Compulsory Question Assessment

Question 1

How do you recognise that someone is experiencing angina

Answer 1

1. Pain, Tightness, Burning or a Dull Sensation in the chest
2. Arm sensations (pain or heaviness) particularly in L arm
3. Throat, back or abdomen sensations (pain or discomfort)
4. Breathlessness on exertion
5. Fatigue

Question 2

What are the characteristics that make angina unstable?

Answer 2

1. The angina is new (< 1 month)
2. It is experienced at rest
3. It has worsened in frequency, severity and at lower levels of exertion

THESE PATIENTS SHOULD NEVER EXERCISE

Question 3

What are the possible additional signs and symptoms of an MI

Answer 3

1. Crushing, band-like, squeezing chest pain.
2. Radiating to jaw & throat
3. Arm heaviness or pain (one or both)

Milder Discomfort:
4. Similar to indigestion
5. In throat or arm alone
6. In abdomen or back

7. Breathlessness
8. Nausea / Vomitting
9. Pale, cold & clammy
10. Impending doom
11. Weakness / collapse

Question 4

What action would you take with someone who was experiencing chest pain

Answer 4

1. Stop. Sit. Rest
2. GTN (spray or tablets)
3. Repeat after 5 mins
4. 999

IF SYMPTOMS ARE ALLEVIATED, REST FOR 5 MINS THEN RE-WARM

Question 5

How would your action change if you suspected an MI (as opposed to angina)

Answer 5

1. Get to hospital without delay
2. Give 300mg Asprin unless allergic

Question 6

What is the purpose of risk stratification?

Answer 6

1. To determine the risk of a patient having a further cardia event whilst exercising.
2. To enhance programme safety
3. To determine exercise intensity, level of supervision and monitoring (in consultation with rehabilitation team)

THE MORE DAMAGE TO THE MYOCARDIUM (& THEREFORE HEART FUNCTION), THE HIGHER THE RISK OF THIS

Question 7

Which criteria are used for risk stratification?

Answer 7

1. Post event complications (heart failure / ischaemia / angina).
2. Reduced LV Function (<50%)
   Severe = < 35%
   Moderate = 35-49%
3. Residual Angina (ongoing)
   - High risks if angina @ < 5 METS
   - Lightheadedness
   - Dyspnoea at low workloads
   - Silent Ischaemia (ST segment depression on ECG - < 2mm from baseline) during exercise or recovery
4. Serious Arrhythmias
   - Ventricular tachycardia or fibrillation (at rest or exercise) = Cardiac Arrest risk
   - ICD Implant
   - History of CA
5. Reduced Functional Capacity
   < 7 METS on a maximal test = heart not coping with intensity
   HIGH risk @ < 3 METS
6. DRUG Treatment for CLINICAL depression
   As many are arrhythmmogenic
   (Sertraline & Cetralopram are best)

Question 8

What are the absolute contraindications to exercise?

Answer 8

If there are new or worsening symptoms within the previous month or if medication has had to be changed in order to achieve control. The condition is then deemed uncontrolled or unstable.

1. New breathlessness, fatigue or ankle oedema as signs of Unstable heart failure
2. Unresolved unstable angina
3. Atrial or ventricular arrhythmias
4. Palpitations, dizziness or lethargy
5. Tachycardia (>100)
6. BP 180 / 110 or Symptomatic hypotension
   7.Febrile or unwell
7. Unstable diabetes

Question 9

When would you refer a client back to their GP?

Answer 9

First check reasons for deterioration are not down to non compliance with home exercise routine or medication regimen. If no obvious innocent reason, refer when:
1. Exercise performance is reduced
2. Angina: worse or unstable
3. Arrhythmias, breathlessness & other symptoms
4. A further cardiac event

Question 10

What is the recommended time and the physiological reasons for an extended warm up?

Answer 10

Minimum of 15 minutes

Increases coronary blood flow through coronary artery vasodilation matches the demands that pulse-raising activity places on the myocardium.

This increases oxygen and nutrient supply and reduces the risk of ischaemia.

Here are the primary mechanisms involved:

1. Metabolic Factors: During physical activity, the heart muscle’s metabolic rate increases, leading to greater production of metabolites such as adenosine, carbon dioxide, hydrogen ions (H+), and lactate. Adenosine, in particular, is a potent vasodilator and plays a critical role in increasing coronary blood flow. These metabolites cause local vasodilation of the coronary arteries to enhance blood flow to meet the metabolic demands of the heart muscle.
2. Endothelial Factors: The endothelial cells lining the coronary arteries release vasodilatory substances in response to increased shear stress and other stimuli. Nitric oxide (NO) is the most notable of these substances. As blood flow increases during the warm-up, it generates shear stress on the vessel walls, stimulating the endothelial cells to produce more NO. Nitric oxide diffuses into the smooth muscle cells of the blood vessels, causing them to relax and dilate.
3. Autonomic Nervous System: During exercise, the balance of autonomic nervous system activity shifts, with an increase in sympathetic nervous system activity. This generally causes vasoconstriction in most systemic arteries to support blood pressure, but the coronary vessels often respond differently due to the local production of vasodilators that override this effect. Additionally, sympathetic stimulation increases heart rate and contractility, indirectly increasing metabolic demand and the production of vasodilatory metabolites.
4. Oxygen Demand Feedback: As cardiac activity increases, the demand for oxygen rises. The coronary arteries sense the lower oxygen levels (hypoxia) in the heart muscle and respond by dilating to increase blood flow and oxygen delivery, maintaining the supply-demand balance.

Together, these mechanisms ensure that coronary blood vessels appropriately dilate to increase blood flow to the heart muscle during warm-up activities, thereby maximizing oxygen delivery and sustaining increased cardiac workload effectively.

Question 11

How is Venus return maintained during exercise?

Answer 11

Feet need to be kept moving or toes wiggling
- this encourages Venus return via the muscle pump

Any form of breath holding is avoided - this encourages Venus return via the respiratory pump

Details:

1. Muscle Pump: Skeletal muscle contractions play a significant role in promoting venous return. As muscles contract, they compress the veins within and around them, pushing blood towards the heart. This muscle pump mechanism is aided by the presence of one-way valves in the veins, which prevent backflow and ensure that blood moves in the direction of the heart. During exercise, rhythmic contractions effectively increase venous return.
2. Respiratory Pump: Breathing patterns change during exercise, enhancing venous return through the respiratory pump mechanism. During inhalation, the diaphragm descends, decreasing intrathoracic pressure and increasing intra-abdominal pressure. These changes create a pressure gradient that facilitates the flow of blood from the abdominal veins into the thoracic cavity, augmenting venous return to the heart.
3. Sympathetic Nervous System Activation: Exercise stimulates the sympathetic nervous system, which results in vasoconstriction of veins (venoconstriction). This increases venous tone and reduces venous compliance, effectively pushing more blood back to the heart and maintaining venous return.
4. Increased Blood Volume and Cardiac Output: As exercise commences, cardiac output increases due to a rise in heart rate and stroke volume. Stroke volume itself is partly influenced by the Frank-Starling mechanism, where increased venous return stretches the ventricular walls, optimizing their contraction. In addition, redistribution of blood flow during exercise, with more blood directed from the splanchnic circulation to active muscles, helps maintain central venous pressure.
5. Role of the Vasculature: The venous system has high capacitance, which allows it to accommodate a large portion of the total blood volume. During exercise, the redistribution of blood volume, facilitated by alterations in vascular resistance and compliance, aids in maintaining venous return despite changes in body posture or dynamics.

These physiological adaptations work together to enhance venous return during exercise, supporting increased cardiac output and sustaining the supply of oxygen and nutrients to active tissues.

Question 12

What is the recommended time and the physiological reasons for an extended cool down?

Answer 12

10 minutes because it reduces the risk of arrhythmia and hypotension. This is more likely because of:

1. Increased circulating catecholamines (adrenaline and noradrenaline)
2. Older adults take long to return to pre-exercise states due to slowing of baroreceptor responsiveness. These receptors are located in the aortic arch and carotid sinus and act as a rapid feedback mechanism (when blood pressure drops, baroreceptors signal the brain to increase heart rate and constrict blood vessels, raising pressure)

Question 13

Where would supine work be placed in the programme and what are the background physiological reasons?

Answer 13

Supine work should be done after cool down

1. INCREASED PRE-LOAD
   Engaging large muscle groups in standing work increases venous return, leading to a higher preload (the amount of blood that gets loaded into the ventricles of the heart just before contraction) and potentially a stronger heart contraction

A further increased pre-load is caused by lying down.

This carries a risk of arrhythmia in some.

2. JOINTS AND MEDS
   Care should be taken on return to standing due to:
3. Orthostatic hypotension also a consideration especially if taking ACE inhibitors; Alpha and Beta Blockers; Calcium Chanel Blockers; Clonadine; & Diuretics & Nitrates
4. Joint pain and elderly diffs getting down and up