morbidities in cardiac co- outpatient...

Cardiac Comorbidities in Outpatient Settings: Implications for Assessment and Treatment

2/20/2012

Property of A. Lynn Millar, Do not copy without permission 1

Cardiac Co-

Morbidities in

Outpatient Settings

– Implications for

Assessment and

Treatment

A. Lynn Millar, PT, PhD, FACSM

Winston-Salem State University

Combined Sections Meeting 2012

Chicago, IL ◊ February 8 – 11, 2012 Objectives

♥ Identify the most common cardiovascular comorbidities

or treatments that may present in an outpatient setting

♥ Select appropriate assessment techniques based upon

cardiovascular co-morbidity

♥ Select appropriate modifications to physical therapy

interventions based upon selected cardiovascular co-

morbidities or medical treatment

Relevance to PT

♥ Heart disease 2nd only to arthritis in limiting activity

♥ ―leading cause of premature, permanent disability‖ (CDC, 2004)

♥ Common as a co-morbidity

Cardiovascular Disease

Categories

• Coronary heart disease

• Hypertension

• Heart failure

• Vascular disease

Epidemiology of Cardiac

Disease

• 2010 CDC – 27.1 million individuals with heart disease

• Hypertension - >74 million: ―1in 3‖

• Heart failure - 5.8 million, with 670,000 new cases per

year

• Peripheral Arterial disease – 8 million

• Atrial fibrillation – 2.66 million

Hypertension

• ―Almost one fifth (21.3%) of the people with high blood

pressure don't know that they have it.‖ CDC, 2006

• 28% have pre-hypertension

• ―because essential hypertension is manifest at varying ages

and is usually asymptomatic, otherwise healthy patients need

regular and ongoing blood pressure screening‖

Joint agenda for ACS, ADA & AHA, 2004


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PREVALENCE

Variations in Prevalence

• Age

• Gender

• Race

• Heart disease – Pacific Islanders > Am. Indian >White

• HTN – Black > Am. Indian > White

% HTN by Race and Gender From: Health, US, 2004, CDC/NCHS.

0

5

10

15

20

25

30

35

40

45

Caucasion African

American

Hispanic

27.5

40.4

26.7 28.4

43.4

27.8

Males

Females

Co-morbidities in OP

• Jette & Jette, 1996

• 27 – 30 % with 1 co-morbidity category; 13% with 2 co-

morbidity categories; 2% > 2 co-morbidity categories

• Boissonnault, 1999

• 21% with HTN; 7% with heart disease; 3% heart attack

• Ritzwoller et al, 2006

• 7% cardiac disease; 19% HTN; 14% - both heart

disease and HTN


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Initial – Outpatient case

studies

Initial – Case 1

• 65 yo female – “Eval and treat – difficulty

with ADLs”

• Hx – Hyperlipidemia, 5 yrs post MI

• Meds – Beta blocker, statins, NSAIDs

• No family history of CAD

• Symptoms – SOB, Easily fatigued

Initial – Case 2

• 20 yo male – “Eval and treat – anterior knee

pain”

• Hx – Family + HTN; no other significant history

• Symptoms – Knee pain, worse after sitting, running

Initial – Case 3

• 40 year old male - Referral – “Eval and Treat – Impingement syndrome”

• Hx: Pacemaker for arrhythmia – had ―problems after activity‖; no other significant history

• Symptoms – Right shoulder pain, worse with overhead activities

Review of common

cardiac diseases

Coronary heart disease

• Subcategories

• Myocardial

• Valvular

• Conduction

• Most common causes

• Atherosclerosis

• Rheumatic disease

• Congenital


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Myocardial

• Inadequate circulation

• Ischemia infarction with resultant damage to heart

• Abnormality of heart muscle

• ―Cardiomyopathy‖

• All are risk factor for numerous other

diseases and complications

• Early symptoms

• Fatigue, SOB, unusual heart beat

Valvular

• Two primary pathologies – both lead to decreased

systemic blood flow and increased work of the heart

• Incompetence of the valve regurgitation

• Stiffening of the valve stenosis

• Early symptoms

• Fatigue, SOB, dizziness

palpitations

Conduction

• Numerous causes!

• Classification

• Location of conduction abnormality

• Type of conduction abnormality

• Symptoms

• Related to classification

• Arrhythmia > palpitations, ―funny beat‖

• Loss of cardiac output > fatigue, syncope

• Important – may only occur with exercise!

Atrial Fibrillation

• “arrhythmia of old age”

• Loss of normal contraction of the atria

• Associated with 4 – 5 fold increased risk of stroke

• Increased risk of clots

Atrial Fibrillation

• Causes: HTN*, CHF, CAD (valvular disease), diabetes,

surgery

• Symptoms: syncope, fatigue, erratic pulse (palpitations)

• Treatment goals:

• Rate control

• Prevention of thromboembolism

• Correction of the rhythm disturbance

Hypertension

• “Silent killer”

• Often no symptom

• Increased risk of stroke, MI, atrial

fibrillation, Heart failure

BP Classification Systolic BP

(mmHg)

Diastolic BP

(mmHg)

Normal <120 and <80

Prehypertension 120-139 or 80-89

Stage 1 Hypertension 140-159 or 90-99

Stage 2 Hypertension ≥ 160 ≥ 100


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Hypertension

• Risk factors

• Age Males > 45; females > 55

• Family history of HTN

• Race – Black

• Atherosclerosis

• Overweight

• Treatment

• Diuretics

• ACE inhibitors

• Beta blockers

Heart Failure

• Heart failure - inability of heart to maintain cardiac

output

• Decreased ejection or decreased filling

• Associated risks

• Stroke, MI, cachexia, renal failure, arrhythmias

Heart Failure

• Causes: Previous MI, CAD, HTN, cardiomyopathy

• Symptoms

• Dyspnea

• Fatigue

• Limited exercise tolerance

• Fluid retention

• Treatment

• Diuretics

• Inotropic agents (contractility)

• Blood thinners

Peripheral Arterial

Disease

• Causes

• Atherosclerosis

• Symptoms

• Pain, ache or cramp with activity or rest

• Treatment goals

• Improve circulation

Peripheral Arterial

Disease

• Risk factors

• Diabetes mellitus

• Hypertension

• Smoking

• Obesity

• Coronary artery disease

• Treatment

• Anti-platelet

• Anti-lipemic

Medical Treatments

• Medications

• Prevention

• Treatment for known disease

• Surgery

• Corrective

• Implants


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Medications

• Anti-lipemic

• Diuretic

• Anti-thrombotics

• Anti-arrhythmic

• Beta and calcium channel blocker

• Nitrates

• Cardiac glycosides

• ACE & ARB’s

• Anti-platelet

Anti-lipemic

Potential side effects

• Liver function

• Myalgia

• Muscle cramps

• Gastrointestinal problems

• Rash

Diuretics


• Hypotension

• Weakness

• Electrolyte imbalance arrhythmias

• Muscle cramps

Anti-thrombotics

Potential complication

• Monitor for bleeding

Patient education

• Take aspirin or Ticlopidine with food/milk

• Avoid aspirin containing products

• Advise patient to tell all healthcare workers that on

antithrombotic medications

• Vitamin K and alcohol inhibit warfarin

Anti-arrhythmic


• Liver damage

• Lung toxicity

• Neurologic symptoms

• Arrhythmia

Beta and calcium

channel blocker

♥ Many alter rest and exercise HR and BP

Potential Side-effects

• Hypotension (dizziness)

• Fatigue

• Heat intolerance


2/20/2012


Nitrates


• Hypotension

• Dizziness

Cardiac glycosides


• Nausea

• Vomiting

• Fatigue

• Confusion

ACE & ARB’s


• ACE = Angiotension-converting enzyme inhibitor

• Cough

• Electrolyte imbalance arrhythmia

• ARB = Angiotensin II Receptor Blockers

• Electrolyte imbalance arrhythmia

• Rash

Anti-platelet

• Potential side effects

• Nausea

• Dizziness

• Tachycardia

• Muscle pain

• Fluid retention

• Gastrointestinal bleeding

Surgeries

• Correction of myocardial circulation

• Coronary Artery Bypass Graft (CABG)

• Stents

• Valve Replacement

• Pacing

• Transplant

• Augmentation of blood flow

CABG – Potential

complications

• Bleeding

• Altered BP

• Cardiac arrhythmias

• Renal dysfunction

• Infection


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Devices

• Stents

• Pacemakers

• Valves

• Augmentive devices

Stents – Potential

complications

• Acute occlusion of CA

• MI

• CA dissection

• Bleeding

• Compromise to circulation

Pacemakers – Potential

complications

• Loss of capture

• Irregular pace

• Setting of defibrillator

• Activation of defibrillator

set by heart rate

Valves – Potential

complications

• Emboli

• Failure

(regurgitation)

Ventricular Augmentation

– Potential complications

• Bleeding

• Clots

• Loss of function

• Infection

Follow-up 1 - Case

Scenario 2

65 yo female

• Rest HR – 70; BP – 140/70; RR – 17

• Mild LE edema

• Auscultation of Heart sounds

• What do you want to do?????


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Follow-up 1 - Case

Scenario 2

• Contact Physician

• Medical tests

• Echocardiograph – Heart Failure

• Pharmacological Treatment

• Diurectic

• Cardiac glycoside

Follow-up 1 - Case

Scenario 2

20 yo male

• Rest HR – 55; BP – 175/95; RR – 12


Follow-up 1 - Case

Scenario 2

• Repeat resting BP

• Complete knee exam

• Defer resistance tests

• Can start symptom relief treatments that are not contraindicated

• Refer to physician

• Pharmacological Treatment

• Diuretic

• ARB

Follow-up 1 - Case

Scenario 3

40 year old male

• Rest HR – 60; BP – 110/60; RR – 14


Follow-up 1 - Case

Scenario 3

• Complete assessment

• Ask for more information regarding ―problems with

activity

• Ask about parameters of pacemaker

• Monitoring HR response during any activities


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Recommendations/guide

lines

Guide to Physical

Therapist Practice

• Examination

• History

• Systems review

• Cardiovascular

Heart rate

Respiratory rate

Blood pressure

Edema

Initial Examination

• ACSM Risk stratification

Based on presence or absence of:

• Known disease

• Signs or symptoms suggestive of disease

• CVD risk factors

• Assessment of blood pressure

• Pulses

Risk stratification Risk Factors

Age

Gender

Family History

Smoking

Hypertension

Sedentary lifestyle

Obesity

Dyslipidemia

Known metabolic disease

Signs/symptoms

• Ankle edema

• Palpitations or tachycardia

• Intermittent claudication

• Dyspnea

• Pain/discomfort

• Shortness of breath

• Dizziness or syncope

• Unusual fatigue

Heart disease

• Guidelines*

• Initial Examination

• Heart rate and blood pressure – rest and exercise

• Follow-up visits

• Monitor those at increased risk – known disease or anyone with an abnormal response during the first visit

* Guidelines for initial from APTA, AHA, ACC, ACSM (among many)

Heart disease – exercise

recommendations

• Aerobic (low to moderate risk)

• 4 - 7 days per week

• Intensity - 40 – 80% HRR or 11-16 RPE

• Duration – 20 – 60 minutes

• Resistance activity (Low – moderate risk)

• Very light resistance (circuit training)

• Monitor response


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Atrial Fibrillation

• Atrial Fibrillation guidelines

• Criteria for rate control vary with patient age

• 90 and 115 beats per minute during moderate exercise.

Atrial Fibrillation– exercise

recommendations

• Aerobic (low to moderate risk)

• 4 - 7 days per week

• Intensity - 40 – 60% HRR or 11-14 RPE

• Duration – 20 – 60 minutes

• Resistance activity (Low – moderate risk)

• Very light resistance

• Monitor response

Hypertension

• Guidelines

• Initial Examination

• Heart rate and blood pressure – rest and exercise

• Follow-up visits

• Monitor those at increased risk – known disease or

anyone with an abnormal response during the first

visit

Hypertension– exercise

recommendations

• Aerobic

• 4 – 7 days per week

• Session duration – 20 – 60 minutes

• Intensity – 40-80% of exercise capacity/11-16 RPE

• Resistance

• Light - moderate intensity resistance – large muscle groups or circuit training

• Avoid Valsalva maneuver

• Monitor BP response

Heart Failure

• ―Exercise training is beneficial as an

adjunctive approach to improve clinical status

in ambulatory patients with current or prior

symptoms of HF and reduced LVEF‖. –

ACC/AHA, 2009

• ―Healthcare providers should perform periodic

evaluation for signs and symptoms of HF in

patients at high risk for developing HF.‖

HF - Serial Clinical

Assessment

• ADLs

• Volume status and body weight

• Includes sitting and standing BP

• Use of alcohol, drugs, and dietary intake


2/20/2012


Heart Failure – exercise

recommendations

• Aerobic

• 4 – 7 days per week

• Session duration – 20 – 40 minutes

• Intensity – 40-70% of HRR/ 11-16 RPE

• Resistance

• High reps, low resistance – large muscle groups or

circuit training

• Monitoring

• Heart rate, blood pressure, symptoms, edema

Pacemakers and

Defibrillators

• Determine type of pacemaker

• Adapt upper body activities

• May have altered ROM or restrictions on side of pacer

• Determine upper training HR

Upper extremity exercise

• Smaller muscle mass

• Less mechanical efficiency

• Greater stress on heart

• Higher heart rate

• Higher blood pressure

• Recommendations

• Decrease intensity of any UE exercise if required

• Avoid high intensity UE activity if not needed,

especially overhead activity

Recommendations - Case

Scenario 1

65 yo female

• Intervention – After HF under control

• Exercise prescription modifications

• RPE for aerobic exercise

• Monitor response for exercise sessions,

• Limit resistance to body weight, tubing (high reps, low

resistance)

• Follow guidelines for body weight, etc., monitoring


Scenario 2

20 yo male

• Intervention – after BP control

• Exercise Modifications

• Adjust exercise based upon meds if needed

• Monitor BP – rest and response to exercise


Scenario 3

40 year old male

• Exercise modification

• Monitor HR during rehab

• Keep HR at least 10 beats below defibrillator setting


2/20/2012


Summary

Outpatient

“Every Patient is a

Cardiopulmonary Patient” A. Swisher, Editorial

“Indirect” Involvement

• ANY PATIENT!

History & Interview

• Take a thorough history

• Follow-up on signs & symptoms that do not fit

• Ask about medication use

• Especially that day

• Ask about disease control

Heart rate and Pulses

• When

• Rest, pre, during & post exercise

• Where

• Dependent on complaint and purpose

• How long

• 1 min rest (most accurate)

• 15 sec during exercise

Pulses

• Value of Pulses • Estimation of heart rate

• Regularity of heart rhythm

• Strength of blood flow to an are

• Response to intervention

• Grading • 0 = Absent

• 1 = Diminished

• 2 = Normal

• 3 = Bounding • Compare side to side or distal to proximal


2/20/2012


Blood Pressure

• When

– Rest, pre & post exercise

• Where

– Brachial artery

• May do ankle if PAD suspected -

ABI

– Side

• Do not take on side of major

surgeries, lymphedema, access lines

Blood Pressure

• Precaution – BP > normal, but less than 200 systolic

and/or 110 diastolic

• Contraindication - Resting systolic BP > 200 mmHg

and/or diastolic > 110 mmHg

• Stop exercise if:

• Drop in systolic > 10 mmHg, with increase in activity

• Systolic > 250 mmHg or Diastolic > 115 mmHg

• Clinical exercise - >200 mmHg (Goodman & Snyder)

Blood Pressure

• Monitor & Physician Referral

• SPB > 120 and/or DBP > 80, with risk factors

• Difference in pulse pressure > 40

• DBP more than 10 mm Hg during exercise

• SBP > 200 with exercise

• BP changes with other signs & symptoms

Goodman and Snyder, 2007

Emergency

• Un-resolving resting Tachycardia > 120 with

symptoms

• Immediate treatment > Valsalva maneuver; carotid massage

• Resting BP > 200 systolic or 110 diastolic

• May not have symptoms

DISCUSSION

References

• Lloyd-Jones D, Adams RJ, Brown TM, et al. Heart Disease and Stroke Statistics—2010 Update. A Report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2010;121:e1-e170.

• Pickering TG, Hall JE, Appel LJ, et al. Blood pressure measurement in humans: A statement for the professional from the subcommittee of professional and public education of the American Heart Association Council on High Blood Pressure Research. Hypertension. 2004;45:142-161.

• National Center for Health Statistics. Health, United States, 2008 [PDF 8.4M]. Hyattsville, MD: National Center for Health Statistics; 2008.

• Scherer S, Noteboom J, Flynn TW. Cardiovascular assessment in the orthopedic practice setting . J Orthop Sports Phys Ther. 2005;35:730-737.

http://circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.108.191261v1





http://www.cdc.gov/nchs/data/hus/hus08.pdf





2/20/2012


• US Department of Health and Human Services. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. 2004.

• Thompson WR (ed). ACSM’s Guidelines for Exercise Testing and Prescription. 8th Ed. Philadelphia, PA: Lippincotte Williams and Wilkins; 2010.

• Ehrman JK (ed). ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription. 6th ed. Philadelphia, PA: Lippincotte Williams and Wilkins; 2010.

• Goodman C, Snyder T. Differential Diagnosis for Physical Therapists: Screening for Referral. 2007.

• Bonow RO, Bennett S, Casey DE, et al. ACC/AHA Clinical Performance Measures for Adults With Chronic Heart Failure. J Amer C Cardiol. 2005;46:1144-78.

• Hirsch et al. Peripheral Arterial Disease: ACC/AHA 2005 Guidelines for the Management of Patients With (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic): A Collaborative Report From the AAVS/SVS, SCAI, SVMB, SIR, and the ACC/AHA Task Force on Practice Guidelines Accessed at: http://www.acc.org/qualityandscience/clinical/topic/topic.htm#guidelines

• 2009 Focused Update Incorporated Into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults. Accessed at: http://content.onlinejacc.org/cgi/content/full/j.jacc.2008.11.013

• Fuster V, Ryden LE, Cannom DS, et al. ACC/AHA/ESC 2006 Guidelines for management of patients with atrial fibrillation. J Am Coll Cardiol. 2006;48:854-906. Available at: http://www.acc.org/qualityandscience/clinical/topic/topic.htm#guidelines

• Boissonnault, WG. Prevalence of comorbid conditions, surgeries, and medication use in a physical therapy outpatient population: A multicentered study. J Ortho Sports Phys Ther. 1999;29:506-525.

• Guccione AA, Felson DT, Anderson JJ, et al. The effects of specific medical conditions on the functional limitations of elders in the Framingham Study. Am J Pub Health. 1994;84:351-358.

• Jette DU, Jette AM. Physical therapy and health outcomes in patients with spinal impairments. Phys Ther. 1996;76:930-941.

• Ritzwoller DP, Crounse L, Shetterly S, Rublee D. The association of comorbidities, utilization and costs for patients identified with low back pain. BMC Musculoskeletal Disorders. 2006;7:72. Accessed at: http://www.biomedcentral.com/1471-2474/7/72

• 7th Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure. 2004. Accessed at: http://www.nhlbi.nih.gov/guidelines/hypertension/index.htm

• The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents. Accessed at: http://www.nhlbi.nih.gov/health/prof/heart/hbp/hbp_ped.htm

• Peripheral arterial fact sheet. Accessed at: http://www.cdc.gov/DHDSP/data_statistics/fact_sheets/docs/fs_PAD.pdf

http://www.acc.org/qualityandscience/clinical/topic/topic.htm


http://content.onlinejacc.org/cgi/content/full/j.jacc.2008.11.013






http://www.biomedcentral.com/1471-2474/7/72



http://www.nhlbi.nih.gov/guidelines/hypertension/index.htm

http://www.nhlbi.nih.gov/guidelines/hypertension/index.htm

http://www.nhlbi.nih.gov/health/prof/heart/hbp/hbp_ped.htm

http://www.nhlbi.nih.gov/health/prof/heart/hbp/hbp_ped.htm

http://www.cdc.gov/DHDSP/data_statistics/fact_sheets/docs/fs_PAD.pdf




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