Compulsory Question Assessment

Question 1

How do you recognise that someone is experiencing angina

Answer 1

1. Pain, Tightness, Burning or a Dull Sensation in the chest
2. Arm sensations (pain or heaviness) particularly in L arm
3. Throat, back or abdomen sensations (pain or discomfort)
4. Breathlessness on exertion
5. Fatigue

Question 2

What are the characteristics that make angina unstable?

Answer 2

1. The angina is new (< 1 month)
2. It is experienced at rest
3. It has worsened in frequency, severity and at lower levels of exertion

THESE PATIENTS SHOULD NEVER EXERCISE

Question 3

What are the possible additional signs and symptoms of an MI

Answer 3

1. Crushing, band-like, squeezing chest pain.
2. Radiating to jaw & throat
3. Arm heaviness or pain (one or both)

Milder Discomfort:
4. Similar to indigestion
5. In throat or arm alone
6. In abdomen or back

7. Breathlessness
8. Nausea / Vomitting
9. Pale, cold & clammy
10. Impending doom
11. Weakness / collapse

Question 4

What action would you take with someone who was experiencing chest pain

Answer 4

1. Stop. Sit. Rest
2. GTN (spray or tablets)
3. Repeat after 5 mins
4. 999

IF SYMPTOMS ARE ALLEVIATED, REST FOR 5 MINS THEN RE-WARM

Question 5

How would your action change if you suspected an MI (as opposed to angina)

Answer 5

1. Get to hospital without delay
2. Give 300mg Asprin to chew unless allergic. Chewing leads to faster absorption straight through the oral mucosa and upper GI tract which leads to faster inhibition of platelet aggregation.

Aspirin won’t dissolve an existing clot, but it can help prevent the clot from getting bigger and forming new ones whilst other treatments are being arranged. Ensure the person is conscious enough to chew and swallow safely


Question 6

What is the purpose of risk stratification?

Answer 6

1. To determine the risk of a patient having a further cardiac event whilst exercising.
2. To enhance programme safety
3. To determine exercise intensity, level of supervision and monitoring (in consultation with rehabilitation team)

THE MORE DAMAGE TO THE MYOCARDIUM (& THEREFORE HEART FUNCTION), THE HIGHER THE RISK OF THIS

Question 7

Which criteria are used for risk stratification?

Answer 7

1. Post event complications (heart failure / ischaemia / angina).
2. Reduced LV Function (<50%)
   Severe = < 35%
   Moderate = 35-49%
3. Residual Angina (ongoing)
   - High risks if angina @ < 5 METS
   - Lightheadedness
   - Dyspnoea at low workloads
   - Silent Ischaemia (ST segment depression on ECG - < 2mm from baseline) during exercise or recovery
4. Serious Arrhythmias
   - Ventricular tachycardia or fibrillation (at rest or exercise) = Cardiac Arrest risk
   - ICD Implant
   - History of CA
5. Reduced Functional Capacity
   < 7 METS on a maximal test = heart not coping with intensity
   HIGH risk @ < 3 METS
6. DRUG Treatment for CLINICAL depression
   As many are arrhythmmogenic
   (Sertraline & Cetralopram are best)

Question 8

What are the absolute contraindications to exercise?

Answer 8

If there are new or worsening symptoms within the previous month or if medication has had to be changed in order to achieve control. The condition is then deemed uncontrolled or unstable.

1. BP 180 / 110
2. Tachycardia (>100)
3. Temp up (Febrile or unwell
4. Unstable heart failure (New breathlessness, fatigue or ankle oedema)
5. Unresolved unstable angina
6. Unstable diabetes
7. Uncontrolled or Symptomatic Atrial or ventricular arrhythmias
8. Palpitations, dizziness or lethargy
9. Symptomatic hypotension

Question 9

When would you refer a client back to their GP?

Answer 9

First check reasons for deterioration are not down to non compliance with home exercise routine or medication regimen. If no obvious innocent reason, refer when:
1. Exercise performance is reduced
2. Angina: worse or unstable
3. Arrhythmias, breathlessness & other symptoms
4. A further cardiac event

Question 10

What is the recommended time and the physiological reasons for an extended warm up?

Answer 10

Minimum of 15 minutes

SUMMARY
A longer warm-up allows for a gradual increase in heart rate, blood pressure, and cardiac output, reducing the risk of ischemia, arrhythmias, or angina.

Before exercise begins

Muscles need to be warm.
Joints need to be flexible and free.
The heart should be perfused with blood without sudden mechanical or electrical stress.

To allow the muscles to increase in temperature and reduce the risk of injury, particularly in those with comorbidities such as PAD.
Joints need to be taken gently through their range of movement, particularly for those with joint pain and arthritic conditions in order to gain freedom and flexibility enough for stability and safety in the joints and surrounding tendons and connective tissue.
In order for the heart to be perfused with blood the following must happen
Oxygen Demand Feedback - heart muscles respond to hypoxia by dilating
Endothelial response to Nitric oxide (which is produced as a result of sheer stress on the vessel walls) leads to relaxation and dilation enabling the muscle to benefit from increased blood flow, oxygen and nutrients. This improves blood pressure control and reduces peripheral resistance
During early warm up, noradrenaline predominates in response to the beta receptors on the heart unlocking noradrenalin response. This increases heart rate, contraction strength and the speed of conduction through the AV node
As exercise continues and local metabolic demand increases:
Adenosine is produced in active tissues (like heart and skeletal muscle) as a result of ATP breakdown.
It acts locally to dilate blood vessels, especially in coronary circulation, ensuring oxygen supply meets increased demand.
It also has a modulating role, slightly dampening excessive sympathetic stimulation by slowing AV nodal conduction if needed — kind of like a safety valve.

This allows the Ischaemic Threshold to be raised and risks of angina or arrhythmia are reduced.

Question 11

How is Venus return maintained during exercise?

Answer 11

Feet need to be kept moving or toes wiggling
- this encourages Venus return via the muscle pump

Any form of breath holding is avoided - this encourages Venus return via the respiratory pump

Details:

1. Muscle Pump:\
   During exercise, when your skeletal muscles contract (like your calf, thigh, or foot muscles), they squeeze the nearby veins.

Compressesion in the vein, which contains one way valves which divide veins into segments like a ladder, pushes blood up the ladder, toward the heart.

2. Respiratory Pump: During inhalation, the diaphragm descends, decreasing intrathoracic pressure and increasing intra-abdominal pressure. These changes create a pressure gradient that facilitates the flow of blood from the abdominal veins into the thoracic cavity, augmenting venous return to the heart.
3. Sympathetic Nervous System Activation: Exercise stimulates the sympathetic nervous system, which results in vasoconstriction of veins (venoconstriction). This increases venous tone and reduces venous compliance, effectively pushing more blood back to the heart and maintaining venous return.
4. Increased Blood Volume and Cardiac Output: As exercise commences, cardiac output increases due to a rise in heart rate and stroke volume. Stroke volume itself is partly influenced by the Frank-Starling mechanism, where increased venous return stretches the ventricular walls, optimizing their contraction. In addition, redistribution of blood flow during exercise, with more blood directed from the splanchnic circulation to active muscles, helps maintain central venous pressure.
5. Role of the Vasculature: The venous system has high capacitance, which allows it to accommodate a large portion of the total blood volume. During exercise, the redistribution of blood volume, facilitated by alterations in vascular resistance and compliance, aids in maintaining venous return despite changes in body posture or dynamics.

These physiological adaptations work together to enhance venous return during exercise, supporting increased cardiac output and sustaining the supply of oxygen and nutrients to active tissues.

Question 12

What is the recommended time and the physiological reasons for an extended cool down?

Answer 12

An extended, gradual cool down of 10 minutes allows
1. heart
2. blood vessles and
3. autonomic nervous system
to transition safely.

If an older adult with CVD suddenly stops moving:

1. Venous return drops sharply
2. Blood can pool in the legs (because the muscle pump stops, reducing cardiac preload)
3. Cardiac output can fall quickly
4. Blood pressure can fall rapidly causing feelings of dizziness, light headedness and potentially fainting as a result of post-exercise hypotension.
5. Without diastolic pressure in particular, coronary perfusion can become inadequate causing ischaemic symptoms like chest tightness or discomfort.
6. High levels of cirulating catecholamines can provoke arrhythmias if they are not allowed adequate time to metabolise particularly as the baroreceptor reflexes are blunted in these patients. Elevated circulating catecholamines in a body that isn’t moving can trigger sensations of restlessness, unease, or anxiousness.
7. The metabolic byproducts (lactate C02, hdrogen ions, potassium, adenosine) which dilate muscles will not have time to clear causing abrupt vasoconstrition.
8. Accumulated lactate and hydrogen ions can leave the muscles feeling heavy, weak, or stiff. The patient might describe their legs as “wobbly” or like they’re “walking through mud.” Imbalances in potassium, calcium, and hydrogen ions can cause minor muscle irritability, leading to cramps or fasciculations (muscle twitches).
9. Reduced blood flow redistribution to the gut and lingering metabolic acidosis can provoke nausea or an unsettled stomach

Behavioral and Psychological Effects:

1. Patient may avoid future exercise sessions due to unpleasant post-exercise experiences (e.g., dizziness, chest discomfort, muscle pain).
2. Fear or anxiety about physical activity can increase, particularly if symptoms mimic cardiovascular events.
3. Confidence in physical capability decreases, leading to reduced physical activity levels, which worsens cardiovascular conditioning over time.

Question 13

Where would supine work be placed in the programme and what are the background physiological reasons?

Answer 13

Supine work should be done after cool down. Getting up and down often is ill advised because elderly and those with joint pain have difficulty doing this shift often.

When you move from an upright or standing position to lying down:

Gravity no longer pulls blood toward your legs
Blood from the lower limbs and abdominal veins returns more easily to the heart
Venous return increases
This causes an increase in preload (ventricular filling)
Which in turn increases stroke volume

This makes supine work ideal for continuing the work of the cool down by offering breathing and stretching which aid the parasympathtic system to take over and aid HR recovery

Getting up, mid workout can cause:

1. Orthostatic hypotention can happen if you get up from the floor suddenly. It’s also a common side effect of ACE inhibitors; Alpha and Beta Blockers; Calcium Chanel Blockers; Clonadine; Diuretics & Nitrates

Heart failure can cause worsened breathlessness when lying flat (orthopnea) — because the increased preload puts more strain on an already failing heart.