CardioPulmonary Final Review

Risk Factors, Ex termination, Target HR, CABG, RPE

CVD Risk factor Thresholds

Mnemonic: “Ask For History of COPD”

A:

F:

H:

C:

O:

P:

D*2:

“Ask For History of COPD”

A: Age

F: Family

H: HTN

C: Cigarette Smoking

O: Obesity

P: Physical activity

D*2: Dyslipidemia, Diabetes

CVD Risk Factors

Age

Male:

Female:

Male: 45 ≥

Female: 55 ≥

CVD Risk Factors

Family history

i. MI

iI. Coronary Revascularization

iii. Male: Sudden cardiac death before ___ (1°relative)

iv. Female: Sudden cardiac death before ___ (1°relative)

i. MI

iI. Coronary Revascularization

iii. Male: Sudden cardiac death before 55 (1°relative)

iv. Female: Sudden cardiac death before 65 (1°relative)

CVD Risk Factors

Hypertension

i. SBP ≥ ____
and/or

ii. DBP ≥ ____

on two separate occasions

or

iii. on ______________ meds

i. SBP ≥ 130
and/or

ii. DBP ≥ 80

on two separate occasions

or

iii. on antihypertensive meds

CVD Risk Factors

Cigarette Smoking

i. current

ii. quit within previous ___ months

iii. exposure to ______ tobacco smoke

i. current smoker

ii. quit within previous 6 months

iii. exposure to environ tobacco smoke

CVD Risk Factors

Obesity

i. BMI ≥ ___

ii. Male: waist girth > 102 cm (? inches)

iii. Female: waist girth > 88 cm (? inches)

i. BMI ≥ 30

ii. Male: waist girth > 102 cm (40”)

iii. Female: waist girth > 88 cm (35”)

CVD Risk Factors

Physical activity

i. not participating in at least ___-___ min/week of mod to vig physical activity

i. not participating in at least 75-150 min/week of mod to vig physical activity

CVD Risk Factors

Dyslipidemia

i. LDL ≥ ___

ii. HDL < ___ (Male) or < ___ (Female)

iii. Lipid-lowering meds

iv. Total Cholesterol ≥ ____

i. LDL ≥ 130

ii. HDL < 40 (Male) or < 50 (Female)

iii. Lipid-lowering meds

iv. Total Cholesterol ≥ 200

CVD Risk Factors

Diabetes

i. Fasting Plasma Glucose (FPG) ≥ ____

ii. OGTT ≥ ____

iii. HbA1C ≥ ___% (glycolysis in blood)

i. Fasting Plasma Glucose (FPG) ≥ 100

ii. OGTT ≥ 140

iii. HbA1C ≥ 5.7% (glycolysis in blood)

Which of the following is NOT a reason to STOP exercise based on ECG:

a. Symptomatic SVT

b. ST segment elevation > 1mm (infarction)

c. ST segment depression > 2mm (ischemia)

d. 2nd or 3rd degree block

e. A-Tach

f. V-Fib/ A-Fib (with Sx)

g. V-Tach

h. R on T phenomenon (ventricular depolarization on preceding T wave)

e. A-Tach

Same as PAC, A-Flutter (asymptomatic): Monitor and continue at low intensity

A-Flutter, A- Fib (symptomatic): STOP Ex

Which cardiac conditions would you NOT continue exercising at lower intensity while monitoring symptoms?

a. PAC

b. PVC

c. asymptomatic Atrial flutter

d. asymptomatic SVT

e. A-Tach

b. PVC

PVC: ventricles contract before the atria, no P, wide bizarre QRS

3 or more ___ in a row would turn it into V-tach?

a. SVT

b. PAC

c. PVC

c. PVC

This is a 911 situation.

1 PVC missing 1 P: maybe okay

2 PVC missing 2 P: stop exercise

3 PVS missing 3 P: ventricle pumping x3 running out of blood soon → cell death

Which of the following is NOT a reason to STOP exercise based on BP:

a. ↓ SBP ≥ 20mmHg (any time)

b. ↓ SBP ≥ 10mmHg (Exercise)

c. Failure of SBP to rise with increased workload

d. SBP > 250mmHg

e. DBP > 110mmHg

All are reasons to STOP ex based on BP

SBP > 240 mmHg = Exercise HTN

Which of the following is NOT a reason to STOP exercise based on Symptoms:

a. Angina

b. Fatigue (observed or requested)

c. Unable to maintain pace/rhythm

d. Lightheaded, dizzy, confused, nausea

e. Dyspnea, wheezing

f. Cyanosis, O₂sat < 90% Or 5% below resting for pulmonary pt

g. Peripheral Ischemia/Claudication

They all are reasons to STOP ex based on symptoms

What are the target HR range for the following states:

i. Deconditioned: ___-___% HRmax

ii. Weight loss: ___-___% HRmax (longer duration

iii. Cardiopulmonary Conditioning: ___-___% HRmax

iv. Athletes: ___-___ HRmax

i. Deconditioned: 55-65% HRmax

ii. Weight loss: 55-65% HRmax (longer duration

iii. Cardiopulmonary Conditioning: 70-85% HRmax

iv. Athletes: 85-95% HRmax

Which of the following is NOT an indication for CABG surgery?

a. >50% stenosis of L main

b. >70% stenosis of others

c. Severe 3 vessels disease

d. 1 vessel disease with L ventricle dysfunction

e. unstable angina

f. unresponsive stable angina

d. 1 vessel disease with L ventricle dysfunction

You need 2 vessel disease with L ventricle dysfunction

RPE LIGHT Intensity for OP pt on Beta-blocker:

Light: <12: < 40% HRR

RPE MOD (somewhat hard) Intensity for OP pt on Beta-blocker:

Somewhat hard/Mod: 12-13: 40-60% HRR

RPE HARD Intensity for OP pt on Beta-blocker:

Hard: 14-16: 60-80% HRR

Mechanical valve replacement Considerations

Anticoagulants for a lifetime

*Prevent clot formation stroke

Biological valve replacement Considerations

Same guideline as post-CABG

= RPE: 11-16: 40-80% HRR (phase II)

*if ischemic threshold is known, ex 10bpm below

Ankle Brachial Index (Ankle SBP/Arm SBP)

<0.50

Severe arterial disease

Ankle Brachial Index (Ankle SBP/Arm SBP)

0.50-0.74

Moderate arterial disease and rest pain

Ankle Brachial Index (Ankle SBP/Arm SBP)

0.75-0.94

Mild arterial disease and intermittent claudication

Ankle Brachial Index (Ankle SBP/Arm SBP)

0.95-1.19

Normal

Ankle Brachial Index (Ankle SBP/Arm SBP)

>1.2

Falsely elevated, arterial disease, diabetes

Karvonen formula for calculating the target heart range

Target HR =

[(HRmax - HRrest) x % intensity] + HRrest

50-70% = moderate intensity

70-85% = vigorous intensity

(CDC recommendation)

Most ideal resting position of choice for high risk pregnancy patient in her second trimester

Left side lying

This is optimal for reducing pressure on the inferior vena cava and for maximizing cardiac output, thereby enhancing maternal and fetal circulation

Initial strength training recommendation for MI

• After 3 weeks of cardiac rehab

• 5 weeks after MI

• Performed under 50% MHR or 5 METs for 6 weeks

Initial strength training recommendation for CABG

• After 3 weeks of cardiac rehab

• 8 weeks after CABG

• LE resistance training can start immediately in the absence of peri-operative MI

What can be done initially for strength training after MI/CABG

• Begin with elastic bands and light hand weights

• Progress to moderate loads → 12-15 reps

• RPE should range from 11-13

Phases of cardiac rehab

• Begin when pt is medically stable

• Patient education

• Hemodynamic and ECG monitoring

• No resistance training

  • F: 2-3 times/week short sessions

  • I: 50-70% of HRmax

  • T: 10-15 mins (phase I) and 30 mins (phase II) per session

  • T: ADLs, supervised ambulation

Phase I: Acute phase/ Monitoring phase

Cardiac Rehab Education

• Disease process + prognosis

• Individual’s risk factors and recommendations for behavior modification

• General activity guidelines: role of exercise, activity pacing, and HEP

• Medications

• Nutrition and prescribed diet

• Self-monitoring techniques

• What to do in an emergency

Phases of cardiac rehab

• Begin as early as 24hr after discharge up to 6 weeks

• May undergo a symptom-limited maximal stress test (ETT) at 4-6 weeks after MI

• No resistance training

  • F: 2-3 times/week short sessions

  • I: 50-70% of HRmax

  • T: 10-15 mins (phase I) and 30 mins (phase II) per session

  • T: ADLs, supervised ambulation

Phase II: Subacute/ Conditioning phase

• early phase II: 30 mins walking at 3mph with no incline

• late phase II: 30 mins walking at 5 mph with 5% incline

Phases of cardiac rehab

• Begin ~5-6 weeks from discharge extends indefinitely

• Outpatient

  • F: 2-3 sessions/week

  • I: 70-85% of HRmax resistance training

    • Light 1-3lbs (or 30-50% of max weight) band/hand weights

    • 8-10 reps, progress to 12-15 reps

    • Avoid UE resistance as soft tissue is still healing

  • T: 30-60 mins with 5-10 mins of warm up and cool down

  • T: Single mode of training (walking) or multiple modes (treadmill, cycle, ergometer)

Phase III: Training/ Intensive rehab

• 10-40 mins yellow elastic band training/ 2lbs hand weights (consider tissue healing with UE workout)

Phases of cardiac rehab

• Lasts up to 6-12 months before discharge

• Community centers, YMCA, clinical facilities

• Same exercise prescription as phase III

• Exercise: Clinically stable angina, medically controlled arrhythmias

• Progression:

  • F: 3-4 sessions/week

  • I: 50-85% of functional capacity

  • T: 45 mins or more/session

  • T: same as phase III

Phase IV: Conditioning/Maintenance/Prevention phase

Weight reduction for obesity

• Minimum of ____-____ min/week is required

• Frequency: >___ /weeks

• Intensity: initially moderate ___-___ % VO2 progression to > 60%

• Time: from ___-___ min/day (continuous)

• Type: _________ exercise – aerobic, resistance, and flexibility

• 250-300 min/week

• >5days/weeks

• 40-60%

• 45-60 min/day

• moderate

Prone lying on a bed w/2 pillows under pelvis

Superior segments of lower lobes

Sitting on a chair, leaning forward over a folded pillow

Posterior apical segments of upper lobes

Supine lying on a bed with pillow under knees

Anterior segments of upper lobes

Sitting in a recliner, leaning slightly backward

Anterior apical segments of upper lobes

Contraindications for Postural Drainage

• Increased ICP

  • Severe headaches, vomiting, confusion, and vision problems

• Hemodynamically unstable

  • Hypotension, confusion, rapid heart rate, cool skin, and shortness of breath

• Recent esophageal anastomosis

  • Surgically connecting the esophagus to the stomach

• Recent spinal fusion or injury

• Recent head trauma

• Diaphragmatic hernia

Precautions for Postural Drainage

• Pulmonary edema

• Hemoptysis (ptysis: spitting)

  • Coughing up blood

• Massive obesity

• Large pleural effusion

  • Severe shortness of breath, chest pain, and difficulty breathing

• Massive ascites

  • Swollen belly - caused by cirrhosis of the liver or cancer

Atrial tachycardia: _____-_____ heart rate, __________ exercise

100-250, continue

Atrial flutter: _____-_____ HR, saw tooth pattern, __________ exercise

250-350, stop

Atrial fibrillation _____-_____ HR, __________ exercice

400-600, stop