1、心脏康复评定心脏康复评定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
2、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
3、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 visu
4、al 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)
5、?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 wit
6、h 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
7、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
8、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 arou
9、nd 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 you
10、r 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
11、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 list
12、ening 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 breath
13、ing,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 worsened by physical exercise or activity.Therefore,if the suspected anginal pain is unchanged wit
14、h 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 susp
15、ected 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 of impending doom Examinations of Patient Appearance skin color of the peripheral extremities.Pale or cya
16、notic 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 for many years and recently was once again found to be highly predictive of heart disease Anthropometric measu
17、rements 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 massJugular venous distension it is often due to right-sided heart failure.Palpation of the Radial Pulse Pa
18、lpation 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 Diff
19、erent Body PositionsTo 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 dysfu
20、nction.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(compare
21、d 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 ad
22、aptive 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 systemExamination of the Pulse and Arterial Blood PressureDuring Functional Tasks and Exercise Frequent monitoring of t
23、he 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
24、 cardiovascular dysfunction.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 pressureStandard measurement of cardiac function
25、Cardiac catheterization Echocardiography Swan-Gans catheterization Central venous pressure Cardiac enzymes ANP and BNP Radiologic evidenceExercise TestingIndications for Exercise Testing:Diagnosis of Coronary Artery Disease Assessment of Prognosis in Coronary Artery Disease Evaluation of Functional
26、Capacity Evaluation of Therapy for Coronary Disease Determination of Exercise PrescriptionAbsolute 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 pulm
27、onary 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 consentRelative Contraindications to Exercise Testing Left main coronary stenosis or equivalent Modera
28、te 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 blockECG Lead Placement for Exercise TestingProt
29、ocols for Exercise TestingBlood 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 th
30、erapy(-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 stre
31、nuous exercise)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 exerci
32、se 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
33、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 stopRelative Indicat
34、ions 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 F
35、atigue,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 tachycar
36、dia(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
37、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 a
38、nd becomes depressed with exercise:Magnitude of ST depression is determined from the P-Q junction and not the resting J pointCriteria for Reading ST-Segment Changes on the Exercise ECG ST ELEVATION:60 msec after J point in 3 consecutive ECG complexesCriteria for Abnormal and Borderline ST-Segment De
39、pression 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
40、 ST depression at 60 msec after J point on 3 consecutive ECG complexesMorphology of ST-Segment Deviation during Exercise TestingValue of Right-Sided ECG Leads during Exercise Testing for the Diagnosis of CADHorizontal ST-segment Depression during Exercise TestingDownsloping ST-Segment Depression dur
41、ing Exercise TestingST-Segment Depression in Early Recovery Period after Exercise TestingUpsloping ST-Segment Depression during Exercise TestingMorphology of ST-Segment Depression Predicts Severity of Coronary Artery Disease(Goldschlager,1976)Exercise-Induced ST-Segment Elevation with Prior Anterior
42、 Myocardial InfarctionExercise-Induced ST-Segment Elevation in the Setting of Prior Inferolateral MIExercise-Induced Anterior ST-Segment Elevation as Reflection of LAD IschemiaIndications for Exercise Testing in the Diagnosis of Obstructive Coronary Disease CLASS I:Adult patients(including those wit
43、h 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 o
44、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-depressionPre-test Probability of CAD by Age,Gender,and Symptoms Typical/Definite Angina Pectoris Age 30-39 MenIntermediate(10-90%)Women
45、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 Low(75%stenosis
46、,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 diseaseRisk Assessment and Prognosis with Exercise Testing in Patients with Symptoms and Prior History of CAD Class I:Patie
47、nt 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 p
48、atients 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
49、 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 tha
50、t 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 msec Patients with a stab
