PTRS 826 - Clinical Application for Cardiac Muscle Dysfunction and Ischemic Heart Disease

Manifestations of Right Sided Heart Failure

- congestion of peripheral tissues

- dependent edema and ascites

- liver congestion -> signs related to impaired liver function

- GI tract congestion -> anorexia, GI distress, weight loss

Manifestations of Left Sided Heart Failure

- Decreased cardiac output -> activity intolerance and signs of decreased tissue perfusion

- pulmonary congestion

- impaired gas exchanges -> cyanosis and signs of hypoxia

- pulmonary edema -> orthopnea -> cough with frothy sputum and paroxysmal nocturnal dyspnea

Findings with Ischemia

- pain

- ECG abnormality

- Metabolic abnormality

- LV dysfunction

- Vasoactive substrates

What to look at during examination

breathing pattern, color, edema, oximeter, JVD, changes in extremities, weight gain

What to listen to during examination

breath sounds, heart sounds, blood pressure

What to feel for during examination

edema, breathing pattern, pulse (rate, rhythm, force)

New York Heart Association Class 1

cardiac disease without limitations

New York Heart Association Class 2

cardiac disease slight limitation

- physical activity results in fatigue, palpitations, dyspnea (SOBOE), and anginal pain

New York Heart Association Class 3

Cardiac disease marked limitation

- OK at rest, less than ordinary activity causes symptoms of fatigue, palpitations, dyspnea, and anginal pain

New York Heart Association Class 4

cardiac disease but instability to perform physical activity w/o discomfort

- fatigue, palpitations, dyspnea, and anginal pain may be felt at rest

- physical activity intensifies symptoms

97-99 SPO2 relationship with 90-100 PaO2 S&S

none

95 SPO2 relationship with 80 PaO2 S&S

none

90 SPO2 relationship with 60 PaO2 S&S

tachycardia, tachypnea, restlessness

85 SPO2 relationship with 50 PaO2 S&S

incoordination, impaired judgement, labored respirations, confusion

80 SPO2 relationship with 45 PaO2 S&S

tachycardia, tachypnea, restlessness, incoordination, impaired judgement, labored respirations, confusion

Medical interventions of Cardiac Muscle Dysfunction and Ischemic Heart Disease

fundamental treatment is directed at pathophysiologic cause

- improve hearts pumping ability -> beta blockade, vasodilator therapy

- Control sodium intake -> diet, heart healthy, low cholesterol and fat

- Water retention -> diuretics, increase urine output

PT Assessment of Cardiac Muscle Dysfunction and Ischemic Heart Disease

- when did symptoms begin?

- stable, worse, what brings on symptoms (rest, activity)

- chest pain, claudication, SOBOE, sleeping, history

- activity level (FITT principal)

- objective measures / labs -> ECG, Echo, blood gas levels, auscultation, 6MWT, questionnaires, physical appearance, RR, breathing pattern

Inpatient PT care for Cardiac Muscle Dysfunction and Ischemic Heart Disease

- flexibility exercises, cycle ergometry, and treadmill ambulation

- 30 min, 3-5 days / wk, 2-4 weeks, 50-70% of peak cycle work rate

- improvements have been reported in decreased symptoms, improved HR and exercise tolerance

- energy conservation

- self-management

- transfers

- education

Home Care PT Interventions for Cardiac Muscle Dysfunction and Ischemic Heart Disease

- flexibility exercises, cycle ergometry, and walking

- 20-60 minutes, 3-7 days / wk, 50-80% of peak cycle heart rate or O2

- improvements have been reported in decreased symptoms, improved HR, blood pressure, and exercise tolerance via GXT

- self-management of sx, diet, activity, energy conservation, ther ex / act

- ADLs / IADLs

Rehabilitation Centers PT interventions for Cardiac Muscle Dysfunction and Ischemic Heart Disease

- aerobic exercise beneficial

- various methods of aerobic activity

- most use cycle ergometry

- 20-60 min, 3-7 days / wk, 2-57 months, 40-90% of peak cycle heart rate or VO2

- improvements have been reported in decreased symptoms, improved HR, blood pressure and exercise tolerance via GXT

SLE for PT with Chronic Heart Failure

Unilateral exercise better than 2-legged exercise

- severe CHF

- limited exercise tolerance

- low cardiac output especially with exercise

Strength Training with CHF

10 repetitions for 2-4 months OR 60-80% of maximum voluntary contraction

- progression is slow with weight training

Breathing Exercises with CHF

- inspiratory muscle training -> hand-held device

- limited data on yoga -> results positive for decreasing dyspnea

Criteria for modification or termination of exercise

- marked dyspnea or fatigue

- RR > 40 breaths per min

- development of S3 heart sound

- increase in pulmonary crackles

- decrease in HR or BP of > 10 bpm or mmhg during steady state or progressive exercise

- diaphoresis, pallor or confusion

Exercise-Induced Changes in Myocardial Function

- effects on: HR, systolic BP, rate-pressure product, oxygen demand via decreased energy demand, changes in myocardial oxygen consumption (demand vs delivery)

Disease Specific Effects on Heart Rate

- chronotropic incompetence

abnormal heart rate recovery

Chronotropic Incompetence

failure to reach 85% of APMHR in the absence of Beta-Blockers or other medications with similar effects

Abnormal Heart Rate Recovery

a decrease in HR of < 12 bpm in 1 minute of ACTIVE RECOVERY or < 22 bpm at 2 minutes of supine recovery

Disease specific effects on Blood Pressure

in the absence of B-blockers or ACE inhibitors, a failure of systolic BP to rise in proportion to exercise intensity

Phase 1 of Cardiac Rehabilitation

inpatient phase was introduced in the 1960s and consists of the early graded mobilization of the stable cardiac patient to the level of activity required to perform simple household tasks

Phase 2 of Cardiac Rehabilitation

consists of outpatient monitored exercise and risk factor reduction. This multidimensional approach gained popularity in the 1970s and became well structured in the 1980s

Phase 3 of Cardiac Rehabilitation

maintenance phase consists of home- or gymnasium-based exercise with the goal of continuing the risk factor modification and exercise program learned during phase II