sound, S3:
is associated with what?
when is it heard?
- ventricular gallop
- heard early in diastole
abnormal heart sound, S4:
is associated with what?
when is it heard?
- atrial gallop
- heard in late diastole
- increase in HR
- increase in force of contraction
- dilation of coronary arteries
- vasoconstriction of peripheral blood vessels
- decrease in HR
- decrease of force of contraction and speed of conduction
- vasodilation of peripheral vessels of bowel, bladder, and genitals
Cardiac Output formula:
SV x HR = CO
Cardiac Output measures what?
the amount of blood leaving ventricles
Normal cardiac output is what?
Stroke volume is defined as what?
the amount of blood ejected each myocardial contraction
pre-stretch allows for a more efficient contraction
What does Stroke volume include?
the amount of blood in the ventricle at end of diastole
the ability of the ventricle to contract
the force required to open the aortic valve
what is MVO2?
- the energy cost of the myocardium
- (Myocardial oxygen demand)
the formula for rate pressure product:
HR x Systolic BP = RPP
a decrease of MVO2 is usually caused by what?
- normal with exercise
- compensatory with blood loss
- normal with regular endurance exercise
- beta blockers
- ectopic pacemaker of the heart
Electrical Conduction pathway of the heart
- SA node
- AV node
- Bundle of His
- Perkinje fiers
Responses that indicate Termination of Exercise:
- Moderately sever or increasing angina
- marked dyspnea
- dizziness, lightheadedness, ataxia
- cyanosis, pallor
- excessive fatigue or peripheral claudication
- failure of systolic pressure to increase
- hypertensive BP of >200(sys)/>110(dia)
- fall in systolic BP of 10-15 mmHg
- significant change in cardiac rhythm
Hypertension is defined as:
- systolic> 140 mmHg
- diastolic>90 mmHg
Primary cause of hypertension
Secondary Cause of Hypertension
Classes of Medication for Hypertension
- beta blockers
- calcium channel blockers
What is Acute Coronary Syndrome?
an imbalance of myocardial oxygen supply to meet the MVO2 usually due to coronary artery lumen narrowing secondary to atherosclerotic changes
Risk Factors for CAD
- high cholesterol
- Emotional stress
- family history
- sedentary lifestyle
- elevated Blood homocysteine and fibrinogen levels
When does Ischemia occur?
when the lumen is at least 70% occluded
What is ischemia?
temporary deficiency in oxygenated blood flow to tissues
Why does ischemia typically occur?
- atherosclerotic lesions
- spasm of smooth muscle in vessels of arteries
Symptoms of Angina:
- substernal chest pain
- radiate from chest to:
- upper back
- shortness of breath
characteristic traits of Unstable Angina:
- does NOT occur at a predictable RPP
- occurs at rest
- occurs with min exertion
- does NOT stop by decrease of RPP
NEEDS IMMEDIATE MEDICAL ATTENTION
Characteristic traits of Stable Angina:
- occurs at a predictable RPP
- alleviated by stopping activity
- alleviated by rest
- alleviated by nitroglycerin
Characteristics of Prinzmetal Angina:
- caused by VASOSPASM
- NOT by an occlusion
What is an Infarction?
- occlusion of a vessel commonly from rupture of plaque with thrombus formation or spasm of an occluded vessel
- typically in vessels that are <60% occluded
Symptoms of Infarction:
intensity of angina increased to usually 10/10
how long does it take for their to be irreversible changes from an infarction?
irreversible changes may appear 20 min to 2 hours post onset of an MI
- lv failure or significant ventricular arrhythmias post MI
- cardiogenic shock
When does a MI wound stabilize?
What will an EKG demonstrating an ischemic episode look like?
- ST segment depressed
- T wave inverted
what appears in the blood with a positive ischemic event?
- elevated CPK-MB
- elevated troponin
- (both indicative of cell death
What does the medical management for an Ischemic event offer?
- Acute pharmacological
- long term pharmacological
Acute Pharmacological care of an ischemic event:
- thombolytic agent (TPA)
Long term pharmacological
- Beta blockers
- calcium channel blockers
What effect do Beta blockers have in the long term pharmacological care of MI's?
- decrease sympathetic activity
- decrease HR and contractility
what effect do calcium channel blockers have in the long term pharmacological care of MI's?
- Decrease BP
- decrease smooth muscle spasm
what effect do Nitrates have in the long term pharmacological care of MI's?
- they act as vasodilators
- increase dilation of coronary arteries
What are types of Revascularization procedures?
- percutaneous transluminal coronary angioplasty with stent
- laser surgery
When are PT interventions included in the care for PTCA pts?
2 wks post procedure
Possible limitations for CABG pts?
- No wheelchair self-propulsion with UEs
- Avoid pulling/pushing with UEs
- No AROM >90 of flex, abd, hor abd
- no driving
- avoid passenger airbags in car
- shower with spray to back -avoid incision site
Considerations with CABG patients
- blood loss
- common arrhythmias
- energy cost of healing
When do CABG pts typically begin cardiac rehab?
- 6 wks after surgery
- dependent upon incision site and blood counts
what is heart failure?
syndrome which results in inadequate systemic perfusion typically from a surpassed MI
Left sided Heart-failure presents as:
- inadequate CO
- blood flow back up into the lungs
Right sided heart failure presents as:
elevated pulmonary artery pressure causing a RV insult
there's a venous back up
showing in jugular vein dissension and peripheral edema
what is it called when both sides fail in Heart failure?
what does it mean when there is systolic dysfunction?
- ventricle contraction is decreased
- decreased SV
- decreased CO
- decreased EF
What does it mean when there is diastolic dysfunction?
- no relaxation of ventricles
- ventricles fill
- decreased SV
- decreased CO
- normal EF
What does a pt present with when they are experiences HF?
- pitting edema
- enlarged heart
- pulmonary edema on x-ray
- abnormal lung sounds
- paroxysmal nocturnal dyspnea
What is watched with HF?
- sodium intake
- fluid intake-possible restriction
- weight-sudden weight gain indicated worsening
3 types of Valvular Heart disease:
Stenosis disfunction of Valvular HD:
- narrowing of the passage
- become more rigid and smaller
Prolapse disfunction of Valvular HD:
- enlarged valve become floppy
- has a ballooning effect
Regurgitation disfunction of Valvular HD:
forward and backward movement of blood in valve due to incomplete closure
Types of abnormalities in electrical conduction in the heart
- ectopic beats
what is an ectopic eat?
a beat that originates from any other site than the sinus node
types of ectopic beats would include:
Bigeminy is when:
every other beat is a PVC
Trigeminy is when:
every third beat is a PVC
It is normal to have a PVC ectopic beat with the intake of what?
what is a heart block?
conduction time through the AV node is prolonged
Types of arrhythmias:
- A fib
- Ventricular tachycardia
- Ventricular fibrillation
Describe A Fib:
- varied number of P waves
- -worried about blood clots
a premature atrial contraction
ectopic beat originating in the atria
- Paroxysmal atrial tachycardia
- results in HR of 150-200 bpm
premature ventricular contraction
- no P wave
- wide QRS complex
- if PVC's increase-->possible MI
What is Ventricular Tachycardia?
- when there are 4 or more PVC's in a row
- there is a rapid decrease in CO
What is Ventricular Fibrillation?
- when the ventricles do not contract but quiver.
- ineffective CO
What is AICD?
Automatic Implantable cardiac defibrillator
implanted device that gives electric shocks when HR is higher than programmed limit
What is important for the PT/PTA with pt's with AICD?
- know the limit to avoid exercise intensity that would activate the device
- avoid UE/strengthening exercise initially
- may be interfered with by electromagnetic signals
what is a pacemaker?
- device that has rate and rhythm sensitivity
- ability to override certain arrhythmias
What is included in Cardiovascular Examination?
- Medical Record review
- Patient interview
- Vital signs
- Observation, inspection, palpation
What is looked at in the Medical record review?
- medical history
- blood tests for specific cardiac enzymes
- electrolytes- K, Mg, Ca
- Kidney function-BUN, creatine
- Cholesterol, LDL, triglyceride, blood sugars
- arterial blood gasses
- results of diagnostic studies
- flow charts over past 24 hours
What is gathered in the patient interview?
- previous level of functioning
What is examined in the gathering of Vitals?
- HR and rhythm
- respiratory rate, rhythm, dyspnea
- blood pressure
Orthostatic hypotension occurs when?
during a position change from lying to either sitting or standing
Symptoms of Orthostatic Hypotension:
- drop of >20 mmHg between measurements
- standing BP of <100 mmHg
Risk factors of Orthostatic Hypotension:
- prolonged bedrest
- volume depletion
- muscle atrophy
- vasodilation medication
- antihypertensive medication
What is monitored in Observation, Inspection and Palpation of the patient?
- skin color
- cool fingertips
- edema of extremities
Bilateral edema of the extremities is associated with what?
What is Auscultion seeking to find?
- abnormal heart sounds -S3 or S4
- pericardial friction rub
- abnormal lung sounds
what is bruit?
- narrowing within an artery due to athersclerosis
- typically in carotid or femoral arteries
What tests and measures can be used in the Cardiovascular examination?
- Cardiac Catheterization
- Invasive Monitors
- Exercise Tolerance tests
what is an EKG?
12 lead in which each coronary artery is represented by a lead to give a general schema for myocardial perfusion
during rest & exercise
What is Cardiac Catheterization?
insertion of a catheter into a major artery and advancing it through the aorta till it reaches the LV
What is Coronary angiogram?
injecting a radio opaque into the coronary arteries to observe blood flow and determine lesions or obstructions
What is an Echocardiogram?
US of mall motion, integrity, valvular status, wall thickness, chamber size, LV function
What is the Swan-Ganz catheter?
catheter inserted through the vessels entering the right side of the heart to record pressures-"central Line"
What is the purpose of the ETT?
examine the ability of the cardiovascular system to accommodate to increase in VO2
determine the functional aerobic capacity by detection of ischemia
What is the MET?
- systemic oxygen requirement at rest
- roughly 3.5 ml O2/kg of body weight/ min
what does a Positive stress test mean?
that there is a point in which myocardial O2 supply is inadequate to meed the need
what does a negative stress test mean?
there is balance between oxygen supply and the demand
What can be used for and ETT if the patient is unable to physically do the ETT on a bike or treadmill?
pharmacological stress tests
What are the 3 major factors in Pathophysiology concerning PT interventions for specific pathologies?
- Inadequate Oxygen supply
- decrease in ventricular contraction
- alteration in electrical impulse
what is cor pulmonale?
R ventricular hypertrophy
What is more common, LV impairments or RV?
LV impairments are more common
Exercise prescription is based on what?
FITT (frequency, intensity, time, type)
what patients are excluded from an exercise prescription?
- unstable angina
- symptomatic HF
- uncontrolled arrhythmias
- mod-sev aortic stenosis
- uncontrolled DM
- acute systemic illness or fever
- uncontrolled tachycardia
- resting systolic BP >200 or diast BP >110
what do most patients benefit in exercise from?
- 12+ wks
- 20-40 min of aerobic exercise
- 70-85% of baseline max exercise test HR
What is crucial in prescribed exercise for those with CAD?
warm up to allow vasodilation of coronary arteries
What to be aware of and ready to handle during exercise with your patient:
- symptomatic angina
- need for NTG-under tongue(quick acting)
- cardiac pain vs. referred pain
Phase 1 of PT interventions with MI patients
- after patient has been stable for 24 hours
- vitals are taken prior, during, and post activity
Goal of Phase 1 of PT interventions with MI patients:
- monitor activity tolerance
- prepare for discharge
- patient education
- support risk factor modification
- emotional support
- collaborate with team
Intensity during Phase 1 of PT with MI patients:
<11 on Borg scale
20 bpm increase with the MET level set (unless on beta blockers)
Level 1 of inpatient cardiac program
- 1-1.5 METs
- ankle pumps
- deep breathing
- limited self care
level 2 of inpatient cardiac program:
- 1.5-2 METs
- out of bed tasks
Level 3 of inpatient cardiac program:
- 2-2.5 METs
- increase ambulation
- (based on time rather than distance)
Level 4-5 of inpatient cardiac program:
- 2.5-5 METs
- increase in ambulation
- exercise including some UE exercises
Level 6 of inpatient cardiac program:
What should be documented of the IP cardiac program?
- types of sitting/standing exercises
- stair climbing
- duration of task
- number of rests
- vitals: pre, during, post
- response to activity
- patient education
What does the Home exercise program look like for Phase 1 interventions for patients with an MI?
- 4-6 wks while myocardium heals
- gradual increase in ambulation time (20-30 min)
- 1-2 activity sessions/ day reached by end of the 4-6wks
- intersperse rest and activity throughout day
Phase II of intervention for MI patients:
- 4-6wks after the MI
- intensity based on 40-60% of MHR or 40-70% of MET level
- intensity remains for 3 consecutive sessions before increasing
what are some special considerations for Phase II?
- Positive ETT- do NOT exceed 90% of RPP
- strength trainig- begin with elastic bands, 1-3 lbs (ONLY AFTER 3 WKS, 5 WKS FOR MI, 8 WKS FOR CABG!!!!)
what are some guidelines for using resistance training in Phase II?
- large muscle groups BEFORE small
- exhale with exertion
- avoid tight grip exercises
- Focus on borg scale 11-13 range
- slow controlled movements
- Stop with presentation of any warning signs
Interventions for CHF:
- address systemic conditioning
- Peripheral endurance training
- low level resistance training
- respiratory muscle training
- energy conservation training
- AVOID ISOMETRICS
What should I educate my patient on?
- activity guidelines
- self monitoring of pulse and RPE
- symptom recognition
- lifestyle choices/issues
- psychological/ social issues
- prevention of CAD- modifying risk factors