Cardiopulm Unit 4 Lecture Part A Flashcards
What is Atherosclerosis? What is the Primary Pathology for this?
A disease that causes progressive hardening and narrowing of medium and large arteries including the coronary, cerebral, and peripheral arteries
- Due to the build up of plaques made up of lipids, cholesterol, calcium and cellular debris
What is the role of LDL (low-density lipoprotein) with Atherosclerosis?
LDL crosses dysfunctional endothelium, entering the wall of the artery, causing WBCs to stream in to digest the LDL
- This is the beginning of the “fatty streak”
What can an Atheroma/Atherosclerotic plaque do?
- It can stay in the artery wall, growing to a certain size and stopping. This may or may not cause Sx
- It can grow in a slow, controlled way into the path of blood flow eventually causing significant occlusion and ischemia (~70% occlusion is understood to cause ischemia)
- It can suddenly rupture and stimulate further thrombosis which may emboliz, rapidly occlude the lumen to precipitate ischemia or infarction, or gradually become incorporated into the plaque, contributing to its growth
What are the Risk Factors of Heart and Cardiovascular Disease?
Why is Cigarette Smoking a Risk Factor of Heart and Cardiovascular Disease?
Because it may lead to impaired endothelial vasodilation and endothelial damage
- Smoking is a leading preventable cause of death and is associated with an increased risk of CVD
How can a persons Physical Activity affect the Heart and Cardiovascular Disease?
- Both aerobic and muscle-strengthening physical activity contributes to ideal cardiovascular health.
- Regular exercise, including moderate to vigorous activities, has a clinically meaningful impact on major CVD risk factors, improving lipid profiles and reducing the incidence of hypertension and dyslipidemia
Why is Obesity a Risk Factor of Heart and Cardiovascular Disease?
- BMI ≥30 kg/m2 is a significant risk factor for atherosclerosis as it is associated with a range of adverse metabolic effects, including dyslipidemia, hypertension, and insulin resistance, which contribute to endothelial dysfunction and plaque formation.
- Additionally, the pro-inflammatory state induced by excess adipose tissue exacerbates vascular inflammation, further accelerating the atherosclerotic process
Why is LDL a Risk Factor of Heart and Cardiovascular Disease?
- Particles can infiltrate the arterial wall, become oxidized, and initiate the formation of atherogenic plaques. This process leads to arterial narrowing and increased risk of cardiovascular events
Why is Diet a Risk Factor for Heart and Cardiovascular Disease?
- Diet plays a crucial role in the development of atherosclerosis, with diets high in saturated fats, trans fats, and cholesterol contributing to the buildup of arterial plaques.
- Conversely, diets rich in fruits, vegetables, whole grains, and omega-3 fatty acids can help reduce inflammation and improve lipid profiles, thereby mitigating the risk of atherosclerosis
Why is Elevated Fasting Blood Glucose levels a Risk Factor of Heart and Cardiovascular Disease?
This indicates impaired glucose metabolism, which can damage the arterial lining and contribute to endothelial dysfunction.
- Persistent hyperglycemia accelerates the atherosclerotic process by increasing oxidative stress and inflammation within the vascular system, heightening the risk of cardiovascular diseases
Why is Family Hx of CHD a Risk Factor of Heart and Cardiovascular Disease?
- Defined as its presence in a parent or sibling, is a minor risk factor for the development of CAD. Except for familial hypercholesterolemias, no genetic link has been
established for CHD. - The modification of risk factors in subjects with a strong family history of premature coronary disease provides a reduction in the overall risk of developing a subsequent disease
Why is Aging a Risk Factor of Heart and Cardiovascular Disease?
Aging is associated with cumulative exposure to risk factors and age-related changes in the vascular system, such as increased arterial stiffness and endothelial dysfunction.
- These factors contribute to the enhanced vulnerability of older individuals to plaque formation, narrowing of arteries, and an increased risk of atherosclerotic cardiovascular diseases
Why is Gender a Risk Factor of Heart and Cardiovascular Disease?
- Gender plays a significant role in the development and presentation of atherosclerosis, with men generally experiencing a higher risk of atherosclerotic cardiovascular diseases at an earlier age compared to premenopausal women, who are thought to receive some protective effects from estrogen.
- However, this gender gap narrows with advancing age, particularly after menopause, when
the risk for women increases and becomes more comparable to that of men
Why is Chronic stress a Risk Factor of Heart and Cardiovascular Disease?
Chronic stress contributes to the development of atherosclerosis by inducing a cascade of physiological responses that include increased arterial inflammation, elevated blood pressure, and dysregulation of
lipid metabolism, thereby accelerating plaque formation and vascular damage.
- Additionally, stress-related behaviors such as poor diet, smoking, and physical inactivity can further exacerbate the risk of atherosclerotic cardiovascular diseases
Guidelines for Risk Assessment
With a person with Hypertension, what is the goal we should have to decrease risk assessment?
- < 140/90mmHG
- < 130/85mmHG if renal insufficiency or heart failure present
- < 130/80mmHG if diabetic
- Initiate drug therapy if lifestyle modification is ineffective physical activity
- The Goal: At least 30 min of moderate intensity (40-60% of max) activity, most days of the week
With a person with Hypertension, what is the goal for Lipid management to decrease risk assessment?
Goal:
- LDL < 160mg/dL if ≤1 risk factor for CHD present
- LDL < 100mg/dL if ≥ 2 risk factors present and CHD risk is
≥ 20% or if person is diabetic
- Drug therapy may also be indicated if triglycerides are >150mg/dL or HDL is < 40mg/dL for men or < 50mg/dL for women
CHD = Coronary Heart Disease
With a patient under weight management, what is the goal for Diabetes management to decrease risk assessment?
Goal:
- Normal fasting plasma glucose (110mg/dL) and near normal HbA1c (7%)
What is the General Clincial Course of Coronary Heart Disease (CHD)?
often used interchangeably with Coronary Artery Disease (CAD)
- Stable Angina (This may be skipped with sedentary pt)
- Acute Coronary Syndrome (Heart Attack)
- Cardiac Muscle Dysfunction (After HA, tissues not regen. it scars)
- Sudden Cardiac Death
When a person has Coronary Heart Disease and they are at the last stage, Sudden Cardiac Death, what happens that usually causes the death of the patient?
Venticular Tachycardia and Ventricular Fibrillation, leading to the cessation of CO, are the usual cause of death
When a person has Coronary Heart Disease and they are at the last stage, Sudden Cardiac Death, what must be done for the patients only chance of survival?
Prompt delivery of quality cardiopulmonary resuscitation with AED within 10 min and entry into medical system is their only chance of survival
In a healthy person, what are the different factors that come in affect to maintain Metabolic Demand and Oxygen Supply?
Metabolic Demand
- HR
- Contractility (BP)
Oxygen Supply
- Blood substrat
- A-VO2
- Coronary flow distribution
What happens if Metabolic Demand and Oxygen supply do not match each other?
There will be Ischemia
How is Ischemia Measured?
- Angina
- ECG Abnormalities (T-wave and ST-segment changes
- Metabolic abnormality
- LV dysfunction
- Vasoactive substrates
What is Angina?
- Sensation of Cardiac ischemia produced by an imbalance between myocardial oxygen supply and demand
-Its often the reason the patients seek initial medical attention
What may cause an onset of Stable Angina? What is it relieved by?
The onset of this imbalance is generally predictable at a certain workload
- Relieved by resting, reducing the intensity of the activity and/or taking sublingual nitroglycerin
Beyond physical exertion and emotional stress, cold weather and heavy meals are also known precipitants of angina
Where is Angina felt?
- Anywhere above the waist but most likely in the chest, neck or jaw
What is Angina typically described as?
Diffuse ache, squeezing, tightness, fullness, heaviness, burning or pressure
- It is not usually described as focal, sharp or stabbing
What Sx of angia will men present with?
Substernal (e.g., Levine’s Sign) or chest tightness or indigestion that radiates, sometimes into the arm or into the jaw or neck
What Sx of angia will women present with?
Tightness or discomfort posteriorly between the scapula or with Sx of indigestion, nausea, SOB or simply excessive fatigue
What may cause Silent Ischemia?
Neuropathy with impaired sensory afferentn conduction (e.g., as in diabetes)
What is Anginal Equivalents?
Sx such as dyspnea, fatigue, lightheadedness and belching may be presenting sx of angina. These are more common in diabetes, woman and elderly
- They may be managed just like regular angina (e.g., with rest, nitroglycerin, etc)
What must a clinician do upon presentation of suspected angia?
Have the patient stop and assume a resting position, then consider the following:
- Do the Sx relieve with rest? True stable angina pain should only increase with increases in myocardial oxygen demand and decrease with cessation of exercise/activity and/or nitroglycerin
- Does the patient have risk factors for atherosclerosis?
- Could the patient have a MSK chest injury?
-Does palpating the painful area, deep breathing or AROM of the thorax/UEs increase sx? Any changes in sx with palpation, deep breathing, AROM of UEs argues against MI source of pain
Chest pain that does not relieve with rest should be considered an emergency
What should be done with those individuals with suspected demand ischemia, that is used for risk stratification, exercise prescription and clinical diagnosis?
They should ideally be referred to cardiology and be assessed with Cardiopulmonary Exercise Testing (CPX or CPET) or at least an Exercise Tolerance Test (ETT) or a chemical stress test
In the absenceof the results from a CPET, ETT or Chemical stress test, what should us, the PTs be monitoring?
- Vitals
- S/S that suggest cardiac ischemia
- S/S of a developing arrhythmias (e.g., irregular pulses and/or reports of “palpitations/fluttering”)
What may PTs use to SCREEN Vitals, S/S that suggest cardiac ischemia, and S/S of a developing arrhythmias?
A submaximal exercise test that utilizes target HRs (e.g., 85% of the age-predicted Maximal HR) via walking or cycle protocols
If an individual has increased arrhythmia(s) with activity, particularly if accompanies by S/S of hemodynamic instability (hypotension, lightheadedness), what must be done?
This warrents Termination of testing and follow up with the medical team for ECG-guided, graded exercise testing and/or Holter Monitoring
What is an Anginal Threshold?
The Anginal Threshold is the point during physical exertion at which cardiac ischemia occurs due to insufficient oxygen supply to the heart muscles
How can PTs screen for Anginal Threshold?
PT can utilize submaximal exercise testin to screen for an anginal threshold and if one is found, aim to correlate to objective measurements such as:
- HR
- RPE level
- Work rate (e.g., watts, MET level)
We Do NOT push through pain!!!!!!!!!
What happens if a patient has an identified ischemic threshold (i.e. angina and/or ≥ 1 mm ischemic ST-segment depression on exercise test)?
The exercise intensity should be prescribed at a HR andn work rate below this point , with an upper limit of a minimum of 10 beats/min below the HR at which the ischemia was initailly identified
What is Acute Coronary Syndrome (ACS)?
This is a range of conditions associated with sudden, reduced blood flow to the heart
What is Acute Coronary Syndrome typically associated with? What 3 heart conditions is it primarily related to?
Typically associated with an atherosclerotic plaque rupture in an already blocked artery
Primarily related to 3 heart conditions:
- Unstable Angina
- Non-ST-Segment elevation MI (NSTEMI)
- ST-Segment elevation MI (STEMI)
The NSTEMI and STEMI are types of heart attacks
What is Unstable Angina?
aka “Preinfarction Angina”
The presence of S/S of an inadequate blood supply to the myocardium that doesn’t follow a predictable pattern like stable angina, which typically occus with exertion and alleviates with rest
What is the Symptom Severity and Pattern of Unstable Angina?
The pain and discomfort associated with UA can be more severe, frequent, or prolonged than the individuals typical anginal episodes
What are the Precipitating Factors of Unstable Angina?
Unlike Stable Angina, which is often triggered by physical exertion or stress, unstable angina can occur spontaneously without a clear trigger or with a lower level activity
What is the Response to Medications for Unstable Angina?
While stable angina usually response well to rest and sublingual nitroglycerin, Unstable Angina might not respond as effectivley to these interventions (e.g., relief may be less complete or of shorter duration)
How is Unstable Angina Diagnosed?
This involves a combination of clinical assessments, ECGs and Blood Test.
- ECG may show changes indictative of schemia (ST-segment depression and/or T-wave inversion)
- Blood test for cardiac biomarkers- proteins and enzymes that suggest myocardial damage- are usually negative
What can Unstable Angina progress to?
It may progress to Acute Myocardial Infarction (AMI) if the underlying pathophysiology is not promptly corrected
What is a Myocardial Infarction?
A clincial event resulting in myocardial necrosis due to ischemia
How does a Myocardial Infarction differ from an unstable angina?
Unlike unstable angina, where there is reversible myocardial ischemia without cell death
- MI involve irreversible damage with necrosis of the heart muscle cells
The progression from ischemia to infarction is time-dependent
MI is characterized by what Sx?
typically more intense compared to those of unstable angina
- Sweating
- Weakness
- Lightheadedness
- Palpitations
- This can also lead to a dramatic sympathetic nervous system response due to a sudden drop in cardiac output
What is Acute Myocardial Infarction?
A clinical event resulting in myocardial necrosis due to ischemia
What are the 2 different types of AMI?
- Non-ST Segment Elevation Myocardial Infarction (NSTEMI)
- ST-Segment Elevation Myocardial Infarction (STEMI)
What is a Non-ST Segment Elevation Myocardial Infarction (NSTEMI)?
(Type of AMI)
- The blood supply to the heart is reduced, usually due to a partial blockage of a coronary artery, causing some amount of heart muscle damage.
- The ECG does not show ST-segment elevation but may display other signs of ischemia, such as ST-segment depression or T-Wave inversion (similar to stable or unstable angina)
NSTEMIs are sometimes referred to as subendocardial infarctions as they only affect the inner layers of the heart muscle
What is a ST Segment Elevation Myocardial Infarction (STEMI)?
(A type of AMI)
- A more substanital blockage of a coronary artery leads to a significant portion of the heart muscle being deprived of oxygen
- The ECG shows elevation in the ST segment, indicative of extensive heart muscle damage
STEMIs are sometimes referred to as Transmural infarction because they typcially involve the full thickness of the heart muscle wall, from the endocardium to the epicardium
Beyond ECG changes, both NSTEMI and STEMI show evidence through blood analysis, what may we see?
We may see characteristic changes to Cardiac Biomarkers such as Troponin, Creatine Kinase-MB, and/or Myoglobin can indicate heart muscle injury and are used to confirm diagnosis of AMI
What does the Management of AMI include?
This includes immediate medical intervention to restore blood flow and prevent further heart muscle damage, followed by long-term treatment to manage risk factors and prevent recurrence.
- Lifestyle modifications, medication adherence, and regular follow-up with a healthcare provider are crucial for recovery and secondary prevention
With AMI management, what happens with Immediate reperfusion?
If reperfusion occurs within about 20 minutes, most of the at-risk area can be salvaged, meaning the heart muscle can recover without significant damage. This is the ideal scenario and underscores the importance of prompt medical intervention
With AMI managment, what happens with Reperfusion within a few hours?
If reperfusion occurs within about 2 to 4 hours, there can be partial salvage of the heart muscle. Some areas will become necrotic with hemorrhage and contraction bands, which are signs of irreversible damage, but some muscle tissue remains viable albeit with post- ischemic dysfunction
With AMI management, what happens with Permanent Occlusion?
Without reperfusion, the entire area at risk progresses to a completed infarct, meaning all the tissue in the area becomes necrotic. This results in the loss of muscle function in the affected area and can lead to serious complications, including heart failure and arrhythmias
If the Left Coronary Artery is occluded, where would the myocardial wall be affected?
- Anterior and lateral left ventricle
- Anterior septum
- Parts of left and right atria
- A variable amount of right ventricle depending
on individual coronary circulation
If the Left Coronary Artery is occluded, what are some common complications?
- Left Ventricular Pump Dysfunction
- Ventricular and Atrial Arrhythmias
If the Left Anterior Descending Artery is occluded, where would the myocardial wall be affected?
- Anterior left ventricle
- Anterior septum
If the Left Anterior Descending Artery is occluded, what are some common complications?
- Left ventricular pump dysfunction
- Ventricular Arrythmias
If the Circumflex Artery is occluded, where would the myocardial wall be affected?
- Parts of left and right atria
- Lateral and a variable amount of right ventricle depending on individual coronary circulation
If the Circumflex Artery is occluded, what are some common complications?
- Left atrial dysfunction
- Mitral valve regurgitation
- Atrial arrhythmias
If the Right Coronary Artery is occluded, where would the myocardial wall be affected?
- Inferior left ventricle
- AV node
- SA node in some individuals
If the Right Coronary Artery is occluded, what are some common complications?
- Right ventricular pump dysfunction
- Bradycardia
- AV blocks
- Ventricular and atrial arrhythmias
If a patient presents to the hospital with Sx suggestive of an acute cardiac problem, a series of diagnostic test are performed to confirm the diagnosis, evaluate the severity and guide treatment decisions. What is the initial approach and what other test are done?
Inital approach includes Electrocardiogram and blood test
May include the following exams:
- Cardiac catheterization
- Echocardiography
- Chest X-rays
- Holter monitoring
What is Cardiac Catheterization?
An invasive procedure that provides valuable information for the diagnosis and management of patients with cardiac disease
What is the Goal of Cardiac Catheterization?
- Establish of confirm a diagnosis of cardiac dysfunction of heart disease
- Demonstrate the severity of coronary artery disease (CAD) or valvular dysfunction
- Determine guidelines for optimal management of the patient, including medical and surgical management as well as program of exercise
What are the Guidelines for Post-Cardiac Catheterization care?
- Involves 4 to 6 hours of bed rest for femoral access to prevent complications
or - Wrist weight bearing restrictions for 24 to 72 hours if the radial artery is used
What are the PT Considerations for Cardiac Catheterization?
- Patients are usually on bed rest for approximately 4-6 hours when venous access is performed or for 6-8 hours when arterial access is performed
- The extremity that provided access should remaining immobile with a sandbag over the access site to provide constant pressure to reduce the risk of vascular complications. Some hospital use a knee immobilizer as assist with immobilizing
PT interventions should be modified or deferred within the parameters of these precautions. Normal mobility can progress after precautionary period
Why are Chest X-Rays a good diagnostic tool?
- It helps in identifying cardiac abnormalities such as cardiomegaly and signs of heart failure such as pleural effusions and pulmonary edema.
- Additionally, chest X-rays can detect complications related to cardiac procedures and the presence of medical devices like pacemakers
What is an Echocardiogram?
A noninvasive test for cardiac function that shows real time images of the beating heart
What can an Echocardiography be used to assess?
Echocardiography can be used to assess cardiac function, identify areas of ischemia or infarction, and evaluate complications such as ventricular wall motion abnormalities, helping guide treatment decisions
What does a Holter Monitor do?
Holter monitors provide continuous 24-hour ECG to monitor heart rhythm and are useful for diagnosing and managing cardiac arrhythmias
What are the Indications for a Holter Monitor?
- Status/post myocardial infarctions, because arrythmias are commonly associated with coronary disease, ischemia, and injury
- To evaluate symptoms that may be caused by arrhythmias (e.g., dizziness, syncope, palpitations, or SOB at rest as well as with activity)
- To evaluate antiarrhythmic therapy and/or pacemaker functioning
What is Percutaneous Coronary Intervention (PCI)?
PCI is an umbrella term that encompasses any of the following coronary procedures that are used to treat narrowed or blocked coronary arteries:
- Percutaneous transluminal coronary angioplasty (PTCA) a.k.a. angioplasty
- Stenting
- Atherectomy
Many patients undergo outpatient testing for stenosis or ischemic changes to plan an elective PCI, but those with Acute Coronary Syndrome (ACS), characterized by sudden-onset ischemia leading to unstable angina, may necessitate emergency PCI
What is an Angioplasty and Stenting?
- A catheter with a small balloon at the tip is threaded through the blood vessels to the narrowed or blocked coronary artery. Once in place, the balloon is inflated to compress the plaque against the arterial wall, thereby widening the artery and restoring blood flow.
- Frequently, a stent—a small wire mesh tube—is also inserted to keep the artery open after the procedure
- This treatment is commonly used in cases of CAD and ACS to alleviate symptoms and improve blood flow to the myocardium
What is Atherectomy?
- A catheter typically equipped with a cutting or grinding device is used to remove plaque from a blood vessel.
- There are different types of atherectomy procedures, including rotational, directional, and laser atherectomy, each with its own specific technique for plaque removal.
- The objective is the same as with other PCI procedures: to improve blood flow through the coronary arteries by removing or reducing obstructions caused by plaque buildup
What is a Coronary Artery Bypass Graft (CABG)?
- A blood vessel from another part of the body (i.e., a “graft”) is used to create a “bypass” around the blocked or narrowed section of a coronary artery.
- This allows blood to flow more freely to the heart muscle, alleviating symptoms like angina and reducing the risk of heart attack
- If uncomplicated, the typical length of stay (LOS) after a CABG is about 4-7 days
What is Median Sternotomy?
A technique which involves making a vertical incision down the middle of the chest and then dividing the sternum to provide direct and wide accessto the heart and surrounding structures
What are the Complications of Median Sternotomies?
Bleeding and hematoma formation, chronic pain, arrythmias, post-operative pulmonary complications
(e.g., pneumonia), and sternal dehiscence and infection
What are Major Risk Factors for Complications for Median Sternotomies?
Obesity, previous sternotomy,
and diabetes
What are the Impacts and Restrictions Post-Surgery with a Median Sternotomy?
Impacts:
- Surgery results in systemic effects altering body structure, function, activity levels, and participation in Activities of Daily Living (ADLs)
Restrictions:
- Though variations in restrictions and timelines by surgeons exist, many restrict arm use for 6 to 12 weeks to prevent wound infection or dehiscence. However, the concept of a fixed “amount of load” or “healing time” may be inappropriate, and patients are encouraged to resume load-bearing ADLs at their own pace, following the principle of “Keep Your Move in the Tube”
Why is “Moving In the Tube” important Post-sternotomy?
- Encourages active patient participation in functional tasks and ADLs, based on current evidence of its safety and benefits.
- Based on biomechanical principles the relate to the load on the lever arm of the humerus across different positions
-As weighted and resistive motions move away from the midline, the greater the stress on the sternum. This is movement outside “the tube”. - The implementation of “Keep Your Move in the Tube” should start immediately post-operation, emphasizing consistent messaging from the treatment team
What are the Expected S/S following CABG?
- Pain, discomfort, and some degree of swelling, redness, and drainage at the incision site (chest and possibly leg if a graft was taken from there) is common.
- Feeling tired and weak is common as the body is using a lot of energy to heal.
- Patients may have limited mobility and may need assistance with movement.
- Some degree of fluid retention and swelling, especially in the legs, can occur due to decreased physical activity.
- Shortness of breath, especially if fluid accumulates in the lungs (i.e., due to pleural effusion), is not uncommon.
- Cognitive changes, including memory loss, concentration issues, or other cognitive impairments, is not uncommon within a condition known as “postperfusion syndrome”.
- Mood swings, anxiety, or depression can occur as a response to the stress of surgery and the recovery process
What is the function of a Pacemaker?
These create an artificial electrical voltage difference between 2 electrodes
- Marked by a pacer spike on ECG
What are different conditions that use Pacemakers?
Pacemakers are used for a variety of conditions which include: Sick Sinus Sydrome, 2nd degree or complete heart block, cardiac denervation (after transplant), severe sinus rhythm, easily provoked angina, CHF
- Symptomatic Bradycardia is a common theme
When it comes to Pacemakes, what should the focus of the PT be?
PTs should be monitoring ECG, Sx, and BP at rest and during exercise and/or functional training
When montioring ECG, what are signs of Pacemaker Failure?
- Lack of Spike
- Spike in wrong location
What are some Post-Op Precautions with Pacemakers?
Immediately after permanent pacemake placement:
- Ipsilateral AROM should be < 90° for 4 weeks
- Arm sling may be used
What are Automatic Implantable Cardioverter Defibrillator (AICD/ICD) used for?
Used to manage uncontrollable, life-threatening ventricular arrythmias by sensing the heart rhythm and defibrillating the myocardium
- Knowing the discharge rate allows for safe prescription of exercise
–Stay ~20-30 bpm under this rate
After a diagnosis of ventricular tachycardia, a patient has an ICD implanted. The purpose of the ICD is to:
Prevent sudden death due to Ventricular Tachycardia
