心脏康复评定.ppt

CARDIOVASCULAR EVALUATIONDR.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 you 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 shortness 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 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 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 and 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 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?.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 scaleIs this ok with you?.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?.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 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.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 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 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.Other Symptoms of Heart DiseasedyspneaFatigueDizzinessLight headednessPalpitationsa sense of impending doom.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.Examinations 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.Anthropometric 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 mass.Jugular venous distensionit is often due to right-sided heart failure.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 Breathing Cycle.Measurement of the Systolic and Diastolic Blood Pressure and Pulse in Different Body Positions.To 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.To 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.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 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.Examination 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.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 functionSymptoms and functional classificationCold,pale,and possibly cyanotic extremitiesJugular venous distension and peripheral edemaHeart soundsPulseElectrocardiographyBlood pressure.Standard measurement of cardiac functionCardiac catheterizationEchocardiographySwan-Gans catheterizationCentral venous pressureCardiac enzymesANP and BNPRadiologic evidence.Exercise Testing.Indications for Exercise Testing:Indications for Exercise Testing:Diagnosis of Coronary Artery DiseaseDiagnosis of Coronary Artery DiseaseAssessment of Prognosis in Coronary Artery Assessment of Prognosis in Coronary Artery DiseaseDiseaseEvaluation of Functional CapacityEvaluation of Functional CapacityEvaluation of Therapy for Coronary DiseaseEvaluation of Therapy for Coronary DiseaseDetermination of Exercise PrescriptionDetermination of Exercise Prescription.Absolute 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 consent.Relative 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 block.ECG Lead Placement for Exercise Testing.Protocols for Exercise Testing.Blood 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).Heart 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 stop.Relative 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).Criteria 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 point.Criteria for Reading ST-Segment Changes on the Exercise ECGST ELEVATION:60 msec after J point in 3 consecutive ECG complexes.Criteria 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 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 Testing.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 Infarction.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 DiseaseCLASS I:CLASS I:Adult patients(including those with RBBB or less than 1 mm or Adult patients(including those with RBBB or less than 1 mm or resting ST-depression)with an intermediate pretest probability resting ST-depression)with an intermediate pretest probability of CAD,based on gender,age,and symptomsof CAD,based on gender,age,and symptomsCLASS IIa:CLASS IIa:Patients with vasospastic anginaPatients with vasospastic anginaCLASS IIb:CLASS IIb:Patients with a high pretest probability of CAD by age,Patients with a high pretest probability of CAD by age,symptoms,and gendersymptoms,and genderPatients with a low pretest probability of CAD by age,symptoms,Patients with a low pretest probability of CAD by age,symptoms,and genderand genderPatients with less than 1 mm of baseline ST depression and Patients with less than 1 mm of baseline ST depression and taking digoxintaking digoxinPatients with ECG criteria of LVH and less than 1 mm St-Patients with ECG criteria of LVH and less than 1 mm St-depressiondepression.Pre-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 .Pre-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 disease.Risk 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