Cardiac Conditions and Hypertension
PTA 103 Introduction to Clinical Practice 2

Introduction

Cardiac conditions can follow a progressive continuum from single body system to multiple body system impairments and dysfunction. In this lesson, we will start understanding some of the cardiac conditions and cardiac procedures you will frequently encounter in all settings involving adults. There is a significant risk for true life and death situations when working with this population.  While exploring this information keep in mind that the most common physical therapy intervention is exercise, and the heart is the literal primary driving force for exercise. Factors that affect exercise tolerance will be dealt with nearly daily in your career as a PTA. Furthermore, these conditions all exist on a continuum where hypertension (HTN) often contributes to common cardiac diseases and disorders, such as myocardial infarction (MI) and congestive heart failure (CHF). Your role in rehabilitation and patient education for health and wellness promotion could literally save a life.

Cardiac Conditions Objectives

1. Describe the pathophysiology of common cardiac conditions and cardiac procedures to minimize decline in organ function.
2. Describe the functional anatomy of the 4 chambers of the heart and relate how damage or compromise to the ventricles will affect activity tolerance.
3. Explain the systolic and diastolic phases of blood pressure and report what implications each hold for body homeostasis and exercise tolerance.
4. Describe the signs and symptoms of selected cardiac conditions
5. Describe the purpose of selected cardiac procedures
6. Describe and recognize the absolute contraindications for exercise in patients with cardiac conditions, including indications to stop an exercise test.
7. Recognize the role HTN plays in the development of other cardiac, vascular and neurologic pathologies.

During a written case simulation, you may be asked to demonstrate your ability to:

1. Describe and select the pertinent tests and measures utilized to assess cardiac responses to exercise.
2. Provide a rationale for aerobic conditioning for patients with cardiac conditions
3. Describe the effects that medications used for the treatment of heart conditions have on exercise tolerance.
4. Provide a rationale for an aerobic training method for a given rehabilitation scenario.
5. Educate a well and cardiac rehab patient on parameters for increasing and maintaining aerobic fitness.
6. Collaborate with the supervising PT to educate patients and community members about smoking-related health risks and smoking cessation
7. Demonstrate understanding of the role of the PTA in creating healthier communities as obliged by the Standards of Ethical Conduct

Cardiac Red Flags

Symptoms of Cardiac Pathology

• Chest Pain
• Shortness of Breath
• Cardiac arrhythmia
• Fainting
• Claudication
• Fatigue
• Edema especially of extremities UE, LE or both

Symptoms of that may indicate Myocardial Infarction= Heart Attack

• Severe chest pain (substernal pressure, "There is an elephant standing on my chest".)
• Chest heaviness
• Radiating pain down one or both arms
• Weakness or unexplained fatigue
• Fainting
• Nausea and or Vomiting
• Diaphoresis
• Shortness of Breath

Symptoms for women experiencing a MI can be different. In addition to the above, symptoms may include

• neck, jaw or upper back pain (Mayo clinic, 2019)
• abdominal pain
• lightheadedness or dizziness

Red Flags - Exercise termination indicators

• symptoms of cardiac pathology or MI (see above)
• systolic blood pressure (BP) drops more than 10 mmHg from baseline BP
• ataxia or dizziness
• moderate to severe angina
• cyanosis or pallor
• subject heart rate is above target heart rate
• subject has significant cardiac history and heart rate is 30 beats per minute (bpm) above resting heart rate

 References

Mayo Clinic, 2019. Heart Attack. Know the Signs and Symptoms. Available at.

     http://www.mayoclinic.org/diseases-conditions/heart-attack/in-depth/heart-   attack-symptoms/art-20047744

Smoking Cessation Education

The overwhelming evidence since the 1950's, 60+ years ago is the relationship between smoking and pre-mature death.  This most recent article adds even more health problems to smoking: an addiction that destroys the cardio-pulmonary system and an addiction that kills over 400,000 Americans pre-maturely every year.

As prescribed by the PTA Standards of Ethical Conduct (Standard 8) PTA's are obliged to educate members of the community about the inherent risks of smoking, direct patients and others to smoking cessation resources in an effort to improve public health

Standard #8: Physical therapist assistants shall participate in efforts to meet the health needs of people locally, nationally, or globally (APTA, 2019)

Reference

Standards of Ethical Conduct for the PTA, 2019. American Physical Therapy Association.

Cardiac Anatomy and Physiology

Back in PTA 100....

In Unit 3 of PTA 100, we covered the role of physical therapy with patients with cardiovascular conditions. We encourage you to go back to your notes from Unit 3. Specific examples of stress testing is included in this section. You should start to recognize that the interventions for conditioning and cardiac conditions are similar in that the primary impairment is typically impaired aerobic capacity and endurance.

Donor Heart

The following information is all review from anatomy. Utilize it as personally needed.

Review anatomy of heart chambers, coronary arteries and heart conduction system in anatomy text. Tutorials to refresh your memory are included below:

Capillary Exchange

You are not expected to memorize the values contained in the above link

Specific anatomical references in the heart are below. You are not expected to recall anatomy at this level. These resources are included for your reference only if you would like more specific landmarks for cardiac anatomical terms

External Anatomy of the Heart (ASPSU, 2019)

apex - The tip or pointed end of the heart; in the anatomical position, the confluence of the inferior and left borders; it is a projection inferiorly, anteriorly and to the left of the left ventricle.

base - The broad superior surface of the heart, from which the great vessels emerge.

auricle - (1)  The free portion of the myocardial wall of each atrium which has a superficial similarity in shape to an ear, it contracts along with the rest of the atrial wall to move blood from the atria to the ventricles; it is regulated by the Autonomic Nervous System; (2) The outer projecting portion of the ear, also called the pinna.

coronary sulcus - The slight groove seen on the external surface of the heart which indicates the borders between the atria and the ventricles; coronary vessels follow portions of the groove.

interventricular sulcus - The slight groove seen on the external surface of the heart which indicates the borders between the right and the left ventricles; coronary vessels follow portions of the groove.

Procedures and Equipment

Reading Assignment

Chapter 25 in Cameron and Monroe, pages 348-352 on BP.
This section is a review of BP content from PTA 101. Basic vital sign information can be cross referenced in Week 1. Be sure you make special note of Table 22-3. Focus your studying on recognizing risk factors and BP values which may result in cessation of activity. 

Applying Principles of De conditioning to Cardiac Conditions

Go back through your notes from Cameron and Monroe, pages 359-360, 361-362, and 363-366 (stopping at case study) 23-1. Again, the emphasis will be on reinforcing strategies for assessing exercise tolerance and safe exercise progressions. The Borg RPE scale is a reliable measurement for patients with cardiac conditions (Box 23-1).

Cardiac Telemetry

This is one option for patients to monitor energy expenditure and conservation.

to watch and for a brief explanation on video

Here is the You Tube address if you are having trouble opening the video

http://www.youtube.com/watch?v=487nEIm2UCs&feature=player_embedded

Common Cardiac Conditions

Below are the primary cardiac conditions that you may encounter. Realize that all the safety considerations for applying exercise are aimed at avoiding causing another MI or sudden cardiac arrest. The role of the PTA is to recognize the signs and symptoms that may indicate excessive stress and possible and/or immediate danger to the cardiovascular system. PTAs should also be able to appropriately monitor and modify exercises consistent with with safe activity guidelines.

Arrhythmia

Pathology of conduction in the heart. Can occur at the SA node, AV node, Purkinje fibers, and bundle branch blocks

1. Types of arrhythmias: bradicardia and, tachycardia (atrial and ventricular)
2. Symptoms = palpitations, lightheadedness, syncope (fainting), and cardiac arrest
3. Atrial Fibrillation is the most common form of arrhythmia
4. Clinical significance
1. may be the first manifestation of heart disease
2. may precipitate heart failure or ischemia
3. can predispose to intracardiac clot formation and embolic events (stroke, MI, peripheral emboli)
4. Beta blockers make sure the heart beats slower and does not work as hard in order to control blood pressure

Can you think of how the use of beta blockers may affect a patient during exercise?

Stable and Unstable Angina

Angina Pectoris:stable angina - chest pain with exertion

Acute coronary syndrome:unstable angina - chest pain at rest

Read the linked web resources and be able to distinguish between the tow and discriminate the appropriate response if these symptoms present in a clinical situation.They can be frequently encountered when working with any population aged 40+.

 Myocardial Infarction

Web exploration: Myocardial Infarction:

Hypertension

Web exploration: Hypertension Tutorial:

Note that hypertension definitions fluctuate. For the purposes of this course, we will use current guidelines by the American Heart Association: 130/80.

Scope of practice alert: 130/80 is a blood pressure measure. Hypertension is a diagnosis. PTAs report outcomes of tests and measures, but DO NOT classify readings in diagnostic terms. In short, do not report to a patient that they have "hypertension" if you get a high blood pressure measure.

Common Cardiac Procedures

PTAs are work with patients with recent or prior history of one or more invasive cardiac procedures. A PTA is an educator, so must have a basic understanding of procedures and their resultant influence on activity and exercise:

In your note taking, be sure you can identify the procedure's purpose for improving cardiovascular function

1. Angioplasty: http://www.heart.org/idc/groups/heart-public/@wcm/@hcm/documents/downloadable/ucm_300437.pdf
2. Electrocardiogram
3. Valve Replacement 
4. Bypass Graft : http://watchlearnlive.heart.org/CVML_Player.php?moduleSelect=corabg
5. Pacemaker 

Data Collection

Careful, systematic, and continuous data collection is essential when you are engaging in activities to restore function. With movement comes increase demand on the body systems and structures, and PTAs are using clinical reasoning from the data collected to make decisions that are safe and provide the appropriate workload to the system so that it can improve.

Observation

A PTA may observe one or more of the following indicators to guide exercise effort and modify interventions:

• color: excessive redness or cyanosis; pallor (loss of color)
• diaphoresis: increased sweating
• cognition: a change in mental status, attention, or confusion
• breathing patterns: may become labored, shallow, rapid
• posture and behaviors: flexing, grimacing, reaching for chest, rubbing jaw and arm, movement compensations

Depending on the severity and associated signs and symptoms, this may indicate a need to stop the intervention.

Standardized Tests and Measures

This may be collected at baseline, during activity, following activity, or referenced from prior sessions to guide treatment planning. Examples include:

1. Angina scale - patient self-rating of chest pain quality and behavior (1-4 scale)
2. Dyspnea scale - qualitative assessment of ventilation and perfusion (0-3 scale)
3. Rated Perceived Exertion (modified Borg) - self-rating of perceived physiological effort and exercise intensity. Guides clinical and patient self-assessment of intensity, especially in situations where medication prevents heart rate increases above a threshold (for example, beta blockers)

Objective Tests and Measures

1. Vital signs (includes pain scales)
1. heart rate rhythm/quality
2. breathing pattern
2. Age
3. Distance
4. Time
5. Frequency
6. Level of assist

Knowledge Translation Check!

Applied Learning from Deconditioning

Revisit Chapter 23 in Cameron

Answer the following questions:

1. What are the deconditioning effects associated with bed rest?
2. How long should someone continue aerobic exercise conditioning to notice a positive change?
3. What are current recommendations from the AHA and CDC for an effective conditioning program?
4. What frequency of exercise is needed to maintain aerobic fitness?
5. What are characteristics of an aerobic exercise program?
6. What is the difference between the four methods of aerobic training ( continuous, interval, circuit, and circuit interval) and when are they used during rehabilitation?
7. What is an example of a warm up and cool down and why are they important?
8. How do resting HR change depending on patient's age and medical condition?
9. What test and measure results would indicate termination of a stress test?

 Reference:

American Physical Therapy Association. 2019. Standards of Ethical Conduct for the PTA. Available at: http://www.apta.org/uploadedFiles/APTAorg/About_Us/Policies/Ethics/StandardsEthicalConductPTA.pdf?navID=10737423626

Austin Pea State University. 2019. Anatomy of the Heart. Available at: http://www.apsu.edu/

Cleveland Clinic. 2019. Rate of Perceived Exertion. Available At: https://my.clevelandclinic.org/health/articles/17450-rated-perceived-exertion-rpe-scale

Mayo Clini 2019. Sign and Symptoms of a Heart Attack: Available at: https://www.mayoclinic.org/diseases-conditions/heart-attack/symptoms-causes/syc-20373106