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MU PT 7890 – Case Management I
Monitoring Cardiovascular and Pulmonary Signs & Symptoms.
Abnormal Vital Signs can occur:
 At resting
 In response to activity
 As a delayed return to baseline after activity has ended
PT intervention must be adjusted, and exercise prescription titrated in response to:
 Elevated Vital Signs beyond target range
 RPE beyond determined safe range
 Pt. verbalization of distress
 Therapist’s observation of pt’s. distress
 Any other measurable or observable cardiopulmonary S/S such as:
o CHF / Pump Failure: tachycardia, dyspnea, fatigue orthopnea, incr LE edema, wt gain > 2-3# / day,
JVD, rales / crackle, S3 heart sound (RIR HR)
o CAD: angina, diaphoresis, pallor, nausea, confusion, dizziness, pt. denial, fatigue, claudication,
previously consistently Regular HR becomes Irregular, (ECG: ST depression)
o SBP fails to rise, or it decreases significantly (10-20) in response to activity (r/o the “pre-exercise
nervousness effect”). Sign of acute heart pump failure. Sometimes referred to as “cardiac
decompensation”.
o Note that HR response to activity can be blunted by:
 Beta Blockers (also lowers resting HR). Rely more on BP and RPE
 Normal effect of aging
Remember: interpreting CV response as either normal, abnormal or dangerous is MULTIFACTORIAL
1. Number of risk factors / history (Risk Stratification: see ACSM, 7th edition, p.21-34)
2. Number and type and dosage level of cardiac meds (Beta Blocker?)
3. Vital signs (before, during, after) [For post vitals, check HR first because it will change the fastest]
4. Patient report
5. Your observations
Responding to Cardiac Distress Scenarios your next actions will be to:
a. Stop testing; call 911; retrieve the AED; monitor vitals continuously; document IF:
 No respiration or pulse – start CPR
 Non-stable angina NOT RELIEVED with Nitro
 No angina, but PERSISTENT patient symptoms: diaphoresis, pallor, nausea, confusion, ataxia,
dizziness, (dyspnea > 3/10), NOT relieved with rest
b. Stop testing; monitor vitals q 5 minutes; call the PCP to report findings and solicit guidance IF:
 Significant report of symptoms: angina, diaphoresis, pallor, nausea, confusion, ataxia, dizziness,
(dyspnea > 3/10) that is RELIEVED with rest
c. Monitor q 5 minutes; document; FAX vital signs to PCP after the screening has ended IF:
 Abnormal vital signs that stabilize with rest (or if elevated resting BP). No major or persistent patient
symptoms
Monitor vital signs before during and after each test. If there is an untoward vital sign response, continue
monitoring and documenting every 5 minutes until SBP returns to within ~10-20mm of pre-exercise, and also HR
returns to within ~10-20 bpm of pre-exercise. Note heart rhythm pre and post, especially if changes from regular
HR in pre-exercise to irregular HR in post-exercise period.
Angina differential diagnosis:
o Location
o Description: described as dull & constant, not as throbbing or sharp
o Aerobic activity: makes it worse (distinguished from musculoskeletal activity / tissue tension testing /
palpation)
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o
o
o
o
Deep Breath: should not make angina worse vs. pleural friction rub, intercostal mm, restrictive causes
(thoracotomy)
Position: no position of comfort / relief if angina
Nitro: relieves … unless massive MI!
Gall bladder, spleen, pancreas, kidney can all refer to the ipsilateral shoulder area
initiate
In the presence of
Cardiac
Pump
Failure
OK to
when
Speaks s dyspnea & RR <30
Rales < ½ lungs
HR < 120
Cahalin 1996
(DeTurk p.526)
initiate if
Do not
HR < 40, > 130
SBP > 180
DBP > 100
RR > 35
Cahalin 1994
(O’Sullivan, 4ed. p.506)
terminate








Modify or
if …
Dyspnea > 3/10 “Moderately SOB”
RR > 40
S3 heart sound appears
New / increased crackles
Pulse pressure < 10 (SBP-DBP)
HR or BP decreases > 10 (be aware of
pre-exercise jitters)
Incr. Supraventricular and ventricular
ectopy
angina, diaphoresis, pallor, nausea,
confusion, ataxia, dizziness
Cahalin 1996 (DeTurk p.526)




SBP > 220
DBP > 110
SBP decreases > 20 (be aware of preexercise jitters)
Significant change in rhythm
ACSM 4ed. (O’Sullivan 4ed. p.490)
Normals
with a low # of
Risk Factors






SBP decreases 20
SBP > 260
DBP > 115
HR does not increase with exercise
Angina, diaphoresis, pallor, nausea,
confusion, ataxia, dizziness
Significant change in rhythm
ACSM 6ed. p.80
Determining Maximum or Target HR (THR)
As you know, the traditional method of calculating HR max: 220 – age, has large standard errors of prediction. It is
most valid for a person 40 years old. It gives too high a prediction for those younger, and it gives too low a
prediction for those older. With that as a caveat, ACSM still describes its use.
Alternatively, the Heart Rate Reserve (HRR) “Karvonen” method can be use to calculate Target HR.
HRR = [(HR max – HR rest) x ___ %] + HR rest
Correspondence of 2 methods of THR calculation to Borg RPE
% of HRR
% of 220-age
RPE
40-59
55-69
12-13
60-84
70-89
14-16
13 = Somewhat Hard
15 = Hard
ACSM 6th ed. p.150, adapted from Pollock 1998
Also see DeTurk p.66, Table 3-8
Healthy Vital Sign Response:
Healthy adult men < 55 years old (n = 700) exercising at 66% of maximal effort (13 RPE “Somewhat Hard”) demonstrate a
rise of:
 SBP ~ 32
 HR ~ 50
ACSM 6ed. p.118, Wolthius 1977
Healthy SBP increase related to METs
For healthy persons, SBP will rise in a linear fashion with exertion: 7-8 mm Hg rise for every MET level of work
above the basal MET level of 1-2 METs.
Hillegass p.512 - from ACSM 3rd ed.
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Predictors of successful CHF rehab:
 Resting HR < 90 bpm
 Rise in HR of > 50 bpm during exercise testing
 Rise in SBP > 10mm during exercise
 Pulse Pressure (SBP – DBP) > 10mm
 VO2 Max > 10 ml/kg/min (~ 3 METS)
A reduction of CO with exercise indicates person is unlikely to improve with aerobic training.
DeTurk p.530 (multiple sources)
Formula for predicting VO2 Max, based on 6MW distance:
Peak VO2 = 0.03 x distance (meters) + 3.98
Example: 300 m (a threshold value for long term survival) 0.03 x 300 + 3.98 = 12.98 ml/kg/min (3.7 METS)
DeTurk p.28, p.321-322
Requesting Patient Records
o PT is responsible (liable) to solicit results of most recent GXT from Cardiologist or PCP if history or S/S
suggest active disease.
o Also solicit EF, or NYHA classification for known CHF or suspected CHF.
It is not unusual for an official diagnosis of CHF to NOT be included in a patient’s medical history. IF you think a
patient has the profile of congestive heart failure (ankle edema, dyspnea at rest or with minimal exertion, S3 heart
sound, crackles in lower lobe of lungs), THEN auscultate lung bases for adventitious breath sounds both pre and
post exercise! Also auscultate heart rhythm apically to detect S3 heart sound.
Normal, expected response to exercise (submaximal, 13/20 RPE on Borg) would be:
 Rise in SBP > 20-30 mm -- Prost
 SBP returns to ~10-20 mm of pre-exercise rate within 5 minutes of stopping, & sitting in the chair -- Prost
 HR returns to ~10-20 bpm of pre-exercise within 5 minutes of stopping, & sitting in the chair -- Prost
In the absence of 12-lead ECG graded exercise test
 Keep exercise HR < 130 bpm – Coffman (Remember that the original Borg numbers were equivalent to the
HR divided by 10, e.g. 130 bpm divided by 10 = 13 RPE “Somewhat Hard”)
 Keep HR 10 bpm below level of stable angina occurrence.
 Keep HR 10 bpm below rate at which a pacemaker internal defibrillator is activated
 Calculate target HR using HRR method or 220-age. For persons with risk factors, start at 50-60% of Max
(see Table above: ACSM 6th ed. p.150, adapted from Pollock 1998)
 Rely more on RPE
Effects of Aging on HR
 Resting HR in the elderly is no different than resting HR in normal, young population
 In the elderly population, HR response to exercise can be less brisk (therefore use a longer warm up and
cool down), and also will not rise to as high of a maximal HR (compared to young normal),
 In the absence of graded exercise stress test results, keep exercise HR under 130bpm (Coffman).
 NOTE IF PARTICIPANT IS TAKING A BETA BLOCKER: this will blunt their HR response to exercise,
therefore HR is not a reliable measure. Rely on Borg RPE scales and BP response.
 Heart Rate Reserve (HRR) or Karvonen method yields more appropriate target HR for the elderly:
HRR = [ ((220-age) – Rest HR) x ___% ] + Rest HR (Bottomley p.454, and elsewhere)
For pacemakers without “R” rate modulation feature, substitute SBP for HR (ACSM 6th edition p.189-190)
Billek-Sawhney. JOSPT 1998 (n=68)
62% of OPPT orthopedic patients had secondary cardiovascular disease
Think about the increased ENERGY EXPENDITURE of the following orthopedic activities:
 Partial WB amb, post op
 BKA amb (c/s AD)
 TKR AAROM
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Bottomley, p.184 -- see concept of RESERVE CAPACITY as applied to the cardiovascular system
Misc:
When referring to ACSM, remember that most ACSM testing guidelines are for ECG testing. These may be done
at a submaximal RPE, or at a maximal RPE. Tests of maximal capacity (the cardiologist may be present) intend to
induce ischemia or an ectopic beat, for diagnostic purposes. The goal is to observe for any abnormalities when at a
maximal stress load, e.g. ST depression on an ECG, or poor perfusion on a radioisotope scan (Thallium or
Technetium-Sestamibi). This is of course a very different situation than the clinic!