Risk Stratification/exercise prescription Flashcards
What is risk stratification
- Medical decision making
- The constellation of activities eg. labs, interview, clinical testing used to determine a person’s risk for experience a particular condition and the need or lack thereof for preventive intervention
How is risk determined
- Known presence of disease (CVD, CHD)
- Number of risk factors (1 or >1)
- Presence of signs or symptoms
First step in risk management determination: know disease, what are the known diseases we are concerned with?
- Cardiovascular: Cardiac (MI, CAD), Peripheral vasculature, Cerebrovascular
- Pulmonary: COPD, asthma, Interstitial lung disease, cystic fibrosis
- Metabolic: diabetes, kidney disease
- These can eventually affect the heart
- *USE CLINICAL JUDGMENT – some people have these well managed
Risk factor categories
- age
- family history
- smoking
- HTN
- Dyslipidemia
- impaired fasting glucose
- obesity
- Sedentary lifestyle
- high HDL = negative risk factors
Age as a risk factor
- Men > 45
women > 55
give +1
Family history as a risk factor
- MI, revascularization procedure or sudden death before 55 in father/other 1st degree male relative of 65 in mother of 1st degrees female relative
- +1
smoking as a risk factor
- current smoker or those who have quit within the last 6 months +1
HTN as a risk factor
- systolic BP>140mmHg or diastolic >90 mmHg
- confirmed on at least to consecutive occasions or currently on HTN meds
Dyslipidemia as a risk factor
- LDL >130
- HDL <40
- on lipid lowering meds
- total cholesterol >200
fasting blood glucose as a risk factor
fasting blood glucose >100 confirmed by measurement on a least two separate occasions
obesity as a risk factor
- body mass index >30 or waist girth >102for men (40 inch)
- and 88 cm (34 inches) for women
sedentary lifestyle as a risk factor
- not participating in at least 30 minutes of moderate-level activity at least 3 days/week for 3 months
High HDL as a risk factor
- HDL of > 60 can subtract a point
What other signs and symptoms should you look and listen for
- Pain, discomfort in the chest, neck, jaw, arm, or other areas that may be result of ischemia
- SOB at rest or with mild exertion
- Dizziness or syncope
- Orthopnea or PND
- Ankle edema in gravity dependent positions
- Palpitations or tachycardia
- Intermittent claudication
- Known heart murmur
- Unusually fatigue or SOB with usual activity
What does it mean if they have a known CV disease in logical model for risk classification of CVD
High risk patient
What classification if a patient has no known CVD but has major signs and symptoms
- high risk
What classification does a patient get if they have no known CVD, no major signs or symptoms, but have >2 number of CVD risk factors
Moderate risk
What classification do I give someone if they have no known CVD, no major signs and symptoms, and <1 risk factor
low risk
Low risk individuals for CVD
- Individuals who are asymptomatic with no more than one risk factor threshold
- If there vitals are okay and normal response to exercise = don’t need to take them all the time
moderate risk individuals for CVD
Those who meet the threshold for 2 or more risk factors
High risk of CVD
- Those with known cardiovascular,pulmonary or metabolic disease or significant signs and symptoms
- Check vitals initially, every visit and before they leave
Exercise testing: maximal exercise testing
- VO2 max or maximal oxygen consumption, refers to the maximum amount of oxygen that an individual can utilize during intense or maximal exercise
- This test is the gold standard cardio-respiratory fitness
- Not done in clinic
Submaximal exercise testing
- Has a predetermined end point (based on heart rate or BP targets) unless signs and symptoms occur or the goal is achieved
- Has a determined end point
- Get them to a percentage of the max heart rate
- Could use BP and have a set end point
- Outpatient will have different end points than inpatient
- RPE could also be an endpoint
Types of sub-maximal testing
- Cycling tests
- Submaximal treadmill tests
- 6 minutes walk test
- 12 minute run/walk test
- Functional activity (in acute care the tests are functional activities)
Why sub maximal exercise testing?
- Assess current performance/patient status
- Fitness
- Functional limitations
- Look at change over time
- Examine the effect of PT intervention medications
Submaximal exercise predictive responses (what can be used to measure
- Resting vital signs: an indicator of fitness and health. Does your patient have reserve for activity
- Target vital signs (endpoints of activity)
- Heart rate recovery
- Heart rate variability
- Rate pressure product
- Self-perceived rating scales (borg/borg dyspnea scale)
Patient should not exercise if pulse rate is
- > 120 -130
- <40 bpm
In acute care when should you terminate exercise
1. pulse rate
2. respiration
3. SBP
4. DBP
5.SPO2
6. arrhythmias
7. RPE
- 20-30 above resting
- talk test
- > 200
- > 110
- <88
- > 6/min
- 11-12 (6-20 RPE) ~3 (0-10) RPE
HRR
- heart rate reserve
- (HRR) = Max HR - resting HR)
- BP - is there enough room to work
- How much room
- Max systolic-resting systolic
Normal response to exercise for vital signs
- Blood pressure increases about 10 mmHg per MET (moderate activity 3-5.9 METs)
- HR increases about 10-15 bpm per MET
- Many individuals will have abnormal responses related to deconditioning and disease
Max heart rate/target training heart rate
- TTHR = 220-age x 65% (low end of range) and TTH = 220 - age x 85% (high end of range)
heart rate reserve method for training heart rate
- Heart rate reserve = [(HRmax-RHR)x%]-HR resting
- THR (low end) = [(HRmax-HRresting)x60%] + HR resting
- THR (High end) = [(HR max-HRresting)x80%] +HR resting
- Using this method, deconditioned individuals can still benefit from work as low as 50% of HRmax or heart rate reserve method. Start low, progress as patient tolerates
Heart rate recovery
- A measure of how quickly your HR returns to normal after you stop exercising
- A shorter recovery generally indicates better CV health health and links to lower risk of developing cardiovascular disease
- Generally 18 beats or higher is - recommended
Grading scale for heart rate recovery in one minute
- Generally 18 beats or higher is recommended
<12 bpm in one minute is an indicator of poor cardiovascular health and increased risk for disease
0-12 = poor
12-24 = average
24-36 = good
36-48 = excellent
48-60 = superior
Heart rate variability
- A measure of the impact of your autonomic nervous system
- HRV is a measure of variance between heartbeats or RR intervals
- Higher variability indicates better fitness fitness
Indicates effective autonomic nervous system input - High = sympathetic and parasympathetic nervous system work well together
Rest your HR gets slower - Lower = sympathetic nervous doesn’t get rest possibly due to stress
How does HRV work
- Brain → ANS
ANS: - Exercise and stress → sympathetic NS activation → decreased HRV: fatigue and reduced performance
- OR rest and recovery → parasympathetic NS activation → growth and repair, increased HRV: readiness, increased performance
Rate pressure product
- Cardiovascular product or double produce RPP = SBP x HR
- There is stable angina
- They are seeing a physician but no evidence of tissue death
- Given nitroglycerin
- Ask how often do you take it and do you have it?
- Used to predict the workload that corresponds with the onset of angina/claudication
General indications for stopping exercise testing
- Onset of angina or angina like symptoms (If they are aware they have angina and it increase to moderately severe/increasing chest pain)
- Drop in systolic BP of >10 mmHg from baseline despite an increase in workload
- Excessive rise in BP
(Systolic pressure >200 mmHg or diastolic >110 mmHg
SOB, Wheezing, leg cramps or significant claudication) - Signs or poor perfusion: lightheadedness, confusion, ataxia, pallor, cyanosis, nausea, cold, clammy skin
- Presence of arrhythmias other than sustained ventricular tachycardia
- Failure of HR to increase with increase intensity
- Subject request to stop
- Physical or verbal manifestations or severe fatigue
- Failure of testing equipment
health related components of fitness and describe
- Cardiorespiratory endurance:
The ability of the circulatory and respiratory system to supply oxygen during sustained physical activity - Body composition: The relative amounts of muscle, fat, bone, and other vital
parts of the body - Muscular strength: The ability of muscle to exert force
- Muscular endurance: The ability of muscle to continue to perform without fatigue
- Flexibility: The range of motion available at a joint
Skill related components of fitness
- Agility: the ability to change the position of the body in space with speed and accuracy
- Coordination: the ability to use the senses, such as sight and hearing, together with body parts in performing task smoothly and accurately
- Balance: the maintenance of equilibrium while stationary or moving
- Power: the ability or rate at which one can perform work (force or speed)
- Reaction time: the time elapsed between stimulation and the beginning of the reaction to it
- Speed: the ability to perform a movement within a short period of time
Exercise prescription
- Frequency: most days/week
- Intensity: based on RPE, target training heart rate range, patient response
- Time: start at an amount that the patient can tolerate
Can be accumulated throughout the day - Type: a safe activity that is enjoyable and or meaningful to the patient. - Lifestyle activities
- No two exercise prescriptions are the same
BORG scale
- 6-9 very light about 50-60% Max HR
- 10- 12: noticable breathing deeper but comfortable ~60-70% HR max
- 13-14: aware of breathing harder more difficult to hold a conversation ~70-80% max HR
- 15-16: getting uncomfortable about 80-90% max HR
- 17-20 maximum exertion, hard about 90-100%
Should not exercise if patients respiratory rate is
> 30 breaths per minute
What does a low HRV mean
- sympathetic system is predominant,
- This indicates that the body is under stress from exercise, psychological or physical stressors.
What does a high HRV mean
- parasympathetic is functioning
- A high HRV indicates better fitness and improved ability to manage and recover from physical and psychological stress.
