Which demographics independently predict survival?
- Age is an independent predictor of survival in virtually every cardiopulmonary disorder.
- Sex and ethnicity are also important.
What causes peripheral edema?
Coronary Heart Failure (mostly right side)
Be familiar with the epidemiology discussed regarding low back pain.
-80% of the population will complain of low back pain.
-Can range from a mild muscle strain to a life-threatening ruptured abdominal aortic aneurism .
Know the risk factors for stroke.
Prior history of CVA (Cerebrovascular Accident)
Atrial fibrillation
LV dysfunction
Aneurysms
Carotid artery stenosis
Uncontrolled Hypertension (HTN)
Be able to describe peripheral neuropathy.
Common in diabetics
Nerves of the leg are damaged and stop functioning properly, with the result that people can no longer feel their toes and feet
Lose the ability to feel pain
Possible for the patient to develop wounds without their knowing
Be able to define syncope.
Short loss of consciousness and muscle strength
Characterized by fast onset, short duration, and spontaneous recovery
Know what is important when characterizing patient symptoms.
Onset, provocation (testing to elicit specific response or reflex) and palliation (to alleviate the symptoms of), quality, region and radiation, severity, timing, associated signs and symptoms
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Be familiar with the appropriate timing of graded exercise testing (GXT).
3 days following uncomplicated MI (in other words, fairly minimal heart damage, no heart failure)
-Normal responses (no ST changes, normal hemodynamics, no arrhythmias) and acceptable MET level achieved will help with discharge decision.
Following revascu
Know what classifies someone as high risk.
Abnormal GXT response at low workloads (<5 METs). EX: A patient who complains of angina pain and demonstrates 2.5 mm of ST-segment depression in four ECG leads just 3 min into and exercise test at a workload or FC that approximates just 4 or 5 METs has a
Know the appropriate duration of a GXT.
The protocol should allow the patient to exercise for a minimum of 8 min and preferably not more than 12 min. This will provide enough time for significant physiologic adaptations to exercise to occur but will reduce the likelihood of ending the GXT due t
Know the absolute contraindications to performing a GXT.
Absolute:
1. Significant change on the resting ECG suggesting ischemia, acute myocardial infarction (within past 2 days), or other acute cardiac event.
2. Unstable angina not controlled by medical therapy.
3. Uncontrolled cardiac arrhythmia causing sympto
Know the criteria for classifying an effort as maximal following a GXT.
1. Plateau in VO2 (<2.1 ml x kg-1 x min-1 increase).
2. A respiratory exchange ratio value greater than 1.1
3. Venous blood lactate exceeding 8 to 10 mM (24).
These criteria rely on having a metabolic cart to measure oxygen consumption or a lactate analyz
Know the health related components of fitness.
1. Cardiorespiratory endurance (aerobic fitness): ability of the cardiorespiratory system to transport oxygen to active skeletal muscles during prolonged submaximal exercise and the ability of the skeletal muscles to use oxygen through aerobic metabolic p
Know the differences observed when comparing exercise responses during leg ergometry and treadmill exercise.
Specificity of Training: Person's VO2 peak will be 5% to 15% higher on a treadmill versus a cycle ergometer. The majority of this difference is related to both the weight independence associated with sitting on a bike and the smaller total muscle mass use
Know the individual Duke Nomogram criterion.
Determines the 5 yr survival and average annual mortality rate. Measuring gas exchange is the most accurate measurement of FC. In addition to peak oxygen uptake (VO2), the slope of the change in minute ventilation (VE) to change in carbon dioxide (VCO2) p
Know the order of pathology leading to MI.
...
Know which coronary lesions are more susceptible to rupture.
Rupture-prone lesions are <50% occlusive before becoming disrupted.
Be familiar with the characteristics of typical angina.
-Typical angina is provoked by exertion, emotions, cold and heat exposure, meals, and sexual intercourse; it is relieved by rest or nitroglycerin or both. Angina pectoris is transient, referred cardiac pain resulting from MI.
Pain may be located in the su
Know the primary focus of inpatient cardiac rehab following MI.
1. Express sympathy
2. Develop discrepancy: the patient needs to perceive a discrepancy between present behavior and important goals.
3. Roll with resistance: avoid arguing for change.
4. Support self-efficacy: an important motivator for change is the pat
Know when it is appropriate to add resistance training into the training program post-MI.
5 wks recommended
As early as 2 wks
Know the important considerations when prescribing resistance training post-MI.
Avoid Valsalva maneuver.
Know the reasons for a symptom-limited GXT in a patient who suffered an acute MI.
Provides evidence of the ischemic threshold (heart rate and systolic blood pressure that corresponds to the first evidence of ischemia. Basically, testing involving minimal stress to evaluate cardiac output and the amount of stress the heart can take. Aka
Know what factors are associated with an increased risk of recurrent event in post-MI patients.
Not attending cardiac rehabilitation.19% of Medicare beneficiaries do not participate in outpatient cardiac rehab. Older adults, nonwhites, patients with comorbidities, patients with low economic status, people who are unemployed, single parents, and wome
Know the relationship between coronary heart disease and gender.
Prevalence rate slightly higher in men. Increases with age in women.
Know what conditions are considered an acute coronary syndrome.
Acute coronary syndromes include unstable angina pectoris, acute myocardial infarction, and potentially sudden cardiac death.
Know the recommended intensity for aerobic exercise training in post-MI patients.
RPE 11 to 16
40% to 80% of heart rate reserve
+ 20 beats/min and RPE 11 to 14
Below ischemic threshold
Know the relationship between training intensity and ischemic chest pain.
Start with 2-3 METs and increase by .5-1 increments
Know the reasons for coronary artery bypass revascularization surgery
Used for patients who are post-PTCA (percutaneous transluminal coronary angioplasty), stenting, or both
Patients who are no longer candidates for angioplasty
Those with multivessel disease not amendable to stenting or angioplasty
Those with technically di
Know the potential complications of angioplasty.
Acute vessel closure
Chronic restenosis
Thrombotic distal embolism
Myocardial infarction Arrhythmias
Dissection of the coronary artery
Bleeding
Know the advantages of drug-eluting stents versus bare-metal stents.
Prevents acute closure
Provides a vehicle for local drug delivery
Be familiar with the forms of dyspnea.
Paroxysmal nocturnal dyspnea
Sudden awakening caused by labored breathing
Orthopnea
Difficulty breathing in supine position
Dyspnea on exertion
Labored or difficult breathing during exertion
Know the characteristics of patients suffering from heart failure.
Ejection fraction that is reduced (systolic) or unchanged or slightly decreased (diastolic) at rest An increase in LV mass, with end-diastolic and end-systolic volumes that are increased (systolic failure) or decreased (diastolic failure)
Edema or fluid r
Know what changes can be expected with continued regular aerobic exercise training in patients with heart failure.
Improved exercise tolerance and quality of life
Moderate reduction for the risk of all-cause death or hospitalization
No change or modest change in cardiac output
Increase in peak HR
Mild cardiac reverse modeling
Improved ability to dilate small blood ves
Know the relationship among endothelial function, heart failure, and exercise training.
Endothelial dysfunction
Decrease in percentage of myosin heavy chain type I isoforms, diminished oxidative enzymes, and decreased capillary density
Know the mortality rates for newly diagnosed heart failure.
5 year mortality rate for a person newly diagno
Know the risk factors for peripheral arterial disease (PAD).
Smoking, diabetes, hypertension, hypercholesterolemia, high triglyceride levels, high leukocyte count, high homocysteine and fibrogen levels, increased blood viscosity, and elevated C-reactive protein
Know the testing methods for assessing PAD.
Treadmill protocol, ABI measurement, arm/leg ergometry, stair stepping, and active pedal plantar flexion
Incremental and constant speed walking shuttle tests
Be familiar with the effects of exercise on intermittent claudication symptoms.
Increased walking distance
Increased distance at claudication onset
Reduction in adverse CV event risk
Low-intensity training more beneficial than high intensity training
Intensity guided by IC symptoms recommended
Increased pain tolerance
Know the possible mechanisms related to the improvements in walking distance in patients with intermittent claudication.
Increased angiogenesis leading to increase of blood flow
Reduction in blood viscosity
Attenuation of atherosclerosis
Increased pain tolerance
Increase extraction of oxygen and metabolic substrates
Improved endothelial function
Improved carnitine metabolis
Be familiar with critical limb ischemia.
-1-2% of patients with PAD experience critical limb ischemia
-Older age and highly obese individuals at risk
-Severe blockage of arteries in the lower extremities
-Complications of poor circulation can include sores and wounds that won't heal in the legs
Know the common locations for claudication.
Lower extremities (especially in calves which is the most common)
IC in thigh and ass more indicative of disease in profunda femoris
Know the common age groups for pacemaker implantation.
85% of those who need a pacemaker are over the age of 65 with an equal distribution among men and women.
Know which patients benefit from cardiac resynchronization.
The patients that benefit from cardiac resynchronization are those with advanced heart failure. Many of these patients have left bundle branch block or an interventricular conduction delay resulting in left ventricular dyssynchrony and a high morality rat
Be familiar with left ventricular ejection fraction.
Percentage of blood that is ejected from the left ventricle per beat (normal 55-60%); EF = [(EDV - ESV)/EDV] X 100, where EDV = end-diastolic volume and ESV = end-systolic volume. Decreases are noted with systolic heart failure to values 35% to 40%
Be familiar with chronotropic incompetence.
In patients with cardiovascular risk factors or known coronary heart disease and taking a ?-adrenergic blocking agent, achieving a peak HR that is ? 62% of age predicted
Occurs in 20%-25% of patients with HF
Powerful and independent predictor of mortality
Know the coding system for pacemaker functions.
V= ventricle
A= Atrium
D= Dual
I= Inhibited
T= Trigger
R= Rate responsive
4 codes
1st chamber placed, 2nd chamber sensed, 3rd sensing response, 4th rate responsive
Understand the mode switching function.
To prevent the dual-chamber pacemaker from tracking or matching every atrial impulse with a ventricular pacing pulse, mode switching controls ventricular rate. Mode switching temporarily reverts to a non-tracking mode so that irregular or excessive atrial
Know the sensor methods used to detect a need for increased heart rate.
Vibration sensors use a piezoelectric crystal located at the pulse generator to detect forces generated during movement. These forces are transmitted to the sensor through connective tissue, fat and muscle. Acceleration sensors detect body movement in ant
Know which patients benefit from rate-responsive pacemakers
The patients that benefit from rate-responsive pacemakers are ones that their native sinus node cannot increase heart rate to meet metabolic demands
Know how a pacemaker might protect against a high ventricular rate.
A pacemaker might protect against a high ventricular rate by mode switching controls. Mode switching temporarily reverts to a nontracking mode so that the irregular or excessive atria activity does not drive the ventricles to an extremely high rate. There
Know the recommended exercise protocols for patients with PAD.
Cardiovascular and functional testing
Standardized treadmill protocol where ABI is taken before and after
Typical protocol is a constant speed of 2 mph with 2% grade increase every 2 minutes
Endpoint = patient's tolerance of leg pain
Abnormal when ankle p
Know the important considerations when prescribing exercise to someone with a defibrillator.
Considerations when prescribing exercise to someone with a defibrillator are that they have a limited exercise capacity. Exercise physiologist must pay attention to signs and symptoms that might occur with increased heart rate such as exercise-induced ang
Know the benefit of cardiac resynchronization in patients with heart failure.
The benefit of cardiac resynchronization in patients with heart failure are optimization of ejection fraction, decrement in mitral regurgitation, and left ventricular remodeling, thus resulting in symptom improvement and increased quality of life. Improve
Understand what a firing threshold is, and how this affects exercise prescription.
Firing threshold is the threshold in which an ICD device will shock. For patients with an internal cardioverter defibrillator, the exercise heart rate should be kept at least 20 beats below the firing threshold.
Know the symptoms of SA node dysfunction.
Symptoms of SA node dysfunction are bradycardia, fatigue, light-headedness, exercise, intolerance, and syncope.
Understand escape rhythms.
Atrial escape rhythm 60-80 beats
Junctional escape rhythm 40-60 beats
Ventricular escape rhythm 20-40 beats
Know how the severity of PAD is categorized.
Fontaine Stages: I. Asymptomatic
IIa: Mild claudication
IIb: Moderate to severe claudication
III: Ischemic rest pain
IV: Ulceration or gangrene
Rutherford Category: 0: Asymptomatic
1: Mild claudication
2: Moderate claudication
3: Severe claudication
4: Is
Be able to describe sick sinus syndrome.
Rhythm disorders that involve the SA Node are classified as sick sinus syndrome. Sick sinus syndrome is the inability to generate a heartbeat or increase the heart rate in response to the body's changing circulatory demands. This causes fatigue, light-hea
Know the components of cardiac output.
Strove volume X Heart Rate
Rate- responsive pacemakers have been created to increase cardiac output during PA in patients with chronotropic incompetence
Understand the conduction pathway for depolarization.
...
Understand the relationship between the direction of depolarization and the location of a positive electrode.
Depolarization within myocytes toward a positive electrode produce an upward deflection on the EKG.
Understand the relationship between a rate-responsive pacemaker and heart rate response for different training protocols.
The relationship between a rate-responsive pacemaker and heart rate is that rate-responsive pacemakers sense the body's physical need for increased cardiac output and produce an appropriate cardiac rate in patients with chronotropic incompetence. So the p
Know the unipolar and bipolar leads.
Bipolar: Limb Leads = I, II, III
Precordial = N/A
Unipolar: Limb Leads = aVR, aVL, aVF
Precordial Leads: V1-V6