Cardiac Examination & CPET Lecture Notes PDF

Cardiac examination By: Dr. Mona Abd Elkhalek Dr. Ahmed Abd Elhalim Dr. Eman Naser  Heart’s position in thorax 2  Heart’s position in thorax  In mediastinum – behind sternum and pointing left, lying on the diaphr...

Cardiac examination By: Dr. Mona Abd Elkhalek Dr. Ahmed Abd Elhalim Dr. Eman Naser  Heart’s position in thorax 2  Heart’s position in thorax  In mediastinum – behind sternum and pointing left, lying on the diaphragm  It weighs 250-350 gm (about 1 pound) Feel your heart beat at apex 3 (this is of a person lying down) CXR (chest x ray) Normal male 4  Chambers of the heart ❑Chambers of the heart divided by septae: Two atria-divided by interatrial septum  Right atrium  Left atrium Two ventricles-divided by interventricular septum  Right ventricle  Left ventricle 5  simplified… ❑Cone shaped muscle ❑Four chambers Two atria, two ventricles ❑Double pump – the ventricles ❑Two circulations Systemic circuit: blood vessels that transport blood to and from all the body tissues Pulmonary circuit: blood vessels that carry blood to and from the lungs 6  Valves (Three tricuspid - One bicuspid) ❑“Tricuspid” valve  RA to RV ❑Pulmonary or pulmonic valve  RV to pulmonary trunk (branches R and L) ❑Mitral valve (the bicuspid one)  LA to LV ❑Aortic valve  LV to aorta 7  Function of AV valves 8  Function of semilunar valves (Aortic and pulmonic valves) 9 Cardiac Cycle The heart=a muscular double pump with 2 functions Overview  The right side receives oxygen- poor blood from the body and tissues and then pumps it to the lungs to pick up oxygen and dispel carbon dioxide  Its left side receives oxygenated blood returning from the lungs and pumps this blood throughout the body to supply oxygen and nutrients to the body tissues 11  Pattern of flow Body to right heart to lungs to  Body left heart to body  RA Body, then via vena cavas and coronary sinus to RA, to RV, then to lungs via pulmonary arteries,  RV then to LA via pulmonary veins, to LV, then to  Lungs body via aorta  LA From body via SVC, IVC & coronary sinus to  LV RA; then to RV through tricuspid valve; to lungs through pulmonic valve and via  Boby pulmonary arteries; to LA via pulmonary veins; to LV through mitral valve; to body via aortic valve then aorta 13  Cardiac Examination 14  Cardiac Examination Examination of cardiac patient is case divided into two basicsteps: Subjective Objective  Cardiac Examination Subjective Objective ❑ Based on patient interviewing ❑ Based on examining the patient ❑ Open ended questions ❑ Includes : General and Local (About signs and symptoms examination related to cardiac cases : ❑ Includes specific tests as : Dyspnea ECG Chest pain Chest radiographs Palpitation Echocardiography Syncope Cough Hemoptysis 16  Patient interview ❑ 1-Medical record review ❑ 2-Determine the over all cognition. ❑ 3-Patient should describe on his own words, the quality and location of symptoms. Cardiac symptoms ❑ It is the pain that occur anywhere above the waist. ❑ They are typically exaggerated by exertion and are relieved with rest. ❑ Like(chest pain, tightness or pressure, shortness of breath, palpitation, indigestion, burning)  Cardiac history 1. Patient must be aware with risk factors to enables the therapist to develop realistic goal for long term goals of treatment plan. 2. From the history can determine if the patient has any risk factors of heart disease. HTN D.M Obesity Sedentary Stress Smoking Major Risk factors: lifestyle ↑cholesterol Old age Male gender serum Family history  Cardiac Risk-Factor  Cardiac risk factors are divided into two major groups: Reversible and irreversible risk factors ❑ Reversible risk factors for cardiac disease include: 1. Sedentary lifestyle 2. Hyperlipidemia, 3. Cigarette smoking 4. Diabetes mellitus 5. Hypertension. 6. Obesity  Cardiac Risk-Factor ❑Irreversible risk factors include: 1. Male gender 2. Past history of vascular disease 3. Age 4. Family history.  General Cardiac Examination 21  General Cardiac Examination Physical development. (Body Build) Posture: orthopneic posture, prayer’s posture. Vital Signs (HR - Respiration – BP) Nodding of the head (de Musset sign) Colour (Pallor. Malar flush. Cyanosis) Finger clubbing Oedema Nodules Fever 22  General Cardiac Examination Body building ❑Height: Dwarf undergrowth:(Short associated with CHD) Marfan syndrome:(Very tall, Sternum depression and Aortic incontinence.) ❑Weight: Under weight : CHD or RHD Overweight→ Atherosclerosis 24 Orthopneic posture Prayer’s posture Position: Orthopnea → LHF Squatting → CHD Leaning forward→ pericarditis or mediastinal syndrome Color: Pallor → all skin become pale and the tongue yellow as in patients with LHF , RHD and anemia Jaundice →yellow discoloration of skin as in MI or pulmonary infarction. Cyanosis→ bluish coloration skin & mucous membrane (central or peripheral). Malar flush Cardiac edema Rheumatic nodules  General Cardiac Examination Vital signs  Monitor vital signs at rest, during session, and after session. Pulse rate (HR)  Palpation of arterial pulsation (radial pulse or femoral pulse or from both at the same time)  To detect any abnormality in rate, rhythm , amplitude or delay of pulsation) RR:  Both rate and rhythm should be noted as well as breathing pattern and use of accessory muscle.  N.B: PND→LVF BP:  Should be consider the measurement position (supine, sitting, standing). Palpation of peripheralpulses Site of jugular veins Examining the venous pressure  Local Cardiac Examination 33  Local Cardiac Examination Combined inspection and palpation ❑ Shape of precordium : Bulging Chest deformities ❑ Apex beat. ❑ Abnormal pulsations. ❑ Thrills. 34 Apex beat site Sites of abnormal pulsations  Thrills ❑ Palpable vibration (vigor contraction)over chest wall in murmurs ❑ Thrill at apex when patient turned to left and hold expiration which may be systolic or diastolic ❑ Thrill at the base when patient leaned forward and hold expiration which is systolic Thrills  Thrills Location of Thrill Associated Disorder Over the base of the heart at the 2nd intercostal space, just to the right of Aortic stenosis the sternum, during systole At the apex during systole Mitral regurgitation To the left of the sternum at the 2nd Pulmonary stenosis intercostal space during systole To the left of the sternum at the 4th Small muscular ventricular septal intercostal space defect (Roger disease) Percussion of the cardiacmuscle Auscultation  Auscultation Auscultation Locations Aortic valve Second right intercostal space, upper right sternal border Pulmonary valve Second left intercostal space (ICS), left sternal border Tricuspid valve Fourth left intercostal space, left sternal border Mitral valve Fifth left intercostal space, mid- clavicular line 42  Auscultation Normal Heart Sounds  S1 “Lub” The first heart sound is the sound occurs with ventricular contraction a marks the approximate beginning of systole. The sound is created by the closure of the Atrioventricular valves (Tricuspid and Mitral).  Auscultation Normal Heart Sounds  S2 “Dub” The second heart sound marks the beginning of ventricular relaxation and end of systole. Thus, it also marks the approximate beginning of diastole. The sound is created by closure of the Semilunar valves (Aortic and Pulmonic). The second heart sound is of shorter duration and higher frequency than the first heart sound.  Auscultation Extra heart sounds  S3 (lub - dub –ta) occurs at the beginning of diastole after S2 and is lower in pitch than S1 or S2 as it is not of valvular origin. Indicative of ventricular failure.  Auscultation Extra heart sounds  S4 Occurs prior to S1, produced by the sound of blood being forced into a stiff or hypertrophic ventricle.  Auscultation Extra heart sounds  Murmurs  Heart murmurs are extra sounds during the cardiac cycle, such as whooshing or swishing made by turbulent blood flow often due to a faulty valve 48  Cardiopulmonary exercise testing (CPET) 49 Cardiopulmonary exercise testing (CPET) 51  Cardiopulmonary exercise testing (CPET) It is a unique tool to assess the limits and mechanisms of exercise tolerance. It also provides indices of the functional reserves of the organ systems involved in the exercise response, with inferences for system limitation at peakexercise.  Cardiopulmonary exercise testing (CPET) CPET provides a global assessment of the integrative exercise responses involving different body systems, which are not adequately reflected through the measurement of individual organ system function. This relatively noninvasive, dynamic physiologic overview permits the evaluation of both sub maximal and peak exercise responses, providing relevant information for clinicaldecision-making.  Cardiopulmonary exercise testing (CPET) Exercise testing uses the stimulus–response method of assessment. Accordingly, a standard exercise stimulus is applied to the testing subject and the subject’s physiological response is measured and later interpreted against recognizedstandards.  Cardiopulmonary exercise testing (CPET) The normative standard values are themselves compiled from typical responses to the exercise stress in ahealthy matched population. Because the goal of exercise testing is to evaluate how organs and systems linking external to internal respiration under conditions of increased metabolic demand, the exercise stimulus is typically increased progressively and applied on large muscle groups, such asthose used in running or riding abicycle.  Indications for Cardiopulmonary Exercise Testing 1. Evaluation of exercise tolerance. 2. Evaluation of undiagnosed exercise intolerance. 3. Evaluation of patients with cardiovascular diseases. 4. Evaluation of patients with respiratory diseases/symptoms. 5. Direct measurement of peak oxygen consumption per unit time (functional capacity) 6. Preoperative evaluation. 7. Exercise evaluation and prescription for Cardiac & pulmonary rehabilitation. 8. Evaluation of impairment/disability. 9. Evaluation for lung, heart, and heart–lung transplantation 56 Contra-indications for Cardiopulmonary Exercise Testing Contra-indications for Cardiopulmonary Exercise Testing Normal response to exercise  Metabolic equivalent (MET): Resting metabolic unit—1 MET = 3.5 ml O2 consumed per kilogram of body weight per minute  Total Oxygen Consumption (VO2) represents the oxygen consumption of the whole body; therefore, it mainly represents the work of the peripheral skeletal muscles rather than myocardial muscles.  Types of CPET Maximal tests Submaximal test  Maximal exercise testing Maximal exercise tests either measure or predict maximum oxygen consumption (Vo2max) and have been accepted asthe basis for determining fitness.  Theoretically, maximum test criteria are ▪ Plateau of Vo2max with further increases in workload. ▪ Obtaining HR max within 15 beats per minute of age-predicted HR max (ie , 220- age) ▪ A respiratory exchange ratio >1.10 (ratio of metabolic gas exchange calculated by carbon dioxide production divided byVO2).  The limitations to assess maximal performance with a Vo2max test The ability of an individual is able to attain a Vo2max without fatiguing first or being limited by musculoskeletal impairments or other problems. Higher levels of motivation are required by the individual. Maximal tests require additional monitoring equipment (electrocardiograph machine) and trained staff.  Sub maximal exercise testing Sub maximal exercise testing overcomes many of the limitations of maximal exercise testing, and it is the method of choice for the majority of individuals seen by physical therapists in that these individuals are likely to be limited physically by pain andfatigue.  Submaximal exercise tests can be used to Predict Vo2 max. Make diagnoses and assess functional limitations. Assess the outcome of interventions such as exercise programs. Measure the effects of pharmacological agents. Types of submaximal exercise tests Submaximal exercise tests Predictive Performance tests tests  Predictive submaximal tests ❑ which are submaximal tests that are used to predict maximal aerobic capacityas: 1. Modified Bruce Treadmill Test. 2. Single-Stage Submaximal Treadmill Walking Test. 3. Astrand and Rythming Cycle Ergometer Test. 4. Canadian Aerobic Fitness Test. 5. 12-Minute Run Test. 6. 20-Meter Shuttle Test.  Performance submaximal tests That involve measuring the responses to standardized physical activities that are typically encountered in everyday lifeas: 1. Self-Paced Walking Test. 2. Modified Shuttle Walking Test. 3. Bag and Carry Test. 4. Timed Up & GoTest. 5. 12- and 6-Minute Walk Tests.  Equipment and methodology The goal of cardiopulmonary exercise testing is to evaluate the organs and systems involved in the exercise response, under conditions of progressively intense physical stress. Therefore, exercise testing involves large muscle groups, usually the lower extremity muscles as in running on the treadmill or pedaling on a cycle ergometer. It is usually most efficient to employ a progressively increasing work rate protocol so that a range of exercise intensities can be studied in a short period of time. Differences between cycle ergometer and treadmill  Exercise testing protocols Several protocols can be used with either a cycle ergometer or a treadmill. Classification based on the manner in which the work rate is applied: Progressive incremental exercise (every minute) or continuous ramp protocol. Multistage exercise protocol (every 3 minutes, with a “pseudo”- steady state at eachlevel). A constant work rate (the same work rate, usually for 5 to 30 minutes). A discontinuous protocol, which consists of short periods (3–4 minutes) of constant work rate exercise separated by resting periods and with loads progressively increased which is rarely usedclinically. Modified Bruce Treadmill Test  12- Minute WalkTest A corridor, approximately 20 m in length is required. The individual walks a measured distance For the 12-MWT, the individual is instructed “to cover as much ground as possible in 12 minutes and to keep going continuously if possible but not to be concerned if you have to slow down or rest”. If encouragement is given, predetermined phrases should be delivered every 30 s while facing the individual. On completion of the test, the individual should continue walking to cooldown.  Main measurements during CPET Maximal oxygen uptake (Vo2 max) Anaerobic threshold (AT) Ventilation Peak respiratory exchange ratio (RER) Exercise heart rate (HR) Exercise blood pressure (BP) 75  Main measurements during CPET Maximal oxygen uptake (Vo2 max): ▪ Maximal oxygen uptake (Vo2 max) is the greatest amount of oxygen a person can take in from inspired air while performing dynamic exercise involving a large part of total musclemass. ▪ It is the best index of aerobic capacity and the gold standard for cardiorespiratory fitness. ▪ Vo2 max represents the amount of oxygen transported and used in cellular metabolism.  Maximal oxygen uptake (Vo2 max): ▪ Vo2 max is determined during dynamic exercise from a "plateauing” of O2 despite work continuing to increase. ▪ In the absence of a discernible plateau, the highest O2 actually attained on the test is more properly termed Vo2 peak. ▪ Both Vo2 max and Vo2 peak are conventionally expressed in units of milliliters per minute (mL/min), liters per minute (L/min) or, corrected for body weight, as milliliters per minute per kilogram (mL/min/kg).  Maximal oxygen uptake (Vo2 max): ❑ The main determinants of normal Vo2 max are genetic factors and quantity of exercising muscles ❑ Vo2 max is also dependent on age, sex, body size and cardio- vascular clinical status ❑ Physical activity has an important influence on Vo2 max After 3 weeks of bed rest; there is a 25% decrease in Vo2 max in healthy men. In moderately active young men, Vo2 max is ≈ 12 METs, whereas individuals performing aerobic training such as distance running can have a Vo2 max as high as 18 to 24 METs (60 to 85 mL/kg/min).  Maximal oxygen uptake (Vo2 max): Vo2 max = C O P X a-v O2 difference ❑ As, COP= SVx HR ❑ and because S Vonly increases to a certain level, VO2 is directly related toH R. ❑ The maximum a-v O2 difference (which increases with exercise) during exercise has a physiological limit of 15% to 17%; hence, if maximum effort is achieved, Vo2 max can be used to estimate maximum COP.  Maximal oxygen uptake (Vo2 max): ❑ A decrease in Vo2 max is a general indicator of reduced exercise capacity. There is a multifactorial etiology of reduced Vo2 max; a reduced Vo2 max may reflect: Problems with oxygen transport (C O P, O2- carrying capacity of the blood), Pulmonary limitations (mechanical, control of breathing or gasexchange), Oxygen extraction at the tissues (tissue perfusion, tissue diffusion), Neuromuscular or musculoskeletal limitations, and, of course, effort.  Anaerobic threshold (AT) ❑ The anaerobic threshold (AT), also known as the lactate threshold, lactic acid threshold, gas exchange threshold, or ventilatory threshold, is considered an estimator of the onset of metabolic acidosis caused predominantly by the increased rate of rise of arterial lactate during exercise. ❑ The AT is referenced to Vo2 at which this change occurs and is expressed as a percentage of the predicted value of Vo2 max (%Vo2 max predicted).  Anaerobic threshold (AT) ❑ The increase in lactic acid that appears in the blood as exercise intensity increases has important physiologic consequences: First, the buildup in lactic acid reduces the pH of both blood and interstitial fluid, which in turn could compromise cellular function. Second, the reduced pH stimulates ventilation as the body attempts to buffer the increased acid by decreases in PCO2.  Anaerobic threshold (AT) In normal individuals, the AT occurs at about 50– 60% Vo2max predicted in sedentary individuals, with a wide range of normal values extending from 35 to 80%. The ATis determined by age and modality. The AT is highly modality specific, with arm exercise resulting in lower values versus leg exercise and with cycle ergometry resulting in lower (5–11%) values versus treadmill, a reflection of differences in exercising muscle mass.  Anaerobic threshold (AT) ❑ The AT reduced in various clinicalconditions. ❑ Values below 40% of predicted Vo2max may indicate: Acardiac, Pulmonary (desaturation) Or other limitation in O2 supply tothe tissues, Or underlying mitochondrial abnormality (e.g., muscle dysfunction in cardiopulmonary diseases).  Ventilation Increased ventilation (VE) during exercise is one of the primary means by which arterial blood regulates gases and acid–base status under conditions of increased the metabolic demands of the exercising muscles. The most common ventilatory indices assessed during exercise include changes in total minute ventilation (VE), tidal volume (VT), respiratory frequency (fR) and the efficiency of ventilation (VE versus O2or CO2)  Ventilation ❑ The rise in VE with exercise is associated with an increase in both depth and frequency of breathing. ❑ In healthy individuals, increases in tidal volume responsible for increases in ventilation during low levels of exercise. ❑ A s exercise progresses, both VTand fR increase until 70 to 80% of peak exercise; thereafter fR predominates. VT usually plateaus at 50 to 60% of VC.  Peak respiratory exchange ratio (RER) Defined as the VCO2/VO2 ratio. As exercise progresses to higher intensities, VCO2outpaces VO2, increasing the ratio. Currently is the best non-invasive indicator of exercise effort. Peak value ≥1.10 widely accepted as excellent exercise effort.  Exercise heart rate (HR) ❑ In patients not prescribed a beta-blocking agent; provides insight into cardiac response to exercise. ❑ Peak H Rshould not be used as the primary gauge of subject effort given its wide variability. ❑ Increase~10 beats per 3.5 mL O2/kg/min increase in VO2. ❑ Achieve at least 85% of age-predicted maximal HR with good effort.  Exercise blood pressure (BP) Provides insight into cardiovascular response to exercise. S B P increase ~10 mm Hg per 3.5 mL O2 / kg/ min increase in VO2. Upper range of normal maximal S B P is ~210 mm Hg for males and ~190 mm Hg for females. DBP remains the same or slightly decreases.  Absolute end points: ❑ Signs of severe fatigue ❑ Patient request ❑ Sustained ventricular tachycardia, Supraventricular tachycardia ❑ Moderate to severe angina ❑ Signs of poor perfusion: moderate to severe dizziness, near-syncope, confusion, ataxia, cold or clammy skin ❑ Technical difficulties in monitoring ECG or BP ❑ Drop in systolic BP despite increasing work rate in the presence of other signs of ischemia or worsening arrhythmia ❑ New onset atrial fibrillation ❑ ST elevation > 1mm OR ST depression > 2mm ❑ Systolic BP > 250mmHg or diastolic BP > 115mmHg 90 91