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PET3932 – SECTION 02CUMULATIVE (FINAL) STUDY GUIDECh 1, 4, 5, & 6 (Exam 1 Material) – Benefits & risks associated with physical activity, Health-related physical fitness testing and interpretation, Clinical exercise testing, & Interpretation of clinical exercisetest resultsHandouts: History of Framingham Heart Study (link), Risk Assessment Tool (link), PA Compendium, Case Study 1 Clinical Exercise Testing (p.114) “Standard graded exercise tests (GXT) are used clinically to assess a patient’s ability to tolerate increasing intensities of aerobic exercise. Electrocardiographic (ECG), hemodynamic, and symptomatic responses are monitored during the GXT for manifestations of myocardial ischemia, hemodynamic/electrical instability, or other exertion-related signs or symptoms. Ventilator expired gas analysis may also be performed during the GXT, particularly in patients with congestive heart failure (CHF), suspected/confirmed pulmonary limitations, and/or unexplained Dyspnea upon exertion.” Assessment/Diagnosis of CAD/CHD (Looking for underlying Coronary Artery Disease)  *this is what will be further discussed throughout this study guide. Risk factors Signs & symptoms Resting ECG (Electrocardiogram) Cardiac biomarkers  measured to evaluate heart function (myocardial infarctions, etc.) Exercise ECG (including those done in the ER) Exercise nuclear imaging (perfusion, nuclear, thallium, cardiolite) Pharmacological  how do they react to dobutamine, dipyridamole, & adenosine Echocardiography  an ultrasound examination of the heart CT scan (electron beam computed tomography) Coronary angiography  uses dyes & x-rays to show the inside of the coronary arteries. Autopsy Classification of CAD risk factors Primary non-modifiable (these are factors that cannot be changed)  Advancing age Male gender Family Hx Primary modifiable (these are factors that can be changed) Dyslipidemia  Hypertension Tobacco smoking Diabetes mellitus Overweight or obesity Sedentary lifestyle Atherogenic lifestyle  promotes the formation of fat in arteries Emerging risk factors (lipids)  lipid changes that happen over time  Lipoprotein (α) Lipoprotein remnants Small LDL (low-density lipoprotein) particles HDL subspecies Apolipoproteins B & A-1 TC/HDL ratio (Total Cholesterol/High-Density Lipoprotein ratio) Emerging risk factors (non-lipids)  other changes that happen over time Homocysteine (amino acid – LDL, clot) (metabolic syndrome) Thrombogenic & hemostatic factors Inflammatory markers (C-reactive protein) Impaired glucose tolerance  Subclinical atherosclerosis & plaque burden Risk Assessment tool for estimating your 10-year risk of having a heart attack (handout): http://cvdrisk.nhlbi.nih.gov/calculator.asp Takes into account your age, gender, total cholesterol, HDL cholesterol, whether you smoke, systolic blood pressure, and if you’re taking medication for high blood pressure. Total cholesterol: the sum of all the cholesterol in your blood (the higher your total cholesterol, the greater your risk for heart disease).- Lower risk: < 200 mg/dL- Borderline-high risk: 200 – 239 mg/dL- More than twice the risk as someone below 200 mg/dL: ≥ 240 mg/dL HDL cholesterol: “good” cholesterol; high density lipoproteins (HDL) carry cholesterol in theblood from other parts of the body back to the liver; helps keep cholesterol from building upin the walls of the arteries; the higher your HDL, the better.- Major risk factor: < 40 mg/dL- Lower risk factor: 40 – 59 mg/dL- Protective against heart disease: ≥ 60 mg/dL Framingham Heart Study (handout): http://www.framinghamheartstudy.org/about-fhs/history.php “CVD is the leading cause of death & serious illness in the U.S.” This study was a big deal b/c, for the first time, it tracked a large group of people for a long period of time in order to identify the common factors or characteristics that contribute to CVD (participants had not suffered heart attacks, strokes, or CVD symptoms yet). After 3 generations of studies, extensive physical examinations, and lifestyle interviews, they found: The major CVD risk factors: high blood pressure, high blood cholesterol, smoking, obesity, diabetes, and physical inactivity. The effects of related factors: blood triglyceride and HDL cholesterol levels, age, gender, and psychosocial issues. Major signs or symptoms suggestive of cardiovascular, pulmonary or metabolic disease Angina (symptom of hard/soft/silent ischemia) SOB at rest or with mild exertion Dizziness or syncope Orthopnea or paroxysmal nocturnal dyspnea Ankle edema Palpitations or tachycardia Intermittent claudication Known heart murmur Unusual fatigue or SOB with usual activities Prizmental (random heat problems – coronary spasms) Claudication → sign of diabetes ECG reading (p.148 *see images) P wave: electrical impulse going through atria (superior aspect of heart) Atrial depolarization (atria – pacemaker of the heart) QRS complex: electrical impulse going though the ventricles Ventrical depolarization T wave Ventrical repolarization – electrical recovery (repolarization) of the ventricles ST-segment depression: (p.149) Most common manifestation of exercise-induced myocardial ischemia “Horizontal or downsloping ST-segment depression is more indicative of myocardial ischemia than is upsloping depression.” ST-segment elevation: early repolarization (p.148) Evidence of transmural ischemia (acute MI) Will come back down as an inverted T wave Significant Q wave Old MI Q wave width: >40 msec Q wave height: > ¼ of R wave EKG – important pointers when performing test Magnitude: amount (1 ml, 2 ml, etc.) – the greater the amount, the worse it is Slope (ST-segment depression): upsloping (best)→horizontal→ downsloping (worst) Number of leads used Duration of EKG EKG – severity of ischemia ≥ 1 mL horizontal or downsloping ST depression is positive for ischemia If you see 2 mL → stop testing Use 2-lead to check for arrhythmia → arrhythmia can result in ischemia RPP: Rate Pressure Product “double product” RPP = Heart Rate [HR] x Systolic Blood Pressure [SBP] Signs of an acute MI Symptomology (myocardial


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