Stress Testing in Cardiac Population Flashcards
Before doing and exercise test what information do me need from EHR or physician?
Medical history Results from physical exam: BP, cholesterol levels, lipoprotein levels, blood components PFT Previous GXT or EKG Body comp
What information is essential for conduction GXT?
Medical history
Risk factor appraisal
Determine level of supervision: physician present
Absolute vs. relative contraindications for GXT
Mode and extent of GXT
What are absolute and relative contraindications for GXT?
Absolute contraindications: indication of MI, moderate to severe angina, >20 mmHg drop in SBP, onset of arrhythmia, severe SOB, diaphoresis, dizziness, blurred vision, confusion, subject requests to stop
Relative contraindications: increasing chest pain, EKG changes from baseline, wheezing, leg cramping, abnormal SBP or DBP, moderate SOB
what are components of a GXT?
EKG (HR, ischemia, arrhythmias)
VO2 max vs. peak (gas exchange)
BP
RPE/Angina/Dyspnea
Symptoms
Protocol (TM, cycle, arm ergometer, nustep, recumbent cycle, pharm)
Exercise capacity (workload and time–> norms)
What are the three types of stress tests in cardiac patients?
Diagnostic (no meds) for CAD: symptom limited endpoint
Functional (with meds): identify cardiovascular response to exercise, low level GXT prior to discharge, stop at 4-6 METS or 75% APHRmax, comfortable walking speed
Therapeutic (with/out meds): optimize medical management, endpoint may be a MET level= work of ADLS
What is the NY heart association classification?
Class 1: disease w/o limitations
Class 2: disease w/ slight limitations (physical activity results in fatigue, dyspnea, etc)
Class 3: disease w/ marked limitations (OK at rest, less than ordinary activities cause symptoms)
Class 4: disease but inability to perform physical activity w/o discomfort (symptoms at rest, activity exacerbates symptoms)
What are effects of medications on patients with CHF and exercise performance?
Digoxin: diffuse ST effects, may increase performance
Diuretics: may decrease BP
Vasodilators: Increase HR, decrease BP, increase performance
ACE inhibitors: decrease BP, increase performance
Antiarrhythmic: may increase HR but little effect on performance
What are special considerations with GXT in CHF?
Ventilation/perfusion inequalities cause increased dead space and hyperventilation/dyspnea
Increased risk of dysrhythmias
What are objectives of stress tests in MI?
Quantitatively and accurately assess: chronotropic capacity and HR recovery, aerobic capacity, myocardial aerobic capacity (RPP), exertional symptoms, changes in electrical function
What is low level exercise testing in MI?
below 5 METS or significantly below peak, gradually increase stages
Get hemodynamic measures after each stage
Get functional capacity
Make patient more confident that they can return to activity
What are PT essentials for GXT in MI?
Have pt keep NTG with them during exercise.
Angina = reportable symptom
Always know what meds pt is taking: action, dosage
Monitor post-exercise recovery for 10 minutes: get to 100bpm before you let them go home. Also need to be asymptomatic
What are indicators of an adverse prognosis in people with MI?
Ischemic ST depression at low level of exercise
Functional capacity
What are special considerations for GXT in MI?
Patients who have PAD or DM2
Select equipment adjusted by 1 MET increments
Minimum frequency of training in 3 nonconsecutive day/week
Safety education
What safety education should in do in MI patients?
Monitor signs and symptoms
Medications
ADLs/Return to work
Sexual activity (positions, monitor sx even during sex)
What are the cardiac markers (onset, peak, return to normal)?
CK: 3-4 hours, 33 hours, 3 days
Troponins: 3-12 hours, 18-24 hours, up to 10 days
Myoglobin: 1-4 hours, 3-15 hours
LDH: 12-24 hours, 72 hours, 5-14 days
What should cholesterol levels look like?
> 40 for HDL
What should labs look like for coagulation profiles?
Prothrombin time: measures coagulation of blood
It’s elevated when there is increased time to form a clot: caution when high so patient doesn’t cut self
What should blood cell counts look like in lab report?
Hemoglobin: 12-15/100 for females, 13-16/100 for males, low levels stress heart
Hematocrit: 38-47% females, 35-44% males
WBC: 4500-11000/microL, response to infection
What should kidney values look like for lab reports?
BUN: 8-18 mg/dL, if elevated it’s indication of heart or renal failure, retention of urea; if decreased it’s indication of starvation, dehydration or organ dysfunction
Creatine: measure of renal efficiency, normal is 4 indicated renal insufficiency or failure
What should lab values be for fasting serum glucose?
70-100 mg/dL
>100-125= insulin resistance/prediabetes
>126 = diabetes
What is cardiovascular diagnostic tests for HR rhythm abnormalities?
Holter monitor, 12 lead EKG, exercise EKG
What are diagnosistice tests for ventricular size and EF?
Chest xray, MUGA, echo
What are diagnostic tests for ischemia?
EKG, exercise EKG, pharmacologic stress test, SPECT, cardiac cath
valve integrity: echocardiograph, contrast echo, cardiac cath
What are diagnostic tests for acute MI?
Cardiac enzymes, resting EKG
What are diagnostic tests for cardiac muscle pump?
MUGA, Echo, ventriculography
What are diagnostic tests for vascular diagnostic testing?
ABI, ultrasound, exercise studies
What is a MUGA?
Multi-gated acquisition scan
Non invasive test to determine pumping function of ventricles.
Radioactive tracer injected and gamma camera detests radiation
Highly accurate
What is PET used for?
Positron emission tomography. Radioactive tracer (radioisotope, natural body compound- glucose)
Resting coronary blood flow then given dipyridamole (anticoagulant) for “stress” test
Blood flow reassessed to detect stenosis
Used to assess arteries and detect coronary stenosis.
Low false positive: more accurate at detecting coronary issues
What is SPECT used for?
Single photon emission computed tomography
Uses gamma rays to detect myocardial blood flow
Radioactive agent, 3D 360 rotating camera
What is radionuclide perfusion testing with SPECT?
Give radioactive agent at peak of stress test. Then while patient is at rest 4 hours later.
Trying to look at when you stress the heart, and if there is ischemia or actually dead tissue in heart
What are the methods, measures, endpoints, and comments for exercise testing and MI?
Methods: Cycle (ramp protocol 17 W/min; staged protocol 25-30 W/3 min stage) or treadmill (1-2 METs/3 min stage)
Measures: EKG, HR, BP, RPP, RPE, angina scale, gas analysis, radionuclide testing
Endpoints: serious dysrhythmias, >2mm ST segment depression or elevation, ischemic threshold, T wave inversion with significant ST change, SBP >250 or DBP >115, +3 or earlier on angina scale
Comments: use low level treadmill protocol for acute MI, minimal treadmill speed should be
What are methods, measures, endpoints, and comments for exercise testing in CHF?
Methods: aerobic (cycle- ramp or staged or TM), endurance (6MW), functional (lifestyle specific tests)
Measures: for aerobic-EKG, HR, BP, RPP, RPE, dyspnea scale, respired gas analysis; for endurance- distance; for functional- performance related to ADLs
Endpoints (aerobic): serious dysrhythmias, T wave inversion with significant ST change, hypotensive response, perceived SOB and fatigue, VO2 peak and vent threshold
Endpoints (endurance): note stops for rest, sitting done ends the test
Comments: 6MW useful throughout training
