心脏康复评定

CARDIOVASCULAREVALUATION DR LiangQi APATIENTCASEEXAMPLE 1 Whyareyouheretoday 2 Haveyoubeendiagnosedwithacardiacdisorderinthepast 3 Haveyouhadanyspecialteststoexamineyourheartlikeanelectrocardiogram stresstest echocardiogram orcardiaccatheterization 4 Doyouexperienceanginaorshortnessofbreathatrest onlywithactivity exercise orbothatrestandwithactivity exercise 5 Ifyouexperienceanginaorbecomeshortofbreathduringactivityorexercisecouldyoupleasedescribethetypeofactivityorexercisewhichproducesyouranginaorshortnessofbreath 6 Canyoudescribeyouranginaorshortnessofbreath Canyouhelpmeunderstandyouranginaorshortnessofbreathbypointingtothenumbers1through4todescribethelevelofanginayouexperienceatrestandexerciseorbypointingtoyourlevelofshortnessofbreathusingthis10 pointscaleorbymarkingthisvisualanalogscale 7 CouldIfeelyourpulsetodetermineyourheartrateandthestrengthofyourpulse 8 CouldIplacethisfingerprobeonyourindexfingertoobtainanoxygensaturationmeasurement 9 CouldIplacetheseelectrodesonyourchesttoobtainasimplesingle leadelectrocardiogram ECG 10 CouldItakeyourbloodpressurewhileyouareseatedandthencompareittothebloodpressurewhileyouarelyingdownandthenstanding Iwouldalsoliketoobserveyourpulse oxygensaturation ECG andsymptomswhenyouarelyingdownandstanding 11 CouldIlistentoyourheartandlungswithmystethoscope WhileIdothisIwillconcentrateonwatchingyourECGsothatIcanidentifyyourheartsoundsandanychangesintheECGwhileyouarebreathingdeeplywhenlisteningtoyourlungs 12 CouldIplace1ofmyhandsonyourstomachand1handonyourupperchesttodeterminehowyoubreathe 13 CouldIplacemyhandsonthelowermostribsoneachsideofyourchesttodeterminehowyoubreathe 14 CouldIplacemyhandsonyourbacktodeterminehowyoubreathe 15 CouldIwrapmytapemeasurearoundyourchestatseveraldifferentsitestodeterminehowyoubreathe 16 NowthatIunderstandsomeverybasicinformationaboutthemannerinwhichyoubreathecouldyoupleasebreatheinthemannerIinstructyouviasoundsImake pressurefrommyhands methodsIshowtoyou ordifferentbodypositions IwilloccasionallyplacemyhandsonyourchestandwrapmytapemeasurearoundyourchesttodeterminehowyoubreatheduringthesesimpletestsandIwillaskyoutoidentifyyourlevelofshortnessofbreathusingthe10 pointscaleorvisualanalogscale Isthisokwithyou 17 CouldImeasurethestrengthofyourbreathingmusclebyhavingyouplacethismouthpieceinyourmouthandbreatheinandoutasdeeplyandasforcefullyasyouareable 18 Iwouldlikeyoutonowperformtheactivityorexercisewhichproducesyouranginaorshortnessofbreath Couldyoupleasedothisnow Thankyouforgivingmethechancetoexamineyoutoday Iwillcallyourphysiciantogetsomemoreinformationaboutyoulikeelectrocardiogram echocardiogramandpulmonaryfunctionteststhatyousaidwereperformedlastweekaswellasthearterialbloodgasresults chestX ray andexercisetestresults PhysicalTherapyExamination MedicalInformationandRiskFactorAnalysislisteningtothepatientspasthistoryandprimarycomplaintsiscriticalintheexaminationprocess ExaminationsofPatientAppearance categorizedbyspecificsignsandsymptoms Angina MethodsToEvaluateAnginafromNonanginalPain Ifasuspectedanginalpainchanges increasesordecreases withbreathing palpationinthepainfularea ormovementofajoint ie shoulderflexionandabduction itisverylikelythatthepainisNOTangina Angina MethodsToEvaluateAnginafromNonanginalPain itcanbeworsenedbyphysicalexerciseoractivity Therefore ifthesuspectedanginalpainisunchangedwiththepreviouslycitedmaneuversandthepainoccurredwithexertion itisSUSPECTforangina Ifthesuspectedanginalpainisunchangedbythesemaneuvers ifthepainoccurredwithexertion andifthepaindecreasesorsubsideswithrest itisverylikelythatthepainISangina Finally ifthesuspectedpaindecreasesorsubsideswithnitroglycerin itisevenmorelikelythatthepainISangina Other SymptomsofHeartDisease dyspneaFatigueDizzinessLightheadednessPalpitationsasenseofimpendingdoom ExaminationsofPatientAppearance skincoloroftheperipheralextremities Paleorcyanoticskininthelegs feet arms andfingersisassociatedwithpoorcardiovascularfunction ExaminationsofPatientAppearance Diagonalearlobecrease Thisphenomenonhasbeeninvestigatedformanyyearsandrecentlywasonceagainfoundtobehighlypredictiveofheartdisease Anthropometricmeasurements bodyweightfingerpressureonanedematousareaGirthmeasurementsskin foldcalipermeasurementscalculationofthebodymassindexmeasurethepercentageofbodyfatandleanmusclemass Jugularvenousdistension itisoftenduetoright sidedheartfailure PalpationoftheRadialPulse Palpationoftheradialpulsecanprovideimportantinformationaboutthestatusofthecardiovascularsystem MeasurementoftheSystolicBloodPressureandPulseDuringBreathingandSimplePerturbationsoftheBreathingCycle MeasurementoftheSystolicandDiastolicBloodPressureandPulseinDifferentBodyPositions ToDeterminetheStatusoftheCardiovascularSystem observationofadecreaseinsystolicanddiastolicbloodpressurewithoutasubsequentincreaseinheartratewhenchangingbodypositionfromsupinetostandingisconsideredapositivesignforautonomicnervoussystemdysfunction ToDeterminetheHealthoftheCardiovascularSystem Acardiovascularsystemthatrespondsrapidlytobodypositionchangeislikelyinabetterstateofhealththanacardiovascularsystemthatrespondssluggishly Bothanunchangedordecreasedheartrateafterstandingfor30seconds comparedtotheheartrateat15seconds issuggestiveofautonomicdysfunction asluggishorhypoadaptive lessthannormal heartrateandbloodpressureresponseduringachangeinbodypositionsupinetostandingshouldbeconsideredabnormalandsuggestiveofanunhealthycardiovascularsystem amoreadaptiverapidincreaseinheartrateandbloodpressureaftermovingfromasupinetostandingposition approximately30seconds islikelyassociatedwithahealthiercardiovascularsystem ExaminationofthePulseandArterialBloodPressureDuringFunctionalTasksandExercise Frequentmonitoringoftheheartrateandbloodpressuremaybethebestwaytoexaminethesafetyofexerciseandhelptoestablishguidelinesandproceduresforfunctionalorexercisetraining anincreaseinthediastolicbloodpressurewhenthediastolicbloodpressureshouldbedecreased orlow isastrongindicatorofcardiovasculardysfunction Potentialindirectmeasuresofcardiacfunction SymptomsandfunctionalclassificationCold pale andpossiblycyanoticextremitiesJugularvenousdistensionandperipheraledemaHeartsoundsPulseElectrocardiographyBloodpressure Standardmeasurementofcardiacfunction CardiaccatheterizationEchocardiographySwan GanscatheterizationCentralvenouspressureCardiacenzymesANPandBNPRadiologicevidence ExerciseTesting IndicationsforExerciseTesting DiagnosisofCoronaryArteryDiseaseAssessmentofPrognosisinCoronaryArteryDiseaseEvaluationofFunctionalCapacityEvaluationofTherapyforCoronaryDiseaseDeterminationofExercisePrescription AbsoluteContraindicationstoExerciseTesting AcuteMI within2days High riskunstableanginaUncontrolledcardiacarrhythmiasActiveEndocarditisSevereaorticstenosisDecompensatedheartfailureAcutepulmonaryembolusorinfarction DVTAcutenoncardiacdisorderaffectingoraggravatedbyexerciseAcutemyocarditis pericarditisPhysicaldisabilityprecludessafeandadequatetestInabilitytoobtainconsent RelativeContraindicationstoExerciseTesting LeftmaincoronarystenosisorequivalentModerateaorticvalvularstenosis ElectrolytedisorderTachyarrhythmiasorBradyarrhythmiasAtrialfibrillationwithuncontrolledventricularresponseHypertrophicCardiomyopathy gradient MentalimpairmentleadingtoinabilitytocooperateHigh degreeAVblock ECGLeadPlacementforExerciseTesting ProtocolsforExerciseTesting BloodPressureResponses ExerciseTesting DependencyoncardiacoutputandperipheralresistanceNormalresponses IncreaseinSBP 20 30mmHg NochangeorfallinDBPInadequateriseinSBP Myocardialischemia severeLVsystolicdysfunction aorticorLVOTobstruction drugtherapy blockers Exercise InducedHypotension 10mmHgbelowbaseline Severemyocardialischemia 50 positivepredictivevalueforleftmainor3 vesseldisease valvularheartdisease cardiomyopathynoevidenceofclinicallysignificantheartdisease dehydration antihypertensivetherapy prolongedstrenuousexercise HeartRateResponsetoExerciseTesting AcceleratedHeartRateResponse Deconditioning prolongedbedrest anemia metabolicdisorders conditionsassociatedwithdecreasedbloodvolumeorlowsystemicvascularresistance autonomicinsufficencyChronotropicincompetence Inadequateexerciseeffort drugtherapy blockers PrognosticSignificance PeakHR RestingHR 220 age RestingHR 0 80 Lauer 1999 PeakHR 130bpm Ellestad EvaluationofExerciseEffortduringExerciseTesting TheBorgPerceivedExertionScale ExerciseCapacity ExerciseTesting METcapacity1MET 3 5ml kg minO2consumptionFunctionalAerobicImpairment FAI BruceProtocolspecific PredictedMETlevel nomograms PredictedVO2 ACSMformulae PracticalAspects LackofassociationbetweenLVEFandexercisecapacityPrognosticvalueofdecreasedexercisecapacityandactiveCADPredictorofpatient sdisability ExerciseTesting Complications MIordeath Upto10per10 000tests 1per2 500 Lifethreateningventriculararrhythmias 0 5per100 000Cardiac Bradyarrhythmias tachyarrhythmias acutecoronarysyndromes heartfailure hypotension syncope deathNoncardiac Musculoskeletaltrauma soft tissueinjuryMiscellaneous Severefatigue dizziness myalgias AbsoluteIndicationsforTerminationofExerciseTest ST segmentelevation 1 0mm inleadswithoutQ waves otherthanV1oraVR Dropinsystolicbloodpressure 10mmHg persistentlybelowbaseline despiteanincreaseinworkload whenaccompaniedbyanyotherevidenceofischemiaModeratetosevereangina grades3 4 Centralnervoussystemsymptoms ataxia dizziness nearsyncope Signsofpoorperfusion cyanosisorpallor SustainedventriculartachycardiaTechnicaldifficultiesmonitoringtheECGorsystolicBPPatient srequesttostop RelativeIndicationsforTerminationofanExerciseTest STchanges horizontalordownsloping 2mm ormarkedaxisshiftDropinsystolicbloodpressure 10mmHg persistentlybelowbaseline despiteanincreaseinworkload intheabsenceofotherevidenceofischemiaandnopresyncopalsymptomsIncreasingchestpainFatigue shortnessofbreath wheezing legcramps orclaudicationHypertensiveresponse SBP 250mmHgand orDBP 115mmHg Developmentofbundle branchblock LBBB thatcannotbedistinguishedfromventriculartachycardia EvidenceofanteriorischemiaArrhythmiasotherthansustainedventriculartachycardia frequentmultifocalPVC s ventriculartriplets SVT heartblock orbradyarrhythmias GeneralAppearance diaphoresis peripheralcyanosis CriteriaforReadingST SegmentChangesontheExerciseECG STDEPRESSION Measurementsmadeon3consecutiveECGcomplexes STlevelismeasuredrelativetotheP Qjunction3keymeasurements P Qjunction J point 60 80msecafterJ point use60msecforHR 130bpmWhenJ pointisdepressedrelativetoP Qjunctionatbaseline NetdifferencefromtheJjunctiondeterminestheamountofdeviationWhentheJ pointiselevatedrelativetoP Qjunctionatbaselineandbecomesdepressedwithexercise MagnitudeofSTdepressionisdeterminedfromtheP QjunctionandnottherestingJpoint CriteriaforReadingST SegmentChangesontheExerciseECG STELEVATION 60msecafterJpointin3consecutiveECGcomplexes CriteriaforAbnormalandBorderlineST SegmentDepressionontheExerciseECG ABNORMAL 1 0mmorgreaterhorizontalordownslopingSTdepressionat60msecafterJpointon3consecutiveECGcomplexesBORDERLINE 0 5to1 0mmhorizontalordownslopingSTdepressionat60msecafterJpointon3consecutiveECGcomplexes2 0mmorgreaterupslopingSTdepressionat60msecafterJpointon3consecutiveECGcomplexes MorphologyofST SegmentDeviationduringExerciseTesting ValueofRight SidedECGLeadsduringExerciseTestingfortheDiagnosisofCAD HorizontalST segmentDepressionduringExerciseTesting DownslopingST SegmentDepressionduringExerciseTesting ST SegmentDepressioninEarlyRecoveryPeriodafterExerciseTesting UpslopingST SegmentDepressionduringExerciseTesting MorphologyofST SegmentDepressionPredictsSeverityofCoronaryArteryDisease Goldschlager 1976 Exercise InducedST SegmentElevationwithPriorAnteriorMyocardialInfarction Exercise InducedST SegmentElevationintheSettingofPriorInferolateralMI Exercise InducedAnteriorST SegmentElevationasReflectionofLADIschemia IndicationsforExerciseTestingintheDiagnosisofObstructiveCoronaryDisease CLASSI Adultpatients includingthosewithRBBBorlessthan1mmorrestingST depression withanintermediatepretestprobabilityofCAD basedongender age andsymptomsCLASSIIa PatientswithvasospasticanginaCLASSIIb PatientswithahighpretestprobabilityofCADbyage symptoms andgenderPatientswithalowpretestprobabilityofCADbyage symptoms andgenderPatientswithlessthan1mmofbaselineSTdepressionandtakingdigoxinPatientswithECGcriteriaofLVHandlessthan1mmSt depression Pre testProbabilityofCADbyAge Gender andSymptoms Typical DefiniteAnginaPectorisAge30 39MenIntermediate 10 90 WomenIntermediateAge40 49MenHigh 90 WomenIntermediateAge50 59MenHighWomenIntermediateAge60 69MenHighWomenHigh Pre testProbabilityofCADbyAge Gender andSymptoms Atypical PossibleAnginaPectoris Age30 39MenIntermediateWomenVeryLow 5 Age40 49MenIntermediateWomenLow 10 Age50 50MenIntermediateWomenIntermediateAge60 69MenIntermediateWomenIntermediate Pre testProbabilityofCADbyAge Gender andSymptoms NonanginalChestPain Age30 39MenLowWomenVeryLowAge40 49MenIntermediateWomenVeryLowAge50 59MenIntermediateWomenLowAge60 69MenIntermediateWomenIntermediate Pre testProbabilityofCADbyAge Gender andSymptoms Asymptomatic Age30 39MenVeryLowWomenVeryLowAge40 49MenLowWomenVeryLowAge50 59MenLowWomenVeryLowAge60 69MenLowWomenLow IndicationsforExerciseTestingintheDiagnosisofObstructiveCoronaryDisease ClassIII PatientswiththefollowingECGabnormalities WPWsyndrome electronicallypacedventricularrhythm greaterthan1mmrestingST depression completeLBBBPatientswithadocumentedMIorpriorcoronaryangiographydemonstratingsignificantCADhaveanestablisheddiagnosis ischemia prognosis ExerciseTesting SensitivityandSpecificityfortheDiagnosisofCAD Sensitivity Truepositives truepositives falsenegatives x100Specificity Truenegatives falsepositives truenegatives x100StandardExerciseTest mostlymen Sensitivity 68 Specificity 77 PredictiveAccuracy 73 Basedon1 0mmST segmentdepression ExerciseTestingintheDiagnosisofCoronaryArteryDiseaseinWomen ECGAnalysisalone Sensitivity 46 79 Specificity 48 86 UseofDukePrognosticScore LowRiskscore 19 1 CAD 75 stenosis 3 5 3 vesselorleftmaindiseaseIntermediateRiskscore 34 9 CAD 75 stenosis 12 4 3 vesselorleftmaindiseaseHighRiskScore 89 2 CAD 75 stenosis 46 3 vesselorleftmaindisease RiskAssessmentandPrognosiswithExerciseTestinginPatientswithSymptomsandPriorHistoryofCAD ClassI PatientundergoinginitialevaluationwithsuspectedorknownCADincludingthosewithcompleteRBBBandlessthan1mmofrestingECG exceptions ClassIIb PatientswithsuspectedorknowCADpreviouslyevaluated nowpresentingwithsignificantchangeinclinicalstatusLow riskacutecoronarysyndromepatients8 12hoursafterpresentationwhohavebeenfreeofactiveischemiaorheartfailuresymptoms LevelofEvidence B Intermediate riskacutecoronarysyndromepatients2 3daysafterpresentationwhohavebeenfreeofactiveischemiaorheartfailuresymptoms LevelofEvidence B RiskAssessmentandPrognosiswithExerciseTestinginPatientswithSymptomsandPriorHistoryofCAD ClassIIa Intermediate riskacutecoronarysyndromepatientswhohaveinitialcardiacmarkersthatarenormal arepeatECGwithoutsignificantchange andcardiacmarkers6 12hoursaftertheonsetofsymptomsthatarenormalandnootherevidenceofischemiabyobservation LevelofEvidence B ClassIIb PatientswiththefollowingECGabnormalities WPWsyndrome electronicallypacedventricularrhythm 1mmormoreofrestingST depression completeLBBBorIVCDwithaQRSduration 120msecPatientswithastableclinicalcoursewhoundergoperiodicmonitoringtoguidetreatment RiskAssessmentandPrognosiswithExerciseTestinginPatientswithSymptomsandPriorHistoryofCAD ClassIII Patientswithsevereco morbiditylikelytolimitlifeexpectancyand orcandidacyforrevascularizationHigh riskacutecoronarysyndromepatients LevelofEvidence c Short termRiskAssessmentforDeathorNonfatalMIinPatientswithAcuteCoronarySyndrome HIGHRISK atleastoneofthefollowingfeatures CharacterofPain Prolongedongoing 20min restchestpainClinicalFeatures Pulmonaryedema neworworseningMR S3ornew worseningrales hypotension bradycardia tachycardia age 75yrsECGFindings AnginaatrestwithtransientSTchanges 0 05mV BBB neworpresumednew sustainedventriculartachycardiaBiochemicalMarkers Elevatedtroponin I Short termRiskAssessmentforDeathorNonfatalMIinPatientswithAcuteCoronarySyndrome INTERMEDIATERISK Nohigh riskfeaturebutmusthaveoneofthefollowing History PriorMI peripheralorcerebrovasculardisease CABGorprolongedaspirinuseCharacterofPain Prolonged 20min restangina nowresolved withmoderatetohighlikelihoodofCADRestangina 70yrsECGFindings T waveinversionsgreaterthan0 2mV pathologicalQ wavesBiochemicalMarkers Borderlineelevatedtroponin I Short termRiskAssessmentforDeathorNonfatalMIinPatientswithAcuteCoronarySyndrome LOWRISK Nohighorintermediateriskfeaturesbutanyofthefollowing CharacterofPain New onsetorprogressiveCCSCIIIorIVanginainpast2weekswithmoderatetohighlikelihoodofCADECGFindings NormalorunchangedECGduringanepisodeofchestdiscomfortBiochemicalMarkers Normal PrognosticFactorsfromExerciseTesting Electrocardiographic MaximumST depressionMaximumST elevationST depressionslope morphology NumberofleadsshowingSTchangesDurationofSTdeviationintorecoveryST HRindexesExercise inducedventriculararrhythmiasTimetoonsetofSTdeviation PrognosticFactorsfromExerciseTesting Hemodynamic MaximumexerciseheartrateMaximumexerciseSBPMaximumexercisedoubleproduct HRxSBP Totalexerciseduration functionalcapacity ExertionalhypotensionChronotropicincompetenceAbnormalheartraterecovery HeartRateRecoveryAfterExerciseTestingPredictsOutcomeinCAD PrognosticFactorsfromExerciseTesting Symptomatic Exercise inducedanginaExercise inducedsymptoms SOB dizziness Timetoonsetofangina PrognosticScoreinAssessmentofCardiacEventRiskduringExerciseTesting DukePrognosticScore TreadmillScore exercisetimex5 amountofST segmentdeviation 4xexerciseanginaindex 0 none 1 presentbutnotlimiting 2 reasontostopthetest HighRisk 5 0 5 annualmortality InformationadditivetocoronaryanatomyandLVEF DukePrognosticScoreNomogram CombinedPrognosticFactorsIncreasePredictiveValueofExerciseTestingDatainCAD IndicationsforExerciseTestingafterMyocardialInfarction ClassI Beforedischargeforprognosticassessment activityprescription evaluationofmedicaltherapy submaximalversusmaximal submaximal4 6days Earlyafterdischargeforprognosticassessment activityprescription evaluationofmed