Introduction to advanced cardiopulmonry rehabilitation
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Introduction to Advanced Cardiopulmonry Rehabilitation. PED 596 Spring 2002. Review Physiological Responses to Exercise. Exercise is Homeostatic Emergency. Acute = Accommodate. Immediate response to an “Exercise Emergency” GOAL : Maintain homeostasis. Chronic = Adapt.

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Review physiological responses to exercise l.jpg
Review Physiological Responses to Exercise

Exercise is Homeostatic Emergency


Acute accommodate l.jpg
Acute = Accommodate

  • Immediate response to an “Exercise Emergency”

  • GOAL: Maintain homeostasis


Chronic adapt l.jpg
Chronic = Adapt

  • Repeated exposures to “Exercise Emergencies” stimulate adaptive changes

  • Training Effects


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Define “Exercise”

  • You should get more “exercise!”

    • Muscular activity (work)

    • Induces increased oxygen uptake

    • Increased cardiac output

    • Increased cellular energy metabolism

  • WORK CAPACITY and THE PHYSIOLOGICAL RESPONSE TO WORK


Bottom line emergency 1 exercise demands atp supply and substrate delivery systems l.jpg
Bottom Line - Emergency #1: Exercise Demands: ATP supply and substrate delivery systems

  • ATP Supply:

    • Fuel Supply: Glucose, Fatty Acids

    • Oxygen Supply

    • Metabolic Machinery: Rate Regulating Enzymes

  • Delivery System:

    • Cardiopulmonary Systems


Bottom line emergency 2 exercise demands better machinery l.jpg
Bottom Line - Emergency #2: Exercise Demands: Better machinery

  • Work Output is an “external” product of exercise

  • Work Capacity is in part determined by Muscle strength

  • Muscle Strength: Function of cross-section and neurological efficiency


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Adaptation: Improves the ability to respond to each “Homeostatic Emergency”


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Specificity of Training:

  • Peripheral Adaptations:

    • Muscle Fiber: Protein synthesis, metabolic enzymes, mitochondrial density, glycogen, triglyceride and myoglobin stores

    • Angiogenesis

  • Central Adaptations:

    • Cardiovascular: Cardiac output, peripheral resistance, blood volume, RBC, ventilatory threshold, insulin sensitivity



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Clinical Indications for Exercise Testing:

  • Diagnosis: Reproduce symptoms

    • CP, SOB, Poor work tolerance

    • ECG 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:

  • 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:

  • 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 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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Less expensive

Less space

Quieter

Less ECG artifact

Easier BP’s

Non-Weight dependent

More flexibility in protocols

More reproducible (not-patient dependent)

More accurate work determinations

Bike vs. Treadmill


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Specificity of Testing:

  • Patient Preference / Experience

  • Diagnostic Protocols:

    • To Elicit Symptoms

    • Often quit at ~80% predicted HR Max


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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


Myocardial o2 demand mvo 2 depends on l.jpg
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 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 Placement

  • 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-V6

    • Traditional precordial positioning


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V1-V2: 4th intercostal space –R/L of sternum

V4: 5th intercostal space – midclavicle line

V3: Between V2 and V4

V5: At horizontal level of V4, anterior to axilla

V6: Midaxillary at horizontal level of V4


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Treadmill Protocols:

  • Treadmill Speed: Individualize

  • Increment Size: Age, condition

    • Larger incremental increases for younger, more fit patients

    • Smaller incremental increases for elderly, de-conditioned

  • Test Length:

    • Between 8-12 minutes


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Estimating Work Capacity: Selecting Protocols

  • Healthy Men >40 years old

    • 75% have 12.5 MET capacity

    • 50% ~ 10 METs

  • Healthy Women >40 years old

    • 75% have 10 MET capacity

    • 50% ~8-9 METs

  • Choose a protocol that achieves the estimated MET capacity between 8-12 minutes


Commonly used clinical protocols l.jpg
Commonly Used Clinical 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


Measurements hr bp ecg l.jpg
Measurements: HR, BP, ECG

  • Pre-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, Symptoms

  • 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:

  • 1+: Light, barely noticeable

  • 2+: Moderate, bothersome

  • 3+: Severe, very uncomfortable

  • 4+: Most severe pain ever experienced


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Post Exercise Period:

  • For Maximal Diagnostic Sensitivity:

    • No Cool Down

    • 10-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


Testing competencies l.jpg
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


Exercise test endpoints l.jpg
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 Interaction

HHMI Cardiology Lab


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Cardiovascular Pharmacology

Exercise Implications


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Understanding the Role of 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?


Cardiovascular response to exercise acute chronic l.jpg
Cardiovascular Response to 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,


Therefore l.jpg
Therefore:

  • Any drug that acts on the autonomic nervous system, heart, blood vessels or kidneys may impact exercise


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Diuretics:

ACE Inhibitors

Beta-blockers

Ca++ Channel blockers

Nitrates

Anti-hypertensive

Anti-hypertensive, CHF,

Anti-hypertensive, tachycardias

Anti-hypertensive, tachycardias

Anti-anginal

Drug Classifications: Mechanism: Use:


Diuretics l.jpg
Diuretics:

  • Alter renal reabsorption or secretion of H2O and/or Na+

  • Increase diuresis

  • Used for Hypertension and CHF

  • May cause electrolyte imbalances: especially K+


Commonly used diuretics l.jpg
Commonly Used Diuretics:

  • Thiazide Diuretics: Diuril, (Lozol)

  • Loop Diuretics: Lasix, Bumex, Edecrin

  • K+ Sparing: Aldactone, Dyazide


Effects of diuretics on exercise see acsm l.jpg
Effects of Diuretics on Exercise: (See ACSM)

  • Very little effect except for decreased blood pressure

  • CAUTION: May cause PVC’s or false + ischemia signs with electrolyte imbalances


Ace inhibitors l.jpg
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)


What does angiotensin ii do l.jpg
What Does Angiotensin II Do?

Vasoconstriction

Blood Pressure

Increase H2O and N+

Retention

Stimulate release of

ADH and Aldosterone

Net Effect:

Increase Blood Pressure


Therapeutic uses of ace inhibitors l.jpg
Therapeutic Uses of ACE Inhibitors:

  • Hypertension: Improved diuresis, vascular relaxation

  • CHF: 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


Commonly used ace inhibitors l.jpg
Commonly Used ACE Inhibitors:

  • Captopril (Capoten): Used in mild to moderate hypertension

  • Vasotec, Lotensisn: Used in all hypertensions and CHF

  • Zestril, Prinivil: Once a day dosing


Effects of ace inhibitors on exercise l.jpg
Effects of ACE Inhibitors on Exercise:

  • Little effect except to decrease blood pressure

  • May actually improve exercise capacity in patients with CHF


Beta blockers l.jpg
Beta-Blockers:

  • Beta-adrenoceptor antagonist:

    • Reduces SNS stimulation of Beta-receptors

    • Prolongs AV conduction ( HR)

    • Inhibit Phase 4 Depolarization

    • Decrease Contractility

    • Decreases MVO2

    • Contraindicated: CHF*, asthma, diabetes


Therapeutic uses of beta blockers l.jpg
Therapeutic Uses Of Beta-Blockers:

  • Used for treating mild to moderate hypertension

  • Treating Angina

  • Reducing tachyarrhythmias


Commonly used beta blockers l.jpg
Commonly Used Beta-Blockers:

  • Inderal

  • Lopressor

  • Corgard

  • Blocadren

  • Tenormim

  • Lopressor


Effect of beta blockers on exercise l.jpg
Effect of Beta-Blockers on Exercise:

  • Reduced resting and exercise HR/BP

  • Reduced ischemia

  • Exercise capacity equivocal: may decrease in patients without angina


Calcium channel blockers l.jpg
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


Therapeutic uses of calcium channel blockers l.jpg
Therapeutic Uses of Calcium Channel Blockers:

  • Treatment of Hypertension

  • Tachyarrhythmias

  • Cautious use in CHF


Commonly used calcium channel blockers l.jpg
Commonly Used Calcium Channel Blockers:

  • Verapamil: Calan, Verelan

  • Diltiazem: Cardizem

  • Nifedipine: Procardia

  • Nicardipine: Cardene


Effects of calcium channel blockers on exercise l.jpg
Effects of Calcium Channel Blockers on Exercise:

  • Check ACSM Manual

  • Variable Effects on Heart Rate

  • Blood Pressure

  • Exercise Capacity


Nitrates l.jpg
Nitrates:

  • Dilates all blood vessels

  • Relieves symptoms of angina:

    • Vasodilation decreases cardiac pre-load and MVO2

    • Fast acting

    • Short lived effects


Nitroglycerine l.jpg
Nitroglycerine:

  • Generally used for immediate relief of angina

  • Sublingual: also Isordil, Sorbitrate

  • Adverse Effects:

    • Orthostatic hypotension

    • Headache, reflex tachycardia

    • Excesses can produce methemoglobin - hemolysis


Exercise and nitrates l.jpg
Exercise and Nitrates:

  • Increase HR

  • Decrease BP

  • Increase exercsie capacity for those with angina


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