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PET3932 (SECTION 2): EXERCISE & DISEASEEXAM 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 “Standard graded exercise tests (GXT) are used clinically to assess a patients’ ability to tolerate 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 Emerging risk factors (lipids) Lipoprotein (α) 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: > 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: 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” RPP = Heart Rate [HR] x Systolic Blood Pressure [SBP] Signs of an acute MI Symptomology (myocardial infarctions, indigestion, etc.)  EKG (ST elevation) 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 might be combined with other tests/diagnostic modalities such as echocardiography or radionuclide imaging Might need/use pharmacological test to insult myocardium (especially if too unfit) Exercise Nuclear Imaging (p.134) Angina Anesthesia & surgery MI damage 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

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