MU PT 7890 – Case Management I
Monitoring Cardiovascular and Pulmonary Signs & Symptoms.
A. Abnormal Vital Signs can occur:
1.	At resting
2.	In response to activity
3.	As a delayed return to baseline after activity has ended

B. PT intervention must be adjusted, and exercise prescription titrated in response to: 
1.	Elevated Vital Signs beyond target range 
2.	RPE beyond determined safe range 
3.	Pt. verbalization of distress 
4.	Therapist’s observation of patient’s distress 
5.	ADVERSE CARDIOPULMONARY S/S:
o	Volume Overload - CHF - Pump Failure: tachypnea, dyspnea, orthopnea, fatigue, increased LE edema, wt gain > 2-3# / day, Jugular Venous Distension (JVD), rales / crackles, auscultated S3 heart sound.
o	Ischemia - CAD: angina, diaphoresis (hot-sweaty, but cold-clammy is worse), pallor, nausea, confusion, dizziness, pt. denial, fatigue, claudication, previously Regular HR becomes Irregular, (ECG: ST depression)
o	SBP (or HR) 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”.  The reserve capacity of the heart has been exceeded.  SBP rising excessively is bad, but it is a worse sign if it FALLS.

C. Remember: interpreting CV response as either normal, abnormal or dangerous is MULTIFACTORIAL
1.	Number of risk factors / history  		ACSM, 7th edition, p.22, 25, 27
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

D. Responding to Cardiac Distress occurring during exercise
Scenario #1: abnormally high vitals during exercise that come down when RPE is reduced.  No patient complaint
Your response: Titrate RPE and % THR to a lower level and continue exercising; assess vital signs and tolerance at the 				reduced level; document 

Scenario #2: vital signs drop with exercise, but stabilize with rest.  No patient S&S.
	Your response: Stop exercise; monitor vitals q 5 minutes; document. FAX vital signs to PCP.

Scenario #3: angina (non-stable), diaphoresis, pallor, nausea, confusion, ataxia, dizziness, that is RELIEVED with rest.
	Your response: Stop exercise; monitor vitals q 5 minutes; document.  CALL the PCP to report findings and solicit guidance

Scenario #4: Angina (non-stable) that is NOT RELIEVED with sublingual nitroglycerin  -- OR --
	No angina, but diaphoresis, pallor, nausea, confusion, ataxia, dizziness, NOT RELIEVED with rest.
	Your response: Stop exercise.  Call 911.  Retrieve the AED.  Monitor vitals continuously, document.

Monitor vital signs before during and after each aerobically demanding activity.  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 during, or in the post-exercise period.
E. Angina differential diagnosis:
1.	Location
2.	Description: pressure, squeezing, dull, constant, burning.  Not usually described as throbbing or sharp.
3.	Aerobic activity makes it worse.  Distinguish this from purely musculoskeletal ROM by tissue tension testing and palpation.  There may also be trigger points in the intercostals muscles that can be treated.
4.	A deep breath or cough should NOT make angina worse.  If worse, it may be due to parietal pleura that is inflamed and rubbing (made worse with trunk ROM and rotaton); or it may be an intercostal muscle strain (recent pneumonia or bronchitis with violent coughing episodes); or recent thoracotomy leading to restricted unilateral chest wall excursion (sidebending away from lesion would worsen this pain).  
5.	Position: there is no position of comfort / relief for angina. Autosplinting behavior (lying on the affected side to relieve pain) points to chest wall musculoskeletal lesion, or to parietal pleura inflammation.
6.	Nitro should relieve angina.  But if one pill every 5 minutes (3 pills, in 15 minutes total) does not relieve angina or constitutional S&S (diaphoresis, nausea), it is a massive MI requiring emergency help!
7.	Gall bladder, spleen, pancreas, kidney (organs that may be inflamed, infected or obstructed, that are close to the diaphragm: C5-6) can all refer pain to the ipsilateral shoulder area (C4-6).
F. Interpreting Vital Signs and patient S&S
F.1: When is it safe to BEGIN exercise?
For persons with heart disease do not begin exercise if:
o	Resting SBP > 200 mmHg
o	Resting DBP > 110 mmHg
o	Resting tachycardia > 120 bpm
ACSM  Guidelines for Exercise Testing and Prescription. (2006). 7th ed. p.176, Box 8-1
From: American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR). 2004. Guidelines for Cardiac Rehabilitation and Secondary Prevention Programs. 4th ed. Champaign, IL: Human Kinetics. 36, 119

For persons with congestive heart failure, OK to start if:
o	Speaks w/out dyspnea, and RR < 30
o	Crackles < ½ lungs
o	HR < 120 bpm
DeTurk W. Cahalin L. (2004) Cardiovascular and Pulmonary Physical Therapy: An Evidence Based Approach. New York: McGraw-Hill p.526, Box 17-11.
From: Cahalin LP. (1996). Heart Failure. Phys Ther. 76:5529.

F.2: When should exercise be STOPPED for safety reasons?
For persons with heart disease, stop exercise if:
o	Exercising DBP > 110 mmHg
o	Signs of intolerance, e.g. angina, diaphoresis, pallor, nausea, confusion, ataxia, dizziness, arhythmia
ACSM  Guidelines for Exercise Testing and Prescription. (2006). 7th ed. p.177, Box 8-2
From: American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR). 2004. Guidelines for Cardiac Rehabilitation and Secondary Prevention Programs. 4th ed. Champaign, IL: Human Kinetics. 36, 119

For persons with congestive heart failure, stop exercise if:
o	Dyspnea > 3/10  “Moderately SOB”
o	RR > 40
o	S3 heart sound appears
o	New / increased crackles
o	Pulse pressure < 10 (SBP-DBP)
o	HR or BP decreases > 10 (but also rule out pre-exercise jitters, nervousness)
o	Incr. Supraventricular and ventricular ectopy
o	Angina, diaphoresis, pallor, nausea, confusion, ataxia, dizziness
DeTurk W. Cahalin L. (2004) Cardiovascular and Pulmonary Physical Therapy: An Evidence Based Approach. New York: McGraw-Hill p.526, Box 17-11.
From: Cahalin LP. (1996). Heart Failure. Phys Ther. 76:5529.

F.3: What INTENSITY is appropriate for the NEW cardiac patient (without an Exercise Tolerance Test, ETT)?
Beginning intensity for cardiac patients:
o	RPE < 13/20 (or if deconditioned can start at 10-11 RPE)
o	Post MI (or without an ETT)
•	HR < 120 bpm
•	Rise of 20 bpm over resting HR
•	* 20 bpm is an “arbitrary upper limit”*
o	Post Surgery (CABG):
•	HR < 130 bpm
•	Rise of 30 bpm over resting HR
•	* 30 bpm is an “arbitrary upper limit”*
o	Progress intensity to individual tolerance, if asymptomatic.
Adapted from: ACSM  Guidelines for Exercise Testing and Prescription. (2006). 7th ed. p.175, p.185
G.
 Adult	SBP	DBP	
Normal BP	< 120	< 80	
PreHypertension	120-139	80-89	
HTN - Stage 1	140-159	90-99	
HTN - Stage 2	> 160	> 100	
Seventh Report of the Joint National Committee on Detection Education and Treatment of High Blood Pressure (JNCVI) 2003

H. Ejection Fraction (EF), defines degrees of heart failure:
CHF is quantified by an echocardiogram (US) reading of elevated EDV and decreased SV
•	Mild failure: 40-60% 
•	Moderate failure: 20-40%
•	Severe failure < 20%  
I. Determining Maximum or Target HR (THR)
An Exercise Tolerance Test (ETT), also known as a Graded Exercise Test (GXT) with or without ECG is the gold standard for determining THR.  In the absence of this, formulas may be used.  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.  It more closely approximates the relationship between HR and VO2 Max.  Most valid when used for the normal population.
HRR = [(HR max – HR rest) x ___ %] + HR rest  

J. Correspondence of  Borg RPE to the % of  Target HR 
	Borg RPE 	% of HRR	% of HR Max (220-age)	
Initial conditioning stage	12-13	40-60 %	55-70 %	
Improvement stage	14-16	60-85 %	70-90%	
 			ACSM 7th ed. p.150, 153     Also see: ACSM 6th ed. p.199: Pollock.      Also see: DeTurk p.66, Table 3-8

K. Wolthius: Vitals for Submaximal Exercise:
Healthy adult men 45-55 years old (n = 100) exercising at:
•	70% of maximal effort (HR Max and VO2 Max): caused an ↑ HR 53 bpm, and an ↑ SBP 28 mm Hg
•	89% of maximal effort (HR Max and VO2 Max): caused an ↑ HR 84 bpm, and an ↑ SBP 45 mm Hg			           
Wolthius RA (1977) The response of healthy men to treadmill exercise.  Circulation 55:153:153-157.
L. Healthy Exercise Vitals:
1.	SBP will rise in a linear fashion with exertion, 10 mm for every MET level above the basal MET level of 1-2 METs.	     						Watchie 2nd ed. p.278 - from ACSM 4th ed.
2.	SBP increases 20 mm or more with minimal to moderate exercise.  	Goodman & Snyder 4th ed. p.191
SBP increases 40-50 mm with intense exercise.                      		Goodman & Snyder 4th ed. p.191
3.	Heart rate rises linearly 10 bpm for each MET level			ACSM 7th ed. p.117

M. Normal, post-exercise response
1.	HR returns to pre-exercise level within 3-5 minutes of stopping, & resting – Pierson 2007 (no citation)
2.	SBP returns to pre-exercise level within 5-7 minutes of stopping, & resting – Pierson 2007 (no citation)

N. In the absence of 12-lead ECG graded exercise test
1.	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”)
2.	Keep HR 10 bpm below level at which stable angina occurs.
3.	Keep HR 10 bpm below the rate at which a pacemaker internal defibrillator is activated
4.	Calculate target HR using HRR method or 220-age.  For persons with risk factors, start at 50-60% of Max    
5.	*Note: according to ACSM (7th ed. p.175) increasing 20 bpm is an “arbitrary upper limit” and the person should be progressed as tolerated as long as they are asymptomatic.
6.	Silent ischemia?  Use standing HR at rest + 20 bpm 
	Lauer MS (2002). Exercise testing for assessment of autonomic function.  Am Heart J. 144 (4) 580-582.
7.	Rely more on RPE!

O. Effects of Aging on HR
1.	Resting HR in the normally aging older adult may be lower due to fiber loss in the conduction system (Watchie p.45, Frownfelter p.688)
2.	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).
3.	HR is often not a reliable measure.  Rely more on Borg RPE scales and BP response.
4.	Heart Rate Reserve (HRR) or Karvonen method yields more appropriate target HR for the elderly:             
HRR = [ ((220-age) – Rest HR) x ___% ] + Rest HR                                    (Bottomley 3rd ed. p.348-349)                                                  
For pacemakers without “R” rate modulation feature, substitute SBP for HR          (ACSM 7th  ed.  p.195-196)

P. Beta Blocker medication (-olol) lowers BP and HR.  Resting HR can be as low as 50-60 bpm.  Beta Blockers will blunt HR response to exercise, causing a slow, minimal rise in HR in response to exertion.  In this case it is best to rely on RPE to monitor the effects of exercise.
An important potential side effect of [non-selective] beta blockers is bronchospasm (coughing).  Second generation beta blockers [selective to Beta 1 receptors] do not have this side effect.

Q. Blood Serum Volume changes: 
1.	Dehydration (serum volume loss, or hypovolemia) causes a compensatory increase in HR.
2.	Serum volume overload (CHF) can also cause a compensatory increase in HR.
3.	Significant blood loss (hypovolemia), e.g. from trauma, will cause BP to fall, a sign of shock.

R. Requesting Patient Records
1.	The PT is responsible (liable) to solicit most recent Exercise Tolerance Test (ETT) from Cardiologist/PCP if history or S/S suggest active heart disease
2.	Also solicit Ejection Fraction % and 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), it is important to auscultate lung bases for adventitious breath sounds both pre and post exercise!  Also auscultate heart rhythm apically to detect S3 heart sound.
S. Female Heart Disease
•	Women & MI symptomology: Goodman p.289
•	Society for Women's Health Research     http://www.womenshealthresearch.org/site/PageServer?pagename=hs_healthfacts 
•	Women's Health Initiative: Risks and Benefits of Estrogen Plus Progestin in Healthy Postmenopausal Women. JAMA. 2002;288:321-333.
•	NHLBI: Postmenopausal Hormone Therapy        http://www.nhlbi.nih.gov/health/women/ 

T. Safety Issue:   when should you take vital signs?  According to Billek-Sawhney (1998), 62% of OPPT orthopedic patients (n=68) have secondary cardiovascular disease.  Think about the increased ENERGY EXPENDITURE of transtibial amputee amb: ↑ 20-40%, transfemoral amputee amb: ↑ 50-80%, and bilateral transfemoral: ↑ 300% (Seymour R., 2002).  
Also consider the increased energy expenditure of PWB ambulation, or the pain/stress of AAROM after total knee arthroplasty.	
Seymour, R.  (2002). Prosthetics and Orhtotics: Lower Limb and Spinal. Philadelphia: Lippincott, Williams and Wilkins.