MU School of Health Professions
Department of Physical Therapy
PT 7890 Case Management I
Objectives: Cardiovascular Rehabilitation
1. A&P: Describe blood circulation through the heart pump, including the name, and timing of valves in the
cardiac cycle*. Relate the closing of valves to the 1st and 2nd heart sounds. Define End Systolic Volume (ESV),
End Diastolic Volume (EDV), Stoke Volume (SV), Ejection Fraction (EF), Cardiac Output (CO). Relate EF,
SV, EDV and CO values to the presentation of a failing heart pump. Draw the layers of the heart muscle from
superficial to deep. Review coronary artery names, location, and the structures they supply, appreciating
anatomic variants, particularly of the RCA and the circumflex artery (see drawing in O’Sullivan p.591, also
Coffman syllabus p.23). Draw and label a picture that would be used to explain location of a blocked coronary
artery to a patient. Explain the electrical conduction systems in both lay and technical terms and correlate
electrical events to the ECG waveform (the cycle of depolarization and re-polarization to different zones of the
heart). Define preload, afterload, contractility, and appreciate their interplay in describing heart pump
function, both normal and in pump dysfunction / failure (Guide Practice Pattern 6D). Also associate different
categories of drugs with their modulation of these 3 elements of pump mechanics. Hillegass C.2.
2.
Describe congenital heart defects. Describe heart disease that may be acquired in infancy and childhood,
realizing that acquired cardiac diseases or impairments may be compatible with life, and that cardiopulmonary
impairments may go unrecognized until adulthood (when they could manifest as CHF, Pulm HTN, Angina,
Syncope, Arrhythmias).
3.
List and explain the significance of risk factors for heart disease (modifiable and unmodifiable). Explain how
risk factor analysis would affect your treatment of a patient who does not have a history of heart disease.
Explain how risk factor analysis would affect your treatment of a patient who has a history of heart disease, but
is referred to PT for some other problem. Hillegass p.717-718, 693, also ACSM
4.
Review the etiology, pathophysiology, and clinical symptoms of coronary artery disease (CAD). Hillegass C.3
5. Review steps in a clinical examination and differential diagnosis for shoulder pain; differentiate musculoskeletal
signs and symptoms from visceral (myocardial) signs and symptoms. Discuss the possible relationship between
visceral pain and shoulder/arm/hand pathology.
Goodman: Physician referral: p.318-320; Overview: Cardiac Chest Pain Patterns: p.321-325; Key Points to
Remember: p.325; Subjective Examination: p.326-327. Also p.805-813
6. Outline departmental emergency preparation, including drills, crash cart, and individual responsibilities, for
inpatient vs. outpatient settings. Include protocol for caring for patient, significant others. (Sharon Coffman
syllabus p.17: “Distress and emergency measures: Code Lab)
7. Explain implications of calling 911: first responders, ambulance; ethical or legal questions regarding patient/family
wishes; reimbursement for services.
8. Perform CPR and use AED appropriately.
9. Define and describe 4 types of angina pectoris or coronary insufficiency, and the appropriate clinical response to
each situation. Describe how the experience of angina may differ for women. Hillegass p.97-98, p.642-643.
Goodman p.780-781
Calculate the Rate Pressure Product (RPP) as an indicator of myocardial oxygen demand (MVO2). RPP is most
useful for the patient with stable angina, i.e. titrate exercise intensity so that the RPP is below the anginal
threshold. Remember, RPP is not normed, and is only applicable to that individual. RPP = SBP x HR (drop
the last 2 digits of the 5 digit number)
10. Describe the continuum of myocardial involvement: ischemia, injury, and infarction, and the resulting zonal
impairment of wall motion, electrical conduction, and rhythm. Draw and label a picture that would be used to
explain this to a patient.
O’Sullivan p.605, also, Hillegass p.413 shows a subendocardial event, which occurs from the inside out. The
subendocardium is the most distal to the coronary artery circulation, and perforating veins pass through the
myocardium to reach it.
11. Explain the pathologic changes that occur in an MI. and the functional variations that occur when different arteries
are blocked.
Hint: see Sharon Coffman’s syllabus p.23 (at the bottom of the page) “Related Signs and Symptoms”, to help you
categorize your responses. Look at the anatomic areas supplied by the different arteries.
Recalling the different layers of the heart muscle (obj. #1), differentiate subendocardial (Hillegass p.413 Fig 9-51C) and transmural infarction (O’Sullivan p.605 Fig. 16-10), and how they may affect an exercise program.
Recognize how activity and exercise that is too aggressive may contribute to pathologic changes.
12. Review an ECG strip and calculate HR. Describe or recognize basic changes that can occur during ischemia,
injury, and infarct. Recognize a premature ventricular contraction (PVC), and use the number occurring per minute
and grouping characteristics as a guide to safe exercise. See O’Sullivan p.602-605, Fig 16.10.
Five big boxes = 1 sec. Count 6 seconds, then count the number of QRS spikes within 6 seconds and multiply by
10. Hint: try to pick a QRS spike that falls close to a line as your starting point. Only count the normal QRS spikes
to arrive at the bpm.
13. Pharmacology: Define pharmacokinetics, pharmacodynamics. Describe the major categories of pharmaceuticals
used to manage cardiovascular disease, give one example of each, state the anticipated beneficial effect, and
possible side effects affecting an exercise program. Define and give an example of a positive inotrope and a
negative chronotrope.
 Antihypertensives
 Hyperlipidemia
 Anti Clotting
 Nitrates (cause vasodilation of peripheral smooth muscle to reduce Preload)
 Antiarrhythmics
 Heart Failure:
14. Briefly describe information obtained from the following diagnostic procedures:
(see Hillegass C.8 reading assignment)
 Cardiac catheterization or coronary angiogram
 Cardiac Enzymes: CPK, LDH, Troponin
 Echocardiogram
 Exercise Tolerance Test (ETT); Stress Test; Graded Exercise Test (GXT)
o active OR pharmacologically induced using adenosine, dobutamine, or dipyridamole (persantine)
(incidentally, persantine is also prescribed for Platelet Aggregation Inhibition)
o with or without Perfusion Testing (radionuclide study) using Thallium or Technetium (Sestamibi)
 Ambulatory ECG (telemetry); 24 hour Holter monitor; Telephonometry
15.
Explain etiology, and possible S&S of a dissecting aortic aneurysm.
16.
Apply specific information about how ejection fraction, cardiac output, and segmental heart wall motion may be
important when developing a patient’s exercise program. Apply these measures to the NYHA CHF functional
categories
17.
Describe indications for, and the procedure for accomplishing percutaneous transluminal coronary
angioplasty (PTCA). Draw or describe a stent and explain its use. (Coffman syllabus p.23)
18.
Overview Phase I through Phase IV cardiac rehabilitation programs. Provide examples of low energy
activities (in METS) that are appropriate during Phase I. Determine the MET level of stair climbing. List
diagnoses commonly referred for Phase II Cardiac Rehab. Appreciate the impact of managed care on the
eligibility and reimbursement of Phase 2 Cardiac Rehabilitation.
O’Sullivan p.616-622; Sharon Coffman syllabus p.12, Hillegass p.682
19.
Describe changes to the cardiovascular system that occur with aging. Discuss how typical changes may affect
exercise response. (Bottomley p.32-34, Hillegass p.716-717)
20.
Explain how changes associated with menopause relate to cardiovascular function. Discuss implications of
findings by the WOMENS HEALTH INITIATIVE regarding hormone replacement therapy. Survey current
findings in the field of sex-based biology as related to cardiovascular disease (course website).
21.
Recognize effects of emotional stress on the heart. Recommend relaxation exercises appropriately.
(Kisner & Colby p.196-7: Relaxation Training)
22.
Recognize why a coronary artery bypass graft (CABG) operation is performed. Describe the surgery,
sources of graft material, post-op precautions for exercise. Outline physical therapist involvement with a
CABG patient in a routine case vs. one with complications, (including airway clearance and maintenance of
lung volumes). Compare acute rehab goals for the post CABG patient vs. the post MI patient.
Sharon Coffman syllabus p.12, O’Sullivan p.633
23.
Identify S/S that preclude the initiation or continuation of an exercise session for a patient with CAD,
arrhythmia, CHF, or heart transplant.
24.
Review the etiology, pathophysiology, and clinical symptoms of Cardiac Pump Dysfunction and Pump Failure,
Pattern 4D (Congestive Heart Failure, Cardiomyopathy, Cardiac Muscle Dysfunction). Distinguish Left and
Right Heart Failure in terms of etiology and S&S. Given a patient description, determine a New York Heart
Association (NYHA) functional classification. Describe characteristics of an exercise program for this
population.
Hillegass C.3 reading assignment, also Sharon Coffman’s syllabus: p.13-14.
25.
Considering that the 200-age formula overestimates target heart rate (THR) for the young, and underestimates
for the elderly, use the following alternative methods:
o Tanaka et al: HR max = 208 – (0.7 x age)
o Karvonen / Heart Rate Reserve: [HR max – Resting HR] x _____ % + Resting HR
o Borg 12-13 – “Somewhat Hard” = 60% HR Max
o Borg 16 – “Hard – Very Hard” = 85% HR Max
Given patient information, use the Tanaka or Karvonen to calculate THR for a desired exercise intensity
26.
Explain the effects of sexual activity on the heart in terms of MET level and in lay terms by comparing sexual
intercourse to the physical effort involved in other routine activity.
27.
Describe the procedure for heart transplant (orthotopic, the most common). Describe differences in exercise
response and ECG tracings in the case of a transplant. Describe differences in exercise prescription for heart
transplant patient. Hillegass C.12
28.
Identify typical psychological issues related to heart disease, and possible ethnic / cultural variations. State
epidemiology rates for heart disease by ethnic groups. Find resources for patient and significant other’s
questions: prognosis, control of one’s life; return to work; sexuality; fear of sudden death. Develop a position
on PT responsibility to help patient deal with these issues. (AHA website for starters)
29.
Identify conditions for which pacemakers are commonly prescribed. Given a pacemaker code, explain its
function. NASPE / BPEG pacemaker coding system described in ACSM 7 th ed. p.194-197,
30.
Describe the likely etiology, mechanical affects and pathological results of mitral and aortic valve dysfunction,
from stenotic valves and from insufficient/regurgitant valves. Describe medical management.
Bottomley p.71, Hillegass p.114
31. Pulse Oximeter (Sp02): list possible sources of error in the results. Under what circumstance might the PulseOx
show a normal reading, but the person is dyspnic, cyanotic, or poorly perfused?