Exercise indications/contra

Question 1

Unstable angina (escalating angina or angina at rest)

Answer 1

Do not exercise

Question 2

Resting SBP >200 mmHg or resting DBP >110 mmHg

Answer 2

Do not exercise

Question 3

Orthostatic BP drop of >20 mmHg with symptoms

Answer 3

Do not exercise

Question 4

Critical aortic stenosis (peak systolic gradient >50 mmHg with an AV area <0.75 cm2)

Answer 4

Do not exercise

Question 5

Acute systemic illness or fever

Answer 5

Do not exercise

Question 6

Uncontrolled atrial or ventricular dysrhythmias

Answer 6

Do not exercise

Question 7

Uncontrolled sinus tachycardia (>120 bpm)

Answer 7

Do not exercise

Question 8

Uncompensated CHF (symptomatic at rest)

Answer 8

Do not exercise

Question 9

3rd degree AV Block without a pacemaker

Answer 9

Do not exercise

Question 10

Active pericarditis or myocarditis

Answer 10

Do not exercise

Question 11

Recent embolism

Answer 11

Do not exercise

Question 12

Thrombophlebitis

Answer 12

Do not exercise

Question 13

Uncontrolled Diabetes (resting blood glucose >300 mg/dl or >250 mg/dl with ketones present)

Answer 13

Do not exercise

Question 14

Other metabolic conditions such as acute thyroiditis, hypokalemia, hyperkalemia, hypovolemia, etc…

Answer 14

Do not exercise

Question 15

Critical Aortic Stenosis- Mobilization okay for ADL purposes with MD clearance per AHA [Circulation, 2001;104;1694-1740

Answer 15

Contraindications:Examples of Clinical Exceptions

Question 16

Fever-Temperature >101; the concern is for a sympathetic response to fight the infection including an increase in heart rate at rest; exercise would cause the heart rate to go even higher putting the CAD pt. at risk for ischemia. There is less risk in the surgical pt. who has been fixed. For example, would mobilize a surgical pt. with fever due to atelectasis. Would hold an MI patient with a fever of >101 F.

Answer 16

Contraindications:Examples of Clinical Exceptions

Question 17

Active pericarditis or myocarditis- Avoid strenuous exercise. If stable and being treated, mobilize cautiously while monitoring signs and symptoms. In pericarditis the concern is for pericardial effusion/tamponade. In myocarditis the concern is for heart failure/arrhythmia.

Answer 17

Contraindications:Examples of Clinical Exceptions

Question 18

Recent embolism- Once anticoagulated, mobilize pt. as tolerated with MD approval

Answer 18

Contraindications:Examples of Clinical Exceptions

Question 19

Other metabolic problems, such as acute thyroiditis, hypo or hyperkalemia, hypovolemia etc.- Often can be corrected within hours… may be able to treat later in the day. Electrolyte imbalances can cause dysrhythmia. Hypovolemia can cause orthostasis/exercise intolerance.

Answer 19

Contraindications:Examples of Clinical Exceptions

Question 20

Stop Exercise If:

Answer 20

1. Signs/symptoms of exercise intolerance
   - Severe fatigue or shortness of breath
   - Onset of angina
   - Pallor, cyanosis, or cold and clammy skin
   - Confusion, ataxia, vertigo, visual or gait problems
   - ST displacement (> 2mm horizontal or down sloping depression)
2. DBP >110 mmHg
3. Drop in SBP of >10 mm Hg [with increasing workload accompanied by signs or symptoms; or, drop below standing resting pressure]
4. Onset of 2nd degree or 3rd degree AV Block
5. Significant ventricular or atrial arrhythmias [sustained VT or increasing PVC’s, rapid SVT]
6. Claudication (grade 3 on 4 point scale)
7. Patient request

Question 21

Considerations when Assessing Responses

Level of patient conditioning

Answer 21

Anticipate an exaggerated HR response and potential drop in BP with deconditioning (due to relative hypovolemia from bedrest and/or decrease in vascular smooth muscle tone)

Question 22

Considerations when Assessing Responses

Medications patient is taking

Answer 22

Expect flat HR and BP responses on beta blockers

Expect exaggerated HR response on bronchodilators

Question 23

Considerations when Assessing Responses

Goal of medical therapy

Answer 23

Recent non-hemorrhagic CVA: SBP ≥150 mmHg
Acute renal failure: SBP ≥150 mmHg
Recent AVR or Aortic Dissection Repair: SBP <150 mmHg
Heart Failure: SBP often allowed to 70 or 80 mmHg if pt. asymptomatic