Class 16

Question 1

What is Tachycardia/Tachyarrhythmia?

Answer 1

• Increased heart rate for any reason, especially if elevated heart rate is not expected in circumstance
• Formally defined as heart rate over 100, keeping in mind that this heart rate can be normal in some exertion & stress situations
• Sinus tachycardia is used when beat is normal other than being too fast; other types of tachycardia are usually associated with heart rhythm abnormalities

Question 2

What are Causes of Tachycardia?

Answer 2

• Anxiety, emotional distress
• Fever
• Heavy alcohol use, alcohol withdrawal
• High caffeine consumption
• Smoking
• High or low blood pressure, low core blood volume
• Electrolyte imbalances, e.g., potassium, sodium, calcium & magnesium
• Hyperthyroidism
• Anemia
• Bleeding/hemorrhage
• Medication side effects; illicit use of stimulants, incl. cocaine, methamphetamine
• Can be promoted by some types of dysrhythmia

Question 3

What are S/S of Tachycardia?

Answer 3

• Often none
• Sensation of a racing, pounding heartbeat, palpitations
• Chest pain
• Light-headedness
• Fainting (syncope)
• Shortness of breath

Question 4

What is Bradycardia/Bradyarrhythmia?

Answer 4

• Decreased heart rate for any reason, especially if low heart rate is not expected in circumstance
• Formally defined as heart rate below 60, keeping in mind that this heart rate can be normal, e.g., during parts of sleep, in young adults, trained athletes – can be beneficial in allowing for longer diastole fill time
• Bradycardia is used similarly to what is described for sinus tachycardia

Question 5

What are Causes of Bradycardia/Bradyarrhythmia?

Answer 5

• Aging-related heart tissue changes
• Damage to heart tissues from heart disease or heart attack
• AV conduction block
• Congenital heart defect
• Inflammatory heart conditions (endocarditis, myocarditis, pericarditis)
• Complication of heart surgery
• Hypothyroidism
• Electrolyte imbalances
• Obstructive sleep apnea
• Inflammatory disease, eg. rheumatic fever or lupus
• Certain medications, including sedatives, opioids, & drugs used to treat heart rhythm disorders, high blood pressure, certain mental health disorders

Question 6

What are S/S of Bradycardia/Bradyarrhythmia?

Answer 6

Abnormally slow heartbeat can prevent brain & other organs from getting enough oxygen, possibly resulting in:

• Often no S/S apparent
• Chest pain
• Confusion, memory problems
• Dizziness or light-headedness
• Fatigue, tires easily during physical activity
• Fainting (syncope) or near-fainting
• Shortness of breath

Question 7

What is Dysrhythmia, Arrhythmia?

Answer 7

Abnormalities in heart rhythm. Dysrhythmia is more correct term, since arrhythmia implies no rhythm, however arrhythmia is more frequently used.

More frequently used when rhythm disturbance is related to conduction system abnormalities (SA node, intranodal, AV node, electrical conduction in heart wall).

When SA node is source of problem, person may need implanted pacemaker

Tachycardia & bradycardia are technically forms of
dysrhythmia, since they represent changed rhythm,
but term dysrhythmia/arrhythmia is not usually
applied in straightforward (e.g., sinus) cases

Combinations of fast or slow beat + rhythm abnormality are fairly common in heart disease, especially when conduction system is damaged dysfunctional, or when neurological controls on heartbeat are not working properly d/t neurological injury or pathology.

Abnormal rhythm can arise from areas in heart wall that are damaged, e.g., from MI. Scarred/abnormal tissue can be irritant that mechanically tugs on normal myocardial cells, causing them to depolarize. When this occurs, their intercalated disks convey signal to neighbouring cells. New beat competes with normally generated beat.

Question 8

What is Fibrillation?

Answer 8

Heartbeat is rapid, irregular/chaotic, & muscle fibres are contracting asynchronously. Another term often used to describe this heart wall action is “flutter.” Given the way heart’s conduction network acts to contract two atria together, then two ventricles, fibrillation is typically atrial or ventricular.

Question 9

What is Atrial Fibrillation (A-fib)?

Answer 9

Most common cardiac dysrhythmia. Its disorganization of SA node signals producing atrial wall quivering action rather than effective atrial contraction. It’s often episodic, but can be more chronic as well.

Question 10

A-fib is generally not lethal in immediate sense, but there are three significant issues which are?

Answer 10

• Erratic signal spreads to AV node, causes disorganized cardiac muscle activity in ventricles – stroke volume & ventricular contraction are both subpar.
• Heart comes under stress caused by tissue signals that it needs to improve output consistency. Heart wall perfusion also experiences some compromise, causing CHF over time.
• Significant risk of embolic stroke; turbulence created in heart chambers promotes thrombosis. Brain embolism is most common, but thromboemboli could also travel into other tissues supplied off aorta, or into lungs if thrombus is right sided (less common).

Question 11

What are S/S of Fibrillation?

Answer 11

• frequently none
• feeling of fast/pounding heart, &/or fluttering/palpitations; may be chest pain
• general fatigue
• dizziness, light-headedness
• dyspnea unusual for person
• decreased exercise tolerance, feeling of weakness
• orthostatic hypotension

Question 12

What are Medical Treatments for Fibrillation?

Answer 12

• Medications to attempt to slow heart rate & stabilize contraction – can help, but are generally not a sufficient treatment on their own
• Powerful anticoagulant
• Electrical cardioversion: use of low-energy shocks to reset heart rhythm; usually temporary solution
• Pulmonary vein ablation: use of catheters to deliver energy around pulmonary veins; makes heart respond better to A-fib meds; variable long term effectiveness, can be permanent solution for some people
• Left atrial appendage closure devices: there is area in LA that is bit of a cavity; swirling inside it makes it most common location for thrombosis. Procedures that close off access to this location reduce stroke risk. Common procedures – insertion of Watchman device.
• MAZE procedure: creation of a specifically located scar tissue path that causes electrical impulses to travel in more normal pattern through chambers; invasive, so only used for severe A-fib, good success rate

Question 13

What are Risk Factors/Causes of Fibrillation?

Answer 13

• Age – incidence increases with age, esp. over 60
• Female – incidence is a bit higher in females
• Hypertension
• Heart disease: CAD, congenital defects, valve problems, CCHF
• Hx of MI or heart surgery (20-40% development of A-fib within days of heart surgery)
• Thyroid dysfunction
• Presence of diabetes, metabolic syndrome, chronic kidney disease, lung disease
• Sleep apnea raises risk substantially
• Alcohol consumption is significant factor
• Obesity
• Race – incidence is bit greater d/t general heart disease susceptibility in African Americans, who also tend to have more severe versions
• Family inheritance is factor in some cases
• Stimulant medications, caffeine consumption
• Significant idiopathic component

Question 14

What are Risk RMT Concerns of Fibrillation?

Answer 14

• Thorough case history taking is necessary to evaluate all cardiovascular factors in case. A-fib itself does not dictate set of specific tx modifications, RMT needs to assess whole scenario & adjust treatment intensity factors accordingly.
• Get a picture of current medical treatment effectiveness in stopping/controlling A-fib, & consequently thromboembolism risk level. Consult with the MD if uncertain.

Question 15

What is Ventricular Fibrillation?

Answer 15

Less common & much more immediately dangerous. Ventricles go into chaotic contraction disarray & heart can easily arrest.

Question 16

What are Risk Factors/Causes of Ventricular Fibrillation?

Answer 16

• During or in days following myocardial infarction
• During or immediately after heart surgery or procedure
• Hx of MI (esp. if there is ongoing dysrhythmia), heart surgery, &/or heart injury increases risk
• Severe electrolyte abnormality
• Heart medications, e.g., digitalis, occasionally have this effect on some people
• Group of more rare genetic conditions

Question 17

What are S/S of Ventricular Fibrillation?

Answer 17

• Dizziness, feeling faint, actual syncope
• Sudden onset of malaise, severe weakness
• Indicators of shock: cold/clammy sweat, pallor, rapid shallow breathing, nausea/vomiting,
pupil dilation, anxiety, confusion, etc.
• Vision distortion

Question 18

What are RMT Concerns of Ventricular Fibrillation?

Answer 18

This is a medical emergency. Do not begin, or cease all treatment & call 911. It’s important to have an awareness of high-risk situations, such as recent MI or heart procedure, & also awareness of individuals whose health hx creates elevated risk of ventricular fibrillation.

Question 19

What is Atherosclerosis?

Answer 19

Disease state that affects arteries (primarily large arteries). Prevalence is so great in North America that its complications combine to constitute most common cause of death in our population.

Question 20

What is Atheroma?

Answer 20

Characteristic lesion of atherosclerosis is atheroma, also referred to as plaque. Consists of soft central area of lipid products & metabolic debris covered by connective tissue ‘cap’. Atheromas are not uniform - among lesions in any given artery some can be larger or smaller, some will have more inner lipid & thinner connective tissue cover or vice versa, & some will be quite stable & others more easily damaged.

Question 21

Atheromas protrude into lumen of artery & can give rise to?

Answer 21

: blood turbulence -> thrombosis
: lesions on atheroma surface -> thrombosis
: lipid contents escape into bloodstream
-> embolism
: weakening of artery wall -> aneurysms
: reduced lumen size -> tissue ischemia,
intermittent ischemic attacks
: atheroma plus thrombus -> infarction

Question 22

The reason atheromas develop is not currently
understood. There are two theories attempting to
explain atherogenesis?

Answer 22

1. Artery Wall Microinjury
2. Mutagenic Factor(s)

Question 23

What is Artery Wall Microinjury?

Answer 23

Most popular theory. Supported by fact that most of risk factors for atherosclerosis involve important elements that are potentially going to have destructive effect inside wall.

Question 24

What is Mutagenic Factor(s)?

Answer 24

Theory comes from fact that some atheromas appear to have derived from small cell population & therefore more like small tumours in origin.

These two possibilities are probably not mutually exclusive. Eg, cigarette smoking is one major risk factors for atherosclerosis, it puts both irritating & mutagenic elements into blood.

At HISTOLOGICAL LEVEL atheroma seems to begin at site of microdamage in tunica intima. Lipid molecules from bloodstream appear to enter artery wall at this site. Since macrophages have routine task of removing debris elements & fats from blood vessel walls, may be some immune system failure involved. Pocket of lipidy material collects associated with thinning of media layer & disruption of tissue elements of intima. Specialized smooth muscle cells in intima layer migrate to lesion & synthesize collagen to create cover.

Question 25

What are Atherosclerosis Risk Factors?

Answer 25

1. Age
   Key factor in modern world but not strong association in less ‘developed’ societies.
2. Hypertension
   Very high correlation - increased hydrostatic pressure on walls causing intima layer stress microinjury.
3. Comorbid Conditions
   High correlation with diabetes, metabolic syndrome, gout, chronic inflammatory conditions such as rheumatoid arthritis, psoriasis, etc.; conditions that tend to combine vessel wall irritation/damage with hypertension &/or cholesterol issues.
4. Gender
   Intrinsic female estrogens appear to have strong protective effect via increasing HDL levels; therefore, males have significantly higher risk factor. Postmenopausal females come close to catching up to their male counterparts’ level of risk. Note: synthetic estrogens do not have same effect, & may promote hypertension as well.
5. Race/Inheritance
   Correlates in North America & Europe with significantly higher risk for blacks, but is not consistent globally. There is evidence of family clustering. In some cases, there is inherited lack of enzymes needed to process cholesterols which leads to early development of severe atherosclerosis.
6. Cigarette Smoking
   Referred to as #1 preventable cause of death in North America, in part because of significance of its contribution to atherosclerosis & associated thrombosis.
7. Excess Alcohol Consumption
8. Chronic Stress, “Type A” Personality, Depression
9. Dietary Factors
   Diet high in saturated fats -> increases LDL concentrations
   Low fibre intake -> reduces clearance of LDL’s
   Junk food -> high saturated fats, trans fats, toxic elements
   Overconsumption of sugar, carbohydrates
   Insufficient vitamins
10. Soft Water Consumption
11. Sedentary Lifestyle
    Exercise increases HDL levels
12. Obesity, esp. Abdominal Obesity
13. Environmental Pollution
    Receiving increasing interest as risk factor

Question 26

What are Atherosclerosis Considerations for Massage Therapist?

Answer 26

1. Atherosclerosis can be completely asymptomatic for long periods of time. When there is diagnosis of atherosclerosis it probably indicates that condition is already significantly progressed
2. Prevalence of atherosclerosis is such that, in combination with #1 above, massage therapist should routinely consider whether patient is high risk & become more observant. In some cases eg. when patient is diabetic, an assumption of significant atherosclerosis can be made. Similarly, history of angina pectoris, myocardial infarction, stroke can virtually be interpreted as diagnosis of significant atherosclerosis, although since other causes are sometimes involved verification is important
3. Atherosclerosis & hypertension are mutually causative - one generally accompanies other.
4. Atherosclerosis, especially when it’s more advanced, correlates strongly with thrombosis. When patient has atherosclerosis, precautions should be taken against significantly increasing blood flow or blood pressure. Check to find out which atheroma locations have been identified. Any information doctor has about risk of thrombosis & embolism in case is important. Anticoagulant therapy necessitates massage treatment adaptation
5. For unknown reasons atheromas become more unstable (friable) as they age (maybe a kind of ‘ripening’ effect?) consequently risk of complications increases with time person has condition.