TherEx.-Heart Disease and Rehabilitation

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TherEx.-Heart Disease and Rehabilitation
2014-02-05 22:17:30
heart disease rehabilitation

heart disease rehabilitation
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  1. Leading cause of death 
    1 in 3 have one or more types of it.
    Cardiovascular Disease
  2. Underlying pathologies of CVD?
    • Atherosclerosis
    • altered myocardial muscle mechanics
    • valvular dysfunction
    • arrhythmias
    • hypertension
  3. Location of heart
    • L thoracic cavity
    • between 2nd and 5th rib
    • base is superior
    • apex is inferior
  4. Layers of pericardium surrounding the heart
    • epicardium
    • pericardial fluid
    • parietal layer
  5. layers of myocardium:
    • endocardium-inner
    • epicardium-outer
  6. purpose of the coronary arteries
    blood supply to myocardium happens during ventricular relaxation
  7. Left Coronary artery branch supplies blood where?
    to the left anterior descending and circumflex
  8. right coronary artery supplies blood where?
    to the posterior descending
  9. how can the lumen be altered?
    • by athersclerotic lesions
    • smooth muscle contraction within the walls
  10. what is occurring during systole?
  11. what is occurring during diastole?
  12. what is occurring during the normal heart sound, S1?
    mitral and tricuspid valves closing
  13. What is occurring during the normal heart sound, S2?
    aortic and pulmonary valves closing
  14. abnormal heart sound, S3:
    is associated with what?
    sounds like?

    when is it heard?
    • CHF
    • ventricular gallop
    • heard early in diastole
  15. abnormal heart sound, S4:

    is associated with what?
    sounds like?
    when is it heard?
    • MI
    • atrial gallop
    • heard in late diastole
  16. ANS includes:

  17. Sympathetic Response:
    • increase in HR
    • increase in force of contraction
    • dilation of coronary arteries
    • vasoconstriction of peripheral blood vessels
  18. Parasympathetic Response:
    • decrease in HR
    • decrease of force of contraction and speed of conduction
    • vasodilation of peripheral vessels of bowel, bladder, and genitals
  19. Cardiac Output formula:
    SV x HR = CO
  20. Cardiac Output measures what?
    the amount of blood leaving ventricles
  21. Normal cardiac output is what?
    4-6 L/min
  22. Stroke volume is defined as what?
    the amount of blood ejected each myocardial contraction
  23. Sterlings Law?
    pre-stretch allows for a more efficient contraction
  24. What does Stroke volume include?
    • preload
    • contractility
    • afterload
  25. Preload is:
    the amount of blood in the ventricle at end of diastole
  26. contractility is:
    the ability of the ventricle to contract
  27. afterload is:
    the force required to open the aortic valve
  28. what is MVO2?
    • the energy cost of the myocardium
    • (Myocardial oxygen demand)
  29. the formula for rate pressure product:
    HR x Systolic BP = RPP
  30. a decrease of MVO2 is usually caused by what?
  31. Tachycardia:

    • normal with exercise
    • compensatory with blood loss
  32. Bradycardia:

    • normal with regular endurance exercise
    • beta blockers
    • ectopic pacemaker of the heart
  33. Electrical Conduction pathway of the heart
    • SA node
    • AV node
    • Bundle of His
    • Perkinje fiers
    • Septum
    • Ventricles
  34. 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
  35. Hypertension is defined as:
    • persistent 
    • systolic> 140 mmHg
    • diastolic>90 mmHg
  36. Primary cause of hypertension
  37. Secondary Cause of Hypertension
    • Renal
    • endocrine
    • vascular
    • neurological
  38. Classes of Medication for Hypertension
    • beta blockers
    • nitrates
    • calcium channel blockers
    • digitalis
    • diuretics
    • vasodilators
    • nicotine
  39. 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
  40. Risk Factors for CAD
    • Smoking
    • high cholesterol
    • HTN
    • DM
    • Emotional stress
    • family history
    • obesity
    • sedentary lifestyle
    • elevated Blood homocysteine and fibrinogen levels
  41. When does Ischemia occur?
    when the lumen is at least 70% occluded
  42. What is ischemia?
    temporary deficiency in oxygenated blood flow to tissues
  43. Why does ischemia typically occur?
    • atherosclerotic lesions
    • spasm of smooth muscle in vessels of arteries
  44. Symptoms of Angina:
    • substernal chest pain
    • radiate from chest to: 
    • shoulder
    • jaw
    • arm
    • upper back
    • indigestion
    • shortness of breath
    • nausea
    • diaphoresis
  45. 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

  46. Characteristic traits of Stable Angina:
    • occurs at a predictable RPP
    • alleviated by stopping activity
    • alleviated by rest 
    • alleviated by nitroglycerin
  47. Characteristics of Prinzmetal Angina:
    • caused by VASOSPASM
    • NOT by an occlusion
  48. 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
  49. Symptoms of Infarction:
    intensity of angina increased to usually 10/10
  50. 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
  51. Complicated MI's
    • ischemia
    • lv failure or significant ventricular arrhythmias post MI
    • cardiogenic shock
  52. When does a MI wound stabilize?
    4-6 wks
  53. Diagnostic tests for CAD
    • 12 lead EKG
    • Blood tests
  54. What will an EKG demonstrating an ischemic episode look like?
    • ST segment depressed
    • T wave inverted
  55. what appears in the blood with a positive ischemic event?
    • elevated CPK-MB
    • elevated troponin
    • (both indicative of cell death
  56. What does the medical management for an Ischemic event offer?
    • Acute pharmacological 
    • long term pharmacological
    • Revascularization
  57. Acute Pharmacological care of an ischemic event:
    • nitroglycerin
    • thombolytic agent (TPA)
  58. Long term pharmacological
    • Beta blockers
    • calcium channel blockers
    • nitrates
  59. What effect do Beta blockers have in the long term pharmacological care of MI's?
    • decrease sympathetic activity
    • decrease HR and contractility
  60. what effect do calcium channel blockers have in the long term pharmacological care of MI's?
    • Decrease BP
    • decrease smooth muscle spasm
  61. what effect do Nitrates have in the long term pharmacological care of MI's?
    • they act as vasodilators
    • increase dilation of coronary arteries
  62. What are types of Revascularization procedures?
    • percutaneous transluminal coronary angioplasty with stent
    • laser surgery
    • CABG
  63. When are PT interventions included in the care for PTCA pts?
    2 wks post procedure
  64. 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
  65. Considerations with CABG patients
    • anesthesia
    • blood loss
    • common arrhythmias
    • energy cost of healing
  66. When do CABG pts typically begin cardiac rehab?
    • 6 wks after surgery
    • dependent upon incision site and blood counts
  67. what is heart failure?
    syndrome which results in inadequate systemic perfusion typically from a surpassed MI
  68. Left sided Heart-failure presents as:
    • inadequate CO 
    • blood flow back up into the lungs

    • shortness of breath
    • cough
  69. 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
  70. what is it called when both sides fail in Heart failure?
    Biventricular failure
  71. what does it mean when there is systolic dysfunction?
    • ventricle contraction is decreased
    • decreased SV
    • decreased CO
    • decreased EF
  72. What does it mean when there is diastolic dysfunction?
    • no relaxation of ventricles
    • ventricles fill
    • decreased SV
    • decreased CO
    • normal EF
  73. What does a pt present with when they are experiences HF?
    • SOB
    • pitting edema
    • enlarged heart
    • pulmonary edema on x-ray
    • abnormal lung sounds
    • paroxysmal nocturnal dyspnea
    • orthopnea
  74. What is watched with HF?
    • sodium intake
    • fluid intake-possible restriction
    • weight-sudden weight gain indicated worsening
  75. 3 types of Valvular Heart disease:
    • stenosis
    • prolapse
    • regurgitation
  76. Stenosis disfunction of Valvular HD:
    • narrowing of the passage
    • become more rigid and smaller
  77. Prolapse disfunction of Valvular HD:
    • enlarged valve become floppy
    • has a ballooning effect
  78. Regurgitation disfunction of Valvular HD:
    forward and backward movement of blood in valve due to incomplete closure
  79. Types of abnormalities in electrical conduction in the heart
    • ectopic beats
    • conduction
    • arrhythmias
    • AICD
    • pacemakers
  80. what is an ectopic eat?
    a beat that originates from any other site than the sinus node
  81. types of ectopic beats would include:
    • PAC
    • PVC
    • Bigeminy
    • Trigeminy
  82. Bigeminy is when:
    every other beat is a PVC
  83. Trigeminy is when:
    every third beat is a PVC
  84. It is normal to have a PVC ectopic beat with the intake of what?
    • nicotine
    • caffeine
  85. what is a heart block?
    conduction time through the AV node is prolonged
  86. Types of arrhythmias:
    • A fib
    • PAC
    • PVC
    • Ventricular tachycardia
    • Ventricular fibrillation
  87. Describe A Fib:
    • varied number of P waves
    • -worried about blood clots
  88. Describe PAC:
    a premature atrial contraction

    ectopic beat originating in the atria
  89. PAT represents:
    • Paroxysmal atrial tachycardia
    • results in HR of 150-200 bpm
  90. Describe PVC:
    premature ventricular contraction

    • no P wave
    • wide QRS complex
    • if PVC's increase-->possible MI
  91. What is Ventricular Tachycardia?
    • when there are 4 or more PVC's in a row
    • there is a rapid decrease in CO
  92. What is Ventricular Fibrillation?
    • when the ventricles do not contract but quiver.
    • ineffective CO
  93. What is AICD?
    Automatic Implantable cardiac defibrillator

    implanted device that gives electric shocks when HR is higher than programmed limit
  94. 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
  95. what is a pacemaker?
    • device that has rate and rhythm sensitivity
    • ability to override certain arrhythmias
  96. What is included in Cardiovascular Examination?
    • Medical Record review
    • Patient interview
    • Vital signs
    • Observation, inspection, palpation
    • Ausculation
  97. What is looked at in the Medical record review?
    • medical history
    • medications
    • blood tests for specific cardiac enzymes
    • electrolytes- K, Mg, Ca
    • CBC-anemia
    • Kidney function-BUN, creatine
    • Cholesterol, LDL, triglyceride, blood sugars
    • arterial blood gasses
    • results of diagnostic studies
    • flow charts over past 24 hours
  98. What is gathered in the patient interview?
    • cognition
    • previous level of functioning
    • pain
  99. What is examined in the gathering of Vitals?
    • HR and rhythm
    • respiratory rate, rhythm, dyspnea
    • blood pressure
  100. Orthostatic hypotension occurs when?
    during a position change from lying to either sitting or standing
  101. Symptoms of Orthostatic Hypotension:
    • lightheadedness
    • dizziness
    • LOB
    • drop of >20 mmHg between measurements
    • standing BP of <100 mmHg
  102. Risk factors of Orthostatic Hypotension:
    • prolonged bedrest
    • volume depletion
    • PVD
    • muscle atrophy
    • vasodilation medication
    • antihypertensive medication
  103. What is monitored in Observation, Inspection and Palpation of the patient?
    • skin color
    • diaphoresis
    • cool fingertips
    • edema of extremities
  104. Bilateral edema of the extremities is associated with what?
  105. What is Auscultion seeking to find?
    • abnormal heart sounds -S3 or S4
    • pericardial friction rub
    • murmurs
    • abnormal lung sounds
    • Bruit
  106. what is bruit?
    • narrowing within an artery due to athersclerosis
    • typically in carotid or femoral arteries
  107. What tests and measures can be used in the Cardiovascular examination?
    • EKG
    • Cardiac Catheterization
    • Echocardiogram
    • Invasive Monitors
    • Exercise Tolerance tests
  108. 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
  109. What is Cardiac Catheterization?
    insertion of a catheter into a major artery and advancing it through the aorta till it reaches the LV
  110. What is Coronary angiogram?
    injecting a radio opaque into the coronary arteries to observe blood flow and determine lesions or obstructions
  111. What is an Echocardiogram?
    US of mall motion, integrity, valvular status, wall thickness, chamber size, LV function
  112. What is the Swan-Ganz catheter?
    catheter inserted through the vessels entering the right side of the heart to record pressures-"central Line"
  113. 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
  114. What is the MET?
    • systemic oxygen requirement at rest
    • roughly 3.5 ml O2/kg of body weight/ min
  115. what does a Positive stress test mean?
    that there is a point in which myocardial Osupply is inadequate to meed the need
  116. what does a negative stress test mean?
    there is balance between oxygen supply and the demand
  117. 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
  118. 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
  119. what is cor pulmonale?
    R ventricular hypertrophy
  120. What is more common, LV impairments or RV?
    LV impairments are more common
  121. Exercise prescription is based on what?
    FITT (frequency, intensity, time, type)
  122. 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
    • thrombophlebitis
  123. what do most patients benefit in exercise from?
    • 3/wk
    • 12+ wks
    • 20-40 min of aerobic exercise
    • 70-85% of baseline max exercise test HR
  124. What is crucial in prescribed exercise for those with CAD?
    warm up to allow vasodilation of coronary arteries
  125. What to be aware of and ready to handle during exercise with your patient:
    • symptomatic angina
    • vitals
    • need for NTG-under tongue(quick acting)
    • cardiac pain vs. referred pain
  126. Phase 1 of PT interventions with MI patients
    • inpatient
    • after patient has been stable for 24 hours
    • vitals are taken prior, during, and post activity
  127. 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
  128. 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)
  129. Level 1 of inpatient cardiac program
    • 1-1.5 METs
    • ankle pumps
    • deep breathing
    • limited self care
  130. level 2 of inpatient cardiac program:
    • 1.5-2 METs
    • out of bed tasks
  131. Level 3 of inpatient cardiac program:
    • 2-2.5 METs
    • increase ambulation
    • (based on time rather than distance)
  132. Level 4-5 of inpatient cardiac program:
    • 2.5-5 METs
    • increase in ambulation
    • exercise including some UE exercises
  133. Level 6 of inpatient cardiac program:
    • 6 METs
    • stair climbing
  134. What should be documented of the IP cardiac program?
    • time
    • distance
    • types of sitting/standing exercises
    • stair climbing
    • duration of task
    • number of rests
    • vitals: pre, during, post
    • response to activity
    • patient education
  135. 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
  136. Phase II of intervention for MI patients:
    • outpatient
    • 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
  137. 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!!!!)
  138. 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
  139. Interventions for CHF:
    • address systemic conditioning
    • Peripheral endurance training
    • low level resistance training 
    • respiratory muscle training
    • energy conservation training
  140. What should I educate my patient on?
    • activity guidelines
    • self monitoring of pulse and RPE
    • symptom recognition
    • nutrition
    • medications
    • lifestyle choices/issues
    • psychological/ social issues
    • prevention of CAD- modifying risk factors