Quiz 1: Cardiac Pathologies Flashcards
Where does the right coronary artery supply blood to?
-R atrium
-Most of R ventricle
-Inferior wall of left ventricle
-AV and SA node (60% of population)
-Bundle of His
Where does the left coronary artery supply blood to?
-Left anterior descending (LAD)
-Left ventricle, septum, inferior apex
-Left circumflex
-Lateral and inferior walls of left ventricle
-SA node (40% of population)
What are the tissue layers of the heart?
-Endocardium
-Myocardium
-Pericardium
What does the pericardium consist of?
-Fibrous pericardium
-Parietal pericardium
-Visceral pericardium (epicardium)
What does the serous pericardium consist of? What is inside the serous pericardium?
-Visceral and parietal pericardium
-Fluid is between these two layers
What is myocardium? How is it different from skeletal muscle?
-Heart muscle
-Different from skeletal muscle due to automaticity
-Pacemaker cells keep the heart moving without conscious voluntary movement
How does the sympathetic and parasympathetic systems influence the heart?
-Vagus nerve bundle (parasympathetic)
-Vasovagal syncope (aka neurocardiogenic syncope)
What external factors can influence the heart rate?
-Stress
-Exercise
-Caffeine
-Drugs
What does the myocardium consist of?
-Contractile elements of the heart
-Conductive elements of the heart
What is the endocardium? What is its function?
-Thin layer of cells lining the inside of the myocardium, valves, and atria
-Has some connective tissue, some elastic fibers, and muscle tissue
-Provides a smooth surface to allow blood and platelets to flow freely and not adhere to heart walls
-Strengthens the valves and supports other heart tissue
-Supports the subendocardial layer which houses the Purkinje fibers
What are the names of the two atrioventricular valves? What chambers are they between?
-Tricuspid/R AV: between R atrium and R ventricle
-Mitral/L AV: between L atrium and L ventricle
What are the names of the two semilunar valves? What two structures are they between?
-Pulmonary: between R ventricle and pulmonary artery
-Aortic: between L ventricle and aorta
What is cardiac output (CO)?
Amount of blood ejected out of the left ventricle into the systemic system per minute
What is a normative value of cardiac output at rest?
4-5 L/min
How is cardiac output calculated?
-Cardiac output (CO)= heart rate (HR) x stroke volume (SV)
-CO= HR x SV
How long does it take blood to travel through the pulmonary and systemic circuits?
About 1 minute
What is stroke volume?
Amount of blood ejected out of the L ventricle/beat
What is a normative value of stroke volume?
55-100 mL/beat
What is stroke volume affected by?
-Left ventricular end diastolic volume (LVEDV)
-End systolic volume (ESV)
What is left ventricular end diastolic volume (LVEDV)?
Amount of blood left in the ventricle at the end of diastole
What is end systolic volume (ESV)?
Volume of blood returning to the heart
What is preload? What is it directly proportional to?
-The amount of stretch experienced by cardiac sarcomeres pre-contraction
-Directly proportional to stroke volume
What affects preload?
Affected by venous return and volume of returning blood
What is Starling’s Law?
The greater the LVEDV the greater the stretch and volume pumped
What is afterload? What is it inversely related to?
-Force left ventricle must generate to overcome aortic pressure to open aortic valve
-Inversely related to SV
What is contractility?
The squeezing pressure of the left ventricle
What is ejection fraction (EF)? What is it used for? What is a normative value for EF?
-Percentage of blood emptied from the ventricle during systole
-Clinically useful way to understand left ventricular function
-Normal values is 60-70% (greater than 55%)
How is ejection fraction calculated?
-EF=SV/LVEDV
What is low EF usually an indicator of?
Usually an indicator of cardiomyopathy or heart failure
What is myocardial oxygen demand? How is it measured? When does it increase?
-Energy cost to myocardium
-Measured with rate pressure product
-Rate pressure product= HR x SBP
-Increases with activity and with HR or BP
What are the neurohumerol influences on sympathetic stimulation (adrenergic) of the heart?
-Control in the medulla via T1-T4
-SA node, AV node, conduction pathways
-Increases HR and force of myocardial contraction
-Coronary artery vasodilation
-Sympathomimetics: antihypertensives are sympathetic blockers
What are the neurohumerol influences on the parasympathetic stimulation (cholinergic) of the heart?
-Control in the medulla via vagus nerve (CN X) and cardiac plexus
-Innervates the SA and AV node
-Slows rate and force of myocardial contraction
-Coronary artery vasoconstriction
What are baroreceptors? Where are they located?
-Pressure receptors
-Located in walls of aortic arch and carotid sinus
What is the circulatory reflex? What changes occur if BP is increased? What changes occur if BP is decreased?
-Responds to BP changes
-Increased BP triggers parasympathetic response, decrease rate and force of contraction, sympathetic inhibition
-Decreased BP triggers sympathetic response, increases HR and BP, vasoconstriction
What are chemoreceptors? Where are they located?
-Detect changes in O2, CO2, and lactid acid (pH) and will effect HR and RR
-Located in the carotid body
-Increased CO2 or decreased O2 or pH= increased HR and RR
-Increased O2= decreased HR
What is hyperkalemia? What effects will this have on the heart?
-Increased concentration of potassium ions
-Decreased HR
-Decreased contractile force
-Arrhythmias and EKG changes
What EKG changes will you see with hyperkalemia?
-Widened PR and QRS intervals
-Tall T waves
What is hypokalemia? What effects will this have on the heart?
-Decreased concentration of potassium ions
-EKG changes
What EKG changes will you see with hypokalemia?
-Flattened T waves
-Prolonged PR intervals
What is hypercalcemia? How does it effect the heart? What other symptoms might someone have?
-Increased calcium concentration
-Increased HR and increased contractility
-Kidneys would also be effected
-Confusion
-Coma
What is hypocalcemia? How does it effect the heart?
-Decreased calcium concentration
-May cause arrythmias
What is hypermagnesmia? How does it effect the heart? How does it effect other systems?
-Increased magnesium concentration
-Calcium blocker
-Arrythmias
-Cardiac arrest
-Hypotension
-Confusion and lethargy
What is hypomagnesmia? How does it effect the heart?
-Decreased magnesium concentration
-Ventricular arrythmias
-Coronary artery vasospasm
What is the cardiac cycle?
The period from one heart beat to the beginning of the next heartbeat
How does the action potential go through the heart?
-Starts at SA node
-Depolarizes atria
-Spreads to AV node
-Bundle of His
-Bundle branches
-Purkinje fibers
What is systole?
The period of contraction that the heart undergoes while it pumps blood into circulation
What is diastole? What occurs during diastole?
-The period of relaxation that occurs as the chambers fill with blood
-The coronary arteries perfuse the myocardium during diastole through capillaries
-As the aortic valve snaps shut, leftover blood is shunted to the coronary arteries
How long is the delay between the action potential getting sent from the SA node to the AV node? What does this delay allow?
-0.1 second
-It allows the atria to contract and the ventricles to fill
What is phase I of the cardiac cycle?
-Diastole/filling period
-Both atria and ventricles are relaxed
-Blood flows into the R atrium from sup. and inf. vena cava and the coronary sinus
-Blood flows into the L atrium from the pulmonary veins
-Both AV valves are open (blood flows from atria into ventricles)
-Semilunar valves are closed
-SA node depolarizes causing atrial contraction (atrial systole)
How much of ventricular filling occurs when the AV valves are open?
70-80%
How much of ventricular filling occurs because of “atrial kick”? When does “atrial kick” occur?
-20-30%
-Occurs during SA node depolarization which causes atrial contraction
How much blood is in the ventricles at the end of atrial systole and just prior to atrial contraction? What is the term that describes this?
-The ventricles contain approximately 130 mL of blood in a resting adult in standing position
-This is known as end diastolic volume (EDV) or preload
What is phase II of the cardiac cycle?
-Isovolumic/isovolumetric contaction
-AV node depolarizes, spreads to the bundle of His
-Muscles in the ventricle start to contract but semilunar valves are not yet open
-Pressure quickly rises above that in the atria, closing the AV valves
-Pressure is not high enough yet to be ejected from ventricles
What is phase III of the cardiac cycle?
-Ejection
-Continued depolarization through the bundle branches and Purkinje fibers creates stronger ventricular contraction
-Pressure in the ventricles rise until it is greater than the pulmonary trunk and aorta, pushing open the semilunar valves
-Blood is ejected from the ventricles (stroke volume)
How much blood remains in the ventricles following phase III of the cardiac cycle (ejection)? What is the term for this?
-50-60 mL of blood remain in the ventricle after ejection
-End systolic volume (ESV)
What is phase IV of the cardiac cycle?
-Isovolumic/isovolumetric relaxation phase
-Ventricular relaxation/diastole follows repolarization of the ventricles
-Early phase of ventricular diastole, the ventricular muscles relax
-Pressure in the ventricles begins to fall and drops below pressure in the pulmonary trunk and aorta
-Semilunar valves close
-AV valves have not yet opening
How many lobes are there in the R lung? How many are there in the L lung?
-R lung: 3 lobes (superior, middle, and inferior)
-L lung: 2 lobes (superior and middle, + lingula)
How many independent segments are there in the R lung? What are their names?
-9 independent segments
-Apical
-Anterior
-Medial
-Lateral
-Anterior basal
-Posterior
-Superior
-Posterior basal
-Lateral basal
How many independent segments are there in the L lung? What are their names?
-10 independent segments
-Apical
-Anterior
-Anterior superior
-Posterior superior
-Inferior
-Anterior basal
-Superior
-Posterior basal
-Lateral basal
-Posterior
What does the conducting zone consist of?
-Trachea
-Primary bronchus
-Secondary bronchus
-Bronchi
-Bronchioles
What does the respiratory zone consist of?
-Respiratory bronchioles
-Alveolar ducts
-Alveolar sacs
What are the pleura of the lungs? What do these layers make up?
-Two layered membrane that folds back on itself
-Visceral pleura (innermost)
-Parietal pleura (outermost)
-These two layers make up the pleural cavity
What is inside the pleural cavity? What is the function of the pleural cavity? What happens if it is not functioning correctly?
-Pleural fluid
-Creates surface tension to keep the lungs in place in the thorax and allows the lungs to expand when the thorax expands
-It also cushions and lubricates the lungs during expansion and retraction
-It it is not functioning, a pneumothorax can occur
What is the parietal pleura innervated by?
Phrenic and intercostal nerves
What are accessory muscles of inspiration?
-SCM
-Scalenes
-Pec minor
What are the principal/main muscles of inspiration?
-External intercostals
-Diaphragm
What is quiet breathing?
-Expiration is quiet breathing because it results from passive recoil of lungs and rib cage
What muscles are involved in active expiration?
-Internal intercostals
-Innermost intercostals
-Rectus abdominis
-Transverse abdominis
-External and internal obliques
What three pressures does breathing depend on?
-Atmospheric (pressure exerted on lungs by atmosphere)
-Intra-alveolar (pressure inside the alveoli)
-Intrapleural (pressure in the pleural cavity)
What keeps the lungs inflated?
-Competing forces of pressure keeps the lungs inflated
-Elasticity of the lungs and surface tension of alveoli creates an inward pull
-Surface tension in the pleural cavity creates an outward pull
-The outward pull is just slightly higher than the inward pull, so the lungs stay inflated
What is the role of surfactant?
Surfactant is a fluid in the alveoli that prevents them from collapsing
What is pulmonary ventilation?
The air that is moving in and out of the lungs
What is the pulmonary cycle?
Inspiration and expiration
What occurs during inspiration?
-Diaphragm contracts, thorax expands inferiorly
-External intercostals contract, pulls ribs up and out to expand thorax anteriorly
-Creates a pressure gradient and drives air into the lungs
What occurs during expiration?
-Expiration is largely passive
-Diaphragm and external intercostals relax which returns thorax to resting position and reduces volume
-Creates a pressure gradient and drives air out of the lungs
What physical properties do the lungs have that facilitate breathing?
-Lung compliance
-Tendency of lungs to recoil (collapse)
-Elastic recoil or elasticity
-Surface tension at air-liquid interface on the alveolar surface acts to collapse the alveoli (surfactant counters this)
-Resistance to airflow at the level of the airways
What conditions can effect the mechanics of breathing?
-Scoliosis
-Pulmonary fibrosis (impairs compliance of lungs)
-COPD
-Asthma
-Premature babies (reduced surfactant)
-TBI (neural control of breathing may be effected)
How is breathing controlled?
-Primarily controlled by medulla and pons (requires repetitive stimulation from brain)
-Respiration driven by CO2 and pH levels in the blood which stimulate central chemoreceptors in the medulla
What is the response if CO2 increases and pH decreases in the blood?
-Stimulates respiratory centers in the medulla to contract diaphragm and external intercostals
-Increases rate and depth of respiration
What is the response if CO2 decreases and pH increases in the blood?
Stimulated respiratory centers in the medulla to lower rate and depth of repiration
What role do the peripheral chemoreceptors in the carotid artery and aortic arch play in the control of breathing?
-They detect changes in CO2, O2, and pH in the blood
-Increase in ventilation occurs when CO2 levels increase or decrease of O2
What is the hypoxic drive to breath? What patient population is this common with? What precautions should be taken in these cases?
-Some patients with COPD trap CO2 and start to rely more on O2 receptors
-Supplemental O2 should be prudently administered because increases of O2 in the blood can suppress the hypoxic drive to breath
How does the hypothalamus and limbic systems effect breathig?
-Anxiety or stress can increase breathing rate
-Extreme fear can cause one to hold their breath
What is inspiratory reserve volume?
The extra volume of air that can be inspired with maximal effort after reaching the end of a normal, quiet inspiration
What is tidal volume?
The amount of air that moves in and out of the lungs during each breath
What is expiratory reserve volume?
The amount of air that can be forcefully exhaled after a normal, quiet breath
What is residual volume?
The amount of air that remains in the lungs after a person has forcefully exhaled as much as they can
What is inspiratory capacity?
-The maximum volume of air a person can inhale after a normal exhale
-Inspiratory reserve volume + tidal volume
What is the functional residual capacity?
-The amount of air remaining in the lungs after a normal exhalation
-Expiratory reserve volume + residual volume
What is vital capacity?
-The maximum amount of air that can be exhaled from the lungs after a maximum inhalation
What is the total lung capacity?
-The volume of air in the lungs upon the maximum effort of inspiration
-Vital capacity + residual volume
Where does gas exchange occur? How does it occur?
-Alveoli
-Respiratory zone
-Diffuses across membranes down a concentration gradient
-Driven by concentration of various gases in the air we breath and blood pH
What needs to occur for effective gas exchange?
Alveoli must be both ventilated and perfused
What is the V/Q match?
The goal is for ventilation (V) to be matched with perfusion (Q)
What does V/Q mismatch indicate?
A pathological state
What can effect the V/Q ratio?
-Positioning
-Pneumonia, emphysema, pulmonary edema, atelectasis
What is atelectasis?
Partial or complete collapse of the lung
Why is V/Q not uniform across the lungs?
Because there are areas of the lungs with greater perfusion and areas with greater ventilation
How does transport of O2 and CO2 occur in the blood?
-Veins carry CO2 to be expelled
-Arteries carry O2 from heart to tissues
-Hemoglobin (4 iron molecules, heme group, and 4 protein molecules/globins)
-Transports 98% of O2 delivered to the periphery (2% in plasma)
-O2 carrying capacity of body is determine by concentration of HgB
What is SaO2?
-Oxyhemoglobin/total hemoglobin (blood gas analysis)
-Called SpO2 when measure with pulse oximeter
What are the normative values for O2 carrying capacity? How does low O2 carrying capacity effect the body?
-Women: 12-16 g/dL
-Men: 13-16 g/dL
-Lower than normal concentrations impairs the body’s ability to circulate O2 and can cause anemia
What is the oxygen hemoglobin dissociation curve? What would a right shift in the curve indicate? What about a left shift?
-Describes the relationship between SaO2 and the partial pressure of arterial O2
-Right shift: reduced oxygen affinity
-Left shift: increases oxygen affinity
What is pericarditis? What are causes of this?
-Inflammation of pericardium or pericardial fluid
-Viral infection (most common)
-Other infection (bacterial, uremia, acute MI, tuberculosis, etc.)
-Systemic diseases (autoimmune disorders, inflammatory disorders, drug toxicity, etc.)
-Trauma
What would be the clinical presentation of acute pericarditis?
-May not present with any signs or symptoms
-Retrosternal chest pain (sharp/stabbing or dull achey)
-Often intensifies with cough and deep breathing
-Often relieved with sitting up and leaning forward
-Dyspnea (non-exertional)
-General malaise/fever
-EKG abnormalities are not common
-Auscultation: friction rub causes by inflammed pericardial layers rubbing against one another
-Usually seen in young and healthy individuals
What is included in the medical work up and management of acute pericarditis?
-Labs will reveal acute inflammation (elevated WBCs, erythrocyte sedimentation rate, C-reactive protein, and troponins may be elevated)
-Echocardiogram to evaluate pericardial effusion
-Management: rest, pain relief usually with NSAIDS
-High dose of antibiotics or pericardial drainage
How long does acute pericarditis usually last?
-Self limited disease
-Usually lasts 1-3 weeks
What is constrictive percarditis?
Chronic pericarditis or pericardial effusion results in thickening and scarring of the pericardium
What is the clinical presentation of constrictive pericarditis?
-Dyspnea and fatigue due to reduced CO
-LE and abdominal swelling
-Dizziness or syncope
-Vague retrosternal chest pain
-Jugular venous distention
What would a medical work up for constrictive pericarditis include?
-Chest X-ray
-Echocardiogram
-CT scan
-Cardiac catheterization
What is pericardial effusion? How does this effect heart function?
-An abnormal accumulation of fluid in the pericardial sac
-Pericardium is relatively stiff and doesn’t tolerate large fluctuations in fluid over a short amount of time
What is a normal amount of fluid to be in the pericardial sac?
15-50 mL
What can cause pericardial effusion?
Pericarditis and other pathologies or trauma can cause pericardial effusion
What is the clinical presentation of pericardial effusion?
-Feeling of fullness in chest
-Cough
-Hoarseness
-Dysphagia
-Serious, sometimes fatal
What is included in the medical work up and treatment of pericardial effusion?
-Muffled heart and lung sounds, dullness of left lung at angle of scapula
-Chest X-ray may show enlarged cardiac silhouette
-Echocardiogram
-Pericardiocentesis to drain fluid
What is cardiac tamponade?
-Excessive over accumulation of fluid in the pericardial space that exerts pressure on the heart
-Any pericarditis can progress to tamponade but most common is neoplastic, post viral, blunt or penetrating chest trauma, or dissecting aortic aneurysm
What is the clinical presentation of cardiac tamponade?
-Poor filling of the heart
-Decreased BP
-Hypotension shock and possibly death
-Decreased CO signs: dyspnea, fatigue, syncope, dizziness
-Cough, tachycardia, tachypnea
-Beck’s triad: hypotension, jugular venous distention with pulsus parodoxus, and decreased heart sounds
What is included in the medical work up and treatment for cardiac tamponade?
-Echocardiogram
-Emergency cardiac tamponade is treated with “cardiac window” or “pericardial window” where they cut a whole in the fibrous pericardium to allow fluid to drain and relieve pressure
-Pericardiocentesis
What is endocarditis? What are common causes?
-Infection of the endocardium from bacteria or fungi
-Travels from another part of the body- most often after dental work or GI/urinary problems
-Catheters, tattoos, IV drug abuse
-Rheumatic fever
What is endocarditis usually treated with? What can untreated endocarditis lead to?
-Treated with long term antibiotics
-Untreated can lead to destruction of valves and is often fatal
What is the clinical presentation of endocarditis?
-Flu like symptoms
-Pain with breathing
-SOB
-Swelling
-Fever
-Rapid onset of flu like symptoms (acute endocarditis)
-May hear mitral valve regurgitation on auscultation
Who is at highest risk for developing endocarditis?
-People with artificial heart valves as they are reservoirs for germs/bacteria
-Damaged valves or congenital heart defect
What are potential complications of endocarditis?
-Bacterial vegetation can travel to other areas of the body
-Heart valve damage
-Abscesses
-Pulmonary embolism
-Kidney and spleen issues
What is included in the medical workup and treatment of endocarditis?
-Labs for inflammation: sed rate, C-reactive protein, WBCs, blood cultures to isolate organism
-EKG
-Echocardiogram
-Long term, high dose antibiotics
-Cardiac supportive measures
-Possible valve replacement
What are some measures for preventing endocarditis?
Prophylactic antibiotics before dental work, upper respiratory procedures involving incisions or biopsies, GI/GU procedures if infection is present
What is myocarditis? What is it typically caused by?
-Inflammatory cardiomyopathy
-Infection or inflammation of the heart walls/muscle
-Generally viral or bacterial infection, rarely is it drug induced
-Rheumatic fever
-Affects both pump and electrical conduction
-Weakens pump action
What is the clinical presentation of myocarditis?
-Diffuse chest pain
-Fatigue
-SOB
-Edema
-Arrhythmias
-Fever
-General malaise
What are complications of myocarditis if it goes untreated?
-Heart failure due to damaged cardiac muscle
-MI or CVA
-Arrhythmias
What is the NIH definition of cardiovascular disease?
The term for all types of diseases that affect the heart or blood vessels, including coronary artery disease which can cause heart attacks, strokes, heart failure, and peripheral artery disease
What is hypertension?
Blood pressure readings consistently over established guidelines
What is the NIH definition of coronary artery disease (CAD)?
A heart condition that involves atherosclerotic plaque formation in the vessel lumen which can lead to impairment in blood flow and oxygen delivery to myocardium
What is the ACC definition of coronary artery disease?
A condition where the blood vessels that supply blood to the heart become damaged or diseased
What is the clinical presentation of someone with cardiovascular disease or CAD?
-Chest pain
-SOB
-Palpitations
-Fatigue
-Syncope
-Social history
-Risk factors for cardiovascular disease
What is included in the medical workup for someone who may have cardiovascular disease?
-Diagnostic tests/imaging
-Lab values
-EKGs
-PMH/PSH, hospital course
-Medications and nutritional intake
-Social history, cognitive and language ability
What are the modifiable risk factors for cardiovascular disease?
-Cholesterol levels
-Stress
-Diabetes
-Diet
-HTN
-Weight (BMI >30kg/m2)
-Activity level
-Tobacco or smoking
What are the non-modifiable/relatively non-modifiable risk factors?
-Age: > 65 men, >55 women
-Family history: cardiac event 1st male relative <55, 1st degree female relative < 65 increases risk 1.5-2 fold
-Genetics
-Gender male > premenopausal women; after menopause risk is =
-Race: African American
-Chronic kidney disease
-Low socioeconomic status
What would be included in the PT evaluation for someone with CAD or high risk for cardiovascular disease?
-General observation: posture, breathing mechanics, cough ability
-Skin: color (is it blue, pale, etc.)
-Vitals: pulse, rhythm, BP, SpO2
-Heart and lung sounds
-Chest wall motion and palpation
-EKG (refer out)
-Circulation and lymphatic system (observe any edema, temp of skin, etc.)
What is the prevalence of ischemic cardiovascular disease?
- > 83 million Americans have one or more forms of cardiovascular disease (1 in 3 adults)
What percentage of people with HTN are undiagnosed? What can unmanaged HTN cause?
-25% of those with HTN are undiagnosed
-Unmanaged HTN can lead to ischemic heart disease such as stroke, CAD, MI, CVA
What are the 2 types of HTN?
-Primary or essential
-Secondary
What is primary HTN?
-Most of the population (90-95%)
-No discernible/readily identifiable cause but associated with CV risk factors
-Largest number of office visits of non-pregnant US adults
What is secondary HTN?
-Small % of population
-Results from another identifiable disease process (kidney disease, endocrine disorders)
What is normal blood pressure?
<120/<80 mm Hg
What is elevated blood pressure?
120-129/<80 mm Hg
What is stage 1 hypertension?
130-139 or 80-89 mm Hg
What is stage 2 hypertension?
≥140 or ≥90 mm Hg
What are risk factors for hypertension?
-Stress
-Sleep apnea
-Birth control pills
-Moderate alcohol use (more than 1-2 drinks/day for men, more than 1 drink/day for women
What are the diagnostic criteria for hypertension?
-Presents with hypertensive emergency (≥180/≥120 mm Hg)
-Presents with ≥160/≥100 with confirmed cardiac risk factors
-Mean home blood pressure is ≥130/≥80 mm Hg
-If out of office BP not attainable, HTN is confirmed if mean BP is ≥130/≥80 mm Hg for 3 visits spaced over weeks to months
What cuff size should a small adult use for BP?
22-26 cm arm circumference
What cuff size should an adult use for BP?
27-34 cm arm circumference
What cuff size should a large adult use for BP?
35-44 cm arm circumference
What cuff size should be used for an adult thigh/bariatric adult use for BP?
45-52 cm arm or leg circumference
What is white coat HTN? Who is this condition more common in? What is the prevalence of it? What is used to diagnose it?
-BP elevated while in the office but normal with ambulatory BP monitor (ABPM) or home BP monitor
-More common in older adults, females, non-smokers
-Prevalence 13-35%
-Becomes clinically significant when office readings are >20/10 mm Hg higher than ABPM or HBPM
What is masked HTN?
-Office BP readings normal but ABPM or HBPM are consistently above normal
What does chronic HTN cause? What are the symptoms?
-Produced an overload on the left ventricle
-Stiff left ventricle leads to heart failure with reduced ejection fraction
-Predisposition towards MI due to insufficient O2 to left ventricle
-Symptoms of decreased CO: dizziness, dyspnea, impaired exercise tolerance
What are options for the management of HTN?
-Weight loss
-Aerobic exercise
-Limit sodium to < 6 g/day
-Reduce alcohol
-Stop smoking
-Treat sleep apnea
-Pharmacotherapy (if daytime BP is ≥ 135 systolic or ≥ 85 mm Hg diastolic)
How much can BP change with each 10kg weight loss?
10 kg weight loss is associated with 5-10 mm Hg drop in SBP
How does aerobic exercise help to lower BP?
It results in lower HR and reduced levels of circulating catecholamines suggesting reduced sympathetic tone of vessels
How much does a sedentary lifestyle increase someone’s risk for HTN?
Sedentary normotensive people have 20-50% higher risk of developing HTN
What medications are typically used to treat HTN?
-Thiazide diuretic
-Long acting Ca2+ channel blocker (amlodipine)
-ACE inhibitors (-prils)
-Beta blockers (-olols)
What are ACSM guidelines for HTN?
-Monitor BP
-Beta blockers increase possibility of hypoglycemia
-Watch for exaggerated response to exercise at low intensities
-Maintain SBP < 220 and/or DBP < 105
-Avoid valsalva
-Extended warm ups and cool downs, especially with beta blockers
-Monitor for post exercise hypotension
What is orthostatic hypotension?
Drop in blood pressure from supine to sit, sit to stand, or supine to stand
How is orthostatic hypotension diagnosed?
Diagnosed by a sustained reduction in systolic blood pressure of at least 20 mm Hg or diastolic blood pressure of 10 mm Hg within 3 minutes of standing after being supine for 5 minutes, or at 60 degrees on a tilt table
What conditions are orthostatic hypotension usually secondary to?
-Failure of autonomic reflex
-Volume depletion
-CV disease
-Adverse reaction to a medication
-Neurogenic diseases
-Paraneoplastic syndrome
What are common symptoms of orthostatic hypotension?
-Lightheadedness
-Dizziness
-Falls
-Loss of consciousness
-Visual and cognitive disturbances
-Weakness and fatigue
Who is orthostatic hypotension more common in?
-Older adults
-Women
-Younger people
What are common treatments for orthostatic hypotension?
-Education
-Avoid volume depletion/dehydration
-Exercise
-Mobility
-Compression stockings/abdominal binders
-Avoid alcohol and heavy meals
-Medications
What is postural orthostatic tachycardia syndrome (POTS)? What are symptoms?
-Defined as a rapid increase in heartbeat of more than 30 bpm in adults or 40 bpm in adolescents or HR exceeding 120 bpm within 10 minutes of rising
-Faintness/lightheadedness
-Symptoms relieved by lying down
What conditions can lead to POTS?
-Menstrual cycles increase risk
-Infections such as COVID
-Major surgery
-Trauma
-Prolonged bedrest
What are common treatment options for POTS?
-Targeting low blood volume
-Higher Na+ intake
-Hydration
-Medication
How can PT’s help with orthostasis?
-Move LE’s before standing
-Move segmentally
-Valsalva if not contraindicated
-Pressure garments
What are exercise guidelines for POTS?
-75% max predicted heart rate or RPE 13-15 in recumbent position
-Start with 30 minutes, 3-4x/week
-Slowly increase duration and intensity in recumbent
-Start to slowly add upright but decrease intensity and duration
-Add warm ups and cool downs
What are the risk factors for CAD?
-Men > 45, women > 55
-Family history: cardiac event 1st degree male < 55, 1st degree female <65
-Current or recent smoker
-Obesity: BMI ≥30
-HTN
-Dislipidemia: LDL ≥ 130 mg/dL, HDL < 40 mg/dL
-Diabetes
-Inflammation
What is HDL? What are normal HDL levels?
-High density lipoprotein
-“Good cholesterol”
-Men > 40 mg/dL
-Women > 50 mg/dL
What are behaviors that raise levels of HDL?
-Weight loss
-Smoking cessation
-Increased aerobic exercise
What can reduce levels of HDL?
Elevated triglyceride levels
What is considered and elevated fasting triglyceride level?
Anything above 200 mg/dL
What is LDL?
-Low density lipoprotein
-“Bad cholesterol”
What levels of LDL are optimal? What levels of LDL put someone at higher risk of myocardial infarction?
-Optimal < 100 mg/dL
-Borderline 130-159 mg/dL
-High risk 160-189 mg/dL
What is the ideal level of LDL cholesterol in the presence of heart disease, stroke, vascular disease, aneurysm, or type 2 diabetes?
Ideal LDL would be less than 75 mg/dL
What is the blood lipid ratio? What does this indicate?
-Total cholesterol/HDL cholesterol
-Higher the ratio, the greater the risk of CVD
What is the PT role in CAD?
-Risk factor stratification/education
-Prevention
-Exercise (aerobic > 150 minutes/week, strength training 2x/week)
How does CAD progress to ischemic heart disease?
Mismatch between myocardial O2 demand and supply occurs
What are symptoms of stable angina due to ischemic heart disease?
-Predictable pattern of transient chest discomfort
-Pressure, tightness, squeezing, burning, heaviness
-“Elephant sitting on my chest”
-Does not vary significantly with inspiration or movement of chest wall
-Levine sign: clenched fist over sternum
-Discomfort often accompanied by tachycardia
-Relieved by cessation of precipitating activity
What is stable angina caused by?
Fixed, obstructive atherosclerotic plaque in one or more arteries, causing stenosis (usually 70% or more)
What are common triggers of stable angina?
-High BP
-Anemia
-Stress
-Extreme cold
-Heavy metals
-Physical exertion
What are common locations where angina is felt?
-Large area over the chest/breastbone
-Between the shoulder blades
-Neck and jaw
-Inside arms
-Left shoulder
-Upper abdomen (can be mistaken for indigestion)
What is the angina scale?
-1+ light, barely noticeable
-2+ moderate, bothersome
-3+ severe, very uncomfortable
-4+ most severe pain ever experienced
What is the Canadian Cardiovascular Angina Classification?
- I: angina with strenuous activity
- II: angina with slightly greater than normal activity
- III: angina resulting in marked limitation in normal activity
- IV: angina at rest
How does cardiac rehab effect risk of mortality and non-fatal MI?
-Reduces total mortality by ≥ 20%
-Reduces cardiac mortality by ≥ 26%
-Decreases non-fatal MI by ≥ 21%
What are the PT exercise guidelines for stable angina?
-30-60 minutes of moderate intensity (40-60% THR), 5 days/week
-Increase daily lifestyle activities
-Resistance train 2 days/week, moderate intensity (40-60% of 10RM)
-Avoid valsalva
-Longer warm up and cool down
What is variant or Prinzmetal angina?
-Develops due to coronary artery spasm, not due to oxygen demand mismatch
-More common in women, smokers and cocaine users
-Rare
-Usually occurs at rest or in the middle of the night
-Patients usually very active
-May or may not have associated CAD
-Vasospasm can be triggered by anything that causes vasocontriction
-Silent ischemia (asymptomatic, detected on EKG)
What is unstable angina?
-Increasingly variable frequency and duration of angina symptoms
-Change in anginal pattern
-Usually indicates a progression of ischemic heart disease
-Often result of a rupture of atherosclerotic plaque
-Often precursor to MI
-Higher morbidity and mortality rates
-Lower physical, emotional threshold to trigger angina symptoms
-Chest pain at rest
What are the PT exercise guidelines for unstable angina?
-Get physician clearance
-Know patients medications
-Lifestyle modifications
-Extended warm up and cool down
-30-40% of THR
-STOP with any onset of angina symptoms
-Shorter duration
-No HIIT
-Take vitals!!!
What is a major symptom/sign that someone is having an MI?
Chest pain greater than 20 minutes without relief with decreasing activity
What is the most common cause of an MI?
Atherosclerotic plaque rupture in an already blocked artery
What are the two types of MI?
-NSTEMI: non ST elevation MI
-STEMI: ST elevation MI
What is the clinical presentation of MI?
-Unstable angina
-Severe “crushing” persistent pain, typically substernal
-Dyspnea
-Diaphoresis and cool, clammy skin
-Nausea, vomiting, weakness
-Pulmonary rales/crackles
-EKG abnormalities
What is included in the medical work up for MI?
-Presenting symptoms
-EKG
-Serum biomarkers (troponins, CK)
What is the medical management of MI?
-Early recognition is key
-Time is tissue: rapid revascularization
-Cardiac catheritization
-CABG
-Manage arrhythmias
-Echocardiogram
-Supplemental O2
-Continuous EKG monitoring
What is the time frame for optimal outcomes for MI patients?
If time from onset of symptoms to cathlab table is less than 90 minutes
What time frame from onset of symptoms to treatment can myocardial injury be reversed?
20 minutes
What is the Thrombolysis in Myocardial Infarction (TIMI) risk score?
-Predicts likelihood of death or subsequent ischemic events
1. Age > 65
2. ≥ 3 CAD risk factors
3. Known coronary artery stenosis ≥ 50%
4. ST segment deviations
5. At least 2 angina episodes in the last 24 hours
6. Use of aspirin in last 7 days
7. Elevated serum troponin or CK
What are potential complications of MI?
-Recurrent ischemia
-Arrhythmias
-Heart failure
-Cardiogenic shock
-Right ventricular infarction
-Mechanical complications
-Acute pericarditis
-Thromboembolism
What should post MI PT look like?
-Know EF to prescribe exercise
-Early mobilization
-Low level aerobic and low intensity strength training
-Patient eduction on self-monitoring, risk factors
-Discharge planning
What is an inotrope?
-A substance that alters the force of muscle contraction
-A positive inotrope will increase strength of muscular contraction
What is cardiac muscle dysfunction (CMD)? What is the most common cause of cardiac muscle dysfunction?
-Heart is unable to pump blood forward at a sufficient rate or volume to meet the metabolic demands of the body
-Impaired left ventricular function
-Congestive heart failure (CHF)
What is the prevalence of CHF?
-5.7 million Americans have CHF
-Lifetime risk to develop HF is 1 in 5 adults at age 40
-Over 85, risk is 65%
How does hypertension lead to CMD?
-Increased arterial pressure leads to left vetricular hypertrophy
-Leads to overstretched contractile fibers and less-effective pump
How does CAD lead to CMD?
Related to dysfunction of left or right ventricle as a result of injury
What can cause CMD?
-HTN
-CAD
-Cardiac arrhythmias
-Rapid or slow arrhythmias can impair function of ventricles
-Renal insufficiency
-Cardiomyopathy
How does renal insufficiency lead to CMD?
Acute or chronic insufficiency produces fluid overload
What is the leading cause of heart failure and cardiac transplant?
Cardiomyopathy
What are the three main types of cardiomyopathy?
-Dilated
-Hypertrophic
-Restrictive
What is dilated cardiomyopathy?
-Ischemic or non-ischemic
-Enlarged ventricle
-Systolic dysfunction
What is hypertrophic cardiomyopathy?
-Abnormal left ventricular wall thickness
-Diastolic dysfunction
What is restrictive cardiomyopathy?
-Abnormal left vetricular wall stiffness but not thickness
-Diastolic dysfunction
What is primary cardiomyopathy?
-Usually inherited (familial)
-No other cardiac problems
-Usually younger onset
What is secondary cardiomyopathy?
Caused by a medical condition
What can cause dilated cardiomyopathy?
-Idiopathic
-Systemic, significant, long-term, uncontrolled HTN
-Family history/genetics
-Inflammatory myocarditis
-Toxicity due to alcoholism and cocaine use or chemotherapy
-Metabolic disorders
-Pregnancy related
What can cause hypertrophic cardiomyopathy?
-Genetic
-Autosomal dominant mutations
What can cause restrictive cardiomyopathy?
-Hemochromatosis
-Metabolic diseases
-Radiation therapy
-Scleroderma
-Fibrotic tissue
What are the signs and symptoms of dilated cardiomyopathy?
-Same symptoms as heart failure with reduced ejection fraction
-S3 heart sound and mitral valve regurgitation
-Crackles/rales and dullness to percussion
-Imaging shows enlarged heart
What are signs and symptoms of hypertrophic cardiomyopathy?
-Symptoms vary widely
-Average age of presentation age 20
-Dyspnea and angina (not because of CAD)
-High O2 demand due to thick cardiac wall
-Arrhythmias and syncope
-S4 heart sound
What are signs and symptoms of restrictive cardiomyopathy?
-Decreased CO
-Fatigue and decreased exercise tolerance
-Systemic edema > pulmonary congestion
-JVD
-Ascites
-Hepatomegaly
-Arrhythmias
How can heart valve abnormalities effect the contractility of the heart?
A blocked or incompetent valve causes the heart to contract more forcefully
What are heart valve abnormalities associated with?
Myocardial dilation and hypertrophy
What are common surgeries for heart valve abnormalities?
-Valve replacement
-Valvuloplasty
-Valvulotomy
-Commisurotomy
What is pulmonary hypertension?
-Defined by mean pulmonary artery pressure (mPAP)
-Abnormal is > 25 mm Hg or in patients with COPD if > 20 mm Hg
How can a pulmonary embolism lead to cardiac muscle dysfunction?
-Results in dysfunction due to elevated pulmonary artery pressures that increase R ventricular work
-Potentially life threatening
What is the treatment of a pulmonary embolism?
-Rapid acting fibrinolytic agent
-Sedative to decrease anxiety and pain
-Oxygen
-Embolectomy
How can age effect or cause cardiac muscle dysfunction?
-Aging decreases cardiac output by altering contraction and relaxation of cardiac muscle
-Higher prevalence of heart disease and other risk factors in older adults
-Congenital heart disease
What is the universal definition of heart failure?
A clinical syndrome with symptoms and/or signs caused by a structural and/or functional cardiac abnormality and corroborated by elevated natriuretic peptide levels and/or objective evidence of pulmonary or systemic congestion
What is the universal classification of heart failure?
-Stage A: at risk for HF
-Stage B: Pre-HF
-Stage C: Symptomatic HF
-Stage D: Advanced HF
What are the subclassifications of symptomatic and advanced HF?
-HFrEF: symptomatic HF with LVEF ≤ 40%
-HFmrEF: symptomatic HF with LVEF 41-49%
-HFpEF: symptomatic HF with LVEF ≥ 50%
-HFimpEF: symptomatic HF with a baseline LVEF ≤ 40%, a ≥ 10-point increase from baseline, and a second measurement of LVEF > 40%
What is the Frank-Starling mechanism?
-The ability of the heart to change its force of contraction and therefore stroke volume in response to changes in venous return
-Length-dependent relationship (muscle fibers)
-Intrinsic cardioregulatory mechanism
-Allows the heart to adjust rapidly to changing preload conditions to keep the output near constant
How are heart failure etiologies grouped?
-Impair cardiac contractility: systolic dysfunction
-Increase afterload: systolic dysfunction
-Impair ventricular relaxation and filling: diastolic function
What heart failure etiologies cause impaired cardiac contractility?
-Reduction in muscle mass
-Cardiomyopathy
What heart failure etiologies can cause an increase in afterload?
-Systemic/pulmonary HTN
-Aortic or pulmonic valve stenosis
-Both of these lead to ventricular hypertrophy
What heart failure etiologies can impair ventricular relaxation and filling?
-Increased ventricular stiffness/ventricular hypertrophy
-Myocardial disease or infarction
-Mitral or tricuspid valve stenosis
-Pericardial disease
What are the most common contributing etiologies for heart failure?
-HTN
-CAD/ischemia/MI
-Cardiac dysrhytthmias
-Renal insufficiency
-Cardiomyopathy
-Valve abnormalities
-Chronic pericardial effusion
-Pulmonary embolism
-Pulmonary HTN
How does structural pathology of the left ventricle lead to structural heart failure? What are 2 hallmark symptoms?
-Reduces CO and leads to an accumulation of fluid in the left atrium
-Subsequent pulmonary and peripheral congestion
-Dyspnea and cough (CHF)
How does structural pathology of the right ventricle lead to structural heart failure? What are the hallmark symptoms?
-Reduction in right ventricular CO which results in venous congestion
-JVD
-Peripheral edema
-Ascites
-Pleural effusion
-Weight gain
What is right heart failure also known as?
Cor Pulmonale
How does structural pathology of both ventricles lead to structural heart failure? What are the hallmark symptoms?
-Left ventricle overloads resulting in pulmonary edema
-Right ventricle overloads resulting in systemic congestion
-Dyspnea
-Cough
-Peripheral edema
-Weight gain
-JVD
What is Heart Failure with Reduced Ejection Fraction (HFrEF)?
-Systolic dysfunction
-Left ventricle has diminished capacity to eject blood due to impaired contractility or pressure overload
-Pump problem: either too stretched out or too damaged
What is Heart Failure with Preserved Ejection Fraction (HFpEF)?
-Diastolic dysfunction
-Impaired diastolic relaxation
-Ventricular wall stiffness
-Extensibility problem: muscle cannot accommodate pressure changes required for physiologic changes associated with exercise
-More common in older adults, females > males
What is the New York Heart Association classification of HF?
- I: No limitation of physical activity; ordinary activity does not cause SOB
- II: Slight limitation of physical activity; ordinary physical activity results in fatigue, palpitation, dyspnea
- III: Marked limitation of physical activity; comfortable at rest; less than ordinary activity causes fatigue, palpitation, or dyspnea
- IV: Unable to carry on any physical activity without discomfort; symptoms of heart failure at rest
What is the AHA classification of heart failure? What is different about this classification than others?
-Stage A: at risk
-Stage B: patients with structural disease
-Stage C: patients who have developed clinical HF
-Stage D: patients with refractory HF requiring advanced intervention
-There is no moving backwards in this scale, unlike NYHA
What is compensated heart failure?
Patient with diagnosed HF but not exhibiting signs of pulmonary or peripheral congestion
What is acute uncompensated heart failure?
The presence of new or worsening symptoms of dyspnea, fatigue, or edema that leads to hospitalization or unscheduled medical care
What other systems are affected by HF?
-Renal function
-Pulmonary function
-Hepatic function
-Skeletal muscle dysfunction
-Pancreatic function
What does the medical management of heart failure include?
-Lifestyle changes
-Pharmacologic
-Mechanical management (LVAD, pacemakers, impella, etc.)
-Surgical management
-Dialysis to manage fluid overload and reduce work of kidneys
What would the physical therapy exam include for heart failure?
-Vitals
-Review imaging reports
-Breathing/RR
-Dyspnea
-Heart and lung sounds (S3, rales/crackles)
-May have orthopnea (harder to breathe while lying down)
-Check edema
-Assess exercise tolerance
-Cognition
-Nutritional status
How is orthopnea described?
By number of pillows needed to allow the patient to breathe with ease and comfort
What are the benefits of exercise for heart failure?
-Improved exercise tolerance
-Improved coronary artery flow
-Improved quality of life but no evidence or reduced mortality
-Safe with monitoring of vitals and lower intensities
What is the exercise guidelines for heart failure?
-Resistance training with light weights (large muscle groups)
-Avoid valsalva
-Light to moderate (1-5 on modified Borg)
-Work up to 150 minutes/week
-Aerobic > resistance
-Prolonged warm up and cool down
What are PT implications for heart failure?
-Vitals
-Heart and lung sounds throughout
-Start slow and build up
-Monitor edema
-Focus on functional activities
What is Life’s Simple 7?
-7 modifiable risk factors changeable through behavior modification
-Smoking
-Diet
-Glucose
-BMI
-Physical activity
-BP control
-Cholesterol
-Assigned 0-2 points each for a total of 14
What is Life’s Essential 8?
-Predictor of heart health
-Smoking
-Diet
-BMI
-Sleep
-Physical activity
-BP
-Cholesterol
-Glucose
How can PT’s treat acute uncompensated heart failure?
-Education on disease management
-Encourage low sodium, mediterranean diet
-Encourage safe activity
-Educate patient on symptoms of exacerbation
-Early mobilization
-Monitor vitals and RPE
-Reduce effects of prolonged bed rest
How much weight gain would be a red flag for patients with heart failure or other CVD?
-2-3 lbs in 24 hours
-11 lbs in 3 days
When is a CABG performed?
-Emergency situations: MI, CVA
-Urgently: symptoms prompt patient to seek medical care
-Electively: blockage found on cardiac stress test
How many arteries can a CABG involve?
Between 1-4 arteries depending on which are blocked
What are the class I indications for a CABG according to AHA?
-Over 50% left main artery stenosis
-Over 70% stenosis of the proximal LAD and proximal circumflex arteries
-Three-vessel disease in asymptomatic patients or patients with mild stable angina
-Three-vessel disease with poximal LAD stenosis in patients with poor LV function
-Over 70% proximal LAD stenosis with either an ejection fraction below 50% or demonstrable ischemia on noninvasive testing
What are other indications for CABG?
-Disabling angina
-Ongoing ischemia in the setting of a non-ST segment elevation MI that is unresponsive to medical therapy
-Poor LV function
-Inability to perform or failure to resolve symptoms with percutaneous re-vascularization (PTCA)
-Patients with advanced kidney disease that PTCA would be dangerous for due to contrast dye
What are the outcomes of CABG vs PTCA?
-CABG shown to have better long term outcomes than catheter based interventions
-CABG has lower risk of CVA or MI
-CABG can have a higher morbidity rate and longer recovery
What are the most common approaches for CABG?
-Sternotomy: either directly through midline of the sternum or costo-sternal junction
-“On” or “off” pump
-Anterior thoracotomy: used for LAD
-Lateral thoracotomy: used for smaller vessels, often “off” pump
-Minimally invasive direct CABG: robotic assisted
What is an “on” pump CABG?
A CABG when the heart is connected to tubing which intercepts blood coming into the right atrium, stores it in a reservoir, adds oxygen/removes CO2, cools the blood, and delivers it to the body
How long does an “on” pump CABG give the surgeon?
About an hour to perform the CABG while the heart is on the pump
What is an “off” pump CABG?
The CABG is performed while the heart is beating
What are advantages to “on” pump CABG?
-Gives surgeon more time for complicated cases
-More complete vascularization
-Better for emergent CABG
What are disadvantages to “on” pump CABG?
-“Pump Head” or Post Operative Cognitive Decline (POCD)
-Can delay discharge due to POCD
What is POCD?
-Due to decreased oxygen to brain
-Could be reaction from anesthesia
-More pronounced in older adults
-Delirium, cognitive changes, brain fog
-Short lived (10-14 days)
What are advantages of “off” pump CABG?
-No need to stop the heart so no POCD
-Lower risk of clotting, arrhythmias
-Shorter hospital stays
-Reduction in mortality
What are common harvest sites for CABG?
-Saphenous vein
-Left internal thoracic (mammary) artery
-Radial artery
-Right internal thoracic (mammary) artery
-Short saphenous vein
-Cephalic vein or UE vein
What is the disadvantage for using great saphenous vein for CABG?
High re-occlusion rate
What harvest site for CABG has shown the best outcomes?
Left internal thoracic (mammary) artery
What are the possible thoracic surgery complications?
-15-20% of patients have complications, and 3-4% of those will die
-Surgical access and donor site infection
-Pain
-Blood loss
-Pulmonary complications
-Cardiac complications
-Decreased CO
-Arrhythmias
-Bleeding
-Ischemia or subsequent MI
-Stroke
-DVT
What are indications for valve repairs and replacements? What valves are the most commonly repaired/replaced?
-Stenotic valves
-Incompetent or “leaky” valves
-Aortic valve and mitral valve most commonly repaired/replaced
What causes stenotic valves? How does it affect the heart? How is it rated?
-Atherosclerotic plaques
-Increase afterload and work of the heart which can lead to cardiomyopathy
-Rated mild (1+) to critical (4+)
How does an incompetent or “leaky” valve affect the heart? How is it rated?
-Allows back flow or regurgitation
-Rated mild (1+) to critical (4+)
What are risk factors for heart valve dysfunction?
-Endocarditis
-Rheumatic fever
-History of IV drug abuse
-Chronic and poorly managed HTN
-Congenital valve defects
When would a valve repair or replacement be performed?
If the rating was 2+ or worse
What are the different methods for valve repairs/replacements?
-Mechanical
-Biotissue
-Transcatheter aortic valve replacement (TAVR)
-Transcetheter mitral valve replacement (TMVR)
What is the annuloplasty valve repair?
Replaces the ring of the valve but leaves the leaflets in place
What is the mechanical method of valve replacement? What population is this usually done in? What are the drawbacks of it?
-Ball or disc mechanism
-Highly durable and can last a lifetime
-Younger patients
-Subtle but audible “click” with heart contractions
-Anticoagulants for lifetime
What is the biotissue method of valve replacement? What population is this usually done in? What are the drawbacks of it?
-Uses human, bovine, or porcine heart valves
-Lifetime coagulation not needed
-Older patients
-Only 10-20 years durability
What often occurs in conjunction with a valve replacement?
It is not uncommon to perform a CABG and valve replacement at the same time
What are post op considerations?
-Medications: some may effect HR, BP, and O2
-Sternal precautions
What risk factors increase risk of dehiscence of sternum after thoracic/open heart surgery?
-Female
-Diabetes
-Bilateral internal mammary artery harvesting
-Re-operation procedures
-Increased blood product requirement
What movement has the greatest and least amount of sternum separation and skin movement that should be avoided during sternal precautions?
-Greatest: pushing up from a chair with UE
-Least: overhead movements
What is the Sternal Instability Scale?
-0: clinicall stable sternum (no detectable motion)
-1: Minimally separated sternum
-2: Partially separated sternum regional
-3: Completely separated sternum, entire length
What is the ACSM guidelines for movement with sternal precautions?
-5-8 weeks no lifting anything more than 5-8 lbs
-ROM exercises and lifting 1-3 lbs if there is no evidence of sternal instability
-Patients should limit ROM with any onset of feelings of pulling on the incision or mild pain
What are traditional sternal precautions?
-No lifting, pulling, pushing > 10 lbs
-No use of UE for sit to stand
-Counter pressure with valsalva
-No driving 2-4 weeks
-Avoid horizontal abduction past midline
-No scapular retraction
-No lifting arms > 90 degrees
What is the “Keep your move in the tube” principle?
Patients who are at low risk of sternal dehiscence can lift their arms above head, push themselves out of a chair, etc. as long as their arms are tucked in very close to their body
What are post op CABG and valve replacement considerations?
-Vitals
-Post-op cognition
-Signs of post intensive care syndrome
-Lab values for anti-coagulation levels and signs of infection
-Lines and tubes and mechanical intervention
-Harvest vein site
-Sternal incision site
-Deep breathing, coughing
-Functional mobility
-Mechanical ventilation
-Discharge planning
What is an abdominal aortic aneurysm?
-Abnormal focal dilation of the abdominal aorta, 50% larger than normal due to a weakened vessel wall
-Mostly asymptomatic
-Described relative to the involvement of the renal or visceral vessels
-Most common of aneurysms
Where do 80% of aortic aneurysms occur?
Between the aortic bifurcation and the renal arteries
How are aortic aneurysms usually found?
-Usually found by pulsatile mass on physical examination
-Abdominal imaging
-US screening for cardiac disorder
-During work up for associated cardiac disease
-During cardiac catheterization
What are risk factors for an abdominal aortic aneurysm?
-Smoking
-Male gender
-Advancing age
-Caucasian race
-Atherosclerosis
-Family history of AAA
-Other arterial aneurysms
-Connective tissue disorder
-Prior history of aortic dissection
-Prior history of aortic surgery
What types of abdominal aortic aneurysms are there?
-Symptomatic (non-ruptured): 5-22% of patients
-Ruptured: mortality rate > 80%
What are symptoms of a non-ruptured aortic aneurysm?
-Pain is most common symptom
-Most often abdominal, but can also radiate to back, flank, pelvis, groin, or thigh
-May present with general malaise
What is the most common treatment of abdominal aortic aneurysm?
Endovascular repair
When are heart transplants done?
-End stage heart disease
-NYHA stage III-IV, AHA stage D uncompensated HF
-Poor quality of life
What are absolute contraindications for heart transplant?
-Solid organ or blood malignancy in the last 5 years
-ETOH, tobacco, or substance abuse < 6 months
-HIV
-SLE, sarcoidosis, amyloidosis
-Irreversible hepatic or renal dysfunction
-Significant COPD
-Pulmonary HTN
-Severe cerebrovascular disease
-Hep B or C
What are relative contraindications for heart transplant?
-Age > 70
-Active infection
-Active peptic ulcer
-Severe DM
-Severe PVD
-Symptomatic carotid stenosis
-Uncorrected AAA
-BMI > 35 kg/m2
-Severe pulmonary dysfunction
-Severe HTN
-Dementia or poor social support
What is a heterotropic heart transplantation (HTT)?
-“Piggyback”
-Native heart is not removed
-Donor heart is connected ot the native heart via right/left atria
What is a total heart transplantation?
Complete excision of the recipient atria with complete atrioventricular transplantation, bicaval and pulmonary venous anastomoses
What is the biatrial technique of heart transplantation?
-Biatrial anastomoses whereby donor and recipient atrial cuffs are sewn together
-Leaves recipient SA node intact
-Two separate P waves will be seen on EKG
What are PT considerations for heart transplantation?
-Infection control
-Aerobic endurance
-Vitals
-Denervated heart
-Often out of ICU in 48 hours
-Denervation of donor heart requires adequate warm up and cool down
-HR monitoring is not an accurate measure of exercise intensity
What are outcome measures that should be considered post heart transplantation?
-6MWT
-30 second chair stand
-Frailty scales
What are signs and symptoms of rejection?
-Low grade fever
-Myalgia and fatigue
-Hypotension with activity but hypertension at rest
-Decreased exercise tolerance and dyspnea
-Arrhythmias
-Weight gain due to fluid retention
-Decreased urine output
What will aerobic power be at after 1 year post heart transplantation?
40-50% of age matched controls
What will peak exercise CO be at after 1 year post heart transplantation?
30-40% lower than age matched controls
What are physical therapy priorities post cardiac surgery?
-Pulmonary hygeine
-Vitals and activity tolerance management
-Cognitive management
-Sternal or thoracotomy wound management
-LE donor site management (CABG)
-Mobility
-Discharge planning
What is a sign of SA node dysfunction? What is the typical treatment?
-Marked sinus bradycardia (HR < 60 BPM) or sinus arrest
-Paroxysmal supraventricular tachycardias (PSVT): atrial fibrillation or flutter
-Permanent pacemaker & anti-arrhythmic drugs
What types of pacemakers are there?
-Temporary
-Permanent
What are the 3 types of temporary pacemakers?
-Transcutaneous: electrodes placed on chest wall
-Transatrial: electrodes are placed directly onto the atria, usually right
-Transvenous: electrodes placed directly onto the ventricle
What are indications for temporary pacemakers?
-Acute MI
-Post-cardiac surgery
-Drug toxicity
-Bridge to permanent pacemaker
What are the characteristics of a permanent pacemaker?
-Small. lightweight (1-2 oz.)
-Battery operated
-Wires implanted into the heart
-Device implanted distal to left clavicle area
-Sends electrical stimulus directly to heart muscle
What are common indications for a permanent pacemaker?
-SA node dysfunction
-2nd degree AV block with symptomatic bradycardia
-3rd degree AV block with symptomatic bradycardia, CHF, a-fib/flutter, or documented periods of asystole
-Acute anterior MI w/ 2nd or 3rd degree AV block
-Severe bundle branch blocks
What are some conditions that may warrant a pacemaker?
-Syncope
-Dizziness
-CHF
-Mental confusion
-Palpatations
-Dyspnea
-Exercise intolerance
What is the pacing of the right atrium if the pacemaker is placed there?
Increases atrial contribution to ventricular filling, resulting in increased CO
What is the pacing of the right ventricle if the pacemaker is placed there?
Increases rate in presence of heart block or symptomatic bradycardia
What is the pacing of dual chamber if the pacemaker is placed there?
-Electrodes placed in R atrium and R ventricle
-Maintains timing between atrial & ventricular contractions further increasing CO
What are the different modes of pacing?
-Fixed
-Demand
-Rate-responsive
What is the fixed mode of pacing?
Fires at a specific, preset rate
What is the demand mode of pacing?
-Fires only when HR falls below preset value
-Sensing mechanism: ability of pacemaker to determine when intrinsic rate id adequate
-Pacing mechanism: triggered when no intrinsic ventricular complex occurs within set parameters
What is the rate-responsive mode of pacing?
-Fires depending on patient’s level of activity and respiration
-Automatically increased with increased CO
-Many new pacemakers use this type of pacing
What are ICD’s? How do they work?
-Implantable cardioverter defibrillator
-Newer pacemakers have ICD’s embedded in them
-Delivers a shock to the heart to cardiovert when a fatal arrhythmia is detected
What are ICD’s indicated for?
Indicated for life threatening arrhythmias
What is a cardiac resynchronization device?
-A type of ICD
-Used with CHF, paces both ventricles at once
What are PT implications for working with patients with pacemakers and ICD’s?
-Is patient fully dependent upon temporary pacemaker?
-Be careful with wires and leads: dislodging them could kill a patient
-Patient education: no prolonged contract with electrical devices
What are general precautions for post implantation of a pacemaker or ICD?
-Bedrest for a few hours
-Sling on left arm for 24 hours
-Avoid L shoulder flexion, abduction > 90 degrees
-No driving until cleared by electrophysiologist
What is a Holter Monitor?
-Ambulatory electrocardiography device
-A portable device that continuously monitors electrical activity of the heart for 24 hours or more
-Useful for observing occasional cardiac arrhythmias
-Records activity via a series of electrodes attached to the chest
What is an LVAD?
-Left ventricular assistive device
-A mechanical pump that takes over the function of the damaged ventricle to restore normal blood flow
What are the two types of LVADs?
-Pulsatile: older, noisy
-Axial flow: continuous flow, more popular now, quiet
What are indications for an LVAD?
-Bridge to transplant
-Destination therapy: long term, implant is permanent
What is the life expectancy of someone with an LVAD?
5-10 years
What is the criteria for an LVAD?
-At least 2 admissions to the hospital
-Not improving with medications
-Hyponatremic
-Hypovolemic
-Inotrope dependent
-Ejection fraction < 35%
How does an LVAD affect the functioning of the heart?
-Restores CO and blood pressure
-Reduces the work of the left ventricle and prevents further damage
-Improves perfusion to all body organs
-LVAD most common but RVAD or BiVAD is also possible
What is the typical battery life of an LVAD?
-Anywhere between 7-17 hours depending on brand
-360 uses
What are the oeprating procedures of LVADs?
-Test Select Button: performed everyday
-Steady audio tone should be heard
-All lights should illuminate for 5 seconds
-If this doesn’t happen, the controller needs to be replaced
-Only use fully charged batteries
-Make sure to only disconnect one battery at a time when switching them out
What does the “+++” symbol mean on an LVAD?
-Blood flow is moving at over 10 L/min through the pump which is abnormal
-This could be normal in larger patients
-Could be indicative of a clot forming in the pump
What does the “—” symbol mean on an LVAD?
-Blood flow is moving at less than 2.5 L/min through the pump
-This could be normal for smaller sized patients
-Could be indicative that patient is hypovolemic (“dry”) and requires fluid bolus
When is a “+++” or “—” not a red flag? When does it become a red flag?
-If you are moving a patient
-It becomes a red flag if it is sustained
What vitals should be taken for patients with LVAD?
-BP
-MAP
-Pulse (may be thready or absent)
-Oxygen saturation
What is an impella?
-Mechanical circulatory assistive device
-Mini VAD that pumps blood from L ventricle into aorta
-2.5-5 L/min
When is an impella indicated?
-Patients with MI complicated by cardiogenic shock
-Needs circulatory support with complicated PCI/PTCA
-Severe uncompensated HF
-Myocarditis
-Conditions where the L ventricle needs to rest to reduce work of the heart
-Off pump CABG
How long is an impella approved to be used for by the FDA?
-6 hours in 2015
-Now approved for 14 days and for off label use for slightly longer periods
What are precautions for PT after LVAD, impella, or ICD placement?
-Level of arousal
-Anticoagulants
-Vasopressors
-High level oxygen support
-Arrhythmias
-Pulmonary artery catheter
-Arterial lines
-Central venous pressyre line
-Chest tubes
-Median sternotomy
-Intra aortic balloon pump removal
-Patients with impella dye to cardiogenic shock
What is cardiogenic shock?
The heart can no longer pump an adequate volume of blood to meet the needs of the organs
What are contraindications for PT post VAD, impella, or ICD placement?
-VAD malfunction
-Intra-aortic balloon pump
-Open chest
-Active bleeding
-Hemodynamic instability
-Full ventilator support
What does PT interventions include post VAD, impella, or ICD placement?
-Focus on function
-STRICT sternal precautions (no Move in the Tube)
-Pulmonary care
-Be careful with percussion
-Post-op pain can lead to kyphotic posture which can compromise the drive line and reduce blood flow
-HR will be blunted by beta blockers
-Stop if symptoms of angina appear or dyspnea > 5 on Borg
-Vitals!!!
