introduction to advanced cardiopulmonry rehabilitation ped 596 spring 2002
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Introduction to Advanced Introduction to Advanced Cardiopulmonry Cardiopulmonry
RehabilitationRehabilitation
PED 596
Spring 2002
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Review Physiological Review Physiological Responses to ExerciseResponses to Exercise
Exercise is Homeostatic Emergency
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Acute = AccommodateAcute = AccommodateImmediate response to an “Exercise Emergency”GOAL: Maintain homeostasis
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Chronic = AdaptChronic = AdaptRepeated exposures to “Exercise Emergencies” stimulate adaptive changes
Training Effects
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Define “Exercise”Define “Exercise”You should get more “exercise!”
Muscular activity (work)Induces increased oxygen uptakeIncreased cardiac outputIncreased cellular energy metabolism
WORK CAPACITY and THE PHYSIOLOGICAL RESPONSE TO WORK
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Bottom Line - Emergency #1Bottom Line - Emergency #1: : Exercise Demands: ATP supply Exercise Demands: ATP supply and substrate delivery systemsand substrate delivery systems
ATP Supply: Fuel Supply: Glucose, Fatty Acids
Oxygen Supply
Metabolic Machinery: Rate Regulating Enzymes
Delivery System: Cardiopulmonary Systems
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Bottom Line - Emergency #2Bottom Line - Emergency #2: : Exercise Demands: Better Exercise Demands: Better machinerymachinery
Work Output is an “external” product of exerciseWork Capacity is in part determined by Muscle strengthMuscle Strength: Function of cross-section and neurological efficiency
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AdaptationAdaptation: Improves the ability : Improves the ability to respond to each “Homeostatic to respond to each “Homeostatic
Emergency” Emergency”
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Specificity of Training: Specificity of Training:
Peripheral Adaptations: Muscle Fiber: Protein synthesis, metabolic enzymes, mitochondrial density, glycogen, triglyceride and myoglobin storesAngiogenesis
Central Adaptations:Cardiovascular: Cardiac output, peripheral resistance, blood volume, RBC, ventilatory threshold, insulin sensitivity
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Exercise Testing: Clinical Exercise Testing: Clinical
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Clinical Indications for Clinical Indications for Exercise Testing:Exercise Testing:
Diagnosis: Reproduce symptomsCP, SOB, Poor work toleranceECG changes?
Functional Testing:Work Capacity, BP response to exercise, Exercise duration
Prognosis:AHA, AACVPR, ACP: Risk Stratification, Duke’s 5-Year Mortality prognosis
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Diagnosis:Diagnosis:
Indications:Confirm or rule out suspected myocardial ischemia
Mechanisms for syncope (LOC)
Suspected arrhythmias (palpitations with symptoms) during exercise
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Functional Capacity:Functional Capacity:Indications:
Assessing work capacity for return to work/leisure activites
Used in determining risk/prognostic stratification
Used in determining therapy choices
Exercise Prescription: Phase II Entrance requirements
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Prognostic BenchmarksPrognostic Benchmarks
<5 METs: poor prognosis especially under 65 years old
10 METs: considered normal fitness: survival good – regardless of intervention
13 METs: good prognosis even with CAD present
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BikeBike vs. vs. TreadmillTreadmill
Less expensive
Less space
Quieter
Less ECG artifact
Easier BP’s
Non-Weight dependent
More flexibility in protocolsMore reproducible (not-patient dependent)More accurate work determinations
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Specificity of Testing:Specificity of Testing:
Patient Preference / Experience
Diagnostic Protocols:
To Elicit Symptoms
Often quit at ~80% predicted HR Max
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Critical Measurements:Critical Measurements:
Work Loads: MET calculations
ECG: Clean ST-Segment changes
BP: Accurate work SBP/DBP
RPP: MVO2 eliciting CP
Elicited Symptoms: CP, SOB, Syncope
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Myocardial O2 demand (MVO2) depends on..
Myocardial tension (pressure x volume)
Inotropic State (Measure?)
Chronotropic state (Measure?)
Myocardial mass
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Indirect measure of MVO2Indirect measure of MVO2
Rate pressure product (a.k.a. double product, tension-time index)
Considers 2 of the MVO2 indices:
HR X SBP
Good estimate of oxygen use by the heart.
Used to determine angina threshold
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12-Lead ECG: Electrode 12-Lead ECG: Electrode PlacementPlacement
RA/LA: On Shoulders at distal ends of clavicles: (Not over large muscle masses)
RL/LL:Base of Torso: Just medial to the iliac crests
Chest Leads: V1-V6Traditional precordial positioning
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V1-V2: 4th intercostal space –R/L of sternumV4: 5th intercostal space – midclavicle lineV3: Between V2 and V4V5: At horizontal level of V4, anterior to axillaV6: Midaxillary at horizontal level of V4
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Treadmill Protocols:Treadmill Protocols:Treadmill Speed: IndividualizeIncrement Size: Age, condition
Larger incremental increases for younger, more fit patientsSmaller incremental increases for elderly, de-conditioned
Test Length: Between 8-12 minutes
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Estimating Work Capacity: Estimating Work Capacity: Selecting ProtocolsSelecting Protocols
Healthy Men >40 years old75% have 12.5 MET capacity
50% ~ 10 METs
Healthy Women >40 years old75% have 10 MET capacity
50% ~8-9 METs
Choose a protocol that achieves the estimated MET capacity between 8-12 minutes
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Commonly Used Clinical Commonly Used Clinical Protocols: Protocols:
Naughton: 2.0 mph X 3.5% increases every 2 minutes
Max METs = 9 /16 minutes
Balke: 3.3 mph X 3% increases every 3 minutes
Max METs = 12 /18 minutes
McHenry: Similar to Balke but Stage I is 2.0 mph/3% grade
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Measurements: HR, BP, Measurements: HR, BP, ECGECGPre-Test: Supine and Exercise Position
Exercise: HR/BP in final minute of each stage – ECG every minute and whenever irregularities appear
Post-Test: Immediately post exercise and every 1-2 minutes until full recovery
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Measurements: RPE, Measurements: RPE, SymptomsSymptoms
RPE: In the last minute of each stage
Symptoms: Note symptoms that occur:
Ask frequently, “How are you feeling?”
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Rating Anginal Symptoms: Rating Anginal Symptoms:
1+: Light, barely noticeable
2+: Moderate, bothersome
3+: Severe, very uncomfortable
4+: Most severe pain ever experienced
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Post Exercise Period: Post Exercise Period: For Maximal Diagnostic Sensitivity:
No Cool Down10-sec ECG immediately 6-8 minutes of supine monitoring* - record ECG every minute or after any irregularity
*Unless patient is severely dyspneic – then sitting preferred
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Testing Competencies: Testing Competencies:
Know Absolute and Relative indications for test termination:
3+ to 4+ angina
Suspected MI
Drop in SBP with increased work
Serious arrhythmias
Signs of poor perfusion
Patient request
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Exercise Test Endpoints:Exercise Test Endpoints:
Pre-determined HR achieved
Pre-determined Workload achieved
Patient c/o CP, SOB, leg pains, fatigue
ECG changes:Significant ST changes
New Bundle branch or AV block
Increasing PVC frequency, VT or Fib
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A Little Diagnostic A Little Diagnostic InteractionInteraction
HHMI Cardiology Lab
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Cardiovascular Cardiovascular PharmacologyPharmacology
Exercise Implications
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Understanding the Role of Understanding the Role of Medications in Exercise:Medications in Exercise:
What is the physiological response to exercise?
What is the mechanism of action of the drug?
Is there individual variability?
How are generalities best applied to exercise testing and prescription?
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Cardiovascular Response to Cardiovascular Response to Exercise: Acute / Chronic Exercise: Acute / Chronic
Changes in Autonomic Nervous System
SNS: Acute responses
PSNS: Resting status in trained persons
Cardiovascular Changes:HR, BP, myocardial contractility, venous return, vascular resistance,
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Therefore: Therefore:
Any drug that acts on the autonomic nervous system, heart, blood vessels or kidneys may impact exercise
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Drug Classifications: Drug Classifications: Mechanism: Mechanism: Use: Use:
Diuretics:
ACE Inhibitors
Beta-blockers
Ca++ Channel blockers
Nitrates
Anti-hypertensiveAnti-hypertensive, CHF, Anti-hypertensive, tachycardiasAnti-hypertensive, tachycardiasAnti-anginal
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Diuretics: Diuretics:
Alter renal reabsorption or secretion of H2O and/or Na+
Increase diuresis
Used for Hypertension and CHF
May cause electrolyte imbalances: especially K+
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Commonly Used Diuretics:Commonly Used Diuretics:
Thiazide Diuretics: Diuril, (Lozol)
Loop Diuretics: Lasix, Bumex, Edecrin
K+ Sparing: Aldactone, Dyazide
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Effects of Diuretics on Effects of Diuretics on Exercise: (See ACSM)Exercise: (See ACSM)
Very little effect except for decreased blood pressure
CAUTION: May cause PVC’s or false + ischemia signs with electrolyte imbalances
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ACE Inhibitors: ACE Inhibitors: Inhibits Renin-Angiotensin Aldosterone (RAA) System:
Renin is released from kidneys in response to hypotension/ Na+
Renin increases levels of Angiotensin I (liver)Angiotensin Converting Enzyme (ACE) converts Ang I to Angiotensin II (active)
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What Does Angiotensin II Do?What Does Angiotensin II Do?
Vasoconstriction Blood Pressure
Increase H2O and N+
Retention
Stimulate release of ADH and Aldosterone
Net Effect: Increase Blood Pressure
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Therapeutic Uses of ACE Therapeutic Uses of ACE Inhibitors: Inhibitors:
Hypertension: Improved diuresis, vascular relaxationCHF: The combined effect of diuresis, vascular relaxation reduces Pre/After-Loads on heart
* Affects diuresis without direct action on kidneys – can be used in patients with impaired kidney function
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Commonly Used ACE Commonly Used ACE Inhibitors:Inhibitors:
Captopril (Capoten): Used in mild to moderate hypertension
Vasotec, Lotensisn: Used in all hypertensions and CHF
Zestril, Prinivil: Once a day dosing
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Effects of ACE Inhibitors on Effects of ACE Inhibitors on Exercise: Exercise:
Little effect except to decrease blood pressure
May actually improve exercise capacity in patients with CHF
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Beta-Blockers: Beta-Blockers: Beta-adrenoceptor antagonist:
Reduces SNS stimulation of Beta-receptorsProlongs AV conduction ( HR)Inhibit Phase 4 DepolarizationDecrease Contractility
Decreases MVO2
Contraindicated: CHF*, asthma, diabetes
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Therapeutic Uses Of Beta-Therapeutic Uses Of Beta-Blockers:Blockers:
Used for treating mild to moderate hypertension
Treating Angina
Reducing tachyarrhythmias
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Commonly Used Beta-Commonly Used Beta-Blockers:Blockers:
InderalLopressorCorgardBlocadrenTenormimLopressor
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Effect of Beta-Blockers on Effect of Beta-Blockers on Exercise:Exercise:
Reduced resting and exercise HR/BP
Reduced ischemia
Exercise capacity equivocal: may decrease in patients without angina
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Calcium Channel Blockers:Calcium Channel Blockers:
Block slow calcium channels in myocardial and vascular smooth muscle cells:
Reduce vasoconstriction
Decrease cardiac contractility
Decrease MVO2
Can lead to AV-Block
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Therapeutic Uses of Calcium Therapeutic Uses of Calcium Channel Blockers:Channel Blockers:
Treatment of Hypertension
Tachyarrhythmias
Cautious use in CHF
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Commonly Used Calcium Commonly Used Calcium Channel Blockers: Channel Blockers:
Verapamil: Calan, Verelan
Diltiazem: Cardizem
Nifedipine: Procardia
Nicardipine: Cardene
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Effects of Calcium Channel Effects of Calcium Channel Blockers on Exercise:Blockers on Exercise:
Check ACSM Manual
Variable Effects on Heart Rate
Blood Pressure
Exercise Capacity
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Nitrates:Nitrates:
Dilates all blood vessels
Relieves symptoms of angina:Vasodilation decreases cardiac pre-load and MVO2
Fast acting
Short lived effects
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Nitroglycerine:Nitroglycerine:
Generally used for immediate relief of anginaSublingual: also Isordil, SorbitrateAdverse Effects:
Orthostatic hypotensionHeadache, reflex tachycardiaExcesses can produce methemoglobin - hemolysis
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Exercise and Nitrates:Exercise and Nitrates:
Increase HR
Decrease BP
Increase exercsie capacity for those with angina