心脏康复评定

1、CARDIOVASCULAR EVALUATION,DR. Liang Qi,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?,4. Do y

2、ou experience angina or shortness of breath at rest, only with activity/exercise, or both at rest and with activity/exercise?,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 sho

3、rtness of breath?,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

4、 this 10-point scale or by marking this visual analog scale?,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?,9. Could I place these electrodes on your chest to

5、obtain a simple single-lead electrocardiogram (ECG)?,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 a

6、nd standing.,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.,12. Could I place 1 of my hands on you

7、r 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

8、 several different sites to determine how you breathe?,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 wi

9、ll 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?,17. Could I measure the

10、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?,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?,Thank

11、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 re

12、sults.,Physical Therapy Examination,Medical Information and Risk Factor Analysis listening to the patients past history and primary complaints is critical in the examination process.,Examinations of Patient Appearance,categorized by specific signs and symptoms,Angina-Methods To Evaluate Angina from

13、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 Angina from Nonanginal Pain,it can be wors

14、ened 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 th

15、e 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.,Other Symptoms of Heart Disease,dyspnea Fatigue Dizziness Light headedness Palpitations a sense

16、of impending doom,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 Appearance,Diagonal earlobe crease. This phenomenon has been investigated

17、 for many years and recently was once again found to be highly predictive of heart disease,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 mus

18、cle mass,Jugular venous distension,it is often due to right-sided heart failure.,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 Simp

19、le Perturbations of the Breathing Cycle,Measurement of the Systolic and Diastolic Blood Pressure and Pulse in Different Body Positions,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 w

20、hen changing body position from supine to standing is considered a positive sign for autonomic nervous system dysfunction. .,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 cardiova

21、scular 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.,a sluggish or hypoadaptive (less than normal) heart rate and blood pressure response during a change in b

22、ody position supine to standing should be considered abnormal and suggestive of an unhealthy cardiovascular system.,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 cardiov

23、ascular system,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.,

24、an increase in the diastolic blood pressure when the diastolic blood pressure should be decreased (or low) is a strong indicator of cardiovascular dysfunction. .,Potential indirect measures of cardiac function,Symptoms and functional classification Cold, pale, and possibly cyanotic extremities Jugul

25、ar venous distension and peripheral edema Heart sounds Pulse Electrocardiography Blood pressure,Standard measurement of cardiac function,Cardiac catheterization Echocardiography Swan-Gans catheterization Central venous pressure Cardiac enzymes ANP and BNP Radiologic evidence,Exercise Testing,Indicat

26、ions 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,Absolute Contraindications to Exercise Testing,Acute MI (within 2 day

27、s) 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

28、safe and adequate test Inability to obtain consent,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 Hypert

29、rophic Cardiomyopathy (? gradient) Mental impairment leading to inability to cooperate High-degree AV block,ECG Lead Placement for Exercise Testing,Protocols for Exercise Testing,Blood Pressure Responses: Exercise Testing,Dependency on cardiac output and peripheral resistance Normal responses: Incre

30、ase 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 lef

31、t main or 3-vessel disease), valvular heart disease, cardiomyopathy no evidence of clinically significant heart disease (dehydration, antihypertensive therapy, prolonged strenuous exercise),Heart Rate Response to Exercise Testing,Accelerated Heart Rate Response: Deconditioning, prolonged bed rest, a

32、nemia, 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,

33、 1999) Peak HR 130 bpm (Ellestad),Evaluation of Exercise Effort during Exercise Testing: The Borg Perceived Exertion Scale,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 (nomogra

34、ms) Predicted VO2 (ACSM formulae) Practical Aspects: Lack of association between LVEF and exercise capacity Prognostic value of decreased exercise capacity and active CAD Predictor of patients disability,Exercise Testing - Complications,MI or death: Up to 10 per 10,000 tests (1 per 2,500) Life threa

35、tening ventricular arrhythmias: 0-5 per 100,000 Cardiac: Bradyarrhythmias, tachyarrhythmias, acute coronary syndromes, heart failure, hypotension, syncope, death Noncardiac: Musculoskeletal trauma, soft-tissue injury Miscellaneous: Severe fatigue, dizziness, myalgias,Absolute Indications for Termina

36、tion of Exercise Test,ST-segment elevation ( 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 ischemia Moderate to severe angina (grades 3-4) Centra

37、l 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,Relative Indications for Termination of an Exercise Test,ST changes (horizontal

38、 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 clau

39、dication 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 tripl

40、ets, SVT, heart block, or bradyarrhythmias) General Appearance (diaphoresis, peripheral cyanosis),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 ju

41、nction, 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 exe

42、rcise: Magnitude of ST depression is determined from the P-Q junction and not the resting J point,Criteria for Reading ST-Segment Changes on the Exercise ECG,ST ELEVATION: 60 msec after J point in 3 consecutive ECG complexes,Criteria for Abnormal and Borderline ST-Segment Depression on the Exercise

43、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 ms

44、ec after J point on 3 consecutive ECG complexes,Morphology of ST-Segment Deviation during Exercise Testing,Value of Right-Sided ECG Leads during Exercise Testing for the Diagnosis of CAD,Horizontal ST-segment Depression during Exercise Testing,Downsloping ST-Segment Depression during Exercise Testin

45、g,ST-Segment Depression in Early Recovery Period after Exercise Testing,Upsloping ST-Segment Depression during Exercise Testing,Morphology of ST-Segment Depression Predicts Severity of Coronary Artery Disease (Goldschlager, 1976),Exercise-Induced ST-Segment Elevation with Prior Anterior Myocardial I

46、nfarction,Exercise-Induced ST-Segment Elevation in the Setting of Prior Inferolateral MI,Exercise-Induced Anterior ST-Segment Elevation as Reflection of LAD Ischemia,Indications for Exercise Testing in the Diagnosis of Obstructive Coronary Disease,CLASS I: Adult patients (including those with RBBB o

47、r 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 o

48、f 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,Pre-test Probability of CAD by Age, Gender, and Symptoms,Typical/Definite Angina Pectoris Age 30-39 MenIntermediate (10-90%)

49、 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 by Age, Gender, and Symptoms,Atypical/Possible Angina Pectoris: Age 30-39 MenIntermediate Women Very Low (5%) Age 40-49 MenIntermediate Women L

50、ow (10%) Age 50-50 MenIntermediate Women Intermediate Age 60-69 Men Intermediate Women Intermediate,Pre-test Probability of CAD by Age, Gender, and Symptoms,Nonanginal Chest Pain: Age 30-39 MenLow Women Very Low Age 40-49 MenIntermediate Women Very Low Age 50-59 MenIntermediate Women Low Age 60-69 M

51、enIntermediate Women Intermediate,Pre-test Probability of CAD by Age, Gender, and Symptoms,Asymptomatic: Age 30-39 MenVery Low Women Very Low Age 40-49 MenLow Women Very Low Age 50-59 MenLow Women Very Low Age 60-69 MenLow Women Low,Indications for Exercise Testing in the Diagnosis of Obstructive Co

52、ronary Disease,Class III: Patients with the following ECG abnormalities: WPW syndrome, electronically paced ventricular rhythm, greater than 1 mm resting ST-depression, complete LBBB Patients with a documented MI or prior coronary angiography demonstrating significant CAD have an established diagnos

53、is (?ischemia, prognosis),Exercise Testing; Sensitivity and Specificity for the Diagnosis of CAD,Sensitivity = True positives/true positives + false negatives x 100 Specificity = True negatives/false positives + true negatives x 100 Standard Exercise Test (mostly men)* Sensitivity = 68% Specificity

54、= 77% Predictive Accuracy = 73% *Based on 1.0 mm ST-segment depression,Exercise Testing in the Diagnosis of Coronary Artery Disease 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 dise

55、ase 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,Risk Assessment and Prognosis with Exercise Testing in Patients with Symptoms and Prior History of CAD,Class I: Patient undergoing initi

56、al 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 h

57、ours 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 Pro

58、gnosis 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

59、 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 msec Patients with a stable clinical course who undergo periodic monitoring to guide treatment,Risk Assessment and Prognosis with Exercise Testing in Patients with Symptoms and Prior History of CAD,Class III: Patients with severe co-morbidity likely to limit life expectancy and/or cand