Cardiovascular Responses to Exercise and Exercise in Special Populations Flashcards
screening before starting an exercise program
- May be self guided → may help person determine if should consult MD (self guided questionnaires)
- Professionally guided → Consult MD to determine safety of staring exercise program
Specific stratification for “apparently healthy patients” and for “cardiac patients”
– Low – Moderate – High
exercise should include warm-up and cool-down, and this is especially important for which CV patients?
- Heart Transplants
- Left Ventricular Assisstive Device
Abnormal responses to exercise:
- Decreased HR
- Decrease SBP more than 10 mmHg
- Arrhythmia
- Angina
- Rales/crackles develop after exercise.
Contraindications to Exercise/Cardiac Rehab
- Unstable angina
- Resting SBP > 200 mmHg or resting DBP >110 mmHg
- Orthostatic BP drop of > 20 mmHg with symptoms
- Critical aortic stenosis
- Acute systemic illness or fever (temp ≥ 101 F)
- Uncontrolled atrial or ventricular arrythmias
- Uncontrolled sinus tachycardia, >120 bpm
- Uncompensated Congestive Heart Failure (symptomatic at rest)
- 3rd degree Atrioventricular (AV) block (without pacemaker) “complete heart block”
- Active pericarditis or myocarditis
- Uncontrolled diabetes
- ??? Recent embolism
- ??? Thrombophlebitis
- ??? Other metabolic problems like acute thyroiditis, hypo/hyperkalemia, hypovolemia, etc.
exercise on a patient with potassium levels bellow 3.2 mmol/L or above 5.1 mmol/L?
Increased risk for life-threatening arrythmias
Reasons to Stop Exercise:
- Onset of angina or angina-like symptoms
- Drop in SBP >10 mmHg from baseline despite increasing workload
- Hypertensive response
- Shortness of breath, wheezing, leg cramps or claudication (grade 3 on a 4 point scale)
- Signs of poor perfusion
- Failure of heart rate to increase with increased exercise intensity
- Noticeable change in heart rhythm
- Significant arrhythmias
- ST displacement (> 2 mm horizontal or downsloping depression)
- Patient request
- Physical or verbal manifestation of severe fatigue
- Failure of monitoring equipment
review
SYSTOLIC HEART FAILURE:
-
Decreased CONTRACTILITY
- Likely due to loss of functional muscle from infarction OR process affecting myocardium
-
Increased PRELOAD
- Likely due to valvular regurgitation
-
Increased AFTERLOAD
- Likely due to HTN
-
Changes in CHRONOTROPY
- Heart rate is too slow or too rapid
→ All these problems lead to PUMP FAILURE
review
DIASTOLIC HEART FAILURE:
-
Diastole may be impaired due to
- Excessive hypertrophy of ventricles
- Changes in composition of myocardium
-
EDV may be decreased due to decreased filling of the left ventricle due to increased
stiffness -
Decrease in compliance of the LV, at any EDV →leads to an increase in the ventricular
pressure - Overall will usually see elevated diastolic pressures → may lead to decreased cardiac output
Exercise Considerations for Patients with CHF:
- lower baseline BP (SBP 70-90’s mmHg), need ≥ 60mmHg for organ perfusion
- Orthostatic hypotension
- Look for decrease in SBP, fatigue, and SOB
- Monitor lung sounds and peripheral edema for signs of increased failure
- Awareness of patient’s weight for fluid overload
Left ventricle not working efficiently:
Increased left atrial dilatation→ Increased pressure in pulmonary vessels→ Transudation of fluid from pulm caps
if the right ventricle is not working effectively →
Prolonged pulm HTN → Increased right ventricle afterload → Anatomical changes to right ventricle (dilatation → possible hypertrophy) → Right ventricular EDP increases → Reflects back up to right atrium & venous system
May see JVD, liver engorgement, ascities, & peripheral edema
• Major determinants of BP:
- CO
- Peripheral resistance
- Both factors have several determinants
HTN is Dx when SBP is ≥ ____ mmHg and/or DBP is ≥ ____ mmHg
140/90
Increased pressure on LV can create →
Left ventricular hypertrophy → diastolic dysfunction due to poor relaxation can occur
Most common complications of HTN:
– CVD
– CHF
– CVA
– Renal failure
– Aneurysm
– PVD/PAD
– Retinopathy
💡peak HR?
Exercise considerations for patients with HTN
Overtime changes?
- 15-30% reduction in exercise capacity
- SV increases abnormally and peak HR is lower
- Moderate endurance training will elicit an average reduction of 5-7 mmHg for resting BP in people with HTN
- Focus on aerobic training (ex: 10,000 steps)
exercise considerations for exercise in pt with resting SBP > 200 and/or DBP > 110 mmHg
- Get MD clearance
- Try to keep SBP ≤ 220 mmHg and/or DBP ≤ 105 mmHg with exercise
- Consider UE endurance work over LE
- Exercise should be terminated if BP > 250/110
Exercise should be terminated if BP > _____
250/110
what type of exercise is best for patients with PVD/PAD
- ❗️Short, frequent bouts of activity with short rest periods when necessary
- Work up to pain, then rest
- Gradually increase exercise time
- Walking is a good, functional activity
- Swimming, rowing, biking (alternatives to walking)
- Focus on low intensity, interval training
💡 cold weather? pt education?
More exercise considerations for patients with PVD/PA
- Cold weather can induce vasospasm
- As pt progresses, watch out for other symptoms
- Encourage lifestyle changes
- Effects of medications
- Improvement in exercise tolerance may unmask myocardial ischemia
- These patients are at high risk for CAD
exercise reduces or increases insulin secretion?
reduces
exercise stimulates ______ production in the liver
glucose
Exercise Considerations for Patients with DM
LOW BLOOD GLUCOSE – Below ______ = do not exercise
70mg/dL
Exercise Considerations for Patients with DM
when glucose is less than 100mg/dL =
wait until glucose is at least 100 before initiating exercise
Exercise Considerations for Patients with DM
Type 1 DM: If glucose level greater than 250 mg/dL (fasting glucose level) Most sources say to test urine for ketones → If ketones present in urine then…
avoid exercise
Type 2 DM: If greater than 300 mg/dL some sources say to avoid exercise. Others say to use caution with exercise. If too high risk increases for
Diabetic Ketoacidosis
General exercise considerations for patients with DM
- Important to monitor BG
-
Timing of exercise:
- Exercising late in evening increases risk of nocturnal hypoglycemia
- Avoid exercise during periods of peak insulin activity
- Autonomic neuropathy → in pt with DM this increases likelihood of CVD
- Retinopathy: avoid SBP>170 mmHg and excessive jarring activities
Athletes with DM (often type 1):
- Need to do intense monitoring
- Avoid exercising at time of peak insulin effect (BG drops!)
- May need a longer more gradual progression to a higher level of training
- 5-10g carb snacks for every 30-45 min of prolonged exercise
Weight loss of _____ provides significant health benefits
5-10%
intensity in obese patient should be…
goal?
- 50-60%
- Goal of 45-60 min of low to mod intensity aerobics 3-5 days/wk
Renal failure and exercise
- Begin with low intensity & gradually increase based on patient tolerance
- Use RPE as HR may not be reliable indicator of exercise intensity
- Leg fatigue is common complaint
Marfan’s Syndrome:
- Connective Tissue Diseases
- Cardiac manifestations may range from minimal to severe
- Frequent issues with:
• Valves • Aneurysms
radiation treatment of cancer can cause…
- Pericarditis,
- MI—ischemia and infarction,
- vascular injury,
- myocardial fibrosis,
- atherosclerosis,
- pneumonitis
chemotherapy treatment in cancer can casue:
- Cardiomyopathy
- later stage ventricular dysfunction
- pneumonitis
radiation & chemotherapy can have affect on hematopoiesis:
- Anemia, thrombocytopenia, neutropenia/leukopenia
- Depends on area being irradiated (lots of bone marrow or not)
Hot Environments: Exercise Considerations
- peripheral vasodilation
- Increased HR
- Dehydration → Decreased blood volume → may lead to ischemia
Cold Environments: Exercise Considerations
- vasoconstriction
- Can cause increased arterial BP
- Need to adequately hydrate despite lack of noticeable perspiration
High Altitude: Exercise Considerations
- Higher altitude → progressive decrease in atmospheric pressure → decreases partial pressure of O2 in inspired air →decreased arterial oxygen levels
- May see:
– Acute mountain sickness, high-altitude pulmonary edema, & high-altitude cerebral edema
hyperglycemia
hypoglycemia
peak insulin action time and exercise in patients with DM
DO NOT EXERCISE
peak insulin = blood glucose is at its lowest
💡evening or mornings?
when is the best timing to exercise with patients with DM?
- Exercising late in evening increases risk of nocturnal hypoglycemia
- Avoid exercise during periods of peak insulin activity
