Special Pops: CVD

1 MI occurs every ____

• 42s

1 death every ____

• 40s

How many deaths due to CVD every second?

• 2,354

Of those experiencing an MI, how many will die?

• 1/3

____% die within one year

• 40

What is atherosclerosis?

• plaque in coronary arteries

• most often in bifurcating artery (main splits into two smaller branches)

• slow process —→asymptomatic for years

Normal functioning blood vessels produces ___ which is a vasodilator that inhibits thrombosis (blood clot) formation

• nitric oxide

When do blood vessels, specifically the endothelium (inner lining) begin to have improper function?

• repeated damage caused by increased adhesiveness of platelets (form clots) and impaired vasodilation

What are foam cells?

• early atherosclerotic lesions on endothelium

• accumulation of lipids which creates the yellow foamy appearance

• begin inflammatory process

What is a fibrous cap?

• layer of connective tissue that forms over plaques developing within the walls of arteries, acting as a physical barrier covering the plaques core

What aggravates fibrous caps?

• turbulent blood flow

• chemical factors

• anything else that can weaken the fibrous cap

What happens once the fibrous cap is opened?

• contents spill into the lumen of artery

• thrombus formation (blood clots)

• incorporation into arterial wall (repeatedly occurs, giving layered appearance and result in rapid progression in size)

What is ischemia?

• inadequate blood flow or supply

• myocardial O2 supply < myocardial o2 demand

When are symptoms of ischemia experienced at rest?

• when greater than 75% of vessel is occluded (blocked)

What is an MI?

• heart attack

• myocardial infarction

What causes a MI?

• Ischemic cascade

• infarction

What happens during the ischemic cascade

• stiffening of the left ventricle

What happens as a response to the stiffening of the left ventricle?

• decreased diastolic filling

• systolic dysfunction

• abnormal contractions

• arrhythmias

• angina pectoris (chest pain)

What happens during the infarction?

• stunned tissue (temporary loss of function)

• necrosis (permanent loss of function)

• Ischemia > 20-60min

What is a normal ejection fraction?

• 55-65%

What is a CABG?

• coronary artery bypass graft

• most common open-heart surgery

What does the CABG procedure do?

• restores blood flow to the myocardium

Who are candidates for a CABG?

• multi-vessel occlusion (3+)

• failed PTCA/PTCA + stent

• no longer a candidate for PCTA

• Technically difficult vessels

How long should CABG patients limit lifting with upper body?

• 5-8 weeks, 5-8lbs

How long before you can start cardiac rehab with a CABG patient?

• can start CR within a week of surgery

What is a PTCA?

• percutaneous transluminal coronary angioplasty

• balloon surgery - inflation of ballon compresses lesion

What’s the benefit of drug-eluting stents?

• slow release of drugs inhibits formation of scar tissue

What are complications of PTCA?

• reocclusion (blockage)

• restenosis (narrowing)

• acute thrombotic occlusion (blood clot)

• MI

• arrhythmias

• dissection of coronary artery

• bleeding

What is recommended for all CABG patients to start a supervised/monitored exercise program?

• GXT

When can CABG patients give near max effort?

• 4 weeks post-surgery

• after incisional pain has dissipated

When should cabg patients follow up?

• 3-6 months, then yearly

When can PTCA patients do a GXT?

• 2 days after

When should pcta patients follow up?

• 6 months, then yearly

What signs/symptoms are suggesting a patient is at an increased risk for recurrent cardiac events?

• inability to exercise

• substantial exercise-induced myocardial ischemia

• exercise capacity < 5 METS (17/5 ml/kg/min)

• failure of systolic BP to increase at least 10 mmHG

What are absolute contraindications to GXT after MI?

• acute MI, within 2 days, or other acute cardiac event

• unstable angina

• uncontrolled cardiac arrhythmias

• syptomatic, severe aortic stenosis

• uncontrolled symptomatic heart failure

• acute pulmonary embolus or infarction

• acute myocardiites or pericardis

When can MI patients complete GXT?

• after stabilized/symptom free at rest

• 4-6 days after acute MI before discharge (sub-max protocol)

• 7+ days post MI (symptom limited max effort)

When should GXT be terminated?

• dysrhythmia greater/equal 2mm ST depression/elevation

• T wave inversion

• SBP > 250

• DBP > 115

• SBP decrease greater/equal 10

• 3+ on angina scale

During inpatient cardiac rehab, what should they focus on before leaving the hospital?

• mobilization —→ 2-4 times per day

• secondary prevention goals

When can patients begin outpatient cardiac rehab?

• 1-2 weeks after discharge

• 36 visits

Indication for in/outpatient cardiac rehab

• medically stable post myocardial infarction

• stable angina

• CABG surgery

• PCTA

• stable heart failure

• heart transplant

• valvular heart disease/surgery

• PAD

• at risk for coronary artery disease with diagnoses of diabetes mellitus, dyslipidemia, HTN, obesity

Contraindications for in/outpatient cardiac rehab

• unstable angina

• uncontrolled HTN —→ SYS > 180 DIA >110

• orthostatic BP drop > 20 mmhg with symptoms

• significant aortic stenosis

• uncontrolled atrial/ventricular arrhythmias

• uncontrolled sinus tachycardia (>120 bpm)

• active pericarditis or myocarditis

• aortic dissection

• uncontrolled diabetes mellitus

What are the goals of exercise training?

• increase vo2 max

• decrease angina —→ decrease myocardial o2 demand, decrease SBP and DBP

• decrease triglycerides

• increase HDL

• decrease glucose

Cardio FITT

F: 4-7 days/week

I: RPE 11-16, 40-80% exercise capacity (VO2 or HR), upper limit HR (during exercise) RHR + 20 bpm and RPE 11-14 (when exercise test info not gathered), 10 bpm below ischemic threshold (if positive for ischemia during exercise test)

T: 5-20 min warm up/cool down (include static stretching), 20-60 minutes, 5–10-minute bouts initially or as tolerated (progress: increase gradually 1-5 min each session or 10-20% per week

T: aerobic: treadmill, recumbent bike, elliptical, arm/leg ergometer

When can CABG patients use their arms?

• when sternum is healed

• limited ROM movements within 4 weeks

• heavy resistance training avoided until 12 weeks post op

Resistance FITT

F: 2-3 days per week, non consecutive days

I: RPE 11-14, 30-60% 1RM progress to 60-80% 1RM

T: 12-15 reps, 1-4 sets progress to 1-4 sets, 8-12 reps

T: body weight, bands, free weights, machines

major muscle groups

8-10 different exercises

What are the reasons for stress testing after an MI?

• evaluate symptoms, potential myocardial ischemia

• determine need for coronary angiography in patients treated initially with non-invasive strategy

• determine the effectiveness of medical therapy

• assess future risk and prognosis

• objectively determine the exercise capacity (exercise prescription)

When can an MI patient begin resistance training?

• 2-5 weeks after event

What do antiplatelet do? How do they effect exercise?

• block platelet aggregation

• no effect on exercise

what do beta blocker do? How do they effect exercise?

• reduces HR and BP

• decreases HR and BP during exercise

What do ace inhibitors do? How do they effect exercise?

• decrease BP

• no effect on HR during exercise, lower BP during exercise

What do calcium channel blocker do and what’s their effect on exercise?

• vasodilation, decrease BP

• decreases HR and BP during exercise

Do statin drugs have any effect on exercise?

• no

drugs ending in ine

• Ca channel blocker

drugs ending in pril

ace inhibitors

What effects do diuretics have on exercise? What do they end in?

• no effect on HR, decrease BP

• end in ide

What do vasodilators do? effects on exercise?

• relax blood vessels

• raise ischemic threshold, increase/no effect on HR, decrease BP, increase exercise capacity in pts with CHF, no effect on ex. capacity in pts w/o CHF

There is a ____% decrease in mortality when exercise capacity is increased by 1 MET

• 8-17%