Compulsary Clinical Information

Question 1

How do you recognise that someone is experiencing angina

Answer 1

Tightness/ burning/ dull sensation in chest

Shoulder / arm pain

Breathless

Pain in throat / jaw or abdomen

Question 2

What are the characteristics that make angina unstable?

Answer 2

New onset angina (less than one month to establish a pattern)

Angina at rest

Increase in frequency - using gtn more often

Severity - not relieved as easily by rest or gtn, need more doses

Occurs at lower level of usual exertion - not reproducible at same workload

Patient must see gp

Absolute contraindication to exercise

Question 3

What are the possible additional signs and symptoms of an MI

Answer 3

Central chest pain, May radiate to jaw/arm/throat, abdomen or back:

• can be severe in nature I.e. crushing, tightness
• but may be mild discomfort like indigestion therefore the clue is that it is not stable angina is ;
• it is prolonged and not relieved by rest or gtn

Pale, clammy, shocked and agitated

Nausea/vomiting

Anxiety / impending doom

Question 4

What action would you take with someone who is experiencing chest pain during exercise? And how would your action change if you suspected an MI?

Answer 4

Immediate action:

• stop exercise
• sit patient down on floor, knees up to chest, back against the wall
• if uses GTN, suggest taking a dose
• repeat up to 2 times at 5 minute intervals

Further action:

If pain relieved - rest 5 mins, rewarm and resume activity

If no relief 5 mins after 2nd dose call 999

Question 5

What is the purpose of risk stratification? What are the criteria that will increase a persons risk during exercise?

Answer 5

To determine the level of risk of a patient having a further cardiac event whilst exercising

Complications:

• heart failure
• post event/ procedure angina / ischaemia

Poor Lv function:

• EF <40% poor LVF (or seriously impaired)
• EF 40 - 49 % moderate LVF (or mildly impaired)

Residual ischaemia:

• ongoing angina symptoms
• *ST ⬇️ on ECG during exercise or in recovery if known

Ventricular arrhythmias:

• history of complex ventricular arrhythmias
• survivor of cardiac arrest

Maximal functional capacity test less than 7 mets

Clinically significant treated depression

Question 6

What are the absolute contra indications to exercise?

Answer 6

• unstable angina (risk of provoking ischaemia or MI)
• unstable or acute heart failure - putting oedema, dyspnoea
• unstable diabetes - uncontrolled blood sugars
• new or uncontrolled arrhythmias (irregular pulse, (AF, heart block) new unexplained bradycardia, ?need pacemaker)
• pre exercise resting or uncontrolled tachycardia > 100bpm after 5 mins seated rest, unless an explained cause like rushed, nervous, caffeine, smoking
• hypertension - resting sbp >180 mmhg or dbp >100mmhg
• Symptomatic hypotension (dizziness, lightheaded ness)
• Febrile illness (cold , flu, fever)

Question 7

When would you refer a client back to their gp?

Answer 7

• deteriorating functional capacity - despite apparent compliance with the prescribed exercise regimen. May be due to progression of disease or medication. Check compliance with exercise and medication
• worsening of angina or development of unstable angina - ask them to see gp for assessment ASAP. May be progression of chd
• worsening of other symptoms, e.g. suspected arrhythmias, excessive breathlessness, pitting oedema. May be sign of reduction in LVF &/ or progression of CHD
• any further cardiac event, e.g. further Mi, need to be assessed in phase 3