心脏康复评定ppt课件

CARDIOVASCULAREVALUATION,DR.LiangQi,1,APATIENTCASEEXAMPLE,2,1.Whyareyouheretoday?2.Haveyoubeendiagnosedwithacardiacdisorderinthepast?3.Haveyouhadanyspecialteststoexamineyourheartlikeanelectrocardiogram,stresstest,echocardiogram,orcardiaccatheterization?,3,4.Doyouexperienceanginaorshortnessofbreathatrest,onlywithactivity/exercise,orbothatrestandwithactivity/exercise?,4,5.Ifyouexperienceanginaorbecomeshortofbreathduringactivityorexercisecouldyoupleasedescribethetypeofactivityorexercisewhichproducesyouranginaorshortnessofbreath?,5,6.Canyoudescribeyouranginaorshortnessofbreath?Canyouhelpmeunderstandyouranginaorshortnessofbreathbypointingtothenumbers1through4todescribethelevelofanginayouexperienceatrestandexerciseorbypointingtoyourlevelofshortnessofbreathusingthis10-pointscaleorbymarkingthisvisualanalogscale?,6,7.CouldIfeelyourpulsetodetermineyourheartrateandthestrengthofyourpulse?8.CouldIplacethisfingerprobeonyourindexfingertoobtainanoxygensaturationmeasurement?,7,9.CouldIplacetheseelectrodesonyourchesttoobtainasimplesingle-leadelectrocardiogram(ECG)?,8,10.CouldItakeyourbloodpressurewhileyouareseatedandthencompareittothebloodpressurewhileyouarelyingdownandthenstanding?Iwouldalsoliketoobserveyourpulse,oxygensaturation,ECG,andsymptomswhenyouarelyingdownandstanding.,9,11.CouldIlistentoyourheartandlungswithmystethoscope?WhileIdothisIwillconcentrateonwatchingyourECGsothatIcanidentifyyourheartsoundsandanychangesintheECGwhileyouarebreathingdeeplywhenlisteningtoyourlungs.,10,12.CouldIplace1ofmyhandsonyourstomachand1handonyourupperchesttodeterminehowyoubreathe?13.CouldIplacemyhandsonthelowermostribsoneachsideofyourchesttodeterminehowyoubreathe?14.CouldIplacemyhandsonyourbacktodeterminehowyoubreathe?15.CouldIwrapmytapemeasurearoundyourchestatseveraldifferentsitestodeterminehowyoubreathe?,11,16.NowthatIunderstandsomeverybasicinformationaboutthemannerinwhichyoubreathecouldyoupleasebreatheinthemannerIinstructyouviasoundsImake,pressurefrommyhands,methodsIshowtoyou,ordifferentbodypositions?IwilloccasionallyplacemyhandsonyourchestandwrapmytapemeasurearoundyourchesttodeterminehowyoubreatheduringthesesimpletestsandIwillaskyoutoidentifyyourlevelofshortnessofbreathusingthe10-pointscaleorvisualanalogscaleIsthisokwithyou?,12,17.CouldImeasurethestrengthofyourbreathingmusclebyhavingyouplacethismouthpieceinyourmouthandbreatheinandoutasdeeplyandasforcefullyasyouareable?,13,18.Iwouldlikeyoutonowperformtheactivityorexercisewhichproducesyouranginaorshortnessofbreath.Couldyoupleasedothisnow?,14,Thankyouforgivingmethechancetoexamineyoutoday.Iwillcallyourphysiciantogetsomemoreinformationaboutyoulikeelectrocardiogram,echocardiogramandpulmonaryfunctionteststhatyousaidwereperformedlastweekaswellasthearterialbloodgasresults,chestX-ray,andexercisetestresults.,15,PhysicalTherapyExamination,MedicalInformationandRiskFactorAnalysislisteningtothepatientspasthistoryandprimarycomplaintsiscriticalintheexaminationprocess.,16,ExaminationsofPatientAppearance,categorizedbyspecificsignsandsymptoms,17,Angina-MethodsToEvaluateAnginafromNonanginalPain,Ifasuspectedanginalpainchanges(increasesordecreases)withbreathing,palpationinthepainfularea,ormovementofajoint(ie,shoulderflexionandabduction)itisverylikelythatthepainisNOTangina.,18,Angina-MethodsToEvaluateAnginafromNonanginalPain,itcanbeworsenedbyphysicalexerciseoractivity.Therefore,ifthesuspectedanginalpainisunchangedwiththepreviouslycitedmaneuversandthepainoccurredwithexertion,itisSUSPECTforangina.Ifthesuspectedanginalpainisunchangedbythesemaneuvers,ifthepainoccurredwithexertion,andifthepaindecreasesorsubsideswithrest,itisverylikelythatthepainISangina.Finally,ifthesuspectedpaindecreasesorsubsideswithnitroglycerin,itisevenmorelikelythatthepainISangina.,19,20,OtherSymptomsofHeartDisease,dyspneaFatigueDizzinessLightheadednessPalpitationsasenseofimpendingdoom,21,22,ExaminationsofPatientAppearance,skincoloroftheperipheralextremities.Paleorcyanoticskininthelegs,feet,arms,andfingersisassociatedwithpoorcardiovascularfunction.,23,ExaminationsofPatientAppearance,Diagonalearlobecrease.Thisphenomenonhasbeeninvestigatedformanyyearsandrecentlywasonceagainfoundtobehighlypredictiveofheartdisease,24,Anthropometricmeasurements,bodyweightfingerpressureonanedematousareaGirthmeasurementsskin-foldcalipermeasurementscalculationofthebodymassindexmeasurethepercentageofbodyfatandleanmusclemass,25,Jugularvenousdistension,itisoftenduetoright-sidedheartfailure.,26,27,28,PalpationoftheRadialPulse,Palpationoftheradialpulsecanprovideimportantinformationaboutthestatusofthecardiovascularsystem.MeasurementoftheSystolicBloodPressureandPulseDuringBreathingandSimplePerturbationsoftheBreathingCycle,29,MeasurementoftheSystolicandDiastolicBloodPressureandPulseinDifferentBodyPositions,30,ToDeterminetheStatusoftheCardiovascularSystem,observationofadecreaseinsystolicanddiastolicbloodpressurewithoutasubsequentincreaseinheartratewhenchangingbodypositionfromsupinetostandingisconsideredapositivesignforautonomicnervoussystemdysfunction.,31,ToDeterminetheHealthoftheCardiovascularSystem,Acardiovascularsystemthatrespondsrapidlytobodypositionchangeislikelyinabetterstateofhealththanacardiovascularsystemthatrespondssluggishly.Bothanunchangedordecreasedheartrateafterstandingfor30seconds(comparedtotheheartrateat15seconds)issuggestiveofautonomicdysfunction.,32,asluggishorhypoadaptive(lessthannormal)heartrateandbloodpressureresponseduringachangeinbodypositionsupinetostandingshouldbeconsideredabnormalandsuggestiveofanunhealthycardiovascularsystem.,33,amoreadaptiverapidincreaseinheartrateandbloodpressureaftermovingfromasupinetostandingposition(approximately30seconds)islikelyassociatedwithahealthiercardiovascularsystem,34,ExaminationofthePulseandArterialBloodPressureDuringFunctionalTasksandExercise,Frequentmonitoringoftheheartrateandbloodpressuremaybethebestwaytoexaminethesafetyofexerciseandhelptoestablishguidelinesandproceduresforfunctionalorexercisetraining.,35,anincreaseinthediastolicbloodpressurewhenthediastolicbloodpressureshouldbedecreased(orlow)isastrongindicatorofcardiovasculardysfunction.,36,Potentialindirectmeasuresofcardiacfunction,SymptomsandfunctionalclassificationCold,pale,andpossiblycyanoticextremitiesJugularvenousdistensionandperipheraledemaHeartsoundsPulseElectrocardiographyBloodpressure,37,Standardmeasurementofcardiacfunction,CardiaccatheterizationEchocardiographySwan-GanscatheterizationCentralvenouspressureCardiacenzymesANPandBNPRadiologicevidence,38,ExerciseTesting,39,IndicationsforExerciseTesting:,DiagnosisofCoronaryArteryDiseaseAssessmentofPrognosisinCoronaryArteryDiseaseEvaluationofFunctionalCapacityEvaluationofTherapyforCoronaryDiseaseDeterminationofExercisePrescription,40,AbsoluteContraindicationstoExerciseTesting,AcuteMI(within2days)High-riskunstableanginaUncontrolledcardiacarrhythmiasActiveEndocarditisSevereaorticstenosisDecompensatedheartfailureAcutepulmonaryembolusorinfarction,DVTAcutenoncardiacdisorderaffectingoraggravatedbyexerciseAcutemyocarditis,pericarditisPhysicaldisabilityprecludessafeandadequatetestInabilitytoobtainconsent,41,RelativeContraindicationstoExerciseTesting,LeftmaincoronarystenosisorequivalentModerateaorticvalvularstenosis(?)ElectrolytedisorderTachyarrhythmiasorBradyarrhythmiasAtrialfibrillationwithuncontrolledventricularresponseHypertrophicCardiomyopathy(?gradient)MentalimpairmentleadingtoinabilitytocooperateHigh-degreeAVblock,42,ECGLeadPlacementforExerciseTesting,43,ProtocolsforExerciseTesting,44,BloodPressureResponses:ExerciseTesting,DependencyoncardiacoutputandperipheralresistanceNormalresponses:IncreaseinSBP(20-30mmHg)NochangeorfallinDBPInadequateriseinSBP:Myocardialischemia,severeLVsystolicdysfunction,aorticorLVOTobstruction,drugtherapy(-blockers)Exercise-InducedHypotension(10mmHgbelowbaseline)Severemyocardialischemia(50%positivepredictivevalueforleftmainor3-vesseldisease),valvularheartdisease,cardiomyopathynoevidenceofclinicallysignificantheartdisease(dehydration,antihypertensivetherapy,prolongedstrenuousexercise),45,HeartRateResponsetoExerciseTesting,AcceleratedHeartRateResponse:Deconditioning,prolongedbedrest,anemia,metabolicdisorders,conditionsassociatedwithdecreasedbloodvolumeorlowsystemicvascularresistance,autonomicinsufficencyChronotropicincompetence:Inadequateexerciseeffort,drugtherapy(-blockers),PrognosticSignificance:(PeakHR-RestingHR)/(220-age-RestingHR)10mmHg(persistentlybelowbaseline)despiteanincreaseinworkload,whenaccompaniedbyanyotherevidenceofischemiaModeratetosevereangina(grades3-4)Centralnervoussystemsymptoms(ataxia,dizziness,nearsyncope)Signsofpoorperfusion(cyanosisorpallor)SustainedventriculartachycardiaTechnicaldifficultiesmonitoringtheECGorsystolicBPPatientsrequesttostop,50,RelativeIndicationsforTerminationofanExerciseTest,STchanges(horizontalordownsloping2mm)ormarkedaxisshiftDropinsystolicbloodpressure10mmHg(persistentlybelowbaseline)despiteanincreaseinworkload,intheabsenceofotherevidenceofischemiaandnopresyncopalsymptomsIncreasingchestpainFatigue,shortnessofbreath,wheezing,legcramps,orclaudicationHypertensiveresponse(SBP250mmHgand/orDBP115mmHg)Developmentofbundle-branchblock(LBBB)thatcannotbedistinguishedfromventriculartachycardia;?EvidenceofanteriorischemiaArrhythmiasotherthansustainedventriculartachycardia(frequentmultifocalPVCs,ventriculartriplets,SVT,heartblock,orbradyarrhythmias)GeneralAppearance(diaphoresis,peripheralcyanosis),51,CriteriaforReadingST-SegmentChangesontheExerciseECG,STDEPRESSION:Measurementsmadeon3consecutiveECGcomplexes!STlevelismeasuredrelativetotheP-Qjunction3keymeasurements(P-Qjunction,J-point,60-80msecafterJ-point-use60msecforHR130bpmWhenJ-pointisdepressedrelativetoP-Qjunctionatbaseline:NetdifferencefromtheJjunctiondeterminestheamountofdeviationWhentheJ-pointiselevatedrelativetoP-Qjunctionatbaselineandbecomesdepressedwithexercise:MagnitudeofSTdepressionisdeterminedfromtheP-QjunctionandnottherestingJpoint,52,CriteriaforReadingST-SegmentChangesontheExerciseECG,STELEVATION:60msecafterJpointin3consecutiveECGcomplexes,53,CriteriaforAbnormalandBorderlineST-SegmentDepressionontheExerciseECG,ABNORMAL:1.0mmorgreaterhorizontalordownslopingSTdepressionat60msecafterJpointon3consecutiveECGcomplexesBORDERLINE:0.5to1.0mmhorizontalordownslopingSTdepressionat60msecafterJpointon3consecutiveECGcomplexes2.0mmorgreaterupslopingSTdepressionat60msecafterJpointon3consecutiveECGcomplexes,54,MorphologyofST-SegmentDeviationduringExerciseTesting,55,ValueofRight-SidedECGLeadsduringExerciseTestingfortheDiagnosisofCAD,56,HorizontalST-segmentDepressionduringExerciseTesting,57,DownslopingST-SegmentDepressionduringExerciseTesting,58,ST-SegmentDepressioninEarlyRecoveryPeriodafterExerciseTesting,59,UpslopingST-SegmentDepressionduringExerciseTesting,60,MorphologyofST-SegmentDepressionPredictsSeverityofCoronaryArteryDisease(Goldschlager,1976),61,Exercise-InducedST-SegmentElevationwithPriorAnteriorMyocardialInfarction,62,Exercise-InducedST-SegmentElevationintheSettingofPriorInferolateralMI,63,Exercise-InducedAnteriorST-SegmentElevationasReflectionofLADIschemia,64,IndicationsforExerciseTestingintheDiagnosisofObstructiveCoronaryDisease,CLASSI:Adultpatients(includingthosewithRBBBorlessthan1mmorrestingST-depression)withanintermediatepretestprobabilityofCAD,basedongender,age,andsymptomsCLASSIIa:PatientswithvasospasticanginaCLASSIIb:PatientswithahighpretestprobabilityofCADbyage,symptoms,andgenderPatientswithalowpretestprobabilityofCADbyage,symptoms,andgenderPatientswithlessthan1mmofbaselineSTdepressionandtakingdigoxinPatientswithECGcriteriaofLVHandlessthan1mmSt-depression,65,Pre-testProbabilityofCADbyAge,Gender,andSymptoms,Typical/DefiniteAnginaPectorisAge30-39MenIntermediate(10-90%)WomenIntermediateAge40-49MenHigh(90%)WomenIntermediateAge50-59MenHighWomenIntermediateAge60-69MenHighWomenHigh,66,Pre-testProbabilityofCADbyAge,Gender,andSymptoms,Atypical/PossibleAnginaPectoris:Age30-39MenIntermediateWomenVeryLow(75%stenosis,12.4%3-vesselorleftmaindiseaseHighRiskScore:89.2%CAD75%stenosis,46%3-vesselorleftmaindisease,72,RiskAssessmentandPrognosiswithExerciseTestinginPatientswithSymptomsandPriorHistoryofCAD,ClassI:PatientundergoinginitialevaluationwithsuspectedorknownCADincludingthosewithcompleteRBBBandlessthan1mmofrestingECG(exceptions-ClassIIb)PatientswithsuspectedorknowCADpreviouslyevaluated,nowpresentingwithsignificantchangeinclinicalstatusLow-riskacutecoronarysyndromepatients8-12hoursafterpresentationwhohavebeenfreeofactiveischemiaorheartfailuresymptoms(LevelofEvidence=B)Intermediate-riskacutecoronarysyndromepatients2-3daysafterpresentationwhohavebeenfreeofactiveischemiaorheartfailuresymptoms(LevelofEvidence=B),73,RiskAssessmentandPrognosiswithExerciseTestinginPatientswithSymptomsandPriorHistoryofCAD,ClassIIa:Intermediate-riskacutecoronarysyndromepatientswhohaveinitialcardiacmarkersthatarenormal,arepeatECGwithoutsignificantchange,andcardiacmarkers6-12hoursaftertheonsetofsymptomsthatarenormalandnootherevidenceofischemiabyobservation(LevelofEvidence=B)ClassIIb:PatientswiththefollowingECGabnormalities:WPWsyndrome,electronicallypacedventricularrhythm,1mmormoreofrestingST-depression,completeLBBBorIVCDwithaQRSduration120msecPatientswithastableclinicalcoursewhoundergoperiodicmonitoringtoguidetreatment,74,RiskAssessmentandPrognosiswithExerciseTestinginPatientswithSymptomsandPriorHistoryofCAD,ClassIII:Patientswithsevereco-morbiditylikelytolimitlifeexpectancyand/orcandidacyforrevascularizationHigh-riskacutecoronarysyndromepatients(LevelofEvidence=c),75,Short-termRiskAssessmentforDeathorNonfatalMIinPatientswithAcuteCoronarySyndrome,HIGHRISK(atleastoneofthefollowingfeatures):CharacterofPain:Prolongedongoing(20min)restchestpainClinicalFeatures:Pulmonaryedema,neworworseningMR,S3ornew/worseningrales,hypotension,bradycardia,tachycardia,age75yrsECGFindings:AnginaatrestwithtransientSTchanges0.05mV,BBB(neworpresumednew),sustainedventriculartachycardiaBiochemicalMarkers:Elevatedtroponin-I,76,Short-termRiskAssessmentforDeathorNonfatalMIinPatientswithAcuteCoronarySyndrome,INTERMEDIATERISK:Nohigh-riskfeaturebutmusthaveoneofthefollowing:History:PriorMI,peripheralorcerebrovasculardisease,CABGorprolongedaspirinuseCharacterofPain:Prolonged(20min)restangina,nowresolved,withmoderatetohighlikelihoodofCADRestangina(70yrsECGFindings:T-waveinversionsgreaterthan0.2mV,pathologicalQ-wavesBiochemicalMarkers:Borderlineelevatedtroponin-I,77,Short-termRiskAssessmentforDeathorNonfatalMIinPatientswithAcuteCoronarySyndrome,LOWRISK:Nohighorintermediateriskfeaturesbutanyofthefollowing:CharacterofPain:New-onsetorprogressiveCCSCIIIorIVanginainpast2weekswithmoderatetohighlikelihoodofCADECGFindings:NormalorunchangedECGduringanepisodeofchestdiscomfortBiochemicalMarkers:Normal,78,PrognosticFactorsfromExerciseTesting,Electrocardiographic:MaximumST-depressionMaximumST-elevationST-depressionslope(morphology)NumberofleadsshowingSTchangesDurationofSTdeviationintorecoveryST/HRindexesExercise-inducedventriculararrhythmiasTimetoonsetofSTdeviation,79,PrognosticFactorsfromExerciseTesting,Hemodynamic:MaximumexerciseheartrateMaximumexerciseSBPMaximumexercisedoubleproduct(HRxSBP)Totalexerciseduration(functionalcapacity)ExertionalhypotensionChronotropicincompetenceAbnormalheartraterecovery,80,HeartRateRecoveryAfterExerciseTestingPredictsOutcomeinCAD,81,PrognosticFactorsfromExerciseTesting,Symptomatic:Exercise-inducedanginaExercise-inducedsymptoms(SOB,dizziness)Timetoonsetofangina,82,PrognosticScoreinAssessmentofCardiacEventRiskduringExerciseTesting,DukePrognosticScore:TreadmillScore=exercisetimex5(amountofST-segmentdeviation)-4xexerciseanginaindex(0=none,1=presentbutnotlimiting,2=reasontostopthetest)HighRisk:+5(0.5%annualmortality)InformationadditivetocoronaryanatomyandLVEF,83,DukePrognosticScoreNomogram,84,CombinedPrognosticFactorsIncreasePredictiveValueofExerciseTestingDatainCAD,85,IndicationsforExerciseTestingafterMyocardialInfarction,ClassI:Beforedischargeforprognosticassessment,activityprescription,evaluationofmedicaltherapy(submaximalversusmaximal,submaximal4-6days)Earlyafterdischargeforprognosticassessment,activityprescription,evaluationofmedicaltherapy,andcardiacrehabilitationifpre-dischargeexercisetestwasnotdone(symptom-limited,about14-21days)Lateafterdischargeforprognosticassessment,activityprescription,evaluationofmedicaltherapy,andcardiacrehabilitationiftheearlyexercisetestwassubmaximal(symptom-limited3-6weeks),86,IndicationsforExerciseTestingafterMyocardialInfarction,ClassIIa:Afterdischargeforactivitycounselingand/orexercisetrainingaspartofcardiacrehabilitationinpatientswhohaveundergonecardiacrevascularizationClassIIb:PatientswiththefollowingECGabnormalities:CompleteLBBB,Pre-excitationsyndrome,LVH,Digoxintherapy,greaterthan1m