Cardiac Disease and Physical Activity PDF

Cardiac Disease and Physical Activity EDDIE MCGUINNESS PHD  Anatomy of the Heart and Blood Vessels  Closed circulatory system composed of:  Blood  Heart  Blood vessels The Heart The Heart  Located between the lungs (slightly on the LHS) & just above the diaphragm....

Cardiac Disease and Physical Activity EDDIE MCGUINNESS PHD  Anatomy of the Heart and Blood Vessels  Closed circulatory system composed of:  Blood  Heart  Blood vessels The Heart The Heart  Located between the lungs (slightly on the LHS) & just above the diaphragm.  Made of cardiac muscle and surrounded by a double membrane called the pericardium.  Pericardial fluid between the two membranes help reduce friction when the heart beats.  Cardiac muscle is a special type of involuntary muscle that never tires. Myocarditis Cardiac tamponade Double Circulatory System  Double circulation means that blood flows:  From the heart to the lungs and then back to the heart (pulmonary circuit)  From the heart to the rest of the body and back to the heart (systemic circuit).  Blood supply to the heart  The muscle of the heart is supplied with blood by the coronary (or cardiac) arteries.  These branch from the aorta at the point where it leaves the heart.  Blood is drained to the heart by the coronary or cardiac veins.  These return the blood directly to the right atrium.  Blockage of the coronary arteries is a common cause of heart attack. Heartbeat Control  Although heartbeat is usually controlled by the pacemaker, it can be altered by nervous stimulation from the brain or by hormones.  Pacemaker is located at the top of the right atrium.  Heartbeat is controlled by:  SA node in the wall of the right atrium, which causes the atria to contract  AV node which sends electrical impulses down the septum which causes the ventricles to contract Heart rate diurnal variation  Diastole and Systole  Diastole is when the heart is relaxed.  Systole is when the heart contracts.  The stages of heartbeat are:  Diastole: blood enters the atria  Atrial systole: blood is pumped to the ventricles  Ventricular systole: blood is pumped out of the heart.  Blood Pressure (BP)  Blood pressure is the force of blood against the walls of the arteries.  Normally the higher value is a measure of the systolic pressure; the lower value is a measure of the diastolic pressure.  1. Blood enters the heart:  The atria and ventricles are both relaxed (diastole)  Blood enters the atria  All valves are closed 2. Blood is pumped from the atria to the ventricles: Cardiac Cycle  Electrical impulses from the SA node cause the atria to contract (atrial systole)  Blood is pumped to the ventricles  The tricuspid and bicuspid valves open  The vena cava and pulmonary veins close to stop blood entering the atria  The semilunar valves remain closed. Cardiac Cycle  Cardiac Cycle 3. Blood leaves the heart.  The atria relax  Impulses from the AV node cause the ventricles to contract (ventricular systole)  Blood is forced out of the heart into the pulmonary artery and the aorta  The pressure forces the semilunar valves to open  The pressure closes the tricuspid and bicuspid valves  The ventricles now relax again  The semilunar valves close, which prevents blood from flowing back into the heart (or ventricles)  The vena cava and pulmonary veins open the cycle starts again. Cardiac Disease Epidemiology (WHO, 2021)  Leading cause of death worldwide  17.9 mill deaths 2019 from CVD  32% of all global deaths  85% of these HA and Stroke  17 mill premature deaths 2019 from non-communicable diseases  38% of these CVD  Low- and middle-income countries  80% of all deaths, 88% of pre-mature deaths Cardiovascular Disease: Types (WHO, 2021)  A group of disorders of the heart and blood vessels  coronary heart disease: a disease of the blood vessels supplying the heart muscle;  cerebrovascular disease: a disease of the blood vessels supplying the brain;  peripheral arterial disease: a disease of blood vessels supplying the arms and legs;  rheumatic heart disease: damage to the heart muscle and heart valves from rheumatic fever, caused by streptococcal bacteria;  congenital heart disease: birth defects that affect the normal development and functioning of the heart caused by malformations of the heart structure from birth  Deep vein thrombosis and pulmonary embolism: blood clots in the leg veins, which can dislodge and move to the heart and lungs   Acute coronary syndrome: the manifestation of coronary artery disease as increasing symptoms of angina pectoris, myocardial infarction, or sudden death  Cardiovascular disease: diseases that involve Manifestations the heart and/or blood vessels; includes cardiac/pulmonary hypertension , coronary artery disease, peripheral arterial disease; of Cardiac includes but not limited to atherosclerotic arterial disease  Cerebrovascular disease: diseases of the blood Diseases (ACSM’s vessels that supply the brain  Coronary artery disease: disease of the Guidelines for Exercise arteries of the heart (usually atherosclerotic)  Myocardial ischemia: temporary lack of Testing and adequate coronary blood flow relative to myocardial oxygen demands; often manifested as Prescription, 2018) angina pectoris  Myocardial infarction: injury/death of the muscular tissue of the heart  Peripheral arterial disease: diseases of arterial blood vessels outside the heart and brain Cardiac Disease Prevention  Most CVD is preventable by addressing behavioural risk factors  Unhealthy diet  Tobacco use  Obesity  Harmful use of alcohol  Physical inactivity Cardiac Disease Risk Factors  Age  Family Hx  Cigarette smoking  Physical Inactivity  Obesity  Hypertension  Dyslipedemia  Diabetes  Signs and Symptoms of Cardiac Disease  Often times no symptoms  MI or Stroke may be the first sign  MI Symptoms:  Pain or discomfort in:  Centre of chest (Angina)  Arms, left shoulder, jaws, neck, back  Dyspnoea  Nausea  Dizziness or Syncope  Cold sweats  Pale Colour Signs and Symptoms cont.  Ankle oedema – DVT,  Palpitations/Tachycardia  Intermittent Claudication – cramp like pain in lower extremities with poor blood supply – atherosclerosis indicator  Unusual fatigue or shortness of breath with normal activities  Signs and Symptoms of Cardiac Disease  Stroke Signs and Symptoms  Sudden weakness of face, arm, leg  Usually one side of the body  numbness of the face, arm, or leg, especially on one side of the body;  confusion, difficulty speaking or understanding speech;  difficulty seeing with one or both eyes;  difficulty walking, dizziness and/or loss of balance or coordination;  severe headache with no known cause; and/or  fainting or unconsciousness Cardiac Disease Assessment and Diagnosis  Heart Rate  Blood Pressure  Body weight/BMI/ BF%  Medication Changes  ECG and HR surveillance  Coronary Angiogram  Echocardiogram  CPET stress test  Appropriate screening and assessment for CVD can reduce risk of SCD or AMI  Used in conjunction with risk factor profiling PAR-Q+ Self Screening Tool: Pre- Exercise Exercise preparticipation health screening checklist ECG (ElectroCardioGram)  LOWEST RISK Characteristics of patients at lowest risk for exercise participation (all American characteristics listed must be present for patients to remain at lowest Association of risk)  Absence of complex ventricular dysrhythmias during exercise testing Cardiovascular recovery and and Pulmonary  Absence of angina or other significant symptoms (e.g., unusual shortness of Rehabilitation breath, light-headedness, or dizziness, during exercise testing and recovery) Risk  Presence of normal haemodynamics during exercise testing and recovery Stratification (i.e., appropriate increases and decreases in heart rate and systolic blood pressure with increasing workloads and recovery) Criteria for  Functional capacity ≥7 metabolic equivalents (METs) Patients with Nonexercise Testing Findings  Resting ejection fraction ≥50% Cardiovascular  Uncomplicated myocardial infarction or revascularization procedure Disease  Absence of complicated ventricular dysrhythmias at rest  Absence of congestive heart failure  Absence of signs or symptoms of postevent/postprocedure myocardial ischemia  Absence of clinical depression Cont.  MODERATE RISK Characteristics of patients at moderate risk for exercise participation (any one or combination of these findings places a patient at moderate risk)  Presence of angina or other significant symptoms (e.g., unusual shortness of breath, light-headedness, or dizziness occurring only at high levels of exertion [≥7 METs])  Mild-to-moderate level of silent ischemia during exercise testing or recovery (ST- segment depression 20 mm Hg with symptoms  Significant aortic stenosis (aortic valve area 120 beats · min −1)  Uncompensated heart failure Contraindicatio  Third-degree atrioventricular block without pacemaker  Active pericarditis or myocarditis ns for CR   Recent embolism (pulmonary or systemic) Acute thrombophlebitis  Aortic dissection  Acute systemic illness or fever  Uncontrolled diabetes mellitus  Severe orthopedic conditions that would prohibit exercise  Other metabolic conditions, such as acute thyroiditis, hypokalemia, hyperkalemia, or hypovolemia (until adequately treated)  Severe psychological disorder  Outpatient Rehab  Class 1 Recommendation for (Thomas et al 2007) for patients with:  a recent MI,  acute coronary syndrome event/angina  coronary artery bypass surgery  PCI, heart failure (HF) hospitalization  heart valve repair or replacement  heart or heart/lung transplantation   Develop and assist the patient to implement a safe and effective formal exercise and lifestyle physical activity program.  Provide appropriate supervision and monitoring to detect change in clinical status.  Provide ongoing surveillance to the patient’s health care providers in order Outpatient to enhance medical management. CR Goals  Return the patient to vocational and recreational activities or modify these activities based on the patient’s clinical status.  Provide patient and spouse/partner/family education to optimize secondary prevention (e.g., risk factor modification) through aggressive lifestyle management and judicious use of cardioprotective medications.  Cardiovascular risk factor assessment and counselling on aggressive lifestyle management Education and support to make healthy lifestyle changes to reduce the risk of a secondary cardiac event Outpatient Development and implementation/supervision of a safe and CR effective personalized exercise plan Component Monitoring with a goal of improving blood pressure, lipids/cholesterol, and diabetes mellitus s Psychological/stress assessment and counselling Communication with each patient’s physician and other health care providers regarding progress and relevant medical management issues Return to appropriate vocational and recreational activities Outpatient Exercise Testing  Testing for CVD pts is  Symptom limited  Pt. has to be stable  Ideally not during time when beta blocker is in effect  No different to standard exercise testing procedures (see chapter 5 ACSM’s Guidelines for Exercise Testing and Prescription)  Treadmill, cycle ergometer, arm ergometer, seated stepper most common methods  Initially sub maximal with similar magnitude increments in work Testing Protocols  Not too many guidelines on exercise protocol selection  Bruce Treadmill Protocol the most widely used (Myers et al., 2000)  Total exercise duration of 6-12 minutes  Bruce protocol has high initial aerobic requirements (5 METS) with relatively big increments (3 METS) so modified protocols have been designed for less functional pts. (Fletcher et al., 2013)  CPET stress test  Useful for diagnosis of CVD  Also gives gas analysis and VO2 information which can be helpful for intensity selection in subsequent Ex Rx. Bruce Protoc ol Modifie d Bruce Protoco l Protocol Compariso ns Interpreting Exercise Test Data  Heart Rate Response  BP response  ECG response  Symptoms  HR Response  Normal – Increases at rate of 10bpm per 1 MET  In IHD  Attenuated by Beta blockers  Failure to achieve 85% of age predicted HR Max indicative of increased risk of morbidity and mortality  Post exercise decline  Failure to decrease by at least 12 bpm after minute 1, 22bpm after minute is a sign of increased risk of M and M.  BP  response Normal  Increase of 10mm.HG per 1 MET (greater among men)  Attenuated for vasodilators, beta blockers, calcium blockers  Hypertensive  SBP greater than 250 mm.HG means stop the test  Greater than 210 in men and 190 in females is an exaggerated response and indicative of hypertension or future hypertension.  Hypotensive  Decrease of SBP by greater than 10 mm.HG is abnormal associated with ischemia, left ventricle dysfunction, and increased risk of cardiac events  Post Ex  6 mins normally to get back to normal rates, anything outside of this needs investigation.  ECG Response  Normal  P-wave: increased magnitude among inferior leads  PR segment: shortens and slopes downward among inferior leads  QRS: Duration decreases, septal Q-waves increase among lateral leads, R waves decrease, and S waves increase among inferior leads.  J point (J junction): depresses below isoelectric line with upsloping ST segments that reach the isoelectric line within 80 ms  T-wave: decreases amplitude in early exercise, returns to preexercise amplitude at higher exercise intensities, and may exceed preexercise amplitude in recovery  QT interval: Absolute QT interval decreases. The QT interval corrected for  HR increases with early exercise and then decreases at higher HRs. Exercise Prescription  FITT recommendations appropriate  Ex Rx techniques for healthy adult pop can be applied to many CVD pts.  Specific modifications/considerations needed  Base your programme on the individual as well as the various other physiological responses to exercise  FITT Recommendations for CVD Aerobic Strength/Resistance Flexibility Frequenc 3-5 days a week (5 2-3 non-consec d.w Daily most effective y preferrable) Intensity 40-80% of HRR, VO2R, Vo2 10-15 reps of each exercise Point of tightness/slight peak when available. without sig fatigue, RPE 11- discomfort Outside of this use RHR 13 or 40-60%1RM +20-30bpm, or 12-16 RPE Time 20-60min 1-3 sets of 8-10 diff 15s for static, more than 4 exercises, major muscle repetitions for each group focus exercise Type Arm ergo, arm and leg dual Equipment that’s safe and Static and dynamic focused ergo, recumbent ergo, comfortable for pt use on major joints of limbs elliptical, stair climber, and lower back, consider rower PNF Considerations/Modifications  Frequency depends on baseline exercise tolerance, exercise intensity, fitness and other health goals, and types of exercise that are incorporated into the overall program  General guidelines for adults and older adults suggest exercise bouts of at least 10 min each  patients with very limited exercise capacities, multiple shorter (i.e.,