Cardiac pathologies

Hypertension

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

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: 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-Hypertension (Pre-HTN): Ok to initiate therapy. Monitor for signs/symptoms with exercise.
• Stage 1: Do not start therapy. Refer the patient back to the supervising physical therapist and/or primary care physician
• Stage 2: Do not start therapy. Refer the patient back to the supervising physical therapist and/or primary care physician
• Hypertensive crisis: Medical emergency- call 911

Orthostatic hypotension

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)
    • Head injuries are contraindicated for the use of the 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)

Angina pectoris

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

• Angina left untreated will evolve into a 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.

Myocardial infarction

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

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

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)

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)

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)

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