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.,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-pointscaleorvisualanalogscaleIsthisokwithyou?,.,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.,.,.,OtherSymptomsofHeartDisease,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)10mmHg(persistentlybelowbaseline)despiteanincreaseinworkload,whenaccompaniedbyanyotherevidenceofischemiaModeratetosevereangina(grades3-4)Centralnervoussystemsymptoms(ataxia,dizziness,nearsyncope)Signsofpoorperfusion(cyanosisorpallor)SustainedventriculartachycardiaTechnicaldifficultiesmonitoringtheECGorsystolicBPPatientsrequesttostop,.,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),.,CriteriaforReadingST-SegmentChangesontheExerciseECG,STDEPRESSION:Measurementsmadeon3consecutiveECGcomplexes!STlevelismeasuredrelativetotheP-Qjunction3keymeasurements(P-Qjunction,J-point,60-80msecafterJ-point-use60msecforHR130bpmWhenJ-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(75%stenosis,12.4%3-vesselorleftmaindiseaseHighRiskScore:89.2%CAD75%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,completeLBBBorIVCDwithaQRSduration120msecPatientswithastableclinicalcoursewhoundergoperiodicmonitoringtoguidetreatment,.,RiskAssessmentandPrognosiswithExerciseTestinginPatientswithSymptomsandPriorHistoryofCAD,ClassIII:Patientswithsevereco-morbiditylikelytolimitlifeexpectancyand/orcandidacyforrevascularizationHigh-riskacutecoronarysyndromepatients(LevelofEvidence=c),.,Short-termRiskAssessmentforDeathorNonfatalMIinPatientswithAcuteCoronarySyndrome,HIGHRISK(atleastoneofthefollowingfeatures):CharacterofPain:Prolongedongoing(20min)restchestpainClinicalFeatures:Pulmonaryedema,neworworseningMR,S3ornew/worseningrales,hypotension,bradycardia,tachycardia,age75yrsECGFindings:AnginaatrestwithtransientSTchanges0.05mV,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,evaluationofmedicaltherapy,andcardiacrehabilitationifpre-dischargeexercisetestwasnotdone(symptom-limited,about14-21days)Lateafterdischargeforprognosticassessment,activityprescription,evaluationofmedicaltherapy,andcardiacrehabilitationiftheearlyexercisetestwassubmaximal(symptom-limited3-6weeks),.,IndicationsforExerciseTestingafterMyocardialInfarction,ClassIIa:Afterdischargeforactivitycounselingand/orexercisetrainingaspartofcardiacrehabilitationinpatientswhohaveundergonecardiacrevascularizationClassIIb:PatientswiththefollowingECGabnormalities:CompleteLBBB,Pre-excitationsyndrome,LVH,Digoxintherapy,greaterthan1