637 Ch20 Prevention and Health Promotion

Who is primary prevention for? What do primray prevention programs target?

• Individuals who are at high or moderate risk for CVD prior to dx, including a family history

• Primary Prevention Programs target:

  • Resting BP - reduce

  • Blood Sugar Education - improve glucose tolerance and insulin sensitivity

  • Cholesterol - reduce LDL, improve total cholesterol/HDL ratio

  • Sedentary lifestyle - reduce BMI, increase aerobic conditioning and exercise capacity

What are modifiable risk factors for CVD?

• Tobacco use

• Elevated cholesterol

• High BP

• Deconditioning/sedentary lifestyle

• Obesity

How should clinicians tailor their advice to a patient for primary prevention of CVD? What kind of approach is preferred? When should it begin?

• Sociodemographic characteristics, educational status, cultural, work, and home environment

• Patient-centered, team approach

• Begin at 20 y/o, repeat every 4-6 yrs (more risk = more often)

What is in the ABCDE checklist?

• Assess, antiplatelet therapy

• Blood pressure

• Cholesterol, cigarette smoke

• Diabetes, diet and weight

• Exercise, economic and social factors

When and how do you measure exercise readiness?

• Prior to starting an exercise program

• PAR-Q or PAR-Q+

What is the PAR-Q+? What additional follow up medical questions does it include?

• 7 step PA readiness questionnaire

• Follow up:

  • Risk factors

  • Mental health

  • Metabolic disease

  • Respiratory disease

  • Stroke

  • CA

  • MSK

  • CV disease

  • SCI

  • Blood pressure

Describe the risk assessment goals for hypertension, weight management, and dietary intake

What kind of patients participate in cardiovascular rehabilitation programs? Primary vs secondary?

What do the CR programs include?

1. Education of the patient & fam for recognition, prevention & treatment of CVD

2. Bettering/reducing RFs

3. Deal w/ psych & behavioral factors that influence recovery

4. Structured, progressive PA

5. Vocational/return to leisure activities counseling

6. ADL and funcitonal training

What individuals are considered NOT good candidates for CR?

1. Pts have overt HF, unstable angina pectoris, hemodynamically unstable, serious arrhythmias, conduction defects, or impaired fx of other organ systems

2. Pts have uncontrolled HTN

3. Pts have other disease/illness that precludes exercise

4. Healthy individuals

Describe two signs that would indicate that a patient in your clinic is not a good candidate for CR.

1. Chest pain at rest

2. Falling BP with exercise

Describe the four phases of CR.

1. Phase 1: acute, in hospital

   1. Ambulating by day 2 post-surgical stay (CABG)

   2. Moved to step-down unit after 24-48hrs from ICU (MI) and d/c in 2 days

2. Phase 2: 3 days a week for 12 weeks (36 sessions)

   1. Early outpatient or intensive monitoring

3. Phase 3: 2-3 days/week for 3 months

   1. Intensive training and maintenance, less monitoring

   2. No EKG

4. Phase 4: independent exercise and lifestyle management

   1. Maintenance and independence; primary prevention for high-risk patients

When does Phase 1 CR begin? What are the overall goals? What do the goals include?

• Begins when pt transfers from ICU to step-down/telemetry unit, can also begin in ICU/CCU, CONSIDERED STABLE

• Overall goals: assess safety performing activities for d/c, increase knowledge of disease and management

• Goals include:

  • Keep team members up to date on pt’s hemodynamic status, current level of activity & guidelines, vital responses to activity to inform medical management

    • Pt continuously monitored via ECG, hemodynamics assessed w/ movement & ADLs

  • Pt & fam education on RFs, modifications, self-monitoring techniques, activity guidelines, and enrollment for Phase 2 CR

What does a PT initial assessment include for Phase 1 CR?

• Chart review

• Patient-family/care partner interview

• Physical examination

• Activity & ambulation evaluation

• Ambulation activity

When do you want to monitor sxs and ECG during Phase 1 CR?

Before, during, and immediately after activity and 1-3 min after

When is it appropriate to increase activity in Phase 1 CR? What can the pt’s response be dependent on? Frequency of Phase 1 CR?

• Pt is hemodynamically stable and ECG responses to activity is normal

• Dependent on:

  • # of days of bed rest, complicated course, PLF, MD orders

  • HR > or equal to 120 bpm or 20-30 above resting is the ceiling (exception: rate reducing meds → consider other hemodynamic signs, sxs, and ECG findings)

• 1x/day, 10-15 mins (10 for modified programs)

What is the HR ceiling for Phase 1 CR?

HR > or equal to 120 bpm or 20-30 above resting is the ceiling (exception: rate reducing meds → consider other hemodynamic signs, sxs, and ECG findings)

What is the McNeer criteria for complicated MI?

• Poor ventricular fx

• Significant ischemia w/ low-level activity

• Cardiogenic shock

• Vtach/Vfib

• Aflutter/Afib

• 2nd/3rd degree AV block

• Persistent sinus tachycardia (>100 at rest)

• Persistent systolic hypotension (systolic BP <90 mmHg at rest)

• Pulmonary edema

What kind of BP issue fits the criteria for a complicated MI?

Persistent systolic hypotension (systolic BP <90 mmHg at rest)

What are indications to modify during Phase 1 CR?

1. Large infarction, but stable after 2-3 days

2. Resting tachycardia (100bpm) or inappropriate HR increase w/ self-care activities

3. BP failing to rise or decrease w/ self-care activities

4. ECG >6-8 PVC/min or progressive HB w/ self-care activities

5. Need for prolonged bed rest (>4 days)

6. If an individual is considered to have experienced complications w/ his or her acute Mi per McNeer Criteria

What are indicaitons to withold Phase 1 CR?

1. Severe pump failure: SOB, peripheral edema, diaphoresis, or chest x-ray, falling BP response to activity

2. Classification in a high-risk subset, described by:

3. Recurrent malignant arrhythmias

   1. Vtach, 4 PVCs in a row, Vfib and no internal/external defibrillator

4. Angina pectoris

5. 2nd/3rd degree HB

6. Persistent hypotension (even w/ vasopressors)

7. Rapid atrial rhythm

8. Unstable angina pectoris or change in sxs in preceding 24hrs

What are cardiac procedures done with median sternotomy?

CABG, LVAD placement

What do sternal precautions do? How long does it last? Lifting restriction? Risk factors with sternal precautions?

• Reduce chance of sternal wound dehiscence or infection

• SP limit UE movement for 6-12wks

• 5-10lb lifting restriciton

• RF: obesity, previous sternotomy, diabetes requiring medication for blood glucose control, HF, respiratory failure

What are the most important factors of keep your move in the tube?

• Position, force, and lever arm of humerus (the further from the sternum the more force on the incision)

  • Weighted and resisted movements should not move away from midline

What are general precautions of Phase 1 CR?

• Do not initiate exercise within 1hr of eating

• Avoid:

  • Isometric holding

  • Breath holding

• Pt’s status should be reassessed before the start of each session

  • ECG

  • Vitals: HR, BP

  • Heart and lung auscultation

  • Sxs

What are relative contraindications (abnormal exercise responses) for continuing exercise?

• Unusual HR increase >50 bpm w/ low level activity

• BP HTN, high systolic >210 mmHg or diastolic >110 mmHg

• Drop in SBP >10mmHg with low-level exercise

• Sxs w/ activity

  • Angina ¼
    Excessive dyspnea 2+/4+

  • Excessive fatigue

  • Mental confusion/dizziness

  • Severe leg claudication 8/10

• Signs of pallor, cold sweat, ataxia

• Changing heart sounds w/ activity - new murmur or ventricular gallop

• Changing lung sounds w/ activity - increase in level of rales w/ sxs of SOB

• An ECG abnormality, including marked ST-segment changes

If a pt has a drop in 10mmHg SBP with standing, is this considered a contraindication for continuing exercise?

No, only with low level exercise

Describe the 5-grade/10-grade angina and dyspnea rating scale.

What are other Phase 1 CR education will the pt receive besides PA?

• Diet & nutrition

• Psychologic and behavioral rehab

Because of the shorter time frame of Phase 1 CR, what are outcomes based on? Can you name some specific outcome measured used during this phase?

• Based on functional limitations or disabilities that were quantified during initial assessment

What should be done in terms of D/C planning for Phase 1 CR?

• Planning a day prior/stabilized

• Activity guidelines, sxs to pay attention to, medicaiton schedule & dietary regimen

• Referral to outpatient PT (must be able to handle PT 3x/wk)

• Low level sxs - limited exercise test

What is the goal of post acute phase rehab?

• To reduce mortality due to a CV event or diagnosis, cardiac RF modificaiton, control cardiac sxs, stabilize or reverse atherosclerotic process, etc.

What are groups that are commonly referred to CR?

• MI, HF, angioplasty/stent, heart transplant, stable angina, CABG, valve replacement

• Also: comorbid conditions, poor EF, cardiomyopathy, serious arrhythmias

What is the difference between the goals of Phase 1 and 2 CR?

1. Make pt appropriate for D/C

2. Lower RHR & BP, reduce risk

What would qualify a pt for home based CR? Is it a feasible option? How would you monitor vitals?

• Pt can’t attend outpatient CR center b/c of availability, location, socio/economic factors, transportation

• More extensive monitoring, instruction and education w/ PT and nursing

• Tele-based CR: sensor technology, communication technology, data analysis

What has CR shown to help?

Increase in baseline; reduce occurrence of coronary events, improve aerobic capacity, increase EF, stroke volume and rate pressure product

Describe 7 risk factors that are involved as a CR program component? What would the assessment and intervention consist of?

What aspect of aerobic exercise training can be modified for the patient? What does this benefit/improve?

• Intensity - to achieve benefits for reduced RHR and improve SV

• 70-85% maxHR or modified to 40-50%

Using HR as your measure for aerobic exercise training can have what complications?

• BBs, CCBs, surgical intervention, pacemakers

What RPE score is equivalent to the ventilatory/anaerobic threshold?

13 (somewhat hard)

Training HR with RPE is especially helpful for what pt population?

Afib

Describe abnormal responses to exercise. BP changes?

• Systolic >240 mmHg

• Diastolic >110 mmG

• >20 mmHg drop from upright resting BP

Stable cardiac patients can exercise up to what on the angina scale?

1: light, barely noticeable

What other program interventions besides aerobic training will pts receive?

• Resistance training, coupled w/ breathing strategies

• Circuit training

• Flexibility programming

*What are 3 factors that influence exercise programs?

• Altitude - >3500’ increases HR to meet CO, sxs angina

• Cold - increase in peripheral resistance, increases arterial BP, sxs ischemia

• Heat and humidity - dilation of peripheral vasculature and HR increases to maintain CO

What can you educate pts on for factors that can influence their exercise program?

• Be aware of altitude changes

• Wear warm clothing and stay hydrated in the cold

• Avoid vigorous exercise >75F or high humidity >65-70%, wear loose clothing, stay hydrated, sunscreen, shade during heat