PET3932 SECTION 2 EXERCISE DISEASE EXAM 1 STUDY GUIDE Assessment Diagnosis of CAD CHD looking for underlying Coronary Artery Disease Risk factors Signs symptoms Resting ECG Cardiac biomarkers Exercise ECG including in the ER Exercise nuclear imaging perfusion nuclear thallium cardiolite Pharmacological dobutamine dipyridamole adenosine Echocardiography CT scan electron beam computed tomography Coronary aniography Autopsy P 114 quote increasing intensities of aerobic exercise Classification of coronary risk factors Primary non modifiable Advancing age Male gender Family Hx Primary modifiable Dyslipidemia Hypertension Tobacco smoking Diabetes mellitus Overweight or obesity Sedentary lifestyle Atherogenic lifestyle Standard graded exercise tests GXT are used clinically to assess a patients ability to tolerate Emerging risk factors lipids Lipoprotein Lipoprotein remnants Small LDL particles HDL subspecies Apolipoproteins B A 1 TC HDL ratio Emerging Risk factors non lipids Homocysteine amino acid LDL clot metabolic syndrome Thrombogenic hemostatic factors Inflammatory markers C reactive protein Impaired glucose tolerance Subclinical atherosclerosis plague burden Risk Assessment tool for estimating 10 year risk of developing hard CHD Framing Hand Ten Year Risk Major signs or symptoms suggestive of cardiovascular pulmonary or metabolic disease Angina symptom of ischemia hard soft silent 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 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 depression subendocardial ischemia ST elevation transmural ischemia acute MI Will come back down as an inverted T wave Evidence of ischemia or recent MI Significant Q wave Old MI Q wave width 40 msec Q wave height 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 upsloping best horizontal downsloping worst Number of leads Duration 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 arythmia arythmia can result in ischemia RPP Rate Pressure Product double product Signs of an acute MI EKG ST elevation RPP Heart Rate HR x Systolic Blood Pressure SBP Symptomology myocardial infarctions indigestion etc Cardiac biomarkers levels of myoglobin troponin I LDH total CK CK MB Difference between MIs Acute MI recently happened Major MI larger MI Depression comes before elevation Clinical exercise ECG GXT p 128 p 144 Box 6 1 Insult the myocardium Want to evoke abnormal BP ischemia etc in order to decide what test to give based on level of fitness bad hip etc 85 max age HR enough effort 220 age APMHR Age Predicted Max Heart Rate ECG 1 mL depression horizontal etc Stop at 2 mL BP systolic BP should increase with workload Silent ischemia no symptoms Diastolic BP should be stable 10 mL mmHg at rest Gas exchange ventilatory response Best predictor of mortality Arterial blood gases VO2 METs indirect or estimated 1 MET 3 5 mL min of oxygen per kg of body weight per minute 5 METs are needed for ADLs Activities for Daily Living 1 MET rest 10 METs sedentary college female 12 METs sedentary college male Btwn 12 14 METs for work pretty low mortality despite other problems MET metabolic equivalent One MET is a big deal in a clinical setting ability to function etc RPE other scales RPE Rating of Perceived Exertion 6 to 20 Borg Scale p 80 Not as good overall level of fatigue perception of effort RPE 0 to 10 scale Better than 6 to 20 scale Angina Scale p 132 1 mild barely noticeable 2 moderate bothersome 3 moderately severe very uncomfortable 4 most severe or intense pain ever experienced Dyspnea shortness of breath p 132 1 to 4 scale Limiting factor in COPD or asthma patient Claudication leg pain p 132 Grade 0 no pain Grade I definite discomfort or pain Grade II moderate discomfort Grade III intense pain Grade IV excruciating Signs Symptoms Clinical Exercise ECG radionuclide imaging Exercise Nuclear Imaging p 134 Angina Anesthesia surgery MI damage might be combined with other tests diagnostic modalities such as echocardiography or Might need use pharmacological test to insult myocardium especially if too unfit Symptoms after treatment for CAD Use thallium instead of EKG b c of lack of blood flow Thallium is a tracer picked up by blood Thallium is much more sensitive of a test Compare to at rest vs active detect defect cardio light Ischemia defect shows up hours later Old MI nachrosis defect immediately post hours later 1 2 weeks post MI ischemia around nachrosis defect immediately post hours later Where arrhythmias can start irritable Pharmacologic Test p 135 Can t exercise Vasodilator adenosine or dipyridamole Positive inotropic chronotropic dobutamine Low sensitivity always combined with imaging May be combined with light exercise Echocardiogram structural hemodynamics p 134 Heart valves Congenital heart disease Pericarditis Endocarditis Pumping function Source of blood clot TEE transesophageal echocardiogram Electron Beam Computed Tomography EBCT Heart Scan coronary calcium scale p 136 Angiogram detect blockage Autopsy detect plack etc ECG Akinetic wall is not moving MOST severe Diskinetic impaired irregular Hypokinetic wall is moving fast LEAST severe Indications Applications Clinical Exercise Testing Diagnostic do they have the disease or not Prognosis how bad is it Pre post discharge therapeutic Functional VO2 or METs can be pre or post discharge Many times GXT ing is done for more than one reason identified above including for the purpose of Ex Rx Why we do diagnostic exercise testing p 115 table 5 1 Remember Exercise electrocardiography for diagnostic purposes is less accurate in women largely because of a greater number of false positive responses Clinical ECG testing has its best predictive validity for people with intermittent pre testing for disease multiple risk factors but asymptomatic Pretest Clinical probability of CAD P 116 figure 5