CARDIAC CONDITIONS
CARDIAC DISEASES
MORTALITY
ARTERIOSCLEROSIS VS ATHEROSCLEROSIS
CORONARY ARTERY DISEASE
• AKA "Acute Coronary Syndromes”
• An atherosclerotic disease process that narrows the lumina
of coronary arteries, resulting in ischemia to the myocardium
• Primary impairment involves an imbalance of the
myocardial oxygen supple to meet the myocardial oxygen
• Refers to a spectrum of conditions compatible with acute
myocardial ischemia and/or infarction that are usually due to
an abrupt reduction in
RISK FACTOR: CORONARY AD
STAGES OF HYPERTENSION
Risk of Coronary Heart Disease Among Smokeless Tobacco
Users: Results of Systematic Review and Meta-Analysis of
Global Data
 A significant positive association was detected
between SLT use and risk of fatal CHD especially for
European users and those consuming snus/snuff. In
view of the positive association even after strict
adjustment for smoking, these results underscore
the need for inclusion of cessation efforts for
smokeless tobacco in addition to smoking for control
of fatal cardiovascular diseases.
Low cigarette consumption and risk of coronary heart
disease and stroke: meta-analysis of 141 cohort studies in 55
study reports
 Smoking only about one cigarette per day carries a
risk of developing coronary heart disease and stroke
much greater than expected: around half that for
people who smoke 20 per day. No safe level of
smoking exists for cardiovascular disease. Smokers
should aim to quit instead of cutting down to
significantly reduce their risk of these two common
major disorders.
Type D Personality as a Risk Factor in Coronary Heart
Disease:
 One in four patients with CHD has a Distressed (Type
D) personality, which is characterized by two stable
traits: social inhibition and negative affectivity.
Predicts increased mortality and morbidity burden,
and poorer health-related quality of life. Part of a
family of psychosocial risk factors that affect CHD
prognosis. The pattern of co- occurrence of these
psychosocial factors and intra-individual differences
in psychosocial profiles may affect risk prediction
accuracy. Multiple biological and behavioral CLINICAL SIGNS AND SYMPTOMS : ANGINA PECTORIS
processes have been associated with Type D
personality.

Loneliness and social isolation as risk factors for coronary

heart disease and stroke:
 Our findings suggest that deficiencies in social
relationships are associated with an increased risk of
developing CHD and stroke. Future studies are
needed to investigate whether interventions HEARTBURN
targeting loneliness and social isolation can help to
prevent two of the leading causes of death and
disability in high-income countries.
Genetic Risk, Adherence to a Healthy Lifestyle, and Coronary
Disease
 Across four studies involving 5S,685 participants,
genetic and lifestyle factors were independently
associated with susceptibility to coronary artery
disease. Among participants at high genetic risk, a
favorable lifestyle was associated with a nearly 50%
lower relative risk of coronary artery disease than FEMALE & MALE
was or unfavorable lifestyle.

CLINICAL MANIFESTATION:
I. ANGINA
- Cardiac-related chest pain is due to ischemia.
- Ischemia is a temporary condition due to the imbalance
between the myocardial oxygen supply and demand.
- (+) Levine Sign
- Referred pain: jaw, neck, upper traps chest shoulder L arm
- Angina can spread anywhere between the belly button and
the jaw, including to the shoulder, arm or hand- usually on
TYPES OF ANGINA
the left side.
1. Chronic Stable angina
- “predictable angina"
- Physical Exertion
- Emotional stress
- Respond to rest and nitrates
- Sensation as an intensity less than 5/10, which improves to
0/10
2. Unstable Angina
- “Preinfarction Angina"
- “Progressive Angina"
- “Cresendo Angina"
- occurs at rest
- Warrants immediate medical intervention
- Don't respond to nitrate
- C/I to exercise
3. Nocturnal Angina USUAL DISTRIBUTION OF PAIN WITH MYOCARDIAL
- Exertion caused by dreams LSCHEMIA
- Common among CHF
4. Prinzmetal Angina
- “Variant Angina”
- Common among: F>M
- Vasospasm of coronary arteries in the absence of occlusive
disease.
- Long term DOC: calcium blockers

CLINICAL MANIFESTATION: CAD

II: INJURY
 represents the presence of a new acute MI. DYSPNEA SCALE
 myocardial tissue is being acutely injured during a
sudden heart attack
III. INFARCTION
 depicts an old heart attack with dead tissue that
cannot be reversed.
 irreversible changes start to appear 20 minutes to 2 ANGINA SCALE
hours from the onset of myocardial ischemia.
ZONE OF ISCHEMIA, INJURY, INFARCTION

ELECTROCARDIOGRAM

EVALUATION TRIAD OF ACD/CAD

CARDIAC ENZYMES ASSOCIATED WITH MYOCARDIAL INJURY
AND INFARCTION
• Record of electrical events in the myocardium that can be
correlated with mechanical events
• P wave: depolarization of atrial myocardium.
 Signals onset of atrial contraction
• QRS complex: ventricular depolarization (0.6-0.10
 Signals onset of ventricular contraction..
• T wave: repolarization of ventricles
• PR interval or PQ interval: 0.16 sec (0.12-0.20s)
 Extends from start of atrial depolarization to star of
ventricular depolarization (QRS complex) contract
and begin to relax
 Can indicate damage to conducting pathway or ”-
AV node if greater than 0.20 sec (200 msec)
• Q-T interval: time required for ventricles to undergo a single
cycle of depolarization and repolarization
 Can be lengthened by electrolyte disturbances,
conduction problems, coronary ischemia, myocardial
damage
ECG ABNORMALITIES
 Absence of P-wave
 C/I to exercise
PQ interval
 < 0.12s — fast conduction
 0.20s — slow conduction heart block)
HEART BLOCKS
FIRST DEGREE HEART BLOCK.
 Prolonged P-R (or P-Q) Interval CLINICAL MANIFESTATIONS: MYOCARDIAL INFARCTION
 increases to greater than 0.20 second Lasts for 20 mins
• Chest, upper extremity, mandibular or epigastric discomfort
(with exertion or at rest)
• dyspnea or fatigue
• the discomfort is diffuse not localized, nor positional, nor
SECOND DEGREE BLOCK.
affected by movement of the region
- HALLMARK: "dropped beats" of the ventricles
Recurrent Myocardial Infarction
• Mobitz Type 1 (Wenkebach)
• MI that occur 28 days following an incident of MI
 Progressive lengthening of the PR interval and (+)
Reinfarction
dropped beats
• MI that occurs within 28 days of an incident or recurrent MI
• Mobitz Type 2 (Hay)
 (N) PR interval and (+) dropped beats
CONGESTIVE HEART FAILURE
• “Cardiac decompensation
• A condition in which the heart is unable to maintain
adequate circulation of the blood to meet the metabolic
needs of the body
• Types of CHF
THIRD DEGREE HEART BLOCK 1. Left-sided (ventricular) Heart Failure
 poor conduction in the A-V node or A-V bundle 2. Right-sided (ventricular) Heart Failure
becomes severe, complete block of the impulse from 3. Biventricular Heart Failure
the atria into the ventricles occurs

ECG ABNORMALITIES
QRS Complexes
 Prolong (>0.10s): Bundle Branch Block (BBB)
 Wide, bizzare, odd: Premature ventricular
contraction (PVC)
ST Segment
 Prolonged: CHF
 Elevated: Myocardial Infarction
 Depressed: Myocardial Ischemia
T Wave
 Inverted: Myocardial ischemia

MYOCARDIAL INFARCTION CLASSIFICATIONS OF HEART FAILURE
• “Coronary occlusion I. Dilated Cardiomyopathy
• Complete vessel occlusion • Most common cause > CAD
• Rupture of a vulnerable plaque w/ resultant formation of a • Other cause:
thrombus • Myocarditis
• Irreversible myocardial cell damage • Alcohol abuse
 20 min-2 hr • LV failure and systolic dysfunction
• Complete necrosis
 2-4 hr
• ST segment elevation + increased cardiac Enzymes
Dilated cardiomyopathy PATHOPHYSIOLOGY

II. Hypertrophic Cardiomyopathy

• Diastolic dysfunction with increased ventricular mass
Example:
• Chronic hypertension
• Aortic stenosis

PRESSURE-OVERLOAD HYPERTROPHY
• concentric increase in wall thickness
• new sarcomeres are predominantly assembled in parallel to
the long axes of cells, expanding the cross-sectional area of
myocytes
VOLUME-OVERLOAD HYPERTROPHY CAUSES OF CARDIAC MUSCLE DYSFUNCTION
• Ventricular dilation
• New sarcomeres assembled in response to volume overload
are largely positioned in series with existing sarcomeres.

CLINICAL MANIFESTATIONS: CHF

Ill. Restrictive Cardiomyopathy
• Diastolic dysfunction due to the presence of excessively
rigid ventricular walls resulting to decrease in compliance
Left Sided Heart Failure
• AKA Forward heart failure
• blood is not adequately pumped into systemic circulation
• due to an inability of left ventricle to pump
• pulmonary artery pressures & Pulmonary edema
dyspnea
 CLINICAL SIGNS AND SYMPTOMS : RIGHT SIDED HF

TABLE 13.6 EXAMPLE OF HEMODYNAMIC PRESSURES

ASSOCIATED WITH HEART FAILURE

CLINICAL SIGNS AND SYMPTOMS

• Fatigue and dyspnea after mild physical exertion or exercise CVP = central venous pressure: LV = left ventricle:
• Persistent spasmodic cough, especially when lying down, PAP = pulmonary artery pressure:
while fluid moves from the extremities to the lungs PCWP = pulmonary capillary wedge pressure,
• Paroxysmal nocturnal dyspnea (occurring suddenly at night) RV = right ventricle;
• Orthopnea (person must be in the upright position to
breathe) PERICARDITIS
• Tachycardia • Inflammation of the pericardium
• Fatigue and muscle weakness • Secondary to bacterial / viral agent
• Edema (especially of the legs and ankles) and weight gain • Decrease in pericardial fluid
• Irritability/restlessness • (+) pericardial friction rub
• Decreased renal function or frequent urination at night • Aggravating factor: mimic chest pain; trunk movement
• Relieving factor: kneeling on all 4’s; leaning forward
RIGHT SIDED HEART FAILURE
• AKA Backward heart failure VALVULAR DYSFUNCTION
• blood is not adequately returned from the systemic Stenosis
circulation to the heart • A narrowing or constriction that prevents the valve from
• due to failure of the RV & Pulmonary hypertension opening fully
Insufficiency (regurgitation)
• Occurs when the valve does not close properly and causes
blood to flow back into the hear chamber
Prolapse
• Occurs when enlarged leaflets bulge backward into the
atrium

MITRAL VALVE PROLAPSE

• AKA “Floppy valve syndrome
 “Barlow's syndrome
 “Click-murmur syndrome
• A pathologic, anatomic, and physiologic abnormality of the
mitral valve apparatus affecting mitral valve leaflet motion
CLINICAL MANIFESTATIONS: CHF • one or both mitral valve leaflets are “floppy” and prolapse,
COR PULMONALE or balloon back, into the left atrium during systole
• Peripheral edema (bilateral legs)
• Chronic cough
• Central chest pain
• Exertional dyspnea or dyspnea at rest
• Distention of neck veins
• Fatigue
• Wheezing
• Weakness
 CONGENITAL ANOMALIES
1. Atrial Septal Defect
- Defect of Interatrial septum
- Blood shunt from (L) to (R)
2. Ventricular Septal Defect
- Defect of the interventricular septum
- Blood shunt from (L) to (R)

3. Coarctation of Aorta
- Constriction of proximal and distal Aorta
- Inc BP especially on UE
4. Patent ductus Arteriosus
CLINICAL MANIFESTATION: MITRAL VALVE PROLAPSE
- Ductus arteriosus: connects the Pulmonary artery to aorta
- (+) ductus arteriosus after birth
- Blood shunt from (L) to (R)

MITRAL VALVE PROLAPSE TRIAD

1. Fatigue
2. Palpitations
3. Dyspnea

5. Tetralogy of Fallot
- Pulmonary artery Stenosis
- Aorta Over-riding to the right
- Right ventricular Hypertrophy
- Interventricular septal defect
- Blood shunt from (R) to (L)
FUNCTIONAL CLASSIFICATIONS OF PATIENTS WITH DISEASES
OF THE HEART

PHARMACOLOGICAL MANAGEMENT REVASCULARIZATION

• Principle: Increase contractility and relieve congestion
• Positive inotropes (digoxin): increase contractility
• Diuretics: increase preload, thereby LVEDV
• Afterload reducers: ACE & ARB
PHARMACOLOGICAL MEDICATION
Percutaneous transluminal coronary angioplasty (PTCA)
• under fluoroscopy, surgical dilation of a blood vessel using a
small balloon-tipped catheter inflated inside the lumen

Intravascular stents
• an endoprosthesis (pliable wire mesh) implanted post
angioplasty to prevent restenosis and occlusion in coronary
or peripheral arteries
• often coated in medication to prevent thrombosis
REVASCULARIZATION
Coronary Artery Bypass Graft (CABG)
• surgical circumvention of an obstruction in a coronary
artery using an anastomosing grañ
• Blood vessels:
 Great saphenous vein
 Internal mammary artery
 Internal thoracic artery
MEDICAL MANAGEMENT  Radial artery (non-dominant arm)
Revascularization
• PTCA
• CABG
Symptomatic CHF Class III/IV
• Heart transplant
• Left ventricular devices (LVAD)
• Myoplasty
• Pacemaker
PT MANAGEMENT: CARDIAC REHABILITATION
Four distinct phases:
• Acute inpatient care
• Home-based recuperation
• Outpatient program
• Independent self-care
EVIDENCE-BASED PT MANAGEMENT
Exercise-Based Cardiac Rehabilitation for Coronary Heart
Disease
 This study confirms that exercise-based CR reduces
cardiovascular mortality and provides important
data showing reductions in hospital admissions and
improvements in quality of life. These benefits
appear to be consistent across patients and
intervention types and were independent of study
quality, setting, and publication date.

The effectiveness of yoga in modifying risk factors for

cardiovascular disease and metabolic syndrome:
 There is promising evidence of yoga on improving
cardio-metabolic health. Findings are limited by
small trial sample sizes, heterogeneity, and
moderate quality of RCTs.

Early postoperative physical therapy for improving short-

term gross motor outcome in infants with cyanotic and
acyanotic congenital heart disease
 Our findings suggested that infants with cyanotic
CHD are likely at a greater risk of gross motor delays,
the recovery of which might differ between infants
with cyanotic and acyanotic CHD after cardiac
surgery. Early postoperative physical therapy
promotes gross motor recovery.

The effect of exercise therapy on depressive and anxious

symptoms in patients with ischemic heart disease: A
systematic review
 There is a general paucity of data on the effect of
exercise precluding firm conclusions about the
effectiveness of exercise for depressive and anxiety
symptoms in IHD patients

Additional Physical Therapy Services Reduce Length of Stay

and Improve Health Outcomes in People With Acute and
Subacute Conditions: An Updated Systematic Review and
Meta-Analysis
 Additional PT services improve pt activity and
participation outcome while reducing hospital length
of stay for adults. These benefits are likely safe and
there is preliminary evidence to suggest they may be
cost effective