Cardiovascular Responses to Exercise

Cardiovascular Responses to Exercise and Exercise in Special Populations

• Exercise benefits and cardiovascular responses
• Exercise considerations for special populations

Objectives

• Describe the benefits of exercise accurately
• Explain risk screening and stratification before exercise
• Note what makes up an exercise program
• Accurately describe a normal response to exercise
• Pinpoint abnormal responses and their causes
• Determine when exercise/cardiac rehab are not advised
• State reasons to stop exercise
• Explain important things to know about exercise/PT for special patient groups

Benefits of Exercise

• Enhances cardiovascular and respiratory system function
• Lowers CAD risks
• Provides psychological benefits by easing anxiety and depression and improving overall mood
• Raises quality of life, including lowering fall risk in older people
• Helps prevent or lessen functional limits in older adults
• Leads to decreased mortality and morbidity
• Primary prevention lowers death rates from CAD
• Primary prevention lowers combined CV disease, CAD, stroke, type 2 diabetes, and stroke incidence rates
• Secondary prevention lowers deaths from cardiovascular issues in post MI patients who do cardiac rehab exercise
• Secondary prevention may not decrease nonfatal reinfarction rates

Starting an Exercise Program

• Screenings may be self or professionally guided
• Self-guided screenings may help decide if one should consult MD (self-guided questionnaires)
• Professionally guided screenings consult MD in safety of staring exercise program
• Risk stratification is based on presence/absence of known CV/pulm/metabolic disease
• Risk stratification looks at presence/absence of signs/symptoms suggestive of CV/pulm/metabolic disease
• Stratification considers presence/absence of CVD risk factors
• Risk categories include low, moderate, high
• There is specific stratification for "apparently healthy patients" and for "cardiac patients"
• CV event risk elevates as a direct function of intensity and presence of risk factors
• Exercise should include warm-up, stretching, exercise, cool-down
• Warm-up is a transition phase to allow body to adjust to changing demands
• The warm up is when CV complications from strenuous activity may occur
• Cool-down allows gradual heart rate and BP recovery and metabolic end product removal
• A cool-down may enhance venous return and prevent post-exercise hypotension

Normal Response to Exercise

• Heart rate increases
• Systolic BP Increases
• Diastolic BP is unchanged
• Stroke Volume Increaess
• Cardiac Output Increases
• Oxygen consumption increases

Abnormal Responses to Exercise

• Decrease in HR with an increase in workload
• Decrease in SBP > 10 mmHg despite increased workload or failure to increase with workload
• Dyspnea, diaphoresis, pallor, duskiness, dizziness, nausea, and claudication
• Arrhythmias occur post-exercise
• Rales/crackles or an S3 appears after exercise
• Angina occurs
• Potential causes include Ischemia, Arrhythmia, Heart Failure, and Medication intolerance
• Potential causes include Volume depletion (dehydration, poor intake, bleeding, bed rest)
• Autonomic dysfunction decor Elp!

Contraindications To Exercise/Cardiac Rehab

• Unstable angina
• Resting SBP > 200 mmHg or resting DBP >110 mmHg
• Orthostatic BP drop > 20 mmHg with symptoms
• Critical aortic stenosis
• Acute systemic illness or fever (temp 101 F)
• Uncontrolled atrial or ventricular arrythmias
• Uncontrolled sinus tachycardia, >120 bpm
• Uncompensated Congestive Heart Failure
• 3rd degree Atrioventricular (AV) block without pacemaker "complete heart block"
• Active pericarditis or myocarditis
• Uncontrolled diabetes
• Recent embolism
• Thrombophlebitis
• Other metabolic problems like acute thyroiditis, hypo/hyperkalemia, hypovolemia, etc.

Relative Contraindications

• Conditions that warrant caution related to general lab values
• Putting patients at risk for coronary ischemia in person with CAD
• Hemoglobin levels below 8 g/dL in CAD patients, or below 7 g/dL in those without CAD
• Fever >= 101 F
• Potassium (K+) levels of < 3.2 mmol/L or > 5.1 mmol/L, increases the risk for life-threatening arrhythmias

Reasons To Stop Exercise

• Onset of angina or angina-like symptoms
• Drop in SBP >10 mmHg from baseline despite increasing workload
• Hypertensive response
• Shortness of breath, wheezing, leg cramps or claudication (grade 3 on a 4 point scale)
• Signs of poor perfusion
• Failure of heart rate to increase with increased exercise intensity
• Noticeable change in heart rhythm
• Significant arrhythmias
• ST displacement (> 2 mm horizontal or down sloping depression)
• Patient request
• Physical or verbal manifestation of severe fatigue
• Failure of monitoring equipment
• Considerations when assessing responses depend on Level of patient conditioning

Factors to Assess when Responding

• Anticipate exaggerated HR response and potential BP drop
• Deconditioned: See A-V O2 difference↑ with exercise, lower than trained individual, lower RBC concentration
• Medications taken
• Underlying Disease
• Medical therapy goals such as in recent hemorrhagic CVA (SBP < 150 mmHg), embolic CVA (SBP > 140 mmHg)
• Recent AVR or aortic dissection repair (SBP < 150mmHg)
• Medical therapy goals such as in Heart Failure, where SBP often allowed to 70-80 mmHg if pt asymptomatic

Special Populations

• CAD or Post-MI, Congestive heart failure, and Post-open heart surgery
• Heart transplant, Hypertension, PVD/PAD, Diabetes mellitus, and Obesity
• Renal failure/insufficiency, Collagen vascular dz, Connective tissue dz, Cancer, and Hematologic d/o
• AIDS and COPD and Restrictive Lung Disease
• Patients With CAD or MI should have considerations for factors that increase risk of ischemia
• Orthostatic hypotension issues should be considered in Patients With CAD or MI
• SBP decreases and anginal equivalents should be considered in Patients With CAD or MI
• Nitroglycerin and hypotension should be considered in Patients With CAD or MI
• Use rating of perceived exertion with special patients
• Educate special patients on normal/abnormal signs/symptoms
• Educate special patients which suggest exercise intolerance and need for medical attention

Systolic and Diastolic Heart Failure (CHF)

• Systolic Heart failure includes decreased contractibility likely due to loss of functional muscle from infarction
• Also a process affecting myocardium, increased preload due to valvular regurg, and increased afterload due to HTN
• Sysolic HF includes changes in Chronotropy where Heart rate is too slow or too rapid, and can lead to PUMP FAILURE
• Diastolic Heart failure includes where diastole may be impaired due to excessive hypertrophy of ventricles
• Also that changes in composition of myocardium or EDV may be decreased due to decreasing filling of the left ventricle
• Increased ventricular stiff increases pressure and decreases cardiac output
• Left ventricle dysfunction is Decreased SV , Increased EDV, Decreased EF (SV/EDV and CO), Increased LVEDV
• Also Decreased LV compliance/ Increased left atrial dilatation, Increased pressure in pulmonary vessels, Transudation of fluid from pulm caps
• Left ventricle dysfunction often Also includes Inhibits diastolic coronary blood flow to the endocardium, May stretch mitral valve annulus
• Left ventricle dysfunction can also lead to mitral valve regurgitation
• Right ventricle dysfunction includes Prolonged pulm HTN and increased afterload (pressure)
• Prolonged pulm HTN also changes right ventricle and can Reflects back up to right atrium & venous system, causing elevated JVD
• It also causes liver engorgement, ascities, & peripheral edema, Hypoxia, hypercapnia, & or acidosis

Exercise and CHF

• May have lower baseline BP (SBP 70-90's mmHg) and need at leas 60mmHg for organ perfusion
• Must consider orthostatic hypotension and Closely assess position change
• Must Look for decrease in SBP, fatigue, and SOB, as well as Monitor lung sounds and peripheral edema
• Need Awareness of patient's weight for fluid overload
• Hypertension includes when Failure of the body's control mechanisms to respond to increase BP
• Diagnosed when SBP is ≥ mmHg and/or DBP is ≥ mmHg. (Check current guidelines - this value is highly variable depending on guideline source and year)
• Many elderly will have HTN
• Primary vs Secondary HTN, where primary is 90-95%, have no discernible and secondary is results from medical problem (Reno-vascular or Endocrine)

Hypertension (HTN)

• Increase pressure on LV can create LVH diastolic dysfunction due to poor relaxation
• Can lead to CVD, CHF, CVA, Renal failure Aneurysm, PVD/PAD and Retinopathy
• Treatment includes Normalize BP With Rest and exercise or reversing LVH and Lifestyle changes
• Exercise Considerations include a 15-30% reduction in exercise capacity
• SV increases abnormally and peak HR is lower, also causes CO decrease exercise time and anaerobic threshold
• Exercise training with moderate endurance will elicit around 5-7 mmHg for resting BP in people with HTN

Hypertension Precautions

• Resting SBP > 200 and/or DBP > 110 mmHg requires MD clearance
• Must Keep SBP ≤ 220 mmHg and/or DBP ≤ 105 mmHg with exercise
• Must consider UE endurance work over LE and exercise should be terminated if BP > 250/110
• Must Know Effects of meds and emphasize endurance work with cool-down
• Endurance exercise promotes vasodilation & ↓TPR and avoid valsalva with resistance training
• PVD/PAD has problems in circulation to the muscles or other body parts and is caused by smoking
• Despited by burning, searing, aching, tightness, or cramping and uses the claudication scale
• Benefits include an increase in functional capacity, short bouts of activity, increase collateral circulation
• Focus on low intensity, interval training exercise, working up to pain, then rest
• Increase gradually time spent, use walking, swimming, rowing, or biking
• Must be aware of weather causing vasospasm, As pt progresses, lifestyle and Effects of medications

Diabetes Mellitus

• Decreased insulin or action causes diabetes affecting Eyes, Kidneys, and Heart as well as Microangiopathies
• This overall increases risk to CV system, is treated with diet and with research on pancreas and cell transplant
• PRE-DIABETES and METABOLIC SYNDROME have risks for heart disease from high glucose (not diagnosis level)
• LOW BLOOD GLUCOSE (BG) requires less or no exercise and treat with CHO.
• HIGH BLOOD requires exercise is ok, test urine for ketones and use caution
• Autonomic neuropathy increases cardiac risks

Exercise and Insulin

• Ensure Good footwear and careful foot inspection
• Take precaution in environment and carry ID
• Avoid extreme pressures on exercise day and provide snacks
• Athletes with high and low can intense monitoring
• Monitor responses and adjust for exercise

Obesity and Exercise

• Obesity has excess body weight and impacts many systems
• CV, muscular, mental
• Exercise includes monitoring intensity and responses at under 60%

Renal Failure

• Impact kidney functions with fluid control, osmolality, electrolyte balance
• Complications from kidney impact cardio system
• Treatment include renal diet and management Patients with chronic kidney disease tend to have low functional capacity
• Treatment requires proper dialysis and monitoring fatigue

Collagen and Exercise

• Collagen vascular dz and connective tissue dz are very severe in long term impact
• Can affect multiple major outcomes and cardio system

Hematologic Disorders

• Anemia presents fatigue, exertional dynspnea, and induce cardio system risks
• Body response by raising cardiac and decrease resistance
• Exercise monitor system load

Additional Issues:

• HIV/AIDS puts you at risk for pulmonary and potential cardio. Must factor in if issues are from disease or meds
• Hot, cold, elevation all require special cardio support and knowledge
• Hot increase vasodilation, elevate HR, and dehydration. Increase cool clothing, fluid/ electrolytes and limit activity
• Cold: vasoconstriction and can increase the need for arterial pressure and oxygen. Increase cold clothing
• Elevation can decrease O2 and increase pulmonary edema, but takes 1 week for the body to adjust

Cases

• Review cases require all the cardio systems and metabolic factors knowledge
• Know when to monitor, when to adjust and when to stop, plus which testing is critical