Podcast
Questions and Answers
What is the function of the interventricular septum?
What is the function of the interventricular septum?
The pulmonary valve is located between the right atrium and the right ventricle.
The pulmonary valve is located between the right atrium and the right ventricle.
False
What is the name of the valve between the left atrium and the left ventricle?
What is the name of the valve between the left atrium and the left ventricle?
Left AV (bicuspid) valve
The _______________________ is the muscular wall that separates the ventricles.
The _______________________ is the muscular wall that separates the ventricles.
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What is the name of the valve between the right ventricle and the pulmonary artery?
What is the name of the valve between the right ventricle and the pulmonary artery?
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The heart is located in the abdominal cavity.
The heart is located in the abdominal cavity.
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What is the name of the system that includes the pulmonary and systemic circuits?
What is the name of the system that includes the pulmonary and systemic circuits?
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The _______________________ is the outermost layer of the heart.
The _______________________ is the outermost layer of the heart.
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Match the following heart structures with their functions:
Match the following heart structures with their functions:
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The heart has three layers: endocardium, myocardium, and epicardium.
The heart has three layers: endocardium, myocardium, and epicardium.
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What is the main function of the pericardium?
What is the main function of the pericardium?
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The pericardial cavity is filled with 50 mL of pericardial fluid.
The pericardial cavity is filled with 50 mL of pericardial fluid.
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What is the function of the fibrous skeleton of the heart?
What is the function of the fibrous skeleton of the heart?
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The ______________ layer of the pericardium is the outer wall of the sac.
The ______________ layer of the pericardium is the outer wall of the sac.
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Match the following structures with their descriptions:
Match the following structures with their descriptions:
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What is the main component of the myocardium?
What is the main component of the myocardium?
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The pericardial sac is anchored to the diaphragm superiorly and sternum anteriorly.
The pericardial sac is anchored to the diaphragm superiorly and sternum anteriorly.
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What is the function of the pericardial fluid?
What is the function of the pericardial fluid?
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The coronary blood vessels travel through the ______________ layer.
The coronary blood vessels travel through the ______________ layer.
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Match the following structures with their functions:
Match the following structures with their functions:
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What is the duration of the PR interval on the diagram?
What is the duration of the PR interval on the diagram?
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The atria contract during the T wave
The atria contract during the T wave
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What is the name of the segment between the Q wave and the S wave?
What is the name of the segment between the Q wave and the S wave?
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The QT interval is the duration of the action potential from the start of the ______________ wave to the end of the T wave.
The QT interval is the duration of the action potential from the start of the ______________ wave to the end of the T wave.
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Match the following parts of the heart with their corresponding contractions:
Match the following parts of the heart with their corresponding contractions:
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What is the unit of measurement for the amplitude of the ECG wave?
What is the unit of measurement for the amplitude of the ECG wave?
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What is the role of the sinoatrial node?
What is the role of the sinoatrial node?
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The atrioventricular node is responsible for distributing excitation through the ventricular myocardium.
The atrioventricular node is responsible for distributing excitation through the ventricular myocardium.
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What is the role of the Purkinje fibers?
What is the role of the Purkinje fibers?
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Excitation spreads through the ______________ after the atrioventricular node fires.
Excitation spreads through the ______________ after the atrioventricular node fires.
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Match the following structures with their functions:
Match the following structures with their functions:
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How many cusps does the Right AV valve have?
How many cusps does the Right AV valve have?
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The Left AV valve has three cusps.
The Left AV valve has three cusps.
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What is the purpose of the chordae tendineae?
What is the purpose of the chordae tendineae?
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The valves in the heart ensure a one-way flow of blood through the ______________.
The valves in the heart ensure a one-way flow of blood through the ______________.
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Match the following heart valves with their descriptions:
Match the following heart valves with their descriptions:
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What is the name of the valve that has two cusps?
What is the name of the valve that has two cusps?
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The heart has a two-way flow of blood.
The heart has a two-way flow of blood.
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What is the function of the atrioventricular (AV) valves?
What is the function of the atrioventricular (AV) valves?
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What happens to monocytes after they differentiate into macrophages?
What happens to monocytes after they differentiate into macrophages?
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Injured endothelial cells release inflammatory mediators and TF which promotes inflammation and coagulation.
Injured endothelial cells release inflammatory mediators and TF which promotes inflammation and coagulation.
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What is the result of the stimulation of EC receptors by damage-associated molecular patterns?
What is the result of the stimulation of EC receptors by damage-associated molecular patterns?
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Chronic ______________ and immune dysregulation play a role in the development of atherosclerosis.
Chronic ______________ and immune dysregulation play a role in the development of atherosclerosis.
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Match the following with their functions:
Match the following with their functions:
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What is the result of cells of injured tissue undergoing morphological and functional modifications?
What is the result of cells of injured tissue undergoing morphological and functional modifications?
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What is the percentage of Australians who had 1 or more conditions related to heart, stroke, or vascular disease in 2022?
What is the percentage of Australians who had 1 or more conditions related to heart, stroke, or vascular disease in 2022?
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Cardiovascular disease has a greater impact on females in Australia.
Cardiovascular disease has a greater impact on females in Australia.
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What is the prevalence of heart, stroke, and vascular disease in Indigenous Australians compared to non-indigenous Australians?
What is the prevalence of heart, stroke, and vascular disease in Indigenous Australians compared to non-indigenous Australians?
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In 2022, approximately ______________ million Australians had 1 or more conditions related to heart, stroke, or vascular disease.
In 2022, approximately ______________ million Australians had 1 or more conditions related to heart, stroke, or vascular disease.
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Which of the following is a risk factor for cardiovascular disease?
Which of the following is a risk factor for cardiovascular disease?
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Match the following demographics with their corresponding prevalence of cardiovascular disease:
Match the following demographics with their corresponding prevalence of cardiovascular disease:
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Cardiovascular disease is a major health problem in Australia.
Cardiovascular disease is a major health problem in Australia.
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What is the name of the condition that describes many different conditions affecting the heart and blood vessels?
What is the name of the condition that describes many different conditions affecting the heart and blood vessels?
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What is the primary function of the vascular endothelium?
What is the primary function of the vascular endothelium?
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Nitric oxide (NO) is a potent vasoconstrictor.
Nitric oxide (NO) is a potent vasoconstrictor.
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What is the name of the enzyme responsible for producing nitric oxide (NO) from L-arginine?
What is the name of the enzyme responsible for producing nitric oxide (NO) from L-arginine?
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What is the primary underlying mechanism for the development of endothelial dysfunction?
What is the primary underlying mechanism for the development of endothelial dysfunction?
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Chronic exposure to cardiovascular risk factors and _______________________ stress can lead to endothelial dysfunction.
Chronic exposure to cardiovascular risk factors and _______________________ stress can lead to endothelial dysfunction.
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Endothelial dysfunction is characterized by increased anti-inflammatory effects.
Endothelial dysfunction is characterized by increased anti-inflammatory effects.
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Match the following chemicals with their functions in vascular tone regulation:
Match the following chemicals with their functions in vascular tone regulation:
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What is the role of eNOS in healthy endothelium?
What is the role of eNOS in healthy endothelium?
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C-reactive protein (CRP) is a protein present in the ______________________ response.
C-reactive protein (CRP) is a protein present in the ______________________ response.
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What is the result of chronic exposure to cardiovascular risk factors and oxidative stress on the vascular endothelium?
What is the result of chronic exposure to cardiovascular risk factors and oxidative stress on the vascular endothelium?
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Match the following molecules with their effects on endothelial dysfunction:
Match the following molecules with their effects on endothelial dysfunction:
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Endothelial dysfunction is a major contributor to the progression of atherosclerotic cardiovascular disease.
Endothelial dysfunction is a major contributor to the progression of atherosclerotic cardiovascular disease.
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What is the result of overexpression of TNF-α and IL-1?
What is the result of overexpression of TNF-α and IL-1?
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What is the name of the monolayer of cells covering the lumen of the vessels?
What is the name of the monolayer of cells covering the lumen of the vessels?
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Endothelial dysfunction is characterized by increased NO bioavailability.
Endothelial dysfunction is characterized by increased NO bioavailability.
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What is the effect of oxidative stress on endothelial function?
What is the effect of oxidative stress on endothelial function?
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Where are atherosclerotic lesions usually generated in the entire vascular tree?
Where are atherosclerotic lesions usually generated in the entire vascular tree?
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Low endothelial shear stress is associated with upregulation of eNOS.
Low endothelial shear stress is associated with upregulation of eNOS.
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What is the main mechanism of the beneficial effects on the cardiovascular system during exercise?
What is the main mechanism of the beneficial effects on the cardiovascular system during exercise?
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C-reactive protein is a marker of ______________ levels.
C-reactive protein is a marker of ______________ levels.
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Match the following with their descriptions:
Match the following with their descriptions:
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Endothelial dysfunction is only associated with cardiovascular disease.
Endothelial dysfunction is only associated with cardiovascular disease.
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Which of the following is a risk factor for endothelial dysfunction?
Which of the following is a risk factor for endothelial dysfunction?
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What is the name of the journal where the article 'Endothelial dysfunction: clinical implications in cardiovascular disease and therapeutic approaches' was published?
What is the name of the journal where the article 'Endothelial dysfunction: clinical implications in cardiovascular disease and therapeutic approaches' was published?
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What is the primary pathway for transmitting cardiac pain?
What is the primary pathway for transmitting cardiac pain?
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The atria and ventricles are supplied with parasympathetic sensory innervation.
The atria and ventricles are supplied with parasympathetic sensory innervation.
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What is the basis for cardiac pain referred to the chest, wall, arm, and back?
What is the basis for cardiac pain referred to the chest, wall, arm, and back?
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Sympathetic impulses from the heart converge with impulses from somatic thoracic structures onto the same ascending _______ neurons.
Sympathetic impulses from the heart converge with impulses from somatic thoracic structures onto the same ascending _______ neurons.
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Match the following components of the cardiac pain pathway:
Match the following components of the cardiac pain pathway:
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What is the role of vagal afferent fibers in cardiac pain?
What is the role of vagal afferent fibers in cardiac pain?
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Localisation of ischemic pain can predict the site of myocardial ischemia.
Localisation of ischemic pain can predict the site of myocardial ischemia.
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What is the name of the theory that explains cardiac pain referred to the chest, wall, arm, and back?
What is the name of the theory that explains cardiac pain referred to the chest, wall, arm, and back?
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In addition to sympathetic afferent fibers, _______ afferent fibers also play a role in cardiac pain.
In addition to sympathetic afferent fibers, _______ afferent fibers also play a role in cardiac pain.
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What is the basis for cardiac pain referred to the jaw and neck?
What is the basis for cardiac pain referred to the jaw and neck?
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What is the level of discomfort or pain described as 'excruciating and unbearable pain'?
What is the level of discomfort or pain described as 'excruciating and unbearable pain'?
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Monitoring should continue for at least 10 minutes after exercise.
Monitoring should continue for at least 10 minutes after exercise.
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What should be recorded during the post-exercise period?
What should be recorded during the post-exercise period?
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ST-segment changes that occur only during the ______________ period are currently recognized to be an important diagnostic part of the test.
ST-segment changes that occur only during the ______________ period are currently recognized to be an important diagnostic part of the test.
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What is the minimum duration of monitoring after exercise?
What is the minimum duration of monitoring after exercise?
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HR and BP should return to exact baseline levels before discontinuation of monitoring.
HR and BP should return to exact baseline levels before discontinuation of monitoring.
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What is the purpose of walking 'recovery' with a standardized speed?
What is the purpose of walking 'recovery' with a standardized speed?
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Match the following with their descriptions:
Match the following with their descriptions:
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During the post-exercise period, HR and BP should return to near ______________ levels before discontinuation of monitoring.
During the post-exercise period, HR and BP should return to near ______________ levels before discontinuation of monitoring.
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The heart rate recovery (HRR) is not an important prognostic marker.
The heart rate recovery (HRR) is not an important prognostic marker.
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Study Notes
Heart Structure
- The heart has four chambers: Right Atrium, Right Ventricle, Left Atrium, and Left Ventricle.
- The heart has four valves: Tricuspid valve, Mitral valve, Pulmonary valve, and Aortic valve.
- The valves ensure a one-way flow of blood through the heart.
Atrioventricular (AV) Valves
- Right AV valve has three cusps → Tricuspid valve.
- Left AV valve has two cusps → Mitral or Bicuspid valve.
- Chordae tendineae: cords connect AV valves to papillary muscles on the floor of ventricles.
- Prevent AV valves from flipping inside out or bulging into the atria when the ventricles contract.
The Heart Wall
- Pericardium: double-walled sac that encloses the heart.
- Allows heart to beat without friction, provides room to expand, yet resists excessive expansion.
- Anchored to diaphragm inferiorly and sternum anteriorly.
Pericardial Cavity
- Space inside the pericardial sac filled with 5 to 30 mL of pericardial fluid.
Epicardium (Visceral Pericardium)
- Serous membrane covering the heart.
- Adipose in thick layer in some places.
- Coronary blood vessels travel through this layer.
Myocardium
- Layer of cardiac muscle proportional to work load.
- Muscle spirals around heart, producing a wringing motion.
- Fibrous skeleton of the heart: framework of collagenous and elastic fibers.
- Provides structural support and attachment for cardiac muscle and anchor for valve tissue.
Endocardium
- Smooth inner lining of the heart and blood vessels.
- Covers the valve surfaces and is continuous with the endothelium of blood vessels.
Blood Flow Through the Chambers
- Deoxygenated blood from the body enters the Right Atrium through the Superior and Inferior vena cava.
- Blood then flows through the Tricuspid valve into the Right Ventricle.
- From the Right Ventricle, blood flows through the Pulmonary valve into the Pulmonary artery.
- Oxygenated blood from the lungs returns to the heart through the Pulmonary veins and enters the Left Atrium.
- From the Left Atrium, blood flows through the Mitral valve into the Left Ventricle.
- From the Left Ventricle, blood flows through the Aortic valve into the Aorta.
Heart Location
- The heart is located in the thoracic cavity, superior to the diaphragm.
- The heart is anchored to the diaphragm inferiorly and sternum anteriorly.
Cardiovascular System
- The cardiovascular system has two major circulatory circuits: Pulmonary and Systemic.
- The Pulmonary circuit transports deoxygenated blood from the heart to the lungs and returns oxygenated blood from the lungs to the heart.
- The Systemic circuit transports oxygenated blood from the heart to the rest of the body and returns deoxygenated blood from the body to the heart.
Cardiovascular Disease
- Cardiovascular disease (CVD) is a term that describes many different conditions affecting the heart and blood vessels.
- Common and serious types of CVD include coronary heart disease, stroke, and heart failure.
- Despite declining mortality and hospitalisation rates, CVD remains a major health problem in Australia.
- CVD has a greater impact on males, the elderly, Indigenous Australians, and people living in remote and socioeconomically disadvantaged areas.
Prevalence of Cardiovascular Disease in Australia
- In 2022, approximately 1.3 million Australians (5.3%) had one or more conditions related to heart, stroke, or vascular disease.
- The prevalence of CVD increases with age, with 0.6% of Australians aged 0-44 years and 27.7% of those aged 75 years and over affected.
- Socioeconomically disadvantaged individuals are more likely to be affected, with 8.2% compared to 3.6% of those who are not disadvantaged.
- Indigenous Australians are 2.1 times more likely to be affected than non-Indigenous Australians.
Endothelial Dysfunction and Cardiovascular Disease
- Endothelial dysfunction is an important factor in the progression of atherosclerotic CVD.
- The vascular endothelium is a monolayer of cells covering the lumen of the vessels, playing a complex role in maintaining homeostasis.
- Chronic exposure to cardiovascular risk factors and oxidative stress can overwhelm the defense mechanisms of the vascular endothelium, leading to endothelial dysfunction.
Nitric Oxide and Endothelial Dysfunction
- Nitric oxide (NO) is the most potent endogenous vasodilator in the body, maintaining homeostasis by inhibiting platelet aggregation, inflammation, and oxidative stress.
- NO is produced and released from L-arginine through the activity of endothelial NO synthase (eNOS).
- Oxidative stress can deteriorate endothelial function, and NO production is impaired in endothelial dysfunction.
Oxidative Stress and Endothelial Dysfunction
- Oxidative stress is the most common underlying mechanism for the development of endothelial dysfunction.
- Up-regulation of reactive oxygen species (ROS) leads to impaired homeostasis, reduced anti-inflammatory effects, and increased vascular permeability to lipoproteins.
- Endothelial NO synthase (eNOS) can become a potential ROS generator when in a pathological uncoupled state.
Chronic Inflammation and Endothelial Dysfunction
- Chronic inflammation is another common underlying mechanism for endothelial dysfunction.
- Dysfunctional endothelium promotes ROS generation and aggravates inflammation, amplifying inflammation signaling pathways.
- C-reactive protein (CRP) and tumor necrosis factor alpha (TNF-α) are involved in the inflammatory response, promoting leukocyte adherence and migration.
Shear Stress and Endothelial Dysfunction
- Locally disturbed shear stress by pulsatile blood flow is one of the modulators of the atherogenic process.
- Low endothelial shear stress (ESS) is associated with plaque progression and vulnerability, while high ESS is associated with upregulation of eNOS.
- Increases in vascular blood flow and shear rate are considered the main mechanisms of the beneficial effects on the cardiovascular system during exercise.
Meeting the Client (A)
- Informed consent is essential before exercising, and it involves identifying individuals at risk of adverse exercise-related cardiovascular events.
- Health screening and cardiovascular risk factor analysis are crucial in determining the appropriate objective physiological tests and devising an intervention program.
- Ability to predict rare exercise-related events is low due to the high prevalence of cardiovascular disease risk factors among adults and the rarity of exercise-related sudden cardiac death and acute myocardial infarction.
Interview
- The interview process consists of two main steps:
- General interview for subjective information
- Assessment and evaluation for objective measures (anthropometric, BP, CV fitness, strength, mobility, etc.)
- The interview environment should be quiet, secure, and free of distractions, with the use of lay terms and empathy to build trust.
Reason for Referral
- The reason for referral is usually self-explanatory (e.g., increase exercise tolerance, improve ROM, or behavioral changes)
- It is essential to bridge the gap between the nature of the referral and the client's interpretation to establish a good working relationship
Demographics
- Age, sex, and ethnicity are related to the risk of cardiovascular conditions and/or comorbidities
- Age is an independent predictor of survival in almost all cardiopulmonary conditions
- Sex may affect exercise compliance and disease management, with CVD onset generally 10 years later in women
- Ethnicity differences are often related to differences in SES and access to care
History of Present Illness
- Record and convey primary information related to the condition leading to the referral
- Chief complaint, summary of manifestations, and information about date of onset, chronicity of symptoms, types of symptoms, exacerbating or alleviating factors, and major interventions
- Ask specific questions about symptoms using OPQRTS and A (Onset, Provocation and palliation, Quality, Region and radiation, Severity, Timing, and Associated signs and symptoms)
Medications and Allergies
- Current medication list is essential, considering how they align with current and previous medical history
- Ask about dose, administration route, frequency, and time of day taken, as well as allergy history
Medical History
- Concise, relevant list of past medical problems, including dates
- All conditions, injuries, etc., as one may influence another and exercise prescription
Family History/Social History
- Family history should be restricted to heritable disorders in first-degree family members
- Relevant heritable conditions include cancers, Type II diabetes, familial hypercholesterolemia, sudden death, and premature coronary artery disease
- Social history includes information about the client's lifestyle and living patterns, including smoking, alcohol, illicit drugs, occupation, transportation, housing, routine, and leisure activities
Goals (SMARTER)
- Behavior: smoking, alcohol, nutrition, physical activity, and weight management
- Biomarkers: lipids, blood pressure, fasting blood glucose concentrations
- Medications
- Cardiopulmonary condition and associated symptoms
Physical Examination
- [No specific information provided]
Informed Consent
- Informed consent from individuals before exercise testing is an essential ethical and legal step
- Form must be read and signed, with an opportunity to ask questions
- Clients under 18 years must have a parent/caregiver sign consent as well
Symptoms of Cardiovascular Disease (CVD)
- Orthopnoea: dyspnoea at rest in a recumbent position, quickly relieved by sitting or standing upright (Left Ventricular Dysfunction, LVD)
- Paroxysmal nocturnal dyspnoea: occurs 2-5 hours after the onset of sleep, relieved by sitting on bedside (LVD)
- Ankle oedema: bilateral characteristic of Heart Failure (HF) or bilateral chronic venous insufficiency; unilateral often lymphatic blockage; generalised nephrotic syndrome or hepatic cirrhosis
- Palpitations: rapid or forceful heart, sudden tachycardia, bradycardia, ectopic beats, SV changes from valvular regurgitation (anxiety, high Q, anaemia, fever)
- Intermittent claudication: pain in the lower limbs during exercise from a lack of blood supply (atherosclerosis); onset during ambulation, disappears 1-2 mins of rest; increased prevalence of Coronary Artery Disease (CAD)
- Known heart murmur: some innocent but may indicate valvular disease or other CVD; rule out hypertrophic cardiomyopathy and aortic stenosis = high risk of exercise related sudden cardiac death
- Unusual fatigue or SOB with usual activities: can be benign, may also signal the onset of, or change in CVD
Diagnostic Clinical Exercise Testing
- Diagnostic clinical exercise test for Ischaemic Heart Disease (IHD) needs specialist attendance
- Also used for pulmonary diseases, pacemaker or HR response, claudication, disability, and Prognosis Assessment (PA)
- Prognosis: ST-segment depression, magnitude, number of leads identified, time to onset and recovery from
- Functional capacity (FC) in metabolic equivalents (METS) or VO2max (1 MET/3.5ml.kg-1.min-1 = 15% risk of CVD related mortality)
Exercise Protocol Design
- Consider: purpose of evaluation, specific outcomes desired, characteristics of individual being tested (age, gender, PA status, fitness, experience, orthopedics, symptomatology)
- Most common exercise test protocols: Bruce, Ellestad, Naughton, Balke-Ware
- Need to consider: modality, ramp vs. step, start load, load increments, stage duration, test duration, onset of “fatigue”, peak metabolism
Tools to be Used During Exercise Testing
- 12-lead electrocardiogram: heart rate, varying software, anomaly flagging capabilities
- Blood pressure: sphygmomanometer and stethoscope, automatic option; consider accuracy
- Pulse oximetry: finger or earlobe based, may be integrated into ECG software or single device
- Scales: perceived exertion, angina, dyspnoea, intermittent claudication
- Charts: normative data, data specific to conditions (e.g. ejection fraction and performance)
- Senses: sight (pallor, cyanosis, ataxia) and sound (dyspnoea) very important
Angina, Dyspnoea, and Intermittent Claudication Scales
- Four-point dyspnoea scale: 1 = Mild, noticeable to patient but not the observer; 2 = Mild, some difficulty, noticeable to observer; 3 = Moderate difficulty, but patient can continue; 4 = Severe, difficulty, patient cannot continue
- Four-point peripheral vascular disease scale: 1 = Definite discomfort or pain but only of initial or modest levels; 2 = Moderate discomfort or pain from which the client's attention can be diverted; 3 = Intense pain from which the client's attention cannot be diverted; 4 = Excruciating and unbearable pain
Termination of the Test
- Termination criteria: absolute and relative contraindications
- Post-exercise period: monitoring should continue for at least 6 min after exercise or until ECG changes return to baseline and significant signs and symptoms resolve
- ST-segment changes that occur only during the post-exercise period are currently recognized to be an important diagnostic part of the test
- Heart rate recovery (HRR) from exercise is an important prognostic marker that should be recorded
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Description
This quiz covers the structure and components of the human heart, including its valves, arteries, and chambers. It includes identification of the aorta, pulmonary artery, and ventricles.