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 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 and 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: systolic: 120-129 and diastolic: <80
  • Stage 1 hypertension: systolic: 130-139 or diastolic: 80-89
  • Stage 2 hypertension: systolic = or > 140 or diastolic: = or > 90
  • Hypertensive crisis: Higher than 180 and/or higher than 120

PTA implication for initiating therapy for hypertensive individuals

• Normal blood pressure (<120/<80 mmHg)
  • No intervention modifications needed
  • Continue routine monitoring as appropriate
• Elevated blood pressure (SBP 120-129 and DBP <80 mmHg)
  • Safe to initiate therapy
  • Monitor blood pressure response to exercise and activity
  • Educate on lifestyle modification
• Stage 1 (SBP 130-139 OR DBP 80-89 mmHg):
  • Usually safe to initiate therapy if asymptomatic
  • Monitor blood pressure closely during activity
  • Notify supervising PT as appropriate
  • Referral may be needed if BP is consistently elevated or patient is symptomatic
• Stage 2 (SBP ≥140 OR DBP ≥90 mmHg) - precaution:
  • Use clinical judgment before initiating moderate or vigorous exercise
  • Resting BP should be reassessed
  • PTA should communicate findings to supervising PT
  • Medical referral may be indicated, especially if:
    • BP is significantly elevated
    • Patient is symptomatic
    • BP rises excessively with activity
• Hypertensive crisis - contraindication:
  • Medical emergency
  • Do not initiate treatment
  • Reassess BP

Example: applying the hypertension staging decision

A patient arrives for an outpatient session, and you measure a resting blood pressure of 152/94 mmHg. The patient feels well and has no symptoms. How should you proceed?

Work through it in three steps - stage the reading, match it to the right action, then decide who owns the next decision:

• Stage the reading. A systolic of 140 mmHg or higher, or a diastolic of 90 mmHg or higher, is stage 2. At 152/94 mmHg, both values put this patient in stage 2 - not a hypertensive crisis, which needs a systolic above 180 and/or a diastolic above 120.
• Match it to the action. Stage 2 is a precaution, not a contraindication. You don’t stop all care, but you also don’t jump into moderate or vigorous exercise. Recheck the resting pressure first.
• Decide who owns the call. Communicate the finding to the supervising PT, who decides whether therapy proceeds and whether a medical referral is warranted (for example, if the pressure is markedly elevated, the patient becomes symptomatic, or the pressure rises excessively with activity).

Answer: recheck the resting blood pressure and report the finding to the supervising PT before initiating exercise. Recognizing the change and communicating it - rather than modifying the plan of care yourself - is the PTA’s role.

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 the previous position in which they did not have symptoms
  • The patient’s blood pressure should be checked 1 minute after return to the previous position
• Chronic orthostatic hypotension
  • Use of an abdominal binder to assist with increasing intra-abdominal pressure and thus increasing blood pressure
  • Use of compression socks on the bilateral lower extremities to assist with increasing peripheral pressure and thus increase blood pressure
  • Use of the tilt table
    • Typically used for patients with symptomology becoming present with small positional changes (i.e., become dizzy when the head of the bed is elevated)
  • 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)

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 are typically relieved with rest and/or nitroglycerin
• Nitroglycerin tabs are delivered sublingually (under the tongue) and up to 3 spaced 5 minutes apart are given. If no resolution of symptoms occurs it is considered unstable angina and EMS is activated.
• Unstable: chest pain has an unpredictable pattern; can occur at rest or with exertion
  • No relieving factors as pain increases over a period of time and intensifies. EMS is activated.

Crucial aspects of angina

• Untreated or worsening angina increases the risk of myocardial infarction.
• If nitroglycerin does not resolve symptoms after the doses described above, the patient needs to go to the emergency room, as a myocardial infarction is likely to have occurred.

Definitions

Nitroglycerin

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

Calcium channel blockers

Relaxes blood vessels and allows adequate blood flow to the 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

PTA response to signs of myocardial infarction

• Stop the activity and have the patient rest in a comfortable position
• Activate EMS (call 911) and get the AED; a suspected myocardial infarction is a medical emergency
• Stay with the patient, monitor vital signs and responsiveness, and notify the supervising PT
• Be prepared to begin CPR and use the AED if the patient becomes unresponsive and is not breathing normally

Heart failure

Definitions

Heart failure

Inadequacy of the 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 the left ventricle, which causes back-up of fluid to the lungs
• Symptoms: Dyspnea, cough, wheezing, orthopnea, paroxysmal nocturnal dyspnea, pulmonary rales, hypotension, dependent edema (swelling of the ankles), weight gain, 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: prominent bilateral edema in the legs, ankles, feet, rapid unexplained 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 the physician, as adjustments may need to be made to medications
  • Weight gain of 2-3 lbs in 24 hours
  • Increased cough
  • Peripheral edema
  • Increased shortness of breath and activity
  • Orthopnea
• Red zone - Symptoms indicate a medical emergency
  • Shortness of breath without exertion
  • Unrelieved chest pain
  • Paroxysmal 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, and swallowing

Congenital heart defects

Congenital heart defects are present at birth and are grouped by the direction of the shunt:

• Acyanotic (left-to-right shunt): atrial septal defect (ASD), ventricular septal defect (VSD), and patent ductus arteriosus (PDA). Oxygenated blood returns to the lungs, so there is usually no cyanosis.
• Cyanotic (right-to-left shunt): deoxygenated blood bypasses the lungs, causing cyanosis (bluish lips and nail beds), tachypnea, tachycardia, and low oxygen saturation.
  • Tetralogy of Fallot: VSD, pulmonary stenosis, an overriding aorta, and right ventricular hypertrophy
  • Tricuspid atresia: the tricuspid valve never forms, so blood crosses an atrial opening from right to left. The right ventricle is hypoplastic (underdeveloped) and the left ventricle does all the pumping, so the ECG shows left ventricular hypertrophy and left axis deviation.
• PTA considerations: monitor oxygen saturation and color during activity; report desaturation or increasing cyanosis to the supervising PT.

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, the pain subsides when the activity is ceased.
• Trophic changes
  • Hair loss
  • Shiny skin
  • Hardened nails
• Pain in lower extremities with activity and relieved with rest
• Positive rubor of dependency test
  • Pallor and increased pain with leg elevation, followed by dependent rubor (a dusky or bright-red discoloration) when the leg is returned to a dependent (lowered) position
• Decreased or absent peripheral pulses
• Decreased skin temperature of the extremity
• Skin ulcerations on the lateral malleolus

Venous disease (venous insufficiency)

Definitions

Venous disease (venous insufficiency)

Distended and swollen superficial veins that primarily impact the lower extremities

Symptoms

• Varicose veins
• Hemosiderin staining of the lower extremities
  • Due to distended veins causing red, purplish discoloration of the lower extremities
• Inverted champagne-shaped lower extremities
• Skin ulcerations to the medial malleolus
• Aching pain and heaviness that worsen with dependency and are relieved by elevation
• 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 the deep vein

Characteristics

• Can occur in the upper or lower extremity
• Associated with prolonged immobilization, bed rest, surgery, trauma

Symptoms

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

Confirmation of DVT diagnosis

• Utilization of Wells Criteria - Clinical predictive rule (used when you suspect DVT by a 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 a physician

Special considerations for physical therapy assistant and DVT

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