Cardiovascular assessment

Question 1

What is the CSEP-PATH procedure for blood pressure?

Answer 1

The CSEP-PATH procedure includes guidelines for when to proceed with appraisal based on systolic and diastolic blood pressure cutoffs.
* If systolic pressure is <160 mmHg AND diastolic pressure is <90 mmHg proceed with the appraisal

Question 2

What should be done if a person’s blood pressure is elevated during a reading?

Answer 2

If either systolic pressure is ≥ 160 mmHg OR diastolic pressure is ≥ 90 mmHg, have the individual sit quietly for an additional 5 minutes. If the elevated reading persists after the second measure, physician clearance is recommended

Question 3

What factors influence blood pressure?

Answer 3

Blood volume, vascular resistance (dilation vs. constriction), and cardiac output influence blood pressure

Question 4

How does elevated blood pressure affect the heart?

Answer 4

Elevated blood pressure increases the “afterload” on the heart, which is the pressure the heart needs to overcome to eject blood during systole. It also can damage small vessels and capillaries in end-organs

Question 5

What is the auscultation method for measuring blood pressure?

Answer 5

The auscultation method involves listening to bodily sounds using a stethoscope to identify systolic and diastolic pressures. It identifies the pressure at which blood is able to squeeze into the arm (systole) and the point at which the cuff no longer impedes blood flow (diastole)

Question 6

What is the physiological principle behind blood pressure measurement with a cuff?

Answer 6

The cuff is inflated to stop blood flow, then deflated while listening for the turbulent flow of blood entering the arteries. The pressure in the arteries is higher than the cuff

Question 7

What are Korotkoff sounds?

Answer 7

Korotkoff sounds are the tapping sounds heard through a stethoscope when taking blood pressure.
* Phase I is a clear “tapping” sound that indicates systolic pressure, and Phase V is when the “tapping” disappears, indicating diastolic pressure.
* There are also softer tapping sounds and muffled tapping sounds in Phases II, III, and IV, respectively

Question 8

What are the proper conditions for taking blood pressure?

Answer 8

• The individual should be seated, relaxed, legs not crossed, and not talking.
• The cuff should be at the level of the heart with the arm supported.
• The cuff should be of appropriate size (L= 80% of arm circumference, W= 40% of arm circumference), and inflated to ~30 mmHg above systolic pressure

Question 9

Where is blood pressure normally taken?

Answer 9

Blood pressure is normally taken from the brachial artery

Question 10

What is the recommended rate of cuff deflation?

Answer 10

The cuff should be deflated at a rate of 2-3 mmHg/s

Question 11

How does blood pressure measurement tend to be affected in terms of systolic and diastolic readings?

Answer 11

Systolic pressure tends to be underestimated, while diastolic pressure tends to be overestimated

Question 12

How should repeated blood pressure measurements be timed?

Answer 12

Repeated blood pressure measures should be separated by 1+ minute

Question 13

What is the effect of hydrostatic pressure on blood pressure measurements?

Answer 13

Hydrostatic pressure affects blood pressure due to the density of the blood, gravity, and height. There is an approximate ±0.8 mmHg change for every cm

Question 14

What is the formula for hydrostatic pressure?

Answer 14

Pressure = ρ * g * h, where ρ is the density of liquid (blood), g is gravity (9.81 m/s^2), and h is height

Question 15

What is the CSEP-PATH cutoff for heart rate?

Answer 15

If heart rate is 99 bpm or less (< 100 bpm), proceed with the appraisal. If >99 bpm, have the individual sit quietly for an additional 5 min. If the heart rate is still >99 bpm after a second reading, physician clearance is recommended

Question 16

What is tachycardia?

Answer 16

Elevated HR is termed tachycardia

Question 17

What is an electrocardiograph?

Answer 17

An electrocardiograph is the machine (oscilloscope/chart recorder) used to measure the electrical activity of the heart.

Question 18

What is an electrocardiogram?

Answer 18

An electrocardiogram is the tracing of the electrical activity of the heart

Question 19

What does an ECG measure?

Answer 19

An ECG measures the electrical activity of the heart along different vectors. It’s used to assess basic abnormalities in heart function

Question 20

What is the scope of practice for a CSEP-CPT regarding ECG interpretation?

Answer 20

A CSEP-CPT is NOT sanctioned by CSEP to “Use an ECG for any purpose.”

Question 21

What is the scope of practice for a CSEP-CEP regarding ECG and blood pressure?

Answer 21

A CSEP-CEP can measure and monitor heart rate, electric activity of the heart (using ECG), and blood pressure (by auscultation unless hearing impaired) at rest, during exercise, and post-exercise. These measures can be used to identify, but not diagnose, irregularities

Question 22

What are the limitations for a CSEP-CEP regarding diagnosis?

Answer 22

A CSEP-CEP is not sanctioned to “Diagnose pathology based on any assessment or observation.”

Question 23

How many electrodes and leads are required for a 12-lead ECG?

Answer 23

A 12-lead ECG requires 10 electrodes and provides 12 leads

Question 24

What is a “lead” in ECG?

Answer 24

• A lead consists of two terminals (electrodes) that form an axis to provide a different view or tracing of the heart’s electrical activity.
• A lead is directional and aligned with a particular vector from the -ve electrode towards the +ve electrode.

Question 25

What are the three orthogonal planes that a 12-lead ECG provides information about?

Answer 25

A 12-lead ECG provides spatial information about the heart's electrical activity in the right-left, superior-inferior, and anterior-posterior planes.

Question 26

What determines the ECG waveform?

Answer 26

The orientation of the lead (vector) in relation to the electrical current of the heart is what produces the ECG waveform.

Question 27

How does the direction of the electrical current affect the ECG waveform?

Answer 27

If the direction of current is pointing in the same direction as the lead, it produces a positive deflection. If pointing in the opposite direction, it results in a negative deflection

Question 28

What are limb leads?

Answer 28

Limb leads are 6 important vectors derived from the electrodes placed on the limbs

Question 29

What are the bipolar limb leads?

Answer 29

Leads I, II, and III are referred to as bipolar leads

Question 30

What are augmented limb leads?

Answer 30

Augmented (unipolar) limb leads use two electrodes to create a "null point" which is compared to the 3rd electrode. These are aVR, aVL, and aVF

Question 31

What are precordial leads?

Answer 31

Precordial leads "look" at the heart in the horizontal plane and are located in close proximity to the heart. They measure the change in electrical potential along a vector from the heart towards the electrode and are "unipolar"

Question 32

What are the standard deflections in an ECG?

Answer 32

P = Atria depolarization. QRS = Ventricle depolarization. T = Ventricle repolarization. U = repolarization of purkinje cells and/or papillary muscle of valves. R-R = 1 heart beat

Question 33

What is the J point?

Answer 33

The J point is the transition point between the QRS complex and the ST segment

Question 34

What are the normal ranges for the PR interval?

Answer 34

The normal PR interval is 0.12 - 0.20 seconds

Question 35

What are the normal size ranges for the QRS complex?

Answer 35

The QRS complex should be <2.5 mm in size and the QRS interval is 0.07 - 0.11 seconds

Question 36

What should be expected with the ST segment?

Answer 36

The ST segment should be smooth & gradual, which indicates the ventricular refractory period

Question 37

What is the relationship between the QT interval and the R-R interval?

Answer 37

The QT interval should be < 1/2 the distance of the R-R interval.

Question 38

What are the dimensions of a large and small box on an ECG grid?

Answer 38

One large box = 5 small boxes. On a standard chart recorder speed (25 mm/sec), one large box = 0.20 sec and one small box = 0.04 sec

Question 39

How is heart rate calculated using the R-R interval?

Answer 39

Two methods for calculating heart rate are shown: * Method 1: RR Interval (in seconds), Rate = 60 / RR Interval. * Method 2: Rate = 1500 / # of small boxes between R-R intervals

Question 40

What is the definition of tachycardia?

Answer 40

Tachycardia is a rapid beating greater than 100 bpm at rest in an untrained adult

Question 41

What is bradycardia?

Answer 41

Bradycardia is a heart rate beating < 60 bpm at rest in an untrained adult (symptomatic < 50 bpm).

Question 42

What is an arrhythmia?

Answer 42

Arrhythmia refers to an abnormal rate, rhythm, or conduction of electrical impulse in the heart

Question 43

What can cause an arrhythmia?

Answer 43

Causes of arrhythmia are multifaceted and can be related to fever, dehydration, shock, hormonal imbalance, stress, various types of cardiac abnormalities, and heart failure

Question 44

What is a premature ventricular contraction (PVC)?

Answer 44

A PVC is caused by depolarization of the ventricle before the atria can contract (absence of a P wave before another QRS complex). The QRS complex and T waves look abnormal compared to a normal ECG

Question 45

When do PVCs need to be treated?

Answer 45

PVCs need to be treated when they occur at the rate of > 6 per minute

Question 46

What is a Sinus Pause?

Answer 46

A sinus pause is a failure of the S-A node firing

Question 47

What is Third Degree Heart Block?

Answer 47

Third degree heart block is where the atria and ventricles contract independently of each other. It can be identified by the presence of P waves that are not associated with QRS complexes. It is an emergency and often requires defibrillation

Question 48

What are the characteristics of S-T depression and what may it indicate?

Answer 48

S-T segment depression/elevation of >1.0 mm 0.08 s after the J point may indicate Myocardial Ischemia

Question 49

What is fibrillation and what is the treatment?

Answer 49

Fibrillation is uncoordinated atria or ventricle contractions caused by re-entry of electrical impulses, and it requires defibrillation

Question 50

When is an ECG recommended in exercise testing centers?

Answer 50

An ECG is highly recommended in exercise testing centers, especially with untrained, older, or diseased individuals.

Question 51

What should be done with an ECG during exercise testing?

Answer 51

A resting ECG should be established looking for abnormalities. A tracing should be recorded every workload during exercise