Cardiac Pathophysiology & Intervention PDF

Cardiac Pathophysiology & Intervention Heidi Tymkew PT, DPT, MHS, CCS Inflammatory Disorders of the Heart Endocarditis Symptoms: ▪ Chills/fever ▪ Joint and muscle pain ▪ Red spots or nodes on hands/feet ▪ Shortness of breath with activity ▪ Fatigue ▪ Swelling...

Cardiac Pathophysiology & Intervention Heidi Tymkew PT, DPT, MHS, CCS Inflammatory Disorders of the Heart Endocarditis Symptoms: ▪ Chills/fever ▪ Joint and muscle pain ▪ Red spots or nodes on hands/feet ▪ Shortness of breath with activity ▪ Fatigue ▪ Swelling Treatment: ▪ IV antibiotics ▪ Surgery if it damages the heart valves ▪ May need to limit exercise during the acute phase of endocarditis  Pericarditis ▪ Inflammation of the pericardial sac around the heart ▪ Often idiopathic but can be caused by injury to pericardium (i.e. post CABG surgery), MI, autoimmune diseases, or viral infections ▪ Symptoms: ▪ Chest pain or pain between shoulders (sharp/stabbing that gets worse with cough, swallow, deep breaths or lying flat but feels better with sitting and leaning forward) ▪ Pericardial rub  Pericarditis ▪ Treatment: ▪ Anti-inflammatory, steroids and pain meds ▪ Antibiotic (if caused by bacterial infection) ▪ Surgery (rare) – pericardial window to drain the inflamed lining ▪ Physical Activity usually restricted for a minimum of 1-3 months https://ucsfhealthcardiology.ucsf.edu/patient-care/clinical-services/myocarditis-center Myocarditis ▪ Treatment ▪ No standard treatment ▪ Treat heart failure and arrhythmias ▪ Avoid physical activity for at least 3-6 months – need clearance from a cardiologist Oncology Related Heart Disorders  Oncology Related Heart Disorders Some cancer treatments can injure the heart muscle and blood vessels → increased risk of CV disease 2-6 times higher CVD mortality risk Cardiotoxicity = functional or structural damage to the CV system related to cancer treatments Chemotherapy Anthracycline drugs (doxorubicin, daunorubicin) Cisplatin Chest radiation Immunotherapy (Immune checkpoint inhibitors) Targeted therapies Oncology Related Heart Disorders CV disorders that can result from cancer treatment: Cardiomyopathy or Heart failure Coronary artery disease/MI Valvular heart disease Arrhythmias Pericarditis or myocarditis Hypertension Stroke Blood clots (DVT or PE) Peripheral artery disease  Oncology Related Heart Disorders Cardiac tests used during/after cancer treatments BNP, NT-proBNP Troponin I or T Lipid profile EKG Echocardiogram Cardiac MRI Medical Intervention Cardioprotective strategies to reduce the impact of the cancer treatments Dexrazoxane, ACE Inhibitors, Beta-blockers Lifestyle modifications/risk factor management Treatment for the specific CV disorder Autonomic Dysfunction Heidi Tymkew PT, DPT, MHS, CCS Autonomic Nervous System (ANS) Controls involuntary physiologic processes Sympathetic Nervous System (SNS) Parasympathetic Nervous System (PNS)  Causes of Autonomic Dysfunction Result of a Preexisting Hereditary Acquired/Idopathic Condition Familial dysautonomia Neurocardiogenic syncope DM Hereditary sensory POTS Autoimmune diseases neuropathy type 3 Multisystem Atrophy (RA, lupus) Pure autonomic failure Neurogenic orthostatic hypotension Parkinson’s disease Dementia with Lewy Bodies Medications Trauma Normal Response to Position Change In a person with an intact ANS, the change from supine to standing will results in: Blood pooling in the abdomen and legs (500-800 ml) ANS is activated to compensate for and maintain CO by increasing HR and peripheral vasoconstriction ↑ HR 10-20 bpm Min change in systolic BP ~5 mmHg ↑ in DBP Postural Orthostatic Tachycardiac Syndrome (POTS) Autonomic disorder that involves an excessive tachycardia in standing in the absence of orthostatic hypotension and other medical condition/medications Primary affects females between the ages of 15-50 years (with the majority being between 15-25 years of age) Affects ~ 500,000 Americans Diagnosis of POTS The exact underlying cause is not known Often triggered by viral/bacterial infection Diagnosed with a 10-minute standing test or a head-up tilt table test Lie supine x 10 min – obtain HR/BP Stand up/tilt up and measure HR/BP at 1,2,5, 10 minutes + test = Sustained HR > 30 bpm (>40 bpm in people from ages 12-19 years) with no change in BP Symptoms of orthostatic intolerance for > 6 months Absence of other causes of sinus tachycardia Changes in HR and SV during a Tilt Table Test (Bryarly et al. J Am Coll Cardiol, 2019)  Acrocyanosis Effects ~50% of people with POTS Red-blue discoloration of the legs in standing which are cold to touch (Raj, Circulation, 2013) Treatment of POTS Pharmacological interventions No approved medications Some meds are used to treat the symptoms (Midodrine to ↑ BP and Propranolol to ↓HR) Ivabradine (↓HR)  Exercise conditioning has been deemed as a fundamental aspect of POTS treatment Short-term exercise (3 months) ↑ Peak VO2 Treatment ↑ Cardiac size and mass ↑ Blood volume of POTS After 3 months of training the majority (71%) of patients no longer met the objective criteria for POTS (George et al., Heart Rhythm, 2016)  Initially avoid upright exercise and gradually progress activity Aerobic training Rowing machine, recumbent bike, swimming → upright bike, TM, jogging Warm up and cool down Treatment May have to start with short duration but work up to 30 minutes/session of POTS Work up to 75% Max HR or RPE 13-15 Initial goal is 3-4x/week for 25-30 minutes and then progress to 5- 6x/week for 45-60 min Interval training may be beneficial Try not to take more than 2 days off from exercising Treatment of POTS Strength training Use of body weight or seated machines 1-2x/week for 15-40 minutes a session Focus on LE and core Take at least a day off between strength workouts  Treatment of POTS Other common interventions Gradual increase in salt intake – up to 10 grams/day Increased fluid (2-3 L/day) Sleeping in the head-up position Treatment of POTS Other common interventions Compression garments May help to reduce the patient’s heart rate and symptoms during upright activity Consider Lower leg Abdominal binder Full compression garment  Treatment of POTS Other common interventions Lifestyle adaptations Eating smaller meals Consume more protein Limit caffeine and alcohol Avoid prolong standing Limit exposure to heat Sleep hygiene Treatment of POTS Physical Counter Maneuvers Help reduce venous pooling in the LE May help to reduce symptoms (Lowe, 2008) How would you treat a patient who has POTS? Orthostatic Hypotension  Decrease of SBP by 20 mmHg or more and more than 10 mmHg of DBP within 3 minutes of standing Common disorder that increases with age Orthostatic Causes Hypotension Dehydration (OH) Blood loss Certain medications Neurologic disorders (i.e. Parkinson’s) Cardiovascular disorders Endocrine disorders (i.e. DM)  People at risk: Prolonged bed rest or post surgical Volume depleted Vasodilators or antihypertensive Orthostatic meds Central or peripheral nervous system Hypotension disease Parkinson disease, SCI Increased age Autonomic dysfunction Orthostatic Hypotension Symptoms Common Less common Dizziness Chest pain Lightheadedness Neck/shoulder pain Dimming of vision or Dyspnea visual blurring Seizure-like tonic Weakness/buckling of LE movements Fatigue Headache Palpitations Nausea Cognitive slowing Syncope  Correct any reversible conditions Drug side effects, hypovolemia Treatment Pharmacological therapy Midodrine of OH Fludrocortisone Pyridostigmine **Monitor for supine hypertension  Diet Exercise prior to meals Avoid alcohol and large meals Increase intake of caffeine and salt Treatment of Adequate hydration Limit exposure to hot showers/baths Orthostatic and weather Hypotension Use of compression stockings and/or abd binders Sleep with head of bed elevated ~ 15-20 degrees  Compression of Legs and/or Abdomen Reduction of symptoms have been seen in older adults, autonomic dysfunction and SCI  Treatment of OH Physical Counter Maneuvers Help reduce venous pooling in the LE May help to reduce symptoms Avoid straining and prolonged, static standing Change positions slowly (Lowe, 2008) Tips when Treating a Patient with Orthostatic Hypotension Monitor vital signs with position changes, during ambulation and ADLs Be aware of medications used for treatment of OH Teach physical maneuvers to avoid OH Make the patient safe to go home – may need modifications for ADLs and/or AD for mobility Encourage (safe) physical activity to prevent deconditioning/loss of function How would you treat a patient who has OH? Acute Care Setting Outpatient Setting What would you want to monitor closely? COVID AND REHAB  During the initial COVID time point, little was known about the disease so there was limited rehab intervention Rehab services were often delayed due to PPE shortage, uncertainty of the disease, need to COVID-19 follow isolation protocols and insufficient staff to provide care Use of rehab services increased over time  Clinical symptoms ranged from asymptomatic to severe disease Mild – Flu-like symptoms, cough and fever, loss of smell/taste, GI symptoms Moderate to Severe – ARDS, pneumonia, septic shock, multiorgan failure Acute COVID Multisystem involvement No consensus about the optimal approach to early Stage (1st 5 mobility for people with critical illness due to COVID Early mobility needs to be based on the patient’s weeks) response to mobility Close monitoring of vital signs at all times May need to titrate oxygen to maintain the patient’s SpO2 >88-90% PT Intervention consisted of: proning, airway clearance, early mobility, strengthening activities  “Post-COVID-19 condition occurs in individuals with a history of probable or confirmed SARS- CoV-2 infection, usually 3 months from the onset of COVID-19 with symptoms that last for Long COVID at least 2 months and cannot be explained by an alternative diagnosis.” (WHO) (Post-Acute ~10-15% of Americans report having long COVID symptoms (CDC) Sequelae of COVID-19) Long COVID can present with debilitating symptoms and medical conditions that lead to physical, social and psychological disability  Long COVID People who are more likely to develop Long COVID Severe COVID illness Underlying health condition prior to COVID Did not get the COVID vaccine Long COVID Symptoms (Scurati et al. Int J Mol Sci, 2022) (Tabacof et al, Am J Phys Med Rehabil, 2022)  Cognition: St Louis University Mental Status Examination (SLUMS) Quality of Life: APTA Core PROMIS Global 10 EQ-5D-5L Outcomes Strength: Medical Research Council Sum Score(MRC-SS) Function: Short Physical Performance Battery (SPPB) Endurance: 2-Minute Step Test  Obtain medical history related to COVID illness Hospitalization/ICU Assess the patient and determine impairments Rehab Tips Monitor vital signs throughout the session Assess for nl/abn response to activity for Long Oxygenation HR response COVID POTS symptoms Signs of exercise intolerance/fatigue Assess cognition  Progressive activity/exercise program Individualized to each patient based on symptoms Pulmonary rehab program Autonomic Conditioning Therapy Rehab Tips Monitor for post-exertional symptom exacerbation for Long Teach pacing/energy conservation Provide POTS interventions if appropriate COVID Education Determine what triggers the symptoms Use of relaxation techniques and/or massage How would you treat a patient who has COVID? Acute Care Setting Outpatient Setting What would you want to monitor closely?