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
• Hypertension is usually silent, so blood pressure has to be measured rather than inferred from symptoms. When signs and symptoms do occur (usually with severe elevation), they include: 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: systolic higher than 180 and/or diastolic higher than 120
• Prazosin (Minipress) is an alpha-blocker used to treat high blood pressure.

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 the supervising PT, who decides whether therapy proceeds; recognizing and reporting the reading, not changing the plan of care, is the PTA’s role
  • 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
  • If the patient has symptoms such as chest pain, shortness of breath, back pain, numbness or weakness, vision change, difficulty speaking, or confusion (hypertensive emergency), activate EMS right away - do not wait for a recheck to see whether the pressure comes down - and notify the supervising PT
  • If the patient has no symptoms, have them rest, recheck BP after at least 1 minute, and notify the supervising PT immediately

Orthostatic hypotension

Definitions

Orthostatic hypotension

Systolic BP falls at least 20 mmHg and/or diastolic BP falls at least 10 mmHg within 3 minutes of moving from supine/sitting to standing.

Symptoms of orthostatic hypotension

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

Syncope (fainting) is a temporary loss of consciousness that usually happens when blood pressure drops suddenly and blood flow to the brain decreases. Orthostatic hypotension can result from reduced blood volume (dehydration or blood loss), medications, or autonomic dysfunction as in Parkinson disease or spinal cord injury. Hypovolemic shock causes cool, clammy, pale skin, a rapid and often weak pulse, and low blood pressure.

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)
    • Not used with unstable hemodynamics, an unstable or recent lower-extremity fracture, or an acute lower-extremity DVT
  • Medical management (physician-prescribed) - Midodrine
    • The physician may prescribe midodrine to raise blood pressure in chronic orthostatic hypotension, as seen in spinal cord injury, when the nonpharmacological measures above do not resolve symptoms. Medication is not a PTA intervention: the PTA’s role is the nonpharmacological measures above plus monitoring the BP response (including supine BP, since midodrine can cause supine hypertension) and reporting changes to the supervising PT

Angina pectoris

Definitions

Angina pectoris

Imbalance of cardiac workload due to an insufficiency in oxygenation of heart tissue, most often caused by narrowed coronary arteries that cannot meet a rise in the heart’s oxygen demand, leading to temporary 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. EMS is activated.
• Untreated or worsening angina increases the risk of myocardial infarction.

Nitroglycerin protocol

• Nitroglycerin tabs are delivered sublingually (under the tongue); up to 3 doses are given, spaced 5 minutes apart.

PTA response to angina

• Stop the activity and have the patient rest in a seated or comfortable position
• Have the patient take their prescribed nitroglycerin per the protocol above
• Monitor vital signs and notify the supervising PT
• Activate EMS if pain is not better 5 minutes after the first nitroglycerin dose, is getting worse, or occurs at rest (unless the patient’s physician has given different instructions); treat it as a possible myocardial infarction

Definitions

Nitroglycerin

Vasodilator (primarily venous, also coronary) that reduces cardiac workload and improves blood flow to the heart; the primary medication for angina.

Calcium channel blockers

Relaxes blood vessels and allows adequate blood flow to the heart

Myocardial infarction

Definitions

Myocardial infarction

Death (necrosis) of part of the myocardium from prolonged ischemia due to blockage of one or more 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

Ischemic pain from the heart is not triggered by respiration, movement, or palpation, and it is commonly accompanied by diaphoresis and nausea.

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

• Mechanism: the left ventricle fails to pump blood forward adequately, so blood backs up into the pulmonary circulation, causing pulmonary congestion and edema
• Symptoms: dyspnea, cough, wheezing, orthopnea, paroxysmal nocturnal dyspnea, pulmonary rales, hypotension, lightheadedness, poor exercise tolerance

Right-sided heart failure

• Mechanism: the right ventricle fails to pump blood forward adequately into the pulmonary circulation, causing increased systemic venous pressure
• Symptoms: prominent bilateral edema in the legs, ankles, and feet, dependent edema, rapid weight gain, ascites, liver engorgement, cyanosis, jugular vein distention

Patients with heart failure are taught to weigh themselves daily, report rapid weight gain, and limit dietary sodium, because salt promotes fluid retention. They should keep taking prescribed diuretics even though these increase urination, and should talk to their provider rather than stopping them; the PTA does not change medications.

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 - Hold or modify activity per the plan of care and report findings to the supervising PT, who coordinates with the physician (medication adjustment may be needed)
  • Weight gain of 2-3 lbs in 24 hours
  • Increased cough
  • Peripheral edema
  • Increased shortness of breath with 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
  • Stop activity, activate EMS, and notify the supervising PT

Exercise-termination criteria and cardiac rehab dosing are covered in the next chapters, Cardiac rehabilitation and Cardiac exercise testing.

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

Pain typically eases when sitting and leaning forward and worsens when lying supine. Report new or worsening substernal pain, fever, or tachycardia to the supervising PT before continuing treatment.

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.
• 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
• 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 skin temperature of the extremity

Venous disease (venous insufficiency)

Definitions

Venous disease (venous insufficiency)

Distended and swollen superficial veins that primarily impact the lower extremities

Symptoms

• Inverted champagne-shaped lower extremities
• Moderate to severe edema in lower extremities

Special diagnosis of venous disease

Deep vein thrombosis (DVT)

Definitions

Deep vein thrombosis (DVT)

A blood clot in a deep vein, most often in the leg or pelvis; the vein may also be inflamed (thrombophlebitis)

Characteristics

• Can occur in the upper or lower extremity
• Associated with prolonged immobilization, bed rest, surgery, trauma
• A person who is pregnant, or who had a baby in the previous 6 weeks, has a higher chance of deep vein thrombosis
  • A clot can go unnoticed in pregnancy, so deep tissue massage of the legs is avoided during pregnancy and soon after delivery: deep pressure could dislodge it

Symptoms

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

Confirmation of DVT diagnosis

• Wells Criteria - a clinical prediction rule clinicians use to estimate the probability of DVT when it is suspected
  • Score -2 to 0: low probability that DVT is present
  • Score: 1-2: moderate probability that DVT is present
  • Score 3-8: high probability that DVT is present
• Duplex (Doppler) ultrasound - noninvasive imaging, ordered by the physician, that confirms a DVT

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 (IVC) filter - stops lower extremity clots from traveling to the lungs