心脏康复评定课件

1、CARDIOVASCULAR EVALUATION,DR. Liang Qi,1,PPT学习交流,A PATIENT CASE EXAMPLE,2,PPT学习交流,1. 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 cath

2、eterization?,3,PPT学习交流,4. Do you experience angina or shortness of breath at rest, only with activity/exercise, or both at rest and with activity/exercise?,4,PPT学习交流,5. If you experience angina or become short of breath during activity or exercise could you please describe the type of activity or ex

3、ercise which produces your angina or shortness of breath?,5,PPT学习交流,6. Can you describe your 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 p

4、ointing to your level of shortness of breath using this 10-point scale or by marking this visual analog scale?,6,PPT学习交流,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 meas

5、urement?,7,PPT学习交流,9. Could I place these electrodes on your chest to obtain a simple single-lead electrocardiogram (ECG)?,8,PPT学习交流,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 ob

6、serve your pulse, oxygen saturation, ECG, and symptoms when you are lying down and standing.,9,PPT学习交流,11. Could I listen to your heart 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

7、 are breathing deeply when listening to your lungs.,10,PPT学习交流,12. Could I place 1 of my hands on your stomach and 1 hand on your upper chest to 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 h

8、ands 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 you breathe?,11,PPT学习交流,16. Now that I understand some very basic information about the manner in which you breathe could you please breathe in the manner I

9、instruct you via sounds I make, pressure from my hands, methods I show to you, or different body positions? I will occasionally place my hands on your chest and wrap my tape measure around your chest to determine how you breathe during these simple tests and I will ask you to identify your level of

10、shortness of breath using the 10-point scale or visual analog scaleIs this ok with you?,12,PPT学习交流,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?,13,PPT学习交流,18. I would li

11、ke you to now perform the activity or exercise which produces your angina or shortness of breath. Could you please do this now?,14,PPT学习交流,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

12、 and pulmonary function tests that you said were performed last week as well as the arterial blood gas results, chest X-ray, and exercise test results.,15,PPT学习交流,Physical Therapy Examination,Medical Information and Risk Factor Analysis listening to the patients past history and primary complaints i

13、s critical in the examination process.,16,PPT学习交流,Examinations of Patient Appearance,categorized by specific signs and symptoms,17,PPT学习交流,Angina-Methods To Evaluate Angina from Nonanginal Pain,If a suspected anginal pain changes (increases or decreases) with breathing, palpation in the painful area

14、, or movement of a joint (ie, shoulder flexion and abduction) it is very likely that the pain is NOT angina.,18,PPT学习交流,Angina-Methods To Evaluate Angina from Nonanginal Pain,it can be worsened by physical exercise or activity. Therefore, if the suspected anginal pain is unchanged with the previousl

15、y 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 pain 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 pa

16、in decreases or subsides with nitroglycerin, it is even more likely that the pain IS angina.,19,PPT学习交流,20,PPT学习交流,Other Symptoms of Heart Disease,dyspnea Fatigue Dizziness Light headedness Palpitations a sense of impending doom,21,PPT学习交流,22,PPT学习交流,Examinations of Patient Appearance,skin color of

17、the peripheral extremities. Pale or cyanotic skin in the legs, feet, arms, and fingers is associated with poor cardiovascular function.,23,PPT学习交流,Examinations of Patient Appearance,Diagonal earlobe crease. This phenomenon has been investigated for many years and recently was once again found to be

18、highly predictive of heart disease,24,PPT学习交流,Anthropometric measurements,body weight finger pressure on an edematous area Girth measurements skin-fold caliper measurements calculation of the body mass index measure the percentage of body fat and lean muscle mass,25,PPT学习交流,Jugular venous distension

19、,it is often due to right-sided heart failure.,26,PPT学习交流,27,PPT学习交流,28,PPT学习交流,Palpation of the Radial Pulse,Palpation of the radial pulse can provide important information about the status of the cardiovascular system. Measurement of the Systolic Blood Pressure and Pulse During Breathing and Simpl

20、e Perturbations of the Breathing Cycle,29,PPT学习交流,Measurement of the Systolic and Diastolic Blood Pressure and Pulse in Different Body Positions,30,PPT学习交流,To Determine the Status of the Cardiovascular System,observation of a decrease in systolic and diastolic blood pressure without a subsequent inc

21、rease in heart rate when changing body position from supine to standing is considered a positive sign for autonomic nervous system dysfunction. .,31,PPT学习交流,To Determine theHealth of the Cardiovascular System,A cardiovascular system that responds rapidly to body position change is likely in a better

22、 state of health 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.,32,PPT学习交流,a sluggish or hypoadaptive (less than normal) heart rate and b

23、lood pressure response during a change in body position supine to standing should be considered abnormal and suggestive of an unhealthy cardiovascular system.,33,PPT学习交流,a more adaptive rapid increase in heart rate and blood pressure after moving from a supine to standing position (approximately 30

24、seconds) is likely associated with a healthier cardiovascular system,34,PPT学习交流,Examination of the Pulse and Arterial Blood PressureDuring Functional Tasks and Exercise,Frequent monitoring of the heart rate and blood pressure may be the best way to examine the safety of exercise and help to establis

25、h guidelines and procedures for functional or exercise training.,35,PPT学习交流,an increase in the diastolic blood pressure when the diastolic blood pressure should be decreased (or low) is a strong indicator of cardiovascular dysfunction. .,36,PPT学习交流,Potential indirect measures of cardiac function,Sym

26、ptoms and functional classification Cold, pale, and possibly cyanotic extremities Jugular venous distension and peripheral edema Heart sounds Pulse Electrocardiography Blood pressure,37,PPT学习交流,Standard measurement of cardiac function,Cardiac catheterization Echocardiography Swan-Gans catheterizatio

27、n Central venous pressure Cardiac enzymes ANP and BNP Radiologic evidence,38,PPT学习交流,Exercise Testing,39,PPT学习交流,Indications for Exercise Testing:,Diagnosis of Coronary Artery Disease Assessment of Prognosis in Coronary Artery Disease Evaluation of Functional Capacity Evaluation of Therapy for Coron

28、ary Disease Determination of Exercise Prescription,40,PPT学习交流,Absolute Contraindications to Exercise Testing,Acute MI (within 2 days) High-risk unstable angina Uncontrolled cardiac arrhythmias Active Endocarditis Severe aortic stenosis Decompensated heart failure Acute pulmonary embolus or infarctio

29、n, DVT Acute noncardiac disorder affecting or aggravated by exercise Acute myocarditis, pericarditis Physical disability precludes safe and adequate test Inability to obtain consent,41,PPT学习交流,Relative Contraindications to Exercise Testing,Left main coronary stenosis or equivalent Moderate aortic va

30、lvular stenosis(?) Electrolyte disorder Tachyarrhythmias or Bradyarrhythmias Atrial fibrillation with uncontrolled ventricular response Hypertrophic Cardiomyopathy (? gradient) Mental impairment leading to inability to cooperate High-degree AV block,42,PPT学习交流,ECG Lead Placement for Exercise Testing

31、,43,PPT学习交流,Protocols for Exercise Testing,44,PPT学习交流,Blood Pressure Responses: Exercise Testing,Dependency on cardiac output and peripheral resistance Normal responses: Increase in SBP ( 20-30 mmHg) No change or fall in DBP Inadequate rise in SBP: Myocardial ischemia, severe LV systolic dysfunction

32、, 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 heart disease, cardiomyopathy no evidence of clinically significant heart disease (dehy

33、dration, antihypertensive therapy, prolonged strenuous exercise),45,PPT学习交流,Heart Rate Response to Exercise Testing,Accelerated Heart Rate Response: Deconditioning, prolonged bed rest, anemia, metabolic disorders, conditions associated with decreased blood volume or low systemic vascular resistance,

34、 autonomic insufficency Chronotropic incompetence: Inadequate exercise effort, drug therapy (-blockers), Prognostic Significance: (Peak HR - Resting HR)/(220-age-Resting HR) 0.80 (Lauer, 1999) Peak HR 130 bpm (Ellestad),46,PPT学习交流,Evaluation of Exercise Effort during Exercise Testing: The Borg Perce

35、ived Exertion Scale,47,PPT学习交流,Exercise Capacity - Exercise Testing,MET capacity 1 MET = 3.5 ml/kg/min O2 consumption Functional Aerobic Impairment (FAI) (Bruce Protocol specific) Predicted MET level (nomograms) Predicted VO2 (ACSM formulae) Practical Aspects: Lack of association between LVEF and ex

36、ercise capacity Prognostic value of decreased exercise capacity and active CAD Predictor of patients disability,48,PPT学习交流,Exercise Testing - Complications,MI or death: Up to 10 per 10,000 tests (1 per 2,500) Life threatening ventricular arrhythmias: 0-5 per 100,000 Cardiac: Bradyarrhythmias, tachya

37、rrhythmias, acute coronary syndromes, heart failure, hypotension, syncope, death Noncardiac: Musculoskeletal trauma, soft-tissue injury Miscellaneous: Severe fatigue, dizziness, myalgias,49,PPT学习交流,Absolute Indications for Termination of Exercise Test,ST-segment elevation ( 1.0 mm) in leads without

38、Q-waves (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 ischemia Moderate to severe angina (grades 3-4) Central nervous system symptoms (ataxia, dizziness, near syncope) Signs of p

39、oor perfusion (cyanosis or pallor) Sustained ventricular tachycardia Technical difficulties monitoring the ECG or systolic BP Patients request to stop,50,PPT学习交流,Relative Indications for Termination of an Exercise Test,ST changes (horizontal or downsloping 2 mm) or marked axis shift Drop in systolic

40、 blood pressure 10 mmHg (persistently below baseline) despite an increase in workload, in the absence of other evidence of ischemia and no presyncopal symptoms Increasing chest pain Fatigue, shortness of breath, wheezing, leg cramps, or claudication Hypertensive response (SBP 250 mmHg and/or DBP 115

41、 mmHg) Development of bundle-branch block (LBBB) that cannot be distinguished from ventricular tachycardia; ? Evidence of anterior ischemia Arrhythmias other than sustained ventricular tachycardia (frequent multifocal PVCs, ventricular triplets, SVT, heart block, or bradyarrhythmias) General Appeara

42、nce (diaphoresis, peripheral cyanosis),51,PPT学习交流,Criteria for Reading ST-Segment Changes on the Exercise ECG,ST DEPRESSION: Measurements made on 3 consecutive ECG complexes ! ST level is measured relative to the P-Q junction 3 key measurements (P-Q junction, J-point, 60-80msec after J-point - use 6

43、0 msec for HR 130 bpm When J-point is depressed relative to P-Q junction at baseline: Net difference from the J junction determines the amount of deviation When the J-point is elevated relative to P-Q junction at baseline and becomes depressed with exercise: Magnitude of ST depression is determined

44、from the P-Q junction and not the resting J point,52,PPT学习交流,Criteria for Reading ST-Segment Changes on the Exercise ECG,ST ELEVATION: 60 msec after J point in 3 consecutive ECG complexes,53,PPT学习交流,Criteria for Abnormal and Borderline ST-Segment Depression on the Exercise ECG,ABNORMAL: 1.0 mm or gr

45、eater horizontal or downsloping ST depression at 60 msec after J point on 3 consecutive ECG complexes BORDERLINE: 0.5 to 1.0 mm horizontal or downsloping ST depression at 60 msec after J point on 3 consecutive ECG complexes 2.0 mm or greater upsloping ST depression at 60 msec after J point on 3 cons

46、ecutive ECG complexes,54,PPT学习交流,Morphology of ST-Segment Deviation during Exercise Testing,55,PPT学习交流,Value of Right-Sided ECG Leads during Exercise Testing for the Diagnosis of CAD,56,PPT学习交流,Horizontal ST-segment Depression during Exercise Testing,57,PPT学习交流,Downsloping ST-Segment Depression duri

47、ng Exercise Testing,58,PPT学习交流,ST-Segment Depression in Early Recovery Period after Exercise Testing,59,PPT学习交流,Upsloping ST-Segment Depression during Exercise Testing,60,PPT学习交流,Morphology of ST-Segment Depression Predicts Severity of Coronary Artery Disease (Goldschlager, 1976),61,PPT学习交流,Exercise

48、-Induced ST-Segment Elevation with Prior Anterior Myocardial Infarction,62,PPT学习交流,Exercise-Induced ST-Segment Elevation in the Setting of Prior Inferolateral MI,63,PPT学习交流,Exercise-Induced Anterior ST-Segment Elevation as Reflection of LAD Ischemia,64,PPT学习交流,Indications for Exercise Testing in the

49、 Diagnosis of Obstructive Coronary Disease,CLASS 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 symptoms CLASS IIa: Patients with vasospastic angina CLASS IIb: Patients with a high pr

50、etest probability of CAD by age, symptoms, and gender Patients with a low pretest probability of CAD by age, symptoms, and gender Patients with less than 1 mm of baseline ST depression and taking digoxin Patients with ECG criteria of LVH and less than 1 mm St-depression,65,PPT学习交流,Pre-test Probabili

51、ty of CAD by Age, Gender, and Symptoms,Typical/Definite Angina Pectoris Age 30-39 MenIntermediate (10-90%) Women Intermediate Age 40-49 MenHigh (90%) Women Intermediate Age 50-59 MenHigh Women Intermediate Age 60-69 MenHigh Women High,66,PPT学习交流,Pre-test Probability of CAD by Age, Gender, and Sympto

52、ms,Atypical/Possible Angina Pectoris: Age 30-39 MenIntermediate Women Very Low (5%) Age 40-49 MenIntermediate Women Low (10%) Age 50-50 MenIntermediate Women Intermediate Age 60-69 Men Intermediate Women Intermediate,67,PPT学习交流,Pre-test Probability of CAD by Age, Gender, and Symptoms,Nonanginal Ches

53、t Pain: Age 30-39 MenLow Women Very Low Age 40-49 MenIntermediate Women Very Low Age 50-59 MenIntermediate Women Low Age 60-69 MenIntermediate Women Intermediate,68,PPT学习交流,Pre-test Probability of CAD by Age, Gender, and Symptoms,Asymptomatic: Age 30-39 MenVery Low Women Very Low Age 40-49 MenLow Wo

54、men Very Low Age 50-59 MenLow Women Very Low Age 60-69 MenLow Women Low,69,PPT学习交流,Indications for Exercise Testing in the Diagnosis of Obstructive Coronary Disease,Class III: Patients with the following ECG abnormalities: WPW syndrome, electronically paced ventricular rhythm, greater than 1 mm rest

55、ing ST-depression, complete LBBB Patients with a documented MI or prior coronary angiography demonstrating significant CAD have an established diagnosis (?ischemia, prognosis),70,PPT学习交流,Exercise Testing; Sensitivity and Specificity for the Diagnosis of CAD,Sensitivity = True positives/true positive

56、s + false negatives x 100 Specificity = True negatives/false positives + true negatives x 100 Standard Exercise Test (mostly men)* Sensitivity = 68% Specificity = 77% Predictive Accuracy = 73% *Based on 1.0 mm ST-segment depression,71,PPT学习交流,Exercise Testing in the Diagnosis of Coronary Artery Dise

57、ase in Women,ECG Analysis alone: Sensitivity:46-79% Specificity:48-86% Use of Duke Prognostic Score: Low Risk score: 19.1% CAD 75% stenosis, 3.5% 3-vessel or left main disease Intermediate Risk score: 34.9% CAD 75% stenosis, 12.4% 3-vessel or left main disease High Risk Score: 89.2% CAD 75% stenosis

58、, 46% 3-vessel or left main disease,72,PPT学习交流,Risk Assessment and Prognosis with Exercise Testing in Patients with Symptoms and Prior History of CAD,Class I: Patient undergoing initial evaluation with suspected or known CAD including those with complete RBBB and less than 1 mm of resting ECG (excep

59、tions - Class IIb) Patients with suspected or know CAD previously evaluated, now presenting with significant change in clinical status Low-risk acute coronary syndrome patients 8-12 hours after presentation who have been free of active ischemia or heart failure symptoms (Level of Evidence=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),73,PPT学习交流,Risk Assessment and Prognosis with Exercise Testing in Patients with Symptoms and Prior Histo