EHR 519 weeks 3-6
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Questions and Answers

What stimulates the release of angiotensin I?

  • Angiotensin-converting enzyme
  • Aldosterone release
  • Stimulation from the sympathetic nervous system (correct)
  • Stimulation from the parasympathetic nervous system

    • Angiotensin II is a potent vasodilator.

    False

    What is the outcome of angiotensin II stimulating the release of aldosterone?

    Rise in blood pressure related to sodium and water retention

    Untreated HT causes further __________ damage and atherosclerotic progression.

    <p>ED</p> Signup and view all the answers

    Match the following co-morbidities of hypertension with their descriptions:

    <p>Hypertrophic dilated cardiomyopathy = A heart condition where the heart muscle becomes thickened Chronic heart failure = A condition where the heart is unable to pump enough blood End-stage renal disease = A condition where the kidneys are no longer able to function</p> Signup and view all the answers

    What is the effect of ageing on the aorta and elastic arteries?

    <p>Stiffening of the aorta and elastic arteries</p> Signup and view all the answers

    The widening of the pulse pressure with ageing is a strong predictor of stroke.

    <p>False</p> Signup and view all the answers

    What is the result of increased pulse pressure in the early part of diastole?

    <p>Improving coronary perfusion</p> Signup and view all the answers

    The reflected waves move from early diastole to late __________ with ageing.

    <p>systole</p> Signup and view all the answers

    What is the consequence of increased left ventricular afterload?

    <p>Left ventricular hypertrophy (LVH)</p> Signup and view all the answers

    What is a common symptom of a hypertensive crisis?

    <p>All of the above</p> Signup and view all the answers

    Most individuals with hypertension experience symptoms.

    <p>False</p> Signup and view all the answers

    What is the systolic blood pressure threshold for a hypertensive crisis?

    <p>180 mmHg</p> Signup and view all the answers

    Individuals with ______________ hypertension do not require medical evaluation of exercise testing prior to beginning an exercise program.

    <p>controlled</p> Signup and view all the answers

    Match the following symptoms with their corresponding conditions:

    <p>Headache = Hypertensive crisis Dizziness = Hypertensive crisis Blurred vision = Hypertensive crisis Fatigue = Not a symptom of hypertensive crisis</p> Signup and view all the answers

    All individuals with hypertension require medical evaluation of exercise testing prior to beginning an exercise program.

    <p>False</p> Signup and view all the answers

    What is measured during exercise testing?

    <p>Ventilatory expired gas</p> Signup and view all the answers

    The treadmill test is typically performed at a rate of ______________ METs for 3 minutes.

    <p>2-3</p> Signup and view all the answers

    What is the term for the presence of red blood cells in urine?

    <p>Hematuria</p> Signup and view all the answers

    What is the term for nose bleeding?

    <p>Epistaxis</p> Signup and view all the answers

    What is the primary purpose of determining 1RM or MVC in exercise prescription?

    <p>To estimate the maximum intensity of exercise</p> Signup and view all the answers

    A sudden increase in exercise intensity is recommended in exercise prescription for hypertension.

    <p>False</p> Signup and view all the answers

    What are the key considerations for exercise prescription in individuals with hypertension?

    <p>Level of BP control, recent changes in antihypertensive medications, medication-related adverse effects, presence of target organ disease and other comorbidities, and age</p> Signup and view all the answers

    An exaggerated BP response to relatively low exercise intensities and at __________ levels is a special consideration in exercise prescription.

    <p>HR</p> Signup and view all the answers

    Match the following factors with their impact on exercise prescription in hypertension:

    <p>Level of BP control = Influences exercise intensity and frequency Age = Affects exercise program duration and progression Medication-related adverse effects = Requires adjusting exercise intensity and duration Presence of target organ disease = Influences exercise type and intensity</p> Signup and view all the answers

    What should be monitored during exercise in individuals with hypertension?

    <p>Physical signs and symptoms, abnormal BP or HR responses, and ECG</p> Signup and view all the answers

    Valsalva maneuver is recommended during exercise in individuals with hypertension.

    <p>False</p> Signup and view all the answers

    What is the recommended duration for increasing exercise duration in the initial phase of exercise prescription?

    <p>4-6 weeks</p> Signup and view all the answers

    During exercise, an exaggerated pressor response is characterized by a systolic BP of more than __________ mmHg or a diastolic BP of more than __________ mmHg.

    <p>250, 115</p> Signup and view all the answers

    What is the recommended approach to progressing exercise in individuals with hypertension?

    <p>Increase exercise duration first, then intensity and frequency</p> Signup and view all the answers

    What information should be included in the summary report regarding angina status?

    <p>The onset, intensity, and grade reached, as well as interventions during recovery</p> Signup and view all the answers

    A peak SBP of >250 mmHg is a relative contraindication for exercise testing.

    <p>False</p> Signup and view all the answers

    What is the term used to describe the estimated functional capacity of an individual?

    <p>METs</p> Signup and view all the answers

    A failure of HR to decrease by at least __________ beats after 1 min, or __________ beats by 2 min is independently associated with increased risk for mortality over the next 3 to 5 years.

    <p>12, 22</p> Signup and view all the answers

    What is the prognostic value of a poor HR response?

    <p>That of an exercise-induced myocardial perfusion deficit</p> Signup and view all the answers

    Match the following components with their descriptions in a summary report:

    <p>Angina status = Presence or absence of angina, onset, intensity, and grade reached, and interventions during recovery ECG findings = ST-segment information gathered at rest, during exercise, and in recovery Functional Capacity = Estimated METs or measured O2, as an absolute number and qualified relative to normative data HR responses = Determine if normal (exceeded 80% of age predicted) or consistent with a chronotropic incompetence response</p> Signup and view all the answers

    A normal BP response is defined as an increase of 5 mmHg per 1 MET of work.

    <p>False</p> Signup and view all the answers

    What is the significance of a peak SBP of >250 mmHg during exercise testing?

    <p>Absolute contraindication</p> Signup and view all the answers

    The magnitude of the increase in BP during exercise approximates __________ mmHg per 1 MET of work.

    <p>10</p> Signup and view all the answers

    What is the innermost layer of the artery?

    <p>Endothelium</p> Signup and view all the answers

    Atherosclerosis is a disease process that results in blood flow limiting lesions in the epicardial coronary, carotid, iliac, and femoral arteries, and the aorta.

    <p>True</p> Signup and view all the answers

    What are the factors that can cause chronic excessive injury to endothelial cells?

    <p>Smoking and chemical irritants, Low-density lipoprotein cholesterol (LDL), Hypertension, Hyperglycemia and T2DM, Plasma homocysteine, Infectious agents (herpes)</p> Signup and view all the answers

    The endothelium plays a critical role in regulating __________ and anti-thrombotic properties.

    <p>hemostasis</p> Signup and view all the answers

    Match the following layers of the artery with their descriptions:

    <p>Endothelium = Inner, single-cell layer of the artery Media = Contains most of the smooth muscle cells plus elastic connective tissues Adventita = Outermost layer of connecting tissue, fibroblasts and a few smooth muscle cells</p> Signup and view all the answers

    What happens to slowly progressing plaques?

    <p>They gradually internalize monocytes and lipids</p> Signup and view all the answers

    Selective coronary angiography is a sensitive test for detecting atherosclerotic lesions.

    <p>False</p> Signup and view all the answers

    Where do obstructive coronary lesions occur most frequently?

    <p>In the first 4 to 5 cm of the epicardial coronary arteries</p> Signup and view all the answers

    Local stressors or chemical factors within the lesion may cause the plaque to ____________________.

    <p>rupture</p> Signup and view all the answers

    Match the following characteristics of atherosclerotic lesions with their descriptions:

    <p>Rapidly progressing lesions = Incorporate thrombus into the plaque Slowly progressing lesions = Gradually internalize monocytes and lipids Advanced atherosclerotic plaques = Rupture and form thrombus repeatedly</p> Signup and view all the answers

    What is the primary purpose of graded exercise testing (GXT)?

    <p>To assess the cardiovascular response to exercise</p> Signup and view all the answers

    All individuals with hypertension require medical evaluation of exercise testing prior to beginning an exercise program.

    <p>True</p> Signup and view all the answers

    What are the common modes of graded exercise testing?

    <p>Treadmill test, bicycle ergometer, or arm ergometer</p> Signup and view all the answers

    Untreated hypertension can cause further __________ damage and atherosclerotic progression.

    <p>vascular</p> Signup and view all the answers

    Match the following conditions with their corresponding risk factors:

    <p>Atherosclerosis = High blood pressure Ischemic Heart Disease = Smoking Angina = High cholesterol Myocardial Infarction = Physical inactivity</p> Signup and view all the answers

    What is a result of increased permeability to lipoproteins and other substances in the blood?

    <p>All of the above</p> Signup and view all the answers

    Monocytes accumulate LDL, altering the oxidation process and transform into macrophages.

    <p>True</p> Signup and view all the answers

    What is the result of growth factors expressed by platelets, monocytes, and damaged endothelium?

    <p>Growth and proliferation of certain cells, migration of cells into the area of injury.</p> Signup and view all the answers

    The earliest detectable lesion of atherosclerosis is characterized by the presence of _______________.

    <p>fatty streaks</p> Signup and view all the answers

    Match the following components with their presence in a fibromuscular plaque:

    <p>Fibrous cap = 1 Lipids = 2 Inflammatory cells = 3 Smooth muscle cells = 4 Thrombus and calcium = 5</p> Signup and view all the answers

    What is the most common cause of chronic mitral regurgitation?

    <p>Myxomatous changes seen in mitral valve prolapse (MVP)</p> Signup and view all the answers

    Mitral valve stenosis blocks blood flow coming out of the LV.

    <p>False</p> Signup and view all the answers

    What is the result of untreated aortic valve regurgitation over time?

    <p>LVH and dilation, eventually leading to arrhythmias, LV impairment, and heart failure.</p> Signup and view all the answers

    Aortic valve stenosis restricts blood flow from the LV to the ______.

    <p>aorta</p> Signup and view all the answers

    Match the following valve problems with their descriptions:

    <p>Mitral valve regurgitation = Mitral valve stenosis Narrowing of the valve, restricting blood flow = Valve does not close completely, allowing blood to flow back</p> Signup and view all the answers

    Inflammation plays a significant role in many types of macrovascular calcification, including CAVD.

    <p>True</p> Signup and view all the answers

    What is the main function of the heart valves?

    <p>To ensure that blood flows with suitable force in the proper direction at the correct time</p> Signup and view all the answers

    Valve disorders can be congenital or acquired.

    <p>True</p> Signup and view all the answers

    What is the term for the condition where the valves become too narrow and hardened, or are unable to close completely?

    <p>Valvular heart disease (VHD)</p> Signup and view all the answers

    The heart valves consist of an outer layer of ________________ cells, surrounding 3 layers of matrix.

    <p>endothelial</p> Signup and view all the answers

    Match the following heart valves with their descriptions:

    <p>Aortic valve = Between the left ventricle and aorta Mitral valve = Between the left atrium and left ventricle Tricuspid valve = Between the right atrium and right ventricle Pulmonary valve = Between the right ventricle and pulmonary artery</p> Signup and view all the answers

    Which of the following factors activates vascular biomineralization and vascular osteogenic signalling processes?

    <p>All of the above</p> Signup and view all the answers

    Exercise can improve the mechanical function of a valve.

    <p>False</p> Signup and view all the answers

    What are the common symptoms of calcific aortic valve disease?

    <p>Shortness of breath, Fatigue, Swollen feet or legs, Heart palpitations, Dizziness or fainting, Coughing up blood, Chest pain</p> Signup and view all the answers

    The primary clinical approach for valve repair or replacement is ____________________.

    <p>surgery</p> Signup and view all the answers

    Match the following effects of valvular heart disease on exercise response with their descriptions:

    <p>Tachycardia = Atrial fibrillation Rapid heart rate = Abnormal heart rhythm</p> Signup and view all the answers

    What is the recommended approach for patients with moderate-to-severe aortic stenosis?

    <p>Avoid vigorous or competitive exercise</p> Signup and view all the answers

    What is the purpose of exercise testing in asymptomatic patients with valvular heart disease?

    <p>To assess HR and BP responses and exercise-induced symptoms</p> Signup and view all the answers

    Regular exercise has been shown to slow the progression of valvular heart disease.

    <p>False</p> Signup and view all the answers

    What type of test is recommended for patients who are not amendable to treadmill testing?

    <p>6MWT</p> Signup and view all the answers

    The American College of Sports Medicine (ACSM) recommends using free weights and weight machines for resistance training in patients with PAD.

    <p>True</p> Signup and view all the answers

    What is the recommended intensity for resistance training in patients with PAD?

    <p>RPE 11 to 14, 30% to 80% of 1RM</p> Signup and view all the answers

    The average walking speed of a PAD patient is approximately __________ mph.

    <p>1.5 to 2.0</p> Signup and view all the answers

    Match the following types of exercises with their descriptions:

    <p>Aerobic = Walking Resistance = Free weights, weight machines, elastic bands, stability ball High rep muscle endurance = Testing for muscle endurance Isokinetic strength = Measuring muscle strength at a constant speed</p> Signup and view all the answers

    Valsalva maneuver is recommended during exercise in individuals with hypertension.

    <p>False</p> Signup and view all the answers

    What is the primary goal of aerobic exercise in patients with PAD?

    <p>All of the above</p> Signup and view all the answers

    What is the recommended duration of aerobic exercise in patients with PAD?

    <p>30 to 45 minutes</p> Signup and view all the answers

    All individuals with hypertension require medical evaluation of exercise testing prior to beginning an exercise program.

    <p>False</p> Signup and view all the answers

    What is the success rate of PTCA (PCI) in patients with unstable angina?

    <p>84%</p> Signup and view all the answers

    CABG improves long-term survival.

    <p>True</p> Signup and view all the answers

    What is the primary benefit of stent therapy?

    <p>Relief of angina pectoris and improvement of quality of life</p> Signup and view all the answers

    The occlusion rate of CABG is approximately __________% after 5 years.

    <p>20%</p> Signup and view all the answers

    What is the primary finding of the study comparing CABG and PCI with drug-eluting stent?

    <p>CABG reduces major adverse cardiac or cerebrovascular events compared to PCI with drug-eluting stent</p> Signup and view all the answers

    Restenosis rates are higher with drug-eluting stents compared to metal stents.

    <p>False</p> Signup and view all the answers

    What is the risk of thrombosis and acute closures with stent therapy?

    <p>1-2%</p> Signup and view all the answers

    The restenosis rate of metal stents is approximately __________%.

    <p>25-40%</p> Signup and view all the answers

    Match the following revascularization procedures with their characteristics:

    <p>CABG = Improves long-term survival and relief of angina pectoris PTCA (PCI) = Success rate of 84% in patients with unstable angina Stent therapy = 95% success rate and 1-2% risk of thrombosis and acute closures</p> Signup and view all the answers

    PCI is safer than CABG in high-risk patients.

    <p>True</p> Signup and view all the answers

    What is the final pathway for many cardiovascular disorders?

    <p>Heart failure</p> Signup and view all the answers

    The incidence of heart failure has decreased in Australia since 2002.

    <p>False</p> Signup and view all the answers

    What is the estimated rate of heart failure in Indigenous Australians compared to non-Indigenous Australians?

    <p>2.9 times higher</p> Signup and view all the answers

    Systolic heart failure is characterized by a reduced ______________ fraction.

    <p>ejection</p> Signup and view all the answers

    Match the following types of heart failure with their descriptions:

    <p>Systolic heart failure = Heart muscle is weak, ventricular myofibrils can't contract or relax against load. Diastolic heart failure = Ventricles are stiff, unable to expand or relax and fill under pressure.</p> Signup and view all the answers

    Diastolic heart failure is characterized by a reduced ejection fraction.

    <p>False</p> Signup and view all the answers

    What is the result of heart failure?

    <p>Reduced cardiac output and/or elevated intracardiac pressures</p> Signup and view all the answers

    Heart failure can be cured.

    <p>False</p> Signup and view all the answers

    What are the common symptoms of severe heart failure?

    <p>dyspnoea, ankle swelling, and fatigue + structural signs = peripheral oedema</p> Signup and view all the answers

    Cardiomyopathy is a condition where the entire heart muscle, or a large part of it, is weakened due to ____________________.

    <p>disease</p> Signup and view all the answers

    Match the following conditions with their descriptions:

    <p>Chronic Heart Failure = Occurs when the heart function less effectively Cardiomyopathy = A condition where the entire heart muscle, or a large part of it, is weakened due to disease Hypertension = A condition where blood pressure is elevated</p> Signup and view all the answers

    What is the primary goal of treating heart failure?

    <p>improve quality of life, reduce hospital admissions, and prolong life</p> Signup and view all the answers

    What percentage of end of diastole filling volume is ejected in HFrEF?

    <p>55%</p> Signup and view all the answers

    Peak VO2 of 70% of predicted peak is associated with higher mortality rates.

    <p>False</p> Signup and view all the answers

    What is the definition of ventilatory efficiency?

    <p>Slope of the relationship of VE to CO2 production during exercise.</p> Signup and view all the answers

    Echocardiogram is used to measure ______________ contraction (ejection) and relaxation.

    <p>LV</p> Signup and view all the answers

    Match the following with their descriptions:

    <p>Peak VO2 = predictor of mortality rates Ventilatory efficiency = slope of VE to CO2 production during exercise V-slope method = plotting VCO2 over VO2 GXT = determination of peak O2 consumption, ventilator efficiency</p> Signup and view all the answers

    What is the cut-off point for very high risk of mortality according to ventilatory efficiency?

    <p>&gt;45</p> Signup and view all the answers

    Prediction equations can accurately estimate functional capacity in patients with HF.

    <p>False</p> Signup and view all the answers

    What is the primary purpose of exercise testing in patients with HF?

    <p>Determination of peak O2 consumption and ventilator efficiency.</p> Signup and view all the answers

    Study Notes

    Hypertension

    • Hypertension is often referred to as the "silent killer" because most patients do not have specific symptoms related to their high blood pressure.
    • It is the most common, costly, and modifiable cardiovascular disease (CVD) risk factor.
    • The lifetime risk of developing hypertension is 90%, and one in five people with elevated blood pressure will develop the condition within 4 years.
    • Lifestyle factors play a large contribution to the management of hypertension.

    Definition and Classification

    • Classification is based on the average of two or more properly measured, seated blood pressure readings on each of two or more office visits.
    • CVD doubles for every increment increase in systolic blood pressure (SBP) of 20mmHg or diastolic blood pressure (DBP) of 10 mmHg above 115/75 mmHg.
    • Other descriptive terms include:
      • Secondary or inessential hypertension (HT with known cause)
      • Isolated systolic hypertension (SBP of ≥140 mmHg and DBP <140 mmHg)

    Pathophysiology

    • Blood pressure (BP) is the force that blood exerts against a vessel wall.
    • Flow is the amount of blood flowing through an organ, tissue, or blood vessel in a given time (i.e., ml/min).
    • Perfusion is the flow per given volume of mass of tissue (ml.min.g).
    • Hemodynamics is the study of the physical principles of blood flow and are based on pressure and resistance.
    • The formula for blood flow is F ∝ ΔP/R.

    Blood Pressure

    • Systolic blood pressure (SBP) is the peak arterial blood pressure attained during ventricular contraction.
    • Diastolic blood pressure (DBP) is the minimum arterial blood pressure occurring during the ventricular relaxation between each cardiac cycle.
    • Pulse pressure (PP) is the difference between SBP and DBP.
    • Mean arterial pressure (MAP) is the mean pressure from several intervals throughout the cardiac cycle.
    • High MAP increases the risk of atherosclerosis, kidney failure, and aneurysm.

    Peripheral Resistance

    • Peripheral resistance is the opposition to blood flow moving away from the heart.
    • Moving blood would exert no pressure against a vessel wall unless it encountered at least some downstream resistance.
    • Vasoactive substances, such as bradykinin, endothelin, and atrial natriuretic peptide, affect sodium transport and vascular tone.

    Hypercoagulability

    • Hypertension confers a prothrombotic or hypercoagulable state.
    • Those with HT have endothelial dysfunction or damage, abnormal blood constituents, and blood flow changes.

    Autonomic Nervous System

    • Those with HT often have increased release of, and enhanced peripheral sensitivity to, norepinephrine.
    • Increased responsiveness to stressful stimuli is another feature of arterial hypertension.
    • This is linked to the renin-angiotensin system.

    Pathophysiology – Secondary Hypertension

    • Secondary hypertension is a small percentage of cases.
    • Causes include:
      • Renal (sodium and fluids in the kidneys leading to volume expansion or an alteration in renal secretion of vasoactive materials)
      • Endocrine (abnormality of the adrenal glands)

    Renin-Angiotensin System

    • Renin is secreted from the juxtaglomerular apparatus of the kidney in response to glomerular under perfusion or a reduced salt intake.
    • Renin converts renin substrate to angiotensin I, which is rapidly converted to angiotensin II in the lungs by angiotensin-converting enzyme (ACE).
    • Angiotensin II is a potent vasoconstrictor and causes a rise in blood pressure.

    Co-morbidities

    • Untreated hypertension causes further endothelial damage and atherosclerotic progression, which further promotes atherosclerosis.
    • Additional deleterious outcomes include:
      • Hypertrophic dilated cardiomyopathy
      • Compromised ventricular ejection and cardiac output
      • Chronic heart failure
      • Heart valve defects
      • End-stage renal disease
      • Myocardial infarction
      • Stroke
      • Aneurysm

    Clinical Considerations – Signs and Symptoms of Hypertension

    • Many individuals with hypertension do not experience symptoms
    • Symptoms tend to appear during a hypertensive crisis (SBP >180mmHg or DBP >120mmHg)
    • Common symptoms of hypertension include:
      • Headache
      • Dizziness
      • Palpitations
      • Epistaxis (nose bleed)
      • Hematuria (RBC in urine)
      • Blurred vision

    Exercise Testing and Prescription

    • Individuals with controlled hypertension (115 mmHg) do not require medical evaluation before starting an exercise program
    • During exercise testing, consider:
      • Treadmill test (2-3METs/3min stage)
      • Rate Pressure Product (RPP)
      • Arrhythmias and myocardial ischemia
      • Use of medications (vasodilators or β-blockers) and their timing relative to exercise
      • Ventilatory expired gas responses
      • Resistance exercise (free weights or machines) to determine 1RM or MVC
      • Observe for physical signs and symptoms, abnormal BP or HR responses, and exaggerated pressor response

    Role of Exercise Prescription

    • Progress gradually, avoiding large increases in FITT components (Frequency, Intensity, Time, and Type)
    • Increase exercise duration over the first 4-6 weeks, and then increase frequency, intensity, and time to achieve recommended quantity and quality of exercise over 18-24 months

    Considerations for Exercise Prescription

    • Level of BP control
    • Recent changes in antihypertensive medications
    • Medication-related adverse effects
    • Presence of target organ disease and other comorbidities
    • Age

    Special Considerations

    • An exaggerated BP response to relatively low exercise intensities and at HR levels is a concern for individuals with hypertension

    Graded Exercise Testing (GXT)

    • Purpose: Explain the purpose of GXT, common modes and protocols, and which populations they are used for.
    • Learning outcomes: Be able to describe the relative and absolute contraindications to terminate a GXT, and explain the appropriate measures to be recorded before, during, and after a GXT.

    Cardiovascular Diseases

    • Atherosclerosis: A type of cardiovascular disease.
    • Ischemic Heart Disease: A type of cardiovascular disease.
    • Angina: A type of cardiovascular disease.
    • Peripheral artery disease: A type of cardiovascular disease.
    • Valvular diseases: A type of cardiovascular disease.
    • Myocardial infarction: A type of cardiovascular disease.

    Gas Exchange

    • Independent, graded, and inverse association between directly measured or estimated VO2 peak and mortality.
    • 13% reduction in risk for all-cause mortality associated with each 1-MET increase in cardiorespiratory fitness.
    • Useful in defining prognosis (and thus help guide the timing for cardiac transplantation) in patients with heart failure.
    • Slope of change in VE to change in VCO2 production (Ve-VCO2 slope) during an exercise test is related to prognosis for patients with CHF.
    • Other measures from CPET: ventilatory-derived AT, oxygen pulse, oxygen uptake efficiency slope, partial pressure of end tidal CO2, breathing reserve, and respiratory exchange ratio.

    Diagnostic Value of GXT

    • Greatest in those with intermediate probability of CAD, based on:
      • Age and sex
      • Presence of symptoms (stable or unstable)
      • Prevalence of CAD in other persons of the same age and sex
    • Factors that influence prognosis of CVD:
      • Angina
      • Presence of ST-segment depression evident on the ECG during exercise or in recovery
      • Magnitude of ST depression (1 mm vs. 3 mm, where more ST depression represents greater risk)
      • The number of ECG leads showing significant ST-segment depression
      • Time of onset for ST depression during exercise
      • Time during recovery to resolve ST-segment abnormalities observed during exercise
      • Functional capacity (FC) as measured by exercise duration or metabolic equivalents of task (METs)

    Example

    • Client A:
      • Angina pain
      • Demonstrates 2.5 mm of ST-segment depression in four ECG leads just 3 min into an exercise test
      • Functional capacity (FC) that approximates just 4 METs
    • Client B:
      • Symptom-free
      • Completes 10 METs of work
      • No ECG evidence of ST-segment depression

    ECG Findings

    • ST-segment or J-point elevation on a resting ECG is often attributable to early repolarization and not necessarily abnormal in healthy people.
    • New ST-segment elevation with exertion (with normal resting ECG) → rare finding, may suggest transmural ischemia or a coronary artery spasm.
    • When Q waves are present on the resting ECG from a previous infarction, ST elevation with exertion may reflect a LV aneurysm or wall motion abnormality.
    • ST-elevation can localize ischemic area/arteries involved.

    T-wave Changes

    • Healthy individuals: T-wave amplitude initially decreases with the onset of exercise, then increases at maximal exercise.
    • Flattening or inversion of T waves may not be associated with ischemia.
    • Common in the presence of LVH.
    • Normalization of T-waves also present during ischemic responses associated with coronary spasms.
    • Overall, T-wave changes with exertion are not specific to exercise-induced ischemia.

    Arrhythmia

    • Used to evaluate the effectiveness of medical therapy in controlling an arrhythmia.
    • When arrhythmias appear during the GXT, must document:
      • The onset of the arrhythmia
      • Any signs or symptoms associated with the arrhythmia
      • Any ECG changes (e.g., ST depression)
    • 3 major types of ECG rhythm or conduction abnormalities during exercise:
      1. Supraventricular arrhythmias that compromise cardiac function (e.g., atrial flutter, atrial fibrillation)
      2. Ventricular arrhythmias that have the potential to progress to a life-threatening arrhythmia
      3. The onset of high-grade conduction abnormalities

    Reporting

    • Summary report including information that should be interpreted relative to diagnosis, prognosis, or risk of developing a disorder.
    • Information to include:
      1. Angina status:
        • Present or not
        • If so, onset (HR or MET level)
        • Was angina the reason for test termination
        • Intensity or grade reached
        • Interventions during recovery (rest, medications)
      2. ECG findings:
        • ST-segment information gathered at rest, during exercise, and in recovery
        • If resting ECG normal, simply state, based on the presence or absence of ST depression during exercise, the test does or does not meet the criteria for exercise-induced myocardial ischemia
      3. Functional Capacity:
        • Stated as estimated METs or measured O2, as an absolute number and qualified (e.g., above average, poor, superior) relative to normative data (similar age and gender)
      4. HR responses:
        • Determine if normal (exceeded 80% of age-predicted) or consistent with a chronotropic incompetence (less than 80% of age-predicted) response
        • Prognostic value of poor HR response = that of an exercise-induced myocardial perfusion deficit
      5. BP responses:
        • Identify normal or abnormal BP responses (the magnitude of the increase approximates 10 mmHg per 1 MET of work)
        • Peak SBP of >250 mm Hg = absolute contraindication

    Atherosclerosis and Cardiovascular Disease

    • Atherosclerosis is a disease process resulting in blood flow-limiting lesions in epicardial coronary, carotid, iliac, and femoral arteries, and the aorta.
    • Endothelial injury and subsequent inflammatory response play critical roles in atherosclerosis.
    • Chronic excessive injury to endothelial cells may be due to factors such as smoking, low-density lipoprotein cholesterol (LDL), hypertension, hyperglycemia, and infectious agents.

    Endothelial Dysfunction

    • Endothelial dysfunction leads to increased adhesiveness, platelet deposition, and monocyte adhesion.
    • It also causes increased permeability to lipoproteins and other substances in the blood, and impaired vasodilation with increased vasospasm.

    Platelet and Monocyte Response

    • Platelets adhere to damaged endothelium, releasing growth factors and vasoconstrictor substances like thromboxane A2.
    • Monocytes adhere to injured endothelium, migrate into the intima, and accumulate LDL, altering the oxidation process and transforming into macrophages.

    Growth Factors and Cell Migration

    • Growth factors result in the growth and proliferation of certain cells, migration of cells into the area of injury, and accumulation of cholesterol into the extracellular space.
    • Smooth muscle cells and fibroblasts migrate from the media to the intima, and smooth muscle progenitor cells migrate from bone marrow to the intima.

    Lesion Progression

    • Lesions progress in complexity and size, forming a fibromuscular plaque with a fibrous cap, lipids, inflammatory cells, smooth muscle cells, thrombus, and calcium.
    • Arterial remodeling thickens the vessel wall without changing lumen size, and progression of atherosclerosis reduces lumen size and blood flow.

    Detection of Atherosclerotic Lesions

    • Selective coronary angiography is the gold standard to identify the severity of coronary lesions, but underestimates the degree due to the diffuse nature of the disease process.
    • Obstructive coronary lesions occur most frequently in the first 4 to 5 cm of the epicardial coronary arteries, and obstructive lesions at the origin of the left main and right main coronary arteries.

    Valve Disorders/Valvular Heart Disease (VHD)

    • Damage or defect in one of the four heart valves: Aortic, Mitral, Tricuspid, or Pulmonary
    • Can be Congenital or Acquired
    • Risk factors: Smoking, Gender, Age, Hypercholesterolemia, Hypertension, T2DM

    Valve Structure and Function

    • Valves have an outer layer of endothelial cells, surrounding 3 layers of matrix with specialized functions
    • Matrix has collagens, proteoglycans, elastin
    • Valves open and close approximately 100,000 times a day
    • Healthy valves ensure blood flows with suitable force in the proper direction at the correct time

    Valvular Heart Disease

    • Valves become too narrow and hardened (stenotic) to open fully, or unable to close completely (incompetent)
    • Stenotic valves force blood to back up in the adjacent heart chamber
    • Incompetent valves allow blood to leak back into the chamber that it has just exited
    • Compensatory mechanisms: heart muscle enlarges and thickens (LVH), blood pooling in heart chambers increases risk of stroke or pulmonary embolism

    Mitral Valve Regurgitation

    • Most common cause is myxomatous changes seen in mitral valve prolapse (MVP)
    • Middle layer of valve leaflets becomes thickened, frequently causing leaflet redundancy, making it difficult for them to close properly
    • Chordae tendinae may also be affected, disrupting support of the mitral valve apparatus

    Mitral Valve Stenosis

    • Mitral valve is narrowed and does not close properly
    • Blocks blood flow coming into the left ventricle
    • Common causes: infection, calcification, or genetic

    Aortic Valve Regurgitation

    • Aortic valve does not close completely and allows some of the blood back into the left ventricle
    • LVH and dilation gradually occur over time if left untreated
    • Leads to arrhythmias, LV impairment, and heart failure

    Aortic Valve Stenosis

    • Narrowing of the aortic valve which restricts blood flow from the LV to the aorta and systemic circulation
    • Increases workload on the LV, leading to hypertrophy and heart failure

    Inflammation

    • Inflammation plays a significant role in many types of macrovascular calcification, including CAVD
    • Inflammation-associated factors, such as TNF-α, IL-1β, CRP, and oxLDL, activate vascular biomineralization and vascular osteogenic signaling processes
    • Reactive oxygen species (ROS) have a pro-osteogenic and pathogenic role in CAVD

    Signs and Symptoms

    • Shortness of breath (SOB)
    • Fatigue
    • Swollen feet or legs
    • Heart palpitations
    • Dizziness or fainting
    • Coughing up blood
    • Chest pain

    Treatment

    • Calcific aortic valve disease and other types of VHD are reaching epidemic status
    • Primary clinical approach: valve repair or replacement surgery
    • Aortic valve replacement is the second most frequent cardiac surgery following coronary artery bypass grafting

    Effects on Exercise Training

    • Heart valve stenosis and regurgitation reduce Q
    • Hypertrophy, ventricular dispensability, and diastolic dysfunction
    • Exercise is recommended to improve overall quality of life and ADLs
    • Exercise restrictions: only when disease progresses to the point of affecting resting or exertional symptoms, or compromised hemodynamics

    Effects on the Exercise Response

    • Exercise responses dependent on the type and severity of the VHD and which valve(s) are affected
    • Asymptomatic milder forms: few restrictions
    • Moderate-to-severe aortic stenosis: avoid vigorous or competitive exercise due to the risk of sudden death

    Management and Medications

    • Medications to: widen blood vessels, lower BP, decrease heart's work rate, maintain a regular heart rhythm, lower HR, reduce risk of blood clots, increase force of the heart's contractions

    Recommendations for Exercise Testing

    • Testing primarily completed on asymptomatic patients
    • Difficult to use as a diagnostic tool due to co-morbidities, including left ventricular hypertrophy and exercise-induced S-T segment depression
    • Testing should include assessment of HR and BP responses and exercise-induced symptoms

    Recommendations for Exercise Prescription

    • No prospective studies examining the impact of regular exercise on the progression of valvular heart disease

    Peripheral Artery Disease (PAD)

    • Definition: Complete or partial blockage of the leg arteries by plaque, leading to narrowing of arteries in lower extremities
    • Results in stenosis or occlusions, decreasing blood flow
    • Global prevalence: 202 million cases
    • 35-40% of patients have claudication, characterized by pain, cramping, or aching in calves, thighs, and buttocks
    • 1-2% have critical limb ischemia

    Classification Descriptors and 'Cut-Offs'

    • ABI (Ankle-Brachial Index) calculated by dividing the systolic pressure in the ankle artery by the systolic brachial pressure
    • Normal pulse wave: multiphasic
    • Reduced blood flow due to PAD: dampened and monophasic
    • Critical limb ischemia: presence of ischemic rest pain, foot ulcers, or gangrene attributable to objectively proven arterial occlusive disease

    Risk Factors

    • Smoking
    • Diabetes
    • Hypertension
    • Hypercholesterolemia
    • High levels of homocysteine and fibrinogen
    • Increased blood viscosity
    • Elevated cRP (C-reactive protein)
    • Increased age (>50)
    • Family history of vascular disease

    Pathophysiology

    • Begins with endothelial damage in arteries in the periphery
    • Similar to atherosclerosis, but affects the peripheries
    • Abnormal blood flow is predicted by the severity of the stenosis
    • Leg pain symptoms: cramping, aching, tightening, and fatigue

    Symptoms

    • Claudication: relieved with rest, exertional, and located in the lower extremity
    • Calf claudication: flow-limiting lesions in the femoral and popliteal arteries
    • Buttock pain: flow-limiting lesions in the internal iliac arteries
    • Thigh claudication: flow-limiting lesions in the profunda femoral artery

    ABI and Symptom Severity Scales

    • Normal ABI: 0.91 to 1.30-1.40
    • Mild to moderate PAD: 0.41 to 0.90
    • Severe PAD: 0.00 to 0.40
    • Non-compressible, calcified vessel: >1.30
    • Fontaine Stages: I-IV, with increasing severity
    • Rutherford Categories: 0-6, with increasing severity

    Clinical Considerations

    • If PAD is present, the patient should be treated as if cardiovascular disease is also present
    • Exercise is the first treatment option, and must be supervised
    • Followed by peripheral and surgical options depending on the severity

    Procedures

    • Exercise: gold standard treatment for increasing walking distance
    • Percutaneous transluminal angioplasty (PTA): opens narrowed or blocked blood vessels
    • Bypass grafting: revascularization

    Testing Recommendations

    • Dose and timing of medication are noted and repeated for any subsequent test
    • Measure ABI bilaterally after 5-10 minutes of supine rest, prior to testing
    • Reproducibility: use a standardized treadmill protocol
    • Note the onset of symptoms as close as possible using a numerical scale

    Exercise Prescription

    • Aerobic mode: walking
    • Intensity: walking to moderate pain in 3-5 minutes, followed by rest and resumption of walking
    • Frequency: at least three times per week, progressing to five times per week as tolerated
    • Duration: 30-45 minutes
    • Progression: increase duration by a few minutes each session, up to 50 minutes; increase speed to 3.0 mph
    • Goals: improve peak walking time, claudication onset time, patient-reported outcomes, VO2peak, and functional performance

    Revascularisation

    • Refers to a surgical procedure to provide new or additional blood supply to a body part or organ, including the heart, lungs, kidney, liver, and muscles.
    • Diagnostic testing includes MRI, CT scan, or X-ray fluoroscopy to identify the need for revascularisation or guide the procedure.

    Procedures

    • Percutaneous Transluminal Coronary Angioplasty (PTCA) or Percutaneous Coronary Intervention (PCI) with or without stenting:
      • Involves opening the blocked vessel via balloon dilation (often with stent replacement) to return blood flow to the myocardium.
      • Patients present with exertional chest pain or dyspnoea.
    • Coronary Artery Bypass Surgery (CABG):
      • Revascularisation of a venous graft from the arm or leg or arterial graft (mammary) to provide blood flow to the myocardium beyond the site of occlusion or nearly occluded area.
      • CABG isn't used for everyone with CAD; many with CAD are treated by lifestyle changes, medicines, and another revascularisation procedures (angioplasty).

    Australian Statistics (AIHW)

    • Coronary Angiography:
      • Provides medical professionals with the information to decide on treatment options.
      • 146,000 coronary angiography procedures performed in 2020-21, with 67% men and 33% women.
      • Increased from 2000-2001 by 14% in men and 12% in women.
    • Percutaneous Coronary Interventions (PCI):
      • Coronary angioplasty – catheter inserted with a small balloon, inflated to clear the blockage.
      • Stenting is similar, but a stent (an expandable mesh tube) is inserted into the affected coronary arteries.
      • 48,000 PCIs performed in 2020-21, with 75% men and 25% women.
      • Increased from 2000-2001 by 37% in men and 26% in women.
    • Coronary Artery Bypass Grafting (CABG):
      • Attaching a harvested vessel on the outside of the heart to bypass a blocked artery.
      • 12,700 CABG procedures performed in 2020-21, with 83% men and 17% women.
      • Decreased from 2000-2001 by 51% in men and 67% in women.

    Pathophysiology of Coronary Artery Disease

    • Build-up of macrophages, platelets, calcium, fibrous connection tissue, and lipids in the coronary arteries.
    • Leads to an obstruction of blood flow.
    • Mindful that ECG changes may not be present until a coronary artery has a 75% stenosis, and lesions that compromise 50% or more of the lumen can be clinically significant.

    Coronary Intervention

    • Coronary angioplasty and PTCA are minimally invasive procedures.
    • Acute Myocardial Infarction (MI):
      • Plaque rupture + platelet aggregation.
      • Acute thrombus formation (sudden occlusion).
      • Acute chest heaviness, diaphoresis, and nausea.
      • Urgent PTCA required to limit the myocardial damage.

    Percutaneous Transluminal Coronary Angioplasty (PTCA) or Percutaneous Coronary Intervention (PCI)

    • Coronary angioplasty is less invasive than CABG.
    • Involves opening the blocked vessel via balloon dilation (often with stent replacement).
    • Lower risk than CABG, however, complications include:
      • Rebound vasoconstriction.
      • Chronic restenosis.
      • Embolism.
      • MI.
      • Arrhythmias.
      • Dissection of a coronary artery.

    Stent

    • Stents are used to reduce the risk of an acute closure during a PTCA and restenosis.
    • A stainless steel mesh tube is inserted into the affected coronary artery and expanded.
    • Catheter is removed, and stent remains in the vessel permanently, covered by the endothelium in time.
    • Fast recovery (day-surgery in some cases).

    Coronary Artery Bypass Surgery

    • CABG isn't used for everyone with CAD; many with CAD are treated by lifestyle changes, medicines, and another revascularisation procedures (angioplasty).
    • CABG may be an option for severe blockages for large coronary arteries, especially if the heart's pumping action has already been weakened.
    • CABG may also be an option if blockages in the heart that can't be treated with angioplasty.

    Minimally Invasive and Robotic Coronary Artery Bypass Grafting

    • Introduced in the mid-1990s (Benetti from Buenos Aires).
    • Various variations since then, performed mainly in Central Europe and the USA.
    • Typical procedure:
      • Incision below the areolar in men and breast fold in women (4th intercostal space).
      • The LIMA or RIMA is harvested under direct vision.
      • Pericardium opened, and target vessels are accessed using specifically designed positioners and stabilisers.
      • Anastomoses performed on the beating heart using standard instrumentation and standard anastomotic techniques (sometimes additional intraluminal shunts).

    Heart Failure

    • Heart failure occurs when the heart functions less effectively, resulting in reduced cardiac output and/or elevated intracardiac pressures.
    • Causes of heart failure include heart attack, high blood pressure, damaged heart valves, and cardiomyopathy.
    • Cardiomyopathy weakens the entire heart muscle or a large part of it due to disease.

    Symptoms and Diagnosis

    • Mild heart failure may show few symptoms, while severe cases exhibit dyspnoea, ankle swelling, fatigue, and structural signs of peripheral oedema.
    • Heart failure cannot be cured, but treatment can improve quality of life, reduce hospital admissions, and prolong life.

    Prevalence

    • In Australia, approximately 102,000 people aged 18 and over had heart failure in 2017-2018, with two-thirds being 65 years or older.
    • The rate of heart failure is 2.9 times higher in Aboriginal and Torres Strait Islander people compared to non-indigenous Australians.

    Classification

    • Heart failure can be classified into systolic heart failure (HFrEF) and diastolic heart failure (HFpEF).
    • Systolic heart failure occurs when the heart muscle is weak, and ventricular myofibrils cannot contract or against load.
    • Diastolic heart failure occurs when the ventricle is stiff, and the problem is not contraction, but rather an inability to expand or relax and fill under pressure.

    Diagnosis and Assessment

    • Echocardiogram measures LV contraction (ejection) and relaxation to diagnose heart failure.
    • Blood tests, such as BNP, can aid in diagnosis.
    • Exercise capacity assessments, including peak oxygen consumption (VO2), can indicate 1-year mortality rates.

    Exercise Testing

    • Exercise testing in heart failure patients is similar to other types of heart disease.
    • Modified Bruce or Naughton protocol is used, with cycle ramp 10-15W/min.
    • Ventilatory-derived lactate threshold/gas exchange threshold is a useful measure of exercise capacity.

    Expected Responses

    • Compared to healthy individuals, people with heart failure exhibit central and peripheral differences in exercise responses.
    • Tables 16.1 and 16.3 in the text provide more details on these differences.

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