UMC 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 also the drawing in
O’Sullivan p.476). 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 (Pattern 6D). Also associate different categories of
drugs with their modulation of these 3 elements of pump mechanics.
*Error in Figure 6-8 on p.138 in DeTurk: the labeling of Tricuspid and Semilunar should be reversed /
swapped
2.
Describe congenital heart defects. Describe heart disease that may be acquired in infancy and childhood.
Recognize that these acquired diseases 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 musculoskeletal, neuromuscular, or integumentary problems (ACSM C.2)
4.
Review the etiology, pathophysiology, and clinical symptoms of coronary artery disease.
5. Review steps in a clinical examination 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.
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: “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 sex differences (see obj. #20). Figure 6-5 on p.131 illustrates a partial thickness event
that has occurred on the epicardial layer. The more common occurrence is 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.
10. Describe the continuum of myocardial involvement: ischemia, injury, and infarction, and the resulting zonal
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impairment of wall motion, electrical conduction, and rhythm. Draw and label a picture that would be used to
explain this to a patient.
[Figure 6-5 on p.131 is a poor model. Instead, refer to O’Sullivan p.493.]
11. Explain the pathologic changes that occur in an MI. and the functional variations that occur when different
arteries are blocked. Recalling the different layers of the heart muscle, differentiate subendocardial and
transmural infarction, and how they may affect an exercise program. Explain how an uncomplicated MI patient
may convert to a complicated case; recognize how activity and exercise may contribute to pathologic changes.
12. Review an ECG strip and calculate HR. Describe or recognize basic changes in the ST segment that can occur
during ischemia. Recognize a PVC, and use the number occurring per minute and grouping characteristics as a
guide to safe exercise.
13. Explain the significance of laboratory test measures of cardiac enzymes that help confirm MI. (DeTurk p.308,
O’Sullivan p.494, 498)
14. Describe basic principals of pharmacology (Bill Morrissey’s lecture). 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: p.190-1: T8-1, F8-1
 Hyperlipidemia: p.194: T8-2
 Anti Clotting: p.196: T8-3
 Nitrates: p.209: T8-7 (primarily vasodilation of peripheral smooth muscle to reduce Preload)
 Antiarrhythmics: p.210: T8-8
 Heart Failure: p.211: T8-9
15. Briefly describe information obtained from the following diagnostic procedures:
 Cardiac catheterization or coronary angiogram, p.303
 Chest radiograph, p.308 (define radiopacity, radiolucency)
 Echocardiogram, p.303
 Exercise Tolerance Test (ETT); Stress Test; Graded Exercise Test (GXT)
o active OR pharmacologically induced (using adenosine, dobutamine, dipyridamole, or persantine)
o with or without Perfusion Testing (radionuclide study) using Thallium or Technetium (Sestamibi)
o (p.309, 312-322)
 Ambulatory ECG (telemetry); 24 hour Holter monitor; Telephonometry
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.
17.
Describe indications for, and the procedure for accomplishing coronary angioplasty (PTCA). Draw or
describe a stent and explain its use.
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.
Appreciate the impact of managed care on the eligibility and reimbursement of Phase 2 Cardiac
Rehabilitation, e.g. in 2006, CHF became an eligible condition.
See: DeTurk p.5-7, p.9-10 (turf wars), p.518- 522; O’Sullivan p.497-502; Sharon Coffman syllabus p.12
19.
Describe changes to the cardiovascular system that occur with aging. Discuss how typical changes may
affect exercise response. (Bottomley p.51-4)
20.
Explain how changes associated with menopause relate to cardiovascular function. Discuss implications of
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findings by the WOMENS HEALTH INITIATIVE regarding hormone replacement therapy. Appreciate
current findings in the field of sex-based biology (see obj. #9). (Refer to 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). Sharon Coffman syllabus p.12
Compare acute rehab goals for the post CABG patient vs. the post MI patient.
23.
Identify S/S that preclude the initiation or continuation of an exercise session for a patient with CAD,
arrhythmia, CHF, or heart transplant. (DeTurk p.361-367, F12-4, p.525-6; course website)
24.
Review the etiology, pathophysiology, and clinical symptoms of Cardiac Pump Dysfunction and Pump
Failure, Pattern 4D (Congestive Heart Failure, Cardiomyopathy, Cardiac Muscle Dysfunction). Given a
patient description, determine a New York Heart Association (NYHA) classification (p.279). Describe
characteristics of an exercise program for this population, including possible use of an Inspiratory Muscle
Trainer (IMT) p.522-4. Also see Sharon Coffman’s syllabus: p.13-14.
25.
Considering that the 200-age formula overestimates 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 50% - - - 80% + Resting HR
Understand the Rate Pressure Product (RPP) as an indicator of myocardial oxygen consumption, and therefore a
useful measure for the patient with stable angina
o RPP = SBP x HR (drop the last 2 digits of the 5 digit number)
Calculate or interpret:
o Borg 12-13 – “Somewhat Hard” = 60% HR Max
o Borg 16 – “Hard – Very Hard” = 85% HR Max
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 or heart-lung transplant. Demonstrate awareness regarding
differences in exercise response and ECG tracings in the case of a transplant. Describe differences in
exercise prescription for heart transplant patient.
28.
Identify typical psychological issues related to heart disease, and possible 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.
29.
Identify conditions for which pacemakers are commonly prescribed. Regarding pacemaker codes: be aware
there are 2 systems: the NASPE / BPEG coding system described in ACSM on p.188-191, appears to be in
more common usage than the ICHD coding system given in DeTurk (p.354).
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.106, DeTurk p.138-9
MSH_EP_MUPT 85, 00, 01, 03, 05, 06
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