CARDIAC ASSESSMENT
Cardiovascular Assessment
1.
2.
3.
4.
The medical chart review;
Patient/family interview;
Physical assessment,
Precautions and contraindications
1. MEDICAL CHART REVIEW
1.
Diagnosis and date of event
2.
Symptoms on admission and
after the patient’s admission
3.
Other significant medical
problems in the past medical
history
6. Relevant social history,
including smoking, alcohol and
drug
7. Oxygen therapy and other
respiratory treatment
8. Clinical laboratory data
4.
Current medications
9. Radiological studies
5.
Risk factor for cardio\vascular
and pulmonary
10. Surgical procedures
MEDICAL CHART REVIEW
Other therapeutic regimens
Other diagnostic tests
Electrocardiogram and
Vital signs
telemetry monitoring
Pulmonary function test
Arterial blood gases
cardiac catheterization data
Hospital course since admission.
Occupational history
Home environmental
assessment
2. Patient/family interview
• establishing relation with the patient and family,
• discerning their level of understanding of the medical
problem(s), and
• their goals and expectations for rehabilitation.
Typically, interview questions should be open ended
and straightforward. For example
• What
prompted you to come to the hospital/seek physical therapy?
• Do you ever have problems with shortness of breath, chest pain or
discomfort, lightheadedness or dizziness, getting tired easily, palpitations,
etc.?
• Do you experience any type of discomfort or pain with exertion? If it
occurs during ambulation, at what distance, speed, or incline? What about
stairs?
• Can you describe your symptoms for me?
• What brings on your symptoms? What kinds of things
are you doing immediately before or at the time of the
onset of your symptoms?
• Are your symptoms aggravated by certain positions,
such as lying flat or on one side or the other?
• How long have you had these symptoms?
• Do the symptoms interfere with things you would like to
do? Such as?
• Have you discovered any ways to relieve the symptoms?
• What has your doctor told you about your problem?
• Have you ever received physical therapy for this problem
or any other problem?
• Have you ever smoked? How much and for how long?
• What would you say your major difficulty is right now?
• What would you like us to work on before you go home?
• What are your goals for your recovery?
3. Physical examination
1)
Examine pulse
2)
Examine heart sound
3)
Examine heart rhythm
4)
Blood pressure
5)
Rate and depth of respiration
6)
Oxygen saturation
7)
Examine pain
3. Physical examination
• General
appearance Obesity, cachexia, barrel-shaped chest, signs of
breathing difficulty (e.g., tachypnea, use of accessory muscles of
respiration, intercostal retractions)
• Vital
signs increase or decrease heart rate, blood pressure, or
respiratory rate; presence of fever
• Skin
Cold and clammy in low-cardiac output states; pale, blue, and
cold if peripheral vasoconstriction;
• Cyanosis
(peripheral or central) if marked arterial hypoxemia; or
xanthomas in familial hypercholesterolemia
• Head, eyes, ears, nose, and throat (HEENT)
• Abnormal funduscopic eye examination (e.g., retinal arteriolar changes
in hypertension HTN and DM)
• Abnormal neck examination (e.g., jugular venous distension in right or
biventricular heart failure, exaggerated venous pulse waves in
pulmonary HTN or right-sided valvular disease, or prominent carotid
pulsations in aortic incompetence)
• Signs of upper respiratory infection (which might be seeding lower
respiratory tract)
• Chest, lungs Abnormal chest examination (e.g., decrease chest or
diaphragmatic excursions in chronic obstructive pulmonary disease,
prominent pulsations in cardiac hypertrophy, thrills in valve disease)
• Abnormal breath sounds (e.g., decreased, bronchial, or adventitious
breath sounds
• Cardiovascular Abnormal
heart sounds (e.g., murmurs in valvular
disease, third and/or fourth heart sounds
• if
diastolic dysfunction or reduced ventricular compliance, friction
rubs in pericarditis
• Abnormal
peripheral pulses (e.g., decreased if atherosclerotic
disease or aortic stenosis, bounding in aortic incompetence)
• Abdomen
Enlarged liver and spleen, ascites in right heart failure
• Extremities Abnormal
digital clubbing)
extremity examination (e.g., peripheral edema,
Sign or Symptom of Cardiovascular diseases
• Chest
pain or discomfort due to mismatch between myocardial oxygen
supply and demand (due to coronary disease, LV hypertrophy, LV outflow
obstruction, coronary spasm, microvascular angina), autonomic dysfunction, MV
prolapse
• Claudication due to peripheral arterial disease with mismatch between
peripheral O2 supply and demand
• Clubbing
of digits due to right-to-left shunting in congenital heart disease
• Cough due to acute pulmonary edema, MS
• Cyanosis due to right-to-left shunting in congenital heart disease, significant
decrease cardiac output
• Dizziness due to inadequate cardiac output resulting in # perfusion of the
brain (due to LV dysfunction, LV outlet obstruction, arrhythmias, blood
pooling in lower extremities)
• Dyspnea due to pulmonary venous pressure caused by LV diastolic or
systolic dysfunction (due to coronary ischemia, hypertension, valvular
disease, cardiomyopathy), peripheral arterial disease with lactic acidosis
• Edema due to " Systemic venous pressure due to " RA pressure (e.g.,
LV failure, MS, cor pulmonale, TS, TR, constrictive pericarditis)
• Fatigue due to low cardiac output (due to LV dysfunction, LV outlet
obstruction, arrhythmias), drugs
• Hemoptysis due to acute pulmonary edema, MS
• Hypotension due to decrease cardiac output, vasodilation
• Jugular venous distension due to increase systemic venous
pressure caused by increase RA pressure (see preceding entry for
Edema)
• Nocturia due to CHF with peripheral edema
• Orthopnea In CHF, SOB when lying flat due to increase pulmonary
venous pressure caused by increase venous return to heart, which is not
able to handle increase workload
• Palpitations due to arrhythmias
•
Paroxysmal nocturnal dyspnea In CHF, sudden onset of SOB that awakens patient
at night because of " pulmonary pressures caused by the gradual reabsorption of
edema fluid from the LEs (which are no longer dependent), resulting in " venous
return to heart, which is not able to handle " workload
Functional Classification of Heart Disease
Functional Classification, Exercise Tolerance, Description Approximate
 I (6 –10 METs) Patient with cardiac disease but without any resulting
limitations of physical activity; ordinary physical activity does not cause undue
fatigue, palpitations, dyspnea, or anginal pain
 II (4–6 METs) Slight limitations of physical activity; comfortable at rest, but
ordinary physical activity results in fatigue, palpitations, dyspnea, or anginal
pain
 III (2–3 METs) Marked limitation of physical activity; comfortable at rest, but
less than ordinary physical activity causes symptoms, as above
 IV (<2 METs) Unable to carry out any physical activity without discomfort;
symptoms of cardiac insufficiency or of angina may be present even at rest; if
exertion is undertaken, discomfort increase
Absolute Contraindications
1.
Unstable or rest angina
2.
A recent significant change in the resting ECG suggesting
significant ischemia or recent MI
3.
Dangerous arrhythmias causing symptoms of hemodynamic
changes
4.
Symptomatic CHF/pulmonary edema
5.
Suspected or known dissecting aneurysm
6.
Severe aortic stenosis
Absolute Contraindications
• Acute pulmonary embolus or pulmonary infarction
• Uncontrolled diabetes mellitus
• Uncontrolled HTN: Resting SBP >200 mm Hg and/or resting DBP
>110 mm Hg
• Persistent hypotension after MI (SBP <90 mm Hg)
• Acute systemic infection, accompanied by fever, body aches, or
swollen lymph glands
• Acute pericarditis or myocarditis
High-risk level
• Severely depressed LV function
• Presence of angina or other significant symptoms at low levels
of exertion (<5 METs) or during recovery
• Presence of abnormal physiological responses with exercise
testing
• High level of silent myocardial ischemia
• History of complex ventricular arrhythmias at rest or appearing
or increasing with exercise
• History of cardiac arrest or sudden cardiac death
• Complicated or high-risk MI or revascularization procedure
• (e.g., anterior infarction, large infarct size, infarct extension,
congestive heart failure [CHF], cardiogenic shock, and/or
complex ventricular arrhythmias)
• Presence of congestive heart failure
Low-risk level
• Individuals with a history of a cardiac abnormality
• Presence of normal physiological responses and functional
status of at least 7 METs (metabolic equivalents for energy
expenditure) on exercise testing
• No history of myocardial ischemia or other significant symptoms
of exercise intolerance (unusual shortness of breath,
lightheadedness, or dizziness) during exercise testing and
recovery
• No history of resting or exercise-induced complex arrhythmias
• No history of congestive heart failure
• Status/post uncomplicated MI or revascularization
procedure
• Absence of clinical depression
Intermediate-risk level
• Mildly to moderately depressed LV function
• Presence of angina or other significant symptoms of exercise
intolerance only at high levels of exertion (less than 7 METs)
• Mild to moderate level of silent ischemia during exercise
testing or recovery (<2-mm ST-segment depression from baseline)
• Functional capacity less than 5 or 6 METs on graded
exercise test 3 or more weeks after MI.
• Failure to comply with exercise intensity prescription.
Cardiovascular Diagnostic Tests and Procedures
1) Arterial blood gases (ABGs)
• Is oxygenation normal (Pao2 >80 with O2 saturation [SaO2] >97%)
or adequate (PaO2 >60 with SaO2 >90%)? If SaO2 <85%, exercise is
usually contraindicated.
• Are PaCO2 and pH within normal limits (35–45 mm Hg and 7.35–
7.45, respectively)?
• Are alterations acute or chronic ?
• Was the patient receiving supplemental oxygen when the ABGs
were drawn?
• Does the patient need oxygen during treatment?
2)Cardiac catheterization
 Are the chamber and vessel pressures normal?
 Are there any gradients across the valves?
3) Ventriculography
 Is ventricular performance normal (EF >40%–50%, normal wall
motion)?
 Is there evidence of valvular regurgitation?
4) Angiography
 Are there any obstructions in the coronary arteries?
 If so, how many, in which vessels, and to what degree? Are coronary
artery bypass grafts patent?