Cardiac Clinical Assessments Flashcards
Heart Rate and Pulse Assessments
Measurement of the physical/mechanical activity (contractions) of the heart (not the electrical activity).
-pulse palpation (radial, jugular, dorsalis pedia, or posterior).
-wrist monitors
-chest monitors
Usefulness for cardiac populations…
-pulse = can quickly determine pulse rhythm and strength via radial pulse techniques.
-heart rate monitors = can keep track of heart rate before, during, and after exercise; can help distinguish between RPE scales, and heart rate, especially when there is a blunted heart rate response.
Important thing to remember when working with cardiac populations…
due to medications or other treatments, many cardiac clients will have a blunted heart rate response and generally low heart rate.
Do not sue heart rate training zones for exercise intensity (for this type of population).
-use lower intensity of exercise as well as medications can influence their heart rate.
RPE/RPB Scales
rating of perceived exertion (RPE) and rating of perceived breathlessness (RPB).
Helpful to understand subjective intensity level and breathlessness level in exercise.
Will adapt with exercise conditioning.
Easy for clients to understand for independent exercise.
Better to use for clients that have lower/blunted heart rates or lung conditions.
Angina Scale
Useful for when working with people with angina to understand subjective pain levels related to ischemia.
Ok to exercise at a 0-1/4 on the scale
-if progressing to 2+/4 then modify exercise.
Blood Pressure Measurements
Blood pressure measurements include…
-clinical measurements = automatic or manual sphygmomanometers
-home measurements = self-measured with an automatic cuff
-ambulatory blood pressure = 24 hr Holter (cuff is worn for 24 hours and gives feedback on changes throughout the day).
Blood Pressure Contraindications At Rest
Relative contraindications to beginning exercise exist if resting blood pressure >140/90
Absolute contraindication to beginning exercise is if resting blood pressure is >180/110.
Hypotension (<110/70) is also a cause for concern as it can lead to fainting especially in exercise (relative contraindication).
Blood Pressure Contraindications In Exercise
> 220/110 = cease exercise at this point and proceed to passive recovery
Post-Exercise Hypotension (PEH) Effect
After exercise, blood pressure drops back to resting levels or even lower (hypotension) due to post exercise hypotension mechanisms through systemic vasodilation.
PEH is considered to be a prolonged decrease in resting arterial blood pressure following acute bouts of exercise.
-can last up to 22 hours depending on exercise duration and intensity if you exercise daily.
-daily exercise can reduce chronic hypertension.
-beneficial for people who are hypertensive at rest.
-findings are more inconsistent with normotensive individuals
Post Exercise Hypotension (PEH) Maneuver
Using PEH effect to help lower blood pressure in hypertensive clients.
Helpful to lower BP prior to high intensity activity if resting levels found to be high (>160/90).
Procedure in notes.
Electrocardiograph (ECG)
Measures heart’s electrical activity from electrodes on the skin.
-records voltage over time.
Helps to determine electrical function of the heart and if abnormalities or arrhythmias exist.
useful in graded exercise or exercise stress tests to determine exercise induced arrhythmias.
P-waves = atrial electrical contraction.
PR segment = atrial mechanical contraction.
QRS wave = atria to ventricular electrical conduction.
ST Segment = beginning of ventricular mechanical contraction.
T-wave = ventricular mechanical contraction.
3, 5, and 12 lead ECGs.
-leads mean views of the heart
-electrodes are physical entities on the skin that measure electrical activity of the heart.
-leads are electrical connections that are created from electrodes (they do not mean or related directly to wires attached to the electrodes).
Set up procedure in notes.
12-Lead ECG Electrode Placements
avR (RA) = mid sub-clavicular space on right.
avL (LA) = mid sub-clavicular space on left.
avF (LL) = below V4 electrode, in rib space.
Ground (RL) = lower right chest on rib, or mid sternum on bone.
V1 = 4th intercostcal space on right of sternum.
V2 = 4th intercostal space on left of sternum.
V3 = between V2 and V4 on rib.
V4 = 5th intercostal space on left, in line with mid-clavicle.
V5 = 5th intercostal space on left, in line with anterior axilla.
V6 = 5th intercostal space on left, in line with mid axilla.
Diagram on slide 59.
Clinical or portable ECGs
Kardiamobile
Smart watches
Echocardiograms
Non-invasive measurement of the heart to determine heart structure and hemodynamics.
-many versions exists, such as cardiac ultrasounds.
Create an image of the heart to view valves, chambers, or signs of congenital heart defects.
Can do echos at rest, or during exercise (stress echocardiogram).
Can show damage to valves (regurgitation, stenosis, prolapse).
Can show ejection fractions of the heart.
-indicates how effectively your heart pumps blood with each contraction.
-it specifically measures the percentage of blood that is pumped out of the left ventricle.
-lower % if myocardium is damaged by MI or weakened by heart failure cardiomyopathy.
-normal function = 50-70% EF
-below average function = 35-50% EF
-low function = <35% EF
Main Types of Echocardiograms
Transthoracic (TTE)
Stress echo
Transesophageal
Fetal echo
3D echo
Transthoracic (TTE)
Ultrasound on skin to see into chest cavity, non-invasive
Stress echo
Echo done in exercise medically induced stress.
Transesophageal
Transducer of ultrasound is passed through esophagus
Fetal echo
Done to see fetal baby’s heart
3D echo
Created 3D image of heart.
Exercise Test for Cardiac Conditions
Submaximal VO2 testing
Can include field tests, treadmill tests, cycle ergometer tests, step tests, graded exercise tests, sign and symptom limited stress tests.
Make it client specific = choose based on client functional ability, goals, safety, client preference.
Ensure termination criteria is known
Test Termination Criteria
Onset of angina-like symptoms.
Drop in SBP of >10mmHg with an increase in work rate or if SBP decreases below the value obtained in the same position prior to testing.
Excessive rise in BP = systolic pressure >250mmHg and/or diastolic pressure >115mmHg.
Shortness of breath, wheezing, leg cramps, or claudication.
Signs of poor perfusion = light-headedness, confusion, ataxia, pallor, cyanosis, nausea, or cold and clammy skin.
Failure of HR to increase with increase exercise intensity.
-many cardiac clients will have a blunted HR response to exercise due to medication, but HR should still rise with increases of exercise intensity.
Noticeable change in heart rhythm by palpation or auscultation.
Subject requests to stop.
Physical or verbal manifestations of severe fatigue.
Failure of the testing equipment.
Other possible termination criteria includes pre-determined %HRmax or HRR reached, pre-determined RPE/RPB reached, ECG abnormalities.
Exercise Tests for Cardiac Conditions
*general cardiac testing protocol and graded exercise test/signs and symptoms limited test protocol in notes.
6 min walk test
Rockport 1 mile walk test
Treadmill walk test
Graded exercise test or sign and symptom limited test
-can be done on treadmill or stationary bike.
mCAFT step test
-client may not be able to achieve 85% predicted HR max.
YMCA 3min step test
-client may not be able to step at required cadence, in this case another test would be more beneficial.
Other tests may be more appropriate depending on the client (ie. more fit or younger population).
-use your clinical decision making to determine waht test would be the best to use based on the client.
