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1、关于心脏康复评定第一张，PPT共九十二页，创作于2022年6月A PATIENT CASE EXAMPLE第二张，PPT共九十二页，创作于2022年6月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?第三
2、张，PPT共九十二页，创作于2022年6月4.Do you experience angina or shortness of breath at rest,only with activity/exercise,or both at rest and with activity/exercise?第四张，PPT共九十二页，创作于2022年6月5.If you experience angina or become short of breath during activity or exercise could you please describe the type of activity
3、 or exercise which produces your angina or shortness of breath?第五张，PPT共九十二页，创作于2022年6月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
4、exercise or by pointing to your level of shortness of breath using this 10-point scale or by marking this visual analog scale?第六张，PPT共九十二页，创作于2022年6月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
5、an oxygen saturation measurement?第七张，PPT共九十二页，创作于2022年6月 9.Could I place these electrodes on your chest to obtain a simple single-lead electrocardiogram(ECG)?第八张，PPT共九十二页，创作于2022年6月10.Could I take your blood pressure while you are seated and then compare it to the blood pressure while you are lying
6、down and then standing?I would also like to observe your pulse,oxygen saturation,ECG,and symptoms when you are lying down and standing.第九张，PPT共九十二页，创作于2022年6月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 y
7、our heart sounds and any changes in the ECG while you are breathing deeply when listening to your lungs.第十张，PPT共九十二页，创作于2022年6月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 yo
8、ur chest to determine how you breathe?14.Could I place my hands 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?第十一张，PPT共九十二页，创作于2022年6月16.Now that I understand some very basic information about the m
9、anner in which you breathe could you please breathe in the manner 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
10、these simple tests and I will ask you to identify your level of shortness of breath using the 10-point scale or visual analog scaleIs this ok with you?第十二张，PPT共九十二页，创作于2022年6月17.Could I measure the strength of your breathing muscle by having you place this mouthpiece in your mouth and breathe in and
11、 out as deeply and as forcefully as you are able?第十三张，PPT共九十二页，创作于2022年6月18.I would like you to now perform the activity or exercise which produces your angina or shortness of breath.Could you please do this now?第十四张，PPT共九十二页，创作于2022年6月Thank you for giving me the chance to examine you today.I will c
12、all your physician to get some more information about you like electrocardiogram,echocardiogram 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.第十五张，PPT共九十二页，创作于2022年6月Physical Therapy Examination Med
13、ical Information and Risk Factor Analysis listening to the patients past history and primary complaints is critical in the examination process.第十六张，PPT共九十二页，创作于2022年6月Examinations of Patient Appearance categorized by specific signs and symptoms 第十七张，PPT共九十二页，创作于2022年6月Angina-Methods To Evaluate Angi
14、na from Nonanginal Pain If a suspected anginal pain changes(increases or decreases)with breathing,palpation in the painful area,or movement of a joint(ie,shoulder flexion and abduction)it is very likely that the pain is NOT angina.第十八张，PPT共九十二页，创作于2022年6月Angina-Methods To Evaluate Angina from Nonang
15、inal Painit can be worsened by physical exercise or activity.Therefore,if the suspected anginal pain is unchanged 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 e
16、xertion,and if the pain decreases or subsides with rest,it is very likely that the pain IS angina.Finally,if the suspected pain decreases or subsides with nitroglycerin,it is even more likely that the pain IS angina.第十九张，PPT共九十二页，创作于2022年6月第二十张，PPT共九十二页，创作于2022年6月Other Symptoms of Heart Diseasedyspn
17、eaFatigueDizzinessLight headednessPalpitationsa sense of impending doom 第二十一张，PPT共九十二页，创作于2022年6月第二十二张，PPT共九十二页，创作于2022年6月Examinations 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
18、.第二十三张，PPT共九十二页，创作于2022年6月Examinations of Patient AppearanceDiagonal earlobe crease.This phenomenon has been investigated for many years and recently was once again found to be highly predictive of heart disease 第二十四张，PPT共九十二页，创作于2022年6月Anthropometric measurementsbody weightfinger pressure on an ede
19、matous areaGirth measurements skin-fold caliper measurementscalculation of the body mass index measure the percentage of body fat and lean muscle mass第二十五张，PPT共九十二页，创作于2022年6月Jugular venous distensionit is often due to right-sided heart failure.第二十六张，PPT共九十二页，创作于2022年6月第二十七张，PPT共九十二页，创作于2022年6月第二十八张
20、，PPT共九十二页，创作于2022年6月Palpation of the Radial PulsePalpation of the radial pulse can provide important information about the status of the cardiovascular system.Measurement of the Systolic Blood Pressure and Pulse During Breathing and Simple Perturbations of the Breathing Cycle第二十九张，PPT共九十二页，创作于2022年6
21、月 Measurement of the Systolic and Diastolic Blood Pressure and Pulse in Different Body Positions第三十张，PPT共九十二页，创作于2022年6月To Determine the Status of the Cardiovascular Systemobservation of a decrease in systolic and diastolic blood pressure without a subsequent increase in heart rate when changing bod
22、y position from supine to standing is considered a positive sign for autonomic nervous system dysfunction.第三十一张，PPT共九十二页，创作于2022年6月To Determine theHealth of the Cardiovascular SystemA cardiovascular system that responds rapidly to body position change is likely in a better state of health than a car
23、diovascular 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.第三十二张，PPT共九十二页，创作于2022年6月a sluggish or hypoadaptive(less than normal)heart rate and blood pressure respo
24、nse during a change in body position supine to standing should be considered abnormal and suggestive of an unhealthy cardiovascular system.第三十三张，PPT共九十二页，创作于2022年6月a more adaptive rapid increase in heart rate and blood pressure after moving from a supine to standing position(approximately 30 seconds
25、)is likely associated with a healthier cardiovascular system第三十四张，PPT共九十二页，创作于2022年6月Examination of the Pulse and Arterial Blood PressureDuring Functional Tasks and ExerciseFrequent monitoring of the heart rate and blood pressure may be the best way to examine the safety of exercise and help to esta
26、blish guidelines and procedures for functional or exercise training.第三十五张，PPT共九十二页，创作于2022年6月an increase in the diastolic blood pressure when the diastolic blood pressure should be decreased(or low)is a strong indicator of cardiovascular dysfunction.第三十六张，PPT共九十二页，创作于2022年6月Potential indirect measur
27、es of cardiac functionSymptoms and functional classificationCold,pale,and possibly cyanotic extremitiesJugular venous distension and peripheral edemaHeart soundsPulseElectrocardiographyBlood pressure第三十七张，PPT共九十二页，创作于2022年6月Standard measurement of cardiac functionCardiac catheterizationEchocardiogra
28、phySwan-Gans catheterizationCentral venous pressureCardiac enzymesANP and BNPRadiologic evidence第三十八张，PPT共九十二页，创作于2022年6月Exercise Testing第三十九张，PPT共九十二页，创作于2022年6月Indications for Exercise Testing:Indications for Exercise Testing:Diagnosis of Coronary Artery DiseaseDiagnosis of Coronary Artery Disease
29、Assessment of Prognosis in Coronary Artery DiseaseAssessment of Prognosis in Coronary Artery DiseaseEvaluation of Functional CapacityEvaluation of Functional CapacityEvaluation of Therapy for Coronary DiseaseEvaluation of Therapy for Coronary DiseaseDetermination of Exercise PrescriptionDeterminatio
30、n of Exercise Prescription第四十张，PPT共九十二页，创作于2022年6月Absolute Contraindications to Exercise TestingAcute MI(within 2 days)High-risk unstable anginaUncontrolled cardiac arrhythmias Active EndocarditisSevere aortic stenosisDecompensated heart failureAcute pulmonary embolus or infarction,DVTAcute noncardi
31、ac disorder affecting or aggravated by exerciseAcute myocarditis,pericarditisPhysical disability precludes safe and adequate testInability to obtain consent第四十一张，PPT共九十二页，创作于2022年6月Relative Contraindications to Exercise TestingLeft main coronary stenosis or equivalentModerate aortic valvular stenosi
32、s(?)Electrolyte disorderTachyarrhythmias or BradyarrhythmiasAtrial fibrillation with uncontrolled ventricular responseHypertrophic Cardiomyopathy(?gradient)Mental impairment leading to inability to cooperateHigh-degree AV block第四十二张，PPT共九十二页，创作于2022年6月ECG Lead Placement for Exercise Testing第四十三张，PPT
33、共九十二页，创作于2022年6月Protocols for Exercise Testing第四十四张，PPT共九十二页，创作于2022年6月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 LV systolic dysf
34、unction,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 disease(dehydrati
35、on,antihypertensive therapy,prolonged strenuous exercise)第四十五张，PPT共九十二页，创作于2022年6月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 resistance,
36、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(persistently below
37、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 monitoring
38、the ECG or systolic BPPatients request to stop第五十张，PPT共九十二页，创作于2022年6月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 absen
39、ce 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;?Ev
40、idence of anterior ischemiaArrhythmias other than sustained ventricular tachycardia(frequent multifocal PVCs,ventricular triplets,SVT,heart block,or bradyarrhythmias)General Appearance(diaphoresis,peripheral cyanosis)第五十一张，PPT共九十二页，创作于2022年6月Criteria for Reading ST-Segment Changes on the Exercise EC
41、GST DEPRESSION: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
42、 determines 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第五十二张，PPT共九十二页，创作于2022年6月Criteria for Reading ST-Segment Changes on the E
43、xercise ECGST ELEVATION:60 msec after J point in 3 consecutive ECG complexes第五十三张，PPT共九十二页，创作于2022年6月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 complexe
44、sBORDERLINE:0.5 to 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第五十四张，PPT共九十二页，创作于2022年6月Morphology of ST-Segment Deviation during Exercise Testin
45、g第五十五张，PPT共九十二页，创作于2022年6月Value of Right-Sided ECG Leads during Exercise Testing for the Diagnosis of CAD第五十六张，PPT共九十二页，创作于2022年6月Horizontal ST-segment Depression during Exercise Testing第五十七张，PPT共九十二页，创作于2022年6月Downsloping ST-Segment Depression during Exercise Testing第五十八张，PPT共九十二页，创作于2022年6月ST-Segm
46、ent Depression in Early Recovery Period after Exercise Testing第五十九张，PPT共九十二页，创作于2022年6月Upsloping ST-Segment Depression during Exercise Testing第六十张，PPT共九十二页，创作于2022年6月Morphology of ST-Segment Depression Predicts Severity of Coronary Artery Disease(Goldschlager,1976)第六十一张，PPT共九十二页，创作于2022年6月Exercise-I
47、nduced ST-Segment Elevation with Prior Anterior Myocardial Infarction第六十二张，PPT共九十二页，创作于2022年6月Exercise-Induced ST-Segment Elevation in the Setting of Prior Inferolateral MI第六十三张，PPT共九十二页，创作于2022年6月Exercise-Induced Anterior ST-Segment Elevation as Reflection of LAD Ischemia第六十四张，PPT共九十二页，创作于2022年6月In
48、dications for Exercise Testing in the Diagnosis of Obstructive Coronary DiseaseCLASS I:CLASS I:Adult patients(including those with RBBB or less than 1 mm or resting Adult patients(including those with RBBB or less than 1 mm or resting ST-depression)with an intermediate pretest probability of CAD,bas
49、ed ST-depression)with an intermediate pretest probability of CAD,based on gender,age,and symptomson gender,age,and 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 gende
50、rPatients with a high pretest probability of CAD by age,symptoms,and genderPatients with a low 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 digoxinPatien