心臟康復(fù)評定培訓(xùn)課件

1、心臟康復(fù)評定心臟康復(fù)評定A PATIENT CASE EXAMPLE2心臟康復(fù)評定A PATIENT CASE EXAMPLE2心臟康復(fù)評定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 catheterization?3心

2、臟康復(fù)評定1. Why are you here today?3心臟康4. Do you experience angina or shortness of breath at rest, only with activity/exercise, or both at rest and with activity/exercise?4心臟康復(fù)評定4. Do you experience angina or5. If you experience angina or become short of breath during activity or exercise could you plea

3、se describe the type of activity or exercise which produces your angina or shortness of breath?5心臟康復(fù)評定5. If you experience angina or6. 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

4、 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 visual analog scale?6心臟康復(fù)評定6. Can you describe your angin7. Could I feel your pulse to determine your heart rate and the strength of your pulse? 8

5、. Could I place this finger probe on your index finger to obtain an oxygen saturation measurement?7心臟康復(fù)評定7. Could I feel your pulse to 9. Could I place these electrodes on your chest to obtain a simple single-lead electrocardiogram (ECG)?8心臟康復(fù)評定 9. Could I place these electr10. Could I take your blo

6、od 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.9心臟康復(fù)評定10. Could I take your blood pr11. Could I listen to your he

7、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. 10心臟康復(fù)評定11. Could I listen to your hea12. Could I place 1 of my hands on your st

8、omach 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 hands on your back to determine how you breathe? 15. Could I wrap my tape measure around your chest at sev

9、eral different sites to determine how you breathe? 11心臟康復(fù)評定12. Could I place 1 of my hand16. Now that I understand some very basic information about the manner in which you breathe could you please breathe in the manner I instruct you via sounds I make, pressure from my hands, methods I show to you,

10、 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 shortness of breath using the 10-point scale or visual analog scaleIs this ok

11、with you? 12心臟康復(fù)評定16. Now that I understand some17. 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心臟康復(fù)評定17. Could I measure the streng18. I would like you to now perform th

12、e activity or exercise which produces your angina or shortness of breath. Could you please do this now? 14心臟康復(fù)評定18. I would like you to now peThank you for giving me the chance to examine you today. I will call your physician to get some more information about you like electrocardiogram, echocardiog

13、ram 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心臟康復(fù)評定Thank you for giving me the chPhysical Therapy Examination Medical Information and Risk Factor Analysis listening to the patients past hi

14、story and primary complaints is critical in the examination process. 16心臟康復(fù)評定Physical Therapy Examination MExaminations of Patient Appearance categorized by specific signs and symptoms 17心臟康復(fù)評定Examinations of Patient AppearAngina-Methods To Evaluate Angina from Nonanginal Pain If a suspected anginal

15、 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.18心臟康復(fù)評定Angina-Methods To Evaluate AngAngina-Methods To Evaluate Angina from Nonanginal Painit can be worsen

16、ed 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 pain occurred with exertion, and if the

17、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. 19心臟康復(fù)評定Angina-Methods To Evaluate Ang20心臟康復(fù)評定20心臟康復(fù)評定Other Symptoms of Heart DiseasedyspneaFatigue

18、DizzinessLight headednessPalpitationsa sense of impending doom 21心臟康復(fù)評定Other Symptoms of Heart Dise22心臟康復(fù)評定22心臟康復(fù)評定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. 2

19、3心臟康復(fù)評定Examinations of Patient AppearExaminations of Patient AppearanceDiagonal earlobe crease. This phenomenon has been investigated for many years and recently was once again found to be highly predictive of heart disease 24心臟康復(fù)評定Examinations of Patient AppearAnthropometric measurementsbody weight

20、finger pressure on an edematous areaGirth measurements skin-fold caliper measurementscalculation of the body mass index measure the percentage of body fat and lean muscle mass25心臟康復(fù)評定Anthropometric measurementsbodJugular venous distensionit is often due to right-sided heart failure. 26心臟康復(fù)評定Jugular

21、venous distensionit is27心臟康復(fù)評定27心臟康復(fù)評定28心臟康復(fù)評定28心臟康復(fù)評定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 Breathing and Simple Perturbations of the Brea

22、thing Cycle29心臟康復(fù)評定Palpation of the Radial PulseP Measurement of the Systolic and Diastolic Blood Pressure and Pulse in Different Body Positions30心臟康復(fù)評定 Measurement of the Systolic To Determine the Status of the Cardiovascular Systemobservation of a decrease in systolic and diastolic blood pressure

23、without a subsequent increase in heart rate when changing body position from supine to standing is considered a positive sign for autonomic nervous system dysfunction. .31心臟康復(fù)評定To Determine the Status of thTo Determine theHealth of the Cardiovascular SystemA cardiovascular system that responds rapid

24、ly to body position change is likely in a better 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心臟康復(fù)評定To Determine theHe

25、alth of thea sluggish or hypoadaptive (less than normal) heart rate and blood pressure response during a change in body position supine to standing should be considered abnormal and suggestive of an unhealthy cardiovascular system. 33心臟康復(fù)評定a sluggish or hypoadaptive (lea more adaptive rapid increase

26、 in heart rate and blood pressure after moving from a supine to standing position (approximately 30 seconds) is likely associated with a healthier cardiovascular system34心臟康復(fù)評定a more adaptive rapid increaseExamination of the Pulse and Arterial Blood PressureDuring Functional Tasks and ExerciseFreque

27、nt 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 exercise training. 35心臟康復(fù)評定Examination of the Pulse and Aan increase in the diastolic blood pressure when the diastolic blood pre

28、ssure should be decreased (or low) is a strong indicator of cardiovascular dysfunction. . 36心臟康復(fù)評定an increase in the diastolic bPotential indirect measures of cardiac functionSymptoms and functional classificationCold, pale, and possibly cyanotic extremitiesJugular venous distension and peripheral e

29、demaHeart soundsPulseElectrocardiographyBlood pressure37心臟康復(fù)評定Potential indirect measures ofStandard measurement of cardiac functionCardiac catheterizationEchocardiographySwan-Gans catheterizationCentral venous pressureCardiac enzymesANP and BNPRadiologic evidence38心臟康復(fù)評定Standard measurement of card

30、iaExercise Testing39心臟康復(fù)評定Exercise Testing39心臟康復(fù)評定Indications for Exercise Testing:Diagnosis of Coronary Artery DiseaseAssessment of Prognosis in Coronary Artery DiseaseEvaluation of Functional CapacityEvaluation of Therapy for Coronary DiseaseDetermination of Exercise Prescription40心臟康復(fù)評定Indication

31、s for Exercise TestiAbsolute Contraindications to Exercise TestingAcute MI (within 2 days)High-risk unstable anginaUncontrolled cardiac arrhythmias Active EndocarditisSevere aortic stenosisDecompensated heart failureAcute pulmonary embolus or infarction, DVTAcute noncardiac disorder affecting or agg

32、ravated by exerciseAcute myocarditis, pericarditisPhysical disability precludes safe and adequate testInability to obtain consent41心臟康復(fù)評定Absolute Contraindications to Relative Contraindications to Exercise TestingLeft main coronary stenosis or equivalentModerate aortic valvular stenosis(?)Electrolyt

33、e disorderTachyarrhythmias or BradyarrhythmiasAtrial fibrillation with uncontrolled ventricular responseHypertrophic Cardiomyopathy (? gradient)Mental impairment leading to inability to cooperateHigh-degree AV block42心臟康復(fù)評定Relative Contraindications to ECG Lead Placement for Exercise Testing43心臟康復(fù)評定

34、ECG Lead Placement for ExerciProtocols for Exercise Testing44心臟康復(fù)評定Protocols for Exercise TestingBlood Pressure Responses: Exercise TestingDependency on cardiac output and peripheral resistanceNormal responses: Increase in SBP ( 20-30 mmHg)No change or fall in DBPInadequate rise in SBP:Myocardial is

35、chemia, 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 heart disease, cardiomyopathy no evidence of clinic

36、ally significant heart disease (dehydration, antihypertensive therapy, prolonged strenuous exercise)45心臟康復(fù)評定Blood Pressure Responses: ExeHeart Rate Response to Exercise TestingAccelerated Heart Rate Response:Deconditioning, prolonged bed rest, anemia, metabolic disorders, conditions associated with

37、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 (other than

38、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 perfusion (cyanosis

39、 or pallor)Sustained ventricular tachycardiaTechnical difficulties monitoring the ECG or systolic BPPatients request to stop50心臟康復(fù)評定Absolute Indications for TermiRelative Indications for Termination of an Exercise TestST changes (horizontal or downsloping 2 mm) or marked axis shiftDrop in systolic b

40、lood pressure 10 mmHg (persistently 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

41、)Development of bundle-branch 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 (dia

42、phoresis, peripheral cyanosis)51心臟康復(fù)評定Relative Indications for TermiCriteria 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

43、-point - use 60 msec for HR 130 bpmWhen J-point is depressed relative 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 d

44、etermined from the P-Q junction and not the resting J point52心臟康復(fù)評定Criteria for Reading ST-SegmenCriteria for Reading ST-Segment Changes on the Exercise ECGST ELEVATION: 60 msec after J point in 3 consecutive ECG complexes53心臟康復(fù)評定Criteria for Reading ST-SegmenCriteria for Abnormal and Borderline ST-

45、Segment Depression on the Exercise ECGABNORMAL:1.0 mm or greater horizontal or downsloping ST depression at 60 msec after J point on 3 consecutive 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 up

46、sloping ST depression at 60 msec after J point on 3 consecutive ECG complexes54心臟康復(fù)評定Criteria for Abnormal and BordMorphology of ST-Segment Deviation during Exercise Testing55心臟康復(fù)評定Morphology of ST-Segment DeviaValue of Right-Sided ECG Leads during Exercise Testing for the Diagnosis of CAD56心臟康復(fù)評定Va

47、lue of Right-Sided ECG LeadsHorizontal ST-segment Depression during Exercise Testing57心臟康復(fù)評定Horizontal ST-segment DepressiDownsloping ST-Segment Depression during Exercise Testing58心臟康復(fù)評定Downsloping ST-Segment DepressST-Segment Depression in Early Recovery Period after Exercise Testing59心臟康復(fù)評定ST-Seg

48、ment Depression in EarlyUpsloping ST-Segment Depression during Exercise Testing60心臟康復(fù)評定Upsloping ST-Segment DepressioMorphology of ST-Segment Depression Predicts Severity of Coronary Artery Disease (Goldschlager, 1976)61心臟康復(fù)評定Morphology of ST-Segment DepreExercise-Induced ST-Segment Elevation with P

49、rior Anterior Myocardial Infarction62心臟康復(fù)評定Exercise-Induced ST-Segment ElExercise-Induced ST-Segment Elevation in the Setting of Prior Inferolateral MI63心臟康復(fù)評定Exercise-Induced ST-Segment ElExercise-Induced Anterior ST-Segment Elevation as Reflection of LAD Ischemia64心臟康復(fù)評定Exercise-Induced Anterior S

50、T-SIndications 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 symptomsCLASS IIa:Patients with vasospastic ang

51、inaCLASS 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 criteria of LVH and less than 1 mm St-depress

52、ion65心臟康復(fù)評定Indications for Exercise TestiPre-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 66心臟康復(fù)評定Pre-te

53、st Probability of CAD bPre-test Probability 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-ves

54、sel or left main diseaseHigh Risk Score: 89.2% CAD 75% stenosis, 46% 3-vessel or left main disease72心臟康復(fù)評定Exercise Testing in the DiagnoRisk Assessment and Prognosis with Exercise Testing in Patients with Symptoms and Prior History of CADClass I:Patient undergoing initial evaluation with suspected o

55、r known CAD including those with complete RBBB and less than 1 mm of resting 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

56、 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心臟康復(fù)評定Risk Assessment and Prognosis Risk Assessment and

57、 Prognosis with Exercise Testing in Patients with Symptoms and Prior History of CADClass IIa:Intermediate-risk 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 a

58、re normal and no other evidence of ischemia by observation (Level of Evidence =B)Class IIb:Patients with the 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 sta

59、ble clinical course who undergo periodic monitoring to guide treatment74心臟康復(fù)評定Risk Assessment and Prognosis Risk Assessment and Prognosis with Exercise Testing in Patients with Symptoms and Prior History of CADClass III:Patients with severe co-morbidity likely to limit life expectancy and/or candida

60、cy for revascularizationHigh-risk acute coronary syndrome patients (Level of Evidence =c)75心臟康復(fù)評定Risk Assessment and Prognosis Short-term Risk Assessment for Death or Nonfatal MI in Patients with Acute Coronary Syndrome HIGH RISK (at least one of the following features):Character of Pain: Prolonged