cardio final

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cardio final
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2014-05-05 20:54:36
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  1. Common Indications for exercise testing
    • 1. To determine the cause and level of SOB 
    • 2. To evaluate a patient’s work capacity 
    • 3. Exercise Prescription
  2. Exercise Testing with Pulmonary Disease
    Mild – protocols as with Normal individuals 

    • Moderate (FEV1 < 80% of predicted values) 
    • –Limited by ventilation 
    • –SOB with ADL’s and moderate – fast walking pace 
    • •(3-4 METs) 
    • –Mild-moderate hypoxemia present 
    • •Patients with severe lung disease require a modified approach to exercise testing. 
    • • Tests should be 
    • –Low-level intermittent tests - the patient is given rests between work stages 
    • –Steady-state endurance test at low levels
  3. 6 Minute Walk Test  (6MWT)
    • •6MWD post Inpatient Pulmonary Rehab shown to be a marker of activity tolerance 
    • •Predicts mortality 
    • •Shows a strong positive association between 6MWD and survival 
    • •Demonstrates that InPT Pulm Rehab may ameliorate detrimental effects of acute illness
  4. Dyspnea Scale
    • 0- None
    • 1- Slight
    • 2- Moderate
    • 3- Severe
    • 4- Very Severe
  5. Borg Scale
    • 6-20 
    • •*RPE level of 12-13 = 60% of max HR 
    • •*RPE level of 16 = 85% of max HR.
  6. Monitoring of In-patient Populations
    • Dyspnea Scale 
    • –Scale 1-5, assess SOB. 
    • –1 = little breathlessness related to exercise 
    • –5 = severe breathlessness related to exercise 

    • Angina Scale 
    • –Scale 1-5 
    • –1 = slight pain perception 
    • –5 = infarction pain
  7. Abnormal Responses to Exercise
    HR increases more than 20 to 30 bpm above resting heart rate 

    HR decreases below resting heart rate 

    Systolic blood pressure increases more than 20 to 30 mm Hg above resting level 

    Systolic blood pressure decreases more than 10 mm Hg below resting level 

    Oxygen saturation drops below prescribed level 

    Patient becomes short of breath or respiratory rate increases to a level not tolerated by the patient 

    ECG changes 

    • Nonverbal/nonvital signs of possible exercise intolerance: 
    • –Color changes 
    • –Diaphoresis 
    • –Increased accessory mm use 
    • –Agitation, nonverbal signs of pain
  8. Exercise Prescription for Young Children
    • Intensity: 
    • –Weight loads should permit 8 or more repetitions to be completed  
    • –Resistance exercise should not be performed to the point of severe muscular fatigue 

    • Duration: 
    • –Perform 1 to 2 sets of 8 to 10 different exercises ensuring that all major muscle groups are included in early stages of training 

    • Frequency 
    • –Limit strength training sessions to twice per week and encourage participate in other forms of physical activity
  9. Prescribing Exercise Intensity by METS or Heart Rate
    • MET = 3.5 ml O2/kg/min 
    • METS – maximal MET level on a GXT is 8 METs 
    • •60%: 4.8 METs 
    • •80%: 6.4 METs
  10. types of cardiac medications
    • Decrease myocardial oxygen
    • consumption

    Anti-arrhythmic medications

    Vasodilators

    Anti-hypertensive medications

    Calcium channel blockers
  11. Adrenergic receptors
    • ANS
    • Alpha 1 and 2 - inc HR, contraction smooth muscle

    Beta 1 and 2- Beta 2- brochodilation s inc CO
  12. Cholinergic response
    • PNS
    • Muscarinic- end plate skeletal muscle- where effect occurs- not as strong

    Nicotinic- if only stimulate nicotinic- more sympathetic effect
  13. Sympatholytic Drugs
    • inhibits sympathetic nervous system
    • 􀁻 Beta-blockers
    • 􀁻 Decrease HR and cardiac
    • contraction
    • 􀁻 Decrease in Sympathetic tone
    • 􀁻 Decrease myocardial O2
    • consumption

    non-selective--all beta-blocker receptors are blocked

    selective- only some beta-blocker receptors are blocked

    cardiac selective- beta 1 blocked
  14. Beta Blockers (cardiac and vascular effects)
    • Cardiac Effects:
    • Decrease contractility
    • Decrease relaxation rate
    • decrease HR
    • decrease conduction velocity

    • Vascular Effects:
    • Smooth muscle contraction - mild vasoconstriction
  15. Calcium Channel Blockers
    • dec in myocardial demand
    • inc in myocardial supply
    • b/c dec arterial BP and smooth muscle relaxation
    • relax systemic and coronary smooth muscles
  16. Classifications of Arrhythmic Drugs
    • Class I
    • 􀁺 Sodium channel blockers

    • Class II
    • 􀁺 Beta Blockers

    • Class III
    • 􀁺 Drugs that prolong repolarization
    • 􀁺 Help stabilize rhythms

    • Class IV
    • 􀁺 Calcium Channel Blockers
  17. Vasodilators ( with categories)
    • Inhibiting smooth muscle contraction
    • 􀁺 Not generally the first line in treatment

    • Categorized by mechanism of action:
    • 􀁻 Nitrates
    • 􀁻 Calcium antagonists
    • 􀁻 Angiotensin-converting enzymes
    • (ACE) inhibitors
  18. Vasodilators: Nitrates
    • affect muscle relaxation and dilation
    • in both arteries and veins

    reducing afterload and preload

    • do not increase cardiac blood flow
    • in the atherosclerosis

    • shunt blood to areas of low
    • perfusion
  19. Vasodilators: Calcium antagonists
    • Resulting in:
    • 􀁻 decrease afterload
    • 􀁻 decrease in the oxygen demand of the heart

    • Indications:
    • 􀁺 arrhythmias
    • 􀁺 angina
  20. Vasodilators: Angiotensin-converting
    enzymes (ACE) inhibitors
    • act to prevent angiotensin I
    • from becoming angiotensin
    • II
    • 􀁻 Angiotensin II acts as a
    • vasoconstrictor and
    • retains sodium
    • 􀁻 Inhibition of Angiotensin
    • II production prevents
    • vasoconstriction
    • 􀁻 less sodium is retained

    decrease BP

    • used as a treatment for
    • HTN
  21. First heart sound, (S1)
    • Normal heart sound
    • "lub"

    associated with the closure of the mitral and tricuspid valves
  22. Second heart sound, (S2)
    • normal heart sound
    • "dub"

    associated with the closure of the aortic and pulmonic valves
  23. Third heart sound, (S3)
    • abnormal heart sound
    • heart failure- stretched out heart extra fluid in chamber sloshing around

    • "sloshing-in" 
    • occurs early in diastole during the phase of rapid ventricular filling, (hallmark of CHF)
  24. Fourth heart sound, (S4)
    • abnormal heart sound
    • occurs before S1
    • "a-stiff wall"

    stiff non0complaint ventricle and get a double tap when bld goes in

    occurs late in diastole, prior to S1 and is related to atrial contraction, (left ventricular hypertrophy, hypertension, pulmonary stenosis)
  25. Auscultation of the Heart Sounds (locations)
    • Mitral
    • – near the apex, in 5th intercostal space at the mid clavicular line

    • Tricuspid
    • – at the 5th intercostal space at the left lower sternal border

    • Pulmonic
    • – near the sternum and the 2nd or 3rd intercostal space

    • Aortic
    • – loudest at the right 2nd intercostal space but extending to the apex
  26. Diagnosis of PAD (peripheral arterial disease)
    • History of symptoms
    • – claudication pain
    • • History of risk factors for
    • CAD
    • • Noninvasive tests such as:
    • – segmental limb pressures
    • – pulse volume recordings
    • – arterial ultrasound
    • • Invasive tests include:
    • – arteriography and MRI
  27. Criteria for Stopping a GXT
    • • An oxygen consumption
    • level of 17.7ml of oxygen
    • per kg (6mets) achieved
    • • Fatigue or dyspnea
    • • Maximal heart rate of 120
    • to 130bpm
    • • Frequent unifocal or
    • multifocal PVC
    • • ST-segment depression of
    • 1.0-2.0mm
    • • Claudication pain
    • • Dizziness
    • • Decrease in systolic BP of
    • 10-15mmHg below peak
    • value
    • • Hypertensive BP (systolic
    • over 200mmHg, diastolic
    • over 110mmHg
    • • Level 1 (out of 4) angina
  28. Cardiac Output (CO):
    5 L/min amount of blood ejected into aorta each minute.
  29. Stroke Volume (SV):
    • amount of blood ejected
    • from ventricles with each contraction.

    • represents only about 50% of blood that comes out of ventricle (in terms of efficiency)-
    • so it works with HR to get full CO
  30. Venous Return (VR):
    amount of blood flowing from veins into the right atrium per minute
  31. Three factors interact to influence the SV
    Preload

    Afterload

    Contractility
  32. Preload
    amount of bld before contraction
  33. afterload
    amount of bld left after contraction
  34. contractility
    • affected by both preload and afterload- this is because if there is more pressure ( from excessive blood left in vessel) than there is
    • stretch being placed on tissue so muscle breaks down ( think frayed elastic) and it is unable to preform its function well.
    • this make the HR increase to continue to have CO maintain the same
  35. EJECTION FRACTION (EF):
    the portion of the SV pumped from the left ventricle

    what goes out compared to what comes in
  36. PQRST waves
    P- atrial depolarization

    QRS complex- ventricular depolarization

    T- heart rest for repolarization
  37. Stenosis
    • impedance of forward flow due to
    • an incomplete opening of the valves
  38. Regurgitation
    an incomplete closing of the valve
  39. Murmurs
    extra sounds heard in systole or diastole
  40. 3 major coronary arteries:
    • Circumflex - breaks off from LAD
    • Left Anterior Descending
    • Right Coronary Artery - has Ant and Post branches
  41. CAD
    • limits coronary blood flow
    • but does not significantly inhibit heart muscle


    does not lead to cell death
  42. CHD
    • obstruction that causes
    • permanent damage to the heart muscle fibers,
    • therefore inhibiting heart muscle function.
  43. Coronary Vasospasms
    abnormality of the smooth muscle of the coronary arteries

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