心脏康复评定培训课件_2

,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,心脏康复评定,心脏康复评定,A PATIENT CASE EXAMPLE,A PATIENT CASE EXAMPLE,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?,1. Why are you here today?,4. Do you experience angina or shortness of breath at rest, only with activity/exercise, or both at rest and with activity/exercise?,4. Do you experience angina or,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?,5. If you experience angina or,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 pointing to your level of shortness of breath using this 10-point scale or by marking this visual analog scale?,6. Can you describe your angin,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?,7. Could I feel your pulse to,9. Could I place these electrodes on your chest to obtain a simple single-lead electrocardiogram (ECG)?,9. Could I place these electr,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.,10. Could I take your blood pr,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 are breathing deeply when listening to your lungs.,11. Could I listen to your hea,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 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?,12. Could I place 1 of my hand,16. 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 scale,Is this ok with you?,16. Now that I understand some,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?,17. Could I measure the streng,18. 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?,18. I would like you to now pe,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 results, chest X-ray, and exercise test results.,Thank you for giving me the ch,Physical Therapy Examination,Medical Information and Risk Factor Analysis,listening to the patients past history and primary complaints is critical in the examination process.,Physical Therapy Examination M,Examinations of Patient Appearance,categorized by specific signs and symptoms,Examinations of Patient Appear,Angina-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 Ang,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 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.,Angina-Methods To Evaluate Ang,心脏康复评定培训课件_2,Other Symptoms of Heart Disease,dyspnea,Fatigue,Dizziness,Light headedness,Palpitations,a sense of impending doom,Other Symptoms of Heart Dise,心脏康复评定培训课件_2,Examinations of Patient Appearance,skin 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 Appear,Examinations of Patient Appearance,Diagonal earlobe crease. This phenomenon has been investigated for many years and recently was once again found to be highly predictive of heart disease,Examinations of Patient Appear,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,Anthropometric measurementsbod,Jugular venous distension,it is often due to right-sided heart failure.,Jugular venous distensionit is,心脏康复评定培训课件_2,心脏康复评定培训课件_2,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 Simple Perturbations of the Breathing Cycle,Palpation of the Radial PulseP,Measurement of the Systolic and Diastolic Blood Pressure and Pulse in Different Body Positions,Measurement of the Systolic,To Determine the Status of the Cardiovascular System,observation 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. .,To Determine the Status of th,To Determine theHealth of the Cardiovascular System,A 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.,To Determine theHealth of the,a 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.,a sluggish or hypoadaptive (le,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 healthier cardiovascular system,a more adaptive rapid increase,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 establish guidelines and procedures for functional or exercise training.,Examination of the Pulse and A,an increase in the diastolic blood pressure when the diastolic blood pressure should be decreased (or low) is a strong indicator of cardiovascular dysfunction. .,an increase in the diastolic b,Potential indirect measures of cardiac function,Symptoms and functional classification,Cold, pale, and possibly cyanotic extremities,Jugular venous distension and peripheral edema,Heart sounds,Pulse,Electrocardiography,Blood pressure,Potential indirect measures of,Standard measurement of cardiac function,Cardiac catheterization,Echocardiography,Swan-Gans catheterization,Central venous pressure,Cardiac enzymes,ANP and BNP,Radiologic evidence,Standard measurement of cardia,Exercise Testing,Exercise Testing,Indications for Exercise Testing:,Diagnosis of Coronary Artery Disease,Assessment of Prognosis in Coronary Artery Disease,Evaluation of Functional Capacity,Evaluation of Therapy for Coronary Disease,Determination of Exercise Prescription,Indications for Exercise Testi,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 infarction, DVT,Acute noncardiac disorder affecting or aggravated by exercise,Acute myocarditis, pericarditis,Physical disability precludes safe and adequate test,Inability to obtain consent,Absolute Contraindications to,Relative Contraindications to Exercise Testing,Left main coronary stenosis or equivalent,Moderate aortic valvular 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,Relative Contraindications to,ECG Lead Placement for Exercise Testing,ECG Lead Placement for Exerci,Protocols for Exercise Testing,Protocols for Exercise Testing,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, 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),Blood Pressure Responses: Exe,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, 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 1.0 mm) in leads without Q-waves (other than V,1,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 poor perfusion (cyanosis or pallor),Sustained ventricular tachycardia,Technical difficulties monitoring the ECG or systolic BP,Patients request to stop,Absolute Indications for Termi,Relative Indications for Termination of an Exercise Test,ST changes (horizontal or downsloping 2 mm) or marked axis shift,Drop 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 symptoms,Increasing chest pain,Fatigue, shortness of breath, wheezing, leg cramps, or claudication,Hypertensive 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 ischemia,Arrhythmias other than sustained ventricular tachycardia (frequent multifocal PVCs, ventricular triplets, SVT, heart block, or bradyarrhythmias),General Appearance (diaphoresis, peripheral cyanosis),Relative Indications for Termi,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 60 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 from the P-Q junction and not the resting J point,Criteria for Reading ST-Segmen,Criteria for Reading ST-Segment Changes on the Exercise ECG,ST ELEVATION:,60 msec after J point in 3 consecutive ECG complexes,Criteria for Reading ST-Segmen,Criteria for Abnormal and Borderline ST-Segment Depression on the Exercise ECG,ABNORMAL:,1.0 mm or greater 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 consecutive ECG complexes,Criteria for Abnormal and Bord,Morphology of ST-Segment Deviation during Exercise Testing,Morphology of ST-Segment Devia,Value of Right-Sided ECG Leads during Exercise Testing for the Diagnosis of CAD,Value of Right-Sided ECG Leads,Horizontal ST-segment Depression during Exercise Testing,Horizontal ST-segment Depressi,Downsloping ST-Segment Depression during Exercise Testing,Downsloping ST-Segment Depress,ST-Segment Depression in Early Recovery Period after Exercise Testing,ST-Segment Depression in Early,Upsloping ST-Segment Depression during Exercise Testing,Upsloping ST-Segment Depressio,Morphology of ST-Segment Depression Predicts Severity of Coronary Artery Disease (Goldschlager, 1976),Morphology of ST-Segment Depre,Exercise-Induced ST-Segment Elevation with Prior Anterior Myocardial Infarction,Exercise-Induced ST-Segment El,Exercise-Induced ST-Segment Elevation in the Setting of Prior Inferolateral MI,Exercise-Induced ST-Segment El,Exercise-Induced Anterior ST-Segment Elevation as Reflection of LAD Ischemia,Exercise-Induced Anterior ST-S,Indications for,Exercise Testing in the 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 pretest 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,Indications for Exercise Testi,Pre-test Probability 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,Pre-test Probability of CAD b,Pre-test Probability of CAD by Age, Gender, and Symptoms,Atypical/Possible Angina Pectoris:,Age 30-39,MenIntermediate,Women Very Low (5%),Age 40-49,MenIntermediate,Women Low (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, 46% 3-vessel or left main disease,Exercise Testing in the Diagno,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 (exceptions - 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),Risk Assessment and Prognosis,Risk Assessment and Prognosis with Exercise Testing in Patients with Symptoms and Prior History of CAD,Class 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:,Pa