Cardiopulm - Exercise Testing & Cardiac Rehab

What is the purpose of testing activity tolerance

- Screening for potentially dangerous s/s of exercise intolerance

- Establish safe and appropriate parameters for exercise

- Collect baseline data for outcome assessment

Healthy and asymptomatic patients may begin

Moderate intensity activity safely

Patients who are symptomatic or have chronic conditions/disabilities are advised

To begin exercise after appropriate medical evaluation and guidance of a health care provider

Low-asymptomatic patients have how many risk factors

Moderate-asymptomatic patients have how many risk factors

>/= 2

For patients that are low-symptomatic, there is no recommendation for

A medical exam, exercise test, or MD supervision

For patients that are mod-asymptomatic, there is a recommendation for

A medical exam before vigorous activity

High-symptomatic patients are recommended a

Medical exam, exercise test, and MD supervision of exercise test

Low risk patients can function at around how many METs

7

Moderate risk patients have what kinds of presentations

- Angina or other significant symptoms occurring at around 7 METs

- Mild to moderate level of silent ischemia during exercise testing/recovery

- Functional capacity

The highest risk patients have what presentations

- Complex ventricular dysrhythmias

- High level of silent ischemia

- Abnormal hemodynamic response

- Angina or other significant symptoms at

What are the s/s of heart failure and congestive heart failure

- Chest pain (especially during exertion)

- SOB

- Dizziness/lightheadedness

- Swelling of legs, hands, and feet

- Sudden weight gain

- Sudden fatigue or weakness

What are s/s of exercise intolerance

- Facial expression

- Posture

- Diaphoresis

- Pallor

- Dizziness

- Confusion

- Ataxia

Hemodynamic stability factors (BP, RR, HR, O2) should be assessed

- Before exercise

- After change in position or activity level

- 3 min after exercise

Relative tachycardia is characterized by

HR >20 over baseline

Relative bradycardia is characterized by

HR >20 under baseline

Hypotension is characterized by

Orthostatic hypotension is characterized by

A drop of >20 systolic or 10 diastolic within 3 minutes of standing

SBP should rise by _ per MET increase in workload

10 (+/- 2)

SBP rises with exercises involving _ and DBP increases with exercises involving _

Large muscles; small muscles

During steady submaximal aerobic exercise, SBP will

Rise for the first 2-3 minute then remain constant or slightly decrease

DBP should remain within _ of normal value during exercise

10 mmHg

1 MET is defined as

Amount of 02 consumed while at rest

3 general abnormal BP responses are

- Hypertensive

- Hypotensive

- Blunted

A hypertensive BP response is characterized by

Excessive rise in SBP of >12 mmHg or BPS >10 mmHg per MET

In a hypertensive BP response, DBP remains

Elevated during recovery

A patient with a hypertensive BP response may present with

Headaches, visual impairments, confusion

A hypotensive BP response is characterized by

SBP failing to rise, or falls >10 mmHg

Post exercise hypotenstion occurs with

Sustained LE vasodilation due to inadequate cooldown

S/s of a hypotensive BP response are

- Dizziness

- Lightheaded

- Diaphoresis

- Confusion

- Nausea

- SOB

A blunted BP response is

A lower than expected SBP with increased workloads

A blunted BP response is normal with

Patients on beta blockers, other anti-hypertensive meds, or nitrates

A tachycardic HR response is seen with

HR rising more rapidly than expected

Tachycardic HR response usually occurs in

Deconditioned patients or those with CVD

A brachycardic HR response is characterized by

Blunted HR response of

Brachycardic HR response is commonly seen in

Patients taking beta blockers

HR recovery is calculated by

HR peak _ HR at 1 minute

Abnormal HR recovery indicates

Slow deceleration of HR after stopping exercise

Predictors of increased mortality risk with HR recovery includes

< 12 BPM during upright cooldown

-

Intense exercise can increase RR by up to

40-50

Tachypnea is characterized by

>24 breaths/min

Exercise should be discontinued if RR exceeds

45 breaths/min

Bradypnea is characterized by

SpO2 should generally remain what what level

>90%

If your patient has a cardiac diagnosis SpO2 should be kept above

95%

If your patient has a pulmonary diagnosis SpO2 should be kept above

88%

On a modified RPE/BORG scale, if your patient's SOB level gets to _ you should stop and reasses

>5

Changes in baseline EKG rythyms can be indicative of

- Increasing PVCs

- ST elevation/depression

- Heart block

- T wave inversion

- New onset atrial fibrilation

Rate pressure product is

An index of myocardial O2 consumption during exercise, indicator of the work of the heart

Rate pressure product (RPP) is calculated by

SBP X HR

Absolute contraindications of exercise includes

- Recent significant resting EKG changes suggesting ischemia, MI, or other acute cardiac event

- Unstable angina

- Uncontrolled cardiac dysrhythmias causing hemodynamic compromise

- Symptomatic severe aortic stenosis

- Uncontrolled symptomatic heart failure

- Acute PE or pulmonary infarction

- Acute myocarditis or pericarditis

- Suspected or knowing dissecting aneurysm

- Acute systemic infection, fever, body aches, or swollen lymph glands

Relative contraindications include

- L main coronary stenosis

- Mod stenotic valve disease

- Electrolyte abnormalities

- Severe HTN at rest

- Tachy or brady dysrhythmia

- HIgh degree AV block

- Hypertrophic cardiomyopathy

- Neuro or MSK or rheumatoid disorder exacerbated by exercise

- Ventricular aneurysm

- Uncontrolled metabolic disease

- Chronic infectious disease

- Mental or physical impairment leading to inability to exercse adequately

Relative indications to terminate exercise testing includes

- Decreased SBP >10 mmHg with incresaed workloads or SBP below baseline

- ST depression >2 mm on EKG

- Arrhythmias - PVCs or AV or bundle branch blocks

- Fatigue, SOB, Wheezing, leg cramps, claudication

- Increasing chest pain

- Hypertensive response - SBP >250 or DBP >115

Absolute indications to termine exercise test includes

- Decreased SBP >10 with increased workload

- Moderately severe angina

Increasing nervous symptomes - Ataxia, dizziness, near syncope

- Poor perfusion - pallor, cyanosis

- Equipment failure

- Subject's desire to stop

- Sustained ventricular tachycardia

- ST segment elevation >1 mm

Exercise/activity should abolutely stop if

- Chest pain - angina or increasing anginal pain

- Severe dyspnea

- Dizziness, lightheadedness, faintness

- Marked apprehension, mental confusion

- Ataxia, impaired coordination

- Sudden onset or pallor, diaphoresis/sweating

- LE claudication (pain with exercise(

- Nausea

- Pt unwilling to continue

- Physical signs or c/o severe fatigue

- Maladaptive BP or HR

- Palpitations, EKG changes

- O2 drops below 85 or 3-5 below resting

- Equipment failure

A maximal stress test is

Maximal volitional fatigue/exhaustion, better estimate of VO2 max

A submaximal exercise test is at

You usually want to do at least _ submaximal tests

2

What is generally observed during acute tolerance/endurance testing

To monitor physiological responses

Endurance evaluation should begin only when

Hemodynamically stable

For patients unable to perform traditional exercise, what are other options to "exercise"

- Bed mobility

- Transfers

- Seated/chair exercise

- Standing exercise

- Ambulatory

In a low level exercise program, work muscle groups in what order

From distal groups to proximal

How would you predict VO2 max

0.03 X distance in meters (6 min walk) + 3.98

It is beneficial for patients to train at _ of initial 6MWT speed

75%

What is the goal of cardiac or pulmonary rehab

To maintain or return an indivicual with CV/P dysfunction to full participation in life with a high level of life satisfaction

What are the benefits of cardiopulm rehab

- Greater control of symptoms and increased functional capacity

- More cost effective than many advanced or continued medical and surgical treatments

- long term health benefits

- Reduced risk factors for mortalitty

- Increased self efficacy

- Increased QOL

Cardiac rehab candidates include

- Post MI

- Post CABG

- CHF

- Valve dysdunction, repair

- Pre/post heart transplant

- PAD

Phase 1 of cardiac rehab is

Inpatient,

What is the goal of phase 1 of cardiac rehab

- Optimize O2 transport

- Ability to do ADLs

- Educate on lifestyle changes

What are some things that are discussed with the pt during phase 1 of cardiac rehab

- Risk factors

- Knowledge deficits

- Sub-max exercise test

- Lifestyle recommendations

- Follow up planning

Phase 1 of cardiac rehab should begin when

Hemodynamically stable

Level 1 low level should be done in what position

In bed w/ HOB at 45 degrees

What is an exercise program for level 1 low level exercise

1. Ankle pumps/circles

2. Heel slides

3. Hip ABduction

4. Bicep curls

5. Shoulder flexion (to level of shoulder)

6. Shoulder ABduction

Level 2 of a low level exercise program should be done in what position

EOB or in a chair

What is an exercise program for level 2 low level exercise

1. Ankle pumps

2. LAQ

3. Marching

4. Bicep curls

5. B shoulder flexion w/ hands together

6. Shoulder shrugs

7. Neck circles

Level 3 of a low level exercise program should be done in what position

Sitting

What is an exercise program for level 3 low level exercise

Level 2 exercises plus:

1. Hands behind head, point elbows forward and back (butterfly)

2. Trunk rotations

3. Trunk side bends

Level 4 of a low level exercise program should be done in what position

Standing

What is an exercise program for level 4 low level exercise

Level 2 exercises plus:

1. Heel raises

2. Mini squats

3. Marching in place

4. Trunk rotations

5. Trunk side bends

The goal day 1-3 post MI is to _ and before discharge is to _

Mobilize; ambulate

What exercise frequency should be given to patients in phase 1

2-4x/day in short bouts

What is the intensity level of exercise for patients in phase 1

- 2 to 3 minute warmup

- RPE

What is the timing of exercise given to patients in phase 1

3-5 minute bouts with 1-2 minutes rest, accumulating to 20 minutes of exercise

The goal of progression for patients in phase 1 is

To be able to ambulate continuously for 10-15 minutes

What are some things to include in phase 1 patient education

- HR target 20-30 above resting

- Moderate RPE

- If exercising at home, increase duration by 1 min/day

- Goal is to accumulate 1 hour of exercise per day

- Warning signs of unstable angina or MI

Phase 2 of cardiac rehab is chracterized by

- Outpatient

- 6 weeks-6 months

Phase 2 of cardiac rehabs typicaly occurs in

Supervised hospital, center, or community based programs and can be 1:1 or 4:1

How many sessions of exercise happen in phase 2

3x per week for 6-12 weeks

What intensity level should be implemented in phase 2 of cardiac rehab

Initially at 40-59% of HRR or 64-75% of HRmx and progress to 60-89% HRR or 76-95% HRmax

In phase 2 of cardiac rehab HR should be kept

10 BPM below where symptoms occured

What duration of exercise should be used in phase 2

20-60 minutes per session

In phase 2, cardiac rehab patients should have a prolonged warmup/cooldown of around

5-10 minutes with low to moderate intensity aerobic exercise

What type of exercises should be used in phase 2

Rhythmic exercise that work on large muscle group activities

The goal of progression in phase 2 during the initial 4-6 weeks is

Increasing time by 1min/day and about 5-10 min every 1-2 weeks

The goal of progression in phase 2 after 4-6 weeks is

Increasing intensity, frequency, time, and more challenging modes (no more than 5% each week)

Resistance exercise can only be performed _ after MI with _ weeks of program participation

5 weeks; 3

Resistance training can only be done _ weeks post CABG with at least _ weeks of program participation

8; 3

What are important things to pay attention to during resistance training

- Proper breathing

- No valsalva

- Avoid tight grips

What are general parameters for resistance training in phase 2

- Start with a low weight

- Lift comfortably at RPE

Phase 3 of cardiac rehab is characterized by

- Supervised in hospital, center, or community based program

- Exercise retest

- Review risk factors and lifestyle behaviours

- Revise lifestyle recs

- Large groups

- Minimal monitoring

- 1x/week