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Cardio Pulm Eval > Cardiac Rehab > Flashcards

Cardiac Rehab Flashcards

1
Q

What does early mobilization show

A
  • improved mortality rates
    – Mediated through cardiopulmonary effect
    – Reduced “complications” of hospitalization
    – Quicker recovery
    – Shorter stay
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2
Q

what is cardiac rehab?

A

A comprehensive program of progressive exercise & education designed to optimize a patient’s recovery from cardiovascular disease

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3
Q

Joint Statement by AHA, US Dept. of Health & Human
Services and Agency for Health Care Policy:

A

“comprehensive, long term program involving
medical evaluation, prescribed exercise,
cardiac risk factor modification, education &
counseling”

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4
Q

Which patients qualify for rehab based on the Medicare Guidelines?

A

– MI
– Heart failure
– Cardiac transplantation
– Angina
– CABG
– Valve replacement or repair
* Diagnoses that may qualify:
* CAD w/ angioplasty or stent

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5
Q

do all medicare patients who need CR get it?

A

no- only 11-30%

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6
Q

indications for cardiac rehab

A
  • medically stable post MI
  • stable angina
  • coronary artery bypass graft surgery
  • percutaneous transluminal coronary angioplasty
  • stable heart failure caused by either systolic or diastolic dysfunction (cardiomyopathy)
  • heart transplantation
  • valvular heart disease/surgery
  • PAD
  • At risk for CAD with DM, dyslipidemia, HTN, or obesity
  • other pts who may benefit
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7
Q

Benefits of cardiac rehab

A
  • Improved exercise tolerance
  • Improvement in symptoms
  • Improved blood lipids/BP/ clotting
  • Reduction in smoking
  • Improved psychological well being
  • Reduced mortality
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8
Q

what is included in cardiac rehab?

A

▪ Education: teach patient about HD, exercise, risk
factors, diet, medication, lifestyle changes.
▪ Risk Factors Reduction
▪ Exercise: structured and progressive
▪ Vocational/psychological counseling

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9
Q

Phase one of cardiac rehab

A

Phase I or acute phase:
– begins when patient enters ICU/CCU or step-down unit

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10
Q

Phase II of cardiac rehab

A

subacute /outpatient recovery phase:
– According to Medicare, phase II refers to outpatient
medically supervised programs that are typically initiated
1-3 weeks after D/C and provide ECG monitoring

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11
Q

Phase III of cardiac rehab

A

According to Medicare, refers to maintenance programs
without physician supervision and monitoring.

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12
Q

time frame and facility for Phase I CR

A

▪ Time Frame: 4 - 7 days
▪ Facility: hospital ICU or Step down unit

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13
Q

goals of phase I CR

A

– prevent secondary effects of bed rest
– identify risk factors
– initiate patient & family education

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14
Q

Phase I CR exercise

A
  • Exercise intensity: 1-3 METS,
    – HR 12-25 bpm above resting HR
  • Exercise duration: intermittent (5-15 min)
  • Frequency: 7-day coverage
  • Exercise mode: Bilateral UE & LE ROM
    progressing to 1-2 lbs weights, ambulation, stairs,
    bike, breathing ex
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15
Q

Phase I exercise testing

A

postpone or sub-maximal exercise test

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16
Q

What all is included in phase I Cardiac rehab

A

–Acutely ill patients seen bedside, or hallway
–Ensure medical clearance
–Day to day reassessment of function required.
–Patient education: coughing, deep breathing, sternal precautions,
etc…
–Basic exercise program in bed (AROM)
–Bedside dangle, standing at bed side
–Transfers
–Ambulation/ stairs
–D/C planning (to step down or subacute floor)

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17
Q

Transfer patient out of bed or to sitting at
side of bed

A
  • Check vitals and EKG at rest in bed
  • Explain what you are about to do to the patient
  • Get organized first:
    – Inform nursing
    – Move catheter, IV, monitors and chest tube collection box
    – Have walker/chair ready
    – Review precautions
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18
Q

Transfer post open heart surgery patient out of bed or to sitting at side of bed

A

Log roll technique, hug pillow, sternal precautions

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19
Q

ACSM Guidelines for cardiac patients

A
  • Frequency, Intensity, Time & Type (FITT)
    – 2022 Intensity limitations for acute phase cardiac rehab:
  • PRE < 13 (on 6-20 Borg Scale)
  • Post MI: HR < resting + 20
  • Post surgery: HR < resting + 30
  • Generally for cardiac patients, keep HR < 120 bpm
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20
Q

Contraindications

A

slide 125

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21
Q

Education in Phase I contraindications

A

– No lifting > 5-10 lbs… vs MIT,
– No forceful use of UE or Ab-duction (example: do not
use axillary crutches for patient s/p CABG)

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22
Q

Education in Phase I Rx

A

Exercise on their own or with help form family
– Elevate LE,
– Sit up QD,
– Ambulate BID/TID,
– Perform ankle pumps, SLR, UE ROM

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23
Q

Education in Phase I

A
  • education on disease process
  • Risk factors (diet, smoking, sedentary lifestyle)
  • Role of exercise and activity guidelines (warm up,
    monitor HR, get to target HR, etc)
  • Medication effects on exercise
  • Teach cough technique & self monitoring
  • What to do in case of emergency
  • “Pep talk” on the importance of continuing exercise and
    need to make “life style changes” slowly, over time
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24
Q

move in the tube

A

minimal sternal complications, providing evidence that modified sternal precautions are safe and can benefit patient

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25
Q

Phase II Cardiac Rehab

A
  • Out-patients or people in skilled or rehab unit who require exercise supervision and monitoring to regain full
    function.
  • Require further instruction in self- monitoring and HEP to
    be independent with it.
  • Require further counseling/education to make life style changes
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26
Q

Phase III Cardiac Rehab

A
  • Outpatients requiring less supervision and
    monitoring.
    – Once a week- 3 x/week
    – Phase III: monitoring during exercise, Phase IV:
    weekly/monthly EKG/vital sign checkups.
    – Exercise specialist in charge of advancing
    program and making changes in program as
    symptoms/ex tolerance changes
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27
Q

Assessment

A
  • Part of cardiac rehab which requires the most
    skill/judgment:
    – Perform complete eval, but focus on CV fx
  • What level of exercise will induce beneficial
    changes, but be safe for the patient
    – Need to get to some threshold for benefits
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28
Q

The CCU Medical Chart Review

A
  • Admitting diagnosis, age and date of admission
  • Pt’s signs & symptoms (progress notes)
  • PMH/PSH- progress notes & surgery notes
  • Labs- lab section
  • Meds- physician orders
  • Social Hx. (prog report pt. assessment)
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29
Q

Exercise Prescription

A

An exercise program given to the patient as a result
of an assessment that allows for safe progression in
exercise tolerance and maximizes benefits for an
individual patient.
– Exercise mode
– Duration
– Intensity
– Frequency
– Method of self assessment

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30
Q

What should exercise prescription be based on?

A
  • Based on chart review, labs, tests, exercise testing,
    pt. assessment & pt’s risk status
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31
Q

Exercise prescription mode of exercise

A

– aerobic
* walking
* A-ROM/low resistance-isotonic exercises
* ergometer/biking
* other forms of exercise
– strength training
* weights
* isometric exercise (not good 20 to BP changes)

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32
Q

exercise prescription intensity

A

based on HR and HRR

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33
Q

exercise prescription duration

A

progressive, rest as needed

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34
Q

Modified exercise testing skip this card is dumb

A

You don’t want to bring pt. to
max HR (or even to close) in first week after MI or CABG

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35
Q

exercise testing in clinic first week after cabg or mi

A
  • Warm up with A-ROM or light resistance isotonic exercise.
  • Monitor HR via pulse as pt. performs progressive aerobic
    exercise.
    – Walking down the hall, walking in place (if tubes/lines
    don’t permit pt to ambulate), etc…
  • Stop and measure pulse every 2 minutes
    – how long to return to baseline?
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36
Q

exercise testing in the clinic for acutely ill or patients recovering from recent surgery

A

– Use simple sub-maximal HR (HR after walking x
10, 20, 50 ft…), which does not cause symptoms as
lower end of target HR:
– Target HR zone will be 5 bpm above and below this
value

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37
Q

Review Borg Scale

A
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38
Q

Cardiopulmonary physical assessment

A
  • General appearance
  • Vital signs: BP :100-140/70-90, HR 60-100
  • Auscultation of the heart: S1, S2, S3, S4 murmur
  • Signs of peripheral edema: JVD, swelling
  • Signs of hypoxia: cyanosis, clubbing
  • Signs of CHF: crackles, SOB, orthopnea
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39
Q

Cardiopulmonary physical exam

A
  • Examination of extremities
  • ROM
  • Strength
  • Neuro exam (more in-depth neuro exam if indicated)
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40
Q

Epidemiology of Coronary heart disease

A

▪Most prevalent dx in US & industrialized nations
▪Accounts for ~ 50% of all deaths in US
▪Total # of deaths from CHD has declined over past
decade, but morbidity increased

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41
Q

Framingham Heart Study

A

showed that CHD starts
in 2nd decade & ID’d risk factors

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42
Q

Atherosis

A

accumulation of cholesterol in
macrophages
▪ once mature plaques (fibrous) form, difficult to
reverse

43
Q

Sclerosis

A

inflammatory reaction in media with loss
of distensibility & compliance

44
Q

Modifiable Risk Factors

A

▪ Smoking
▪ Hypertension
▪ most prevalent risk factor in US
▪ BP > than 140/90- increased risk 2º sheer stress on
arteries
▪ Elevated Cholesterol
▪ High LDL and /or total cholesterol, low HDL
▪ Physical Inactivity
▪ Obesity or overweight
▪ Diabetes (blood glucose)

45
Q

non modifiable risk factors

A
  • Family History -
    – hypercholesterolemia
    – familial hypertrophic cardiomyopathy
  • Previous History of Heart Disease
  • Age -
    – age > 65 y/o, but depends on other factors
  • Gender - males have 6 x risk of MI compared to females (< 55
    y/o)
    – But MI is 2nd leading cause of death in females < 45 y/o
    – After menopause, risk for males & females is nearly equal
46
Q

patients with chronic stable angina typically have what kind of lesions

A

concentric

47
Q

patients with unstable angina typically have what type of lesions?

A

eccentric

48
Q

sudden death

A

20-25 % pt’s w/ CHD die w/in 1 hr

49
Q

what is angina

A

imbalance in O2 supply and demand

50
Q

chronic stable angina

A
  • no pain at rest
  • predictable symptoms depending on level of
    exertion
  • increased mortality
51
Q

unstable angina

A

even greater mortality risk than with stable angina

52
Q

unstable angina signs and symptoms

A

▪ Angina at rest
▪ Occurrence of angina at lower level of
activity then usual
▪ Deterioration of previously stable pattern- pain more
often, increased Nitro use
▪ Evidence of loss of myocardial reserve-
decreased distance walked, shorter time to fatigue

53
Q

hospital management of patients with acute MI in first 24 hours

A

▪ Continuously monitored (death occurs in first 24 hr in 25% of
cases)
– EKG: calibrated 12 lead EKG at all times
– Cardiac enzymes every 12 hours
– Monitor physical activity (absolute minimal activity for
12 hours, minimize stress on the heart)
– Echo: check for mural thrombus

54
Q

Procedures/Rx in First 24 Hours after mi

A
  • Pain and/or anxiety should be Rx with analgesics
  • Emergency preparations should be immediately available
    (atropine, lidocaine, TC-pacing patch, defibrillator & epinephrine)
  • Thrombolytics, GP2a/3b or Heparin
    – -break-up clot versus prevent further clot formation
  • Drug Rx: aspirin, -blockers (especially pts w/ ST-elevation),
    nitrates, ACE-inhibitor
  • Calcium channel blockers contraindicated in first 24 hr
55
Q

Immediate Surgical Intervention

A
  • Failed percutaneous transcoronary angioplasty (PTCA) w/ CP
  • Persistent or recurrent ischemia refractory to medical stability
    but not candidate for catheter intervention
  • Cardiogenic shock & coronary artery disease not amenable to
    PTCA
  • Mechanical abnormalities leading to severe pulm congestion or
    hypotension
  • Papillary muscle rupture
56
Q

Risk Stratification after MI- Level I

A

uncomplicated-low risk: pts with:
– small-moderate infarct
– no ischemia or LV failure, shock, serious arrhythmia,
conduction disturbances or serious illness by day 4

57
Q

Risk Stratification after MI- Level 2

A

uncomplicated-mod risk: pts who:
– later (day 2-4) develop poor ventricular function, decreased
cardiac reserve or serious arrhythmia

58
Q

Risk Stratification after MI- Level 3

A

pt with:
– one or more of characteristics listed in uncomplicated MI

59
Q

Endocarditis/myocarditis:

A

▪ bacterial, viral or noninfectious inflammation of
endocardium or myocardium

60
Q

Heart valve disease

A

▪ mitral valve prolapse: mitral valve incompetence.
▪ Rx with valve replacement, valvulotomy (incision of valve) and
commissurotomy (separation of leaflets)
▪ aortic valve insufficiency, regurgitation & stenosis:
▪ valve rupture (chordae tendinea)

61
Q

drug induces cardiomyopathy

A

Often associated with chemotherapy
▪ Anthracyclines (most often- doxorubicin)

62
Q

Prinzmental angina

A

coronary vasospasm

63
Q

CHF is characterized by elevated pulmonary venous pressure - R vs L

A

▪ Right HF- primarily pulmonary congestion
▪ Left HF- primary systemic congestion

64
Q

Prevalence of HF

A

▪ age 55-59 — 1%
▪ but increases to 10% by 80-89 years of age

65
Q

Causes of HF

A

▪ MI or ischemia
▪ Arrhythmia
▪ Renal dysfunction
▪ Cardiomyopathy
▪ Heart valve disease
▪ Pericardial effusion/ myocarditis
▪ Pulmonary embolism (PE)
▪ SCI
▪ Congenital abnormalities
▪ Aging

66
Q

HF facts and prognosis

A

slide 159

67
Q

Stratifying patients with HF

A

slide 160

68
Q

slide 161

A
69
Q

dilated cardiomyopathy

A

ventricle enlarges, but wall thins
− Wall tension must increase

70
Q

concentric hypertrophic cardiomyopathies

A

wall thickens
− May restrict filling

71
Q

Restrictive cardiomyopathy

A

Decreased relaxation, Ex. cardiac tamponade

72
Q

consequences of dilation

A

▪ Energetic disadvantage
▪ Stasis of blood
▪ Perfusion problems
▪elevated EDP limits perfusion in diastole
▪ Arrhythmia’s:
▪atrial fibrillation, heart block

73
Q

Pulmonary edema in CHF

A

– This is often the earliest and primary finding, but may be subtle
– Fluid backs up into pulmonary venous system, leaking into alveoli

74
Q

symptoms of pulmonary edema

A
  • Dyspnea,
  • Exercise intolerance,
  • Orthopnea (inability to lie flat due to SOB),
  • Atelectasis (local collapse of lung)
  • Frothy blood-tinged sputum
  • Non-productive cough
  • Increased RR/tachypnea (normal = 12-18/20, but concern when RR >24 bpm)
  • Paroxysm nocturnal dyspnea
75
Q

how is pulmonary edema managed?

A

pharmacologically with beta blockers, diuretics, and
vasodilators

76
Q

what might pulmonary edema progress to

A

left side and global heart failure
* Systemic venous HTN, ankle swelling, JVD

77
Q

PT Clinical Practice Guidelines for Pts with HF

A

slide 167 key phrases

78
Q

CHF Sxs

A

Dyspnea
* Tachycardia
* Paroxysm nocturnal
dyspnea
* Orthopnea
* Peripheral edema
* Weight gain
* Hepatomegaly
* Crackles
* Presence of S3 or S4
heart sound
* Sinus tachycardia
* Decreased exercise
tolerance
* JVD

79
Q

what to do in event of heart failure

A

▪ Be prepared!
▪ Crash cart
▪ O2
▪ Nitroglycerine
▪ Know your CPR
▪ Good Clinical Judgment:
▪ Know went to listen to patient vs…. push patient to
participate.
▪ Advance patient as appropriate

80
Q

Steps in Designing an Exercise Program
for a Patient with HF

A

– Establish baseline HR, EKG, BP, O2 sat.
– Set target HR (or max safely attainable HR) for
exercise or activity level
– Monitor patient during exercise
– Give adequate rest intervals
– Record HR, BP, EKG, SAO2 and note changes
– Adjust goals/expectations & target HR appropriately

81
Q

anemia with HF

A

often associated with HF
▪paradoxically, may increase CO by decreasing blood viscosity
▪decreases O2 delivery to tissues & heart itself

82
Q

renal failure with HF

A

▪an underlying cause of HF & hypervolemia
▪can be a result of HF secondary decrease CO

83
Q

cardiac tamponade

A

fluid in pericardial space inhibits ventricular filling

84
Q

long term management of HF

A
  • Before D/C, all pts should receive exercise testing (stress treadmill is
    gold standard, but often not realistic for in-patients)
    – 4-7 days for submaximal test
    – 10-14 days for symptom limited test
  • Indefinite Rx w/ ACE-inhibitors, beta-blockers, diuretics
  • Education to attain ideal weight
  • Education regarding reduction in blood chol. and LDL and elevation
    in HDL
  • Smoking cessation
  • Participation in formal cardiac rehab program
85
Q

outcome measures for HF rehab

A
  • gait speed
  • 6 min walk test
  • 3MWT, 5xSTS, TUG, sub and max treadmill/ergometer tests
86
Q

what are pacemakers

A

electronic impulse generator that takes over as the
SA node

87
Q

when is a pacemaker indicated

A

when hemodynamic effect of arrhythmia is either
dangerous or symptomatic

88
Q

what can pacemakers help?

A

– Used to Rx A-Fib, heart block and ventricular dysrhythmias
– Post Sx when normal SA node function is suppressed or
conduction abnormality develops

89
Q

are pacemakers unipolar or bipolar

A

can be either

90
Q

power of pacemakers

A

lithium: 6 years
nuclear (12 years)

91
Q

placement of pacemaker

A
  • endocardial power source in L infraclavicular pocket
  • tip in contact w/ R atrium
92
Q

EKG with pacemaker

A

Vertical spike right before the P wave is indicative of a pacemaker

93
Q

epicardial lead implantation

A

during Sx, electrodes are sewn into myocardial surface
and exit either below xiphoid (temporary) or go to power
source in a subxiphoid pocket

94
Q

endocardial implantation

A

placed intravenously into the R atrium, but can also
perivenously (through the vessel)

95
Q

materials for pacemaker

A

highly flexible multi strand wires

96
Q

Functions of pacemakers

A

▪ Inhibit or trigger a depolarization:
▪ Hyperpolarize membranes
▪ Suppress tachycardia
▪ Demand: increase rate w/ increased endogenous atrial firing rate
(rate-modulation capability)
▪ Allows increase in HR with activity

97
Q

Contraindications with pacemakers

A
  • Electrical interference:
  • Microwaves, diathermy, MRI, etc…
  • E-stimulation: could be lethal!
  • US over the power source
  • L UE abduction/flex past 90° until healed
98
Q

HF often leads to “dyschroynization” of the heart

A
  • Associated with atrial fibrillation and other electrical abnormalities
  • Right & left ventricles depolarizing and beating at different rates
    and out of time:
  • Exacerbates HF
  • Increases risk of “sudden cardiac death”
99
Q

Cardiac resynchronization therapy

A

– Cardiac resynchronization therapy (CRT) has been shown to
decrease symptoms of HF & risk of SCD
* Improves LF function, ejection fraction and Ex tolerance
– May actually induce ventricular remodeling (toward normal)
– Benefits shown by numerous RCTs
– Now considered “class I indication for HF patients” with wide
QRS (key Dx sign), poor LV function and sinus dysrhythmia

100
Q

How is CRT accomplished?

A

with a biventricular pacing system
– Often difficult to achieve a good balance between synchrony
and heart rate
* Dysrhythmias in HF tend to be tachyarrhythmia and it is difficult to
slow the pace with a pacemaker
* Therefore, “ablation therapy” sometimes has to be done along with
biventricular pacing
* Alternately anti-arrhythmic medications have to be used to slow the
intrinsic rate

101
Q

cardiac defibrillators

A

implantable defibrillators to prevent “sudden cardiac death” in
patients with dysrhythmias

102
Q

what do cardiac defibrillators do?

A

Deliver a shock via implanted electrodes either in apex of R
ventricle or outside heart
– Often ICD is also a pacemaker and delivers CRT

103
Q

can you use e stim, ultrasound, etc with cardiac defibrilator?

A

no

104
Q

Pacemakers/CRT/ICD all used with HF
Patients with MetX & Obesity

A

185

Cardio Pulm Eval (10 decks)

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