Download Rehabilitating elderly cardiac patients - Tiffany Steele`s E

By Tiffany Steele, SPTA
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1. Cardiovascular Disease (CVD) statistics
2. Pathophysiological conditions that underlie
CVD
3. The effects of selected medications on Heart
Rate (HR), Blood Pressure (BP) responses
during exercise/ exercise performance.
4. Benefits of exercise for CV conditions
5. Common considerations / precautions and
contraindications to exercise.
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Cardiovascular disease remains the leading cause
of death in the United States, including those over
the age of 85 years.
An estimated 80.7 million Americans have one or
more types of CVD. Approximately 38.2 million
are individuals older than age 60 years.
The total direct and indirect costs of CVD and
stroke were an estimated $448.5 billion in 2008.
These numbers support the ongoing need for
chronic disease management in the elderly and the
potential role cardiac rehabilitation may play.
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Atherosclerosis
Altered myocardial muscle mechanics
Valvular dysfunction
Arrhythmias
Hypertension
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Hypertension
Orthopnea (difficulty breathing while laying
flat)
Palpitations
Dyspnea
Peripheral edema
Chronic medications
Apprehension, anxiety…threat of MI
Arrhythmias
Restricted activity
Atherosclerosis
A disease in which lipid
laden plaque (lesions) is
formed within the inner
layer of the blood vessel of
moderate and large size
arteries.
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It is also the primary
contributor to CVD and
PVD.
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Altered Myocardial
Muscle Mechanics &
Valvular Dysfunctions
Involves the systolic and/ or
diastolic properties of the
myocardium, resulting in an
impairment of LV function.
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Referred to as CHF when
accompanied by signs and
symptoms of edema.
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Other causes include,
myocardial scarring/
remodeling as result of MI,
cardiomyopathy or
impairment in valvular
function, especially the mitral
and aortic valves.
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Arrhythmias
Caused by a disturbance
in the electrical activity of
the heart, resulting in
impaired electrical impulse
formation or conduction.
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Irregular, rapid heart rate
that commonly causes poor
blood flow to the body.
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Most common in elderly
the population would be
atrial fibrillation (a-fib
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Hypertension
Most prevalent CVD in
the US and one of the most
powerful contributors to
cardiovascular morbidity
and mortality.
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Systolic is above 140 mm
Hg
 Diastolic is above 90 mm
Hg
 Three Stages:
1.
130-140 / 90-100
2.
140-160 / 100-110
3.
>160 / >110
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Effects of
Medications on HR,
BP and Exercise:
Beta Blockers:
Used to treat high BP,
heart failure, angina,
arrhythmia, MI
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Slows the heart rate and
reduces the force with
which the heart muscle
contracts, thereby lowering
blood pressure.
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Decreases HR and BP at
rest and exercise
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Calcium Channel Blockers: Used to treat high BP,
angina, arrhythmia.
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Reduce electrical conduction within the heart, decrease
the force of contraction (work) of the muscle cells, and
dilate arteries.
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Dilation of the arteries reduces blood pressure and
thereby the effort the heart must exert to pump blood.
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Increases/decreases HR and decreases BP at rest and
exercise.
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Vasodilators: Used to treat high BP
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Dilates blood vessels, blood flows more easily through
your arteries, your heart doesn't have to pump as hard
and your blood pressure is reduced.
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Increases HR and decreases BP at rest and exercise.
ACE Inhibitors: Used to treat high BP
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Dilates blood vessels to improve the amount of blood the
heart pumps and lowers blood pressure.
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Decreases BP at rest and exercise.
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Digitalis: Used to treat CHF, arrhythmia, to increase
blood flow throughout your body.
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Strengthens the force of the heartbeat by increasing
the amount of calcium in the heart's cells.
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As calcium builds up in the cells, it causes a stronger
heartbeat.
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Decreased HR in patient’s w/ atrial fibrillation and
CHF, no effect on BP at rest and exercise.
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Diuretics: Used to treat high BP, edema, heart failure,
kidney & liver problems.
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Help your body get rid of unneeded water and salt
through the urine. Getting rid of excess fluid makes
it easier for your heart to pump and controls blood
pressure.
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No effect on HR , BP decrease/or may have no effect
at rest or exercise.
Effects of
Medications on HR,
BP and Exercise:
Nitrates:
Used to treat chest pain,
angina, CHF
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Nitrates are a
vasodilator, improving
blood flow and allowing
more oxygen-rich blood
to reach the heart
muscle.
 Increases HR and
decreases BP at rest and
exercise.
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Cardiac rehabilitation is a multidisciplinary
approach to chronic disease management that
encompasses nutrition consultation,
psychosocial services, lifestyle modification,
and risk factor modification management, in
addition to aerobic and resistance training.
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Strengthen your heart and cardiovascular system.
Improve your circulation and help your body use oxygen better.
Improve your symptoms of congestive heart failure.
Increase energy levels so you can do more activities without becoming
tired or short of breath.
Increase endurance.
Lower blood pressure
Improve muscle tone and strength.
Improve balance and joint flexibility.
Strengthen bones.
Help reduce body fat and help you reach a healthy weight.
Help reduce stress, tension, anxiety, and depression.
Boost self-image and self-esteem.
Improve sleep.
Make you feel more relaxed and rested.
Make you look fit and feel healthy.
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Improved cardiorespiratory function
Improved coronary artery disease risk factors:
cholesterol, hypertension, stress, weight,
diabetes, smoking
Improved mental health
Decreased morbidity and mortality
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Medical:
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Patients with stable angina
Myocardial Infarction
CHF
Postsurgical:
Patients who have undergone:
 Coronary artery bypass grafting (CABG)
 Congestive heart failure
 Percutaneous transluminal coronary angioplasty (to open
blocked coronary arteries caused by CAD)
 Heart transplantation
 Heart-valve surgery
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The duration of a common aerobic exercise
training sessions vary from 20 – 40 minutes at
an intensity approximating 70%–85%of the
max HR.
A deconditioned patient may be aerobically
trained at as low as 50%–60%.
Exercise prescriptions are based on:
Frequency
 Intensity
 Time (duration)
 Type (mode)
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Aerobic
F: (Frequency): 4-7 days per week
 I: (Intensity): 50-85% VO2 max/HR max, RPE of 11-13
 T: (Time): 30-60 min/session
 T: (Type) Large muscles, aerobic
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Resistance training
F: (Frequency): 2-3 days per week
 I: (Intensity) Low resistance and high reps
 T: (Time) 1-3 sets; up to 30 minutes/session
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Normal pulse rate for an adult is 60 – 100 bpm
Although there's a wide range of normal, an unusually high or
low heart rate may indicate an underlying problem.
 Tachycardia- HR that is consistently above 100 beats a minute.
 Bradycardia- HR that is below 60 beats a minute
 Signs or symptoms- fainting, dizziness or shortness of breath,
palpitations, angina, and lightheadedness.
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Fitness level significantly impacts the normal pulse rate for
older adults. It is lower if you are well conditioned and higher
if you are not.
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Age
Sex
Activity level
Fitness level
Air temperature
Body position (standing up or lying down, for
example)
Emotions
Body size
Medication use
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Your heart rate tends to increase as you age
because your heart is not as strong or efficient
as it used to be. Aging can also lead to stiffer
arteries that are sometimes clogged with fat,
increasing your heart's workload even further.
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Target Heart Rate: is the desired percent of the
exercise intensity, times the Max HR (220 - age)
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Example : 185 (Max HR: 220-35) X 70%
(Intensity) = THR (130)
Age
50% of Max HR
85% of Max HR
Max HR
50
90 bpm
153 bpm
170
55
83 bpm
140 bpm
165
60
80 bpm
136 bpm
160
65
78 bpm
132 bpm
155
70
75 bpm
128 bpm
150
80
70 bpm
119 bpm
145
85
67 bpm
114 bpm
140
90
65 bpm
110 bpm
130
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VO2max: volume of oxygen you can consume
while exercising at your maximum capacity.
 As we get older our VO2max decreases.
The decline is due to a number of factors
including a reduction in maximal heart rate
and maximum stoke volume (the amount
of blood pumped by the left ventricle of the
heart in one contraction), cardiac output
(CO): the amount of blood that leaves the
ventricles.
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Medications
Post exercise hypotension -Longer cool down
Monitor BP
Hydrate
Avoid isometric activities (patients tends to hold
their breath)
Avoid vigorous activities
Avoid valsalva maneuver (breath holding and
bearing down)
Lifestyle modification
RELATIVE
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Stable cardiovascular disease
(stenosis, blocks, previous MI,
CHF, PVD)
Electrolyte abnormalities
Irregular heart beat
Hypertension: 200/110 mm Hg
NM, MSK, rheumatoid disorder
exacerbation
Uncontrolled metabolic disease
(diabetes)
Chronic infectious disease
Move forward after careful
evaluation
ABSOLUTE
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Recent significant change in
ECG
Unstable cardiovascular disease
(angina, stenosis, heart failure)
Uncontrolled arrhythmias
Hypertension: 200/110 mmHg
Pulmonary embolus
Myo/perocarditis
Aneurysm
Acute infections
Need to wait to be cleared
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6 No exertion at all
7
8 Extremely light
9 Very light
10
11 Light
12
13 Somewhat hard
14
15 Hard (heavy)
16
17 Very hard
18
19 Extremely hard
20 Maximal exertion
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RPE should stay between 11-13
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1.
2.
3.
4.
5.
Top 5 sternal precautions reported by PT’s in order
of importance:
Lifting no more than 10 pounds of weight
bilaterally
No hand over head activities bilaterally
Bilateral sports restrictions (No hand over head
activities bilaterally)
No driving
Active bilateral shoulder flexion no greater than
90°
Vitals:
Contraindications
Precautions
Termination
Pulse Rate
< 50 or >120 bpm
100 – 120 RP
20 – 30 bpm above rest
Respiration Rate
> 30 bpm
Systolic BP
< 80 or >180 MM Hg
Diastolic BP
>110 mm Hg
>110 – 120 mm Hg
O2 Saturation
<88% w no pulm dz
<85% w pulm dz
<90%
Glucose
<70 or >300 g/dL
Other
• Unstable angina
• Recent embolism
• Arrhythmias
• Active peri or
myocarditis
Post CABG 30 bpm
above rest
Post MI/ CHF 20 bpm
above rest
Decreased SBP of 10-20
mm Hg
• Slow recovery time
• Fatigue p 1-2 hrs
• Lack of excessive BP
response to activity
• Arrhythmias
• LE claudication
>20 mm Hg drop
>200-220 mm Hg
• Angina
• Confusion
• Fatigue
• Dizziness
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Risk factors associated with CAD
Anatomy and physiology of the heart: What is
a heart attack?
Angina: What is chest pain?
Relation of diet to heart disease
Diet and weight control
Stress and stress management
Cigarette smoking in relation to heart disease
Drugs used in management of heart disease
and their relationship to exercise
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Physical Rehabilitation 5th Edition, Susan B O’ Sullivan
Effects of Cardiovascular Medications on Exercise responses:
http://ptjournal.apta.org/content/75/5/387
Sternal Precautions:
http://cpptjournal.org/pdfs/members/fulltext/2011/march/sternal
_precautions.pdf
American College of Sports Editions Medicine Guidelines for Exercise
Testing and Prescriptions, 8th Edition
Cardiac Rehabilitation in Older Adults: Benefits and Barriers:
http://www.clinicalgeriatrics.com/articles/Cardiac-RehabilitationOlder-Adults-Benefits-and-Barriers?page=0,0
Heart and Vascular Health & Prevention:
http://my.clevelandclinic.org/heart/prevention/exercise/pulsethr.a
spx
Cardiovascular Risk-Factor Reduction in Elderly Patients With
Cardiac Disease
http://ptjournal.apta.org/content/76/5/469.full.pdf+html