Define HF
Failure of heart to pump enough blood to meet heart tissues’ demands.
What is evidence of ischemia?
What is the monitoring triad?
T & M’s
PT observations
Pt observations
Max Testing Contraindications
Acute pericarditis or myocarditis
Acute MI w/n 2 days
Acute PE, Pulm Infarc., DVT
Acute Aortic Dissection
Active Endocarditis
Physical disability where Ex is unsafe
Sx severe aortic stenosis
Ongoing unstable angina
Uncontrolled arrhythmias w/ hemodynamic compromise
Decompensated HF
Max Testing Indications
Dx severity of CAD
Dx Arrhythmias
Dx Atypical chest pain
Dx Effects of medical or surgical intervention
PX - risk of future events
Assess peak f(x) capacity
BP/HR response
Screen for Ex Rx
Indications to Terminate a Sx-limited Max Test
ST elevation >1mm w/o preexisting Q wave bc of prior MI
Systolic BP drop >10 mmHg, despite incr. in workload, w/ other evidence of ischemia
Mod - Severe angina
CNS Sx - ataxia, dizziness, near syncope
S of poor perfusion: cyanosis, pallor
Sustained Ventr. tachycardia or other arrhythmia: 2nd/3rd AV block that interferes with CO during Ex
Tech difficulties monitoring BP or ECG
Pt requests to stop
Gen. Indications to Stop an Ex Test
Onset of angina or angina-like Sx
Drop in SBP >= 10mmHg w/ incr. in work rate
Excessive rise in BP: SBP>250 or DBP>115
SoB, Wheezing, leg cramps, claudication
S of poor perfusion: light-headed, confusion, ataxia, pallor, cyanosis, nausea, cold/clammy skin
Failure of HR to incr. w/ incr. Ex intensity
Change in Heart rhythm: palpitation or auscultation
Pt asks to stop
Phys./Verbal manifestation of severe fatigue
Failure of testing equip.
Precautions for Ex for Pt w/ Implanted Cardioverter Defibrillators (ICD)
Know the HR at which ICD defibrillates, must be 10bpm under.
Heavy UE activity can dislodge leads during 1st 2-3 weeks.
Absolute Indications for Supplemental O2
Documented hypoxemia:
PaO2 <= 55 mmHg or
SpO2 <= 88%
If Cor Pulmonale:
PaO2 55-59 mmHg or
SpO2 <= 89% or
ECG evid. of RA enlargement or
Hematocrit < 55%
CHF
Specific Situations Indications for Supplemental O2
PaO2 <= 60 mmHg or
SpO2 <= 90% or
Lung disease or sleep apnea w/ desaturation at night despite CPAP
Normoxemic at rest but desaturates during Ex or rest:
PaO2 <= 55 mmHg during Ex or sleep
Clin. S/Sx of hypoxia
Mod - severe dyspnea
Palpitations (incl. tachycardia)
Cyanosis, diaphoresis
Headache
Tachypnea
Angina
Restlessness
Confusion
Tremors
Indications for Cardiac Rehab (CR)
Medically stable Post-MI (last 12 mos)
Stable angina
Post-CABG or PTCA
Cardiomyopathy (incl. stable CHF)
Valvular disease surgery
Transplant
PAD
Mod-high risk for CAD
ST segment depression
Myocardial ischemia
Contraindications for Cardiac Rehab (CR)
Signif. aortic stenosis
Orthostatic BP drop of 20mmHg w/ Sx
Unstable angina
Uncontrolled HTN (Resting at 180 or 110)
Uncontrolled arrhythmia
Uncontrolled sinus tachycardia (HR >120 bpm)
Uncompensated HF
Other Contraindications for Cardiac Rehab (CR)
Active pericarditis or myocarditis
Acute thrombophlebitis
Acute thyroiditis (metabolic)
Acute systemic illness or fever
Aortic Dissection
Hypo-/Hyperkalemia (metabolic)
Hypo-/Hypervolemia (metabolic)
Physical disability where Ex is unsafe
Recent embolism
Severe psych disorder
Uncontrolled DM
3rd degree AV block w/o Pacemaker
IP Rehab Precautions
RPE should not exceed 5-6 / 10
Terminate if:
-PVC’s > 30% of complexes
-ST segment displacement >3mm
–depression = Ex-induced ischemia
–elevation = infarc. or Cor. a. stenosis
IP Contraindications to starting Ex
HR >= 120
SBP >= 200
DBP >= 110
SpO2 < 88% on room air
Indications to Terminate Ex during Cardiac Rehab
Post MI: HR > 20 above resting
Post Heart surgery: HR > 30 above resting
SBP >=220
DBP >=110
SBP drops >10 mmHg
Signif. arrhythmias
2nd/3rd* heart block on ECG
If suppl. O2 needed to maintain 90%
S/Sx of Ex intolerance
ST segment elevation
Acute Myocardial Infarction
Contraindications for SUB max test SBP
SBP >= 200 (IP), >= 180 (OP)
Contraindications for SUB max test DBP
DBP >= 110 (IP/OP)
Contraindications for SUB max test HR
120 bpm (IP/OP)
Contraindications for SUB max test SpO2
88% at rest, on room air.
Contraindications for SUB max test RR:
> = 30 brpm (IP/OP)
