Cardiovascular diseases and cardiac rehab

Question 1

artherosclerosis

Answer 1

disease of lipid laden plaques (lesions) affecting moderate and large size arteries

thickening and narrowing of the intimal layer of the blood vessel wall from focal accumulation of lipids, platelets, monocytes, plaque and other debris

part of CAD that leads to ischemia to the myocardium that can progress to injury and/or death

Question 2

acute coronary syndrome (ACS)/ Coronary artery disease (CAD)

Answer 2

arthersclerotic disease; ranges from angina to infarction to sudden cardiac death
-leading cause of death in US

imbalance of myocardial oxygen supply and demand resulting in ischemic chest pain

symptoms present when lumen is 70% occluded

3 common presentations but may also have silent ischemia diagnosed by presence of a new pathologic Q wave

• most common in patients with diabetes, patients may have ischemia without any symptoms
• subacute occlusions may also produce no symptoms

1- angina
2-MI
3-heart failure
4-sudden death, usually due to significant ischemia or ventricular arrhythmia

Question 3

angina pectoris

Answer 3

chest pain or pressure due to ischemia; may be accompanied by Levine’s sign- clenches fist over sternum

represents imbalance in myocardial oxygen supply and demand; brought on by:

• increased demands on heart: exertion, emotional stress, smoking, extremes of temperature (*cold), overeating, tachyarrhythmias
• vasospasm- may be present at rest

women more often describe sensations of discomfort, crushing, pressing and bad ache when referring to angina

with angina, patients often describe SOB, fatigue, diaphoresis and weakness as symptoms of ACS

older adults present more often with atypical symptoms (absence of chest pain): dyspnea, diaphoresis, nausea and vomiting and syncope

Question 4

types of angina

Answer 4

1- stable:

• classic exertion angina occurring during exercise
• occurs at a predictable RPP
• relieved with rest and/or nitroglycerin

2-unstable (preinfarction, crescendo angina)

• coronary insufficiency at any time w/out precipitating factors or exertion
• chest pain increases in severity, frequency and duration; refractory to treatment
• increases risk for MI or lethal arrhythmia; pain is difficult to control

3-variant (Prinzmetal’s angina)

• caused by vasospasm of coronary arteries in the absence of occlusve disease
• responds well to nitroglycerin or calcium channel blocker long term

Question 5

myocardial infarction

Answer 5

prolonged ischemia, injury and death of an area of the myocardium caused by occlusion of one or more of the coronary arteries

precipitating factors:

• atherosclerotic heart disease with thrombus formation
• coronary vasospasm or embolism
• cocaine use

Impaired ventricular function results in:

• decreased SV, CO and EF
• increased EDVP

electrical instability: arrhythmias, present in injured and ischemic areas

Question 6

zones of infarction

Answer 6

zone of infarction:

• consists of necrotic, non contractile tissue
• electrically inert
• ECG: pathological Q waves

zone of injury:

• area immediately adjacent to central zone
• tissue is non contractile
• cells undergoing metabolic changes
• electronically unstable
• ECG: elevated ST segments in leads over injured area

zone of ischemia:

• outer area
• cells also undergoing metabolic changes
• electrically unstable
• ECG: T wave inversion

Question 7

sites of coronary artery occlusion

Answer 7

R coronary A:

• inferior MI, RA, RV infarction, disturbances of upper conduction system
• blockage could result in arrhythmias, which can be fatal

L coronary A:

• supplies anterior, superior and lateral walls of the LV and the inter ventricular septum
• blockage usually causes LV failure, which leads to pulmonary edema

Circumflex A:

• lateral MI
• ventricular ectopy

L anterior descending A:

• anterior MI
• disturbances of lower conduction system

Question 8

heart failure

Answer 8

clinical syndrome in which the heart is unable to maintain adequate circulation of the blood to meet the metabolic needs of the body

1- L sided heart failure
2- R sided heart failure
3-Biventricular failure
4- compensated heart failure

associated symptoms:

• muscle wasting
• myopathies
• osteoporosis

pathophysiology:
- decreased CO
- elevated end diastolic pressures (preload)
- tachycardia
- contractile deficiency (decreased SV and contractile force)
- impaired ventricular function

Question 9

Left sided heart failure

Answer 9

(congestive heart failure, CHF)

characterized by pulmonary congestion, edema and low CO due to backup of blood from the LV to the LA and lungs.

occurs with:

• insult to the LV from myocardial disease
• excessive workload of the heart (HTN, valvular disease or congenital defects)
• cardiac arrhythmias or heart damage

S&S of pulmonary congestion

• dyspnea, dry cough
• orthopnea
• paroxysmal nocturnal dyspnea
• pulmonary rales, wheezing

S&S of low CO:

• hypotension
• tachycardia
• lightheaded/dizzy
• cerebral hypoxia: irritability, restless, confusion, impaired memory, sleep disturbances
• fatigue, weakness
• poor exercise tolerance
• enlarged heart on chest x-ray
• S3 heart sound, possible S4
• murmurs of mitral or tricuspid regurgitation

Question 10

Right sided heart failure

Answer 10

reduced venous return to the heart from the systemic circulation due to failure of RV; increased pulmonary artery pressures with peripheral edema

characterized by:

• increased pressure load on the RV with higher pulmonary vascular pressures
• mitral valve disease, or chronic lung disease (cor pulmonale)
• produces hallmark signs of jugular vein distention and peripheral edema

S&S:

• dependent edema
• weight gain
• ascites (abnormal abdominal fluid retention)
• liver engorgement (hepatomegaly)
• anorexia, nausea, bloating
• cyanosis
• R upper quadrant pain
• jugular vein distension
• R sided S3 heart sounds
• murmurs of pulmonary or tricuspid insufficiency

Question 11

Biventricular failure

Answer 11

severe LV pathology producing back up into the lungs, increased PA pressure and RV signs of HF

Question 12

compensated heart failure

Answer 12

heart returns to functional status with reduced CO and exercise tolerance

control is achieved through:

• physiological compensatory mechanisms: SNS stimulation, LV hypertrophy, anaerobic metabolism, cardiac dilatation, arterial vasoconstriction
• medial therapy

Question 13

cor pulmonale

Answer 13

failure or hypertrophy of RV resulting from disorders of the lungs, pulmonary vessels or chest wall

the lung pathology (chronic bronchitis or emphysema) produces pulmonary artery HTN that creates a problem for the RV

usually chronic, but may be acute and reversible

Question 14

treatment for heart CHF

Answer 14

bed rest
diuretics
sodium restriction
measures to improve myocardial contractility and correction of arrhythmias

meds:
1-Digitalis (digoxin) 
-increases cardiac pumping ability 
-decreases HR 
2- diuretics (lasix) 
-decrease vascular fluid volume 
-decrease preload and after load
-control HTN

Question 15

ACE inhibitors

Answer 15

Quinipril (accupril)
Captopril (capoten)
Enalopril (vasotec)
Lisinopril (zestril) 
Fosinopril (monopril)
benazepril (lotensin)

Inhibit conversion of angiotensin I to angiotension II (inhibits vascular smooth muscle contraction)

• decreases Na retention and peripheral vasocontriction in order to decrease BP
• also prevents the inactivation of bradykinin (a vasodilator)
• result is arteriolar vasodilation, decreased peripheral resistance and increased flow

usually the 1st step in managing LV failure

can be used with diuretics and calcium channel blockers (for HTN, never for CHF or angina)

side effects:

• nonproductive dry cough
• decreased taste perception

adverse effects:

• excessive hypotension
• hyperkalemia
• angioedema

May react with diuretics and cause hypotension.
-with potassium sparing diuretics, the problem may be hyperkalemia

step 2 with CHF is use of diuretics, especially loop diuretics (lasix)

step 3 with CHF is use of nonselective beta blocker and selective alpha 1 adrenergic blocker (carvedilol)

step 4: digoxin- when there is systolic dysfunction and arrhythmias

Question 16

nitrates

Answer 16

nitroglycerin

decreasepreload through peripheral vasodilation

• reduce myocardial oxygen demand
• reduce chest discomfort (angina)
• may also dilate coronary arteries, improve BF

side effects:

• dizziness
• flushing and headache
• reflex tachycardia

beta blockers and calcium channel blockers may also be used for angina

Question 17

beta-adrenergic blocking agents

Answer 17

Non-selective beta-blockers:
-propanolol (inderl)
-nadolol (corgard)
penbutolol (levatol)

**-olol

Selective beta blockers (beta-1)

• lopressor
• atenolol
• beta1 receptors in the heart
• beta2 receptors in the lungs and some arterioles

“anti-hypertensives”

• reduce myocardial demand by reducing HR and contractility and SV
• control arrhythmias, chest pain
• reduce BP

should be avoided with certain kinds of angina, all COPD, and DM

patients should never suddenly discontinue use of BB since there a risk of sudden death from anginal attack

side effects:

• sleep disturbances
• mental status changes- depression, disorientation
• cold extremities

**patients taking BB- can’t use HR to determine exercise tolerance **

Question 18

Calcium channel blockers

Answer 18

procardia
norvasc
cardizem
verapamil

inhibit flow of calcium ions
decrease HR 
decrease contractility
dilate coronary arteries
reduce BP 
control arrhythmias
chest pain

side effects:

• significant bradycardia
• peripheral vasodilation can cause flushing, headache, ankle swelling, and reflex tachycardia

drug interactions:

• verapamil can result in digoxin toxicity
• verapamil and BB together can cause cardiac depression and AV block

Question 19

anti-arrhythmics

Answer 19

numerous drugs, 4 main classes

alter conductivity
restore normal heart rhythm
control arrhythmias
improve cardiac output

ex:
- quinidine (ACE)
- procanamide

Question 20

digitalis

Answer 20

cardiac glycosides

increases contractility and decreases HR
mainstay in the treatment of CHF (digoxin (lanoxin))

used as step 4 with CHF when there is a systolic dysfunctional and arrhythmias

increases the force of contraction of cardiac muscle without increasing oxygen demand
-EF may increase

adverse effects
-toxicity (signs: cardiac arrhythmia, anorexia, nausea, vomiting, mental status change (hallucinations, blurred vision))

PT** watch for digoxin toxicity

Question 21

diuretics

Answer 21

THIAZIDES
furosemide (lasix)
hydrochlorothizide (esidrix)

• decrease myocardial work (reduce preload and aferload)
• control HTN
• inhibit tubular reabsorption of sodium and chloride in the kidney, which in turn, inhibits water reabsorption and increases urine volume–>ultimate result is decreased vascular resistance

thiazides should NOT be used with the elderly or anyone with renal dysfunction

side effects:

• hyperglycemia especially with diabetes
• hypokalemia
• hyperuricemia- too much uric acid- gout
• increase in LDL
• hypercalcemia

drug interactions:

• increases lithium reabsorption, which can increase lithium blood levels and result in lithium toxicity
• digoxin toxicity

Loop diuretics (furosemide (lasix), bumex, edecrin)

• inhibit sodium and chloride reabsorption in the lop of Henle
• more effective than thiazides
• may be used with elderly

potassium sparing diuretics:
-weak diuretics that prevent hypokalemia

Question 22

aspirin

Answer 22

decreases platelet aggregation

may prevent myocardial infarction

used in treatment of angina, CAD and to prevent MI

shouldn’t be used after acute injury since it prolongs clotting

Question 23

alpha adrenergic blockers

Answer 23

alpha 1 blockers: prazosin (minipress)
-blocks alpha1 receptors in smooth muscle allowing arterial and venous vasodilation

side effects:

• syncope
• headache
• palpitations

alpha 2 blockers (clonidine (catapress))
-stimulate alpha 2 receptors in the brainstem, which decrease sympathetic NS signals with resulting decreased HR, peripheral resistance and BP

side effects:

• dry mouth
• sedation
• depression

Question 24

vasodilators

Answer 24

hydralazine (apresoline)

used in combo with ACE inhibitors ad have increased survival with CHF

can also be used with beta blockers to treat HTN

side effects:

• GI disturbances
• headache
• flushing
• nasal congestion

Question 25

activity restriction with acute MI

Answer 25

activity can be increased once the acute MI has stopped (peak in cardiac troponin levels) limited to 5 METs or 70% of age predicted HRmax for 4-6 weeks following MI

Question 26

activity restriction with acute heart failure

Answer 26

oxygen demand should not be increased in patients in acute or decompensated heart failure gradual increase while monitoring hemodynamic response to activity

Question 27

surgical interventions for heart disease

Answer 27

1- percutaneous transluminal coronary angioplasty (PTCA) 2- intravascular stents 3- coronary artery bypass graft (CABG) 4- transplantation 5- ventricular assist device

Question 28

percutaneous transluminal coronary angioplasty

Answer 28

PTCA under fluoroscopy, surgical dilation of blood vessel using a small balloon tipped catheter inflated inside the lumen relieves obstructed blood flow in acute angina or acute MI results in improved coronary BF, improved LV function, anginal relief

Question 29

intravascular stents

Answer 29

an endoprosthesis (pliable wire mesh) implanted postangioplasty to prevent restenosis and occlusion in coronary or peripheral arteries often coated in medication to prevent thrombosis

Question 30

coronary artery bypass graft

Answer 30

CABG surgical circumvention of an obstruction in a coronary artery using an anastomosing graft (saphenous vein, internal mammary artery) multiple grafts may be necessary results in improved coronary BF, improved LV function, anginal relief

Question 31

heart transplantation

Answer 31

used in end stage myocardial disease (cardiomyopathy, ischemic heart disease, valvular heart disease) heteroptics: leaving the natural heart and piggybacking the donor heart orthotopic: removing the disease heart and replacing it with donor heart

Question 32

ventricular assist device

Answer 32

implanted device (accessory pump) that improves tissue perfusion and maintains cariogenic circulation used with severely involved patients

Question 33

occlusive peripheral arterial disease (PAD)

Answer 33

chronic, occlusive arterial disease of medium and large vessels, the result of peripheral atherosclerosis associated with HRN and hyperlipidemia -also CAD, CVA, DM, metabolic syndrome and a hx of smoking diminished blood supply to affected extremities with decreased or absent pulses color: pale on elevation, red in dependency early stages: intermittent claudication - pain: burning, searing, aching, tightness, cramping - regularly and predictably with walking - relieved with rest late stages: pain with rest, muscle atrophy, trophic changes critical stenosis PAD: patients exhibit resting or nocturnal pain, skin ulcers and gangrene

Question 34

thromboangiitis obliterans (Buerger's disease)

Answer 34

chronic, inflammatory vascular occlusive disease of small arteries and veins occurs commonly in young adults, largely males who smoke begins distally and progresses proximally in both upper and lower extremities patients exhibit paresthesias or pain, cyanotic cold extremity, diminished temperature sensation, fatigue, risk of ulceration and gangrene

Question 35

raynaud's phenomenon

Answer 35

episodic spasm of small arteries and arterioles abnormal vasoconstrictor reflex exacerbated by exposure to cold or emotional stress fingertips exhibit pallor, cyanosis, numbness and tingling largely affects females

Question 36

varicose veins

Answer 36

distended, swollen superficial veins tortuous in appearance may lead to varicose ulcers

Question 37

superficial vein thrombophlebitis

Answer 37

clot formation and acute inflammation in a superficial vein localized pain; usually in saphenous vein

Question 38

deep vein thrombophlebitis (DVT)

Answer 38

clot formation and acute inflammation in a deep vein usually in LE - associated with venous stasis, hyperactivity of blood coagulation and vascular trauma; early ambulation is prophylactic, helps eliminate venous statis S&S - asymptomatic early - progressive inflammation with tenderness to palpation - dull ache, tightness or pain in calf - swelling - warmth - skin discoloration and venous distention may precipitate PE: presents abruptly with chest pain and dyspnea; diaphoresis, cough, apprehension *emergency medical management: anticoagulation therapy (heparin) - ambulation and mobility encouraged after 1 dose - compression stockings

Question 39

chronic venous stasis/incompetence

Answer 39

venous valvular insufficiency: from fibroelastic degeneration of valve tissue, venous dilation classification: I: mild aching, min edema, dilated superficial veins II: increased edema, multiple dilated veins, changes in skin pigmentation III: venous claudication, severe edema, cutaneous ulceration

Question 40

lymphadenopathy

Answer 40

enlargement of nodes, with or without tenderness

Question 41

lymphedema

Answer 41

chronic disorder with excessive accumulation of fluid due to obstruction of lymphatics or removal of lymph nodes causes swelling of the soft tissues results from mechanical insufficiency of the lymphatic system primary lymphedema: congenital condition with abnormal lymph node or lymph vessel formation (hypo/hyperplasia) secondary lymphedema: acquired, due to injury of 1 or more parts of lymphatic system. Possible causes include: - surgery - tumors, trauma or infection affecting lymph vessels - radiation therapy with fibrosis of tissues - chronic venous insufficiency - in tropical and subtropical areas, filariasis (nematode worm larvae in lymphatic system)

Question 42

exercise tolerance testing

Answer 42

determines the physiological responses during measured and graded exercise stress of increasing workloads - determines exercise capacity of individual - establishes basis for exercise prescription - screens patients for possible CAD - assists in the diagnosis of suspected cardiovascular disease maximal ETT: -defined by target endpoint HR submax ETT: - symptom-limited or terminated at 85% of age predicted HRmax - safer - used to evaluate early recovery of patients after MI, CABG or coronary angioplasty continuous ETT: - workload is steadily increased - step test - ramp test discontinuous (interval) ETT: - allows rest - used for patients with more pronounced CAD positive ETT: -indicates O2 supply is inadequate to meet demand; positive for ischemia negative ETT: -balanced O2 supply and demand false positive ETT: false negative ETT: Functional 6 minute walk test -highly correlated to other ETT, sub max and max VO2

Question 43

monitoring exercise and recovery; examine for:

Answer 43

appearance, S&S of excessive effort - persistent SOB - dizziness/confusion - anginal pain - severe leg claudication - excessive fatigue - pallor, cold sweat - ataxia, incoordination - pulmonary rales change in HR- rise with workload, plateau just before VO2max changes in BP - SBP rise with workload - DBP stay roughly the same Rate pressure product RPE: 6-20 - increases linearly * important measure for pets who don't exhibit typical rise in HR with exercise (beta-blockers) pulse oximetry ECG normal changes - tachycardia - rate-related shortening of QT interval - ST segment depression, upsloping, 1mms indicative of myocardial ischemia

Question 44

metabolic equivalents

Answer 44

MET= the amount of oxygen consumed at rest (sitting) = 3.5 mL/kg of body weight per minute at rest, the body consumes about 200-250 mL of oxygen/minute = 1 MET MET levels (multiples of resting VO2) can be directly determined during ETT; using collection and analysis of expired air can be used to predict energy expenditure during certain activities 1.5-2 METs: standing, walking slowly (1mph) 2-3 METs: level walking (2mph); level bicycling (5mph) 3-4 METs: level walking (3mph); biking (6mph) 4-5 METs: walking (3.5 mph); biking 8mph 5-6 METs: walking briskly 4mph; biking 10 mph, 6-7 METs: walking very briskly 5mph; biking 11 mpg; leisurely swimming 7-8 METs: jogging 5 mph; biking 12 mph 8-9 METs running, biking 12 mph, swimming >10 METs: running 6mph

Question 45

guidelines for exercise prescription: TYPE

Answer 45

TYPE - cardiorespiratory endurance - dynamic arm exercise (^HR and BP) - aerobic activities: swimming Early rehab: discontinuous/interval training with frequent rests progressing to continuous (allows patient to work at higher % of VO2 max) Warm up and cool downs -- low intensity cardiorespiratory endurance, flexibility (5-10 minutes) Resistive exercises: - reserved for later cardiac rehab - moderate intensities (60-80 of 1RM) - monitor responses using RPP - precautions: monitor BP, avoid valsalva's - contraindicated for patients with uncontrolled HTN or arrhythmias relaxation training

Question 46

guidelines for exercise prescription: INTENSITY

Answer 46

% of functional capacity revealed on ETT -within 40-85% range HR - % of HRmax - Karvonian's formula: more closely approximates the relationship between HR and VO2max- increased variability in patients on meds - beta blocker and pacemaker: affects ability of HR to rise in response to exercise RPE : 11-13 "light" METs

Question 47

guidelines for exercise prescription: DURATION

Answer 47

conditioning phase may vary from 10-60 minutes depending on intensity moderate intensity ~ 20-30 minutes

Question 48

guidelines for exercise prescription: FREQUENCY

Answer 48

dependen upon intensity and duration avg: 3-5 days/week for exercise at moderate intensities and duration (>5 METs) daily or multiple daily sessions for low intensity (

Question 49

guidelines for exercise prescription: PROGRESSION

Answer 49

modify if: - HR is lower than target HR - RPE is lower - symptoms of ischemia (angina) don't appear rate of progression depends on age, health status, functional capacity, personal goals, preferences * as training progresses, duration is increased first, then intensity

Question 50

consider a reduction in exercise with:

Answer 50

acute illness; fever, flu m acute injury progression of cardiac disease: edema, weight gain, unstable angina overindulgence: food, caffeine, alcohol environmental stressors: heat, cold, humidity,

Question 51

absolute indications to terminate exercise

Answer 51

drop in SBP >10 mmHg moderate to severe angina increasing NS symptoms (ataxia, dizziness, near syncope) signs of poor perfusion technical difficulties in monitoring ECG or BP subject's desire to stop sustained VT ST elevation >1 mm

Question 52

relative indications to terminate exercise

Answer 52

ST or QRS changes (excessive ST depression) or marked axial shift arrhythmias other than sustained VT fatigue, SOB, wheezing, leg cramps or claudication development of bundle branch block that can't be distinguished from VT increasing chest pain hypertensive response (SBP >250 or DBP >115)

Question 53

exercise prescription post percutaneous transluminal coronary angioplasty:

Answer 53

wait to exercise vigorously ~2 weeks post PTCA to allow inflammatory process to subside walking program can be initiated immediately use post PTCA ETT to prescribe exercise

Question 54

exercise prescription post CABG

Answer 54

limit UE exercise while sternal incision is healing avoid lifting, pushing, pulling for 4-6 weeks post

Question 55

absolute contraindications for cardiac rehab

Answer 55

acute MI (within 2 days) unstable angina not previously stabilized by medical therapy uncontrolled cardiac arrhythmias causing symptoms or hemodynamic compromise acute PR or pulmonary infarction acute myocarditis or pericarditis acute aortic dissection

Question 56

relative contraindications for cardiac rehab

Answer 56

L man coronary stenosis moderate stenotic valvular heart disease electrolyte abnormalities severe arterial HTN tachyarrhythmias or bradyarrhythmias hypertrophic cardiomyopathy and other forms of outflow tract obstruction mental or physical impairment leading to inability to exercise adequately high degree AV block

Question 57

phase I: inpatient cardiac rehab (Acute)

Answer 57

length of stay ~ 3-5 days for uncomplicated MI (no persistent angina, malignant arrhythmias or heart failure) GOALS: - initiate early return to independence in ADLs (typically after 24 hours or until patient is stable for 24 hours) - counteract deleterious effects of bed rest; reduce risk of thrombi, maintain muscle tone, reduce orthostatic hypotension, maintain joint mobility - help allay anxiety - provide education - promote risk factor modification Exercise guidelines: - ADLs, selected arm and leg exercises, early supervised ambulation - initial activities: low intensity (2-3 METs) progressing to >5 METs by discharge - post MI: limited to 70% HR max and/or % METs until 6 weeks post-MI - short exercise sessions, 2-3x/day - Post-surgical patients: progressed more rapidly than post-MI, unless peri-operative MI ; lifting activities are restricted for 6 weeks Education: - understanding of cardiac disease, risk factor modification - self monitoring procedures, warning signs or exertion intolerance - energy costs, fatigue, guidelines, pacing, HEP HEP -low risk patients: gradual increase in ambulation: goal of 20-30 minutes, 1-2x/day, 4-6 weeks post MI

Question 58

Phase II: outpatient cardiac rehab (subacute)

Answer 58

Eligible patients: - MI/acute coronary syndrome - CABG - PCI - Stable angina - heart valve surgical repair/replacement - heart or lung replacement - heart failure and PAD GOALS: - improve functional capacity - progress toward full resumption of ADLs and occupational activities - promote risk factor modifications - encourage pacing, energy conservation GUIDELINES: - frequency: 2-3x/week - duration: 30-60 min with 5-10 warm up/cool - patients gradually weaned from continuous monitoring to spot checks and self monitoring - suggested end point: 9 MET functional capacity (5MET capacity is needed for safe resumption of most daily activities) strength training: after 3 weeks cardiac rehab, 5 weeks post-MI or 8 weeks post CABG -begin with elastic bands and light hand weights (1-3 lbs)

Question 59

phase III: community exercise programs (post acute, post discharge)

Answer 59

Goals: -improve/maintain functional capacity -promote self regulation of exercise program promote life long commitment to risk factor modification Exercise guidelines: - entry level: 5 METs, stable angina, medically controlled arrhythmias during exercise - progression: supervised to self-regulation - progress to 50-85% of functional capacity, 3-4x/week, 45 min or more - discharge 6-12 months

Question 60

resistance exercise training

Answer 60

post-MI: - permitted if remain under 70% HRmax or 5 METs for 6 weeks post MI - cautious of valsalva Cardiac surgery: - LE can be initiated right away in absence of peri-operative MI - UE resistance training avoided until soft tissue and bony healing has occurred: 6-8 weeks Post transcatheter procedure (PTCA, etc) -min of 3 weeks following procedure and 2 weeks of consistent participation in a supervised CR endurance training program

Question 61

exercise prescription for patients with heart failure

Answer 61

patients demo significant ventricular dysfunction, decreased CO and low functional capacities assess for signs of decompensation at each visit: increased SOB

Question 62

exercise prescription with cardiac transplant

Answer 62

patients may present with: - exercise intolerance due to extended inactivity - side effects from immunosuppressive drug therapy: hyperlipidemia, HTN, obesity, diabetes, leg cramps - decreased LE strength - increased fracture risk due to long term corticosteroid use HR is no an appropriate measure of intensity longer periods of warm up and cool down

Question 63

exercise prescriptions with pacemakers and automatic implantable cardioverter defibrillators (AICDs)

Answer 63

pacemakers are programmed to pace HR AICDs will deliver electric shock if HR exceeds set limit and/or ventricular arrhythmia is detected avoid UE aerobic or strengthening exercises for 4-6 weeks after implant to allow the leads to scar down

Question 64

exercise training for patients with PAD

Answer 64

may result in improved functional capacity, improved peripheral BF via collateral circulation and muscle oxidative capacity consider interval training with frequent rests walking program: - intensity such that patients reports 1 on claudication scale within 3-5 minutes; stopping if they reach 2 (until pain subsides) - total of 30-60 minutes (intervals) - 3-5 days/week - record time and onset of pain and duration beta blockers for treatment of HTN may decrease time to claudication or worsen symptoms aspirin and warfarin may improve time to claudication high risk for CAD

Question 65

rehab guidelines for patients with chronic venous insufficiency

Answer 65

1- Edema management: positioning: (min of 18 cm above heart); avoid dependent position compression therapy - bandages applied within 20 minutes of rising - paste bandage (Unna boot): 4-7 days - graduated compression stockings (at least 30 mmHg) - compression pump- 1-2 hours/day red flag: consider consequences of compression to a limb with an ABO

Question 66

phase I management of edema secondary to lymphatic dysfunction:

Answer 66

short stretch compression bandage- 24 hours/day manual lymph drainage with complete decongestive therapy - massage and PROM to assist lymphatic flow - decongest proximal segments first, then extremities, directing flow distal to proximal - compression using multilayered padding and short stretch bandages functional activities - walking, cycling - water based - tai chi and balance - ADL training - RED FLAG: strenuous activities, jogging and ballistic movements are contraindicated-- likely to exacerbate lymphedema signs of lymph overload: discomfort, aching or pain in proximal lymph areas, change in skin color meticulous skin care contraindicated modalities: -ice, heat, hydrotherapy, saunas, contrast baths, paraffin-- all cause vasodilation and increase lymphatic load of water compression garments at end of phase I -RED FLAG: excessively high pressures will occlude superficial lymph capillaries and restrict fluid absorption

Question 67

Phase II management (self-management) of lymphedema

Answer 67

``` skin care compression garments exercise lymphedema bandaging at night MLD as needed compression pumps; with caution ``` RED FLAG: pressures >45 mmHg are contraindicated- can cause lymphatic collapse; contraindicated with soft tissue injury education: - skin and nail care - self bandaging - infection management - maintain exercise

Question 68

shock (hypoperfusion)

Answer 68

failure of the circulatory system to perfuse vital organs at first blood is shunted from the periphery to compensate - may lose consciousness - HR increases, increased O2 demand Types of shock: - hemorrhagic: severe internal or external bleeding - psychogenic: emotional stress causes blood to pool in body away from the brain - metabolic: loss of body fluids from heat or severe vomiting or diarrhea - anaphylactic: allergic reaction from drugs, food or insects - cardiogenic: MI or cardiac arrest results in pump failure - respiratory: respiratory illness or arrest results in insufficient oxygenation of the blood - septic: severe infections cause blood vessels to dilate - neurogenic: TBI, SCI or other neural trauma causes disruption of ANS resulting in disruption of blood vessel dilation/constriction S&S: - pale, gray or blue, cool skin - increased, weak pulse - increased RR - decreased BP - irritability or restless - diminishing level of consciousness - nausea/vomitting

Question 69

anti-cholinergic drugs

Answer 69

used with IV for heart block or bradycardia inhibit acetylcholine at the parasympathetic nerves, blocking vagal effects on SA and AV nodes of the heart Side effects: - palpitations - headache - restlessness - ataxia - dry mouth - blurred vision Ex: atropine

Question 70

heart block

Answer 70

when the spread of electrical excitation to the heart is interrupted or slowed atropine (anti-cholinergic med) is given

Question 71

heart failure

Answer 71

when the heart muscle is unable tot adequately pump blood to maintain proper circulation CHF - R heart affected-- peripheral edema - L heart affected-- pulmonary edema - if severe-- edema may be widespread

Question 72

infarction

Answer 72

area of necrotic tissue that results from a loss of blood supply to that area

Question 73

ischemia

Answer 73

the obstruction of circulation that results in a temporary deficiency of blood supplied to a certain area of the heart muscle usually causes pain in chest (angina)

Question 74

lipoproteins

Answer 74

proteins that carry fat in the blood for delivery to the cells low density lipoproteins (LDL)-- associated with arterial damage high density lipoproteins (HDL)-- promote the removal of cholesterol by the liver -engaging in moderate aerobic exercise may elevate HDL levels LDL/HDL ratio is important in reducing risk of heart disease

Question 75

serum enzymes

Answer 75

appear in the circulation following death of cardiac muscle cells creatine phosphate (CPK) lactate dehydrogenase (LDH) serum glutamic oxalacetic transminase (SGOT

Question 76

criteria to terminate inpatient exercise

Answer 76

fatigue, lightheadedness, confusion, ataxia, pallor, cyanosis, dyspnea, nausea, onset of angina with exercise ST displacement (2mm) horizontal or downsloping from rest level ventricular tachycardia or >3 consecutive PVCs drop of SBP of >20mmHg during exercise rise in SBP >220 mmHg or DBP >110 mmHg

Question 77

lymphatic system

Answer 77

includes: lymphatic vessels, lymph fluid, lymph tissues, and organs (nodes, tonsils, spleen, thymus and thoracic duct) lymph contains excess interstitial fluid, WBC, and some proteins almost all tissues have lymphatic vessels except superficial portions of the skin, the CNS and bones lymphatic vessels accompany arteries and veins, and drain lymph from bodily tissues and return it to the venous circulation the R lymphatic duct drains the R arm, R side of the head and R side of the thorax into the R subclavian vein The rest of the body drains into the thoracic duct, which empties into the L subclavian vein major lymph nodes: submaxillary, cervical, axillary, mesenteric, iliac, inguinal, popliteal and cubital