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Diagnosis and Management > Cardiac Rehabilitation > Flashcards

Cardiac Rehabilitation Flashcards

1
Q

Goals of This Talk

  • Learn the basic te_____ of exercise physiology
  • Learn basic principles of Cardiac Rehab (CR)
  • Learn needed t____ to allow for CR
  • Learn the con_____ that are treated as an outpatient
  • Learn the array of delivery methods for CR
A
  • Learn the basic terminology of exercise physiology
  • Learn basic principles of Cardiac Rehab (CR)
  • Learn needed testing to allow for CR
  • Learn the conditions that are treated as an outpatient
  • Learn the array of delivery methods for CR
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2
Q

Background and Significance

  • Cardiac Rehabilitation is an important treatment for ___ stages of cardiac disease
    • Has role in less severe disease as well
      • Primary and secondary pr_____
    • M___faceted approach
    • Must use in combination with ____ management and b____ modification
    • Can help to prolong life and improve outcomes
A
  • Cardiac Rehabilitation is an important treatment for all stages of cardiac disease
    • Has role in less severe disease as well
      • Primary and secondary prevention
    • Multifaceted approach
    • Must use in combination with medical management and behavioral modification
    • Can help to prolong life and improve outcomes
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3
Q

Basic Terms

  • Aer____ Capacity
  • Cardiac Output
  • Heart Rate
  • Stroke Volume
  • Myocardial Oxygen Consumption
A
  • Aerobic Capacity
  • Cardiac Output
  • Heart Rate
  • Stroke Volume
  • Myocardial Oxygen Consumption
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4
Q

Question #1

Exercise capacity is commonly described in terms of:

  1. Work of breathing
  2. Volume of carbon dioxide produced
  3. Metabolic equivalents
  4. Joules/watt hour
A
  1. Metabolic Equivalents
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5
Q

Assessment of Demands of Cardiac Activities

Typically described in terms of metabolic equivalents

1 MET = ___ mL O2/Kg weight/min

  • Use of standardized MET tables can help assess independence AND G_____
  • Help to establish dis_____ and support needs
  • Often use ____ rate to determine intensity
  • __ mets = sawing down a tree
  • __ mets = sexual activity with usual partner (2 flights of stairs)
  • __ mets = sexual activity with unfamiliar partner (4 flights of stairs)
  • __ mets = construction work
  • _- _ mets = office work
A

1 MET = 3.5 mL O2/Kg weight/min

  • Use of standardized MET tables can help assess independence AND GOALS
  • Help to establish disability and support needs
  • Often use heart rate to determine intensity
  • 12 mets = sawing down a tree
  • 4 mets = sexual activity with usual partner (2 flights of stairs)
  • 6 mets = sexual activity with unfamiliar partner (4 flights of stairs)
  • 8 mets = construction work
  • 2-3 mets = office work
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6
Q

Functional ETT (exercise tolerance test) Protocols

  • Numerous protocols
    • Balke-Ware, Naughton, Bruce, others
  • Basic principles
    • Staged lev____
    • Done in con______ setting
    • Tr_______ most common
A
  • Numerous protocols
    • Balke-Ware, Naughton, Bruce, others
  • Basic principles
    • Staged levels
    • Done in controlled setting
    • Treadmill most common
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7
Q

Diagnostic ETT Testing

(treadmill)

  • Ph_______ Stress
    • Dobutamine/adenosine/persantine tests
  • Alternate diagnostic criteria
    • Echocardiography
    • Nuclear Imaging
    • MRI, and others
  • Often done off or on limited meds to provoke events/ischemia
  • But in rehab we want to see max HR to see exercise tolerance not looking for ischemia (f_______ vs. diagnostic test)
A
  • Pharmacologic Stress
    • Dobutamine/adenosine/persantine tests
  • Alternate diagnostic criteria
    • Echocardiography
    • Nuclear Imaging
    • MRI, and others
  • Often done off or on limited meds to provoke events/ischemia
  • But in rehab we want to see max HR to see exercise tolerance not looking for ischemia (functional vs. diagnostic test)
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8
Q

Pros/Cons of Diagnostic ETT for Cardiac Rehab

  • Can assess cardiac r___
  • Help di_____ issues to be treated
  • However
    • Often not useful for setting (1) guidelines
    • Can’t assess fu______ response to exercise
    • Unless done on ____, can’t asses status for PT
    • Does not allow for evaluation of re_____ and post exercise risks
A
  • Can assess cardiac risk
  • Help diagnose issues to be treated
  • However
    • Often not useful for setting heart rate guidelines
    • Can’t assess functional response to exercise
    • Unless done on meds, can’t asses status for PT
    • Does not allow for evaluation of recovery and post exercise risks
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9
Q

Other Diagnostic Studies for CR

  • Baseline cardio____
  • Assessment of is_____ for those with CAD
  • Arr_____ risk assessment
  • Consideration of __VD
    • Can seriously limit progress in a conditioning program
  • Management of C_ _
  • Overall cardiac rehab is very safe 1 event/100k hours of exercise
A
  • Baseline cardiogram
  • Assessment of ischemia for those with CAD
  • Arrhythmia risk assessment
  • Consideration of PVD
    • Can seriously limit progress in a conditioning program
  • Management of CHF
  • Overall cardiac rehab is very safe 1 event/100k hours of exercise
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10
Q

Question #2

Aerobic training in cardiac rehabilitation is done:

  1. Only in patients who have ischemic disease
  2. At low levels of <50% maximum capacity
  3. only after a full level exercise test is done
  4. as either continuous or interval training
A

Answer: 4

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11
Q

Principles of Aerobic Training

  • Intensity
    • __% Max HR is a target in normal individuals
    • __% Max HR is a target in diseased individuals
  • Duration
    • __-__ minutes of aerobic exercise
  • Frequency
    • __ to __ times/week
  • Specificity
    • Should be t____ specific
A
  • Intensity
    • 85% Max HR is a target in normal individuals
    • 60% Max HR is a target in diseased individuals
  • Duration
    • 20-30 minutes of aerobic exercise
  • Frequency
    • 3 to 5 times/week
  • Specificity
    • Should be task specific
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12
Q

Effects of Aerobic Training

  • __creased
    • Aerobic Capacity
    • Cardiac Output
    • Stroke Volume
  • __creased
    • Heart Rate
    • Myocardial Oxygen Consumption
  • Remember: CO = HR x SV
A
  • Increased
    • Aerobic Capacity
    • Cardiac Output
    • Stroke Volume
  • Decreased
    • Heart Rate
    • Myocardial Oxygen Consumption
  • Remember: CO = HR x SV
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13
Q

Benefits of Aerobic Training

  • An____ decreases
  • Reversal of les___
  • Blood pressure __creases
  • Ex_____ tolerance increases
  • Decreased de______/a_____
  • Resting heart rate ___creases
  • Improved q____ of life
A
  • Angina decreases
  • Reversal of lesions
  • Blood pressure decreases
  • Exercise tolerance increases
  • Decreased depression/anxiety
  • Resting heart rate decreases
  • Improved quality of life
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14
Q

Classical Rehabilitation Post MI

  • Classical program designed by Wenger
    • Historically important, no longer used
    • 14 day in hospital program after acute MI
    • Current programs shorter - _-_ days
  • Overall program divided into four phases
    • Ac___ - I
    • Con______ - II
    • Tr______ - III
    • Main______ - IV
A
  • Classical program designed by Wenger
    • Historically important, no longer used
    • 14 day in hospital program after acute MI
    • Current programs shorter - 3-5 days
  • Overall program divided into four phases
    • Acute - I
    • Convalescent - II
    • Training - III
    • Maintenance - IV
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15
Q

Current Cardiac Rehab Schema

  • Overall program divided into three phases
    • Ac____ – Phase 1
    • Tr_______ – Phase 2
    • Man_______ – Phase 3
A
  • Overall program divided into three phases
    • Acute – Phase 1
    • Training – Phase 2
    • Maintenance – Phase 3
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16
Q

Phase 1: Acute

  • Begins in coronary care unit (CCU)
  • ____ Mobilization
    • CCU to __ flights of stairs in
  • Tel______ monitoring at each stage of increased activity
  • Begin patient ed_____ at this time
  • Ends at dis_____ from hospital
  • Low level _______ test prior to discharge
A
  • Begins in coronary care unit (CCU)
  • Early Mobilization
    • CCU to 2 flights of stairs in < 2 weeks
  • Telemetry monitoring at each stage of increased activity
  • Begin patient education at this time
  • Ends at discharge from hospital
  • Low level stress test prior to discharge
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17
Q

Newer Views on Acute Cardiac Rehabilitation (Phase 1)

  • Patients now often have pro_____ post MI
  • Multiple co_____ may exist
  • Survivors of major events with severe debility
    • Long ICU stays
    • Critical illness complications
    • Severe CHF/low EF
  • Phase 1 may be pro_____ in these settings.
A
  • Patients now often have procedures post MI
  • Multiple comorbidities may exist
  • Survivors of major events with severe debility
    • Long ICU stays
    • Critical illness complications
    • Severe CHF/low EF
  • Phase 1 may be prolonged in these settings.
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18
Q

Question #3

For patients with cardiac disease there is:

  1. a role for mixed rehabilitation for patients with complex disease and comorbidity
  2. a defined program of training that progresses from inpatient to home program
  3. a need for all patients to have an inpatient program prior to starting as an outpatient
  4. no role for inpatient rehabilitation after a hospitalization
A

Ans: 1

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19
Q

Extended Phase 1: Phase 1B

  • Continued __patient hospitalization for rehab
  • (1) or (1) rehab settings
  • Usually in patients with advanced needs
  • Goals
    • Safe independent function at ____
    • Prep_____ for phase 2 rehab program
A
  • Continued Inpatient hospitalization for rehab
  • Acute or subacute rehab settings
  • Usually in patients with advanced needs
  • Goals
    • Safe independent function at home
    • Preparation for phase 2 rehab program
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20
Q

Medical Indications for Phase 1B Cardiac Rehabilitation

  • Comorbidity
    • Str____
    • Amp_____/Vascular Disease
    • Advanced A__
    • Severe Decon______
  • Prolonged ____ Stay and Recovery
  • Inability to Progress to Amb_____
A
  • Comorbidity
    • Stroke
    • Amputation/Vascular Disease
    • Advanced Age
    • Severe Deconditioning
  • Prolonged ICU Stay and Recovery
  • Inability to Progress to Ambulation
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21
Q

Medical Indications for Phase 1B Cardiac Rehabilitation

  • Com____ Patient Populations
    • Post Tran_____
    • Complex Cardiac Surgical Patients
  • Severe Congestive (1)
    • When on Stable Regimen
  • Severe Cardiac Arr______
    • Only after adequate control is achieved
A
  • Complex Patient Populations
    • Post Transplant
    • Complex Cardiac Surgical Patients
  • Severe Congestive Heart Failure
    • When on Stable Regimen
  • Severe Cardiac Arrhythmias
    • Only after adequate control is achieved
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22
Q

Prescription Writing for Phase 1B Cardiac Rehabilitation

  • Standard Prescription Rules Apply
    • Diagnosis
    • Prec_____
    • G____
    • Exercises
      • Aer____ Conditioning
      • Str_____ of Upper and Lower Extremities
      • Str_____ Program
    • Mon_____ Guidelines
A
  • Standard Prescription Rules Apply
    • Diagnosis
    • Precautions
    • Goals
    • Exercises
      • Aerobic Conditioning
      • Strengthening of Upper and Lower Extremities
      • Stretching Program
    • Monitoring Guidelines
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23
Q

Goals for Phase 1B Cardiac Rehabilitation

  • Improve Fun______
  • Improve Fit_____
  • Improve Ex_____ response
  • Improve Self-Im____
  • Return to N_____ Activities
  • Decrease Morb____
  • Prevent Comp_______
A
  • Improve Function
  • Improve Fitness
  • Improve Exercise response
  • Improve Self-Image
  • Return to Normal Activities
  • Decrease Morbidity
  • Prevent Complications
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24
Q

Overview of Phase 1B Programs

  • Can Safely Establish a Phase 1B Program in Existing Rehabilitation Facilities
  • Coordinate in a Multidisciplinary Approach
  • Basic Principles of Rehabilitation Apply
  • Must have Close Mon______ and Tightly Written Ex_____ Prescriptions
  • Rehabilitation Approach can Treat Multiple Co______ in Comprehensive Way
A
  • Can Safely Establish a Phase 1B Program in Existing Rehabilitation Facilities
  • Coordinate in a Multidisciplinary Approach
  • Basic Principles of Rehabilitation Apply
  • Must have Close Monitoring and Tightly Written Exercise Prescriptions
  • Rehabilitation Approach can Treat Multiple Comorbidities in Comprehensive Way
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25
Q

End of Phase 1: Home Discharge

  • Maintain ______ mobilization
    • Gradually increase en_____
  • Maximum heart rate as previously determined by low level ETT
  • In Classic program (phase II) a six week program to allow for scar formation
    • Exercise _-_ times per week at _-_ METs maximum
    • ___-___ minute sessions at target HR set by d/c ETT
    • 5 minute warm up/cool down sessions
A
  • Maintain early mobilization
    • Gradually increase endurance
  • Maximum heart rate as previously determined by low level ETT
  • In Classic program (phase II) a six week program to allow for scar formation
    • Exercise 3-5 times per week at 4-5 METs maximum
    • 20-30 minute sessions at target HR set by d/c ETT
    • 5 minute warm up/cool down sessions
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26
Q

Phase 2: Training

  • Classically (phase III) ___ weeks post MI, Sym____ limited full level ETT performed
    • Screen out arr____, is_____
    • Set target (1)
  • Now with revascularization, start as ____ as possible
  • Monitoring with each increase in level
  • Patient self monitoring
    • Borg Scale
    • Heart rate
A
  • Classically (phase III) 6 weeks post MI, Symptom limited full level ETT performed
    • Screen out arrhythmias, ischemia
    • Set target heart rate
  • Now with revascularization, start as soon as possible
  • Monitoring with each increase in level
  • Patient self monitoring
    • Borg Scale
    • Heart rate
27
Q

Phase 2: Training

  • Usual program as ___patient
    • __ sessions a week minimum
    • _-_ weeks in duration, can be longer
    • Up to __ hours per session
    • Cr____ training
    • Always start with warm up/cool down – 20-30 minutes on each piece of apparatus
  • Newer models may include at h___
A
  • Usual program as outpatient
    • 3 sessions a week minimum
    • 6-8 weeks in duration, can be longer
    • Up to 4 hours per session
    • Cross training
    • Always start with warm up/cool down – 20-30 minutes on each piece of apparatus
  • Newer models may include at home
28
Q

Phase 3: Maintenance

  • Most imp____ phase
  • Benefits of training can be lost in a few weeks of being sed____
  • Regular exercise necessary
    • Minimum of _ to _ times a week
    • At least __ minutes of exercise per session excluding warm up and cool down
    • Role for maintenance/wellness program
A
  • Most important phase
  • Benefits of training can be lost in a few weeks of being sedentary
  • Regular exercise necessary
    • Minimum of 2 to 3 times a week
    • At least 30 minutes of exercise per session excluding warm up and cool down
    • Role for maintenance/wellness program
29
Q

Question #4

Which is not a goal of secondary prevention in cardiac rehabilitation?

  1. smoking cessation
  2. weight reduction
  3. removal of atheromatous plaques
  4. diabetic control
30
Q

Secondary Prevention Goals in CR

  1. ______ cessation
  2. (1) Control: <140/90 mmHg or <130/80 in DM or renal disease •
  3. (1) control goals: LDL-C <100 mg/Dl for TG >200, non HDL-C <130 mg/Dl
  4. (1) activity: 30+ minutes for at least 5 days a week
  5. (1) management: BMI 18.5 to 24.9
    1. and waist <40 inches in men and <35 inches in women
  6. (1): HgbA1c <7%
  7. (1): Evaluate for depression
    1. If present => treat
  8. Exercise (1): Assess with ETT
    1. Develop individual training program
  9. (1): Assess current meds
    1. Assure b___ blockade
    2. Assure anti______ agent
    3. Assure ch_______ lowering agent
    4. Assess BP control medications
  10. Assess medication ad______ and knowledge
A
  1. Tobacco cessation
  2. BP Control: <140/90 mmHg or <130/80 in DM or renal disease •
  3. Lipid control goals: LDL-C <100 mg/Dl for TG >200, non HDL-C <130 mg/Dl
  4. Physical activity: 30+ minutes for at least 5 days a week
  5. Weight management: BMI 18.5 to 24.9
    1. and waist <40 inches in men and <35 inches in women
  6. DM: HgbA1c <7%
  7. Depression: Evaluate for depression
    1. If present => treat
  8. Exercise capacity: Assess with ETT
    1. Develop individual training program
  9. Medications: Assess current meds
    1. Assure beta blockade
    2. Assure antiplatelet agent
    3. Assure cholesterol lowering agent
    4. Assess BP control medications
  10. Assess medication adherence and knowledge
31
Q

ACC/AHA Secondary Prevention Goals

32
Q

Practical Issues

  • Classical program used prior to revascularization
  • Patients now with smaller initial MI
    • Sh_____ recovery
    • Re-vascularized at presentation
  • Available to ___ post MI patients, only offered to about 10-20% of patients
  • Limitations of acc_____ and re_____
A
  • Classical program used prior to revascularization
  • Patients now with smaller initial MI
    • Shorter recovery
    • Re-vascularized at presentation
  • Available to all post MI patients, only offered to about 10-20% of patients
  • Limitations of access and referral
33
Q

Exercise Prescription in CR

  • Use patient oriented guidelines
    • RPE = (1) is a great method for patients to self monitor
    • _____ rate targets also great
      • Easier now with wearable ____nologies
      • Can track activity levels as well.
A
  • Use patient oriented guidelines
    • RPE = rating of perceived exertion is a great method for patients to self monitor
    • Heart rate targets also great
      • Easier now with wearable technologies
      • Can track activity levels as well.
34
Q

Principles of Aerobic Training

  • Intensity in general terms
    • __% Max HR is a target in normal individuals
    • __% Max HR is a target in diseased individuals
    • Karvonen’s Technique of target heart rate
  • Duration: __-__ minutes of aerobic exercise
  • Frequency: _ to _ times/week
  • Specificity: Should be ____ specific
A
  • Intensity in general terms
    • 85% Max HR is a target in normal individuals
    • 60% Max HR is a target in diseased individuals
    • Karvonen’s Technique of target heart rate
  • Duration: 20-30 minutes of aerobic exercise
  • Frequency: 3 to 5 times/week
  • Specificity: Should be task specific
35
Q

Coverage for Outpatient Services

  • Most insurance carriers and Medicaid follow Medicare Guidelines
  • Only available for the following:
    • Post M___
    • Post C____, Post V____plasty
    • ______ Angina
    • Post tr_____
    • C___ (started 1/2015)
  • Not for Arrhythmias, other diagnoses
A
  • Most insurance carriers and Medicaid follow Medicare Guidelines •
  • Only available for the following:
    • Post MI
    • Post CABG, Post Valvuloplasty
    • Stable Angina
    • Post transplant
    • CHF (started 1/2015)
  • Not for Arrhythmias, other diagnoses
36
Q

New Frontiers in Cardiac Rehabilitation

  • Modified Cardiac Rehabilitation Programs
    • Spread over ____ than 12 weeks – up to 6 months for 366 sessions
  • Intensive Cardiac Rehabilitation
    • _____ the sessions in 12 weeks – 72 sessions
    • Big focus on ____style modification
  • At _____ cardiac rehabilitation
    • One benefit from COVID-19 emergency changes in care delivery
    • Has payment guaranteed through 12/31/2023
    • Same rates as in person CR
A
  • Modified Cardiac Rehabilitation Programs
    • Spread over more than 12 weeks – up to 6 months for 366 sessions
  • Intensive Cardiac Rehabilitation
    • Double the sessions in 12 weeks – 72 sessions
    • Big focus on lifestyle modification
  • At home cardiac rehabilitation
    • One benefit from COVID-19 emergency changes in care delivery
    • Has payment guaranteed through 12/31/2023
    • Same rates as in person CR
37
Q

Elements of an Outpatient Program

  • Medical s____vision
  • Trained staff - Phys_____/n____/PT’s
  • M_____ strength/endurance/flexibility training
  • Education components must be present
    • Nut_____ counseling
    • Sm_____ cessation
    • S_____ groups
    • Main_____ support
A
  • Medical supervision
  • Trained staff - Physiologists/nurses/PT’s
  • Mixed strength/endurance/flexibility training
  • Education components must be present
    • Nutritional counseling
    • Smoking cessation
    • Support groups
    • Maintenance support
38
Q

Basic Observations on Exercise

  • If exercise was a _______, it would be the highest selling pharmaceutical of all time
  • However, since exercise is _____, it is grossly underutilized for almost every condition for which it would be appropriate
A
  • If exercise was a medication, it would be the highest selling pharmaceutical of all time
  • However, since exercise is work, it is grossly underutilized for almost every condition for which it would be appropriate
39
Q

Rehabilitation in Special Situations

  • A____ Pectoris
    • Begin once?
    • Includes training and maintenance phases
  • Cardiac ________
    • Use limits set by ETT
    • Proceed normally in patients with AICD
      • Avoid AICD firing rate with stress testing and exercise program
A
  • Angina Pectoris
    • Begin once medical management optional
    • Includes training and maintenance phases
  • Cardiac arrhythmias
    • Use limits set by ETT
    • Proceed normally in patients with AICD
      • Avoid AICD firing rate with stress testing and exercise program
40
Q

Rehabilitation After Bypass Surgery

  • Immediate post op period
    • Mobilize starting POD #__
    • Pr______ mobilization POD 2-5
    • Discharge planning and exercise pre_____
  • Symptom limited ETT 3 to 4 weeks post surgery
  • Phase 2 when healing complete
  • Maintenance Phase 3
    • Three types of programs
      • Low, moderate, high intensity
A
  • Immediate post op period
    • Mobilize starting POD #1
    • Progressive mobilization POD 2-5
    • Discharge planning and exercise prescription
  • Symptom limited ETT 3 to 4 weeks post surgery
  • Phase 2 when healing complete
  • Maintenance Phase 3
    • Three types of programs
      • Low, moderate, high intensity
41
Q

Cardiomyopathy: Physiology

  • Patients with ______ fraction < 30%
  • Multiple medical problems
    • High risk of sudden _____
    • Deconditioned
    • Depressed
    • ___ endurance
    • F______
  • Altered physiology
  • Lack of normal response to exercise
    • Possible decrease in ejection fraction, stroke volume, and blood pressure
    • Cardiac _____ may not increase sufficiently to generate a dynamic exercise response
    • Can have pro_____ fatigue post exertion
A
  • Patients with ejection fraction < 30%
  • Multiple medical problems
    • High risk of sudden death
    • Deconditioned
    • Depressed
    • Low endurance
    • Fatigue
  • Altered physiology
  • Lack of normal response to exercise
    • Possible decrease in ejection fraction, stroke volume, and blood pressure
    • Cardiac output may not increase sufficiently to generate a dynamic exercise response
    • Can have prolonged fatigue post exertion
42
Q

Cardiomyopathy: Benefits of Rehabilitation

  • Increased o_____ extraction
  • _____ heart rate at submaximal exercise
  • Increased maximum ____load
  • Can improve fun______ level
A
  • Increased oxygen extraction
  • Lower heart rate at submaximal exercise
  • Increased maximum workload
  • Can improve functional level
43
Q

Cardiomyopathy: Rehabilitation Program Specifics

  • Pr________ warm ups and cool downs
  • Dy_____ exercise preferred over isometrics
  • Target heart rate ___ bpm below any significant endpoint
  • Start and advance under close s_______
  • Continuous t______ for severe left ventricular dysfunction
A
  • Prolonged warm ups and cool downs
  • Dynamic exercise preferred over isometrics
  • Target heart rate 10 bpm below any significant endpoint
  • Start and advance under close supervision
  • Continuous telemetry for severe left ventricular dysfunction
44
Q

Rehabilitation in Cardiomyopathy

  • Graded (1) test for all patients _____ starting exercise program
    • Rule out arr_____, an____, or atypical exercise response
  • Contraindications to rehabilitation (3)
A
  • Graded exercise tolerance test for all patients before starting exercise program
    • Rule out arrhythmias, angina, or atypical exercise response
  • Contraindications to rehabilitation
    • Unstable angina
    • Decompensated CHF
    • Unstable arrhythmias
45
Q

Rehabilitation in Valvular Heart Disease

  • Treat patients with congestive failure as those patients in cardiomyopathy
  • In presence of anticoagulation use low im____ exercises
  • After valve replacement surgery
    • Program is similar to post CABG patient
    • Training can increase work capacity by up to 60%, rate pressure product by up to 15%
A
  • Treat patients with congestive failure as those patients in cardiomyopathy
  • In presence of anticoagulation use low impact exercises
  • After valve replacement surgery
    • Program is similar to post CABG patient
    • Training can increase work capacity by up to 60%, rate pressure product by up to 15%
46
Q

Question #5

Patients with heart disease commonly also have which of the following conditions?

  1. peripheral vascular disease
  2. Cancer
  3. Myeloma
  4. schizophrenia
47
Q

Coincidence of Coronary and Peripheral Vascular Disease

  • High correlation of CAD with (1)
  • PVD affects up to 5% age < __ years
  • PVD affects over 20% age >__ years
  • PVD common in patients undergoing by____ surgery
A
  • High correlation of CAD with PVD
  • PVD affects up to 5% age < 50 years
  • PVD affects over 20% age >70 years
  • PVD common in patients undergoing bypass surgery
48
Q

Risk Factors for PVD

  • (1) is the major risk factor
  • Hyper____ceridemia
  • D____ M____
  • Elevated ch______
  • Overlap with C__ risk factors
A
  • Smoking is the major risk factor
  • Hypertriglyceridemia
  • Diabetes Mellitus
  • Elevated cholesterol
  • Overlap with CAD risk factors
49
Q

Exercise Rehabilitation for PVD

  • Historically ambulation where recommended? (1)
  • More recently supervised exercise on (1) or with other lower extremity exercises
  • Most recent work has been done with constant load treadmill protocols
A
  • Historically community ambulation recommended
  • More recently supervised exercise on treadmills or with other lower extremity exercises
  • Most recent work has been done with constant load treadmill protocols
50
Q

Exercise Training in PVD

Supervised ________ training most effective

  • Protocol devised by WR Hiatt, et al
    • Three sessions per week
    • 5 minute warm up and 5 minute cool down
    • Exercise at a level that creates ________pain in 3 to 5 minutes (as found from exercise test)
    • Gradual increase to >10 minutes over time
    • Increase speed and grade gradually to target of 3 miles per hour, 50 minute training session
  • Guidelines published by the American College of Sports Medicine
    • 20-30 minutes of interval exercise
    • Increase to 40-60 minutes over 4 to 6 weeks
    • Maximum heart rate as determined by exercise testing
    • Airdyne arm-leg ergometry, arm ergometry, water aerobic exercises are alternative exercises
A

Supervised treadmill training most effective

  • Protocol devised by WR Hiatt, et al
    • Three sessions per week
    • 5 minute warm up and 5 minute cool down
    • Exercise at a level that creates claudication pain in 3 to 5 minutes (as found from exercise test)
    • Gradual increase to >10 minutes over time
    • Increase speed and grade gradually to target of 3 miles per hour, 50 minute training session
  • Guidelines published by the American College of Sports Medicine
    • 20-30 minutes of interval exercise
    • Increase to 40-60 minutes over 4 to 6 weeks
    • Maximum heart rate as determined by exercise testing
    • Airdyne arm-leg ergometry, arm ergometry, water aerobic exercises are alternative exercises
51
Q

Outcomes of Exercise in PVD

  • Studies demonstrate
    • Average increase in ____ free walking distance of 134% , range from 44-290%
    • Average increase in peak walking t____ of 96%, range from 25-183%
    • Graded treadmill exercises show increases in maximum ____ consumption and maximum exercise per______
A
  • Studies demonstrate
    • Average increase in pain free walking distance of 134% , range from 44-290%
    • Average increase in peak walking time of 96%, range from 25-183%
    • Graded treadmill exercises show increases in maximum oxygen consumption and maximum exercise performance
52
Q

Cardiac Assessment in PVD

  • Standard treadmill and bicycle stress testing not possible if cl_____ limiting
  • ______ extremity ergometry possible
  • Risk stratification can be done with ph______ stress testing
  • Cardiac ______ in patients at high risk or with positive stress test
A
  • Standard treadmill and bicycle stress testing not possible if claudication limiting
  • Upper extremity ergometry possible
  • Risk stratification can be done with pharmacologic stress testing
  • Cardiac catheterization in patients at high risk or with positive stress test
53
Q

Mechanisms of Improvement

  • Improvement not clearly understood
  • Multiple theories exist
    • Increased blood fl___
    • Altered blood vis_____
    • Improved m_____ oxidative metabolism
    • Improved fatty a____ metabolism
    • Improved g____ efficiency
A
  • Improvement not clearly understood
  • Multiple theories exist
    • Increased blood flow
    • Altered blood viscosity
    • Improved muscle oxidative metabolism
    • Improved fatty acid metabolism
    • Improved gait efficiency
54
Q

Home Exercise Programs

  • Patients can monitor exertion at home
    • Use rating of per_____ exertion through the Borg scale
    • Can do self p____ monitoring
    • Ambulation exercises can be used in proficient prosthetic ambulators
A
  • Patients can monitor exertion at home
    • Use rating of perceived exertion through the Borg scale
    • Can do self pulse monitoring
    • Ambulation exercises can be used in proficient prosthetic ambulators
55
Q

Overview of Cardiac Rehab in PVD

  • Cardiac rehabilitation will increase the exercise tol_____ and p____ oxygen consumption of patients with PVD
  • PVD patients will be able to ambulate better after ex____ training
  • Cardiac _____ testing can be done and has a useful role in the management of patients with PVD and amputation
A
  • Cardiac rehabilitation will increase the exercise tolerance and peak oxygen consumption of patients with PVD
  • PVD patients will be able to ambulate better after exercise training
  • Cardiac stress testing can be done and has a useful role in the management of patients with PVD and amputation
56
Q

Pre-Heart Transplant CR is Essentially CHF Rehabilitation

  • Poor correlation with LV EF
  • Assessed with ____max
  • VO2max reduced in CHF due to:
    • CO response
    • Skeletal muscle blood flow
    • Skeletal muscle abnormalities:
      • type I fibers
      • oxidative capacity
      • capillary density
    • Metabolic abnormalities:
      • early dependence on anaerobic metabolism
      • excess intramuscular acidification
A
  • Poor correlation with LV EF
  • Assessed with VO2max
  • VO2max reduced in CHF due to:
    • CO response
    • Skeletal muscle blood flow
    • Skeletal muscle abnormalities:
      • type I fibers
      • oxidative capacity
      • capillary density
    • Metabolic abnormalities:
      • early dependence on anaerobic metabolism
      • excess intramuscular acidification
57
Q

Debility in the Pre Cardiac Transplant Patient

  • Often chronically in a low _____ state
  • Multi-organ system compromise common
    • R____ involvement
    • H_____ failure
    • Pul_____ compromise
    • M_____ mass loss
  • Severe decon_______
A
  • Often chronically in a low output state
  • Multi-organ system compromise common
    • Renal involvement
    • Hepatic failure
    • Pulmonary compromise
    • Muscle mass loss
  • Severe deconditioning
58
Q

________ Issues in the Pre-Transplant Patient

  • Unemployment
  • Substance abuse history, cigarette use
  • Non-compliance
  • Obesity/Cardiopulmonary cachexia
  • Relative social isolation
  • Criminal record
  • History of psychiatric disorder
A

Psychosocial Issues in the Pre-Transplant Patient

  • Unemployment
  • Substance abuse history, cigarette use
  • Non-compliance
  • Obesity/Cardiopulmonary cachexia
  • Relative social isolation
  • Criminal record
  • History of psychiatric disorder
59
Q

Pre-Operative Rehabilitative Treatment Approaches

  • Attempt to improve general conditioning
    • Graded ex_____ program
    • Preservation and restoration of R__
  • Prevention of the effects of immobility
    • Prevention of dec____
    • Prevention of deep venous ______
    • Improvement of self im____
    • Maintenance of appropriate nut______
  • Attention to s____ care
    • Adaptive devices
    • En____ conservation techniques
  • Mobility issues
    • Use of ass____ devices as needed
    • Use of wheelchair/scooter for longer distances
  • L___ Patients
    • General conditioning program
A
  • Attempt to improve general conditioning
    • Graded exercise program
    • Preservation and restoration of ROM
  • Prevention of the effects of immobility
    • Prevention of decubitis
    • Prevention of deep venous thrombosis
    • Improvement of self image
    • Maintenance of appropriate nutrition
  • Attention to self care
    • Adaptive devices
    • Energy conservation techniques
  • Mobility issues
    • Use of assistive devices as needed
    • Use of wheelchair/scooter for longer distances
  • LVAD Patients
    • General conditioning program
60
Q

Physiology of the Post Cardiac Transplant Patient at Rest

  • Heart rate typically ___ (100 bpm)
    • Loss of vagal inhibition
    • Decreased stroke volume
    • Increased sensitivity to plasma catecholamines
  • Resting ____tension
    • Renal effect of cyclosporine
    • Effect of corticosteroid
  • ______ dysfunction
    • Increased myocardial stiffness
      • Possible myocardial ischemia from accelerated coronary artery disease
      • Side effect of immunosuppressive medications
      • Prolonged ischemic time of donor heart
  • Near _____ resting cardiac output
  • Increased A-V oxygen difference
A
  • Heart rate typically high (100 bpm)
    • Loss of vagal inhibition
    • Decreased stroke volume
    • Increased sensitivity to plasma catecholamines
  • Resting hypertension
    • Renal effect of cyclosporine
    • Effect of corticosteroids
  • Diastolic dysfunction
    • Increased myocardial stiffness
      • Possible myocardial ischemia from accelerated coronary artery disease
      • Side effect of immunosuppressive medications
      • Prolonged ischemic time of donor heart
  • Near normal resting cardiac output
  • Increased A-V oxygen difference
61
Q

Physiology of the Post Cardiac Transplant Patient with Exercise

  • ______ onset of increased heart rate
    • Response to systemic catecholamines
  • _____ maximal heart rate
    • Effect of denervation
  • _____ recovery to resting heart rate
    • Loss of vagal tone
  • _____ maximal cardiac output
  • Increased maximum A-V oxygen difference
  • Decreased maximal voluntary oxygen consumption
  • Higher minute ventilation at a given level of carbon dioxide
62
Q

Post-Operative Rehabilitative Treatment Approaches

  • Graded aerobic conditioning program
    • Begin as ____ as possible post-operatively
    • Early program at ___ levels of intensity
    • Progress to an aerobic program by discharge
  • Post transplant exercise tolerance test
    • Allows estimation of aerobic capacity
    • Goal is aerobic exercise for __-__ minutes/day at least __ to __ times per week
  • Consider ___patient rehabilitation
    • For patients with complications or concomitant disability (e.g. post operative stroke, PVD, etc.)
    • Severe deconditioning
  • Address self care needs
    • Taking m______
    • Address patient education about rejection
    • Difficulties due to side effects of medications
A
  • Graded aerobic conditioning program
    • Begin as soon as possible post-operatively
    • Early program at low levels of intensity
    • Progress to an aerobic program by discharge
  • Post transplant exercise tolerance test
    • Allows estimation of aerobic capacity
    • Goal is aerobic exercise for 30-60 minutes/day at least three to five times per week
  • Consider inpatient rehabilitation
    • For patients with complications or concomitant disability (e.g. post operative stroke, PVD, etc.)
    • Severe deconditioning
  • Address self care needs
    • Taking medications
    • Address patient education about rejection
    • Difficulties due to side effects of medications
63
Q

Areas for Investigation

  • Precise cardiac effect of exercise training
    • Cardiac parameters
    • Cardiovascular risk factors
    • Functional capacity
    • Incidence of cardiac events
  • Precise vascular effect of exercise training
    • Mechanisms of increased ambulation
  • Dosage and types of aerobic training
    • (CAT) =
    • (HIIT) =
A
  • Precise cardiac effect of exercise training
    • Cardiac parameters
    • Cardiovascular risk factors
    • Functional capacity
    • Incidence of cardiac events
  • Precise vascular effect of exercise training
    • Mechanisms of increased ambulation
  • Dosage and types of aerobic training
    • Continuous Aerobic Training (CAT)
    • High Intensity Interval Training (HIIT)
64
Q

Areas for Development

  • Increased av______ of cardiac rehabilitation
  • Increased ref_____ for cardiac rehabilitation
  • Increased coo______ of in-patient and out-patient services
  • Improved community ed_____ programs
  • Improved aftercare and com_____ with stage 3 (IV) rehabilitation
A
  • Increased availability of cardiac rehabilitation
  • Increased referral for cardiac rehabilitation
  • Increased coordination of in-patient and out-patient services
  • Improved community education programs
  • Improved aftercare and compliance with stage 3 (IV) rehabilitation

Diagnosis and Management (36 decks)

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