心脏康复评定培训ppt课件

心脏康复评定心脏康复评定1A PATIENT CASE EXAMPLE2心脏康复评定A PATIENT CASE EXAMPLE2心脏康复评定21.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心脏康复评定1.Why are you here today?3心脏康34.Do you experience angina or shortness of breath at rest,only with activity/exercise,or both at rest and with activity/exercise?4心脏康复评定4.Do you experience angina or45.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?5心脏康复评定5.If you experience angina or56.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 pointing to your level of shortness of breath using this 10-point scale or by marking this visual analog scale?6心脏康复评定6.Can you describe your angin67.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?7心脏康复评定7.Could I feel your pulse to 7 9.Could I place these electrodes on your chest to obtain a simple single-lead electrocardiogram(ECG)?8心脏康复评定 9.Could I place these electr810.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.9心脏康复评定10.Could I take your blood pr911.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 are breathing deeply when listening to your lungs.10心脏康复评定11.Could I listen to your hea1012.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 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 you breathe?11心脏康复评定12.Could I place 1 of my hand1116.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,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 with you?12心脏康复评定16.Now that I understand some1217.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心脏康复评定17.Could I measure the streng1318.I would like you to now perform the activity or exercise which produces your angina or shortness of breath.Could you please do this now?14心脏康复评定18.I would like you to now pe14Thank 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 results,chest X-ray,and exercise test results.15心脏康复评定Thank you for giving me the ch15Physical Therapy Examination Medical Information and Risk Factor Analysis listening to the patients past history and primary complaints is critical in the examination process.16心脏康复评定Physical Therapy Examination M16Examinations of Patient Appearance categorized by specific signs and symptoms 17心脏康复评定Examinations of Patient Appear17Angina-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.18心脏康复评定Angina-Methods To Evaluate Ang18Angina-Methods To Evaluate Angina 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 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 pain decreases or subsides with nitroglycerin,it is even more likely that the pain IS angina.19心脏康复评定Angina-Methods To Evaluate Ang1920心脏康复评定20心脏康复评定20Other Symptoms of Heart DiseasedyspneaFatigueDizzinessLight headednessPalpitationsa sense of impending doom 21心脏康复评定Other Symptoms of Heart Dise2122心脏康复评定22心脏康复评定22Examinations 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.23心脏康复评定Examinations of Patient Appear23Examinations 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心脏康复评定Examinations of Patient Appear24Anthropometric measurementsbody weightfinger 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心脏康复评定Anthropometric measurementsbod25Jugular venous distensionit is often due to right-sided heart failure.26心脏康复评定Jugular venous distensionit is2627心脏康复评定27心脏康复评定2728心脏康复评定28心脏康复评定28Palpation 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 Breathing Cycle29心脏康复评定Palpation of the Radial PulseP29 Measurement of the Systolic and Diastolic Blood Pressure and Pulse in Different Body Positions30心脏康复评定 Measurement of the Systolic 30To Determine the Status of the Cardiovascular Systemobservation of a decrease in systolic and diastolic blood pressure 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心脏康复评定To Determine the Status of th31To Determine theHealth of the Cardiovascular SystemA cardiovascular system that responds rapidly 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心脏康复评定To Determine theHealth of the32a 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心脏康复评定a sluggish or hypoadaptive(le33a 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 healthier cardiovascular system34心脏康复评定a more adaptive rapid increase34Examination 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 exercise training.35心脏康复评定Examination of the Pulse and A35an increase in the diastolic blood pressure when the diastolic blood pressure should be decreased(or low)is a strong indicator of cardiovascular dysfunction.36心脏康复评定an increase in the diastolic b36Potential indirect measures of cardiac functionSymptoms and functional classificationCold,pale,and possibly cyanotic extremitiesJugular venous distension and peripheral edemaHeart soundsPulseElectrocardiographyBlood pressure37心脏康复评定Potential indirect measures of37Standard measurement of cardiac functionCardiac catheterizationEchocardiographySwan-Gans catheterizationCentral venous pressureCardiac enzymesANP and BNPRadiologic evidence38心脏康复评定Standard measurement of cardia38Exercise Testing39心脏康复评定Exercise Testing39心脏康复评定39Indications 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心脏康复评定Indications for Exercise Testi40Absolute 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 aggravated by exerciseAcute myocarditis,pericarditisPhysical disability precludes safe and adequate testInability to obtain consent41心脏康复评定Absolute Contraindications to 41Relative Contraindications to Exercise TestingLeft main coronary stenosis or equivalentModerate aortic valvular stenosis(?)Electrolyte disorderTachyarrhythmias or BradyarrhythmiasAtrial fibrillation with uncontrolled ventricular responseHypertrophic Cardiomyopathy(?gradient)Mental impairment leading to inability to cooperateHigh-degree AV block42心脏康复评定Relative Contraindications to 42ECG Lead Placement for Exercise Testing43心脏康复评定ECG Lead Placement for Exerci43Protocols for Exercise Testing44心脏康复评定Protocols for Exercise Testing44Blood 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 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 heart disease,cardiomyopathy no evidence of clinically significant heart disease(dehydration,antihypertensive therapy,prolonged strenuous exercise)45心脏康复评定Blood Pressure Responses:Exe45Heart Rate Response to Exercise TestingAccelerated Heart Rate Response:Deconditioning,prolonged bed rest,anemia,metabolic disorders,conditions associated 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(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 perfusion(cyanosis or pallor)Sustained ventricular tachycardiaTechnical difficulties monitoring the ECG or systolic BPPatients request to stop50心脏康复评定Absolute Indications for Termi50Relative Indications for Termination of an Exercise TestST changes(horizontal or downsloping 2 mm)or marked axis shiftDrop in systolic blood 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)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(diaphoresis,peripheral cyanosis)51心脏康复评定Relative Indications for Termi51Criteria 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 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 determined from the P-Q junction and not the resting J point52心脏康复评定Criteria for Reading ST-Segmen52Criteria for Reading ST-Segment Changes on the Exercise ECGST ELEVATION:60 msec after J point in 3 consecutive ECG complexes53心脏康复评定Criteria for Reading ST-Segmen53Criteria 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 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 upsloping ST depression at 60 msec after J point on 3 consecutive ECG complexes54心脏康复评定Criteria for Abnormal and Bord54Morphology of ST-Segment Deviation during Exercise Testing55心脏康复评定Morphology of ST-Segment Devia55Value of Right-Sided ECG Leads during Exercise Testing for the Diagnosis of CAD56心脏康复评定Value of Right-Sided ECG Leads56Horizontal ST-segment Depression during Exercise Testing57心脏康复评定Horizontal ST-segment Depressi57Downsloping ST-Segment Depression during Exercise Testing58心脏康复评定Downsloping ST-Segment Depress58ST-Segment Depression in Early Recovery Period after Exercise Testing59心脏康复评定ST-Segment Depression in Early59Upsloping ST-Segment Depression during Exercise Testing60心脏康复评定Upsloping ST-Segment Depressio60Morphology of ST-Segment Depression Predicts Severity of Coronary Artery Disease(Goldschlager,1976)61心脏康复评定Morphology of ST-Segment Depre61Exercise-Induced ST-Segment Elevation with Prior Anterior Myocardial Infarction62心脏康复评定Exercise-Induced ST-Segment El62Exercise-Induced ST-Segment Elevation in the Setting of Prior Inferolateral MI63心脏康复评定Exercise-Induced ST-Segment El63Exercise-Induced Anterior ST-Segment Elevation as Reflection of LAD Ischemia64心脏康复评定Exercise-Induced Anterior ST-S64Indications 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 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 criteria of LVH and less than 1 mm St-depression65心脏康复评定Indications for Exercise Testi65Pre-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心脏康复评定Pre-test Probability of CAD b66Pre-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-vessel or left main diseaseHigh Risk Score:89.2%CAD 75%stenosis,46%3-vessel or left main disease72心脏康复评定Exercise Testing in the Diagno72Risk 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 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 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心脏康复评定Risk Assessment and Prognosis 73Risk Assessment and 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 are 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 stable clinical course who undergo periodic monitoring to guide treatment74心脏康复评定Risk Assessment and Prognosis 74Risk 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 candidacy for revascularizationHigh-risk acute coronary syndrome patients(Level of Evidence=c)75心脏康复评定Risk Assessment and Prognosis 75Short-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 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 at rest with transient ST changes 0.05 mV,BBB(new or presumed new),sustained ventricular tachycardiaBiochemical Markers:Elevated troponin-I 76心脏康复评定Short-term Risk Assessment for76Short-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 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-wavesBiochemical Markers:Borderline elevated troponin-I77心脏康复评定Short-term Risk Assessment for77心脏康复评定培训ppt课件78Prognostic Factors from Exercise TestingElectrocardiographic:Maximum ST-depressionMaximum ST-elevationST-depression slope(morphology)Number of leads showing ST changesDuration of ST deviation into recoveryST/HR indexesExercise-induced ventricular arrhythmiasTime to onset of ST deviation79心脏康复评定Prognostic Factors from Exerci79Prognostic Factors from Exercise TestingHemodynamic:Maximum exercise heart rateMaximum exercise SBPMaximum exercise double product(HRxSBP)Total exercise duration(functional capacity)Exertional hypotensionChronotropic incompetenceAbnormal heart rate recovery80心脏康复评定Prognostic Factors from Exerci80Heart Rate Recovery After Exercise Testing Predicts Outcome in CAD 81心脏康复评定Heart Rate Recovery After Exer81Prognostic Factors from Exercise TestingSymptomatic:Exercise-induced anginaExercise-induced symptoms(SOB,dizziness)Time to onset of angina82心脏康复评定Prognostic Factors from Exerci82Prognostic Score 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 addi