1.5 Cardiac exercise testing

Achievable NPTE-PTA

1. Cardiopulmonary system

Our NPTE-PTA course is now in "early access" - get 50% off for a limited time.

Cardiac exercise testing

6 min read

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Types of test

6-minute walk test
- Test goal: measure distance walked in 6 minutes with or without an assistive device
- Rationale: test for endurance related to cardiovascular health
- Setting used: Phase I and Phase II of cardiac rehabilitation
- Test advantages: Quick assessment of endurance that can be completed for lower-level patients
Graded exercise testing
- Test goal: assess the maximal workload that can be applied to the cardiovascular system via treadmill testing at different grades (incline)
- Rationale: provide the therapist with information on the highest capacity of exercise tolerance
  - Provides the maximal heart rate that can be used to then give the target heart range with activity
- Setting: Phase II cardiac rehabilitation
- Test advantages: Most accurate assessment tool of an individual’s exercise tolerance
Cycle ergometer test:
- Test goal: submaximal test utilized to assess the VO₂max through graded exercise (increasing in resistance)
- Rationale: provides the maximum amount of oxygen your body can use during intense exercise, serving as the best indicator of your cardiovascular fitness and aerobic endurance.
- Setting: Phase II cardiac rehabilitation
- Test advantage: Utilized over maximal exercise testing if the patient is unable to tolerate maximal testing parameters

Definitions

Maximal exercise test: Exercise testing in which the highest resistance, the highest level of intensity, and the longest duration an individual can tolerate.
Submaximal exercise test: Exercise testing that has limits to not exceed a pre-established threshold to not allow for the highest intensity or the highest resistance capable by the patient; utilize the VO₂max number and input into the equation to quantify the individual’s maximal heart rate
VO₂max: Maximum rate of oxygen that can be used in exercise; used specifically in submaximal exercise testing to quantify activity tolerance

Contraindications for exercise testing

Unstable angina
Acute myocardial infarction
Acute congestive heart failure
Uncontrolled arrhythmias
Systolic blood pressure >200 mmHg or diastolic blood pressure >115 mmHg
Severe anemia
Hemoglobin less than 8
Advanced or complicated pregnancy

Reasons to stop exercise testing

Severe ST-segment depression of 2mm or greater
Cardiac arrest
Development of new 2nd or 3rd degree heart block
Patient requests to stop
Severe chest pain, dizziness, or dyspnea
Fall in systolic blood pressure <20 mmHg
Ataxia
Rise in systolic blood pressure >200 mmHg or diastolic > 110 mm Hg

Cardiac medications

Beta blockers (atenolol): hypertension medication
- Mechanism of action: works on the heart muscle by blocking epinephrine; decreased heart rate
- PT implications: do not use heart rate as an indicator for response to exercise; use the perceived exertion scale (RPE) to assist with tolerance to activity
Calcium channel blockers: hypertension medication
- Mechanism of action: works on the heart muscle to prevent calcium from entering heart tissue; increases vasodilation; decreases heart rate
- PT implications: orthostatic hypotension
Angiotensin converting enzyme inhibitors (ACE Inhibitors): hypertension medications
- Mechanism of action: works on the kidneys to stop the conversion of Angiotensin I to converting to Angiotensin II and causes vasodilation in the peripheral vascular system
- PT implications: Orthostatic hypotension, dizziness, palpitations
Diuretics (lasix & hydrochlorothiazide): hypertension medication
- Mechanism of action: works on the kidneys to decrease the fluid retention in the body by moving sodium out of the body
- PT implications: electrolyte imbalance, orthostatic hypotension, muscle cramps, increased urination
Anticoagulants (warfarin, coumadin): decreases clotting of blood
- Mechanism of action: works to reduce the clotting within the blood
- PT implications: hemorrhage risk, can easily bruise
Nitroglycerin: used specifically for angina pectoris
- Mechanism of action: works to relax smooth muscle in the heart, releasing nitric oxide, which will cause vasodilation and a reduction in blood pressure
  - Specifically used in angina pectoris
- PT implications: dizziness, headache, weakness, nausea
Digitalis (digoxin): congestive heart failure medication
- Mechanism of action: inhibits AV node activation
- PT implications: increases renal failure, increased risk for toxicity (digoxin toxicity), which can lead to hospitalization
Antihyperlipidemias (statins): cholesterol medication
- Mechanism of action: blocks the production of cholesterol by the liver
- PT implications: muscle pain, muscle weakness, fatigue, diarrhea, constipation, headache
Amiodarone (antiarrhythmic agent): unstable ventricular tachycardia and recurrent ventricular fibrillation medication
- Mechanism of action: increases the duration of the action potential as well as the effective refractory period for cardiac cells
- PT implications: signs of congestive heart failure, including dyspnea, rales/crackles, peripheral edema, jugular venous distention, and exercise intolerance

Observational cardiac topics

Pulse (also known as heartbeat or rhythm)

0= absent
1+ = weak/thready
2+= diminished
3+= normal
4+= bounding

Pitting edema grading (associated with right-sided heart failure):

Grade 1: 0-2 mm indentation and rebounds immediately
Grade 2: 3-4 mm indentation and rebounds within 15 seconds
Grade 3: 5-6 mm indentation and rebounds within 30-60 seconds
Grade 4: 8mm or more indentation and rebounds 60 seconds or longer

Auscultation of heart sounds

S1:
- Normal heart sound
- First heart sound when atrioventricular (mitral and tricuspid) valves close
- Heard at the 5th intercostal space at the midclavicular line
- Signals the beginning of systole
- Often referred to as “lub”
S2
- Normal heart sound
- Second heart sound when semilunar (aortic and pulmonary) valves close
- Heart at the second intercostal space along the right sternal border
- Signals the beginning of diastole
- Often referred to as “dub”
S3
- Adventitious heart sound in adults and normal in children- Any extra sounds should be reported to the the supervising therapist.
- Heard between the 4th and 5th ribs on left side of chest
- Associated with rapid filling of ventricles during early diastole
- Often associated with fluid overload or a weakened left ventricle, which can be indicative of heart failure, myocardial infarction, dilated cardiomyopathy, valvular regurgitation, or constrictive pericarditis
S4
- Adventitious heart sound in adults and children- Any extra sounds should be reported to the the supervising therapist
- Heard between the 4th and 5th ribs on the left or right side of the chest
- Associated with reduced ventricular compliance or increased resistance to ventricular filling
- Often associated with left ventricular hypertrophy or left-sided heart failure

Types of test

6-minute walk test: measures endurance, quick for lower-level patients, used in Phase I/II cardiac rehab
Graded exercise testing: assesses maximal exercise tolerance, provides maximal heart rate, most accurate, used in Phase II
Cycle ergometer test: submaximal, assesses VO₂max, used if maximal testing not tolerated, Phase II

Definitions

Maximal exercise test: highest resistance/intensity/duration tolerated
Submaximal exercise test: below maximal threshold, uses VO₂max for max heart rate estimation
VO₂max: max oxygen usage rate during exercise, indicator of aerobic fitness

Contraindications for exercise testing

Unstable angina, acute MI, acute CHF
Uncontrolled arrhythmias, severe hypertension (>200/115 mmHg)
Severe anemia (hemoglobin <8), advanced pregnancy

Reasons to stop exercise testing

Severe ST-segment depression (≥2mm), cardiac arrest, new 2nd/3rd degree heart block
Patient request, severe symptoms (chest pain, dizziness, dyspnea)
Systolic BP drop <20 mmHg, ataxia, excessive BP rise (>200/110 mmHg)

Cardiac medications

Beta blockers: decrease HR, use RPE instead of HR for exercise
Calcium channel blockers: vasodilation, decreased HR, risk of orthostatic hypotension
ACE inhibitors: vasodilation, risk of dizziness, palpitations
Diuretics: decrease fluid retention, risk of electrolyte imbalance, cramps, increased urination
Anticoagulants: reduce clotting, hemorrhage/bruising risk
Nitroglycerin: vasodilation for angina, risk of dizziness, headache
Digitalis: inhibits AV node, risk of toxicity, renal failure
Statins: lower cholesterol, risk of muscle pain, weakness
Amiodarone: prolongs action potential, watch for CHF signs

Observational cardiac topics

Pulse grading: 0 (absent) to 4+ (bounding)
Pitting edema grading: 1 (0-2mm, immediate rebound) to 4 (≥8mm, ≥60s rebound)

Auscultation of heart sounds

S1: AV valves close, start of systole, “lub”, 5th intercostal space
S2: semilunar valves close, start of diastole, “dub”, 2nd intercostal space
S3: extra sound, rapid ventricular filling, fluid overload/heart failure, report if in adults
S4: extra sound, reduced ventricular compliance, LV hypertrophy/heart failure, report if present

Cardiac exercise testing

Types of test

6-minute walk test
- Test goal: measure distance walked in 6 minutes with or without an assistive device
- Rationale: test for endurance related to cardiovascular health
- Setting used: Phase I and Phase II of cardiac rehabilitation
- Test advantages: Quick assessment of endurance that can be completed for lower-level patients
Graded exercise testing
- Test goal: assess the maximal workload that can be applied to the cardiovascular system via treadmill testing at different grades (incline)
- Rationale: provide the therapist with information on the highest capacity of exercise tolerance
  - Provides the maximal heart rate that can be used to then give the target heart range with activity
- Setting: Phase II cardiac rehabilitation
- Test advantages: Most accurate assessment tool of an individual’s exercise tolerance
Cycle ergometer test:
- Test goal: submaximal test utilized to assess the VO₂max through graded exercise (increasing in resistance)
- Rationale: provides the maximum amount of oxygen your body can use during intense exercise, serving as the best indicator of your cardiovascular fitness and aerobic endurance.
- Setting: Phase II cardiac rehabilitation
- Test advantage: Utilized over maximal exercise testing if the patient is unable to tolerate maximal testing parameters

Definitions

Maximal exercise test: Exercise testing in which the highest resistance, the highest level of intensity, and the longest duration an individual can tolerate.
Submaximal exercise test: Exercise testing that has limits to not exceed a pre-established threshold to not allow for the highest intensity or the highest resistance capable by the patient; utilize the VO₂max number and input into the equation to quantify the individual’s maximal heart rate
VO₂max: Maximum rate of oxygen that can be used in exercise; used specifically in submaximal exercise testing to quantify activity tolerance

Contraindications for exercise testing

Unstable angina
Acute myocardial infarction
Acute congestive heart failure
Uncontrolled arrhythmias
Systolic blood pressure >200 mmHg or diastolic blood pressure >115 mmHg
Severe anemia
Hemoglobin less than 8
Advanced or complicated pregnancy

Reasons to stop exercise testing

Severe ST-segment depression of 2mm or greater
Cardiac arrest
Development of new 2nd or 3rd degree heart block
Patient requests to stop
Severe chest pain, dizziness, or dyspnea
Fall in systolic blood pressure <20 mmHg
Ataxia
Rise in systolic blood pressure >200 mmHg or diastolic > 110 mm Hg

Cardiac medications

Beta blockers (atenolol): hypertension medication
- Mechanism of action: works on the heart muscle by blocking epinephrine; decreased heart rate
- PT implications: do not use heart rate as an indicator for response to exercise; use the perceived exertion scale (RPE) to assist with tolerance to activity
Calcium channel blockers: hypertension medication
- Mechanism of action: works on the heart muscle to prevent calcium from entering heart tissue; increases vasodilation; decreases heart rate
- PT implications: orthostatic hypotension
Angiotensin converting enzyme inhibitors (ACE Inhibitors): hypertension medications
- Mechanism of action: works on the kidneys to stop the conversion of Angiotensin I to converting to Angiotensin II and causes vasodilation in the peripheral vascular system
- PT implications: Orthostatic hypotension, dizziness, palpitations
Diuretics (lasix & hydrochlorothiazide): hypertension medication
- Mechanism of action: works on the kidneys to decrease the fluid retention in the body by moving sodium out of the body
- PT implications: electrolyte imbalance, orthostatic hypotension, muscle cramps, increased urination
Anticoagulants (warfarin, coumadin): decreases clotting of blood
- Mechanism of action: works to reduce the clotting within the blood
- PT implications: hemorrhage risk, can easily bruise
Nitroglycerin: used specifically for angina pectoris
- Mechanism of action: works to relax smooth muscle in the heart, releasing nitric oxide, which will cause vasodilation and a reduction in blood pressure
  - Specifically used in angina pectoris
- PT implications: dizziness, headache, weakness, nausea
Digitalis (digoxin): congestive heart failure medication
- Mechanism of action: inhibits AV node activation
- PT implications: increases renal failure, increased risk for toxicity (digoxin toxicity), which can lead to hospitalization
Antihyperlipidemias (statins): cholesterol medication
- Mechanism of action: blocks the production of cholesterol by the liver
- PT implications: muscle pain, muscle weakness, fatigue, diarrhea, constipation, headache
Amiodarone (antiarrhythmic agent): unstable ventricular tachycardia and recurrent ventricular fibrillation medication
- Mechanism of action: increases the duration of the action potential as well as the effective refractory period for cardiac cells
- PT implications: signs of congestive heart failure, including dyspnea, rales/crackles, peripheral edema, jugular venous distention, and exercise intolerance

Observational cardiac topics

Pulse (also known as heartbeat or rhythm)

0= absent
1+ = weak/thready
2+= diminished
3+= normal
4+= bounding

Pitting edema grading (associated with right-sided heart failure):

Grade 1: 0-2 mm indentation and rebounds immediately
Grade 2: 3-4 mm indentation and rebounds within 15 seconds
Grade 3: 5-6 mm indentation and rebounds within 30-60 seconds
Grade 4: 8mm or more indentation and rebounds 60 seconds or longer

Auscultation of heart sounds

S1:
- Normal heart sound
- First heart sound when atrioventricular (mitral and tricuspid) valves close
- Heard at the 5th intercostal space at the midclavicular line
- Signals the beginning of systole
- Often referred to as “lub”
S2
- Normal heart sound
- Second heart sound when semilunar (aortic and pulmonary) valves close
- Heart at the second intercostal space along the right sternal border
- Signals the beginning of diastole
- Often referred to as “dub”
S3
- Adventitious heart sound in adults and normal in children- Any extra sounds should be reported to the the supervising therapist.
- Heard between the 4th and 5th ribs on left side of chest
- Associated with rapid filling of ventricles during early diastole
- Often associated with fluid overload or a weakened left ventricle, which can be indicative of heart failure, myocardial infarction, dilated cardiomyopathy, valvular regurgitation, or constrictive pericarditis
S4
- Adventitious heart sound in adults and children- Any extra sounds should be reported to the the supervising therapist
- Heard between the 4th and 5th ribs on the left or right side of the chest
- Associated with reduced ventricular compliance or increased resistance to ventricular filling
- Often associated with left ventricular hypertrophy or left-sided heart failure

Achievable NPTE-PTA

1. Cardiopulmonary system

Our NPTE-PTA course is now in "early access" - get 50% off for a limited time.

Cardiac exercise testing

6 min read

Font

Discuss

Feedback

Types of test

6-minute walk test
- Test goal: measure distance walked in 6 minutes with or without an assistive device
- Rationale: test for endurance related to cardiovascular health
- Setting used: Phase I and Phase II of cardiac rehabilitation
- Test advantages: Quick assessment of endurance that can be completed for lower-level patients
Graded exercise testing
- Test goal: assess the maximal workload that can be applied to the cardiovascular system via treadmill testing at different grades (incline)
- Rationale: provide the therapist with information on the highest capacity of exercise tolerance
  - Provides the maximal heart rate that can be used to then give the target heart range with activity
- Setting: Phase II cardiac rehabilitation
- Test advantages: Most accurate assessment tool of an individual’s exercise tolerance
Cycle ergometer test:
- Test goal: submaximal test utilized to assess the VO₂max through graded exercise (increasing in resistance)
- Rationale: provides the maximum amount of oxygen your body can use during intense exercise, serving as the best indicator of your cardiovascular fitness and aerobic endurance.
- Setting: Phase II cardiac rehabilitation
- Test advantage: Utilized over maximal exercise testing if the patient is unable to tolerate maximal testing parameters

Definitions

Maximal exercise test: Exercise testing in which the highest resistance, the highest level of intensity, and the longest duration an individual can tolerate.
Submaximal exercise test: Exercise testing that has limits to not exceed a pre-established threshold to not allow for the highest intensity or the highest resistance capable by the patient; utilize the VO₂max number and input into the equation to quantify the individual’s maximal heart rate
VO₂max: Maximum rate of oxygen that can be used in exercise; used specifically in submaximal exercise testing to quantify activity tolerance

Contraindications for exercise testing

Unstable angina
Acute myocardial infarction
Acute congestive heart failure
Uncontrolled arrhythmias
Systolic blood pressure >200 mmHg or diastolic blood pressure >115 mmHg
Severe anemia
Hemoglobin less than 8
Advanced or complicated pregnancy

Reasons to stop exercise testing

Severe ST-segment depression of 2mm or greater
Cardiac arrest
Development of new 2nd or 3rd degree heart block
Patient requests to stop
Severe chest pain, dizziness, or dyspnea
Fall in systolic blood pressure <20 mmHg
Ataxia
Rise in systolic blood pressure >200 mmHg or diastolic > 110 mm Hg

Cardiac medications

Beta blockers (atenolol): hypertension medication
- Mechanism of action: works on the heart muscle by blocking epinephrine; decreased heart rate
- PT implications: do not use heart rate as an indicator for response to exercise; use the perceived exertion scale (RPE) to assist with tolerance to activity
Calcium channel blockers: hypertension medication
- Mechanism of action: works on the heart muscle to prevent calcium from entering heart tissue; increases vasodilation; decreases heart rate
- PT implications: orthostatic hypotension
Angiotensin converting enzyme inhibitors (ACE Inhibitors): hypertension medications
- Mechanism of action: works on the kidneys to stop the conversion of Angiotensin I to converting to Angiotensin II and causes vasodilation in the peripheral vascular system
- PT implications: Orthostatic hypotension, dizziness, palpitations
Diuretics (lasix & hydrochlorothiazide): hypertension medication
- Mechanism of action: works on the kidneys to decrease the fluid retention in the body by moving sodium out of the body
- PT implications: electrolyte imbalance, orthostatic hypotension, muscle cramps, increased urination
Anticoagulants (warfarin, coumadin): decreases clotting of blood
- Mechanism of action: works to reduce the clotting within the blood
- PT implications: hemorrhage risk, can easily bruise
Nitroglycerin: used specifically for angina pectoris
- Mechanism of action: works to relax smooth muscle in the heart, releasing nitric oxide, which will cause vasodilation and a reduction in blood pressure
  - Specifically used in angina pectoris
- PT implications: dizziness, headache, weakness, nausea
Digitalis (digoxin): congestive heart failure medication
- Mechanism of action: inhibits AV node activation
- PT implications: increases renal failure, increased risk for toxicity (digoxin toxicity), which can lead to hospitalization
Antihyperlipidemias (statins): cholesterol medication
- Mechanism of action: blocks the production of cholesterol by the liver
- PT implications: muscle pain, muscle weakness, fatigue, diarrhea, constipation, headache
Amiodarone (antiarrhythmic agent): unstable ventricular tachycardia and recurrent ventricular fibrillation medication
- Mechanism of action: increases the duration of the action potential as well as the effective refractory period for cardiac cells
- PT implications: signs of congestive heart failure, including dyspnea, rales/crackles, peripheral edema, jugular venous distention, and exercise intolerance

Observational cardiac topics

Pulse (also known as heartbeat or rhythm)

0= absent
1+ = weak/thready
2+= diminished
3+= normal
4+= bounding

Pitting edema grading (associated with right-sided heart failure):

Grade 1: 0-2 mm indentation and rebounds immediately
Grade 2: 3-4 mm indentation and rebounds within 15 seconds
Grade 3: 5-6 mm indentation and rebounds within 30-60 seconds
Grade 4: 8mm or more indentation and rebounds 60 seconds or longer

Auscultation of heart sounds

S1:
- Normal heart sound
- First heart sound when atrioventricular (mitral and tricuspid) valves close
- Heard at the 5th intercostal space at the midclavicular line
- Signals the beginning of systole
- Often referred to as “lub”
S2
- Normal heart sound
- Second heart sound when semilunar (aortic and pulmonary) valves close
- Heart at the second intercostal space along the right sternal border
- Signals the beginning of diastole
- Often referred to as “dub”
S3
- Adventitious heart sound in adults and normal in children- Any extra sounds should be reported to the the supervising therapist.
- Heard between the 4th and 5th ribs on left side of chest
- Associated with rapid filling of ventricles during early diastole
- Often associated with fluid overload or a weakened left ventricle, which can be indicative of heart failure, myocardial infarction, dilated cardiomyopathy, valvular regurgitation, or constrictive pericarditis
S4
- Adventitious heart sound in adults and children- Any extra sounds should be reported to the the supervising therapist
- Heard between the 4th and 5th ribs on the left or right side of the chest
- Associated with reduced ventricular compliance or increased resistance to ventricular filling
- Often associated with left ventricular hypertrophy or left-sided heart failure

Types of test

6-minute walk test: measures endurance, quick for lower-level patients, used in Phase I/II cardiac rehab
Graded exercise testing: assesses maximal exercise tolerance, provides maximal heart rate, most accurate, used in Phase II
Cycle ergometer test: submaximal, assesses VO₂max, used if maximal testing not tolerated, Phase II

Definitions

Maximal exercise test: highest resistance/intensity/duration tolerated
Submaximal exercise test: below maximal threshold, uses VO₂max for max heart rate estimation
VO₂max: max oxygen usage rate during exercise, indicator of aerobic fitness

Contraindications for exercise testing

Unstable angina, acute MI, acute CHF
Uncontrolled arrhythmias, severe hypertension (>200/115 mmHg)
Severe anemia (hemoglobin <8), advanced pregnancy

Reasons to stop exercise testing

Severe ST-segment depression (≥2mm), cardiac arrest, new 2nd/3rd degree heart block
Patient request, severe symptoms (chest pain, dizziness, dyspnea)
Systolic BP drop <20 mmHg, ataxia, excessive BP rise (>200/110 mmHg)

Cardiac medications

Beta blockers: decrease HR, use RPE instead of HR for exercise
Calcium channel blockers: vasodilation, decreased HR, risk of orthostatic hypotension
ACE inhibitors: vasodilation, risk of dizziness, palpitations
Diuretics: decrease fluid retention, risk of electrolyte imbalance, cramps, increased urination
Anticoagulants: reduce clotting, hemorrhage/bruising risk
Nitroglycerin: vasodilation for angina, risk of dizziness, headache
Digitalis: inhibits AV node, risk of toxicity, renal failure
Statins: lower cholesterol, risk of muscle pain, weakness
Amiodarone: prolongs action potential, watch for CHF signs

Observational cardiac topics

Pulse grading: 0 (absent) to 4+ (bounding)
Pitting edema grading: 1 (0-2mm, immediate rebound) to 4 (≥8mm, ≥60s rebound)

Auscultation of heart sounds

S1: AV valves close, start of systole, “lub”, 5th intercostal space
S2: semilunar valves close, start of diastole, “dub”, 2nd intercostal space
S3: extra sound, rapid ventricular filling, fluid overload/heart failure, report if in adults
S4: extra sound, reduced ventricular compliance, LV hypertrophy/heart failure, report if present

Cardiac exercise testing

Types of test

6-minute walk test
- Test goal: measure distance walked in 6 minutes with or without an assistive device
- Rationale: test for endurance related to cardiovascular health
- Setting used: Phase I and Phase II of cardiac rehabilitation
- Test advantages: Quick assessment of endurance that can be completed for lower-level patients
Graded exercise testing
- Test goal: assess the maximal workload that can be applied to the cardiovascular system via treadmill testing at different grades (incline)
- Rationale: provide the therapist with information on the highest capacity of exercise tolerance
  - Provides the maximal heart rate that can be used to then give the target heart range with activity
- Setting: Phase II cardiac rehabilitation
- Test advantages: Most accurate assessment tool of an individual’s exercise tolerance
Cycle ergometer test:
- Test goal: submaximal test utilized to assess the VO₂max through graded exercise (increasing in resistance)
- Rationale: provides the maximum amount of oxygen your body can use during intense exercise, serving as the best indicator of your cardiovascular fitness and aerobic endurance.
- Setting: Phase II cardiac rehabilitation
- Test advantage: Utilized over maximal exercise testing if the patient is unable to tolerate maximal testing parameters

Definitions

Maximal exercise test: Exercise testing in which the highest resistance, the highest level of intensity, and the longest duration an individual can tolerate.
Submaximal exercise test: Exercise testing that has limits to not exceed a pre-established threshold to not allow for the highest intensity or the highest resistance capable by the patient; utilize the VO₂max number and input into the equation to quantify the individual’s maximal heart rate
VO₂max: Maximum rate of oxygen that can be used in exercise; used specifically in submaximal exercise testing to quantify activity tolerance

Contraindications for exercise testing

Unstable angina
Acute myocardial infarction
Acute congestive heart failure
Uncontrolled arrhythmias
Systolic blood pressure >200 mmHg or diastolic blood pressure >115 mmHg
Severe anemia
Hemoglobin less than 8
Advanced or complicated pregnancy

Reasons to stop exercise testing

Severe ST-segment depression of 2mm or greater
Cardiac arrest
Development of new 2nd or 3rd degree heart block
Patient requests to stop
Severe chest pain, dizziness, or dyspnea
Fall in systolic blood pressure <20 mmHg
Ataxia
Rise in systolic blood pressure >200 mmHg or diastolic > 110 mm Hg

Cardiac medications

Beta blockers (atenolol): hypertension medication
- Mechanism of action: works on the heart muscle by blocking epinephrine; decreased heart rate
- PT implications: do not use heart rate as an indicator for response to exercise; use the perceived exertion scale (RPE) to assist with tolerance to activity
Calcium channel blockers: hypertension medication
- Mechanism of action: works on the heart muscle to prevent calcium from entering heart tissue; increases vasodilation; decreases heart rate
- PT implications: orthostatic hypotension
Angiotensin converting enzyme inhibitors (ACE Inhibitors): hypertension medications
- Mechanism of action: works on the kidneys to stop the conversion of Angiotensin I to converting to Angiotensin II and causes vasodilation in the peripheral vascular system
- PT implications: Orthostatic hypotension, dizziness, palpitations
Diuretics (lasix & hydrochlorothiazide): hypertension medication
- Mechanism of action: works on the kidneys to decrease the fluid retention in the body by moving sodium out of the body
- PT implications: electrolyte imbalance, orthostatic hypotension, muscle cramps, increased urination
Anticoagulants (warfarin, coumadin): decreases clotting of blood
- Mechanism of action: works to reduce the clotting within the blood
- PT implications: hemorrhage risk, can easily bruise
Nitroglycerin: used specifically for angina pectoris
- Mechanism of action: works to relax smooth muscle in the heart, releasing nitric oxide, which will cause vasodilation and a reduction in blood pressure
  - Specifically used in angina pectoris
- PT implications: dizziness, headache, weakness, nausea
Digitalis (digoxin): congestive heart failure medication
- Mechanism of action: inhibits AV node activation
- PT implications: increases renal failure, increased risk for toxicity (digoxin toxicity), which can lead to hospitalization
Antihyperlipidemias (statins): cholesterol medication
- Mechanism of action: blocks the production of cholesterol by the liver
- PT implications: muscle pain, muscle weakness, fatigue, diarrhea, constipation, headache
Amiodarone (antiarrhythmic agent): unstable ventricular tachycardia and recurrent ventricular fibrillation medication
- Mechanism of action: increases the duration of the action potential as well as the effective refractory period for cardiac cells
- PT implications: signs of congestive heart failure, including dyspnea, rales/crackles, peripheral edema, jugular venous distention, and exercise intolerance

Observational cardiac topics

Pulse (also known as heartbeat or rhythm)

0= absent
1+ = weak/thready
2+= diminished
3+= normal
4+= bounding

Pitting edema grading (associated with right-sided heart failure):

Grade 1: 0-2 mm indentation and rebounds immediately
Grade 2: 3-4 mm indentation and rebounds within 15 seconds
Grade 3: 5-6 mm indentation and rebounds within 30-60 seconds
Grade 4: 8mm or more indentation and rebounds 60 seconds or longer

Auscultation of heart sounds

S1:
- Normal heart sound
- First heart sound when atrioventricular (mitral and tricuspid) valves close
- Heard at the 5th intercostal space at the midclavicular line
- Signals the beginning of systole
- Often referred to as “lub”
S2
- Normal heart sound
- Second heart sound when semilunar (aortic and pulmonary) valves close
- Heart at the second intercostal space along the right sternal border
- Signals the beginning of diastole
- Often referred to as “dub”
S3
- Adventitious heart sound in adults and normal in children- Any extra sounds should be reported to the the supervising therapist.
- Heard between the 4th and 5th ribs on left side of chest
- Associated with rapid filling of ventricles during early diastole
- Often associated with fluid overload or a weakened left ventricle, which can be indicative of heart failure, myocardial infarction, dilated cardiomyopathy, valvular regurgitation, or constrictive pericarditis
S4
- Adventitious heart sound in adults and children- Any extra sounds should be reported to the the supervising therapist
- Heard between the 4th and 5th ribs on the left or right side of the chest
- Associated with reduced ventricular compliance or increased resistance to ventricular filling
- Often associated with left ventricular hypertrophy or left-sided heart failure

Key points

Types of test

6-minute walk test: measures endurance, quick for lower-level patients, used in Phase I/II cardiac rehab
Graded exercise testing: assesses maximal exercise tolerance, provides maximal heart rate, most accurate, used in Phase II
Cycle ergometer test: submaximal, assesses VO₂max, used if maximal testing not tolerated, Phase II

Definitions

Maximal exercise test: highest resistance/intensity/duration tolerated
Submaximal exercise test: below maximal threshold, uses VO₂max for max heart rate estimation
VO₂max: max oxygen usage rate during exercise, indicator of aerobic fitness

Contraindications for exercise testing

Unstable angina, acute MI, acute CHF
Uncontrolled arrhythmias, severe hypertension (>200/115 mmHg)
Severe anemia (hemoglobin <8), advanced pregnancy

Reasons to stop exercise testing

Severe ST-segment depression (≥2mm), cardiac arrest, new 2nd/3rd degree heart block
Patient request, severe symptoms (chest pain, dizziness, dyspnea)
Systolic BP drop <20 mmHg, ataxia, excessive BP rise (>200/110 mmHg)

Cardiac medications

Beta blockers: decrease HR, use RPE instead of HR for exercise
Calcium channel blockers: vasodilation, decreased HR, risk of orthostatic hypotension
ACE inhibitors: vasodilation, risk of dizziness, palpitations
Diuretics: decrease fluid retention, risk of electrolyte imbalance, cramps, increased urination
Anticoagulants: reduce clotting, hemorrhage/bruising risk
Nitroglycerin: vasodilation for angina, risk of dizziness, headache
Digitalis: inhibits AV node, risk of toxicity, renal failure
Statins: lower cholesterol, risk of muscle pain, weakness
Amiodarone: prolongs action potential, watch for CHF signs

Observational cardiac topics

Pulse grading: 0 (absent) to 4+ (bounding)
Pitting edema grading: 1 (0-2mm, immediate rebound) to 4 (≥8mm, ≥60s rebound)

Auscultation of heart sounds

S1: AV valves close, start of systole, “lub”, 5th intercostal space
S2: semilunar valves close, start of diastole, “dub”, 2nd intercostal space
S3: extra sound, rapid ventricular filling, fluid overload/heart failure, report if in adults
S4: extra sound, reduced ventricular compliance, LV hypertrophy/heart failure, report if present