Cardiac pathologies

Hypertension

Hypertension is a condition in which the force of blood against artery walls is consistently too high.

Definitions

Hypertension

Elevated systolic, diastolic, or both measured on at least 2 occasions on at least 2 weeks apart

Special considerations with hypertension

• Each 20 mmHg increase in systolic & 10 mmHg increase in diastolic doubles the risk of cardiac disease for those aged 40-70.
• Modifiable risk factors for hypertension are: tobacco use, non-insulin dependent diabetes, high cholesterol, alcoholism, obesity, sedentary lifestyle, stress, and poor nutrition
• Non-modifiable risk factors for hypertension are: African American ethnicity, >60 years old, postmenopausal status, family history of cardiovascular disease
• Signs & symptoms of hypertension are: occipital headache, vertigo, flushed face, epistaxis, visual changes, and nocturnal urinary frequency
• Blood pressure values at rest:
  • Normal: less than 120/80
  • Elevated: 120-129 and 80
  • Stage 1 Hypertension: 130-139 or 80-89
  • Stage 2 Hypertension: 140-149 or 90-99
  • Hypertensive Crisis: Higher than 180 and/or higher than 120

PTA implication for initiating therapy for hypertensive individuals:

• Normal: No intervention changes
• Pre HTN: Ok to initiate therapy. Monitor for signs/symptoms with exercise.
• Stage1: Do not start therapy. Refer patient back to supervising physical therapist and/or primary care physician
• Stage 2: Do not start therapy. Refer patient back to supervising physical therapist and/or primary care physician
• Hypertensive crisis: Medical emergency- call 911

Orthostatic hypotension

Definitions

Orthostatic hypotension

Systolic blood pressure falls 20 mmHg and/or diastolic blood pressure falls 10 mmHg after a change in position

Symptoms of orthostatic hypotension

• Lightheadedness
• Dizziness
• Fainting
• Pallor
• Blurred vision
• Lack of concentration
• Cold, clammy skin

PTA interventions for orthostatic hypotension

• Acute orthostatic hypotension
  • Patient should be returned to previous position in which they did not have symptoms
  • Patients blood pressure should be checked 1 minute after return to previous position
• Chronic orthostatic hypotension
  • Use of abdominal binder to assist with increasing intra-abdominal pressure and thus increased blood pressure
  • Use of compression socks to bilateral lower extremities to assist with increasing peripheral pressure and thus increase blood pressure
  • Use of tilt table
    • Typically used for patients with symptomology becoming present with small positional changes (i.e. become dizzy when head of bed elevated)
    • Head injuries are contraindicated for use of tilt table
  • Use of medication- Midodrine
    • Medication is used to assist with increasing blood pressure for those with chronic orthostatic hypotension as noted in spinal cord injury (used when all other modalities listed above do not work to resolve symptoms)

POTS

Postural Orthostatic Tachycardia Syndrome (POTS) is a form of dysautonomia characterized by an abnormal increase in heart rate upon standing. It affects the autonomic nervous system, leading to poor regulation of blood flow and heart rate.

Mechanism of POTS

When standing

• Gravity pulls blood into the lower body.
• Normally, the body responds by:
  • Constricting blood vessels
  • Increasing heart rate slightly
  • This maintains stable blood pressure and brain perfusion.

Symptoms of POTS

• Dizziness or lightheadedness
• Shortness of breath
• Palpitations (racing heartbeat)
• Fatigue and exercise intolerance
• Brain fog or poor concentration
• Nausea and headaches
• Difficulty concentrating
• Fainting or near-fainting
• Purple hands/feet (dependent cyanosis)
• Sleep disturbances

Causes and risk factors of POTS

• Impaired autonomic nervous system
• Overactive sympathetic response
• Small fiber neuropathy
• Low blood volume (hypovolemia)
• Poor venous return

PTA management of POTS

• Begin with recumbent or semi-recumbent exercises:
  • Recumbent cycling
  • Rowing machine
  • Swimming or water aerobics
  • Supine resistance exercises
• Progress to upright activities as tolerated:
  • Seated to standing transitions
  • Walking programs
• Focus on building lower extremity muscle tone to improve venous return.

Angina pectoris

Definitions

Angina pectoris

Imbalance of cardiac workload due to an insufficiency in oxygenation of heart tissue primarily caused by temporary coronary artery blockage leading to ischemia

Symptoms of angina

• Crushing, pressing sternal ache
• Shortness of breath
• Fatigue
• Diaphoresis
• Generalized weakness
• Syncope
• Nausea/vomiting

Types of angina

• Stable: symptoms occur with exertion and typically relieved with rest and/or nitroglycerin
• Unstable: chest pain has unpredictable pattern; can occur at rest or with exertion
  • No relieving factors as pain increases over a period of time and intensifies

Crucial aspects of angina

• Angina left untreated will evolve into myocardial infarction
• Nitrogylcrin when used is taken sublingually and only three (3) can be taken within 15 minutes
  • If the three are not effective when taken, the patient needs to go to the emergency room as myocardial infarction is likely to have occurred.

Definitions

Nitroglycerin

Medication that causes arterial vasodilation to increase blood flow within heart; primary medication used for angina

Calcium channel blockers

Relaxes blood vessels and allows adequate blood flow to heart

Myocardial infarction

Definitions

Myocardial infarction

Ischemia, injury, or death to part of the myocardium due to blockage in one or more of the coronary arteries which may be caused by atherosclerotic disease, thrombus formation, coronary vasospasm, or embolism

Symptoms of myocardial infarction

• Left-sided chest pain
  • Squeezing, crushing, pressure sensation
• Left-sided neck, jaw, back
• Shortness of breath
• Nausea/vomiting
• Sweating
• Lightheadedness,
• Fatigue
• Tachycardia
• Mid-thoracic pain

Types of myocardial infarction

• STEMI (ST segment elevation myocardial infarction):
  • Develops from complete blockage of the coronary artery which must be repaired by immediate reperfusion/stenting
  • Extensive heart damage is the result
• NSTEMI (non ST elevation myocardial infarction):
  • Develops due to partial blockage of coronary artery with less severe heart damage
  • First line of treatment is changing modifiable risk factors and medication
  • Reversible heart damage is the result
  • May lead to need for reperfusion/stenting

Heart failure

Definitions

Heart failure

Inadequacy of heart to provide adequate blood to meet the metabolic needs of the body and overall decreased cardiac output

Left-sided heart failure

• Causes: pulmonary congestion or edema due to inadequacy of blood flow from left ventricle that causes back-up of fluid to lungs
• Symptoms: Dyspnea, cough, wheezing, orthopnea, paroxsymal nocturnal dyspnea, pulmonary rales, hypotension, lightheadedness, poor exercise tolerance

Right-sided heart failure

• Causes: increased venous pressure due to the right ventricle’s inability to pump blood adequately to the lungs
• Symptoms: dependent edema, weight gain, ascites, liver engorgement, cyanosis, jugular vein distention

Physical therapy assistant clinical considerations for heart failure

• Green Zone- Continue with activity and therapy as tolerated
  • No shortness of breath
  • No swelling
  • No weight gain
  • No chest pain
  • No change in ability to perform normal activities
• Yellow zone- Symptoms need to be reported to physician as adjustments may need to be made to medications
  • Weight gain of 2-3 lbs in 24 hours
  • Increased cough
  • Peripheral edema
  • Increased in shortness of breath and activity
  • Orthopnea
• Red zone- Symptoms indicate medical emergency
  • Shortness of breath without exertion
  • Unrelieved chest pain
  • Paroxsymal nocturnal dyspnea
  • Confusion
  • Weight gain of more than 5 lbs in 3 days

Pericarditis

Definitions

Pericarditis

Inflammation of the pericardium

Causes:

• Viral or bacterial infections
• Chest injuries

Symptoms:

• Fevers
• Chills
• Weakness
• Substernal pain
• Cough
• Tachycardia
• Pain with laughing, coughing, belching, swallowing

Peripheral vascular diseases

Peripheral vascular disease refers to a condition where blood vessels outside of the heart and brain (specifically in the limbs and organs) are affected by narrowing, blocking, or spasms, which reduces blood flow. There are two types: arterial and venous insufficiency

Arterial insufficiency (occlusive arterial disease)

Definitions

Arterial insufficiency (occlusive arterial disease)

Chronic disease of arteries caused by peripheral atherosclerosis causing diminished blood flow to extremities; specifically the lower extremities

Symptoms

• Intermittent claudication
  • Pain in the lower leg that occurs regularly and at predictable distances walked
• Trophic changes
  • Hair loss
  • Shiny skin
  • Hardened nails
• Pain in lower extremities with activity and relieved with rest
• Positive Rubor of Dependency Test
  • Pale and increased pain with leg elevation, and then return to normal skin coloration and decreased pain when in dependent position
• Decreased or absent peripheral pulses
• Decreased skin temperature of extremity
• Skin ulcerations on medial mallelous

Venous disease (venous insufficiency)

Definitions

Venous disease (venous insufficiency)

Distended and swollen superficial veins that primarily impacts the lower extremities

Symptoms:

• Varicose veins
• Hemosiderin staining of lower extremities
  • Due to distended veins causing red, purplish discoloration of lower extremities
• Inverted champagne shaped lower extremities
• Skin ulcerations to lateral mallelous
• Constant pain in all positions
• Moderate to severe edema in lower extremities

Special diagnosis of venous disease

Deep Vein Thrombophlebitis (DVT)

Definitions

Deep Vein Thrombophlebitis (DVT)

Clot formation and inflammation in deep vein

Characteristics

• Can occur in upper or lower extremity
• Associated with prolonged immobilization, bedrest, surgery, trauma

Symptoms:

• Dull ache in extremity
• Tightness in extremity
• Swelling, warmth, and/or redness in extremity

Confirmation of DVT diagnosis

• Utilization of Wells Criteria - Clinical Predictive Rule (used when you suspect DVT by clinician)
  • Score -2 to 0: Low probability of development of DVT
  • Score: 1-2: Moderate probability of development of DVT
  • Score 3-8: High probability of development of DVT
• Doppler study (medical confirmation of presence of DVT)
  • Noninvasive ultrasound utilizing waves to detect blood clots
    • Performed by physician

Special considerations for physical therapy assistant and DVT

• If symptoms observed prior to official diagnosis
  • Do not initiate activity and alert medical team immediately
• Once DVT diagnosed
  • Clearance by medical team and assessment by physical therapist prior to resumption by PTA
  • Options for medical treatment (treatment options can be done alone or in combination)
    • Graded compression socks
    • Anti-coagulation medications
    • Placement of inferior vena cava filter (IVC)
      • Stops lower extremity clots from traveling to lungs