心脏康复评定讲义

1、心脏康复评定A PATIENT CASE EXAMPLE1. Why are you here today?2. Have you been diagnosed with a cardiac disorder in the past?3. Have you had any special tests to examine your heart like an electrocardiogram, stress test, echocardiogram, or cardiac catheterization?4. Do you experience angina or shortness of

2、breath at rest, only with activity/exercise, or both at rest and with activity/exercise?5. If you experience angina or become short of breath during activity or exercise could you please describe the type of activity or exercise which produces your angina or shortness of breath?6. Can you describe y

3、our angina or shortness of breath? Can you help me understand your angina or shortness of breath by pointing to the numbers 1 through 4 to describe the level of angina you experience at rest and exercise or by pointing to your level of shortness of breath using this 10-point scale or by marking this

4、 visual analog scale?7. Could I feel your pulse to determine your heart rate and the strength of your pulse? 8. Could I place this finger probe on your index finger to obtain an oxygen saturation measurement? 9. Could I place these electrodes on your chest to obtain a simple single-lead electrocardi

5、ogram (ECG)?10. Could I take your blood pressure while you are seated and then compare it to the blood pressure while you are lying down and then standing? I would also like to observe your pulse, oxygen saturation, ECG, and symptoms when you are lying down and standing.11. Could I listen to your he

6、art and lungs with my stethoscope? While I do this I will concentrate on watching your ECG so that I can identify your heart sounds and any changes in the ECG while you are breathing deeply when listening to your lungs. 12. Could I place 1 of my hands on your stomach and 1 hand on your upper chest t

7、o determine how you breathe? 13. Could I place my hands on the lowermost ribs on each side of your chest to determine how you breathe? 14. Could I place my hands on your back to determine how you breathe? 15. Could I wrap my tape measure around your chest at several different sites to determine how

8、you breathe? 17. Could I measure the strength of your breathing muscle by having you place this mouthpiece in your mouth and breathe in and out as deeply and as forcefully as you are able? 18. I would like you to now perform the activity or exercise which produces your angina or shortness of breath.

9、 Could you please do this now? Thank you for giving me the chance to examine you today. I will call your physician to get some more information about you like electrocardiogram, echocardiogram and pulmonary function tests that you said were performed last week as well as the arterial blood gas resul

10、ts, chest X-ray, and exercise test results. Physical Therapy Examination Medical Information and Risk Factor Analysis listening to the patients past history and primary complaints is critical in the examination process. Examinations of Patient Appearance categorized by specific signs and symptoms An

11、gina-Methods To Evaluate Angina from Nonanginal Pain If a suspected anginal pain changes (increases or decreases) with breathing, palpation in the painful area, or movement of a joint (ie, shoulder flexion and abduction) it is very likely that the pain is NOT angina.Angina-Methods To Evaluate Angina

12、 from Nonanginal Painit can be worsened by physical exercise or activity. Therefore, if the suspected anginal pain is unchanged with the previously cited maneuvers and the pain occurred with exertion, it is SUSPECT for angina. If the suspected anginal pain is unchanged by these maneuvers, if the pai

13、n occurred with exertion, and if the pain decreases or subsides with rest, it is very likely that the pain IS angina.Finally, if the suspected pain decreases or subsides with nitroglycerin, it is even more likely that the pain IS angina. Other Symptoms of Heart DiseasedyspneaFatigueDizzinessLight he

14、adednessPalpitationsa sense of impending doom Examinations of Patient Appearanceskin color of the peripheral extremities. Pale or cyanotic skin in the legs, feet, arms, and fingers is associated with poor cardiovascular function. Examinations of Patient AppearanceDiagonal earlobe crease. This phenom

15、enon has been investigated for many years and recently was once again found to be highly predictive of heart disease Anthropometric measurementsbody weightfinger pressure on an edematous areaGirth measurements skin-fold caliper measurementscalculation of the body mass index measure the percentage of

16、 body fat and lean muscle massJugular venous distensionit is often due to right-sided heart failure. Palpation of the Radial PulsePalpation of the radial pulse can provide important information about the status of the cardiovascular system. Measurement of the Systolic Blood Pressure and Pulse During

17、 Breathing and Simple Perturbations of the Breathing Cycle Measurement of the Systolic and Diastolic Blood Pressure and Pulse in Different Body PositionsTo Determine the Status of the Cardiovascular Systemobservation of a decrease in systolic and diastolic blood pressure without a subsequent increas

18、e in heart rate when changing body position from supine to standing is considered a positive sign for autonomic nervous system dysfunction. .To Determine theHealth of the Cardiovascular SystemA cardiovascular system that responds rapidly to body position change is likely in a better state of health

19、than a cardiovascular system that responds sluggishly.Both an unchanged or decreased heart rate after standing for 30 seconds (compared to the heart rate at 15 seconds) is suggestive of autonomic dysfunction. a sluggish or hypoadaptive (less than normal) heart rate and blood pressure response during

20、 a change in body position supine to standing should be considered abnormal and suggestive of an unhealthy cardiovascular system. a more adaptive rapid increase in heart rate and blood pressure after moving from a supine to standing position (approximately 30 seconds) is likely associated with a hea

21、lthier cardiovascular systemExamination of the Pulse and Arterial Blood PressureDuring Functional Tasks and ExerciseFrequent monitoring of the heart rate and blood pressure may be the best way to examine the safety of exercise and help to establish guidelines and procedures for functional or exercis

22、e training. an increase in the diastolic blood pressure when the diastolic blood pressure should be decreased (or low) is a strong indicator of cardiovascular dysfunction. . Potential indirect measures of cardiac functionSymptoms and functional classificationCold, pale, and possibly cyanotic extremi

23、tiesJugular venous distension and peripheral edemaHeart soundsPulseElectrocardiographyBlood pressureStandard measurement of cardiac functionCardiac catheterizationEchocardiographySwan-Gans catheterizationCentral venous pressureCardiac enzymesANP and BNPRadiologic evidenceExercise TestingIndications

24、for Exercise Testing:Diagnosis of Coronary Artery DiseaseAssessment of Prognosis in Coronary Artery DiseaseEvaluation of Functional CapacityEvaluation of Therapy for Coronary DiseaseDetermination of Exercise PrescriptionAbsolute Contraindications to Exercise TestingAcute MI (within 2 days)High-risk

25、unstable anginaUncontrolled cardiac arrhythmias Active EndocarditisSevere aortic stenosisDecompensated heart failureAcute pulmonary embolus or infarction, DVTAcute noncardiac disorder affecting or aggravated by exerciseAcute myocarditis, pericarditisPhysical disability precludes safe and adequate te

26、stInability to obtain consentRelative Contraindications to Exercise TestingLeft main coronary stenosis or equivalentModerate aortic valvular stenosis(?)Electrolyte disorderTachyarrhythmias or BradyarrhythmiasAtrial fibrillation with uncontrolled ventricular responseHypertrophic Cardiomyopathy (? gra

27、dient)Mental impairment leading to inability to cooperateHigh-degree AV blockECG Lead Placement for Exercise TestingProtocols for Exercise TestingBlood Pressure Responses: Exercise TestingDependency on cardiac output and peripheral resistanceNormal responses: Increase in SBP ( 20-30 mmHg)No change o

28、r fall in DBPInadequate rise in SBP:Myocardial ischemia, severe LV systolic dysfunction, aortic or LVOT obstruction, drug therapy (-blockers)Exercise-Induced Hypotension ( 10 mmHg below baseline)Severe myocardial ischemia (50% positive predictive value for left main or 3-vessel disease), valvular he

29、art disease, cardiomyopathy no evidence of clinically significant heart disease (dehydration, antihypertensive therapy, prolonged strenuous exercise)Heart Rate Response to Exercise TestingAccelerated Heart Rate Response:Deconditioning, prolonged bed rest, anemia, metabolic disorders, conditions asso

30、ciated with decreased blood volume or low systemic vascular resistance, autonomic insufficencyChronotropic incompetence:Inadequate exercise effort, drug therapy (-blockers),Prognostic Significance:(Peak HR - Resting HR)/(220-age-Resting HR) 0.80 (Lauer, 1999)Peak HR 1.0 mm) in leads without Q-waves

31、(other than V1 or aVR)Drop in systolic blood pressure 10 mmHg (persistently below baseline) despite an increase in workload, when accompanied by any other evidence of ischemiaModerate to severe angina (grades 3-4) Central nervous system symptoms (ataxia, dizziness, near syncope)Signs of poor perfusi

32、on (cyanosis or pallor)Sustained ventricular tachycardiaTechnical difficulties monitoring the ECG or systolic BPPatients request to stopRelative Indications for Termination of an Exercise TestST changes (horizontal or downsloping 2 mm) or marked axis shiftDrop in systolic blood pressure 10 mmHg (per

33、sistently below baseline) despite an increase in workload, in the absence of other evidence of ischemia and no presyncopal symptomsIncreasing chest painFatigue, shortness of breath, wheezing, leg cramps, or claudicationHypertensive response (SBP 250 mmHg and/or DBP 115 mmHg)Development of bundle-bra

34、nch block (LBBB) that cannot be distinguished from ventricular tachycardia; ? Evidence of anterior ischemiaArrhythmias other than sustained ventricular tachycardia (frequent multifocal PVCs, ventricular triplets, SVT, heart block, or bradyarrhythmias)General Appearance (diaphoresis, peripheral cyano

35、sis)Criteria for Reading ST-Segment Changes on the Exercise ECGST DEPRESSION:Measurements made on 3 consecutive ECG complexes !ST level is measured relative to the P-Q junction3 key measurements (P-Q junction, J-point, 60-80msec after J-point - use 60 msec for HR 130 bpmWhen J-point is depressed rel

36、ative to P-Q junction at baseline:Net difference from the J junction determines the amount of deviationWhen the J-point is elevated relative to P-Q junction at baseline and becomes depressed with exercise:Magnitude of ST depression is determined from the P-Q junction and not the resting J pointCrite

37、ria for Reading ST-Segment Changes on the Exercise ECGST ELEVATION: 60 msec after J point in 3 consecutive ECG complexesCriteria for Abnormal and Borderline ST-Segment Depression on the Exercise ECGABNORMAL:1.0 mm or greater horizontal or downsloping ST depression at 60 msec after J point on 3 conse

38、cutive ECG complexesBORDERLINE:0.5 to 1.0 mm horizontal or downsloping ST depression at 60 msec after J point on 3 consecutive ECG complexes2.0 mm or greater upsloping ST depression at 60 msec after J point on 3 consecutive ECG complexesMorphology of ST-Segment Deviation during Exercise TestingValue

39、 of Right-Sided ECG Leads during Exercise Testing for the Diagnosis of CADHorizontal ST-segment Depression during Exercise TestingDownsloping ST-Segment Depression during Exercise TestingST-Segment Depression in Early Recovery Period after Exercise TestingUpsloping ST-Segment Depression during Exerc

40、ise TestingMorphology of ST-Segment Depression Predicts Severity of Coronary Artery Disease (Goldschlager, 1976)Exercise-Induced ST-Segment Elevation with Prior Anterior Myocardial InfarctionExercise-Induced ST-Segment Elevation in the Setting of Prior Inferolateral MIExercise-Induced Anterior ST-Se

41、gment Elevation as Reflection of LAD IschemiaIndications for Exercise Testing in the Diagnosis of Obstructive Coronary DiseaseCLASS I:Adult patients (including those with RBBB or less than 1 mm or resting ST-depression) with an intermediate pretest probability of CAD, based on gender, age, and sympt

42、omsCLASS IIa:Patients with vasospastic anginaCLASS IIb:Patients with a high pretest probability of CAD by age, symptoms, and genderPatients with a low pretest probability of CAD by age, symptoms, and genderPatients with less than 1 mm of baseline ST depression and taking digoxinPatients with ECG cri

43、teria of LVH and less than 1 mm St-depressionPre-test Probability of CAD by Age, Gender, and SymptomsTypical/Definite Angina PectorisAge 30-39MenIntermediate (10-90%) Women IntermediateAge 40-49MenHigh (90%) Women IntermediateAge 50-59MenHigh Women IntermediateAge 60-69 MenHigh Women High Pre-test P

44、robability of CAD by Age, Gender, and SymptomsAtypical/Possible Angina Pectoris:Age 30-39 MenIntermediateWomen Very Low (5%)Age 40-49MenIntermediateWomen Low (75% stenosis, 3.5% 3-vessel or left main diseaseIntermediate Risk score: 34.9% CAD 75% stenosis, 12.4% 3-vessel or left main diseaseHigh Risk

45、 Score: 89.2% CAD 75% stenosis, 46% 3-vessel or left main diseaseRisk Assessment and Prognosis with Exercise Testing in Patients with Symptoms and Prior History of CADClass I:Patient undergoing initial evaluation with suspected or known CAD including those with complete RBBB and less than 1 mm of re

46、sting ECG (exceptions - Class IIb)Patients with suspected or know CAD previously evaluated, now presenting with significant change in clinical statusLow-risk acute coronary syndrome patients 8-12 hours after presentation who have been free of active ischemia or heart failure symptoms (Level of Evide

47、nce=B)Intermediate-risk acute coronary syndrome patients 2-3 days after presentation who have been free of active ischemia or heart failure symptoms (Level of Evidence = B)Risk Assessment and Prognosis with Exercise Testing in Patients with Symptoms and Prior History of CADClass IIa:Intermediate-ris

48、k acute coronary syndrome patients who have initial cardiac markers that are normal, a repeat ECG without significant change, and cardiac markers 6-12 hours after the onset of symptoms that are normal and no other evidence of ischemia by observation (Level of Evidence =B)Class IIb:Patients with the

49、following ECG abnormalities:WPW syndrome, electronically paced ventricular rhythm, 1 mm or more of resting ST-depression, complete LBBB or IVCD with a QRS duration 120 msecPatients with a stable clinical course who undergo periodic monitoring to guide treatmentRisk Assessment and Prognosis with Exer

50、cise Testing in Patients with Symptoms and Prior History of CADClass III:Patients with severe co-morbidity likely to limit life expectancy and/or candidacy for revascularizationHigh-risk acute coronary syndrome patients (Level of Evidence =c)Short-term Risk Assessment for Death or Nonfatal MI in Pat

51、ients with Acute Coronary Syndrome HIGH RISK (at least one of the following features):Character of Pain: Prolonged ongoing (20 min) rest chest painClinical Features: Pulmonary edema, new or worsening MR, S3 or new/worsening rales, hypotension, bradycardia, tachycardia, age 75 yrsECG Findings: Angina

52、 at rest with transient ST changes 0.05 mV, BBB (new or presumed new), sustained ventricular tachycardiaBiochemical Markers: Elevated troponin-I Short-term Risk Assessment for Death or Nonfatal MI in Patients with Acute Coronary SyndromeINTERMEDIATE RISK:No high-risk feature but must have one of the

53、 following:History: Prior MI, peripheral or cerebrovascular disease, CABG or prolonged aspirin useCharacter of Pain: Prolonged ( 20 min) rest angina, now resolved, with moderate to high likelihood of CADRest angina( 70 yrsECG Findings: T-wave inversions greater than 0.2 mV, pathological Q-wavesBioch

54、emical Markers: Borderline elevated troponin-IShort-term Risk Assessment for Death or Nonfatal MI in Patients with Acute Coronary SyndromeLOW RISK:No high or intermediate risk features but any of the following:Character of Pain: New-onset or progressive CCSC III or IV angina in past 2 weeks with mod

55、erate to high likelihood of CADECG Findings: Normal or unchanged ECG during an episode of chest discomfortBiochemical Markers: NormalPrognostic Factors from Exercise TestingElectrocardiographic:Maximum ST-depressionMaximum ST-elevationST-depression slope (morphology)Number of leads showing ST change

56、sDuration of ST deviation into recoveryST/HR indexesExercise-induced ventricular arrhythmiasTime to onset of ST deviationPrognostic Factors from Exercise TestingHemodynamic:Maximum exercise heart rateMaximum exercise SBPMaximum exercise double product (HRxSBP)Total exercise duration (functional capa

57、city)Exertional hypotensionChronotropic incompetenceAbnormal heart rate recoveryHeart Rate Recovery After Exercise Testing Predicts Outcome in CAD Prognostic Factors from Exercise TestingSymptomatic:Exercise-induced anginaExercise-induced symptoms (SOB, dizziness)Time to onset of anginaPrognostic Sc

58、ore in Assessment of Cardiac Event Risk during Exercise TestingDuke Prognostic Score:Treadmill Score = exercise time x 5 (amount of ST-segment deviation) - 4 x exercise angina index (0 = none, 1 = present but not limiting, 2 = reason to stop the test)High Risk: +5 (0.5% annual mortality)Information

59、additive to coronary anatomy and LVEFDuke Prognostic Score NomogramCombined Prognostic Factors Increase Predictive Value of Exercise Testing Data in CADIndications for Exercise Testing after Myocardial InfarctionClass I:Before discharge for prognostic assessment, activity prescription, evaluation of

60、 medical therapy (submaximal versus maximal, submaximal 4-6 days)Early after discharge for prognostic assessment, activity prescription, evaluation of medical therapy, and cardiac rehabilitation if pre-discharge exercise test was not done (symptom-limited, about 14-21 days)Late after discharge for p