Week 2 Flashcards
What is the epidemiology of HTN?
- HTN is the leading risk factor for CVD mortality (13% of global deaths)
- Only about half % of people with HTN are compliant with medications
- Leading cause of CVD worldwide
- “Silent killer” often asymptomatic even at extremes
What kind of disabilities increases the chances of a patient getting HTN?
- Mobility limitation
- Cognitive limitation
- Vision limitation
- Hearing limitation
What are the fast mechanisms for the regulation of fast BP?
Baroreceptor located primarily in the Aortic Arch and Carotid Sinuses
What are the slow mechanisms for the regulation of fast B
• Renin-Angiotensin System (Kidneys)
• Natriuretic peptides (ANP in the atria and BNP in the ventricles) (Heart)
- Act as a counter to RAAS system. released from heart
How does the regulation of arterial blood flow work?
• Sympathetic neural activity: norepinephrine (norEph)
- Goal is to redistribute blood to areas of need, more global
- Arterioles are innervated by sympathetic, which release norEph
- norEph binds to alpha-1 receptors causing vasoconstriction
• Circulating epinephrine
• Circulating hormones: angiotensin II
• Local metabolites: prostaglandins
• Mechanical Factors: muscle contraction, vessel stretch (CA2+ influx)
What does circulating epinephrine bind to?
Beta 2 receptors located in arterial cells. Beta 2 receptors dilate blood vessels, bu they aren’t that many of them
What do local metabolites cause in working muscle?
They cause vasodilation to the working tissue which will allow us to deliver more blood flow, and oxygen and to get rid of waste
What is functional sympatholysis?
How our body regulates BP during exercise
What is functional sympatholysis tightly related to?
The endothelial function, if there is impaired endothelial tissues in the blood some of the function of the functional sympatholysis can be impaired
What is hemodynamics?
Blood flow parallels Cardiac Output
CO = HR X SV
How do you find CO?
Driving pressure divided by resistance to flow.
Or
(MAP-CVP) divided by total peripheral resistance (TPR)
What are the things that affects BP within blood vessels?
- Radius
- Viscosity (hematocrit)
- Length of vessel
- Resistance
Though our larger vessels can undergo larger changes in diameter, the bulk of the resistance in our bodies is in the _____
Though our larger vessels can undergo larger changes in diameter, the bulk of the resistance in our bodies is in the *micorvasculature (smaller vessels), which is why its so important to maintain normal endothelial function in that tissue
What is the role that the PT plays to reduce the risk of hypertension?
- Exercise
- Education
- Interdisciplinary communication
What is the mean arterial pressure for the regulation of BP using baroreflex/baroreceptors?
85 to 100mmHg in adults
What do baroreceptors respond to?
Stretching of the arterial wall
What are the characteristics of baroreceptors responding to stretching of arterial walls?
- Negative feedback loop with the Vagus and Glossopharyngeal nerves
- Arterial pressure suddenly rises, the walls of these vessels passively expand, increases the firing frequency of receptor action potentials.
- If arterial blood pressure suddenly falls, decreased stretch of the arterial walls leads to a decrease in receptor firing.
In the regulation of BP using baroreceptors, what pressures do carotid sinus receptors respond to?
Pressures ranging from 60-180 mmHg
What is the difference between aortic arch receptors and carotid sinus receptors in the regulation of BP with the use of baroreceptors?
Aortic arch receptors have a higher threshold pressure and are less sensitive than the carotid sinus receptors
What is renin?
An enzyme that is released into the circulation by the kidneys due to the detection of low blood flow through the arteries
What is the release of renin stimulated by?
• Sympathetic nerve activation (acting
through β1 -adrenoceptors)
• Renal artery hypotension (caused by systemic hypotension or renal artery
stenosis)
• Decreased sodium delivery to the distal tubules of the kidney
What is an essential hypertension?
Interaction between environmental factors and genetics. Accounts for 95-99% of cases
What is a secondary hypertension?
Result of some biochemical or mechanical pathology, potentially reversible
What are the contributors to HTN?
- Diet…Salt Sensitivity
- Inactivity
- Obesity
- Abnormalities of the adrenal cortex
- Sleep Apnea
- Sympathetic Nervous System Activity
- Kidney Disease
- Congenital Vascular Disorders
- Recreational Drugs and Alcohol
What are the normal BP values for adults?
- Systolic: 100-120mmHg
* Diastolic: 60-80mmHg
How does the RAAS system work?
- Renin is released from the kidneys due to a number of possible causes
- Renin interacts with angiotensinogen with is released from the liver
- Angiotensinogen converts renin to angiotensin 1
- Angiotensin 1 travels through blood flow to the lungs, and interacts with angiotensin converting enzyme, which converts angiotensin 1 to angiotensin 2
What are some causes for the release of renin?
- SNS activity
- Low perfusion of the juxtoglomerular apparatus
What is angiotensin 2?
A potent vasoconstrictor that also works to increase fluid retention. And may also facilitate further SNS activity
What is aortic coarctation?
A congenital narrowing of the aorta
What is the “ideal” BP?
110/70
What is elevatedd BP?
SBP: 120–129 mm Hg
DBP: <80 mm Hg
What is HBP (hypertension) stage 1 BP?
SBP: 130–139 mm Hg
DBP: 80–89 mm Hg
What is HBP (hypertension) stage 2 BP?
SBP: ≥140 mm Hg
DBP: ≥90 mm Hg
What is an hypertensive crisis BP, where emergency care is needed?
Higher than 180 or higher than 110
What is a hypertensive urgency?
A patient with elevated pressures with BP > 180/110 and they show no signs of organ damage
What is a hypertensive emergency?
A patient with elevated pressures with BP > 180/120 and they show signs and symptoms of organ damage
What are the signs of a hypertensive urgency?
- Headache (22%)
- Epistaxis (Nose Bleed) (17%)
- Faintness/SOB (10%)
- Agitation/Anxiety (10%)
What are the signs of a hypertensive emergency?
- Chest pain (27%)
- Dyspnea (22%), and
- Neurological deficit (21%)
What are the common end-organ damage associated with HTN emergencies?
- Acute pulmonary edema
- Acute left ventricular dysfunction
- Acute coronary syndrome (including acute myocardial infarction).
- Cerebral infarction
- Hypertensive encephalopathy
In very severe cases of elevated pressure, we can see acute hypertensive nephrosclerosis, what is it?
An acute injury to the kidneys which occurs typically when pressures exceed 300/150 mm Hg
What is hematuria?
The kidney demonstrates focal small hemorrhages, resulting in blood in the urine. (more common)
What is another way to assess BP?
Pulse pressure
What is pulse pressure?
The value retrieved when you subtract systolic BP - diastolic BP (SBP-DBP)
What is normal pulse pressure?
~40-60mmHg
Why might pulse pressure be a better predictor of CV risk than SBP?
• Low: <40mmHg may indicate pulse narrowing
• Elevated: >60mmHg PP associated with higher CVD morbidity and mortality rates.
• More reflective of microcirculation dysfunction
• Mechanism may be due to endothelial damage from large oscillations in pressure
each cardiac cycle.
How is heart rate assessed?
By palpation or ECG
What is normal heart rate in normal adults?
60-100bpm adults
What is higher resting heart rate independently associated with?
Increased risks of all cause and cardiovascular mortality
• Risk of all-cause and cardiovascular mortality increases by 9% and 8% for every
10 beats/min increment of resting heart rate.
• Especially HR >90
Is HR higher in children or in adults and why?
Higher in children, because their heart is not fully developed yet and doesn’t do so until the age of 12
What is brachial BP?
Standard BP measurement on the upper arm
What are some errors with brachial blood pressures?
• Brachial BP may not accurately reflect central pressure
• A lot of cuffs underestimate systolic and over estimate diastolic
- Better than NOT taking though
• Static/Rest BP is only a snap shot, doesn’t reflect response to load
- Though the more often we take, the better it helps clarify patients normal hemodynamics and aids medical assessment
- Exercise is when adverse events happen
• Might be best to assess response to low to moderate exercise
- Unmasks masked HTN, identifies hyper/hypo responders
- This should be a component of all exams
What are some confounding variables with taking a BP?
• Ambulatory (ABPM) vs home readings (HBPM)
- Every 20min vs 4 times per day, ABPM found to be more accurate however expensive.
• Normal Diurnal variation (Higher in AM vs PM)
- Most people demonstrate a 10%–20% decrease in BP during the evening
• Masked HTN
- Normal office blood pressure and elevated out-of-office blood pressure
• White Coat Syndrome
- Elevated BP in clinic (140/90mmHg) despite normal ABPM or HBPM
• Reading Errors
What can a full bladder do to BP?
Make BP appear higher by 10-15 mmHg
What can an unsupported back do to BP?
Make BP appear higher by 5-10 mmHg
What can an unsupported feet do to BP?
Make BP appear higher by 5-10 mmHg
What can crossed legs do to BP?
Make BP appear higher by 2-8 mmHg
What can an unsupported arm do to BP?
Make BP appear higher by 10 mmHg
What can a cuff over clothing do to BP?
Make BP appear higher by 10-40 mmHg
What can a patient talking or having a conversation do to BP?
Make BP appear higher by 10-15 mmHg
What are the normal results of BP when a patient is in pain?
- Systolic BP increases by 15-25mmHg
- Diastolic BP increases by 10-20mmHg
Values greater than normal considered to
be “hyper-reactive”. Hyper-reactors have increased risk of developing HTN
What are the characteristics of chronic pain and hemodynamics?
• Diminished tolerance to painful stimuli
• Reduced blood pressure response and baroreflex to painful stimuli
• Higher (HR) than healthy subjects at baseline and to painful stimuli
• Lower parasympathetic and increased sympathetic activity.
- Significantly lower HRV
• Increased prevalence of HTN
Why is exercising BP better?
- Resting BP not necessarily indicative of true BP
* Response to exercise may be more useful
What is a hypertensive response?
- Exaggerated hemodynamic response to exercise at maximal efforts
- (SBP) >220mmHg for men; >190mmHg for women.
- (DBP) >10 mmHg or >90 mmHg
What are the characteristics of a hypertensive response?
• Demonstrated in normal and patients with HTN
- Even with well controlled resting BP.
- Can be predictive of future HTN diagnosis
• However can be demonstrated at even low to moderate intensities (3-5METs)
- May be useful for the unmasking of HTN in clinical settings
What is the normal BP response to exercise?
10 mmHg/met systolic
0- 10 mmHg/met diastolic
What are the characteristics of an hypotensive response to exercise?
• LowExBP was associated with increased risk regardless of clinical presentation
exercise mode or exercise intensity (moderate or max)
• 10 mmHg decrease in exercise SBP was associated with higher risk for fatal and
non-fatal cardiovascular events and all-cause mortality.
- An earlier (<5min) the decrease may be worse
What are the characteristics of pulse pressure and risk?
• Pulse pressure (PP=SBP-DBP) might be a better predictor of CV risk than SBP
• Elevated >60mmHg PP associated with higher CVD morbidity and mortality rates
• Mechanism may be due to endothelial damage from large oscillations in pressure
each cardiac cycle.
• More reflective of microcirculation dysfunction
What are the characteristics of pulse pressure and cervical manipulation?
• The results of BP testing, specifically Pulse Pressure may provide direction for risk assessment and/or the management of patients across populations.
• Elevated Pulse Pressures have been associated with increased arterial stiffness
and the development of atherosclerosis.
• Vascular profiling may enhance the risk assessment and clinical reasoning process for manual therapists.
What are the risk factors that are associated with an increased risk of either internal carotid or vertebrobasilar arterial pathology and should be thoroughly assessed during the patient history?
• Past history of trauma to cervical spine
/ cervical vessels
• History of migraine-type headache
• Hypertension
• Hypercholesterolemia / hyperlipidemia
• Cardiac disease, vascular disease, previous cerebrovascular accident or transient ischemic attack
• Diabetes mellitus
• Long-term use of steroids
• Blood clotting disorders / alterations in blood properties (e.g. Anticoagulant Rx)
• History of smoking
• Recent infection
• Immediately post partum
• Trivial head or neck trauma Absence of a plausible mechanical explanation for the patient’s symptoms.
What are the recommendations for a patient with resting vitals of >140/90?
Proceed with usual care
• Contact PCP
• Monitor closely
What are the recommendations for a patient with resting vitals of >160/100?
Hold resistance exercise, consider aerobic
exercise
• Contact PCP
• Monitor closely
What are the recommendations for a patient with resting vitals of >180/110 ?
Hold Exam
• Examine for organ damage
• Contact PCP
• Consider contacting EMS/911
What are the characteristics of using the effects of post exercise hypotension that should be considered?
• Acutely lower blood pressure in an “asymptomatic” (ie not in crisis) patient with
elevated BP
• The cutoff scores for aerobic exercise is 180/110
• Try low grade exercise 5-10minutes, monitor response and recovery
• Effects can last long enough and gives you a reflection on appropriateness for therapeutic interventions
• Use your judgement to manage each case, if you don’t feel comfortable contact referring provider.
What are the characteristics of the use of eccentrics to be considered?
• Improves strength comparable to concentric training.
• Lower RPE, SVR, oxygen consumption, Cardiac Index, peak SBP and HR at similar workloads to concentric.
• May increase muscle soreness more
than CON training
What are the characteristics of thoracic spinal manipulation for neck pain to be considered?
• Patients neck pain with CVD are at greater potential risk for adverse events following cSMT
• Thoracic manipulation is an effective
intervention for neck pain
• Very little response to hemodynamics or
autonomic system
• Does not involve perturbation to cervical
arteries or carotid sinus
What are the characteristics of questionnaires to be considered?
• Physical Activity Readiness Questionnaire (PARQ) - Easy to use, Medicare • Duke Activity Status Index (DASI) - Predictive for Mortality - Related to Peak VO2 • AHA/ACSM Physical Questionnaire - Easy to use, Fitness Industry • Questionnaires can be effective for investigating heath history in PT practice
What is Cardiovascular Disease?
Disease and dysfunction to the myocardium and blood vessels, includes numerous problems, many of which are related to a process called atherosclerosis. Defined by the presence of stenosis which impairs blood flow, flow limiting lesion.
What are the major causes of Cardiovascular Disease?
- Atherosclerosis
- Thrombo-embolism
- Vasculitis
What are the Non Modifiable Risk Factors for Cardiovascular Disease?
• Gender (Male>Female) • Age - Male >40 - Female >50 (post menopause) • Race (African American or Asian) • Family History: 1st degree blood relative that has had coronary heart disease, stroke or heart attack before the age of 55 for males or 65 for females
What are the Modifiable Risk Factors for Cardiovascular Disease?
• Hypertension • Tobacco use • Elevated blood glucose (IFG/diabetes) • Physical inactivity - 150min/week Moderate (3-6METs) - 75min/week Vigorous (<6METs) • Overweight and obesity - Overweight BMI 25-29.9 - Obese BMI >30 • Cholesterol/lipids - Total <180 mg/dL is considered optimal. - HDL 40-60mg/dL - LDL 100-129mg/DL
What is Atherosclerosis?
The hardening of the arteries.
What kind of condition is Atherosclerosis?
A dynamic chronic inflammatory condition
What are the characteristics of Atherosclerosis?
• Slow, progressive disease • Starts in 2nd & 3rd decade of life • Very long incubation period • Often undetectable - Even with moderate to high grade • Initially Plaques are sparsely distributed • Increase in number and size over time • Can affect any artery
What is the role of Endothelial Cells (EC)?
• EC normally produce antithrombotic molecules that prevent blood clots.
• EC modulate the immune response by resisting leukocyte adhesion and therefore inhibiting inflammation.
• Laminar shear stress favors leads to
- NO production
- Kruppel Like Factor 2 (KLF-2); mediates the immune response, prevents deposition
- ++ Superoxide Disumutase (SOD) protects against reactive oxygen species (ROS).
• Branch points are subjected to turbulent flow and tend to lack these effects.
What does Endothelial Cells (EC) do when subjected to various stressors?
EC can also produce prothrombotic molecules.
• In response to injury or infection,
• EC secrete chemokines and produce cell surface adhesion molecules
What are the characteristics of Developmental stage: Fatty streaks of Atherosclerotic Plaque?
- Characterized by lipid-filling smooth muscle cells
* Potentially reversible
What are the characteristics of Developmental stage: Fibrous plaque of Atherosclerotic Plaque?
• Lipoproteins transport/deposits LDLs into the arterial intima
• Fatty streak is covered by collagen and calcium deposits forming a fibrous plaque
that appears grayish or whitish
• Result = Narrowing of the vessel lumen
What are the characteristics of Developmental stage: Complicated lesion/Unstable Plaques of Atherosclerotic Plaque?
- Continued inflammation can result in plaque instability, ulceration, and rupture.
- Lipid core is exposed to the blood stream, platelets accumulate, and thrombus forms.
- Result = Narrowing of lumen or thrombo embolotic event
Worse in younger people
What is the Overview of the Pathophysiology of Atherosclerosis?
- Endothelial dysfunction
- Inflammatory process involving many cellular markers within the lesion
- Deposits of fatty streaks initiating event
- Lesions occur in large and medium sized vessels
- Maybe present throughout a person’s life-time
What are the Complications of Atherosclerosis?
- Calcification of atherosclerotic plaque
- Rupture or ulceration
- Hemorrhage into the plaque -> further narrowing
- Embolization
- Weakening of the vessel wall -> aneurysm
Where in the arterial wall does the endothelial cells lie?
In the intima
What are the layers of the arterial wall from deepest to most shallow?
- Intima
- Media
- Adventitia
What are the implications of endothelial cell dysfunction?
- Inc Adhesiveness of the endothelium (Inc expression of vascular cell adhesion moleculesfor leukocytes, T cells, platelets and inc to oxidized LDL).
- Macrophages engulf oxidized LDL and become foam cells
- Endothelium becomes procoagulant vs. anticoagulant and local adhesion of the above molecules is associated with secretion of cytokines and growth factors
- Transmigration of molecules (e.g., leukocytes) into the wall
What is the key in the prevention of CVD?
Endothelial function
What are the common sites of Atherosclerosis?
- Branches of the iliac arteries
- Popliteal arteries
- Carotids, especially where they branch
- Left subclavian artery
- Coronary artery
What is Peripheral vascular disease (PVD)?
A slow and progressive circulation disorder
caused by narrowing, blockage, or spasms in a blood vessel.
PVD may involve disease in any of the blood vessels outside of the heart like ___
- Arteries (PAD)
- Veins (CVI)
- Lymphatic vessels
Where are the common sites of PVD?
- Branches of the iliac arteries
- Popliteal arteries
- Carotids, especially where they branch
- Left subclavian artery
- Coronary artery
Anywhere we see branches or turbulent flow
What are some Peripheral Arterial Disease Findings?
- Intermittent claudication most common symptom but many patients are asymptomatic or have atypical symptoms
- Pallor on Elevation
- Dependent Rubor
- Impaired capillary refill
- Impaired Peripheral Pulses
- Affected limb may show signs of cyanosis
- Feel cool to the touch
- Numbness or tingling reported in affected area
- Skin may appear shiny, thin, pale, and hairless.
- Nails become thickened and brittle.
What are the characteristics of Intermittent claudication found in Peripheral Arterial Disease?
- Predictable time and intensity, reproducible, doesn’t change with posture,
- Location of the diseased artery determines location of claudication.
- Walking test
What are the characteristics of Pallor on Elevation found in Peripheral Arterial Disease?
- Insufficient arterial pressure to perfuse when leg elevated above level of heart.
- Limb drains of blood turns pale (palor)
What are the characteristics of Dependent Rubor found in Peripheral Arterial Disease?
Blood pooling in maximally dilated capillary bed
What is a way that we often measure blood flow in the limb?
Ankle-Brachial Index (ABI)
How is Ankle-Brachial Index (ABI) done?
- Pt in supine position
- Measure brachial artery pressure using a Dopplar US
- Apply same BP cuff to the ankle on the same side of the body
- Palpate for the posterior tibial (PT) artery and take SBP reading.
- Palpate for the dorsalis pedis (DP) artery and take pressure there.
- Apply BP cuff to the opposite ankle and obtain Post Tib & DorPed pressures.
- Repeat on the other arm
What are the characteristics of Ankle-Brachial Index (ABI)?
- Normally ankle BP is as high as brachial, and thus ABI ≥ 1
- ABI ≤ 0.9 is diagnostic of PAD
- ABI 0.5 – 0.8 are found in patients with claudication
- ABI < 0.5 indicates critical ischemia
- An ABI of 0.9 or lower has a specificity of 83% to 99% and a sensitivity of 69% to 73% in detecting stenoses greater than 50%
- The sensitivity of an ABI less than 1.0 approaches 100%
What is normal capillary refill time?
Under 2 secs
What is a Carotid Bruit?
Sound made by turbulent flow vibrating against arterial wall
What does a carotid bruit indicate?
The presence of an arterial lesion/plaque
What does a carotid bruit do?
Causes the arterial wall to vibrate during systole
What are the clinical implications for PAD?
- High risk individuals should be examined for PAD and AAA.
- Important to monitor hemodynamics during exercise.
- Patients with intermittent claudication usually have some sort of walking impairment that has shown to significantly improve with exercise training.
- Exercise training has shown to be as effective as surgical interventions in reducing symptoms and improving walking distances.
- Patients should be instructed in proper foot care, footwear, and hygiene
- Might improve nocturnal pain by elevating head of bed slightly
What is turgor?
The delayed bounce back when the skin is pulled
In what population is turgor observed?
- In dehydrated patients this return to the resting position is delayed.
- May also observe hypotension, tachycardia, orthostasis, irregular heart rate and ECG
What are the characteristics of “Exercise for claudication different than exercise advised for many other conditions since exertion to the point of leg pain is required for maximum benefits” as a clinical implication for PAD?
- The transient impairments in perfusion that causes claudication during walking is also the stimulus for many of the favorable changes
- For this reason, exercises that use muscles that do not result in claudication pain may not be beneficial for improving claudication symptoms
- For more severe cases: Arm ergometry also improves walking performance.
- Leg strength training improves walking time, although not as much as treadmill exercise training does.
- Interval training with short rest periods for relief of claudication is most effective.
What are the characteristics of interval training done for clinical implications for PAD?
- Exercise at least 3 x/week
- Initial workload/intensity should induce claudication within 3-5 min
- Continues at this workload until the pain is of mod severity (5/10)
- Rest to allow the symptoms to resolve
- Repeat exercise-rest-exercise cycle several with a goal of 30-35minutes for maximum benefits
What is Raynaud’s Syndrome?
Vasospasm causing reduced blood flow
What are the characteristics of primary Raynaud’s Syndrome?
More common in women, onset usually 15-
30, more typical in cold climates, family Hx,
no underlying disease
What are the characteristics of secondary Raynaud’s Syndrome?
- Less common but more serious. S&S usually appear later than primary, around age 40
- Sceleroderma, Lupus, RA, repetitive trauma, smoking, atherosclerosis
What are the characteristics of severe Raynaud’s Syndrome?
Rare, could result in permanent hypoperfusion of digits
What is an Aneurysm?
Localized abnormal dilation by at least 50% compared to normal.
How are aneurysms classified?
According to cause, size and shape
What are the causes of an aneurysm?
Athreosclerosis, congenital infections, Marfans
What are the risk factors of an aneurysm?
• Cardiovascular disease and Risk factors for CVD - Especially smoking • Male • Genetics (marfans) • 40-60 yr old • Hypertension prevaleny
What are the characteristics of a Sacculuar aka Berry aneurysm?
- Small, spherical, 1-1.5 cm.
* Most common in brain tissue
What are the characteristics of a Fusiform aneurysm?
Gradual more progressive
What are the characteristics of a Dissecting aneurysm?
Blood filled channel within aortic wall
What are the characteristics of an Abdominal Aortic Aneurysm?
• Dull, tearing ache/pain in low back, groin
or mid abdominal left flank
• Chest Pain
• Weakness or transient paralysis of legs
• Palpable, pulsating (heart beat) adominal
mass >3cm
• Inter-arm systolic blood pressure
difference >20 mm Hg was an independent
predictor of AAD, with a positive predictive value of 98%
• Absent or decreased peripheral pulses aka
Pulse Deficit
• Tachycardia
How is the palpation of the abdominal aorta done?
• Relax the abdominal muscles completely
- Flex the hips and support head and legs w/ a pillow
• Start just left and superior to the umbilicus
• Apply firm pressure with flattened fingers of both hands.
• To measure width, place one index finger on either side
of the aortic pulse.
- To find each edge, Feel for the strongest pulse on either side then slightly back off.
- It is easier to palpate one side at a time.
- Each systole should move the fingers apart
• Obese individuals and those with massive abdominal musculature, it may be impossible to detect
• Width >2.5cm (approx 2 finger widths) warrant further medical examination
What is Chronic venous insufficiency (CVI)?
A condition that occurs when the vein wall and/or valves in the leg veins do not work effectively, which impairs the ability for blood to return to the heart from the legs, resulting in venous-stasis
What are the systems that venous network in LE commonly affected by chronic venous insufficiency is divided into?
- Superficial, (lesser and greater saphenous)
- Deep, (anterior and posterior tibial, peroneal, popliteal, deep femoral, superficial femoral, and iliac veins)
- Perforating or communicating veins
What may a Chronic venous insufficiency (CVI) result from?
Vein wall degeneration, post-thrombotic
valvular damage, chronic venous obstruction, or dysfunction of the muscular pumps.
What is edema?
A clinically apparent increase in the interstitial fluid volume
Why does edema develop?
When Starling forces are altered so that there is increased flow of fluid from the vascular system into the interstitium.
What is edema due to?
Due to Increase in capillary pressure usually results from an elevation of venous pressure caused by obstruction to venous and/or
lymphatic drainage.
What do we see in generalized edema?
Heart failure, Hypo-albumenia, nephrotic syndrome, Cirrhosis, sepsis
What do we see in localized edema?
Musculoskeletal Injury, DVT
In what cases do we see pitting edema?
In chronic cases
What are the grades of pitting edema?
1+: Barely detectable impression when finger is pressed into skin.
2+ : Slight indentation. 15 seconds to rebound
3+: Deeper indentation. 30 seconds to rebound.
4+: > 30 seconds to rebound.
What are the PT Implications for CVI?
• Exercise increases muscle pump for venous return and kidney function to clear fluid • Short walks with occupations involving prolonged sitting, weight shift in standing • Elastic pressure stockings (effective up to knee- don’t need to go above the knee) • Compression pump - below DBP, 90sec on:30sec off (Generally) • Unna boot • Edema massage helps prevent pitting edema, which increases likelihood of wounds
What are the characteristics of an unna boot as a PT Implications for CVI?
• Semirigid dressing, layered application from 1st metatarsal to below tibial tubercle. • Cast dries 1h, wear 7 days. Muscle contracts and presses against rigid Unna boot to force fluid proximally
What are the contraindications for an edema massage as a PT Implications for CVI?
Uncompensated CHF, untreated infection or cellulitis, active cancer (check with MD), renal failure, and severe pulmonary problems
What is an ulcer?
A persistent discontinuity in the integrity of skin despite sufficient time for healing
What are the characteristics of a venous ulcer?
- Maleolar location (usually Medial)
- Irregular margins
- Hemosiderin staining (browning)
- Varicose veins and pitting edema
What are the characteristics of an arterial ulcer?
- Doral or Distal location (toes)
- Sharp margins
- Painful
- Pallor, loss of hair, nail dystrophy
- Lateral malleolus
What are the characteristics of a neuropathic ulcer?
• Plantar location - Metatarsal heads (especially 2nd ), sole of foot, balls of toes • “Punched Out” margins, usually correspond to pressure point • Insensate, patient often diabetic with peripheral neuropathy • May have arterial insufficiency S/S • In patients with diabetes
What are the differential diagnosis point used for an ulcer?
• Pain due to vascular causes increases with workload
• Neurogenic pain not affected by workload but by posture
• Edema typical with venous or lymph pathology not usuallu arterial
• Pain: ask about TYPE and LOCATION
- Intermittent claudication
- Pain increases with elevation and decreases with dependence arterial disease
What are the characteristics of the intermittent claudication used in the differential diagnosis of an ulcer?
• Cramping type pain, due to ischemia, better with rest- not typically “burning”
• Usually in calves, although can be thigh or buttock
• Pain correlates with area of obstruction: hip and buttock= aorto-iliac occlusion, thigh
pain=iliofemoral occlusion, prox 2/3 calf- superficial femoral artery, distal 1/3calf=
popliteal artery, foot= tibial artery
What are the Wells score criteria descriptions for a DVT and their corresponding points?
- Active cancer (treatment within last 6 months or palliative) (+1)
- Calf swelling >/= 3 cm compared to asymptomatic calf (measured 10 cam below tibial tuberosity) (+1)
- Swollen unilateral superficial veins (non varicose, in symptomatic leg) (+1)
- Unilateral pitting edema ( in symptomatic leg) (+1)
- Previously documented DVT (+1)
- Swelling of entire leg (+1)
- Localized tenderness along the deep venous system (+1)
- Paralysis, paresis or recent cast immobilization of lower extremities (+1)
- Recently bedridden >/= 3 days or major surgery requiring regional or general anesthetic in the past 12 weeks (+1)
- Alternative diagnosis at least as likely (-2)
What is the interpretation of the Wells Score DVT criteria?
• Score >2.0 — High (probability 53%])
• Score 1.0 to 2.0 — Moderate (probability 17%)
• Score <2.0 — Low (probability 5%)
• D-Dimer may be used in either case to
rule in/out DVT
• Moderate to High risk a vascular ultrasound is indicated
What are the Wells score criteria descriptions for a PE (Pulmonary Embolism) and their corresponding points?
• Clinically suspected DVT — 3.0 points
• Alternative diagnosis is less likely than
PE — 3.0 pts
• Tachycardia (heart rate > 100) — 1.5 pts
• Immobilization (≥ 3d)/surgery in previous four weeks — 1.5 pts
• History of DVT or PE — 1.5 pts
• Hemoptysis — 1.0 pts
• Malignancy (with treatment within 6 months) or palliative — 1.0 pts
What is the interpretation of the Wells Score PE (Pulmonary Embolism) criteria?
• Score >6.0 — High (probability 59%)
• Score 2.0 to 6.0 — Moderate (probability
29%)
• Score <2.0 — Low (probability 15%)
• Score > 4 — PE likely. Consider diagnostic
imaging.
• Score 4 or less — PE unlikely. Consider D-dimer to rule out PE
What are the Ischemic Syndromes?
• Angina Pectoris - Stable Angina - Variant Angina - Unstable Angina - Silent Ischemia • Myocardial Infarction
What is Ischemia?
A condition of imbalance between myocardial O2 supply and demand often caused by atherosclerosis of the coronary arteries
What is angina?
Chest pain or discomfort caused due to cardiac ischemia
What are the presentations of angina?
- Heaviness, tightness, pressure
- Discomfort gradually builds
- Gradually subsides
- Episode Lasts (1-15 minutes)
- Often confused with digestive disturbances
What are the major types of angina?
- Stable
- Unstable
- Printzemental
What are the characteristics of a stable angina?
• Discomfort gradually builds • Occurs with exercise at a predictable and consistent intensity • Gradually subsides with rest • Typically Lasts (2-5 minutes) • Rarely more than 5-10 mins • Improve with nitroglycerin
What are the characteristics of an unstable angina?
• Recent or acceleration of angina threshold; New onset < 2 months • Symptoms at rest > 15-20 minutes. • Gradually worsens in a crescendo-like pattern • May not respond to Nitro or Rest • Often precursor to MI
What are the characteristics of angina in special populations?
• Elderly patients: More likely to present with atypical symptoms (SOB, AMS).
• Diabetics: May not be able to accurately sense or describe pain
• Women: More commonly report nausea, emesis, jaw pain, neck pain, and back pain.
• The presence of multiple prescription medications, drugs, and alcohol will
also alter the patient’s ability to perceive discomfort.
• Cultural differences and language barriers.
What is a Myocardial Infarction?
Cell death in the heart muscle caused
by complete and prolonged occlusion
of a coronary artery
What are the causes of increased demand seen in ischemia?
Exercise, Cold weather (increased vascular resistance), mental/emotional stress, spontaneous changes in HR and BP
What are the causes of reduced supply seen in ischemia?
Impaired aortic driving pressure, increased coronary resistance
What are the causes of Ischemic contracture of the myocardium seen in ischemia?
Insufficient or no ATP delivered to break cross myofilament cross-bridge
What are some general neurophysiology of angina?
• Patients frequently misinterpret the origin of visceral pain, as it is often referred to a
different area of the body.
- Ex“: Shoulder pain and myocardial ischemia
• Stimulation of visceral or somatic pain fibers results in two distinct pain syndromes.
• Somatic Fibers
- Usually easily described, precisely located, and usually experienced as a sharp sensation,
• Visceral pain fibers
- internal organs, such as the heart and blood vessels, the esophagus, and the visceral pleura,
- enter the spinal cord at multiple levels and
- Map to areas on the parietal cortex corresponding to the cord levels shared with somatic fibers.
- more often described as discomfort, heaviness, or aching.
• Pain from visceral fibers is more difficult to describe and is imprecisely localized.
What is the end result of an Acute Coronary Syndromes (ACS)?
Sudden death
What are the types of Acute Coronary Syndromes (ACS)?
- Unstable angina
- ST elevation myocardial infarction
- Non ST elevation myocardial infarction
What is a ST elevation myocardial infarction?
Classically seen in a person with myocardial infarction, because the cell membrane potential in the myocardium has been completely altered, which then alters the conductive properties of the heart which is reflected in the ECG on the ST segment
What do we see on the ECG when a person has ischemia?
- Flipped T wave
- Potentially ST depression
- Elevation in biomarkers
What is a Non ST elevation myocardial infarction?
When there is only a depression in the ST segment. The person may only be ischemic
How do we rule in or rule out ischemia in the heart?
Using a biomarker assay, looking specifically at Troponin I and T.
Ischemic infarctions are reversible
What are the values we usually go by when assessing for troponins?
<0.1 - 0.4 ng/ml
What is cardiac troponin I?
An inhibitory subunit
What is cardiac troponin T?
Tropomyosin- binding subunit
What are the normal values of cardiac specific isoenzyme of creatine kinase (CK-MB)?
0-0.4 ng/ml
What are the characteristics of cardiac specific isoenzyme of creatine kinase (CK-MB)?
Elevation within 4 to 8 hrs after coronary artery occlusion, peak between 12 to 24 hrs and return to normal between 3 and 4 days
What are the characteristics of troponin I and T?
Elevations detectable as early as 2 hrs after MI, but not reliably elevated in all patients until 6 to 12 hrs
What is the biggest thing to look for if MI is diagnosed?
Wait for 2 consecutive downtrending values before initiating PT
What are the factors the increases the likelihood of a diagnosis being a MI?
- Associated with exertion
- Radiation to the left arm
- Described as pressure
What are the factors the decreases the likelihood of a diagnosis being a MI?
- Described as positional
- Described as sharp
- Reproducible with palpation (easiest way)
- Not associated with exertion
What is the composite score chest pain due to CAD criteria and corresponding points?
- Age/sex: Men >55y/o; Women > 65 y/o (1)
- Known Vascular Disease (CAD, (1)
- Cerebrovascular Disease) (1)
- Pain worse with exercise (1)
- Pain not elicited with palpation (1)
- Patient assumes pain is of cardiac origin (1)
What is the score interpretation of the composite score chest pain due to CAD criteria?
Score +LR -LR
0 to 1 point 1.09 0
2 to 3 points 1.83 0.003
4 to 5 points 4.52 0.16
What are the clinical implications for PT for patients with heart disease?
• Patients should always have with them their NTG during exercise sessions.
- Patients should report symptoms of chest pain and take NTG as directed.
- If symptoms persist 5 mins after NTG, dose can be repeated two more times with 5 min intervals between doses.
- If symptoms persist seek prompt medical attention.
- NTG can be used prophylactically 5-10 mins before activity.
• Physiologic responses to activity should be monitored (HR, BP, RPP)
What is a Percutaneous Coronary Intervention?
Formerly known as angioplasty with stent) is a non-surgical procedure that uses a catheter and balloon to place a stent to open up blood vessels in the heart that have been narrowed by plaque buildup.
What are the types of stent used in a Percutaneous Coronary Intervention?
- Bare Metal Stents
* Drug Eluting Stents
What is an Endarterectomy?
Surgical removal of part of the inner lining of an artery, any obstructive deposits
• (Usually atherosclerotic plaques)
In what arteries is an endarterectomy most often performed?
In the carotid artery or femoral arteries
What are the treatment options for Arrhythmias?
- Temporary Epicardial Pacer
- Pacemaker
- Implantable Cardioverter Defibrillator (ICD)
What are the characteristics of a temporary epicardial pacer?
• Epicardial pacing wires common after open heart surgery wires exit through mediastinal
incision.
• Cardiac surgery makes myocardium irritable and prone to arrhythmia
• Pacer is used to control heart rate due and rhythm.
What are the exercising parameters for a patient with a pacemaker?
- Know upper limit of pacemaker, max HR to be 10bpm below pacer max
- Target HR based on results of exercise test (symptom limited, vitals monitored)
What is the important feature of an Implantable Cardioverter Defibrillator (ICD)?
It only fires when it detects an arrythmia
What is cardiothoracic surgery: Median Sternotomy often used for?
• Coronary artery bypass graft CABG
• Valve Replacement or repair
- Mitral (MVR) or Aortic (AVR)
• Heart Transplant
What is cardiothoracic surgery: Thoracotomy often used for?
• Lobectomy
• Lung Transplant (Bilateral aka
“Clamshell” for COPD)
What is cardiothoracic surgery: Minimally Invasive Cardiac Surgery (MICS) often used for?
CABG, Valvular Surgery
What is cardiothoracic surgery: Video assisted thoracic surgery (VATS)) often used for?
Lobectomy (lung cancer)
What are the characteristics of a Median Sternotomy?
- One of the most frequent accesses in cardio-thoracic surgery
- Vertical inline incision is made along the sternum.
- Chest wall is retracted Mediastinum exposed
What are some pros of the Minimally Invasive Options?
Reduced postoperative mortality and
morbidity, shorter hospital stay and
better cosmetics
What are the limitations of minimally invasive option of cardiac surgery?
Limited by the longer cross-clamp and cardiopulmonary bypass (CPB) times, which can lead to a clot.
What are the characteristics of a Coronary Artery Bypass Graft ABG?
- 1-2% mortality rate although 5-10% risk of MI during procedure
- Graft vessels sewn to coronary arteries beyond blockage and attached to aorta
- Triple, quadruple or quintuple bypasses are now routine
- Most commonly used vessel for grafts is saphenous vein.
What is the general procedure of a Coronary Artery Bypass Graft ABG?
• CABG surgery takes ~4hours to complete.
• Aorta is clamped off for about 60 minutes
to allow bloodless field and allow bypasses to be connected to aorta.
• Heart is stopped using a chilled K+ solution
• Plastic tubes are placed in RA to channel
venous blood out of the body for passage
through heart lung machine
• Body is supported by cardiopulmonary
bypass for about 90 minutes.
What are the characteristics of Left Internal Mammary Artery (LIMA) Grafts?
•Gaining popularity especially for LAD - Proximal origin off left subclavian maintained and distal end is separated from the chest wall, • Remain open longer (90% in 10yrs) • Compared to 66% of vein grafts, • Also maintain endothelial function • Internal mammary arteries generally not used for emergency CABG surgery
What are the disadvantages of a Left Internal Mammary Artery (LIMA) Grafts?
- Limited length of vessel
- May prolong surgery
- Risk of sternal wound failure
What are the characteristics of Valvular Replacement and Repair ?
• Valves can be mechanical or biological
- Biologic valves made of human, pig or cow tissue (xenografts)
- Typically requiring by-pass and a median sternotomy
• Mechanical typically bi-leaflet valve with 2
carbon leaflets covered with polyester knit fabric
• Mechanical last a lifetime but require
anticoagulant meds
• Young pts may be better candidate for
mechanical due to limited life of biological valve
• Mechanical higher risk for infection, thrombus and emboli. Will need life long anti-coagulation meds
What are the complications of cardiac post surgery?
- DVT and/or Venous Thromboembolism (VTE)
- Intra or Peri-operative MI
- Pericarditis
- Infection
- Sternotomy Failure
- Pulmonary Complications
- Reduced bowel motility
- Deconditioning
- Neurocognitive decline
- Chest wall pain and mobility issues
What are the Inpatient Physical Therapy Implications of cardiac post surgery?
• Getting patient moving,
- Reduces risk of deconditioning, pulmonary complications (atelectasis and pneumonia), bed sores and DVT
• Goals:
- Determine stability for ambulation, transfers, stairs, ADLs, assistive device
needs, tolerance to activity, return to PLOF or as close possible
• Discharge Plans
- Always ask patient if they live alone/family, floors in home, steps to needs, can patient establish self of 1st floor bathroom) may need to talk to family.
What are the usual discharge times for cardiac post surgery?
- CABG 4-5days
- Valve Replacement: 2-3 days
- HTx: 1-2weeks
What are the typical progression and goals of cardiac post surgery?
• Post op day 0 pt transfers to chair with RN in AM
• Post op day 1 pt transfers from sit to stand, gets to doorway, pre gait
- Afternoon ambulation
• Post op day 2-3 chest tubes d/c, cardiac pacer d/c
- Pt must be supine for either and remain still for 1hr with pacer d/c)
- Stairs assessment
- Independent ambulation assessment
• Consider using a standardized assessment,
- 5meter Gait Speed, 6MWT, 2MST, Dynamic Gait Index, POMA
What are some sternal precautions to take after cardiac post surgery?
• No traction forces on sternum for 6-8 weeks,
- longer if osteoporosis or on steroid medication
• No shoulder flexion or abduction >90deg
• Lifting restriction 8-10 lbs 6wk, then 30lb for 3mo
• Minimal or no push/pull. This means
- Use log rolling to get out of bed, get to edge of chair before standing, use momentum and rocking, look up
• If sternal tissue fails, use rectus or pectoral flaps- severe ROM restriction of 20deg flex and abd, no lifting, push or pull
• Monitor incision: 30% mortality of skin opens and becomes infected
• Encourage splinting chest with pillow when coughing
• Avoid valsalva
• No driving due to medications initially, then need to avoid air bag for 4-6wks
What are some Inpatient Physical Therapy Implications: D/C?
- Start patient on basic walking program
* Discuss and obtain referral for cardiac rehab!
What are the types of pacemakers?
- External cutaneous
- Temporary epicardial
- Temporary endocardial
- Permanent pacemaker
When is a temporary endocardial pacer used?
- When there is some sort of temporary HR abnormality that should resolve over time
- While waiting for a permanent pacemaker
What is a permanent pacemaker?
One where everything is internal
