心脏康复评定精选PPT.ppt

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1、关于心脏康复评定第1页，讲稿共92张，创作于星期日A PATIENT CASE EXAMPLE第2页，讲稿共92张，创作于星期日1.Why are you here today?2.Have you been diagnosed with a cardiac disorder in the past?3.Have you had any special tests to examine your heart like an electrocardiogram,stress test,echocardiogram,or cardiac catheterization?第3页，讲稿共92张，创作于

2、星期日4.Do you experience angina or shortness of breath at rest,only with activity/exercise,or both at rest and with activity/exercise?第4页，讲稿共92张，创作于星期日5.If you experience angina or become short of breath during activity or exercise could you please describe the type of activity or exercise which produ

3、ces your angina or shortness of breath?第5页，讲稿共92张，创作于星期日6.Can you describe your angina or shortness of breath?Can you help me understand your angina or shortness of breath by pointing to the numbers 1 through 4 to describe the level of angina you experience at rest and exercise or by pointing to you

4、r level of shortness of breath using this 10-point scale or by marking this visual analog scale?第6页，讲稿共92张，创作于星期日7.Could I feel your pulse to determine your heart rate and the strength of your pulse?8.Could I place this finger probe on your index finger to obtain an oxygen saturation measurement?第7页

5、，讲稿共92张，创作于星期日 9.Could I place these electrodes on your chest to obtain a simple single-lead electrocardiogram(ECG)?第8页，讲稿共92张，创作于星期日10.Could I take your blood pressure while you are seated and then compare it to the blood pressure while you are lying down and then standing?I would also like to obse

6、rve your pulse,oxygen saturation,ECG,and symptoms when you are lying down and standing.第9页，讲稿共92张，创作于星期日11.Could I listen to your heart and lungs with my stethoscope?While I do this I will concentrate on watching your ECG so that I can identify your heart sounds and any changes in the ECG while you

7、are breathing deeply when listening to your lungs.第10页，讲稿共92张，创作于星期日12.Could I place 1 of my hands on your stomach and 1 hand on your upper chest to determine how you breathe?13.Could I place my hands on the lowermost ribs on each side of your chest to determine how you breathe?14.Could I place my h

8、ands on your back to determine how you breathe?15.Could I wrap my tape measure around your chest at several different sites to determine how you breathe?第11页，讲稿共92张，创作于星期日16.Now that I understand some very basic information about the manner in which you breathe could you please breathe in the manner

9、 I instruct you via sounds I make,pressure from my hands,methods I show to you,or different body positions?I will occasionally place my hands on your chest and wrap my tape measure around your chest to determine how you breathe during these simple tests and I will ask you to identify your level of s

10、hortness of breath using the 10-point scale or visual analog scaleIs this ok with you?第12页，讲稿共92张，创作于星期日17.Could I measure the strength of your breathing muscle by having you place this mouthpiece in your mouth and breathe in and out as deeply and as forcefully as you are able?第13页，讲稿共92张，创作于星期日18.I

11、 would like you to now perform the activity or exercise which produces your angina or shortness of breath.Could you please do this now?第14页，讲稿共92张，创作于星期日Thank you for giving me the chance to examine you today.I will call your physician to get some more information about you like electrocardiogram,ec

12、hocardiogram and pulmonary function tests that you said were performed last week as well as the arterial blood gas results,chest X-ray,and exercise test results.第15页，讲稿共92张，创作于星期日Physical Therapy Examination Medical Information and Risk Factor Analysis listening to the patients past history and prim

13、ary complaints is critical in the examination process.第16页，讲稿共92张，创作于星期日Examinations of Patient Appearance categorized by specific signs and symptoms 第17页，讲稿共92张，创作于星期日Angina-Methods To Evaluate Angina from Nonanginal Pain If a suspected anginal pain changes(increases or decreases)with breathing,pal

14、pation in the painful area,or movement of a joint(ie,shoulder flexion and abduction)it is very likely that the pain is NOT angina.第18页，讲稿共92张，创作于星期日Angina-Methods To Evaluate Angina from Nonanginal Painit can be worsened by physical exercise or activity.Therefore,if the suspected anginal pain is unc

15、hanged with the previously cited maneuvers and the pain occurred with exertion,it is SUSPECT for angina.If the suspected anginal pain is unchanged by these maneuvers,if the pain occurred with exertion,and if the pain decreases or subsides with rest,it is very likely that the pain IS angina.Finally,i

16、f the suspected pain decreases or subsides with nitroglycerin,it is even more likely that the pain IS angina.第19页，讲稿共92张，创作于星期日第20页，讲稿共92张，创作于星期日Other Symptoms of Heart DiseasedyspneaFatigueDizzinessLight headednessPalpitationsa sense of impending doom 第21页，讲稿共92张，创作于星期日第22页，讲稿共92张，创作于星期日Examination

17、s of Patient Appearanceskin color of the peripheral extremities.Pale or cyanotic skin in the legs,feet,arms,and fingers is associated with poor cardiovascular function.第23页，讲稿共92张，创作于星期日Examinations of Patient AppearanceDiagonal earlobe crease.This phenomenon has been investigated for many years and

18、 recently was once again found to be highly predictive of heart disease 第24页，讲稿共92张，创作于星期日Anthropometric measurementsbody weightfinger pressure on an edematous areaGirth measurements skin-fold caliper measurementscalculation of the body mass index measure the percentage of body fat and lean muscle m

19、ass第25页，讲稿共92张，创作于星期日Jugular venous distensionit is often due to right-sided heart failure.第26页，讲稿共92张，创作于星期日第27页，讲稿共92张，创作于星期日第28页，讲稿共92张，创作于星期日Palpation of the Radial PulsePalpation of the radial pulse can provide important information about the status of the cardiovascular system.Measurement of t

20、he Systolic Blood Pressure and Pulse During Breathing and Simple Perturbations of the Breathing Cycle第29页，讲稿共92张，创作于星期日 Measurement of the Systolic and Diastolic Blood Pressure and Pulse in Different Body Positions第30页，讲稿共92张，创作于星期日To Determine the Status of the Cardiovascular Systemobservation of a

21、 decrease in systolic and diastolic blood pressure without a subsequent increase in heart rate when changing body position from supine to standing is considered a positive sign for autonomic nervous system dysfunction.第31页，讲稿共92张，创作于星期日To Determine theHealth of the Cardiovascular SystemA cardiovascu

22、lar system that responds rapidly to body position change is likely in a better state of health than a cardiovascular system that responds sluggishly.Both an unchanged or decreased heart rate after standing for 30 seconds(compared to the heart rate at 15 seconds)is suggestive of autonomic dysfunction

23、.第32页，讲稿共92张，创作于星期日a sluggish or hypoadaptive(less than normal)heart rate and blood pressure response during a change in body position supine to standing should be considered abnormal and suggestive of an unhealthy cardiovascular system.第33页，讲稿共92张，创作于星期日a more adaptive rapid increase in heart rate

24、and blood pressure after moving from a supine to standing position(approximately 30 seconds)is likely associated with a healthier cardiovascular system第34页，讲稿共92张，创作于星期日Examination of the Pulse and Arterial Blood PressureDuring Functional Tasks and ExerciseFrequent monitoring of the heart rate and b

25、lood pressure may be the best way to examine the safety of exercise and help to establish guidelines and procedures for functional or exercise training.第35页，讲稿共92张，创作于星期日an increase in the diastolic blood pressure when the diastolic blood pressure should be decreased(or low)is a strong indicator of

26、cardiovascular dysfunction.第36页，讲稿共92张，创作于星期日Potential indirect measures of cardiac functionSymptoms and functional classificationCold,pale,and possibly cyanotic extremitiesJugular venous distension and peripheral edemaHeart soundsPulseElectrocardiographyBlood pressure第37页，讲稿共92张，创作于星期日Standard meas

27、urement of cardiac functionCardiac catheterizationEchocardiographySwan-Gans catheterizationCentral venous pressureCardiac enzymesANP and BNPRadiologic evidence第38页，讲稿共92张，创作于星期日Exercise Testing第39页，讲稿共92张，创作于星期日Indications for Exercise Testing:Indications for Exercise Testing:Diagnosis of Coronary A

28、rtery DiseaseDiagnosis of Coronary Artery DiseaseAssessment of Prognosis in Coronary Artery Assessment of Prognosis in Coronary Artery DiseaseDiseaseEvaluation of Functional CapacityEvaluation of Functional CapacityEvaluation of Therapy for Coronary DiseaseEvaluation of Therapy for Coronary DiseaseD

29、etermination of Exercise PrescriptionDetermination of Exercise Prescription第40页，讲稿共92张，创作于星期日Absolute Contraindications to Exercise TestingAcute MI(within 2 days)High-risk unstable anginaUncontrolled cardiac arrhythmias Active EndocarditisSevere aortic stenosisDecompensated heart failureAcute pulmon

30、ary embolus or infarction,DVTAcute noncardiac disorder affecting or aggravated by exerciseAcute myocarditis,pericarditisPhysical disability precludes safe and adequate testInability to obtain consent第41页，讲稿共92张，创作于星期日Relative Contraindications to Exercise TestingLeft main coronary stenosis or equiva

31、lentModerate aortic valvular stenosis(?)Electrolyte disorderTachyarrhythmias or BradyarrhythmiasAtrial fibrillation with uncontrolled ventricular responseHypertrophic Cardiomyopathy(?gradient)Mental impairment leading to inability to cooperateHigh-degree AV block第42页，讲稿共92张，创作于星期日ECG Lead Placement

32、for Exercise Testing第43页，讲稿共92张，创作于星期日Protocols for Exercise Testing第44页，讲稿共92张，创作于星期日Blood Pressure Responses:Exercise TestingDependency on cardiac output and peripheral resistanceNormal responses:Increase in SBP(20-30 mmHg)No change or fall in DBPInadequate rise in SBP:Myocardial ischemia,severe L

33、V systolic dysfunction,aortic or LVOT obstruction,drug therapy(-blockers)Exercise-Induced Hypotension(10 mmHg below baseline)Severe myocardial ischemia(50%positive predictive value for left main or 3-vessel disease),valvular heart disease,cardiomyopathy no evidence of clinically significant heart di

34、sease(dehydration,antihypertensive therapy,prolonged strenuous exercise)第45页，讲稿共92张，创作于星期日Heart Rate Response to Exercise TestingAccelerated Heart Rate Response:Deconditioning,prolonged bed rest,anemia,metabolic disorders,conditions associated with decreased blood volume or low systemic vascular res

35、istance,autonomic insufficencyChronotropic incompetence:Inadequate exercise effort,drug therapy(-blockers),Prognostic Significance:(Peak HR-Resting HR)/(220-age-Resting HR)0.80(Lauer,1999)Peak HR 1.0 mm)in leads without Q-waves(other than V1 or aVR)Drop in systolic blood pressure 10 mmHg(persistentl

36、y below baseline)despite an increase in workload,when accompanied by any other evidence of ischemiaModerate to severe angina(grades 3-4)Central nervous system symptoms(ataxia,dizziness,near syncope)Signs of poor perfusion(cyanosis or pallor)Sustained ventricular tachycardiaTechnical difficulties mon

37、itoring the ECG or systolic BPPatients request to stop第50页，讲稿共92张，创作于星期日Relative Indications for Termination of an Exercise TestST changes(horizontal or downsloping 2 mm)or marked axis shiftDrop in systolic blood pressure 10 mmHg(persistently below baseline)despite an increase in workload,in the abs

38、ence of other evidence of ischemia and no presyncopal symptomsIncreasing chest painFatigue,shortness of breath,wheezing,leg cramps,or claudicationHypertensive response(SBP 250 mmHg and/or DBP 115 mmHg)Development of bundle-branch block(LBBB)that cannot be distinguished from ventricular tachycardia;?

39、Evidence of anterior ischemiaArrhythmias other than sustained ventricular tachycardia(frequent multifocal PVCs,ventricular triplets,SVT,heart block,or bradyarrhythmias)General Appearance(diaphoresis,peripheral cyanosis)第51页，讲稿共92张，创作于星期日Criteria for Reading ST-Segment Changes on the Exercise ECGST D

40、EPRESSION:Measurements made on 3 consecutive ECG complexes!ST level is measured relative to the P-Q junction3 key measurements(P-Q junction,J-point,60-80msec after J-point-use 60 msec for HR 130 bpmWhen J-point is depressed relative to P-Q junction at baseline:Net difference from the J junction dete

41、rmines the amount of deviationWhen the J-point is elevated relative to P-Q junction at baseline and becomes depressed with exercise:Magnitude of ST depression is determined from the P-Q junction and not the resting J point第52页，讲稿共92张，创作于星期日Criteria for Reading ST-Segment Changes on the Exercise ECGS

42、T ELEVATION:60 msec after J point in 3 consecutive ECG complexes第53页，讲稿共92张，创作于星期日Criteria for Abnormal and Borderline ST-Segment Depression on the Exercise ECGABNORMAL:1.0 mm or greater horizontal or downsloping ST depression at 60 msec after J point on 3 consecutive ECG complexesBORDERLINE:0.5 to

43、1.0 mm horizontal or downsloping ST depression at 60 msec after J point on 3 consecutive ECG complexes2.0 mm or greater upsloping ST depression at 60 msec after J point on 3 consecutive ECG complexes第54页，讲稿共92张，创作于星期日Morphology of ST-Segment Deviation during Exercise Testing第55页，讲稿共92张，创作于星期日Value o

44、f Right-Sided ECG Leads during Exercise Testing for the Diagnosis of CAD第56页，讲稿共92张，创作于星期日Horizontal ST-segment Depression during Exercise Testing第57页，讲稿共92张，创作于星期日Downsloping ST-Segment Depression during Exercise Testing第58页，讲稿共92张，创作于星期日ST-Segment Depression in Early Recovery Period after Exercise

45、 Testing第59页，讲稿共92张，创作于星期日Upsloping ST-Segment Depression during Exercise Testing第60页，讲稿共92张，创作于星期日Morphology of ST-Segment Depression Predicts Severity of Coronary Artery Disease(Goldschlager,1976)第61页，讲稿共92张，创作于星期日Exercise-Induced ST-Segment Elevation with Prior Anterior Myocardial Infarction第62页，

46、讲稿共92张，创作于星期日Exercise-Induced ST-Segment Elevation in the Setting of Prior Inferolateral MI第63页，讲稿共92张，创作于星期日Exercise-Induced Anterior ST-Segment Elevation as Reflection of LAD Ischemia第64页，讲稿共92张，创作于星期日Indications for Exercise Testing in the Diagnosis of Obstructive Coronary DiseaseCLASS I:CLASS I:

47、Adult patients(including those with RBBB or less than 1 mm or resting ST-Adult patients(including those with RBBB or less than 1 mm or resting ST-depression)with an intermediate pretest probability of CAD,based on gender,age,depression)with an intermediate pretest probability of CAD,based on gender,

48、age,and symptomsand symptomsCLASS IIa:CLASS IIa:Patients with vasospastic anginaPatients with vasospastic anginaCLASS IIb:CLASS IIb:Patients with a high pretest probability of CAD by age,symptoms,and genderPatients with a high pretest probability of CAD by age,symptoms,and genderPatients with a low

49、pretest probability of CAD by age,symptoms,and Patients with a low pretest probability of CAD by age,symptoms,and gendergenderPatients with less than 1 mm of baseline ST depression and taking Patients with less than 1 mm of baseline ST depression and taking digoxindigoxinPatients with ECG criteria o

50、f LVH and less than 1 mm St-depressionPatients with ECG criteria of LVH and less than 1 mm St-depression第65页，讲稿共92张，创作于星期日Pre-test Probability of CAD by Age,Gender,and SymptomsTypical/Definite Angina PectorisAge 30-39MenIntermediate(10-90%)Women IntermediateAge 40-49MenHigh(90%)Women IntermediateAge