PET3932 SECTION 02 CUMULATIVE FINAL STUDY GUIDE Ch 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 exercise test results Handouts 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 throughout this study guide Looking for underlying Coronary Artery Disease this is what will be further discussed 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 Primary modifiable these are factors that can be changed Male gender Family Hx 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 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 More than twice the risk as someone below 200 mg dL 240 mg dL Lower risk 200 mg dL Borderline high risk 200 239 mg dL HDL cholesterol good cholesterol high density lipoproteins HDL carry cholesterol in the blood from other parts of the body back to the liver helps keep cholesterol from building up in 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 ST segment depression p 149 Ventrical repolarization electrical recovery repolarization of the ventricles 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 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 infarctions indigestion etc EKG ST elevation Cardiac biomarkers levels of myoglobin Mb troponin I LDH lactate dehydrogenase total CK creatine kinase CK MB Difference between MIs Acute MI myocardial infarction recently or suddenly happens 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 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