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
Cardiac Comorbidities in Outpatient Settings: Implications for Assessment and Treatment
2/20/2012
Property of A. Lynn Millar, Do not copy without permission 2
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
Cardiac Comorbidities in Outpatient Settings: Implications for Assessment and Treatment
2/20/2012
Property of A. Lynn Millar, Do not copy without permission 3
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
Cardiac Comorbidities in Outpatient Settings: Implications for Assessment and Treatment
2/20/2012
Property of A. Lynn Millar, Do not copy without permission 4
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
Cardiac Comorbidities in Outpatient Settings: Implications for Assessment and Treatment
2/20/2012
Property of A. Lynn Millar, Do not copy without permission 5
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
Cardiac Comorbidities in Outpatient Settings: Implications for Assessment and Treatment
2/20/2012
Property of A. Lynn Millar, Do not copy without permission 6
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
Potential side effects
• 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
Potential side effects
• 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
Cardiac Comorbidities in Outpatient Settings: Implications for Assessment and Treatment
2/20/2012
Property of A. Lynn Millar, Do not copy without permission 7
Nitrates
Potential side effects
• Hypotension
• Dizziness
Cardiac glycosides
Potential side effects
• Nausea
• Vomiting
• Fatigue
• Confusion
ACE & ARB’s
Potential side effects
• 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
Cardiac Comorbidities in Outpatient Settings: Implications for Assessment and Treatment
2/20/2012
Property of A. Lynn Millar, Do not copy without permission 8
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?????
Cardiac Comorbidities in Outpatient Settings: Implications for Assessment and Treatment
2/20/2012
Property of A. Lynn Millar, Do not copy without permission 9
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
• What do you want to do?????
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
• What do you want to do?????
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
Cardiac Comorbidities in Outpatient Settings: Implications for Assessment and Treatment
2/20/2012
Property of A. Lynn Millar, Do not copy without permission 10
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
Cardiac Comorbidities in Outpatient Settings: Implications for Assessment and Treatment
2/20/2012
Property of A. Lynn Millar, Do not copy without permission 11
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
Cardiac Comorbidities in Outpatient Settings: Implications for Assessment and Treatment
2/20/2012
Property of A. Lynn Millar, Do not copy without permission 12
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
Recommendations - Case
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
Recommendations - Case
Scenario 3
40 year old male
• Exercise modification
• Monitor HR during rehab
• Keep HR at least 10 beats below defibrillator setting
Cardiac Comorbidities in Outpatient Settings: Implications for Assessment and Treatment
2/20/2012
Property of A. Lynn Millar, Do not copy without permission 13
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
Cardiac Comorbidities in Outpatient Settings: Implications for Assessment and Treatment
2/20/2012
Property of A. Lynn Millar, Do not copy without permission 14
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.
Cardiac Comorbidities in Outpatient Settings: Implications for Assessment and Treatment
2/20/2012
Property of A. Lynn Millar, Do not copy without permission 15
• 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