Cardiac Care & Rehabilitation Handout PDF

Cardiac Care & Rehabilitation Acute Care to Outpatient Ruth Hansen, PT, DPT, PhD, CCS PHTR-627 Outline of Weekend Review homework Quiz Continue/complete EKG Review Physiology – Normal Exercise Response – Abnormal Response Pathology not previously covered in curriculum – What is needed for lab PT exa...

Cardiac Care & Rehabilitation Acute Care to Outpatient Ruth Hansen, PT, DPT, PhD, CCS PHTR-627 Outline of Weekend Review homework Quiz Continue/complete EKG Review Physiology – Normal Exercise Response – Abnormal Response Pathology not previously covered in curriculum – What is needed for lab PT exam – what we need for PM lab Cardiac Physiology Normal & Abnormal Exercise Responses Intramural Blood supply Class A: – Arises from epicardial vessels at an angle and branch within subepicardial layer. Class B: – Arise at right angles to epicardial arteries and plunge toward subendocardial layer. When do the coronary arteries fill and supply blood to the heart? Physiology of Coronary Circulation During systole c. arteries do not get blood. During diastole blood is allowed to flow into the sinus and into coronary arteries. At rest coronary blood flow = 4.5% of Q. With exercise Q ↑ to 5-6 times resting. coronary blood blow is still 4.5% of Q. Blood flow to heart remains a constant percentage of cardiac output, the time for which it occurs is variable. (Less time in diastole during exercise) R ventricle are not affected due to low pressure. Left ventricle generates high intramyocardial pressures and chokes off the arteries supplying it during systole. Coronary blood flow occurs in diastole only Sensitive to ischemia. Physiology Cardiac Physiology and Exercise How do the principles of muscle mechanics, preload, afterload and contractility impact exercise? Explain each of these and importance of pump function during exercise Sliding Filament Theory force is a function of the number of cross bridges that can link during a single contraction. Three Factors that Influence the Heart During Exercise Preload Afterload Contractility Preload What is Preload? – Stretching force that elongates the resting sarcomere before activation governs # of cross bridges/force generation Depends on: venous return, end diastolic volume – Force of contraction will be less at low and extreme high preloads. Afterload What is it? – “Total instantaneous force the heart must generate to elevate the intra-ventricular pressure to aortic pressure (systolic BP)”.Irwin – Velocity and extent of shortening decrease as afterload increases. Contractile State Innate intensity and rate of force development in contractile unit (inotropic). – Increased contractility results in greater velocity of shortening and force development at a given preload. – Independent of preload/afterload Cardiac Output (Q) Definition: – Total amount of blood ejected from the heart per minute – Normal 4-6 L/min Formula: – Q = HR x SV Minute Oxygen Consumption VO2 = Q x (a - vO2 ) VO2 = (HR x SV) x (a - vO2 ) Acute Response to Exercise Increase in Q and redistribution of Q to working muscles Increase HR (initially) Generalized vasoconstriction (SNS) Increased contractility secondary to SNS and ↓ PVR. Local vasodilation in working beds: – total net lowering of PVR – proportional to I of exercise – augment Q without increased contractility due to ↑venous return and ↑ preload. SBP increases because Q increases off setting the decreased TPVR. – BP=Q x TPVR Diastolic BP does not change dramatically (=/- Phases of Cardiovascular Dynamics Anticipatory Initial Phase/initiation Phase Steady state Cardiovascular Drift Chronic Response to Exercise (Training Response) What happens to: – Maximal HR ? remains the same. – VO2 ? – Submaximal HR ? Decreases: More work for a given RPP (HR x SBP). More work before hitting anginal threshold. – Systolic BP ? decreases in some (if hypertensive) Rate Pressure Product What is it? – HR x SBP – Measure of myocardial oxygen demand Rest vs. exercise Change with exercise Abnormal Responses to Exercise Abnormal HR response Arrhythmia Ischemia CHF Left Ventricular Dysfunction Other/Miscellaneous Abnormal HR Response Poor, Slow rise in HR with ↑ work loads – poor physical condition, poor ex tolerance, low resting HR, not on chronotropic limiting drugs, poor prognosis Excessive HR response for work performed – deconditioning, cardiomyopathy, CHF Drop in HR – usually due to arrhythmia Arrhythmia: interruption in the normal rhythm of the heart Atrial Arrhythmias: – PAC, SVT, A-fib – Generally not hemodynamically compromising unless very rapid (200-300). – Cause a reduction in forward blood flow. – Symptoms: lightheaded, dizzy, syncope Premature Ventricular Contraction(PVC) – Need closer evaluation. – Wide Bizarre complexes – Can be common in adult (caffeine, pulmonary disease) – Can be dangerous leading to lethal arrhythmia. When PVC’s Occur at rest… What happens with exercise? PVC’s decrease with exercise – desired response – PVC’s are surpressed by higher order pacemaker as HR ↑ with exercise. PVC’s increase with exercise – less desirable response – PVC’s may be ischemic in origin – discontinue exercise No change in PVC’s with exercise – PVC’s are not exercise related Ischemia Occurs when O2 demand exceeds supply. Brought on by exercise and relieved with rest or nitroglycerine. Changes in ST segment on EKG: – 1 mm depression positive if normal baseline. – If baseline starts depressed must get 2 mm depression to be positive Client may experience angina Angina What is it – Usually described as a crushing sensation. Can be pain in jaw, arm, neck, SOB, or GI disturbances. Can be confused with musculoskeletal pain. If your patient develops angina: – – – – – Terminate exercise/decrease workload. Lie down only if lightheaded. Note workload, symptoms, vitals and notify MD. Differentiate angina from other causes. Nitro if appropriate Angina Levels I II III IV The initial perception of discomfort. Minimal discomfort Initial discomfort worsens over the same body surface area or it extends to another body area (referred pain) Pain becomes more intense to the point patient must stop what they are doing and if prescribed, seeks medication for relief Severe pain, Same severity as is felt during a heart attack Congestive Heart Failure (CHF) Can have chronic CHF at rest or can develop with exercise. Development of S3 heart sound. Crackles in lungs heard on inspiration. Unlike pulmonary crackles they do not clear with cough. Associated with drop in SBP or flat response, rise in HR and SOB. Reasons to Discontinue Exercise: 3 or more consecutive PVC's new onset multifocal PVC's new onset A-fib or flutter supraventricular tachycardia (SVT) new onset any form of heart block chest discomfort Continued New onset dyspnea at lower workload than usual Drop in BP with exercise c/o dizziness New musculoskeletal discomfort New orthopedic or neurologic condition What do you do if you have one of these abnormal responses? Cardiac Rehabilitation Ruth Lyons Hansen, PT,DPT, CCS PT-627 What is Cardiac Rehabilitation? A multidisciplinary program consisting of education, psychosocial support, and exercise to help patients with heart disease reach their maximal functional potential. Overview of Cardiovascular Rehabilitation Cardiac rehabilitation is a comprehensive exercise, education, and behavioral modification program designed to improve the physical and emotional condition of patients with heart disease. Prescribed to control symptoms, improve exercise tolerance, and improve overall quality of life. Multidisciplinary Team Approach May Include Medical Director Behavioral Specialist Referring Physician Occupational Exercise Therapist Physiologist Health Educator Registered Nurse Pharmacist Registered Dietitian Other consulting Respiratory practitioners Therapist Physical Therapist The Domains of Cardiac Rehabilitation Improve Cardiac Function Increase Functional Capacity Decrease Morbidity Mortality Enhance Psychosoci al Well-being Modify Risk Factors Consists Of Education Risk factor reduction Exercise Psychosocial intervention Vocational counseling Goals of Cardiac Rehab To increase functional level through physical training Risk factor modification Other Goals Prevent harmful effects of prolonged bed rest Identify patients whose psychological response to disease may require additional support. Provide monitored setting to identify further cardiac risk. Achieve goals via an interdisciplinary approach. Philosophical Foundation 3 Principles CAD is a chronic progressive disease closely associated with distinct epidemiological risks. Exercise is beneficial if individually designed and objectively evaluated on an ongoing basis. The process of cardiac rehab is a team approach. Phases Phase I – acute inpatient (3-5 days) – Phase 1B – extended inpatient (7-14 days) Phase II – subacute phase monitored outpatient (3 months) Phase III – Long-term follow-up/wellness unmonitored outpatient. Wellness centers, commercial gym, independent at home Other Settings for Cardiac Rehab Inpatient rehab, phase Ib, SNF Home Care: – Heart failure home care team/program – Trans-telephonic monitoring programs Cardiac Pathology Continued Brief Review You should know all cardiovascular pathologies covered in your pathology course. Review Angina – Stable vs unstable Myocardial infarction – STEMI Previously called transmural – N-STEMI Sub-endocardial – Diagnostic criteria for MI EKG changes Lab values CHF Newer Terminology Acute Coronary syndrome – Unstable angina What makes angina unstable??? – NSTEMI: non-ST elevation MI Sub-endocardial – STEMI: ST elevation M How are these diagnosed? Ischemia Requires 12 lead ECG – T wave inversion – ST segment depression Changes Associated with MI Stage STEMI NSTEMI Trans-mural MI Sub-endocardial MI Acute ST elevation Hyper-acute T waves Reciprocal ST depressions in leads opposite MI Evolving Resolution of ST segment Resolution of ST segment T wave inversion Persistence of T wave inversion is possible Development of pathological Q wave Resolved ST segment and T become normal Permanent Q ST depression T wave inversion St segment and T wave become normal From Adamovich, David: The Heart: Fundamentals Of Electrocardiography, Exercise Physiology, And Exercise Stress Testing. Sports Medicine Books 1984, P94 http://www.usfca.edu/fac-staff/ritter/ekg.htm Contiguous Leads http://3.bp.blogspot.com/_2MjIeQJj8UM/SUvC4cH0oUI/AAAAAAAAAdg/jzRq9h2hgH4/s1600h/contiguous+leads.jpg STEMI Location: contiguous and reciprocal leads Site Facing Reciprocal Septal V1, V2` None Anterior V3,V4 None Anterosepal V1. V2, V3, V4 None Lateral I, aVL, V5, V6 II, III, aVF Anterolateral I, AVL, V3,V4, V5, V6 II, III, aVF Inferior II, III, aVF I, AVL Posterior None V1, V2, V3, V4 must have Q or QS in at least 2 Does not give Q wave. R:S ratio of >1 in lead V1 Treatment of ACS (acutely) Morphine Oxygen Nitroglycerine Aspirin Beta Blockers Heparin Glycoprotein IIB/IIIa Inhibitors ACE Inhibitors Revascularization – PTCI/Stents – Coronary Artery Bypass Graft Surgery (CABG) Infarct CK-MB CK-MB-CK (Index) – >5 rules in MI Troponin I – Troponin I < 0.4 (Negative MI) – Troponin I > 2.0 (positive MI) Stent Clinical Implications Post PTCI Early Mobilization (OOB 4-6 hours post) Groin assessment Check Medications Expect pain and hip flexor weakness Coronary Artery Bypass Graft Surgery (CABG) Atherosclerotic lesion progresses to point that artery is occluded or lesion does not respond to angioplasty or stent is risky Vascular grafts are taken from saphenous vein of leg or internal mammary. LE graft is attached proximal and distal to lesion Internal mammary used attached distal to lesion Surgery performed via median sternotomy, and use of heart bypass unit Minimally invasive/non-bypass surgeries now being done on limited basis www.heartonline.org Advances in Bypass Surgery Off-Pump coronary artery bypass (OPCAB) Minimally invasive direct coronary artery bypass Robot assisted minimally invasive bypass surgery Post-op Complications Unstable sternum Arrhythmias Cardiogenic shock Wound closure Neurological – CVA – brachial plexus injury – Anoxia – Post-perfusion syndrome Risk Factors for Sternal Healing Complications Primary Risk Factors Obesity/high body mass index Chronic obstructive pulmonary disease Internal mammary artery grafting (bilateral) Diabetes mellitus Re-thoracotomy Increased blood loss/number of transfused units Higher disability classification (CCS or NYHA) Smoking Prolonged cardiopulmonary bypass/surgical/time Prolonged mechanical ventilation Peripheral vascular disease Female gender with large breast size Secondary Risk Factors – – – – – – – – – – – – – – – Osteoporosis/decreased sternal thickness Longer intensive care unit length of stay Time of surgery Antibiotic administration > 2 hours presurgery Staple use for skin closure Impaired renal function Immunocompromised status Closure by non-cardiovascular surgeon Cardiac reinfarction Inadvertent paramedian sternotomy Emergency surgery ACE inhibitor use Use and duration of temporary pacing wires Septic shock Depressed left ventricular function Pt Implications Sternal precautions (traditional) – avoid pressure or strain on sternum No lifting, pulling or pushing >10lbs 6-8 weeks Bilateral overhead activities Hand-held assist instead of assistive devices Sit to stand without UE push No driving 6-8 weeks – Sternal precautions are almost universally practiced, but controversial and variable Sternal Precautions-Reconsidered Sternal complications are rare – Identifiable risk factors Sternal precautions are restrictive – Prohibit common shoulder and UE movement – Because of restrictions patient’s functional ADL is restricted and assistance is needed Limit ability to go home independently – Healing and remodeling of connective tissue and bone require appropriate loading El-Ansary, 2019 The case against SP The force required to complete 32 activities of daily living and found that a majority of them elicited forces greater than the 10 lbs. – Lifting a gallon of milk from refrigerator (10 lbs) – Pushing a glass door to exit hospital (22 lbs) – Coughing 60-lbs (>lifting two 20-lb weights simultaneously)– – Sneeze exerted force of 90-lbs Most patients cough and sneeze (Adams 2016) El-Ansary, Waddington, G., & Adams, R.D. Control of Separation in Sternal Instability by Supportive Devices : A Comparison of an Adjustable Fastening Brace , Compression Garment , and Sports Tape or adjustable support garment Special Testing: shoulder flexion (uni-/bilateral), trunk lateral flexion or rotation, coughing and opposing movement of upper limb El-Ansary, Waddington, G., & Adams, R.D. Control of Separation in Sternal Instability by Supportive Devices : A Comparison of an Adjustable Fastening Brace , Compression Garment , and Sports Tape or adjustable support garment Valve Replacements Traditionally performed via median sternotomy on bypass machine More recently performed via trans-femoral approach. – initially for high-risk clients Cardiac Tamponade Compression of the heart due to accumulation of fluid in the pericardial sac – Prevents ventricle from filling and contracting properly – Medical emergency – Can be complication of surgery or happen spontaneously PT Implications – phase I Early post-op first 12-24 hours – Prevent pulmonary complications One day post – OOB – Gradual mobilization with monitoring 2-3 Mets, RPE Fairly light, HR increase 10-20 bts – HR, BP, EEG, O2sat, heart/lung sounds with all activities – Watch for orthostatic hypotension Phase II Outpatient or home based Patients with arrhythmias, angina, with exercise, other medical problems or emotional issues benefit from formal program 30-60 min with WU and CD 3 days/week Multiple modes of training up to 9 mets Phase III Location: YMCA, clinical facilities, gym Entry level: Stable angina, medically controlled arrhythmias Progression 50-80% functional capacity 6-12 months/lifetime Recommend regular medical check ups Conduction Disturbances Disruptive of normal rate or rhythm can be symptomatic (syncope, dizziness, angina, dyspnea, palpitations) or lethal (sudden cardiac death.) Treatment – Medical – Pacemaker – AICD Pacemaker Implants designed to deliver a battery supplied electrical stimulus through leads attached to electrodes in contact with heart, used for: – bradycardia – heart block – refractory tachycardia. Pacemaker http://www.nhlbi.nih.gov/health/health-topics/topics/pace/howdoes.html Pacemaker Code 1st letter: pacing location – A=Atria, V= ventricle, D= dual/both, O=none 2nd letter: sensing location 3rd letter: response to pacing – I = Inhibited: inhibits stimulus when own depolarization is sensed – T=Triggered: produces stimulus when no depolarization detected – D = dual; does both 4th letter: programmability/modulation – P=Programmable, M=multi-programmable, O=none 5th letter: antiarrhythmic function – O=none, P=Pacing, S=Shock, D=dual Paced Rhythm Pacemaker: Failure to Capture https://www.practicalclinicalskills.com Pacemaker: Failure to Pace https://ecgwaves.com/topic/assessment-of-pacemaker-malfunction-using-ecg/ Pacemaker PT Implications Limited Shoulder ROM acute post-op Limited lifting >10lbs/strenuous activity for 4 weeks No TENS/electric stimulation/diathermy/microwave Monitor for malfunctioning – Pacemaker spike on EKG – Symptoms May not be able to use HR as exercise Rx – RPE – Training SBP = (SBPmax–SBPrest) x (Intensity 60-80%) + SBPrest Automated Internal Cardiac Defibrillator (AICD/ICD) Similar to pacemaker Delivers an electric shock when HR becomes to fast, or rhythm is VT or VF. Know maximal setting to avoid exercise HR that would stimulate a shock – Keep 10-15 below – If unsure of maximal setting, use 150 Life Vest https://lifevest.zoll.com/medical-professionals/ Congestive Heart Failure Structural classification – Left sided – Right sided Functional Classification – Systolic HF (EF3cm from midclavicular line CHF: Treatment Aerobic Exercise Interval Training Strength Training – Functional strengthening – Closed chain – Standing exercise – Resistive bands Breathing Exercise – Purse lip breathing – IMT Positioning Energy Conservation Cardiac Transplant First human to human transplant performed by Christian Bernard in Capetown, South Africa, 1967 Recipient lived 18 hours Early success was limited Focus on post op care and preventing rejection has improved success Used for treatment Heart failure (class III, IV) – May have LVAD as bridge to transplant Left Ventricular Assist Device LVAD considerations Motor is rotary not pulsatile – SBP only using doppler No exercise: – – – – – – – SBP < 80 Flow rate less than 3L/min Volume 150. O2 sat 1L Ability/willingness to comply with post op regime Financial Donor/Recipient Matching Blood type compatibility Allograph ischemic time less than 5 hours Body weight + 20% Description of Procedure Post-op Complications Rejection Immunosuppresion Transplant Vasculopathy Infection Hypertension Other Post – op care Meds for 72 hrs to keep HR 120 @ rest and no rise >40b/min SBP: – Not > 170 mmHg at rest no rise/fall > 30 mmHg DBP: – Not>120 @ rest, no rise/fall >20mmHg RPE – 13 on standard scale, 3-4 on 10-point scale Cardiovascular Examination Ruth Lyons Hansen DPT, CCS PHTR- 625 Mercy College Physical Therapy Program Physical Therapy Examination History: – Medical information – Risk factors – Angina Differentiate from other causes – Other symptoms of heart disease: Dyspnea, fatigue, dizziness, lightheadedness, palpitations, sense of impending doom Symptom Recognition and Grading New York Heart association Grading of Symptoms Class Symptoms I Ordinary physical activity does not cause undue fatigue, dyspnea, palpitations, pain or angina II Comfortable at rest, ordinary physical activity results in fatigue, dyspnea, palpitations, pain or angina III Comfortable at rest but less than ordinary physical activity results in fatigue, dyspnea, palpitations, pain or angina Uncomfortable at rest experiencing fatigue, dyspnea, palpitations, pain or angina and are unable to perform any physical activity without symptoms and discomfort IV Lab Values of Interest R/O MI – Troponin I, Troponin T (elevate within 3-4 hours) – CKMB – CKMB Index (CKMB/CK x100) Hemoglobin & Hematocrit – Oxygen carrying capacity – blood viscosity Clotting – INR – Platelets BUN/Creatinine – Diuretics BNP – heart failure Measurement Tools Patient appearance HR BP ECG/EKG – separate lecture Ankle – Brachial Index Anthropometric measures/BMI Heart Sounds Breath Sounds- separate lecture Screen integumentary ROM Strength Screen Neurologic – Sensory, balance, coordination Function Tolerance to exercise: – Physiologic response to basic functional activities – 6-minute walk test – Cardiovascular exercise stress test – Cardiopulmonary stress test Patient appearance Skin color – Pale or cyanotic skin associated with poor CV function – Discoloration, loss of hair in extremities can be sign of PVD – Scars or surgical incision (check for signs of poor healing) Edema JVD Body type Expression Breathing pattern Posture Any medical equipment: lines, tubes etc. HR & BP HR: Radial pulse is preferred BP: standard sphygmomanometer and stethoscope – Take at rest: supine, sit, stand – Peak activity – Recovery (5-7 minutes) HR & BP response with positional changes HR & BP should increase with change in position from supine/sitting to standing. Decrease in SBP or DBP without and increase in HR is indicative of autonomic nervous system dysfunction. 30/15 ratio – Normally should be >1 HR and BP responses to Exercise and ADL Need to compare resting and activity levels in the same position. Used to determine status of CV system with activity Used to set, determine the appropriateness and to adjust exercise prescription Valuable but frequently ignored tool. ABI :Technique Measure highest systolic reading in both arms – Record first doppler sound as cuff is deflated – Record at the radial pulse – Use highest of the two arm pressures Measure systolic readings in both legs – Cuff applied to calf – Record first doppler sound as cuff is deflated – Use doppler ultrasound device Record dorsalis pedis pressure Record posterior tibial pressure – Use highest ankle pressure (DP or PT) for each leg Calculate ratio of each ankle to brachial pressure – Divide each ankle by highest brachial pressure ABI Interpretation Ankle-Brachial ratio >0.95: Normal Ankle-Brachial ratio