CardioPulm Exam 2

PT cardiopul m

Percutaneous Coronary Intervention ( Coronary Angioplasty w/stent)

Percutaneous Coronary Intervention ( Coronary Angioplasty w/stent)

What 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/plaque buildup?

Troponin (is the main) , myoglobin & CK-isoforms, CKMB

What are the 3 main biomarkers that indicate myocardial infarction? What is the main marker?

90 mins

What does the AHA recommend as the absolute cut off to get a patient in during a MI with a catheter?

Transmural Infarction ( involves the full thickness of the myocardium)

Beyond 3 hours, what is the cause of a MI?

Subendocardial Necrosis (b/w the endocardium and myocardium)

Where does necrosis occur for a MI that b/w 20-60 mins?

False, only begins after 20 mins

T/F, Necrosis is the result of a MI regardless of the timeline

20 mins

What is the timeline for a myocardial infarction to be considered reversible?

AVO2 Difference (shows peripheral adaptations)

___ ______ is a strong and independent predictor of functional capacity and tolerance to exercise in patients with HF

Increased vascular resistance and renal sodium/water retention

What are the 2 neurohormonal compensatory mechanisms in HF to restore organ perfusion?

Stress → BNP to be released from ventricles, great way to track severity of HF

What is the relationship b/w HF and BNP?

Heart Failure w/ preserved ejection fraction (diastolic HF & elevated filling pressure)

What is HFpEF?

Heart failure w/ reduced ejection fraction (systolic HF)

What is HFrEF?

target LE muscles, 10-25 Hz frequency, biphasic (variable on/off times), (20-60 mins) 5-7x per week

What are the exercise parameter recommendations for NMES for patients w/ HF?

15-20% MIP, 30 mins per day (60s initially), 2x a day not less than 6 hours

What are the exercise parameter recommendation for endurance for inspiratory muscle training for patients w/ HF?

Aerobic training at moderate intensity (60-70% VO2 max)

What is the Gold standard exercise intervention for those with HF?

Narrowing pulse, Arrhythmias, Fluid changes ( fluctuate 3 lbs in 24 hrs, 5lbs in a week)

3 signs of cardiac decomposition

1. avoid exercise after eating and vasodilator meds, 2) use VO2 max rather than age predicted HR max, 3) initial exercise intensity < 10 beats, 4) signs of cardiac decompensation, 5) goal writing

What are the 5 special exercise considerations for HF?

Above 45

Level 4, VE/CO2 slope (high risk for major adverse cardiac event MACE) is….

36-44.9

Level 3, VE/CO2 slope (high risk for major adverse cardiac event MACE) is….

30-35.9

Level 2, VE/CO2 slope (high risk for major adverse cardiac event MACE) is….

Below 30 = normal, (above 30 = pathological reason) Higher slope = you need more ventilation to move out CO2

What is the VE/CO2 slope? Normal?

CPET (cardiopulmonary ET)

What is the Gold Standard for exercise test used for HF?

Incremental shuttle walk test, 6 min walk test, CPET

What are the 3 good exercise tests used for heart failure?

ACE inhibitor, Angiotensin (antagonists), Beta blockers, diuretic and aldosteron

5 big options for pharmacotherapy for HF?

Change in weight: 3lbs overnight, 5lbs in one week, PIP of less urinating

What are the 3 concerns for decompensation resulting in fluid retention secondary to HF?

BNP (increase in BNP concentration is associated w/ 35% increase in relative risk of mortality)

Many patient with stable HF will have elevated ______ but may still fall within the diagnostic range.

Full compensation & Chronic Edema/congestion

What are 2 effects of chronic HF?

Chronic HTN, Valve disease, Various Cardiomyopathies, Chronic Lung disease

What are four causes of chronic HF?

No time to compensate, acute pulmonary edema, acute ischemia

What are 3 effects of acute HF?

Acute MI, Pulmonary Embolism, Severe Malignant HTN

What are 3 causes of acute HF?

Stage C

What is the classification of HF based off NYHA: Patient w/ past or current symptoms of HF associated with underlying structural heart disease

Stage D

What is the classification of HF based off NYHA: Patient with end stage disease who requires specialized treatment

Stage A

What is the classification of HF based off NYHA: Patient at high risk for developing HF with no structural disorder of the heart

Stage B

What is the classification of HF based off ACC/AHA guidelines: Patient with structural disorder w/out symptoms of HF

1

Name the classification of HF based off: No limitation of physical activity, does not fatigue with ordinary physical activity, palpitation or dyspnea

3

Name the classification of HF based off: Marked limitation of physical activity, comfortable at rest but less than ordinary activity causes fatigue, palpitation or dyspnea

2

Name the classification of HF based off: Slight limitation of physical activity, comfortable at rest. Ordinary activity results in fatigue, palpitation and dyspnea

4

Name the classification of HF based off: Unable to carry on any physical activity without discomfort, HF symptoms occurring at rest

Dyspnea, fatigue, weakness, enlarged heart, pulmonary edema, cerebral hypoxia

What are some symptoms of right ventricular failure?

Diastolic Heart Failure

HF classified by impaired relaxation of the heart resulting in an elevated filling pressure (which is known as)

Systolic Heart Failure (most common)

Heart failure classified by impaired contractile function of the heart, resulting in a lower ejection fraction

Systolic HF & Diastolic HF

What are the 2 types of HF?

55-75%

What is a normal ejection fraction?

Muscle Hypothesis: Endothelial dysfunction, Skeletal muscle hypoperfusion, skeletal muscle abnormalities/wasting and ventilatory inefficiency

While HF impacts the cardiac function of the heart, what occurs in the periphery as a consequence of HF? What states this as a big issue?

SV is reduced due to increased afterload in HF patients, we want to decrease systemic resistance by vasodilation to reduce the effect of afterload

Why is vasodilator therapy effective for patients with Heart Failure?

Stroke volume & Heart rate

What are the 2 things that impact Cardiac Output?

Contractility, Preload and Afterload

What 3 cardiac factors impact stroke volume?

After Load

What is the force against the ventricles, that they must act in order to eject blood? Largely dependent on the arterial blood pressure and vascular tone

Preload

What is the degree of myocardial distention prior to shortening, largely dependent on the amount of ventricular filling

Increased SNS activity, Increased Ras-aldo, Increased vasopressin & ADH

What 3 compensation occur with decreased cardiac output?

Decreased blood flow to kidney due to HF results in an increased Na/H2O retention in order to increase perfusion pressure. Results in increased Epi,Renin,Endothelin (vasoconstrictors) and ANP to restore organ perfusion.

What do the kidneys do in response of HF and a decrease in cardiac output?

Restrictive Cardiomyopathy

What type of cardiomyopathy do we see rigid ventricular walls, diastolic dysfunction, least common type of cardiomyopathy?

Hypertrophic Cardiomyopathy

What type of cardiomyopathy is characterized by a considerable increase in cardiac mass (hypertrophy) that may be symmetrical or asymmetrical but w/out cavity dilation?

Dilated cardiomyopathy

What type of cardiomyopathy is characterized by an increased cardiac mass, dilation of all four cardiac chambers with little or no wall thickening and systolic dysfunction eventually leading to left & right ventricular failure?

Dilated, Hypertrophic, Restrictive

What are the 3 main categories of cardio myopathy?

Greater than 160/90

What blood pressure puts individuals at a greater risk for heart failure?

Ischemic HD (most common), Hypertension, Idiopathic cardiomyopathy, Infection, toxins, Valvular disease, Prolonged arrhythmias (Afib)

What are some of the etiological causes of HF? what is the most common?

Heart failure

Shortness of breath, Fluid retention, Fatigue, Orthopnea, paroxysmal nocturnal dyspnea (shortness of breath, seen in babes) are symptoms of what?

Heart failure

What is the syndrome that results from structural or functional cardiac disorder that causes the inability of the heart to eject blood to meet the demands of the body while maintaining normal pressures in it’s chambers and the lungs?

HCM (hypertrophic cardiomyopathy, passed in the mothers gene)

What condition has a genetic component and is linkeed to sudden cardiac death?

Sinus arrhythmia

What is a variable R-R interval that can be felt like a skipped heart beat

LVH is reversible in athletes

What is the difference with LVH in athletes vs someone with HTN?

Fixed S2 & ejection murmur, indicates structural deformity (normal = transient split S2)

What is abnormal/pathological clinical finding in an athlete?

Common genetic abnormalities → certain congenital defects and developmental conditions, Poor socialization, Impaired tolerance to activity

What are some explanations for the association b/w development delay, disabilities and congenital heart defects?

False, normal is from 7-9 (rarely is a baby a perfect 10, though it is ideal)

T/F: Most babies are born with an APGAR score of 10

Cyanotic Conditions, deoxygenated blood is moving to where is should be oxygenated (R-L shunt)

What type of Congenital defects are the most severe? Why?

Prone → side-lying →supine

What is the best positioning for ventilation/perfusion matching for kids with CHD (congenital heart defects) ?

Family Education

What is the primary consideration for PTs for post-op children w/ cardiac issues?

NIPS Scale (neonatal infant pain scale), higher score = more irritable

How can PTs track irritability for a child w/ a congenital heart defect? (what is the scale)

Total Anomalous Pulmonary venous return (TAPVR)

What is the condition where the pulmonary veins don’t connect to the left atrium but instead connect to the left atrium but to the right side? (only way to get O2-blood is through an ASD)

Hypoplastic Left Heart Syndrome (HLHS)

What is the condition where there is failure or inadequate development of the left ventricle?

Transposition of the great vessels

What is called when the positions of the pulmonary artery and aorta are reversed causing deoxygenated blood from the RV →systemic circuit?

1. Ventral septal defects (VSD), 2. Pulmonary valve stenosis, 3. Overriding aorta, 4. RV hypertrophy

What are the 4 defects that make up the tetralogy of fallot?

Pulmonary Valve Atresia

Condition where the pulmonary valve fails to develop so blood regurgitates into the LA via the foramen ovale

Coarctation of the aorta, blood pressure differential

What is the condition that causes pinching of the aorta and can be cyanotic but also acyanotic?

Eisenmenger’s Syndrome

What is the condition that occurs when a VSD switches from being acyanotic to cyanotic due to increased RV pressures?

Ventral Septal Defect (VSD)

What condition is the most common congenital heart defect which forms small defects resulting in a left to right shunt b/w ventricles?

Atrial Septal Defects (ASD → acyanotic)

What condition is associated with a left to right shunt b/w the atria resulting in volume overload on the right side of the heart potentially leading to pulmonary vasculature damage → right heart failure?

Patent Ductus Arteriosus (PDA) ( acyanotic & ductus arteriosus closes at birth, requires surgery b/c baby fatigues easily and susceptible too PNA)

What condition is associated with a left to right shunt from the aorta to pulmonary artery?

Left - Right shunt (oxygenated blood spilling into pulmonary circulation)

What shunt is associated with Acyanotic conditions?

Right - Left shunt (deoxygenated blood is spilling into the systemic circulation)

What type of Shunting is associated with cyanotic conditions?

Ventricular Septal defect (VSD) & Coarctation of the Aorta

What 2 conditions can be either acyanotic or cyanotic defects?

Appearance (pink vs blue), Pulse (higher than 100 for a score of 2), Grimace (cries or pulls away is best), Activity (flexion), Respirations (strong cry)

What are the 5 categories of APGAR? …APGAR is taken at 1 and 5 mins after birth

7-10 = normal, 4-6 fairly low, 0-3 = critically low (~w/congenital disorder)

What APGAR scores are considered normal?

Acyanotic = perfusion is normal to periphery (baby is pinkish)

Cyanotic = perfusion is low to the periphery (baby is blueish)

What is the difference b/w acyanotic and cyanotic congenital heart defects?

Transposition of the great vessels, Pulmonary valve atresia, tetralogy of fallot, hypoplastic left heart syndrome, Shone’s syndrome, TAVPR, Coarctation of the Aorta

What are the 7 cyanotic defects?

Atrial septal defect, Patent Ductus Arteriosus, Ventricular Septal defect

What are the 3 acyanotic defects?

True (50% of infants that undergo interventions for congenital heart lesions → affected by neurodevelopmental disabilities)

T/F: There is a strong association of development disorders and children with congenital heart diseases.

Umbilical Vein (O2 blood from placenta)

What is the name of the vessel that brings oxygenated blood to the baby?

Umbilical Artery ( -O2 blood to placenta)

What is the name of the vessel that carries deoxygenated blood from the baby back to the placenta?

Foramen Ovale (oxygenated blood sent from placenta to circulation). Ductus Arteriosus (shunts blood away from the right side of the heart and allows lungs to develop)

_____ ________ allows the fetus to receive oxygenated blood from the mother while the _ shunts blood away from the lungs to allow them to develop

Fetal Blood Flow

Oxygen rich blood → fetus, through the placenta via the umbilical vein, passes through the foramen ovale into the LV….LV pumps blood into the aorta →periphery and brain …Deoxygenated blood → back to the placenta via the umbilical artery. This is the __ ___ flow

Ductus Arteriosus and Foramen Ovale (both close a few days after birth)

When a baby is growing in the womb what are the 2 openings b/w the left and right side of the heart?

Mesodermal Germ Layer

What aspect of the embryo gives rise to the CV system?

Week 8 (by day 26 a single chamber of the heart is formed)

When after conception does the embryo have a fully developed, 4 chambered pumping heart?

RPE ( HR monitor is unreliable due to abnormal responses)

What is the best way to tackle exercise tolerance to individuals w/ aortic stenosis and many other cardiac conditions?

Usually doesn’t change much with exercise

Does aortic stenosis have an effect on blood pressure?

HR increases in response to exercise (due to decreased SV due to stenosis)

Does aortic stenosis have an effect on HR?

Stable angina so chest pain is related to workload intensity (heart working harder)

What effect does aortic stenosis have on angina?