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: 120-129 and 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
• Pre-Hypertension (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)
  • 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:
• Medical emergency
• Do NOT initiate treatment
• Reassess BP

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
• 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

Crucial aspects of angina

• Untreated or worsening angina increases the risk of myocardial infarction.
• Nitroglycerin, 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 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

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

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 an independent 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
• 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 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
  • 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