CV + Lymph Flashcards
(194 cards)
1
Q
The tricuspid valve prevents the back flow of blood between which chambers of the heart?
A
Right atrium and right ventricle
2
Q
The bicuspid valve prevents the back flow of blood between which chambers of the heart?
A
Left atrium & left ventricle
3
Q
What is the purpose of the semilunar valves?
A
Prevent the back flow of blood between the aorta/pulmonary artery and the left and right ventricles respectively
4
Q
Differentiate systole & diastole
A
Systole: ventricular contraction
Diastole: ventricular relaxation
5
Q
What is end-systolic volume? What is its typical value?
A
Volume of blood remaining in the ventricles after ventricular contraction; ~50 mL
6
Q
What is end-diastolic volume? What is its typical value?
A
Volume of blood remaining in the ventricles after diastole; ~120 mL
7
Q
What is the atria kick? When does it occur & what is its purpose?
A
The atrial kick is the atrial contraction that occurs during the last 1/3 of diastole; completes ventricular filling; adds last 20-30% of end-diastolic volume
8
Q
The right coronary artery supplies what structures of the heart?
A
- Right atrium
- Most of right ventricle
- inferior wall of L ventricle
- AV Node
- Bundle of His
- SA Node (60% of time)
9
Q
The left coronary artery supplies what structures?
A
- Two divisions: LAD, Circumflex
- LAD: left ventricle, interventricular septum, inferior areas of apex
- Circumflex: lateral & inferior walls of L ventricle, portion of L atrium, SA node 40% of time
10
Q
The SA node initiates an impulse at a rate of what? Which divisions of the nervous system can affect this?
A
60-100 beats per minute
Both sympathetic & parasympathetic innervations present
11
Q
The AV node has an intrinsic firing rate of what?
A
40-60 beats per minute
12
Q
Injury at what level of the spinal cord would impact a patient’s ability to reach their age-adjusted max heart rate?
A
T1-T4 and above
13
Q
The purkinje fibers have an intrinsic firing rate of what?
A
20-40 beats per minute
14
Q
Define stroke volume and the typical value in an adult
A
Amount of blood ejected with each contraction; 55-100 mL/beat
15
Q
Stroke volume is influenced by what 3 factors?
A
- Contractility
- Pre-load
- After-load
16
Q
The Frank-Starling Law refers to what?
A
The greater the pre-load, the greater the stroke volume
17
Q
What is the typical cardiac output for a healthy adult at rest? How is this determined?
A
4-5 L/minute; HR x stroke volume
18
Q
What is normal left ventricular end-diastolic pressure?
A
Pressure in the left ventricle during diastole; 5-12 mmHg
19
Q
What is the ejection fraction? What is it’s typical value?
A
- % of blood emptied from ventricle during systole; clinically useful measure of L heart function
- stroke volume/left ventricular end diastolic volume
- Average > 55%
20
Q
What ejection fraction indicates a patient in heart failure?
A
< 40%
21
Q
What is the rate pressure product? How is it calculated?
A
RPP= measure of myocardial oxygen demand aka how much stress is on the heart muscle itself
Heart rate x systolic blood pressure
Normal RPP should not be > 10,000
22
Q
Where is the primary site for vascular resistance?
A
Arterioles
23
Q
What factors influence venous circulation?
A
- Muscle contraction (aka muscle pump)
- Gravity
- Respiration (increases venous return w/ inspiration)
- compliancy of R side of heart
24
Q
Lymph fluid travels through the lymphatic system to eventually reach what structure where it is dumped back into circulation?
A
Left subclavian vein
25
True or false: Abdominal and thoracic cavity pressure does not change with normal breathing.
False
26
Major lymph nodes include what?
- Submaxillary, cervical, axillary, mesenteric, iliac, inguinal, popliteal, cubital
[Sccampii]
27
Discuss the parasympathetic pathway that influences the cardiac system
1. Control center: medulla, cardioinhibitory center
2. vagus nerve/cardiac plexus releases aCh at SA/AV node, myocardium (sparsely)
3. Decreases: HR, contraction force, restricts coronary arteries
28
Discuss the sympathetic pathway that influences the cardiac system
1. Control center: medulla, cardioaccelatory center
2. T1-T4, upper thoracic-superior cervical chain ganglia: release epinephrine/NE at SA/AV node, conduction pathways, & myocytes
3. Increases HR, contraction force, cardiac metabolism, coronary vasodilation
29
An increase in right atrial pressure will typically result in what?
Reflex acceleration of heart rate
30
What are the main mechanisms of controlling heart rate? (4)
1. Baroreceptors sensing pressure --> triggers either a sympathetic or parasympathetic response
2. Chemoreceptors --> high CO2, low pH trigger increase in HR; increased O2 triggers decrease in HR
3. Body temp --> increase BT = increase HR; lower BT = lower HR
4. Ion concentrations
31
Hyperkalemia can result in what consequences for cardiac function?
Decreased HR & contractility
ECG: widened PR interval & QRS; tall T-waves
32
Hypokalemia can result in what consequences for cardiac function?
ECG: flat T-wave, prolonged PR & QT intervals
arrhythmias, ventricular fibrillation
33
Hypercalcemia can result in what consequences for cardiac function?
increased heart actions
34
Hypocalcemia can result in what consequences for cardiac function?
Depressed heart actions
35
Hypermagnesemia can result in what consequences for cardiac function?
arrhythmia or cardiac arrest
36
Hypomegnesemia can result in what consequences for cardiac function?
coronary artery vasospasm, sudden death
37
What specific cardiovascular signs/symptoms should be screened for during the patient interview?
- Chest pain
- Fatigue
- Palpitations
- Dizziness, syncope
- Edema
38
Discuss non-modifiable risk factors for cardiovascular disease
- Age: Men > 45, women > 55
- Family history
- Race: African American
- Gender: men > risk than pre-menopausal women; after menopause risk equalizes
39
Discuss modifiable risk factors for cardiovascular disease
- Cholesterol (total < 200 mg/dL; LDL < 160; HDL > 40)
- Diabetes: A1C < 7%
- Diet: low fat, low sodium, balanced
- Hypertension
- Obesity
- Physical inactivity (30 min +/day/5-6x/wk)
- Tobacco
40
What are considered appropriate values for cholesterol? Total? LDLs? HDLs? Triglycerides?
Total < 200 mg/dL
LDL < 160
HDL > 40
Triglycerides < 150 mg/dL
41
Cyanosis, pallor, and diaphoresis are all potential signs of what?
decreased cardiac output, and low oxygen saturation
42
What pulse is best when examining infants?
brachial pulse
43
Describe the grading scale for peripheral pulses
0= absent
1+= diminished
2+= easily palpable
3+=full pulse
4+= bounding
44
What are the typical heart rate ranges for adults, children, and newborns?
Adult/teen= 60-100 bpm
Children 60-140 bpm
Newborns= 90-164 bpm, avg, 127
45
Postural tachycardia syndrome is defined as
Sustained HR increase ≥ 30 beats per minute w/in 10 minutes of standing
46
Irregular pulse may be associated with what condition(s)?
arrhythmia, myocarditis
47
Weak, thready pulse may be associated with what condition(s)?
low stroke volume, cardiogenic shock
48
Bounding, full pulse may be associated with what condition(s)?
shortened ventricular systole, decreased peripheral pressure, aortic insufficiency
49
Auscultation landmark: aortic valve
2nd right intercostal space @ sternal border
50
Auscultation landmark: pulmonary valve
2nd left intercostal space @ sternal border
51
Auscultation landmark: tricuspid valve
4th left intercostal space @ sternal border
52
Auscultation landmark: mitral valve
5th left intercostal space @ mid clavicle area
53
S1 heart sound indicates what?
- Normal
- Closure of mitral/tricuspid valves
- Marks beginning of systole
- Decreased in 1st degree heart block
54
S2 heart sound indicates what?
- Normal
- Closure of aortic/pulmonary valves
- Marks end of systole
- Decreased in aortic stenosis
55
A systolic murmur falls between what heart sounds? What might it indicate?
- Between S1 & S2
- Valvular disease or may be normal
56
A diastolic murmur falls between what heart sounds? What does it indicate?
- Between S2 and S1
- Usually indicates valvular disease
57
Discuss the following terms related to heart sounds:
Thrill
Bruit
Gallop rhythm
- Thrill: abnormal tremor accompanying a vascular or cardiac murmur, felt on palpation
- Bruit: adventitious sound (blowing sound); common in carotid/femoral arteries; indicates atherosclerosis
58
Discuss a gallop rhythm
- Abnormal rhythm with three sounds in each cycle
- S3: associated w/ ventricular filling; may indicate CHF
- S4: associated w/ ventricular filling & atrial contraction; indicative of pathology e.g. CAD, MI, aortic stenos, or chronic hypertension
59
Discuss the following ECG segments & what event they are linked to:
P wave
PR interval
QRS wave
ST segment
T wave
QT interval
P wave: atrial depolarization
PR interval: impulse traveling from atria ---> purkinje fibers
QRS complex: ventricular depolarization
ST segment: beginning of ventricular repolarization
T wave: ventricular repolarization
QT interval: time for electrical systole
60
How do you calculate heart rate from an ECG, assuming a normal rhythm?
count interval between QRS complex on 6 second strip and multiply by 10
61
Ventricular arrhythmias often result from what?
ectopic cells in the ventricles affecting rhythm; these cells are outside of the normal conduction system
62
Atrial arrhythmias often result from what?
ectopic foci in the atria outside of the SA node
63
Discuss heart blocks
Abnormal delays or failure to conduct through normal conducting system
64
Recognition of which heart block would negate a medical emergency?
Third-degree
65
When would a PVC indicate the potential for a medical emergency?
> 6 per minute
66
Metabolic & drug influences on ECG: Hyper & hypokalemia
Hyperkalemia: widen QRS, flatten p wave, peak T wave
Hypokalemia: flattens T wave (or inverts), produces U wave
67
Metabolic & drug influences on ECG: Hyper & hypocalcemia
Hypercalcemia: widens QRS, shortens QT interval
Hypocalcemia: prolongs QT interval
68
Metabolic & drug influences on ECG: Hypothermia
elevates ST segment, slows rhythm
69
Review BP normative values for adults
70
Review BP normative values for peds
71
Discuss Mean Arterial Pressure (MAP)
- Arterial pressure in large arteries over time
- Dependent upon avg blood flow & arterial compliance
- Important clinical measure in critical care
- Normal: 70-110 mmHg
- < 50 = hypotension
72
Review normal respiration rates:
Adult
Child
Newborn
Adult: 12-20 bpm
Child: 20-30 bpm
Newborn: 30-40 bpm
73
Define paroxysmal nocturnal dyspnea
Sudden inability to breath occurring during sleep; result of LV failure causing pulmonary congestion
74
Adventitious lung sounds: crackles (rales)
Rattling, bubbling sounds
May be d/t secretions in lungs
75
Adventitious lung sounds: Wheezes (ronchi)
Whistling sounds
d/t: pneumonia, bronchitis, COPD
76
Normal SpO2 levels vs. hypoxic SpO2 levels
Normal: 98%-100%
Hypoxemia: <90%
77
Cardiac-associated pain in women is most likely to present in what pattern?
Indigestion, gas-like pain, dizziness, nausea, unexplained weakness/fatigue, pain between shoulder blades, sense of impending doom
78
Ischemic cardiac pain often presents as
Diffuse, retrosternal, tightness/achiness in the chest, dyspnea, sweating, indigestion, dizziness, syncope, anxiety
79
Cardiac pain may refer to where?
Shoulders, back, arms, jaw, neck
80
Dissecting aortic aneurysm pain may refer to where?
Back
81
Define rubor
dependent redness typically associated with PAD
82
Trophic changes associated with PAD include
Pale, shiny, dry skin
Hair loss
83
Discuss Stemmer's Sing & what it indicates
- Skin on dorsum of fingers/toes is resistant to lifting
- Indicates fibrotic changes typically associated w/ lymphadema
84
Peripheral edema is typically associated with what? What about bilateral edema?
Lymphedema, chronic venous insufficiency
Bilateral edema associated w/ CHF
85
Review the grading scale for edema
1+: mild, barely perceptible indentation; <1/4 inch pitting
2+: Moderate, easily identified depression; returns to normal within 15 seconds 1/4-/12 inch pitting
3+: Severe depression, takes 15-30 sec to rebound; 1/2-1 in pitting
4+: Very severe, depression lasts for > 30 sec or more; ≥ 1 in pitting
86
Define the Ankle-Brachial Index and its utility
ABI: ratio of lower extremity pressure divided by upper extremity pressure
Used to assess arterial function
87
Review ABI values and what they indicate
> 1.40: indicates non-compliant arteries
1.00-1.40: Normal
0.91-0.99: Borderline
≤ 0.90: Abnormal
≤ 0.50: severe arterial disease, risk for critical limb ischemia, may have pain @ rest
88
What is the purpose of a Swan-Ganz catheter?
- Inserted through the vessels to the R side of the heart
- Measures central venous pressure, pulmonary artery pressure, pulmonary capillary wedge pressure
89
What is considered to be the primary measure of myocardial ischemia? What are potential qualifying factors?
Cardiac troponin (rise & fall)
Must accompany one of the following:
- symptoms of ischemia
- New or presumed new ST changes on ECG
- New loss of viable mycardium as seen on imaging
- Evidence of intracoronary thrombus
90
Review the lab value, its normal range, & its clinical significance: SpO2
Normal: 98%-100%
<88%-90% usually requires supplemental O2
91
Review the lab value, its normal range, & its clinical significance: PaO2
- Normal: 90-100 mmHg
- ↑: hyperoxygenation
- ↓: cardiac decompensation
- COPD and some neuromuscular disorders
92
Review the lab value, its normal range, & its clinical significance: PaCO2
- Normal: 35-45 mmHg
- ↑: COPD, hypoventilation
- ↓: hyperventilation, pregnancy, pulmonary embolism, anxiety
93
Review the lab value, its normal range, & its clinical significance: pH (whole blood)
- Normal: 7.35-7.45
- ↑ (Respiratory alkalosis): hyperventilation, sepsis, liver disease, fever
- ↑ (Metabolic alkalosis): vomiting, potassium depletion, diuretics, volume depletion
- ↓ (Respiratory acidosis): hypoventilation, COPD, respiratory depressants, myasthenia
- ↓ (Metabolic acidosis): increased acids, renal failure, increased acid intake, loss of alkaline body fluids
94
Review the lab value, its normal range, & its clinical significance: prothrombin time
- Normal: 11-15 sec
- ↑: factor X deficiency, hemorrhagic disease, cirrhosis, hepatitis drugs (warfarin)
95
Review the lab value, its normal range, & its clinical significance: INR
- Normal: 0.9-1.1
- Be careful to reduce fall risk & monitor for signs of bleeding
96
Review the lab value, its normal range, & its clinical significance: white blood cells
- Normal: 4,300-10,800 cells/mm3
- ↑: infection
- ↓: aplastic anemia
- PT considerations: consider metabolic demand when fever is present; use mask when WBC < 1K-2K
97
Review the lab value, its normal range, & its clinical significance: RBCs
- Male norm: 4.6-6.2 10^6/uL
- Female norm: 4.2-5.9 10^6/uL
- ↑: polycythemia
- ↓: anemia
98
Review the lab value, its normal range, & its clinical significance: Hematocrit
- Male norm: 45-52%
- Female norm: 37-58%
- ↑: erythrocytosis, dehydration, shock
- ↓: severe anemias, acute hemorrhage
- PT considerations: can decrease exercise tolerance, increased fatigue, tachycardia
99
Review the lab value, its normal range, & its clinical significance: Erythrocyte Sedimentation Rate
- Male norm: < 15 mm/hr
- Female norm: < 20 mm/hr
- ↑: infection, inflammation
100
Review the lab value, its normal range, & its clinical significance: Hemoglobin
- Male norm: 13-18 g/dL
- Female norm: 12-16 g/dL
- ↑: polycythemia, dehydration, shock
- ↓: anemias, prolonged hemorrhage, RBC destruction
- PT considerations: decreased exercise tolerance, increased fatigue, tachycardia
101
Review the lab value, its normal range, & its clinical significance: Platelet count
- Norm: 150,000-450,000 cells/mm3
- ↑: chronic leukemia, hemoconcentration
- ↓: thrombocytopenia, acute leukemia, aplastic anemia, cancer chemo
- PT considerations: increased risk of bleeding w/ low levels
< 20K: AROM, ADLs only
20-30K: light exercise only
30-50K: moderate exercise only
102
Symptoms of acute coronary syndrome (aka coronary artery disease) usually present with what % of vessel occlusion?
70%
103
Differentiate the three major types of angina
- Stable: classic exertion angina
- Unstable: insufficiency w/out any precipitating factors
- Variant: (Prizmental's angina); caused by coronary artery vasospasm in absence of occlusion
104
Differentiate the pathology of an STEMI vs. a NSTEMI
STEMI: full thickness of myocardium (transmural)
N-STEMI: nontransmural
105
Discuss the clinical manifestations of left vs. right ventricular failure
Left: dyspnea, dry cough, orthopnea, PND, pulmonary rales, hypotension, tachycardia, lightheadedness, dizziness, cerebral hypoxia, fatigue, weakness, poor exercise tolerance, enlarged heart on x-ray, S3 heart sound, murmurs (mitral or tricuspid)
Right: dependent edema, weight gain, ascites, hepatomegaly, anorexia, nausea, bloating, cyanosis, R upper quadrant pain, JVD, R sided S3 heart sounds, murmurs (pulmonary, tricuspid)
106
Clinical Manifestation of HF Zone & PT recommendations: Green Zone
-NO SOB, swelling, fatigue, weight gain, chest pain, decrease in endurance
- Continue activity/therapy as tolerated
107
Clinical Manifestation of HF Zone & PT recommendations: Yellow Zone
- 2-3 lb weight gain in 24 hrs, increased cough, peripheral edema, SOB w/ activity, orthopnea
- Meds may need adjusting; communicate w/ physician
108
Clinical Manifestation of HF Zone & PT recommendations: Red Zone
- SOB @ rest, unrelieved angina, wheezing, PND, 5lb weight change in 3 days, confusion
- Overt decompensation; medical attention ASAP
109
CV medications: ACE inhibitors
- "-prils"
- Inhibit conversion of angiotensin I to angiotensin II
- decreases sodium retention & peripheral vasoconstriction = lower BP
110
CV medications: Angiotensin II receptor blockers (ARBs)
- "-sartans"
- blocks angiotensin II at tissue/smooth muscle level = lowers BP
111
CV medications: Nitrates (nitroglycerin)
- decrease preload via peripheral vasodilation, reduce heart's oxygen demand, reduce angina
112
CV medications: beta blockers
- "-olol"
- reduce HR to reduce cardiac demand = lowers BP
113
CV medications: calcium channel blockers
- "-zem"
- decrease HR, contractility = lower BP, control arrhythmias
114
CV medications: antiarrhythmics
- numerous, 4 main categories
- restore normal rhythm; improve CO
115
CV medications: digitalis
- increase contractility and decrease HR
116
CV medications: diuretics
- reduce preload/afterload to reduce myocardial work
- control hypertension
117
CV medication: aspirin
- decreases platelet aggregation
118
CV medications: tranquilizers
- decrease anxiety, sympathetic effects
119
CV medications: hypolipidemic agents
- "-statins"
- reduce cholesterol
120
When can activity resume after an acute MI? What are the restrictions?
- When MI is over (troponin is trending down)
- ≤ 5 METs or 70% HRmax for 4-6 weeks after
121
When can activity be performed in patients with acute heart failure (decompensation)?
- No activity until patient is stable and no longer showing signs of decomposition.
122
Symptoms of pulmonary embolism include what?
- chest pain, dyspnea, diaphoresis, cough, apprehension
123
Resistance training is contraindicated in patients with what cardiac condition?
uncontrolled hypertension or arrhythmias
124
Discuss the FITT-VP principles of cardiovascular exercise
125
Consider reduction in exercise/activity with what?
- Acute illness: fever, flu
- Acute injury, ortho complications
- Progression of cardiac disease :edema, weight gain, unstable angina
- Overindulgence
- Environmental stressesors
126
Consider response to inpatient exercise that would warrant termination of the session
- Diastolic BP ≥ 10 mmHg
- Decrease in systolic BP > 10 mmHg
- Significant ventricular or atrial dysarrhythmias
- 2nd or 3rd degree heart block
- Signs/symptoms of exercise intolerance
127
Typical exercise prescription post CABG
- Limit UE exercise while sternal incision is healing
- Avoid lifting, pushing, pulling, for 4-6 weeks post-op
128
Typical exercise prescription following PTCA
- wait for @ least 2 weeks to allow inflammation to subside
129
Cardiac Rehab: contraindications for inpatient/outpatient cardiac rehab
- Unstable angina
- Resting SBP > 200 mmHg or DBP > 110 mmHg
- Orthotic BP drop
- Uncompensated CHF
- uncontrolled tachycardia, atrial/ventricular dysrhythmias
- Uncontrolled tachycardia
- Pericarditis, myocarditis
- 3rd degree AV block
- recent embolism
- thrombophlebitis
- Resting changes in ST-segment > 2 mm
- Uncontrolled diabetes mellitus
- Severe ortho conditions that prohibit exercise
- Metabolic conditions: acute thyroiditis, hypokalemia, hyperkalemia, hypovolemia
130
Review Phase 1 of Cardiac Rehabilitation (Acute/Inpatient)
- Early return to functional activities after 24 hours or when stable; prevent secondary complications, education, psychosocial support
- Low-intensity activity (ADLs, arm/leg exercise, ambulation); limit to 70% HRmax until 6 weeks post-MI
-Progress duration/frequency as tolerated
- May have HEP w/ goal of 20-30 min/day at 4-6 weeks post-MI
-Goal to get to tolerance of 5 METs prior to discharge (needed for most ADLs)
131
Review Phase 2 of Cardiac Rehabilitation (Outpatient/Subacute)
- Eligible dxs: MI, CABG, PCI, stable angina, valve repair/replacement, heart/lung transplant, heart failure, PAD potentially
- Improve functional capacity, activity pacing, risk factor modification
- Typically 2-3 sessions/week for 30-60 minutes
- Suggested exit point: 9 METs
- Strength training: after 3 wks of cardiac rehab, 5 wks post-MI, or 8 wks post-CABG; begin light and progress to moderate loads for 12-15 comfortable reps
132
Review Phase 3 of Cardiac Rehabilitation (Post-Acute)
- Improve/maintain functional capacity
- Promote self-regulation
- Entry criteria: functional capacity of 5 METs, clinically stable angina, controlled arrhythmias during exercise
- progress to 50%-85% functional capacity, 3-4x/week, 45 min+/session
133
Discuss some of the critical considerations when prescribing weight training to an individual after a MI
- Avoid valsalva maneuver
- < 70% HRmax or 5 METs for 6 weeks
- Cardiac surgery: LE training immediately, UE avoided for 6-8 weeks while healing
- Post-transcatheter procedure: minimum 3 weeks after procedure & 2 weeks of cardiac rehab
- Should not have evidence of: HF, uncontrolled rhythms, severe vascular disease, uncontrolled HTN, unstable symptoms
134
What should the exercise prescription look like for an individual post-cardiac event?
- Start w/ low resistance (1x10-15)
- Slow progression
- 50% 1 RM, elastic bands, light cuffs/hand weights
- wall pulleys
- RPE 11-13 (light to somewhat hard)
- RPP not to increase cardio recommendation
135
Review the classifications of heart failure
136
What are some of the key statements for PTs treatment pts with heart failure (class II and III)?
- Advocate for ↑ total daily physical activity
- Educate on chronic disease management
- Prescribe aerobic exercise
- Prescribe HIIT
- Prescribe upper/lower body resistance training
- Prescribe inspiratory muscle training
- Prescribe NMES
137
Exercise prescription parameters for patients with stable HFrEF (NYHA Class II & III)
- Aerobic: 20-60 min; 50-90% peak VO2; 3-5x/wk; 8-12 weeks
- HIIT: > 35 min; > 90-95% peak VO2; 2-3x/wk; 8-12 weeks
- UE/LE resistance training: 45-60 min; 60-80% 1RM; 3x/wk; 8-12 weeks
- Inspiratory muscle training: 30 min; > 30% of MIP; 3x/wk; 8-12 weeks
- NMES: biphasic symmetrical pulse, 15-50 htz on/off time= 2/5 sec; pulse width= 200-700; intensity to contraction; 5-7 days/wk; 5-10 weeks
138
How long should UE aerobic or strengthening exercise be avoided following a pacemaker/automatic implantable cardiovertor defibrillator placement?
4-6 weeks
139
What is a special consideration for patients w/ ICDs?
Keep HR at least 10 beats below shock/anti-arrhythmic threshold
140
Exercise considerations for patients with PAD
- May result in improved function
- Consider interval training
- Walking as tolerated 30-60 min, 3-5 days/wk
- Record symptom onset/duration
- Non-weight-bearing exercise less effective at peripheral conditioning, but can be used
- Ensure well-fitting shoes
- beta blockers for HTN may decrease time to claudication
- Patients at high risk for CAD
141
Rehab guidelines for lower extremity exercise in arterial disease
- resisted calf exercise = most effective method of increasing blood flow
- May implement Modified Buerger-Allen exercises (postural exercises to help increase BF)
142
Rehab Guidelines for patients with venous thromboembolism (CPG)
- Screen, screen, screen
- Focus: ambulation, activating muscle pump once meds are at therapeutic level
- Avoid bedrest
- Utilize mechanical compression (@ least 30mmHg of pressure @ ankle)
- May trial intermittent pneumatic compression
- Education, education, education
- Assess fall risk
143
Rehab guidelines for chronic venous insufficiency
- Positioning: elevate extremity @ least 18 cm above heart
- Compression therapy: bandages w/in 20 min of rising; unna boot ( impregnated gauze) for 4-7 days; compression stockings w/ 30-40 mmHg
- Exercise: active ankle exercise, bike, early ambulation ASAP 3-4x/day
- Patient education: skin care, positioning
- Severe conditions may require sx intervention
144
When is compression therapy contraindicated for an individual with chronic venous insufficiency?
- ABI < 0.8 (involved extremity)
- Signs of active cellulitis/infection
- Systemic arterial pressure <80 mmHg
- Advanced peripheral neuropathy
- Uncontrolled CHF
145
Lymphatic vessel contraction is produced via what mechanisms?
1. Autonomic and sensory nerve stimulation
2. Contraction of adjacent muscles
3. Abdominal and thoracic cavity pressure changes during normal breathing
4. Mechanical stimulation of dermal tissue
5. Volume changes within individual lymph vessels
146
Differentiate primary vs. secondary lymphedema
Primary: congenital or hereditary; associated with abnormal lymph formation
Secondary: acquired; usually due to tissue insult from injury or surgery
147
Review the 4 stages of lymphedema
0: at risk, swelling is not yet evident despite reduced capacity
1: reversible; pitting edema resolves w/ elevation; (-) Stemmer's Sign
2: Spontaneously irreversible; elevation does not reduce swelling; (+) Stemmer's Sign
3: elephantiasis; fibrotic deep skin folds; skin may change color; mobility limitations possible
148
Discuss typical findings upon lymph node palpation and when a referral would be appropriate.
Normal: soft, mobile, nontender
Infection: soft, mobile, tender
Referral: hard, immobile lymph nodes
149
Unilateral-presenting diseases that should be considered in the differential diagnosis of lymphedema include what?
Acute DVT, post-thrombolitic syndrome, arthritis, Baker's cyst
149
Bilateral-presenting diseases that should be considered in the differential diagnosis of lymphedema include what?
CHF, chronic venous insufficiency, dependency edema, renal dysfunction, hepatic dysfunction, lipedema
150
What are some of the clinical findings that usually differentiate lipedema from lymphedema?
Lipedema: usually causes (B) symmetrical swelling in LEs that stops @ ankles & wrists; affects mainly women; (-) Stemmer Sign, may be associated w/ hormonal changes, (+) family hx for lipedema
151
Review the treatment & its components of lymphedema
- Manual lymphatic drainage
- Compression bandaging/garments
- Exercise
- Skin care
- Patient education
152
Modalities specifically contraindicated in lymphedema include what?
- Those that cause vasodilation
- electrotherapeutic modalities > 30 hz
153
During examination, which of the following characteristics will MOST likely be observed in a patient with left-sided heart failure?
a. ascites
b. jugular vein distension
c. P-R interval shortening
d. Productive spasmodic cough
d. Productive spasmodic cough
154
A patient is being evaluated for cardiac rehab and the therapist reviews the ECG. At the tail-end of the T-wave, there is a small elevation. According to the ECG, what symptoms will most likely be present in the patient?
a. mild to moderate dyspnea with exertion
b. No observable change in exercise tolerance
c. Reports of retrosternal chest pain
d. Spasmodic productive cough
b. No observable change in exercise tolerance
Small artifact at the end of the T-wave indicates a first-degree heart block. Because the QRS complex is essentially uninvolved, cardiac output is not likely to see significant impairment, which would lead to a relatively normal response to exercise/exertion.
155
Resting HR for the following ages:
Infants
1-12 months
1-3 years
3-5 years
6-12 years
13-17 years
18+
Infants: 120-140
1-12 months: 80-140
1-3 years: 80-130
3-5 years: 80-120
6-12 years: 70-110
13-17 years: 55-105
18+: 60-100
156
Normal ejection fraction is what?
55%-75%
157
Discuss the TYPICAL cardiovascular response to exercise for the following parameters:
HR
SBP
DBP
Tidal volume
Respiratory rate
- HR increases linearly
- SBP increases linearly
- DBP change minimal (+/- 10 mmHg)
- Tidal volume & RR increase
158
Differentiate the hemodynamic response & oxygen consumption capacity of the upper and lower extremities during exercise.
- Upper extremity has increased response (higher HR, SBP, etc.)
- Lower extremity exercise has decreased response compared to upper extremities
- LE has a greater oxygen consumption (VO2max) than UE
- UE has a greater oxygen deficit
159
Discuss abnormal cardiovascular responses to exercise
- Mod to severe/increasing angina
- Marked dyspnea
- Dizziness, light-headedness, ataxia
- Cyanosis/pallor
- Excessive fatigue
- Leg cramps/claudication
- Blunted BP response
- Hypertensive BP response > 200/110
- Fall in sBP of 10-15 mmHg
- significant CHANGE in ECG
160
Discuss the following lab values & what they are assoicated with:
- Creatine kinase-myocardial band
- Lactic dehydrogenase
- troponin
- myoglobin
- Used as clinical lab values following a MI
- Creatine and lactic dehydrogenase are "clean-up" enzymes
- troponin and myoglobin are proteins that increase in the blood after the heart muscle has been damaged
- Will watch values to gauge stage of event
- Usually PT starts AFTER troponin has had 2 consecutive downtrending values
161
What is cardiogenic shock?
- Insufficient BP to the heart and vital organs
162
Side effects associated with statin medications include what?
- Myalgia/myopathy
- Liver impairment (asterixis, CTS, ascites)
- Rhabdomyolysis
- Fever
- Nausea/vomiting
163
Pericarditis-related symptoms are similar to those of a myocardial infarction. What symptoms may differentiate the two?
- Pericarditis has a position-change component; e.g. symptoms are relieved by valsalva or leaning forward
- Pericarditis pain is also aggravated by trunk movement
164
Signs & symptoms of a DVT include
- Often asymptomatic
- Pain in the region
- Unilateral swelling/tenderness/pain
- Warmth & discoloration
- Well's criteria > Homan's sign
165
Is a DVT likely to cause a stroke?
No; the clot is more likely to lodge into the lungs and cause a PE because of the layout of the cardiopulmonary circuit
166
Where does the blood clot typically come from that causes a CVA?
Left ventricle d/t A-fib
167
Signs/Symptoms of an abdominal aortic aneurysm may include:
- Pulsating mass in abdominal area (sometimes)
- Bruit heard over swollen area
- Abdominal/back/flank pain
- Leg pain, claudication
- Poor distal pulses
168
A physical therapist is treating patient who is status-post myocardial infarction in inpatient cardiac rehab and is not taking any medications that impact heart rate. The therapist obtains the following baseline information from the patient following a sit to stand transfer BP 105/88, SPO2 95%, HR 95bpm and RPE 8. The therapist ambulates 50 feet with the patient and reassesses the patient’s vitals. The patient’s vitals are BP 130/88, SPO2 93%, HR 110 BPM and RPE of 15. Which of the following BEST provides evidence of hemodynamic compromise with activity?
1. Systolic increase in BP from 105mmHg to 130mmHg 2. HR increase from 95bpm to 110bpm
3. RPE increase from 8 to 15
4. SpO2 decrease from 95% to 93%.
3. RPE increase from 8 to 15
169
A 59-year-old female patient is receiving physical therapy treatment for osteoarthritis and knee pain. During the exercise intervention, the patient begins to report unusual fatigue, lethargy, and bilateral shoulder achiness. In addition, the patient reports that she has been unable to sleep for the last two nights and is concerned that she may have depression. Upon further questioning, the patient reports symptoms that are temporarily relieved by antacids. Based on these signs and symptoms, which of the following conditions is MOST likely present?
1. Chronic obstructive pulmonary disease
2. Congestive heart failure
3. Gastroesophageal reflux disease (GERD)
4. Myocardial infarction
4. Myocardial infarction
170
A patient initiates a course of physical therapy to address cardiac function. During the initial examination, the patient reports substernal chest pain that radiates into the neck and left arm. The patient also reports difficulty swallowing, cough, and lower extremity edema. When asked about the character of the pain, the patient describes exacerbation with neck and trunk movements and alleviation with sitting upright and leaning forward. Which of the following conditions is MOST likely present?
1. Aneurysm
2. Congestive heart failure
3. Myocardial ischemia
4. Pericarditis
4. Pericarditis
171
Review Cor pulmonale
- Increased pulmonary HTN
- Alveolar damage/capillary wall damage
- Right ventricular hypertrophy
172
Review HR calculation from ECG readings
- 5 little boxes = 1 second
- can count beats per minute
- can count beats in 10 seconds and multiply by 6
- Count big boxes and use the 300, 150, 100, 75, 60, 50 rule (yikes)
173
What is a key way to differentiate atrial fibrillation from atrial tachycardia (similar for ventricular tachycardia and v-fib)?
V-tach and A-tach present on ECG with a "sawtooth" deformity that appears uniform in nature. both A-fib an V-fib resemble trembling and are NOT uniform in nature.
174
Determine if the following ECG changes are normal or abnormal responses to exertion:
- ST depression
- ST depression + upsloping
- ST depression + downsloping
- ST upslope
- ST elevation
- ST horizontal depression
- ST depression: abnormal; ischemia
- ST depression + upsloping; abnormal; ischemia
- ST depression + downsloping; abnormal; ischemia
- ST upslope: normal response to exertion
- ST elevation: abnormal; MI
- ST horizontal depression: abnormal; ischemia
175
What ECG change would precipitate an absolute versus relative indication to stop exercise?
Absolute: ST elevation > 1.0 mm
Relative: ST depression > 2.0 mm
176
What normally happens to these ECG compoentns during exercise?
- P wave
- R wave
- ST segment
- Q-T interval
P-wave height increases
R wave decreases
St segment becomes sharply upsloped
QT interval shortens
177
1st degree heart block is characterized by what?
- delayed PR interval > 0.2 seconds
178
Type I 2nd degree heart block is characterized by what?
- Wenckebach
- Progressively longer PR intervals followed by dropped QRS complex
- Longer longer drop, then you know its a wenckebach
179
Type II 2nd degree heart block is characterized by what?
- Mobitz
- Steady PR interval with dropped QRS complex
- Some P's don't get through, that makes it a type 2
180
3rd degree heart block is characterized by what?
- complete heart block
- Independent P's and QRS's
- Nothing telling the ventricles to contract, the inherent rhythm is low so functionally tolerance would be decreased and they'd likely need a pacemaker before PT
181
An inverted T wave indicates what?
left ventricular hypertrophy
Myocardial ischemia
182
What ECG changes would indicate an absolute contraindication to PT?
sustained ventricular tachycardia
ST elevation > 1.0 mm
183
What ECG changes would indicate a relative contraindication to PT?
ST/QRS changes such as ST depression, downscoping ST segment
Arrhythmias other than sustained v-tach: supraventricular tachycardia, multifocal PVCs, >6 PVCs/minute, PVC triplets, bradyarrhythmias, heart blocks
184
A patient with coronary artery disease has just undergone a triple bypass surgery to improve vascularity to his heart. The patient desires to know how to reduce his morbidity and mortality. Which of the following groupings of signs and symptoms indicates the HIGHEST risk of cardiac morbidity and mortality?
1. Asymptomatic at rest, ejection fraction 60%, functional capacity 6 METs
2. Exercise induced ST-segment depression, ejection fraction 40%, functional capacity 5 METs
3. Exercise induced ST-segment depression, ejection fraction 70%, functional capacity 8 METs
4. Ventricular arrhythmias, ejection fraction 25 %, functional capacity 3 METs
4. Ventricular arrhythmias, ejection fraction 25 %, functional capacity 3 METs
185
During an exercise tolerance test, a patient’s ECG displays a sharply downsloping ST-segment depression of 2.0 mm that was not present at rest. Which of the following actions is the MOST appropriate next step?
1. Continue the test, closely monitoring symptoms and ECG.
2. Continue the test at a higher workload and monitor symptoms and ECG.
3. Discontinue the test and monitor symptoms and ECG for 5 minutes.
4. Discontinue the test and contact the physician immediately.
3. Discontinue the test and monitor symptoms and ECG for 5 minutes.
186
A patient is recovering from a myocardial infarction that occurred 3 days ago. The physical therapist is attempting to determine whether the patient is ready for inpatient cardiac rehabilitation. Each of the following signs is a contraindication to cardiac rehabilitation EXCEPT:
1. Recent embolism
2. Stable angina
3. Third-degree atrioventricular block without pacemaker
4. Uncontrolled hypertension with systolic blood pressure > 180mm Hg
2. Stable angina
187
Indications to begin cardiac rehab include:
medically stable post-MI
stable angina
CABG
stable heart failure
heart transplantation
valvular heart surgery
PAD, CAD
188
Contraindications to begin cardiac rehab include what?
Unstable angina
uncontrolled HTN (>200 or > 110)
Orthostatic drop in BP > 20 w/ symptoms
Aortic stenosis
Uncontrolled arrythmias
pericarditis/myocarditis
3rd degree AV block w/out pacemaker
uncontrolled PE/DVT
189
Review the MET, Hr, and RPE goals for each of the three phases of cardiac rehab
Inpatient: 4-6 METs (5), HR < 120, RPE <13/20
Outpatient: <90% of ischemic RPE, 55-90% Hr max, 12-16 RPE, 5-9 METs
Community: self-regulated, maintenance/progression for 6-12 months
190
Cardiac rehab strength training key points:
- 10-15 reps comfortably
- 11-13 RPE
- large muscle groups
- exhalation w/ exertion
- symptom management
191
Discuss sternal precautions
- UE lifting > 10 lbs
- Pushing/pulling
- scapular adduction
- UE resistive exercise above 90º
- No UE assistance w/ STS
- sternal "splinting" w/ cough, laugh, or sneeze
192
What hemoglobin value would be a contraindication to PT?
< 8 DON'T AMBULATE
193
What hematocrit value would be a contraindication to PT?
Less than 25% --> contraindicated
