Case study (Attached) Answer the 7 Questions. Clearly and thoroughly describe your thought process and rationale for your answer/decision. Topic: Exercise in Chronic Disease: Cardiopulmonary and Met

Case study (Attached) Answer the 7 Questions. Clearly and thoroughly describe your thought process and rationale for your answer/decision. Topic: Exercise in Chronic Disease: Cardiopulmonary and Met
Chap te r 1 3 Acu te C oro n ary S yn dro m es: Unsta b le A ngin a P ecto ris a n d Acu te M yoca rd ia l I n fa rctio n Ray W . S quir e s, P hD , M AAC VPR, F AC SM , F AH A T he b urd en o f d is e ase s o f t h e c ard io vasc u la r s y ste m o n o ur s o cie ty i s h orre n dous. S in ce 1 900, c ard io vasc u la r d is e ase s ( C V Ds), su ch a s c o ro nary h eart d is e ase , s tr o ke, h eart f a ilu re , a n d h yperte n sio n, h av e b een t h e l e ad in g c au se o f d eath i n t h e U nite d Sta te s e v ery y ear w ith t h e e x cep tio n o f 1 918, t h e y ear o f t h e g re at i n flu en za e p id em ic ( 1 ). I n 2 013, C V Ds c au se d 5 4% o f a ll death s i n t h e U nite d S ta te s ( 1 28 d eath s p er 1 00,0 00 p ers o ns), 2 ,2 00 d eath s e ach d ay , a n a v era g e o f 1 d eath e v ery 4 0 s e co nds (2 ). I t i s t h e m ost c o m mon c au se o f d eath f o r b oth m en a n d w om en ( 2 , 3 ). A ppro xim ate ly 5 0% o f a ll c ard io vasc u la r d eath s a re a r e su lt o f c o ro nary h eart d is e ase ( C H D) ( 2 ). For 2 013, C H D c au se d a t o ta l o f 3 70,2 13 d eath s a n d a cco unte d f o r 1 o ut o f e v ery 7 d eath s. A cu te c o ro nary s y ndro m es ( m yocard ia l i n fa rc tio n, u nsta b le a n gin a p ecto ris , a n d s o m e f o rm s o f s u dden c ard ia c d eath ), f o rm s o f C H D, a re a lm ost a lw ay s t h e r e su lt of c o ro nary a rte ry a th ero sc le ro sis a n d s u bse q uen t t h ro m bosis . E ach y ear 5 50,0 00 A m eric an s w ill s u ffe r a n ew m yocard ia l i n fa rc tio n, an d 2 00,0 00 w ill s u ffe r a r e cu rre n t m yocard ia l i n fa rc tio n. S ile n t ( p ain le ss) m yocard ia l i n fa rc tio n w ill o ccu r i n 1 60,0 00 p ers o ns per y ear. E very 4 2 s s o m eo ne i n t h e U nite d S ta te s s u ffe rs a m yocard ia l i n fa rc tio n. T he a v era g e a g e a t t h e f ir s t m yocard ia l in fa rc tio n i s 6 5 y r f o r m en a n d 7 2 y r f o r w om en . T he n um ber o f A m eric an s w ho u nderw en t p erc u ta n eo us c o ro nary i n te rv en tio n (c o ro nary a n gio pla sty , s te n tin g, o r b oth ) o r c o ro nary b ypass g ra ft s u rg ery f o r t r e atm en t o f C H D i n 2 010 w as 9 54,0 00 a n d 3 97,0 00, re sp ectiv ely ( 2 ). A ppro xim ate ly 1 6,3 00,0 00 A m eric an s h av e a h is to ry o f m yocard ia l i n fa rc tio n, a n d 9 ,0 00,0 00 e x perie n ce a n gin a pecto ris ( c h est p ain ). E stim ate d t o ta l c o sts f o r C H D w ere $ 207.3 b illio n f o r 2 013 ( 2 ). T his c h ap te r p ro vid es i n fo rm atio n r e g ard in g t h e f o llo w in g t o pic s: 444 1 . The d is e ase p ro cess o f a th ero sc le ro sis a n d t h ro m bosis 2 . Myocard ia l b lo od f lo w a n d i s c h em ia : a n gin a p ecto ris 3 . Acu te c o ro nary s y ndro m es: d efin itio n, a cu te m yocard ia l i n fa rc tio n, clin ic al a sse ssm en t, d ia g nosis , c la ssif ic atio n b y E C G , man ag em en t str a te g ie s, p ote n tia l c o m plic atio ns, r ig ht v en tr ic u la r i n fa rc tio n 4 . Facto rs a sso cia te d w ith p oor p ro gnosis 5 . Str e ss t e stin g a fte r a cu te m yocard ia l i n fa rc tio n 6 . Exerc is e t r a in in g a n d c ard ia c r e h ab ilita tio n f o r a cu te c o ro nary sy ndro m es Path op hysio lo gy The p ath olo gy o f a cu te c o ro nary s y ndro m es i s c o m ple x ; i t i n volv es t h e dev elo pm en t o f a th ero sc le ro tic l e sio ns i n t h e w alls of t h e c o ro nary a rte rie s with s u bse q uen t t h ro m bosis f o rm atio n r e su ltin g i n a n a b ru pt d ecre ase i n vesse l b lo od f lo w . Ath ero sc le ro sis a n d T hro m bosis Ath ero sc le ro sis i s a d is e ase p ro cess t h at m ay r e su lt i n b lo od-flo w l im itin g le sio ns i n t h e e p ic ard ia l c o ro nary , c aro tid , i lia c, an d f e m ora l a rte rie s, a s well a s t h e a o rta . S om e a rte rie s a re r e sis ta n t t o a th ero sc le ro sis ( b ra ch ia l, in te rn al t h ora cic , i n tr a m yocard ia l) fo r u nknow n r e aso ns ( 4 ). T he p ro cesse s of a th ero sc le ro sis a n d t h ro m bosis a re i n te rre la te d , a n d t h e t e rm ath ero th ro m bosis h as b een a d opte d b y s o m e i n vestig ato rs t o e m phasiz e th is p oin t ( 4 ). The N orm al A rte ry The c h an nel f o r t h e f lo w o f b lo od w ith in t h e a rte ry i s t h e lu m en . T he i n ner, sin gle -c ell l a y er o f t h e a rte ry i s t h e en doth eliu m . T he e n doth eliu m p la y s a critic al r o le i n m ain ta in in g v aso m otio n ( th e d eg re e o f v aso co nstr ic tio n) an d r e g ula tin g h em osta sis (b ala n cin g p ro – a n d a n tith ro m botic p ro pertie s). When i n ta ct, t h e e n doth eliu m p ro duces n itr ic o xid e, a v aso dila to r, a n d su bsta n ces su ch a s p la sm in ogen t h at i n hib it t h ro m bosis f o rm atio n. V ario us re cep to rs , s u ch a s t h ose f o r l o w -d en sity l ip opro te in a n d g ro w th fa cto rs , a re lo cate d o n t h e e n doth elia l c ells ( 5 ). U nder n orm al c ir c u m sta n ces, t h e en doth eliu m p ro te cts a g ain st t h e d ev elo pm en t of a th ero th ro m bosis , b ut 445 when d am ag ed i t p la y s a c en tr a l r o le i n t h e d ev elo pm en t o f t h e d is e ase ( 5 ). Undern eath t h e e n doth elia l b ase m en t m em bra n e i s t h e in tim a , c o nsis tin g of a t h in l a y er o f c o nnectiv e t is su e w ith a n o ccasio nal s m ooth m usc le c ell. The l e sio ns o f a th ero sc le ro sis f o rm in t h e i n tim a ( 5 ). The med ia c o nta in s m ost o f t h e s m ooth m usc le c ells o f t h e a rte ria l w all, i n ad ditio n t o e la stic c o nnectiv e t is su e, a n d i s l o cate d u ndern eath th e i n tim a betw een t h e i n te rn al a n d e x te rn al e la stic l a m in ae. T he s m ooth m usc le c ells main ta in a rte ria l t o ne ( p artia l v aso co nstr ic tio n). Sm ooth m usc le c ells h av e re cep to rs f o r l o w -d en sity l ip opro te in , i n su lin , a n d g ro w th f a cto rs . W hen ap pro pria te ly s tim ula te d , sm ooth m usc le c ells a re c ap ab le o f f u nctio nin g as s y nth etic t is su e, p ro ducin g c o nnectiv e t is su e ( 6 ). The o ute rm ost l a y er o f t h e a rte ria l w all i s t h e adven titia , c o nsis tin g o f co nnectiv e t is su e ( c o lla g en , e la stin ), f ib ro bla sts ( c ells c ap ab le o f sy nth esiz in g c o nnectiv e t is su e), a n d a f e w s m ooth m usc le c ells . T his t is su e is h ig hly v asc u la riz ed ( its b lo od s u pply i s p ro vid ed b y s m all v esse ls c alle d th e v asa vaso ru m ) a n d p ro vid es t h e m ed ia a n d i n tim a w ith o xygen a n d nutr ie n ts ( 5 ). Ath ero gen esis Our u nders ta n din g o f t h e d ev elo pm en t a n d p ro gre ssio n o f a th ero sc le ro sis (a th ero gen esis ) i s i n co m ple te . H ow ev er, i t i s c le ar th at en doth elia l i n ju ry re su ltin g i n en doth elia l d ysfu nctio n a n d a s u bse q uen t in fla m mato ry re sp onse p la y c ritic al r o le s ( 7 ). T he d is e ase p ro cess m ay b eg in i n ch ild hood a n d p ro gre ss f o r d ecad es b efo re a c lin ic al e v en t o ccu rs . The r a te of p ro gre ssio n o f a th ero sc le ro sis m ay n ot b e c o nsis te n t o ver t im e a n d im possib le t o p re d ic t. Under n orm al c o nditio ns, t h e e n doth eliu m m ay e x perie n ce p erio dic min im al a m ounts o f i n ju ry . I n t h ese s itu atio ns, t h e i n here n t re p air pro cesse s o f t h e e n doth eliu m a re a d eq uate t o r e sto re n orm al f u nctio n. How ev er, c h ro nic , e x cessiv e i n ju ry t o e n doth elia l cells i n itia tin g t h e pro cess o f a th ero gen esis m ay r e su lt f ro m m ultip le c au se s, s u ch a s t h e fo llo w in g ( 6 , 7 , 8 , 9 , 1 0, 1 1, 12, 1 3): Tobacco s m oke a n d o th er c h em ic al i r rita n ts f ro m t o bacco Low -d en sity l ip opro te in c h ole ste ro l ( L D L-C ) Hyperte n sio n 446 Gly cate d s u bsta n ces r e su ltin g f ro m h yperg ly cem ia a n d d ia b ete s mellitu s Pla sm a h om ocy ste in e In fe ctio us a g en ts ( e .g ., Chla m yd ia pneu m onia e , h erp es v ir u se s) Endoth elia l d ysfu nctio n m ay r e su lt f ro m t h ese p ote n tia lly i n ju rio us f a cto rs , le ad in g t o t h e f o llo w in g a b norm alitie s c h ara cte ris tic of a n i n fla m mato ry re sp onse : 1 . In cre ase d a d hesiv en ess r e su ltin g i n p la te le t d ep ositio n, m onocy te ad hesio n 2 . In cre ase d p erm eab ility t o l ip opro te in s a n d o th er s u bsta n ces i n t h e blo od 3 . Im pair e d v aso dila tio n, i n cre ase d v aso sp asm Pla te le ts a d here t o t h e d am ag ed e n doth eliu m ( p la te le t a g gre g atio n), f o rm sm all b lo od c lo ts o n t h e v esse l w all ( m ura l t h ro m bi) , an d r e le ase g ro w th fa cto rs a n d v aso co nstr ic to r s u bsta n ces, s u ch a s t h ro m boxan e A 2 ( 5 , 6 ). These c h an ges i n dic ate a s w itc h in e n doth elia l f u nctio n f a v orin g a pro th ro m botic , v aso co nstr ic tiv e s ta te . Monocy te s, a t y pe o f w hite b lo od c ell, a ls o a d here t o t h e i n ju re d en doth eliu m a n d m ig ra te i n to t h e i n tim a. L D L-C e n te rs t h e arte ria l w all an d u nderg oes t h e p ro cess o f o xid atio n. M onocy te s a ccu m ula te L D L-C , au gm en tin g t h e o xid atio n p ro cess, a n d b eco m e tr a n sfo rm ed i n to a dis tin ctly d if fe re n t t y pe o f c ell, t h e m acro phag e ( 5 , 7 ). Gro w th f a cto rs e x pre sse d b y p la te le ts , m onocy te s, a n d d am ag ed en doth eliu m r e su lt i n g ro w th a n d p ro lif e ra tio n ( in cre ase i n cell n um bers an d c ell s iz e) o f c erta in t y pes o f c ells ( m ito gen ic e ffe ct) a s w ell a s t h e mig ra tio n o f c ells i n to t h e a re a o f in ju ry ( c h em ota ctic e ffe ct) ( 5 , 7 ). I n re sp onse t o t h e g ro w th f a cto rs , s m ooth m usc le c ells a n d f ib ro bla sts (u ndif fe re n tia te d co nnectiv e t is su e c ells t h at c an s y nth esiz e f ib ro us t is su e) mig ra te f ro m t h e m ed ia t o t h e i n tim a. S m ooth m usc le p ro gen ito r cells f ro m bone m arro w a ls o m ig ra te t o t h e i n tim a ( 1 4). S om e o f t h ese c ells , i n ad ditio n t o m onocy te s, a ccu m ula te c h ole ste ro l, fo rm in g f o am c ells t h at may r e le ase t h eir c h ole ste ro l i n to t h e e x tr a cellu la r s p ace, g iv in g r is e t o fa tty s tr e ak s, t h e e arlie st vis u ally d ete cta b le ( y ello w m acro sc o pic ap peara n ce) l e sio n o f a th ero sc le ro sis ( 1 1, 1 5). I m mune s y ste m c ells , T ly m phocy te s, are a ls o p re se n t i n f a tty s tr e ak s a n d a re p art o f t h e in fla m mato ry s ta te i n t h e a rte ria l w all ( 1 6). 447 With c o ntin ued m ig ra tio n, p ro lif e ra tio n, a n d g ro w th o f t is su e, t h e l e sio n pro gre sse s i n c o m ple x ity a n d s iz e a n d b eco m es a fib ro m usc u la r p la q ue (1 5). T he c o m positio n o f t h e p la q ue n ow i n clu des a f ib ro us c ap , co nnectiv e t is su e e x tr a cellu la r m atr ix , lip id s, i n fla m mato ry c ells s u ch a s macro phag es a n d T l y m phocy te s, s m ooth m usc le c ells , t h ro m bus, a n d calc iu m . T he t y pic al pla q ue i s f ir m i n t e x tu re a n d p ale g ra y i n c o lo r, a n d i t may c o nta in a y ello w c h ole ste ro l c o re . As t h e i n tim al l e sio ns o f a th ero sc le ro sis p ro gre ss a n d t h ic k en t h e v esse l wall, a c o m pen sa to ry o utw ard e x pan sio n o f t h e v esse l occu rs ( to a p oin t) an d l u m en s iz e r e m ain s u nch an ged . T his i s c alle d a rte ria l r e m odelin g an d may b e e ffe ctiv e i n c o m pen sa tin g f o r p la q ues w hose b ulk m ay r e p re se n t up t o 4 0% o f t h e v esse l d ia m ete r ( 1 7). W ith c o ntin ued pro gre ssio n i n pla q ue b ulk , t h e a re a o f t h e l u m en d ecre ase s, w hic h m ay u ltim ate ly r e su lt in a r e d uctio n i n b lo od f lo w . The p ro gre ssio n o f t h e s iz e a n d v olu m e o f a th ero sc le ro tic l e sio ns i s h ig hly varia b le . S om e l e sio ns a p pear r e la tiv ely s ta b le over m an y y ears , o th er pla q ues m ay s lo w ly p ro gre ss i n s iz e, w hile s till o th er a re as o f ath ero sc le ro sis m ay e n la rg e v ery r a p id ly (6 ). T he s lo w ly p ro gre ssin g pla q ues a re t h ought t o g ra d ually i n te rn aliz e m onocy te s a n d l ip id s, w hile ra p id ly p ro gre ssin g l e sio ns in co rp ora te t h ro m bus i n to t h e p la q ue ( 4 ). L ocal str e sso rs ( e .g ., f ro m t u rb ule n t b lo od f lo w o r v aso co nstr ic tio n) o r c h em ic al fa cto rs ( e n zy m es s u ch a s m eta llo pro te in ase s t h at w eak en t h e f ib ro us c ap ) with in t h e l e sio n m ay r e su lt i n p la q ue r u ptu re o r fis su rin g of t h e f ib ro us cap , e x posin g t h e i n te rn al c o nte n ts o f t h e p la q ue t o t h e b lo od ( 6 , 1 8). Vario us a m ounts o f t h ro m bus f o rm i n re sp onse t o t h is p ro th ro m botic en vir o nm en t a n d m ay b e i n co rp ora te d i n to t h e p la q ue. T he s c en ario o f pla q ue r u ptu re , s u bse q uen t th ro m bus f o rm atio n, a n d i n co rp ora tio n i n to t h e arte ria l w all m ay r e p eate d ly o ccu r, g iv in g a l a y ere d a p peara n ce t o t h e le sio n an d r e su ltin g i n r a p id p ro gre ssio n i n t h e s iz e o f t h e p la q ue. T hese le sio ns, w hic h i n clu de o rg an iz ed t h ro m bus, a re c alle d ad van ced ath ero sc le ro tic p la q ues. Ath ero sc le ro sis a ffe cts a rte rie s i n a n e x tr e m ely d if fu se m an ner, w ith occasio nal d is c re te , l o caliz ed a re as o f m ore p ro nounced narro w in g o f t h e vesse l l u m en ( 1 9). S ele ctiv e c o ro nary a n gio gra p hy i s t h e g old s ta n dard (b est a v aila b le t e st) f o r d ete rm in atio n of t h e s e v erity o f c o ro nary l e sio ns. How ev er, b ase d o n c o m paris o ns o f a n gio gra p hic a n d a u to psy f in din gs, with t h e e x cep tio n of c o m ple te o cclu sio n o f t h e v esse l i n q uestio n ( 1 00% ste n osis ), t h e d eg re e o f s te n osis i s g re atly u ndere stim ate d b y a n gio gra p hy 448 becau se o f t h e d if fu se n atu re o f t h e d is e ase p ro cess ( 2 0). O bstr u ctiv e co ro nary l e sio ns ( s e v ere e n ough t o r e d uce b lo od f lo w ) occu r m ost fre q uen tly i n t h e f ir s t 4 t o 5 c m o f t h e e p ic ard ia l c o ro nary a rte rie s, alth ough m ore d is ta l d is e ase m ay a ls o b e se en . O bstr u ctiv e l e sio ns a t t h e orig in ( o stia l l e sio ns) o f t h e l e ft m ain a n d r ig ht m ain c o ro nary a rte rie s m ay als o o ccu r. For r e aso ns n ot f u lly u nders to od, w om en g en era lly l a g 5 t o 2 0 yr b eh in d m en i n t h e e x te n t a n d s e v erity o f c o ro nary a th ero sc le ro sis (2 1). Ris k F acto rs f o r A th ero sc le ro sis Ris k f a cto rs a re a sso cia te d w ith a n i n cre ase d l ik elih ood t h at ath ero sc le ro sis w ill d ev elo p o ver t im e. S uch f a cto rs h av e b een id en tif ie d on t h e b asis o f o bse rv atio nal s tu die s e v alu atin g c o m mon c h ara cte ris tic s o f pers o ns w ith t h e d is e ase ( 2 2, 2 3). P ossib le mech an is m s o f a th ero gen ic effe ct h av e b een i d en tif ie d f o r s o m e r is k f a cto rs . T he e ffe cts o f r e d ucin g th e s e v erity o f s o m e ris k f a cto rs , e sp ecia lly L D L-C , h av e b een dem onstr a te d t o r e d uce p ro gre ssio n o f t h e d is e ase . P re d ic tin g w heth er a n in div id ual patie n t w ill o r w ill n ot d ev elo p a th ero sc le ro sis b ase d o n t h e pre se n ce a n d s e v erity o f r is k f a cto rs i s v ery i m pre cis e , h ow ev er. Less t h an half o f f u tu re c ard io vasc u la r e v en ts c an b e p re d ic te d u sin g c o nven tio nal ris k f a cto rs ( 2 4): Tobacco u se Dyslip id em ia , e sp ecia lly e le v ate d L D L-C a n d l o w l e v els o f h ig h- den sity l ip opro te in c h ole ste ro l ( H DL-C ) Hyperte n sio n Sed en ta ry l if e sty le Obesity Dia b ete s m ellitu s Meta b olic s y ndro m e ( a c o m bin atio n o f c o nven tio nal r is k f a cto rs asso cia te d w ith o besity a n d i n su lin r e sis ta n ce) Fam ily h is to ry o f p re m atu re c o ro nary d is e ase ( m ale f ir s t- d eg re e re la tiv es < 55 y r o f a g e, f e m ale f ir s t- d eg re e r e la tiv es < 65 yr o f a g e) Male s e x Obstr u ctiv e s le ep a p nea Psy ch oso cia l f a cto rs , s u ch a s d ep re ssio n, a n xie ty , s o cia l i s o la tio n, co ro nary p ro ne p ers o nality ( ty pe A ), l o w er s o cio eco nom ic sta tu s, a n d ch ro nic l if e s tr e sso rs Less w ell- e sta b lis h ed r is k f a cto rs , t e rm ed e m erg in g r is k f a cto rs , a re b ein g 449 in vestig ate d , i n clu din g t h e f o llo w in g ( 2 4, 2 5, 26): Ele v ate d p la sm a h om ocy ste in e, a n i n te rm ed ia ry i n t h e m eta b olis m o f th e e sse n tia l a m in o a cid m eth io nin e Fib rin ogen , a p ro te in f a cto r i n t h e b lo od c o ag ula tio n c asc ad e Lip opro te in (a ) LD L p artic le c o ncen tr a tio n Hig h-s e n sitiv e C -re activ e p ro te in , a m ark er f o r s y ste m ic in fla m matio n Myoca rd ia l B lo od F lo w , M eta b olis m , a n d I sc h em ia Norm al c o ntr a ctio n a n d r e la x atio n o f c ard ia c m yocy te s r e q uir e s t h e pre se n ce o f a d eq uate a m ounts o f a d en osin e t r ip hosp hate (A TP; a h ig h- en erg y p hosp hate m ole cu le ) i n t h e m yocard iu m . T he h eart i s a h ig hly aero bic o rg an w ith a n e x te n siv e c ir c u la to ry sy ste m a n d a b undan t mito ch ondria ( 2 7). Fig ure 1 3.1 i llu str a te s t h e e p ic ard ia l c o ro nary a rte rie s. The c o ro nary a rte ria l s y ste m i n clu des e p ic ard ia l a rte rie s t h at b if u rc ate i n to in tr a m yocard ia l a n d e n dom yocard ia l b ra n ch es. A t r e st, c o ro nary b lo od flo w a v era g es 6 0 t o 9 0 m L · m in −1 · 1 00 g −1 o f m yocard iu m a n d m ay in cre ase f iv e- t o s ix fo ld d urin g e x erc is e ( 2 8). U nder u su al c o nditio ns, t h e heart r e g en era te s A TP a ero bic ally , an d m yocard ia l c ells a re n ot w ell ad ap te d t o a n aero bic e n erg y p ro ductio n. A t r e st, m yocard ia l o xygen upta k e i s a p pro xim ate ly 8 t o 1 0 m L p er 1 00 g o f t is su e p er m in ute . D urin g in te n se e x erc is e , t h e o xygen r e q uir e m en t m ay i n cre ase b y 2 00% t o 3 00% (2 9). The m yocard iu m e x tr a cts n early a ll i ts o xygen f ro m t h e c ap illa ry blo od f lo w ( u nlik e s k ele ta l m usc le ), a n d c o ro nary b lo od f lo w must b e clo se ly r e g ula te d t o t h e n eed s o f t h e m yocard iu m f o r o xygen ( 3 0). W ith a n in cre ase i n m yocard ia l w ork , o xygen d em an d in cre ase s, a n d c o ro nary blo od f lo w m ust a ls o i n cre ase t o p ro vid e t h e n ecessa ry a m ount o f o xygen . 450 Fig u re 1 3.1 The e p ic ard ia l c o ro nary a rte rie s. (a ) A nte rio r v ie w . (b ) Poste rio r v ie w . B la ck s e g m en ts a re p rim e s ite s f o r t h e d ev elo pm en t o f o bstr u ctiv e a th ero sc le ro tic p la q ues. A o = a o rta ; I V C = i n fe rio r v en a c av a; SV C = s u perio r v en a c av a; P A = p ulm onary a rte ry . Rep rin te d b y p erm is sio n f ro m J .T . L ie , P ath olo gy o f C oro nary A rte ry D is e ase , i n Card io lo gy: Fundam en ta ls a nd P ra ctic e, 2 nd e d ., e d ite d b y E .R . G iu lia n i e t a l. ( C hic ag o: M osb y Y earb ook, 1991). B lo od f lo w t h ro ugh a n y r e g io nal c ir c u la tio n, i n clu din g t h e c o ro nary s y ste m , i s d ete rm in ed b y t h e b lo od p re ssu re a n d t h e v asc u la r re sis ta n ce ( 3 0). D urin g s y sto le , i n tr a m yocard ia l p re ssu re i s i n cre ase d ( a s i s v asc u la r r e sis ta n ce) a n d t h e i n tr a m ura l v esse ls are c o m pre sse d . T here fo re , m ost c o ro nary b lo od f lo w o ccu rs d urin g d ia sto le , w hen i n tr a m yocard ia l p re ssu re i s l o w er ( lo w er vasc u la r r e sis ta n ce). B efo re a d ecre ase i n f lo w c an b e m easu re d d is ta l t o a n arro w ed , a th ero sc le ro tic c o ro nary a rte ry s e g m en t, a s u bsta n tia l r e d uctio n in v esse l l u m in al d ia m ete r m ust o ccu r. W hen p la q ue b ulk r e d uces t h e l u m in al c ro ss- s e ctio nal a re a b y 7 5% o r m ore , f lo w i s r e d uced under r e stin g c o nditio ns ( a h em odynam ic ally s ig nif ic an t l e sio n) ( 2 8). B ey ond t h is a m ount o f c ritic al s te n osis , f u rth er s m all decre ase s i n c ro ss-s e ctio nal a re a o f t h e v esse l r e su lt i n l a rg e r e d uctio ns i n f lo w . A r e d uctio n i n t h e l u m en d ia m ete r m ay b e c au se d b y s e v era l f a cto rs ( 3 1, 3 2): Sig nif ic an t a th ero sc le ro tic p la q ue Vaso sp asm w ith out u nderly in g p la q ue Vaso sp asm s u perim pose d o ver a p la q ue 451 Thro m bus a sso cia te d w ith p la q ue r u ptu re Coro nary v aso sp asm m ay r e su lt f ro m s e v era l f a cto rs , s u ch a s e n doth elia l dysfu nctio n, s y m path etic n erv ous s y ste m a ctiv atio n (e .g ., v aso sp asm re su ltin g f ro m e x posu re t o v ery c o ld a m bie n t t e m pera tu re s), a n d blo odborn e s u bsta n ces s u ch a s e p in ep hin e (3 3). Myocard ia l i s c h em ia r e su lts w hen m yocard ia l b lo od f lo w i s i n ad eq uate t o pro vid e t h e r e q uir e d a m ounts o f o xygen f o r A TP r e g en era tio n (o xygen su pply < o xygen d em an d) ( 2 7, 2 8). I s c h em ia m ay r e su lt i n p ro gre ssiv e ab norm alitie s i n c ard ia c f u nctio n, t e rm ed t h e is c h em ic c asc ad e (3 4). T he fir s t a b norm ality i s s tif fe n in g o f t h e l e ft v en tr ic le , w hic h i m pair s d ia sto lic fillin g o f t h e h eart ( d ia sto lic d ysfu nctio n). Seco nd, s y sto lic e m pty in g o f t h e le ft v en tr ic le b eco m es i m pair e d ( s y sto lic d ysfu nctio n). L ocaliz ed a re as o f th e m yocard iu m dev elo p a b norm al c o ntr a ctio n p atte rn s s u ch a s hypokin esis ( re d uced s y sto lic c o ntr a ctio n). Left v en tr ic u la r e je ctio n fr a ctio n ( L V EF) m ay d ecre ase . T hir d , e le ctr o card io gra p hic a b norm alitie s asso cia te d w ith a lte re d r e p ola riz atio n ( S T -s e g m en t c h an ges, T w av e in vers io n) o r a rrh yth m ia s m ay o ccu r. F in ally , s y m pto m s o f a n gin a p ecto ris may d ev elo p. Angin a p ecto ris i s t r a n sie n t r e fe rre d c ard ia c p ain r e su ltin g f ro m myocard ia l i s c h em ia ( 3 5). A m in ority o f p atie n ts w ith s u bsta n tia l am ounts of i s c h em ia d o n ot r e p ort p ain ( s ile n t i s c h em ia ). T he p ain o f a n gin a m ay b e lo cate d i n t h e s u bste rn al r e g io n, j a w , neck , o r a rm s, a lth ough p ain m ay als o o ccu r i n t h e e p ig astr iu m a n d i n te rs c ap ula r r e g io ns. I t i s u su ally desc rib ed a s a f e elin g of p re ssu re , h eav in ess, f u lln ess, s q ueezin g, b urn in g, ach in g, o r c h okin g. T he p ain m ay v ary i n i n te n sity a n d m ay r a d ia te . The patie n t m ay e x perie n ce d ysp nea ( a n gin al e q uiv ale n t) , i f t h e i s c h em ia re su lts i n i n cre ase d l e ft v en tr ic u la r e n d-d ia sto lic pre ssu re a n d i n cre ase d pulm onary v asc u la r p re ssu re . Typic al a n gin a i s p ro voked b y e x ertio n, em otio ns, c o ld a n d h eat e x posu re , m eals , a n d s e x ual i n te rc o urs e ; a n d i s re lie v ed b y re st, n itr o gly cerin , o r b oth . A ty pic al a n gin a i n volv es s im ila r sy m pto m s b ut h as f e atu re s t h at s e t i t a p art f ro m t y pic al a n gin a, su ch a s n o re la tio nsh ip w ith e x ertio n. S ta b le a n gin a i s r e p ro ducib le a n d p re d ic ta b le i n onse t, s e v erity , a n d m ean s o f r e lie f. Unsta b le a n gin a is d efin ed a s n ew onse t o f t y pic al a n gin a; i n cre asin g f re q uen cy , i n te n sity , o r d ura tio n o f pre v io usly s ta b le a n gin a; o r a n gin a th at o ccu rs a t r e st o r i n t h e f ir s t f e w day s a fte r a cu te m yocard ia l i n fa rc tio n. If a n e p is o de o f i s c h em ia i s b rie f, t h e c o ntr a ctile a b norm alitie s d esc rib ed 452 pre v io usly a re q uic k ly r e v ers ib le . B rie f p ostis c h em ic le ft v en tr ic u la r dysfu nctio n i s c alle d s tu nned m yocard iu m (3 6). C hro nic , s u bsta n tia l, nonle th al i s c h em ia m ay r e su lt i n p ro lo nged b ut r e v ers ib le l e ft v en tr ic u la r dysfu nctio n c alle d hib ern atin g m yocard iu m . M yocy te s r e m ain v ia b le b ut ex hib it d ep re sse d c o ntr a ctile f u nctio n. E lim in atio n o f c h ro nic i s c h em ia with r e v asc u la riz atio n r e su lts i n a g ra d ual r e tu rn o f n orm al c o ntr a ctile fu nctio n, a lth ough r e so lu tio n m ay r e q uir e u p t o a year ( 3 7). P ro lo nged , se v ere i s c h em ia r e su lts i n m yocy te n ecro sis ( ir re v ers ib le d am ag e, myocard ia l i n fa rc tio n). Defin it io n o f A cu te C oro n ary S yn dro m es Unsta b le a n gin a p ecto ris , a cu te m yocard ia l i n fa rc tio n, a n d s o m e i n sta n ces of s u dden c ard ia c d eath c o m pris e t h e a cu te c o ro nary sy ndro m es (A CS) (4 ). T he u nderly in g m ech an is m r e su ltin g i n t h ese s y ndro m es i s ath ero sc le ro tic p la q ue e ro sio n, r u ptu re , o r o th er t y pe of p la q ue d is ru ptio n re su ltin g i n t h ro m bus f o rm atio n a n d p ossib ly v aso co nstr ic tio n, w ith su bse q uen t v esse l o cclu sio n a n d a cu te myocard ia l i s c h em ia . The t y pe o f a cu te c o ro nary s y ndro m e t h at o ccu rs i s r e la te d t o t h e d ura tio n of v esse l o cclu sio n. U nsta b le a n gin a i s p ro bab ly th e r e su lt o f t r a n sie n t vesse l o cclu sio n ( < 10 m in ) f o llo w ed b y s p onta n eo us th ro m boly sis ( c lo t dis so lu tio n) a n d v aso re la x atio n. V esse l o cclu sio n p ers is tin g f o r m ore t h an 60 m in r e su lts i n a cu te m yocard ia l i n fa rc tio n. Is c h em ia r e su ltin g f ro m ath ero th ro m botic v esse l o cclu sio n m ay t r ig ger v en tr ic u la r t a ch ycard ia o r ven tr ic u la r f ib rilla tio n an d s u dden c ard ia c d eath ( 4 ). Why d o s o m e p la q ues r u ptu re a n d t h ro m bose ? A ppro xim ate ly t w o-th ir d s of p atie n ts w ith A CS h av e h ig h-ris k o r v uln era b le a th ero sc le ro tic le sio ns with t h in f ib ro us c ap s o verly in g a l ip id -ric h c o re w ith a n a b undan ce o f macro phag es ( 4 ). I n fla m matio n m ed ia te d b y vario us c y to kin es, i n clu din g pro te ase s a n d t u m or n ecro sis f a cto r, e ro des t h e p la q ue f ro m w ith in . T he physic al f o rc es a ssis tin g with p la q ue d is ru ptio n i n clu de i n cre ase d b lo od pre ssu re o r h eart r a te , l o cal v aso co nstr ic tio n, a n d n ic o tin e o r i m mune co m ple x es. Afte r p la q ue r u ptu re , c ir c u la tin g b lo od p la te le ts c o m e i n d ir e ct co nta ct w ith t h e t h ro m bogen ic i n te rn al e n vir o nm en t o f t h e pla q ue, re su ltin g i n c lo t f o rm atio n ( 3 8). Angio gra p hic s tu die s h av e d em onstr a te d t h at m ost o f t h ese r u ptu re -p ro ne le sio ns a re l e ss t h an 5 0% o cclu siv e b efo re t h ey b eco m e dis ru pte d (3 9). This e x pla in s w hy m an y p atie n ts w ho e x perie n ce a n A CS d o n ot h av e 453 warn in g s y m pto m s. H ow ev er, a n gio gra p hic ally s e v ere co ro nary ath ero sc le ro sis d oes i n cre ase t h e l ik elih ood o f a c o ro nary e v en t b y s e rv in g as a m ark er f o r t h e p re se n ce o f e x te n siv e dis e ase , i n clu din g r u ptu re -p ro ne le sio ns. A uto psy s tu die s h av e a ls o d em onstr a te d t h at m an y p atie n ts h av e dis ru pte d p la q ues but n o h is to ry o f a n A CS. T hus, n ot a ll p la q ue d is ru ptio n re su lts i n c lin ic al e v en ts . I n a p pro xim ate ly o ne-th ir d o f c ase s, an A CS re su lts f ro m o nly s u perfic ia l e ro sio n o f a s e v ere ly s te n otic a n d f ib ro tic pla q ue, w ith c lo t f o rm atio n d ue t o a h yperth ro m botic sta te c au se d b y fa cto rs s u ch a s s m okin g, h yperg ly cem ia , o r e le v ate d L D L-C ( 4 ). Acu te M yoca rd ia l I n fa rctio n Acu te m yocard ia l i n fa rc tio n i s t h e n ecro sis ( d eath ) o f c ard ia c m yocy te s re su ltin g f ro m p ro lo nged i s c h em ia c au se d b y c o m ple te vesse l o cclu sio n (4 0). T he k ey e v en t i n d is tin guis h in g r e v ers ib le f ro m i r re v ers ib le (in fa rc tio n) i s c h em ia i s d is ru ptio n o f th e m yocy te m em bra n e ( a l e th al ev en t) . T he m yocy te c an not r e co ver i f m em bra n e d is ru ptio n o ccu rs a n d cy to pla sm ic c o nte n ts s p ill in to t h e c ir c u la tio n. In s o m e p atie n ts , a p re cip ita tin g e v en t, o r t r ig ger, f o r t h e m yocard ia l in fa rc tio n m ay b e d ete rm in ed , s u ch a s p hysic al e x ertio n, em otio nal s tr e ss, or a n ger ( 4 1, 4 2). I t m ay a ls o o ccu r i n t h e s e ttin g o f s u rg ery a sso cia te d with s u bsta n tia l l o ss o f b lo od. There i s e v id en ce f o r c ir c ad ia n v aria tio n, with s lig htly m ore m yocard ia l i n fa rc tio ns o ccu rrin g i n t h e e arly m orn in g hours th an a t o th er t im es, s u ggestin g a r o le f o r s y m path etic n erv ous s y ste m activ atio n a s a t r ig ger ( 4 0, 4 2). Clin ic a l A sse ssm en t When a p atie n t p re se n ts t o a m ed ic al f a cility a n d t h ere i s s u sp ic io n o f ACS, t h e f o llo w in g a sse ssm en t i s w arra n te d . His to ry o f s y m pto m s: S ym pto m s o f m yocard ia l i n fa rc tio n i n clu de ch est p ain o r o th er a n gin al s e n sa tio ns, g astr o in te stin al u pse t, dysp nea, sw eatin g, a n xie ty , o r s y nco pe. I t m ay b e p ain le ss ( s ile n t m yocard ia l in fa rc tio n) i n a p pro xim ate ly 2 5% o f c ase s ( 4 3). Pain i s o fte n s e v ere , but a ll i n te n sitie s o f d is c o m fo rt m ay b e e x perie n ced . E ld erly p atie n ts re p ort m ore d ysp nea, w hile w om en are m ore l ik ely t o r e p ort a ty pic al sy m pto m s, s u ch a s s h ould er, m id dle b ack , o r e p ig astr ic p ain ; f a tig ue; 454 an d g en era l w eak ness (4 4). Physic al e x am in atio n: P atie n ts w ith A CS m ay d em onstr a te t h e fo llo w in g f in din gs o n p hysic al e x am in atio n ( 4 5): Systo lic h ypote n sio n Dia p hore sis Sin us t a ch ycard ia Tach ypnea New m urm ur o f m itr a l r e g urg ita tio n Thir d , f o urth h eart s o unds Pulm on ary r a le s Ele ctr o card io gra m : T he E C G m ay s h ow S T -s e g m en t e le v atio n o r nonsp ecif ic S T -T w av e a b norm alitie s ( s e e E C G C la ssif ic atio n o f Myocard ia l I n fa rc tio n). Chest r a d io gra p h: T his i s u se fu l f o r p atie n ts w ith e v id en ce o f hem odynam ic i n sta b ility o r p ulm onary e d em a. Lab ora to ry r e su lts : T he b io m ark er c ard ia c t r o ponin ( c T n) i s m easu re d tw ic e, 6 t o 1 2 h a p art. A n E C G i s p erfo rm ed o n a d m is sio n an d re p eate d s e ria lly , a s n eed ed . A b lo od l ip id p ro file s h ould b e o bta in ed with in 2 4 h o f s y m pto m o nse t. Dia gn osis o f A cu te M yoca rd ia l I n fa rctio n The d ia g nosis o f m yocard ia l i n fa rc tio n i s b ase d o n t h e p re se n ce o f ele v ate d c ard ia c n ecro sis b io m ark ers p lu s a t l e ast o ne ad ditio nal f a cto r (4 6): Sym pto m s o f i s c h em ia EC G e v id en ce o f m yocard ia l i s c h em ia ( S T -s e g m en t e le v atio n o r dep re ssio n, o r n ew l e ft b undle b ra n ch b lo ck ) New p ath olo gic al Q w av es o n t h e E C G Im ag in g e v id en ce ( u su ally e ch ocard io gra p hy) o f i n fa rc tio n cT n i s t h e p re fe rre d b io m ark er f o r t h e d ete ctio n o f c ard io m yocy te n ecro sis . It i s h ig hly s e n sitiv e a n d s p ecif ic f o r c ard ia c necro sis . E le v atio n o ccu rs 2 to 3 h a fte r t h e o nse t o f i n fa rc tio n a n d r e m ain s e le v ate d f o r 1 t o 2 w k ( 4 7). It s h ould b e n ote d th at c T n i s e le v ate d a fte r p erc u ta n eo us i n te rv en tio n o r card ia c s u rg ery . T he p rio r s ta n dard c ard ia c b io m ark er w as t h e M B f ra ctio n of c re atin e k in ase ( C K -M B) ( 4 8). W hile n ot a s s p ecif ic a n d s e n sitiv e a s cT n, i t i s s till a n a ccep ta b le d ia g nostic t e st i f cT n i s n ot a v aila b le . Afte r m yocard ia l i n fa rc tio n, m yocard ia l c ells d o n ot r e g en era te , a n d healin g o ccu rs v ia s c ar f o rm atio n. D ep en din g o n t h e e x te n t of i n fa rc tio n, 455 sc ar f o rm atio n m ay t a k e d ay s t o w eek s f o r c o m ple tio n. T he l a rg er t h e s iz e of t h e i n fa rc tio n, t h e l a rg er t h e sc ar. ECG C la ssif ic a tio n o f M yo ca rd ia l I n fa rc tio n In fa rc tio ns a re c la ssif ie d a s S T -s e g m en t e le v atio n ( S T EM I) o r n on-S T – se g m en t e le v atio n ( N ST EM I) ( 4 6). Ele ctr o card io gra p hic c rite ria f o r ST EM I a n d N ST EM I a re a s f o llo w s: ST EM I: S T -s e g m en t e le v atio n o f a t l e ast 1 m V i n t w o c o ntig uous le ad s o r n ew l e ft b undle b ra n ch b lo ck NST EM I: S T -s e g m en t d ep re ssio n o r T w av e i n vers io n p ers is tin g a t le ast 2 4 h ST EM I a re t h e r e su lt o f a n o cclu ded e p ic ard ia l c o ro nary a rte ry w ith m ore ex te n siv e m yocard ia l d am ag e a n d a w ors e p ro gnosis . NST EM I h av e l e ss myocard ia l d am ag e b ecau se o f s p onta n eo us t h ro m boly sis ( c lo t dis so lu tio n). Fig ure 1 3.2 s h ow s t h e e v olu tio n o f t h e e le ctr o card io gra m afte r S T EM I, w ith t h e f o rm atio n o f a Q w av e i n dic atin g i n fa rc tio n o f a ll o r most o f t h e t h ic k ness o f t h e v en tr ic u la r w all. T he S T -s e g m en t e le v atio n re su lts f ro m i s c h em ic i n ju ry , a n d i n verte d T w av es are d ue t o i s c h em ia aro und t h e o uts id e b ord ers o f t h e i n fa rc t. A nato m ic l o caliz atio n o f myocard ia l i n fa rc tio ns i s p ossib le if Q w av es a re f o rm ed , a s s h ow n i n Crite ria f o r A nato m ic L ocaliz atio n o f M yocard ia l I n fa rc tio n ( M I) b y Q Wav e A ppeara n ce. 456 F ig u re 1 3.2 The e v olu tio n o f t h e e le ctr o card io gra m i n a cu te S T -s e g m en t ele v atio n m yocard ia l i n fa rc tio n r e su ltin g i n Q w av e f o rm atio n. Rep rin te d b y p erm is sio n f ro m G .T . G au , S ta n dard E le ctr o card io gra p hy, V ecto rc ard io gra p hy a n d Sig nal- A vera g ed E le ctr o card io gra p hy, in C ard io lo gy: F undam en ta ls a nd p ra ctic e, 2nd e d . e d ite d by E .R . G iu lia n i e t a l. ( S t. L ouis : M osb y Y ear B ook, 1 991). Crit e ria f o r A nato m ic L oca liz a tio n o f M yoca rd ia l In fa rctio n ( M I) b y Q W ave A ppea ra n ce 1 . In fe rio r w all M I ( u su ally r ig ht c o ro nary a rte ry o cclu sio n): Q wav e ( > 40 m s d ura tio n, a m plitu de > 25% o f t h e R w av e) i n le ad s II, I II, a n d a V F 2 . Ante rio r w all M I ( le ft a n te rio r d esc en din g c o ro nary a rte ry occlu sio n): Q w av e i n l e ad s V 1 t h ro ugh V 3 ( a n te ro se p ta l) , Q S patte rn in l e ad s V 1 t h ro ugh V 3 ( a n te ro se p ta l) , Q w av e i n le ad s V 2 t h ro ugh V 4 ( a n te rio r), Q S p atte rn i n l e ad s V 2 th ro ugh V 4 ( a n te rio r) 457 3 . Late ra l w all M I ( u su ally c ir c u m fle x c o ro nary a rte ry occlu sio n): Q w av e i n l e ad s V 4 t h ro ugh V 6 o r Q S p atte rn i n le ad s V 4 t h ro ugh V6 4 . Poste rio r w all M I ( u su ally r ig ht c o ro nary a rte ry o cclu sio n): pro m in en t R w av e i n l e ad s V 1 t h ro ugh V 2 w ith p ositiv e T wav es 5 . Hig h l a te ra l w all M I ( u su ally c ir c u m fle x c o ro nary a rte ry occlu sio n): Q w av e i n l e ad s I a n d a V L o r Q S p atte rn i n l e ad s I an d aV L Mech an is tic C la ssif ic a tio n o f M yo ca rd ia l I n fa rc tio n In fa rc tio ns a re a ls o c la ssif ie d b ase d o n t h e p re su m ed c au se o f t h e myocard ia l i s c h em ia ( 4 6): Type 1 : D ue t o p ath olo gy o f t h e w all o f t h e c o ro nary a rte ry , co m monly p la q ue r u ptu re ; r a re ly d ue t o s p onta n eo us c o ro nary dis se ctio n Type 2 : D ue t o i n cre ase d o xygen d em an d o r d ecre ase d s u pply , s u ch as h yperth yro id is m , f e v er, p heo ch ro m ocy to m a, a rrh yth m ia s, hyperte n sio n, c o ro nary a rte ry s p asm , m ic ro vasc u la r s p asm , c o ro nary arte ry e m bolu s, a n em ia , h ypote n sio n Type 3 : S udden u nex pecte d c ard ia c d eath b efo re a v aila b ility o f card ia c b io m ark er a n aly sis Type 4 a: A sso cia te d w ith p erc u ta n eo us c o ro nary i n te rv en tio n ( P C I) Type 4 b: A sso cia te d w ith s te n t t h ro m bosis ( c lo t f o rm atio n w ith in a ste n t) Type 5 : A sso cia te d w ith c o ro nary a rte ry b ypass g ra ft s u rg ery (C A BG ) Dia gn osis o f U nsta b le A ngin a Unsta b le a n gin a h as t h re e p re se n ta tio ns: p ro lo nged r e st a n gin a, n ew -o nse t an gin a, a n d a ccele ra te d a n gin a ( 4 6). D if fe re n tia tio n of u nsta b le a n gin a fro m a cu te m yocard ia l i n fa rc tio n i s b ase d o n b io m ark er e le v atio n. Man agem en t o f A cu te C oro n ary S yn dro m es 458 The f o llo w in g a re t h era p eu tic a p pro ach es t o t r e atin g p atie n ts w ith a cu te co ro nary s y ndro m es ( 4 8, 4 9): Anti- I sc h em ic T hera p y Bed o r c h air r e st w ith c o ntin uous E C G m onito rin g Supple m en ta l o xygen w hen a rte ria l s a tu ra tio ns a re l e ss t h an 9 0% Nitr o gly cerin ; s u blin gual, o ra l, o r i n tr a v en ous a d m in is tr a tio n β-b lo ck er Angio te n sin -c o nvertin g e n zy m e i n hib ito r ( A CEi) i f l e ft v en tr ic u la r eje ctio n f ra ctio n ( L V EF) i s ≤ 40% o r w ith a n te rio r w all myocard ia l in fa rc tio n Angio te n sin r e cep to r b lo ck er f o r p atie n ts w ith e je ctio n f ra ctio ns ≤40% , o r a n te rio r w all m yocard ia l i n fa rc tio n, i f i n to le ra n t of an gio te n sin -c o nvertin g e n zy m e i n hib ito rs Ald oste ro ne a n ta g onis ts f o r p atie n ts w ith S T EM I a n d a n L V EF o f ≤40% w ho a re a lr e ad y r e ceiv in g A CEi Sta tin t o i m pro ve b lo od l ip id p ro file a n d r e d uce t h e r is k o f r e cu rre n t ev en ts In tr a -a o rtic b allo on p um p c o unte rp uls a tio n t o m ain ta in d ia sto lic pre ssu re a n d c o ro nary p erfu sio n Dual A ntip la te le t T hera p y Asp ir in Clo pid ogre l, p ra su gre l, o r t ic ag re lo r Antic o agu la n ts Unfra ctio nate d h ep arin Low m ole cu la r w eig ht h ep arin Biv alir u din ( d ir e ct t h ro m bin i n hib ito r) Pain R elie f ( D esp it e A nti- I sc h em ic T hera p y) Morp hin e Rep erfu sio n T hera p y Rep erfu sio n o f t h e in fa rct-r ela te d a rte ry m ay b e a cco m plis h ed v ia th ro m boly tic t h era p y o r v ia r e v asc u la riz atio n w ith e ith er P C I o r, m uch l e ss co m monly , C A BG ( fo r s e le cte d patie n ts w ith e ith er l e ft m ain o r s e v ere th re e-v esse l c o ro nary a rte ry d is e ase ) ( 4 5, 5 0). T hro m boly tic t h era p y h as 459 not b een dem onstr a te d t o b e b en efic ia l i n N ST EM I. Non -S T -S eg m en t E le va tio n M yo ca rd ia l I n fa rc tio n /U nsta ble Angin a P ecto ris Tw o m an ag em en t o ptio ns a re a v aila b le f o r N ST EM I/u nsta b le a n gin a ( 4 5, 46): 1 . Early i n vasiv e s tr a te g y: D ep en din g o n t h e r e su lts o f c o ro nary an gio gra p hy, t h e p atie n t m ay u nderg o P C I ( b y f a r t h e m ost c o m mon occu rre n ce) o r C A BG i f t h e a n ato m y i s n ot f a v ora b le f o r P C I. M ost patie n ts u nderg o t h e e arly i n vasiv e s tr a te g y i f t h ey a re hosp ita liz ed a t a c en te r c ap ab le o f P C I. 2 . Conse rv ativ e t r e atm en t: O ptim al m ed ic al m an ag em en t w ith g ra d ed ex erc is e t e stin g p erfo rm ed e ith er b efo re d is c h arg e o r e arly afte r dis c h arg e. I f t h e p atie n t a ch ie v es 5 + M ETs w ith out s ig ns o f i s c h em ia , pro gnosis i s f a v ora b le a n d a n gio gra p hy m ay b e defe rre d . ST -S eg m en t E le va tio n M yo ca rd ia l I n fa rc tio n The o ptim al m an ag em en t o f p atie n ts w ith S T EM I i s p ro m pt r e p erfu sio n o f th e i n fa rc t- re la te d a rte ry ( 5 0). T he e arlie r t h e r e p erfu sio n, th e b ette r t h e outc o m e f o r t h e p atie n t i n t e rm s o f l im itin g i n fa rc t s iz e, p re se rv in g l e ft ven tr ic u la r f u nctio n, a n d i m pro vin g su rv iv al. Tw o r e p erfu sio n s tr a te g ie s a re a v aila b le : t h ro m boly sis a n d p rim ary P C I (5 0). P C I i s t h e b est o ptio n f o r t h e p atie n t i f a v aila b le . Thro m boly sis i s perfo rm ed u sin g t is su e i n tr a v en ous p la sm in ogen a ctiv ato rs , s u ch a s te n ecte p la se o r a lte p la se , w hic h b re ak dow n c o ro nary t h ro m bose s. I t i s most e ffe ctiv e i f g iv en d urin g t h e f ir s t 3 h a fte r s y m pto m o nse t. T hese a re th e b en efits o f th ro m boly sis : 1 . It i s r e ad ily a v aila b le i n r u ra l a n d c o m munity h osp ita ls . 2 . It d oesn ’t r e q uir e a c ard io lo gis t o r a c ard ia c c ath ete riz atio n la b ora to ry . 3 . It c an u su ally b e a d m in is te re d w ith in m in ute s o f t h e p atie n t’ s re ach in g t h e h osp ita l. How ev er, t h ro m boly tic t h era p y h as s u bsta n tia l l im ita tio ns ( 5 0): 460 1 . Resto ra tio n o f f u ll c o ro nary b lo od f lo w o ccu rs i n o nly 6 0% t o 7 0% o f case s t r e ate d w ith in 3 h o f s y m pto m o nse t. 2 . Contr a in dic atio ns t o t h ro m boly tic a g en ts , s u ch a s p rio r i n tr a cra n ia l hem orrh ag e, p rio r i s c h em ic s tr o ke, o r a ctiv e b le ed in g, occu r i n 3 0% to 4 0% o f p atie n ts . Patie n ts t r e ate d w ith t h ro m boly sis s h ould b e t r a n sfe rre d i m med ia te ly t o a PC I-c ap ab le f a cility ( fa cilita te d P C I) u nle ss i m possib le becau se o f w eath er or o th er c ir c u m sta n ces. P C I i s b en efic ia l a fte r b oth s u ccessfu l o r f a ile d th ro m boly sis . P rim ary P C I h as im pre ssiv e b en efits ( 5 0): 1 . It i m pro ves m yocard ia l s a lv ag e ( le ss n ecro tic m yocard iu m ). 2 . It l e ad s t o l e ss r e in fa rc tio n a n d v esse l r e o cclu sio n. 3 . It i d en tif ie s c o ro nary a n ato m y m ore s u ita b le f o r C A BG , s u ch a s l e ft main o r s e v ere t h re e-v esse l c o ro nary d is e ase . 4 . The i n vasiv e s tr a te g y h elp s i d en tif y c au se s o f S T -s e g m en t e le v atio n oth er t h an a th ero sc le ro sis , s u ch a s p eric ard itis , m yocard itis , ap ic al ballo onin g s y ndro m e ( T ak ots u bo c ard io m yopath y), c o cain e u se , a n d co ro nary v aso sp asm r e su ltin g f ro m e n doth elia l d ysfu nctio n (4 8). The m ajo r l im ita tio n o f p rim ary P C I i s t h e d ela y i n o pen in g t h e i n fa rc t- re la te d a rte ry o nce s y m pto m s b eg in ( 5 0). F or e v ery 30 m in d ela y , t h ere i s an 8 % i n cre ase i n m orta lity a t 1 y r. D ela y s t o r e p erfu sio n m ay b e p atie n t or h osp ita l d ep en den t. P atie n t- d ep en den t dela y s i n volv e f a ilu re t o re co gniz e a n d a p pre cia te t h e i m porta n ce o f c ard ia c s y m pto m s a n d d ela y s in a ctiv atin g t h e e m erg en cy re sp onse s y ste m ( 9 11). T ypic al p atie n t- re la te d dela y s a re 2 t o 3 h . H osp ita l- d ep en den t d ela y s a re r e la te d t o s y ste m a n d pro cess fa ilu re s f o r t h e p ro m pt d eliv ery o f r e p erfu sio n t h era p y ( 5 1). The o pen -a rte ry h ypoth esis i m plie s t h at e v en a fte r 1 2 t o 4 8 h h av e e la p se d fro m s y m pto m o nse t, P C I m ay s till l im it i n fa rc t siz e a n d i m pro ve s u rv iv al (5 0). A noth er t e rm u se d i n in vasiv e c a rd io lo gy i s no-r e flo w , w hic h i s an gio gra p hic ally o bse rv ed s lo w f lo w i n t h e i n fa rc t- re la te d c o ro nary a rte ry afte r p rim ary P C I a s a r e su lt o f s w olle n en doth elia l c ells a n d s u bse q uen t re d b lo od c ell p lu ggin g o f t h e m ic ro cir c u la tio n ( 5 2a). Pra ctic a l A pplic a tio n 1 3.1 461 Com plic a tio n s o f A cu te M yoca rd ia l I n fa rctio n Arrh yth m ia Sev era l t y pes o f s u pra v en tr ic u la r a rrh yth m ia s a re c o m mon a fte r myocard ia l i n fa rc tio n. Sin us b ra d ycard ia d ue t o e x cessiv e v ag al t o ne o r i s c h em ia o f th e s in oatr ia l n ode Sin us t a ch ycard ia r e la te d t o p ain , f e ar, h eart f a ilu re , o r ex cessiv e s y m path etic n erv ous s y ste m a ctiv atio n Pre m atu re a tr ia l c o ntr a ctio ns— pro vid e n o p ro gnostic in fo rm atio n Atr ia l f ib rilla tio n— obse rv ed i n u p t o 2 0% o f p atie n ts , u su ally tr a n sie n t, m ore f re q uen t i n o ld er p atie n ts , a sso cia te d w ith in cre ase d m orta lity Ven tr ic u la r a rrh yth m ia s a re a ls o c o m mon a fte r m yocard ia l in fa rc tio n. Ven tr ic u la r f ib rilla tio n o ccu rs i n a p pro xim ate ly 5 % o f hosp ita liz ed p atie n ts . β -b lo ck ers a re e ffe ctiv e i n d ecre asin g th e i n cid en ce of t h is a rrh yth m ia i n t h e p eri- in fa rc t p erio d. Ven tr ic u la r t a ch ycard ia i s o bse rv ed i n 1 0% t o 4 0% o f hosp ita liz ed p atie n ts ; i t i s u su ally t r a n sie n t a n d b en ig n i n t h e early postin fa rc t p erio d. Accele ra te d i d io ven tr ic u la r r h yth m i s a ls o o bse rv ed i n 1 0% t o 40% o f h osp ita liz ed p atie n ts . I t i s n ot a sso cia te d w ith in cre ase d morta lity . Pre m atu re v en tr ic u la r c o ntr a ctio ns a re v ery c o m mon d urin g th e p eri- in fa rc t p erio d; t h ere i s n o c le ar r e la tio nsh ip t o t h e r is k of v en tr ic u la r t a ch ycard ia o r v en tr ic u la r f ib rilla tio n. Asy sto le o r e le ctr o m ech an ic al d is so cia tio n i s r a re , b ut i t porte n ds a n e x tr e m ely p oor p ro gnosis . Con ductio n D is tu rb an ces Fir s t- d eg re e A V b lo ck o ccu rs i n 5 % t o 1 0% o f h osp ita liz ed patie n ts . Type I s e co nd-d eg re e A V b lo ck ( W en ck eb ach ) o ccu rs i n 1 0% of h osp ita liz ed p atie n ts . Type I I s e co nd-d eg re e A V b lo ck i s r a re a n d u su ally r e q uir e s 462 pacem ak er i m pla n ta tio n. Thir d -d eg re e A V b lo ck r e q uir e s a t l e ast t e m pora ry p acin g; i t may r e so lv e s p onta n eo usly i n i n fe rio r w all M I. Bundle B ra n ch B lo ck ( B BB) BBB o ccu rs i n a p pro xim ate ly 1 5% o f h osp ita liz ed p atie n ts ; r ig ht bundle b ra n ch b lo ck i s m ore c o m mon t h an l e ft b undle b ra n ch blo ck ( L B BB). L B BB i s a sso cia te d w ith a n i n cre ase d r is k o f t h ir d – deg re e h eart b lo ck a n d i n cre ase d m orta lity . Card io gen ic S hock Card io gen ic s h ock i s t h e r e su lt o f i n ad eq uate c ard ia c o utp ut w ith sig ns o f p ers is te n t h ypote n sio n ( s y sto lic b lo od p re ssu re <80 m mHg fo r m ore t h an 3 0 m in ) a n d a c ard ia c i n dex < 2.0 L · m in −1 · m −2 (n orm al i s a p pro xim ate ly 3 .0 L · m in −1 · m −2 ) i n t h e p re se n ce o f ad eq uate i n tr a v asc u la r v olu m e. I t i s u su ally t h e r e su lt o f a l a rg e myocard ia l i n fa rc tio n. T re atm en t o ptio ns in clu de d ir e ct m onito rin g of p ulm onary c ap illa ry w ed ge p re ssu re w ith a S w an -G an z c ath ete r to d ete rm in e t h e e ffe cts o f p ositiv e in otr o pic a g en ts s u ch a s dobuta m in e, i n se rtio n o f a n i n tr a -a o rtic c o unte rp uls a tio n b allo on pum p t o m ain ta in b lo od p re ssu re , an d p ro m pt p erc u ta n eo us co ro n ary r ev asc u la riz a tio n . M orta lity i s h ig h w ith t h is c o nditio n. In fa rct E xte n sio n a n d E xp an sio n In fa rc t e x te n sio n i s r e cu rre n t n ecro sis o ccu rrin g 2 t o 1 0 d a fte r myocard ia l i n fa rc tio n i n a n a re a r e m ote f ro m t h e o rig in al in fa rc tio n. I n fa rc t e x pan sio n i s t h in nin g a n d d ila ta tio n o f t h e in fa rc te d m yocard iu m w ith out n ew n ecro sis . I t o ccu rs m ost co m monly w ith a n te rio r w all m yocard ia l i n fa rc tio ns a n d m ay re su lt i n a n eu ry sm f o rm atio n, c o ngestiv e h eart f a ilu re , a n d s e rio us ven tr ic u la r a rrh yth m ia s. Myoca rd ia l R uptu re Ruptu re o f t h e v en tr ic u la r f re e w all p re se n ts c ata str o phic ally w ith eith er s u dden d eath d ue t o ele ctr o m ech an ic a l d is so cia tio n (p uls e le ss e le ctr ic a l a ctiv it y ) o r ca rd ia c t a m pon ad e w ith card io gen ic s h ock . F ortu nate ly i t i s r a re a n d o ccu rs m ost co m monly w ith in 4 d o f t h e m yocard ia l i n fa rc tio n. L eft v en tr ic u la r ru ptu re i s m uch m ore c o m mon t h an r ig ht v en tr ic u la r r u ptu re . 463 Pre d is p osin g f a cto rs i n clu de a d van ced a g e a n d f e m ale s e x . T he only a v aila b le t r e atm en t i s e m erg en cy s u rg ery . New M it r a l V alv e R eg u rg it a tio n Mitr a l v alv e r e g urg ita tio n i s m ost o fte n a r e su lt o f p ap illa ry m usc le or c h ord ae r u ptu re r e su ltin g f ro m t h e i n fa rc tio n. I t may a ls o o ccu r becau se o f l e ft v en tr ic u la r d ila ta tio n d ue t o h eart f a ilu re . I t ty pic ally o ccu rs d urin g t h e f ir s t f e w d ay s afte r i n fa rc tio n a n d pre se n ts a b ru ptly w ith h ypote n sio n a n d r ig ht v en tr ic u la r f a ilu re . Tre atm en t i s p ro m pt s u rg ic al i n te rv en tio n, with r e p air o r re p la cem en t o f t h e m itr a l v alv e. Peric a rd ia l E ffu sio n a n d P eric a rd it is Peric ard ia l e ffu sio n i s f lu id a ccu m ula tio n i n t h e p eric ard ia l s p ace. In t h e s e ttin g o f a cu te m yocard ia l i n fa rc tio n, i t i s asso cia te d w ith peric ard itis a n d o ccu rs i n a p pro xim ate ly 1 0% o f h osp ita liz ed patie n ts . T he u su al t r e atm en t i s h ig h-d ose a sp ir in . Postin fa rctio n S yn dro m e Als o k now n a s D re ssle r’s s y ndro m e, p ostin fa rc tio n s y ndro m e i s ple u ritic o r p eric ard ia l c h est p ain a sso cia te d w ith a f ric tio n ru b heard o n a u sc u lta tio n o f t h e h eart. A f o rm o f p eric ard itis , i t u su ally occu rs s e v era l w eek s a fte r m yocard ia l i n fa rc tio n an d i s t r e ate d with h ig h-d ose a sp ir in . Left V en tr ic u la r M ura l T hro m bus Fif ty p erc en t o f p atie n ts w ith a n te rio r w all m yocard ia l i n fa rc tio n will d ev elo p a b lo od c lo t o n t h e e n docard ia l s u rfa ce o f th e l e ft ven tr ic le . A ntic o ag ula tio n w ith w arfa rin f o r a p erio d o f t im e i s t h e usu al t r e atm en t. (5 2a, 5 2b) Rig h t V en tr ic u la r M yoca rd ia l I n fa rctio n Most c o m monly a sso cia te d w ith i n fe rio r w all m yocard ia l i n fa rc tio n, affe ctin g 3 0% o f t h ese p atie n ts , R V i n fa rc tio n i s t h e r e su lt of o cclu sio n o f th e p ro xim al r ig ht c o ro nary a rte ry ( 5 3). P atie n ts w ith R V i n fa rc tio n 464 pre se n t w ith h ypote n sio n a n d s ig ns o f rig ht h eart f a ilu re . I t i s a sso cia te d with h ig h-d eg re e A V b lo ck a n d i n cre ase d i n -h osp ita l m orb id ity a n d morta lity . Thera p y c o nsis ts o f p ro m pt r e p erfu sio n o f t h e r ig ht c o ro nary a rte ry a n d main te n an ce o f a d eq uate R V f u nctio n. F or p atie n ts who s u rv iv e t h e p erio d of h osp ita liz atio n, t h e R V d ysfu nctio n r e so lv es a n d t h ere i s n o a d ditio nal lo ng-te rm i n cre ase i n m orta lity co m pare d w ith p atie n ts w ith i n fe rio r w all myocard ia l i n fa rc tio n w ith out R V i n volv em en t. Facto rs A sso cia te d W it h P oor P ro gn osis The f o llo w in g c h ara cte ris tic s ( o ne o r m ore ) a re a sso cia te d w ith a poor p ro gnosis ( 5 4a, 5 4b): 1 . Left v en tr ic u la r e je ctio n f ra ctio n ≤ 35% ( h eart f a ilu re w ith re d uced e je ctio n f ra ctio n) o r c h ro nic h eart f a ilu re d ue prim arily to d ia sto lic d ysfu nctio n ( h eart f a ilu re w ith p re se rv ed eje ctio n f ra ctio n) 2 . Extr e m ely p oor e x erc is e c ap acity , < 5 M ETs, a sse sse d w ith gra d ed e x erc is e t e stin g 3 . Evid en ce o f e x te n siv e, s e v ere m yocard ia l i s c h em ia d urin g ex erc is e o r p harm aco lo gic s tr e ss t e stin g 4 . Hav in g s u rv iv ed p rim ary ( n ot i n t h e s e ttin g o f a n a cu te myocard ia l i n fa rc tio n) s u dden c ard ia c d eath w ith out t r e atm en t with an i m pla n ta b le c ard io verte r-d efib rilla to r 5 . Sev ere n onre v asc u la riz ed c o ro nary a rte ry d is e ase ( le ft m ain , se v ere p ro xim al t h re e-v esse l d is e ase ) 6 . Com plic atio ns s u ch a s r e n al f a ilu re , s tr o ke Med ic a tio n s f o r O utp atie n ts A fte r M yoca rd ia l In fa rctio n Tab le 1 3.1 p ro vid es a s u m mary o f c o m mon m ed ic atio ns p re sc rib ed f o r patie n ts a fte r m yocard ia l i n fa rc tio n. S ev era l c la sse s o f d ru gs a re asso cia te d with i m pro ved s u rv iv al, s u ch a s a sp ir in , β -b lo ck ers , s ta tin s, a n d 465 an gio te n sin -c o nvertin g e n zy m e i n hib ito rs o r a n gio te n sin re cep to r b lo ck ers an d a ld oste ro ne a n ta g onis ts ( fo r p atie n ts w ith d ep re sse d l e ft v en tr ic u la r eje ctio n f ra ctio n o r a n te rio r wall m yocard ia l i n fa rc tio n) ( 4 9). 466 S tr ess T estin g A fte r A cu te M yoca rd ia l I n fa rctio n E xerc is e t e stin g i s h elp fu l a fte r m yocard ia l i n fa rc tio n f o r t h e f o llo w in g r e aso ns ( 5 5): To e v alu ate s y m pto m s a n d p ote n tia l m yocard ia l i s c h em ia To d ete rm in e t h e n eed f o r c o ro nary a n gio gra p hy i n p atie n ts t r e ate d in itia lly w ith a n onin vasiv e s tr a te g y To d ete rm in e t h e e ffe ctiv en ess o f m ed ic al t h era p y To a sse ss f u tu re r is k a n d p ro gnosis To o bje ctiv ely d ete rm in e e x erc is e c ap acity ( th is i n fo rm atio n i s u se d fo r e x erc is e p re sc rip tio n, e n tr y i n to a n o utp atie n t c ard ia c re h ab ilita tio n p ro gra m , a n d r e tu rn t o w ork a n d o th er a ctiv itie s) S ee t h e C ontr a in dic atio ns s e ctio n o f c h ap te r 5 f o r a b so lu te c o ntr a in dic atio ns t o e x erc is e t e stin g ( 5 5, 5 6). E xerc is e t e st fa cto rs a sso cia te d w ith a n i n cre ase d r is k o f a r e cu rre n t c ard ia c e v en t a n d p oor p ro gnosis i n clu de t h e f o llo w in g ( 5 5, 5 6): In ab ility t o e x erc is e Substa n tia l e x erc is e -in duced m yocard ia l i s c h em ia Exerc is e c ap acity < 5 M ETs Failu re o f s y sto lic b lo od p re ssu re t o i n cre ase a t l e ast 1 0 m mHg T ab le 1 3.2 p ro vid es a n o verv ie w o f s tr e ss t e stin g a fte r m yocard ia l i n fa rc tio n. T he t im in g o f t h e p erfo rm an ce o f a p ostm yocard ia l i n fa rc tio n g ra d ed e x erc is e t e st v arie s, d ep en din g o n t h e c lin ic al s itu atio n a n d t h e 467 pre fe re n ces o f t h e t r e atin g c ard io lo gis t. F or p atie n ts tr e ate d m ed ic ally , a pre d is c h arg e o r e arly p ostd is c h arg e e x erc is e t e st m ay b e p erfo rm ed t o dete rm in e t h e n eed f o r c o ro nary an gio gra p hy ( 5 5, 5 6). G en era lly , i f t e stin g occu rs b efo re 7 d p ostin fa rc tio n, a s u bm ax im al p ro to co l i s s e le cte d , alth ough so m e s tu die s h av e e v alu ate d s y m pto m -lim ite d p ro to co ls a s e arly as 4 d a fte r i n fa rc tio n. S ym pto m -lim ite d t e sts a re g en era lly perfo rm ed 7 o r more d ay s a fte r i n fa rc tio n. T hese t e sts m ay b e p erfo rm ed a t 1 4 t o 2 1 d o r 6 or m ore w eek s a fte r t h e e v en t, dep en din g o n t h e p ra ctic e p atte rn s o f t h e in div id ual c ard io lo gis ts . E xerc is e t e stin g a fte r m yocard ia l i n fa rc tio n i s s a fe if th e p re v io usly m en tio ned c o ntr a in dic atio ns a re n ot p re se n t. I d eally , a sy m pto m -lim ite d g ra d ed e x erc is e t e st s h ould b e p erfo rm ed befo re s ta rtin g outp atie n t c ard ia c r e h ab ilita tio n, a lth ough l o cal p ra ctic e p atte rn s m ay pre clu de t h is . 468 A sse ssm en t o f e x erc is e c ap acity a n d t h e p re se n ce a n d e x te n t o f m yocard ia l i s c h em ia m ay b e a cco m plis h ed u sin g s e v era l d if fe re n t te ch niq ues ( 5 5, 5 6): Sta n dard e x erc is e e le ctr o card io gra m , w ith o r w ith out e x pir e d a ir an aly sis ( c ard io pulm onary e x erc is e t e stin g) Nucle ar i m ag in g m odalitie s t o m easu re m yocard ia l p erfu sio n Ech ocard io gra h ic i m ag in g o f v en tr ic u la r s y sto lic f u nctio n a n d re g io nal w all m otio n I n a ll t e stin g m odalitie s, t h e c lin ic al i n te rp re ta tio n o f t h e t e st r e su lt r e q uir e s i n te g ra tio n o f a ll t h e a v aila b le c lin ic al data . T hese t e sts a re n ot i n fa llib le i n d ete ctin g t h e p re se n ce o r a b se n ce o f m yocard ia l i s c h em ia . A n e x celle n t d is c u ssio n of t e st i n te rp re ta tio n i s p ro vid ed b y E lle sta d a n d c o lle ag ues ( 5 7). S ta n dard e x erc is e e le ctr o card io gra p hy, w ith S T -s e g m en t d ep re ssio n ( o r l e ss c o m monly , S T -s e g m en t e le v atio n) o f > 1 m m a t 0 .0 8 s a fte r t h e J p oin t r e q uir e d f o r t h e d ia g nosis o f i s c h em ia , p ro vid es a s e n sitiv ity o f a p pro xim ate ly 6 5% t o 7 0% ( 5 5). O th er fa cto rs , s u ch a s t h e t im e o f o nse t o f S T d ep re ssio n ( e arly i n e x erc is e v ers u s n ear-m ax im al e x ertio n), t h e m ax im al a m ount o f ST -s e g m en t c h an ge, a n d t h e p re se n ce o f t y pic al a n gin a, i n cre ase t h e a ccu ra cy o f t h e a sse ssm en t o f i s c h em ia . L im ita tio ns o f t h e e x erc is e E C G a re i ts i n ab ility t o d ia g nose i s c h em ia i n t h e s e ttin g o f d ig oxin u se o r a n a b norm al r e st E C G ( p artic u la rly le ft b undle b ra n ch b lo ck ), i n ab ility t o l o caliz e t h e a re a o f t h e m yocard iu m t h at i s i s c h em ic b y S T -s e g m en t d ep re ssio n, l o w er se n sitiv ity t h an w ith i m ag in g t e ch niq ues ( s e n sitiv itie s o f 8 5% +), a n d t h e l a ck o f i n fo rm atio n p ro vid ed r e g ard in g t h e e x te n t of i s c h em ia . T he e x erc is e E C G d oes p ro vid e e v id en ce o f t h e i s c h em ic t h re sh old ( th e h eart r a te a n d s y sto lic b lo od p re ssu re th at c o rre sp onds t o t h e f ir s t e v id en ce o f i s c h em ia ), w hic h i s v alu ab le i n 469 pre sc rib in g p hysic al a ctiv ity f o r p atie n ts . Dir e ct m easu re m en t o f o xygen u pta k e, c arb on d io xid e p ro ductio n, m in ute ven tila tio n, a n d a sso cia te d v aria b le s d urin g g ra d ed ex erc is e (c ard io pulm onary e x erc is e t e stin g) i s p artic u la rly u se fu l i n d ete rm in in g pro gnosis i n p atie n ts w ith c h ro nic h eart fa ilu re ( 5 8). T he t e ch niq ue i s a ls o help fu l i n d ete rm in in g t h e c au se o f u nex pla in ed d ysp nea w ith e x ertio n. I n ad ditio n, t h e dir e ct m easu re m en t o f m ax im al o xygen u pta k e i s m uch m ore accu ra te i n d ete rm in in g a ero bic e x erc is e c ap acity t h an i s e stim atin g ex erc is e c ap acity b ase d o n a ch ie v ed w ork lo ad . Myocard ia l p erfu sio n i m ag in g u sin g r a d io is o to pes ( te ch netiu m s e sta m ib i or t e ch netiu m t e tr o fo sm in ) i s b ase d o n t h e p re m is e th at m yocard ia l u pta k e of t h ese s u bsta n ces i s p ro portio nal t o m yocard ia l b lo od f lo w ( 5 5, 5 6). Im ag es a re o bta in ed a t r e st an d a fte r e x erc is e w ith a s in gle -p hoto n em is sio n c o m pute d t o m ogra p hy c am era s y ste m . R ev ers ib le d efe cts ( b ette r perfu sio n a t re st t h an w ith e x erc is e ) r e p re se n t i s c h em ia . F ix ed d efe cts (p re se n t a t r e st a n d w ith e x erc is e ) r e p re se n t i n fa rc t s c ar o r, le ss c o m monly , stu nned o r h ib ern atin g m yocard iu m . T he i m ag es p ro vid e q uan tif ic atio n o f in fa rc t s iz e. I n e x erc is e e ch ocard io gra p hy, quan tita tiv e e ch o i m ag es o f LV EF a n d e n d-s y sto lic v olu m e, a s w ell a s s u bje ctiv e e ch o i m ag es o f re g io nal w all m otio n a n d t h ic k en in g, are o bta in ed b efo re a n d i m med ia te ly afte r m ax im al e x erc is e ( 5 5, 5 6). T he n ucle ar a n d e ch ocard io gra p hic im ag in g t e ch niq ues are c ap ab le o f l o caliz in g a re as o f i s c h em ia a s w ell a s quan tif y in g t h e e x te n t a n d s e v erity o f i s c h em ia . I m ag in g t e ch niq ues do n ot pro vid e s e ria l i n fo rm atio n r e g ard in g i s c h em ia d urin g g ra d ed e x erc is e a n d th us d o n ot p ro vid e i n fo rm atio n r e g ard in g th e i s c h em ic t h re sh old . Exerc is e f o r s ta n dard e x erc is e e le ctr o card io gra p hy ( w ith o r w ith out card io pulm onary m easu re m en ts ) a n d t h e i m ag in g t e ch niq ues is u su ally perfo rm ed o n a m oto riz ed t r e ad m ill, a lth ough c y cle e rg om etr y , a rm -o nly , or c o m bin atio n a rm a n d l e g e rg om etr y m ay be p re fe ra b le i n c erta in situ atio ns ( 5 6). E xerc is e t e stin g p ro to co ls a n d p ro ced ure s f o r p atie n ts w ith co ro nary a rte ry d is e ase are d esc rib ed i n s e v era l e x celle n t r e fe re n ces a n d will n ot b e r e v ie w ed h ere ( 5 6, 5 7). Pharm aco lo gic s tr e ss u sin g i n tr a v en ous a d m in is tr a tio n o f a c o ro nary vaso dila to r ( a d en osin e) o r a p ositiv e c h ro notr o pic a n d in otr o pic a g en t (d obuta m in e) m ay b e u se d i n c o nju nctio n w ith i m ag in g t e ch niq ues f o r dete ctio n o f m yocard ia l i s c h em ia i n p atie n ts who c an not e x erc is e ad eq uate ly ( 5 5, 5 6). O bvio usly , p harm aco lo gic s tr e ss t e stin g p ro vid es n o 470 in fo rm atio n r e g ard in g e x erc is e cap acity a n d t h e h em odynam ic r e sp onse s to e x erc is e . A den osin e i s t h e m ost c o m mon c o ro nary v aso dila to r u se d i n co nju nctio n with n ucle ar p erfu sio n i m ag in g t e ch niq ues. A n a b norm al f lo w re se rv e ( le ss f lo w i n a p artic u la r r e g io n o f t h e m yocard iu m r e la tiv e to o th er re g io ns) i n t h e t e rrito ry s u pplie d b y a s te n otic c o ro nary a rte ry r e p re se n ts an i s c h em ic r e sp onse . D obuta m in e i s a sy nth etic s y m path om im etic t h at in cre ase s b oth m yocard ia l c o ntr a ctility a n d h eart r a te , t h us e le v atin g myocard ia l o xygen r e q uir e m en t in a m an ner a n alo gous t o e x erc is e . I t i s most c o m monly u se d i n c o nju nctio n w ith e ch ocard io gra p hic a sse ssm en t o f ven tr ic u la r fu nctio n a n d p ote n tia l i s c h em ia . I f a t t h e m ax im um d ose o f dobuta m in e t h e h eart r a te i s b elo w 8 5% o f a g e-p re d ic te d l e v el, atr o pin e may b e g iv en t o f u rth er i n cre ase t h e h eart r a te . Exercis e T ra in in g: I n patie n t C ard ia c Reh ab ilit a tio n Len gth s o f h osp ita l s ta y a fte r a cu te m yocard ia l i n fa rc tio n h av e d eclin ed over t h e p ast t w o d ecad es. C urre n tly , p atie n ts a re hosp ita liz ed f o r n o m ore th an 2 o r 3 d u nle ss c o m plic atio ns a ris e . T he v ast m ajo rity o f p atie n ts w ith unsta b le a n gin a o r a cu te myocard ia l i n fa rc tio n a re t r e ate d i n vasiv ely w ith PC I, a s n ote d p re v io usly . T he d eta ile d , e x pan siv e i n patie n t r e h ab ilita tio n pro to co ls d esc rib ed b y t h is a u th or i n 1 987 s e em a rc h aic c o m pare d w ith to day ’s p ra ctic e p atte rn s ( 5 9). T here i s l ittle o pportu nity fo r f o rm al ex erc is e t r a in in g d urin g h osp ita liz atio n. To m in im iz e t h e d ele te rio us e ffe cts o f b ed r e st, p atie n ts a re m obiliz ed a s so on a s t h ey a re s ta b le . E xposu re t o t h e n orm al str e ss o f g ra v ity i s em phasiz ed i n t h is s ta g e o f r e h ab ilita tio n t o p re v en t o rth osta tic i n to le ra n ce (6 0). P atie n ts s it, s ta n d, perfo rm a ctiv e r a n ge o f m otio n e x erc is e s f o r t h e majo r j o in ts , a n d w alk s h ort d is ta n ces a s s o on a s p ossib le t o p re v en t fu rth er deco nditio nin g. V ario us a llie d h ealth p ro fe ssio nals m ay b e in volv ed i n i n patie n t c ard ia c r e h ab ilita tio n, s u ch a s r e g is te re d nurs e s, physic al t h era p is ts , o ccu patio nal t h era p is ts , a n d e x erc is e p hysio lo gis ts . Patie n ts w ith n eu ro m usc u la r d is e ase s o r oth er c o nditio ns t h at l im it t h eir ab ility t o a m bula te b en efit f ro m f o rm al p hysic al t h era p y t r e atm en ts . A fte r hosp ita l d is m is sa l, fra il e ld erly a n d o th er d eb ilita te d p atie n ts m ay b e re fe rre d t o o utp atie n t p osta cu te o r t r a n sitio nal c are f a cilitie s f o r v ario us tim e p erio ds b efo re r e tu rn in g h om e ( 6 1a). 471 A c ritic al a sp ect o f i n patie n t c ard ia c r e h ab ilita tio n i s t h e i n tr o ductio n o f th e c o ncep ts o f se co n dary c o ro n ary p rev en tio n of a th ero sc le ro sis t o patie n ts a n d f a m ily m em bers ( 6 1a). B asic i n fo rm atio n i s p ro vid ed re g ard in g t h e i m porta n ce o f c ard io pro te ctiv e med ic atio ns, a v oid an ce o f to bacco , h eart- h ealth y e atin g p atte rn s, b lo od p re ssu re a n d b lo od l ip id goals , e x erc is e ( in clu din g an y t e m pora ry r e str ic tio ns i m pose d b y t h e co ro nary e v en t) , p ote n tia l d ep re ssio n a fte r t h e c ard ia c e v en t, a n d r e tu rn t o usu al activ itie s. P atie n ts s h ould b e r e fe rre d t o a n o utp atie n t c ard ia c re h ab ilita tio n p ro gra m i f o ne i s a v aila b le i n t h eir h om e are a. A h om e ex erc is e p re sc rip tio n p ro vid in g g uid an ce a s t o r e co m men ded e x erc is e ty pes, i n te n sity , d ura tio n, f re q uen cy , a n d pro gre ssio n f o r t h e f ir s t f e w week s a fte r h osp ita l d is m is sa l s h ould b e g iv en t o t h e p atie n t. T ypic ally , t h e pre sc rip tio n r e co m men ds walk in g o r s ta tio nary c y clin g a t a c o m fo rta b le in te n sity , b eg in nin g w ith 1 0 t o 2 0 m in o nce o r t w ic e d aily , p ro gre ssin g t o 30 t o 4 5 m in d aily . Exercis e T ra in in g: E arly O utp atie n t Card ia c R eh ab ilit a tio n Outp atie n t c ard ia c r e h ab ilita tio n i s r e co m men ded f o r p atie n ts w ith co ro nary h eart d is e ase b y t h e A m eric an H eart A sso cia tio n, th e A m eric an Colle g e o f C ard io lo gy, a n d t h e A m eric an A sso cia tio n o f C ard io pulm onary Reh ab ilita tio n a n d h as b een a w ard ed a cla ss I i n dic atio n ( th e h ig hest in dic atio n; t h e t r e atm en t i s e ffe ctiv e a n d s h ould b e p ro vid ed ) ( 6 1b). T his phase o f r e h ab ilita tio n can b eg in s o on a fte r h osp ita l d is m is sa l, o fte n w ith in 1 o r 2 w k ( 5 6, 6 1a). D urin g t h e i n te rv al b etw een h osp ita l d is m is sa l an d beg in nin g o utp atie n t r e h ab ilita tio n, p atie n ts a re e n co ura g ed t o e x erc is e in dep en den tly , u sin g t h eir h om e e x erc is e p re sc rip tio n pro vid ed i n t h e hosp ita l. A v arie ty o f h ealth c are p ro fe ssio nals a re t y pic ally i n volv ed i n early o utp atie n t c ard ia c r e h ab ilita tio n, su ch a s p hysic ia n s o r m id le v el pro vid ers , e x erc is e p hysio lo gis ts , r e g is te re d n urs e s, r e g is te re d d ie titia n s, physic al o r o ccu patio nal th era p is ts , s o cia l w ork ers , a n d p sy ch olo gis ts . The i n itia l a sse ssm en t, p erfo rm ed b y c ard ia c r e h ab ilita tio n p ro fe ssio nals , may i n volv e t h e f o llo w in g ( 5 6, 6 1a): 1 . Rev ie w o f t h e m ed ic al r e co rd s, w ith e m phasis o n t h e r e cen t c o ro nary ev en t 2 . Physic al e x am in atio n, p erfo rm ed b y a q ualif ie d m ed ic al p ro fe ssio nal, 472 usu ally a n M D, m id le v el p ro vid er, o r r e g is te re d n urs e ; id eally s h ould in clu de a r e v ie w o f t h e n eu ro m usc u la r s y ste m s i n t e rm s o f p ote n tia l lim ita tio ns t o e x erc is e 3 . Gra d ed e x erc is e t e st, w hic h i d eally s h ould b e p erfo rm ed t o a ssis t w ith ex erc is e p re sc rip tio n a n d w ith r is k a n d p ro gnosis a sse ssm en t; may n ot be a v aila b le i n a t im ely f a sh io n d ep en din g o n l o cal p ra ctic e p atte rn s, so a 6 m in w alk m ay b e p erfo rm ed a s a c h eck of s u bm ax im al e x erc is e re sp onse 4 . Med ic atio n r e v ie w , w ith e m phasis o n c o m plia n ce, s id e e ffe cts , a n d optim al c ard io pro te ctiv e m ed ic atio n u se 5 . Rev ie w o f s ta n dard c o ro nary r is k f a cto rs , w ith e m phasis o n a v oid an ce of t o bacco , p ro per n utr itio n h ab its , c o ntr o l o f b lo od pre ssu re a n d blo od l ip id s, b ody w eig ht o ptim iz atio n, a n d s tr e ss a n d d ep re ssio n man ag em en t 6 . Patie n t- s e le cte d a n d p ro vid er-s e le cte d g oals t o w ork o n d urin g t h e pro gra m 7 . Antic ip ate d r e tu rn t o w ork d ate , i f n eed ed 8 . Expla n atio n o f t h e s h ort- te rm a n d l o ng-te rm b en efits o f e x erc is e tr a in in g, o ptim al c o ntr o l o f c o ro nary r is k f a cto rs , a n d t h e use o f card io pro te ctiv e m ed ic atio ns 9 . Antic ip ate d r e h ab ilita tio n s c h ed ule , i n clu din g n um ber o f re h ab ilita tio n s e ssio ns p er w eek a n d n um ber o f w eek s i n t h e p ro gra m Card ia c r e h ab ilita tio n p ro gra m s a re i d eal f o r h elp in g p atie n ts a ch ie v e t h e se co ndary p re v en tio n g oals o f t a k in g a p pro pria te card io pro te ctiv e med ic atio ns; a v oid in g t o bacco ; f o llo w in g h eart- h ealth y e atin g p atte rn s; perfo rm in g r e g ula r e x erc is e a n d l if e sty le physic al a ctiv ity ; a ch ie v in g a desir a b le b ody w eig ht; o ptim ally c o ntr o llin g b lo od l ip id s, b lo od p re ssu re , an d b lo od g lu co se ; an d m ain ta in in g p sy ch oso cia l h ealth ( 6 1a). T ypic al early o utp atie n t c ard ia c r e h ab ilita tio n p ro gra m s p ro vid e u p t o 3 6 su perv is e d se ssio ns o ver 3 o r m ore m onth s. E ach p atie n t’ s c lin ic al s ta tu s i s ev alu ate d p erio dic ally ( e .g ., h eart r a te , E C G , b lo od p re ssu re , sy m pto m s, mood, m ed ic atio n c o m plia n ce a n d s id e e ffe cts ), a n d o ngoin g m ed ic al su rv eilla n ce i s p ro vid ed . Counse lin g i s a m ajo r c o m ponen t o f p atie n t v is its t o c ard ia c r e h ab ilita tio n. Case m an ag em en t, m ore r e cen tly r e n am ed d is e ase man ag em en t, i n volv es one o r m ore c ard ia c r e h ab ilita tio n s ta ff m em bers t a k in g r e sp onsib ility f o r overs ig ht o f a n i n div id ual patie n t’ s s e co ndary p re v en tio n p ro gra m ( 6 2, 63). Dis e ase m an ag em en t b y c ard ia c r e h ab ilita tio n p ro fe ssio nals h as b een dem onstr a te d t o b e h ig hly e ffe ctiv e i n p ro m otin g p atie n t ad here n ce t o 473 se co ndary p re v en tio n m easu re s. M y o w n p ro gra m i n clu des d is e ase man ag em en t o ver 1 o r m ore y ears o f f o llo w -u p a fte r co m ple tio n o f t h e sta n dard 3 6 c ard ia c r e h ab ilita tio n s e ssio ns c o vere d b y i n su ra n ce ( 6 4). A t e ch niq ue u se d b y h ealth c are p ro vid ers t o h elp p atie n ts m ak e h ealth y ch an ges i n b eh av io r i s m otiv atio nal i n te rv ie w in g ( 6 5). The t e ch niq ue i s n ot dif fic u lt t o l e arn a n d i n volv es d ev elo pin g a p artn ers h ip w ith t h e p atie n t th at h onors t h e i n div id ual’ s pers p ectiv es a n d t a le n ts . T here a re f o ur gen era l p rin cip le s o f m otiv atio nal i n te rv ie w in g: 1 . Expre ss e m path y. 2 . Dev elo p d is c re p an cy : T he p atie n t n eed s t o p erc eiv e a d is c re p an cy betw een p re se n t b eh av io r a n d i m porta n t g oals . 3 . Roll w ith r e sis ta n ce: A void a rg uin g f o r c h an ge. 4 . Support s e lf -e ffic acy : A n i m porta n t m otiv ato r f o r c h an ge i s t h e patie n t’ s b elie f i n t h e p ossib ility o f c h an ge. Exercis e P resc rip tio n The p re sc rip tio n o f e x erc is e a fte r a n a cu te c o ro nary s y ndro m e s h ould b e in div id ualiz ed , b ase d o n f a cto rs s u ch a s t h e f o llo w in g (5 4a, 5 6): Exerc is e c ap acity Is c h em ic o r a n gin al t h re sh old o r b oth Cognitiv e a n d p sy ch olo gic al i m pair m en ts Vocatio nal a n d a v ocatio nal r e q uir e m en ts Musc u lo sk ele ta l l im ita tio ns Obesity Prio r p hysic al a ctiv ity h is to ry Patie n t g oals Tab le 1 3.3 g iv es a n o verv ie w o f t h e c o m ponen ts o f a n e x erc is e pre sc rip tio n f o r a c o ro nary p atie n t. 474 I n a n i d eal w orld , p atie n ts w ith a r e cen t a cu te c o ro nary s y ndro m e w ould e x erc is e w ith m ed ic al s u perv is io n i n a n o utp atie n t card ia c r e h ab ilita tio n p ro gra m f o r a t l e ast s e v era l w eek s. U nfo rtu nate ly , s o m e g eo gra p hic al a re as d o n ot h av e s u ffic ie n t p ro gra m s to e n su re e asy a ccessib ility f o r a ll p atie n ts . P atie n ts m ay p re se n t m ultip le b arrie rs f o r a tte n dan ce a t t h e s ta n dard t h re e su perv is e d e x erc is e s e ssio ns p er w eek o f a t y pic al c ard ia c r e h ab ilita tio n p ro gra m , s u ch a s r e tu rn t o f u ll- tim e e m plo ym en t with in a f e w d ay s o f h osp ita l d is m is sa l, d if fic u lty s e cu rin g r e lia b le t r a n sp orta tio n t o a n d f ro m t h e r e h ab ilita tio n c en te r, an d e x cessiv e o ut- o f-p ock et c o sts ( e .g ., c o in su ra n ce, p ark in g f e es). H ig h-ris k a n d d eb ilita te d p atie n ts a re b est s e rv ed w ith fre q uen t s u perv is e d r e h ab ilita tio n s e ssio ns. N onhig h-ris k p atie n ts m ay b en efit f ro m f le x ib ility i n p ro gra m d esig n. M ed ic are will r e im burs e f o r u p t o 3 6 r e h ab ilita tio n s e ssio ns o ver a 3 6 w k p erio d, a s w ill m ost p riv ate i n su ra n ce p ro vid ers . P atie n ts may a tte n d o ne t o t h re e s e ssio ns w eek ly , w ith a d ditio nal i n dep en den t e x erc is e a s p re sc rib ed b y c ard ia c r e h ab ilita tio n s ta ff. Som e p atie n ts w ill n ot b e a b le t o a tte n d a f o rm al p ro gra m a n d w ill r e q uir e a n e n tir e ly i n dep en den t p ro gra m . R ecen tly p ublis h ed perfo rm an ce m easu re s f o r t h e r e fe rra l t o a n d d eliv ery o f c ard ia c r e h ab ilita tio n a n d s e co ndary p re v en tio n s e rv ic es s h ould h elp patie n ts o bta in a p pro pria te p osth osp ita l c o ro nary d is e ase p re v en tio n c are ( 7 4). 475 Afte r c o m ple tio n o f a s ta n dard c ard ia c r e h ab ilita tio n p ro gra m o f 3 6 se ssio ns, m ost p atie n ts w ill n eed t o c o ntin ue e x erc is e tr a in in g in dep en den tly ( o uts id e o f a f o rm al p ro gra m ). C om plia n ce w ith in dep en den t e x erc is e m ay b e i m pro ved w ith f o llo w -u p vis its w ith h ealth care p ro vid ers . I n m y o w n p ro gra m , p atie n ts a re e n co ura g ed t o r e tu rn f o r re g ula r f o llo w -u p w ith t h e c ard ia c re h ab ilita tio n s ta ff o n a c o ntin uin g b asis (6 4). S om e c ard ia c r e h ab ilita tio n p ro gra m s h av e s u ffic ie n t c ap acity t o offe r p atie n ts a m ain te n an ce e x erc is e p ro gra m ( u su ally p atie n t f u nded ) f o r a p erio d o f m onth s u p t o l if e -lo ng p artic ip atio n. S om e p ro gra m s in clu de sp ouse s t o a id i n r e te n tio n o f p atie n ts i n m ain te n an ce p ro gra m s. Freq uen cy Exerc is e s e ssio ns s h ould o ccu r a t l e ast 3 d /w k a n d i d eally o n m ost d ay s o f th e w eek ( i.e ., 4 -7 d/w k). W ith t h e e x cep tio n o f ex tr e m ely h ig h-ris k patie n ts , o ne o r m ore s e ssio ns p er w eek s h ould b e p erfo rm ed in dep en den tly , o uts id e o f t h e s u perv is e d e n vir o nm en t of a c ard ia c re h ab ilita tio n p ro gra m . P atie n ts w ith v ery l im ite d e n dura n ce m ay p erfo rm multip le s h ort- d ura tio n ( 1 -1 0 m in ) s e ssio ns daily . In te n sit y Exerc is e i n te n sity m ay b e p re sc rib ed u sin g o ne o r m ore o f t h e f o llo w in g: Ratin g o f p erc eiv ed e x ertio n ( R PE ) o f 1 1 t o 1 6 o n a s c ale o f 6 t o 2 0 40% t o 8 0% o f e x erc is e c ap acity u sin g t h e h eart r a te r e se rv e m eth od, or t h e p erc en t p eak o xygen u pta k e r e se rv e t e ch niq ue i f max im al ex erc is e t e st d ata a re a v aila b le When e x erc is e t e st o r p harm aco lo gic s tr e ss d ata a re n ot a v aila b le , upper-lim it h eart r a te o f r e stin g h eart r a te + 2 0 b eats /m in an d R PE o f 11 t o 1 4, g ra d ually t itr a tin g t h e h eart r a te t o h ig her l e v els a cco rd in g t o RPE , s ig ns a n d s y m pto m s, a n d n orm al physio lo gic r e sp onse s Exerc is e i n te n sity s h ould b e k ep t b elo w t h e i s c h em ic t h re sh old , i f o ne h as been d em onstr a te d t o e x is t, u nle ss t h e r e sp onsib le physic ia n r e co m men ds oth erw is e i n p atie n ts w ith i s c h em ia , e v en a t v ery l o w e x erc is e i n te n sitie s. Patie n ts s h ould t a k e t h eir m ed ic atio ns o n s c h ed ule f o r p erfo rm an ce o f ex erc is e t r a in in g s e ssio ns. C han ges i n t h e d ose s o f β-b lo ck ers o r o th er dru gs t h at a ffe ct t h e c h ro notr o pic r e sp onse t o e x erc is e m ay o ccu r. I n t h ese 476 case s, i t i s u nlik ely t h at a n ew e x erc is e t e st w ill b e p erfo rm ed s o le ly f o r t h e purp ose o f d ete rm in in g a n ew t a rg et h eart r a te . U sin g R PE a n d s ig ns a n d sy m pto m s, a s w ell a s d ete rm in in g t h e n ew t a rg et h eart r a te a t p re v io usly perfo rm ed w ork i n te n sitie s, i s r e co m men ded . I t i s co m mon f o r c ard ia c re h ab ilita tio n p ro fe ssio nals t o d ia g nose h ypote n sio n, e ith er o rth osta tic , a t re st, d urin g e x erc is e , o r afte r e x erc is e , d ue t o e x cessiv e m ed ic atio n d osa g e. Dura tio n Patie n ts s h ould p erfo rm w arm -u p a n d c o ol- d ow n a ctiv itie s, i n clu din g sta tic s tr e tc h in g t o i m pro ve r a n ge o f m otio n a n d l o w -in te n sity aero bic ex erc is e , f o r 5 t o 1 0 m in b efo re a n d a fte r t h e c o nditio nin g p hase o f ex erc is e . T he g oal d ura tio n f o r c o nditio nin g aero bic e x erc is e i s 2 0 t o 6 0 min p er s e ssio n. P atie n ts m ay b eg in w ith a n e asily t o le ra b le d ura tio n o f 5 to 1 0+ m in , w ith a gra d ual i n cre ase o f 1 t o 5 m in p er s e ssio n o r 1 0% t o 20% p er w eek , a s t o le ra te d . T he p ro gre ssio n i n d ura tio n s h ould b e in div id ualiz ed fo r e ach p atie n t; s o m e p atie n ts m ay b e a b le t o p ro gre ss much m ore r a p id ly t h an o th ers b ase d o n f itn ess, e x erc is e h ab its im med ia te ly prio r t o t h e c o ro nary e v en t, s y m pto m s, a n d m usc u lo sk ele ta l lim ita tio ns. F ra il a n d o th erw is e e x tr e m ely d eco nditio ned p atie n ts may re q uir e i n te rm itte n t e x erc is e , a lte rn atin g s h ort p erio ds o f e x erc is e w ith r e st bre ak s, a lth ough m ost p atie n ts c an p erfo rm co ntin uous e x erc is e . Typ e Aero bic f o rm s o f e x erc is e s h ould i n clu de r h yth m ic l a rg e-m usc le g ro up activ itie s. I d eally , b oth u pper a n d l o w er e x tr e m ity e x erc is e s sh ould b e in co rp ora te d i n to t h e p ro gra m , s u ch a s t h ese : Tre ad m ill o r t r a ck f o r w alk in g ( jo ggin g o r i n clin ed w alk in g f o r m ore fit p atie n ts ) Uprig ht o r r e cu m ben t c y cle Com bin atio n u pper a n d l o w er e x tr e m ity e rg om ete r Ellip tic al Sta ir s te p per Arm e rg om ete r Row er In dep en den t e x erc is e o fte n i n clu des w alk in g o utd oors , w ith o r w ith out hills , o r w alk in g i n doors a t s h oppin g m alls o r s c h ools th at a re o pen t o t h e 477 public f o r t h is p urp ose . Resis ta n ce T ra in in g The v ast m ajo rity o f p atie n ts w ith t r e ate d a cu te c o ro nary s y ndro m es sh ould p erfo rm s tr e n gth t r a in in g a s a c o m ponen t o f t h eir ex erc is e p ro gra m . Patie n ts w ith s e v ere i s c h em ia o r h em odynam ic i n sta b ility s h ould b e ad eq uate ly s ta b iliz ed b efo re b eg in nin g str e n gth en in g e x erc is e s. T he purp ose s o f s tr e n gth t r a in in g f o r p atie n ts i n clu de t h e f o llo w in g ( 5 6): To i n cre ase m usc u la r s tr e n gth a n d e n dura n ce To d ecre ase c ard ia c d em an ds o f m usc u la r w ork ( re d uce ra te – pressu re p ro d uct [ R PP] w ith l if tin g a n d c arry in g a ctiv itie s o f d aily lif e ) To i m pro ve s e lf -c o nfid en ce To m ain ta in i n dep en den ce ( e n ab le p atie n t t o p erfo rm h ouse h old a n d pers o nal c are d utie s) To p re v en t d is e ase s s u ch a s o ste o poro sis , t y pe 2 d ia b ete s, a n d o besity To s lo w t h e a g e-re la te d d eclin es i n s k ele ta l m usc le m ass a n d s tr e n gth Alth ough g uid elin es f o r s tr e n gth t r a in in g i n c ard ia c p atie n ts t r a d itio nally re co m men d w aitin g 5 w k f ro m t h e d ate o f m yocard ia l in fa rc tio n b efo re beg in nin g s tr e n gth t r a in in g, i n m y o w n p ro gra m p atie n ts b eg in s u ch tr a in in g w ith in 2 w k o f t h e e v en t. S ev era l th ousa n d p atie n ts h av e f o llo w ed th is p ra ctic e, a n d t h ere h av e b een n o c o m plic atio ns a sso cia te d w ith str e n gth t r a in in g. Equip m en t f o r s tr e n gth t r a in in g m ay i n clu de f re e w eig hts , e la stic b an ds, weig ht m ach in es w ith p ulle y d ev ic es, s ta b ility b alls , an d w eig hte d w an ds. Patie n t b ody w eig ht m ay a ls o b e u se d a s r e sis ta n ce f o r s e le cte d e x erc is e s. Movem en ts s h ould b e p erfo rm ed in a s lo w , c o ntr o lle d m an ner w hile main ta in in g a r e g ula r b re ath in g p atte rn a n d a v oid in g s tr a in in g a n d musc u lo sk ele ta l p ain . RPE r a tin gs i n itia lly s h ould r a n ge f ro m 1 1 t o 1 4 o n th e 6 t o 2 0 s c ale . I n itia l r e sis ta n ces s h ould a llo w 1 2 t o 1 5 r e p etitio ns (a p pro xim ate ly 3 0% t o 6 0% o f 1 R M ). T he r e sis ta n ce m ay b e g ra d ually in cre ase d , a n d m ost p atie n ts m ay p ro gre ss t o 8 t o 1 2 r e p etitio ns with a re sis ta n ce o f 6 0% t o 8 0% o f 1 R M , w ith o ne t o f o ur s e ts o f r e p etitio ns. Exerc is e s s h ould b e p erfo rm ed f o r t h e m ajo r musc le g ro ups, u su ally 8 t o 10 d if fe re n t e x erc is e s. F re q uen cy s h ould b e 2 o r 3 s e ssio ns p er w eek o n nonco nse cu tiv e d ay s. 478 Aero bic I n te rv a l T ra in in g Over t h e p ast 3 5 y ears , t h ere h as b een a g ra d ual e asin g o f r e str ic tio ns re g ard in g e x erc is e t r a in in g f o r p atie n ts w ith c ard io vasc u la r dis e ase s. F or ex am ple , o utp atie n t e x erc is e t r a in in g a fte r m yocard ia l i n fa rc tio n n ow beg in s w ith in a f e w d ay s o f h osp ita l d is m is sa l (ra th er t h an s e v era l w eek s), with m ore a g gre ssiv e a ero bic e x erc is e a n d s tr e n gth t r a in in g ( fo rb id den i n th e p ast) . P atie n ts with c h ro nic h eart f a ilu re a re n ow e n co ura g ed t o ex erc is e r a th er t h an t o r e st. T he l a te st e x erc is e t a b oo t o b e l if te d i s h ig h- in te n sity in te rv al t r a in in g f o r c ard ia c p atie n ts . I n vestig ato rs h av e docu m en te d s u perio r i m pro vem en ts i n O 2 peak , m easu re s o f e n doth elia l fu nctio n, a n d l e ft v en tr ic u la r s y sto lic a n d d ia sto lic f u nctio n i n c o ro nary patie n ts w ith h ig h-in te n sity in te rv al t r a in in g ( u p t o 9 5% o f m ax im al h eart ra te f o r s h ort p erio ds o f t im e i n te rs p ers e d w ith l o w er-in te n sity e x erc is e ) co m pare d with c o nven tio nal c o ntin uous a ero bic t r a in in g ( 6 6, 6 7). In m y o w n p ro gra m , w e h av e u se d i n te rv al t r a in in g i n s e v era l t h ousa n d card ia c p atie n ts f o r t h e p ast 9 y r a n d h av e n ot e n co unte re d sa fe ty i s su es o r patie n t r e lu cta n ce t o t r y i t. W e s ta rt w ith a p pro xim ate ly 2 w k o f s ta n dard co ntin uous a ero bic t r a in in g, i n cre asin g th e d ura tio n t o a t l e ast 2 0 m in befo re b eg in nin g i n te rv al t r a in in g. W e s ta rt w ith 3 0 s i n te rv als , t h re e t o fiv e t im es d urin g th e e x erc is e s e ssio n, i n te rs p ers e d w ith l o w er-in te n sity ex erc is e f o r 2 t o 3 m in . O ver a p erio d o f d ay s t o w eek s, t h e l e n gth of t h e hig h-in te n sity i n te rv als i s i n cre ase d t o 6 0 t o 1 20 s o r l o nger, a s t o le ra te d . In te rv al t r a in in g o ccu rs 2 o r 3 d /w k. Bala n ce E xerc is e s Man y p artic ip an ts i n c ard ia c r e h ab ilita tio n p ro gra m s a re o ld er t h an 6 5 y r. With i n cre asin g a g e, t h e n eu ro m usc u la r r e fle x es in volv ed w ith pro prio cep tio n a n d b ala n ce b eco m e l e ss e ffe ctiv e. F alls a re a c o m mon cau se o f m orb id ity a n d m orta lity i n o ld er in div id uals . A b ala n ce ab norm ality w as f o und i n o ver h alf o f a c o nse cu tiv e s a m ple o f 2 84 partic ip an ts i n m y p ro gra m ( 6 8). Wom en a n d p atie n ts o ver 6 5 y r o f a g e were m ore l ik ely t o e x hib it p oor b ala n ce. A s p art o f t h e b ase lin e asse ssm en t o f p atie n ts beg in nin g o utp atie n t c ard ia c r e h ab ilita tio n, a bala n ce a sse ssm en t u sin g s im ple t e ch niq ues s u ch a s t h e s in gle -le g s ta n d an d th e t a n dem g ait ( w alk in g h eel t o t o e i n a s tr a ig ht l in e) s h ould b e perfo rm ed . F or p atie n ts w ith p oor b ala n ce, s p ecif ic e x erc is e s may b e 479 pre sc rib ed ( 5 6). Lif e sty le P hysic a l A ctiv ity In a d ditio n t o f o rm al e x erc is e s e ssio ns, p atie n ts s h ould b e e n co ura g ed t o gra d ually r e tu rn t o g en era l a ctiv itie s o f l if e , su ch a s w alk in g f o r tr a n sp orta tio n, h ouse h old t a sk s, s h oppin g, g ard en in g, n onse d en ta ry hobbie s, a n d s p ort a ctiv itie s ( 5 6). Measu rin g l if e sty le a ctiv ity i s r e la tiv ely easy u sin g a p ed om ete r ( s te p s/d ay ), w ris t- w orn a ctiv ity s e n so r, o r v ario us sm artp hone ap plic atio ns. T he m ore t im e s p en t s ittin g, s u ch a s w atc h in g te le v is io n o r o n t h e c o m pute r, t h e g re ate r t h e r is k o f c ard io vasc u la r an d all- c au se m orta lity a s w ell a s n onfa ta l c ard io vasc u la r e v en ts ( 6 9, 7 0). Gre ate r e n erg y e x pen ditu re r e su ltin g f ro m i n cre ase d lif e sty le p hysic al activ ity f a cilita te s w eig ht l o ss. Exercis e P ro gra m min g f o r O verw eig h t C oro n ary Patie n ts The v ast m ajo rity o f c o ro nary p atie n ts w ho e n te r o utp atie n t c ard ia c re h ab ilita tio n a re e ith er o verw eig ht o r o bese . S ta n dard ex erc is e pro to co ls u se d i n m ost p ro gra m s— 30 t o 4 5 m in o f m odera te – in te n sity a ero bic e x erc is e t h re e t im es p er w eek ( a p pro xim ate ly 800 kcal/w k) f o r 3 m o— are g en era lly n ot a d eq uate t o r e su lt i n su bsta n tia l b ody f a t l o ss. I n vestig ato rs u se d a h ig h-c alo rie ex erc is e pro to co l ( a p pro xim ate ly 3 ,0 00 k cal/w k), w hic h r e q uir e d 4 5 t o 6 0 min o f w alk in g m ore t h an 4 d /w k ( 7 1). C om pare d w ith sta n dard card ia c r e h ab ilita tio n, t h e h ig h-c alo rie e x erc is e p ro to co l r e su lte d i n tw ic e t h e w eig ht l o ss ( 8 .2 k g v s. 3 .7 k g). In m y o w n p ro gra m , w e e n co ura g e p atie n ts w ho d esir e t o l o se co nsid era b le w eig ht t o c o nsu lt w ith o ur r e g is te re d d ie titia n , gra d ually i n cre ase e x erc is e d ura tio n t o 6 0 m in f iv e o r s ix d /w k, in co rp ora te h ig h-in te n sity i n te rv al t r a in in g 2 o r 3 d /w k, an d perfo rm m odera te s tr e n gth t r a in in g u sin g f re e w eig hts a n d w eig ht mach in es 2 o r 3 d /w k. T his h ig h-v olu m e e x erc is e p ro to co l re q uir e s very m otiv ate d p atie n ts . 480 Safe ty o f E xercis e T ra in in g f o r C oro n ary P atie n ts Superv is e d e x erc is e t r a in in g h as b een d em onstr a te d t o b e s a fe f o r p atie n ts with c ard io vasc u la r d is e ase s. F ra n klin a n d c o lle ag ues re p orte d t h e a v era g e in cid en ce o f c ard ia c a rre st, n onfa ta l m yocard ia l i n fa rc tio n, a n d d eath a s one f o r e v ery 1 17,0 00, 2 20,0 00, an d 7 50,0 00 p atie n t- h ours o f partic ip atio n, r e sp ectiv ely ( 7 2). A l a rg e t r ia l o f o ver 1 ,0 00 h ig her-ris k patie n ts w ith c h ro nic heart f a ilu re ( m ore t h an h alf w ith c o ro nary d is e ase ) stu die d t h e s a fe ty o f s u perv is e d a n d i n dep en den t m odera te -in te n sity aero bic ex erc is e t r a in in g. O ver a p pro xim ate ly 3 0 m o, t h ere w ere 3 7 e v en ts asso cia te d w ith e x erc is e t h at r e su lte d i n h osp ita liz atio n. In o ver s e v era l millio n p atie n t- h ours o f e x erc is e , o nly f iv e d eath s o ccu rre d ( 7 3). T he ben efits o f e x erc is e t r a in in g f a r o utw eig h th e r is k s f o r c o ro nary p atie n ts with out a b so lu te c o ntr a in dic atio ns t o e x erc is e . Ben efit s o f C ard ia c R eh ab ilit a tio n a n d S eco n dary Prev en tio n P ro gra m s The f o llo w in g l is t s u m mariz es t h e i m porta n t b en efits a v aila b le t o p atie n ts with c o ro nary d is e ase w ho p artic ip ate i n c ard ia c re h ab ilita tio n ( 7 5, 7 6, 7 7, 78). A s a r e su lt o f t r a in in g, O 2 peak m ay i m pro ve 1 0% t o 2 0% o r m ore (7 5). I n g en era l, t h e m ag nitu de o f t h e r e la tiv e i m pro vem en t i s i n vers e ly pro portio nal to t h e b ase lin e e x erc is e c ap acity . T he r a te o f i m pro vem en t i s gre ate st d urin g t h e f ir s t 3 m o o f t r a in in g, b ut i n cre ase s i n aero bic c ap acity may c o ntin ue f o r 6 m o o r m ore . H ig h-in te n sity i n te rv al t r a in in g r e su lts i n gre ate r i m pro vem en ts i n O 2 peak t h an t r a d itio nal c o ntin uous i n te n sity tr a in in g ( 6 6). Sum mary o f B en efit s o f C ard ia c R eh ab ilit a tio n P ro gra m s Im pro ved a ero bic c ap acity In cre ase i n s u bm ax im al e x erc is e e n dura n ce In cre ase i n m usc u la r s tr e n gth Red uctio n i n s y m pto m s: a n gin a p ecto ris , d ysp nea o n e x ertio n, fa tig ue, c la u dic atio n Vasc u la r r e g en era tio n v ia b one m arro w –deriv ed e n doth elia l pro gen ito r c ells Decre ase i n m yocard ia l i s c h em ia a n d p ote n tia l i n cre ase i n m yocard ia l 481 perfu sio n Im pro ved e n doth elia l f u nctio n Im pro ved l e ft v en tr ic u la r s y sto lic a n d d ia sto lic f u nctio n i n c h ro nic heart f a ilu re Pote n tia l r e ta rd atio n o f c o ro nary d is e ase p ro gre ssio n a n d a ctu al re g re ssio n o f p la q ue In co rp ora tio n o f h eart- h ealth y d ie ta ry p ra ctic es Im pro ved b lo od l ip id p ro file Im pro vem en t i n i n dic es o f o besity Decre ase i n b lo od p re ssu re Decre ase i n t o bacco u se Im pro ved g lu co se i n to le ra n ce a n d i n su lin r e sis ta n ce Decre ase i n i n fla m mato ry m ark ers ( e .g ., h ig h-s e n sitiv e C r e activ e pro te in , h sC RP) Im pro ved a u to nom ic t o ne: l e ss s y m path etic a ctiv ity , m ore para sy m path etic a ctiv ity Red uctio n i n v en tr ic u la r a rrh yth m ia s Im pro ved b lo od p la te le t f u nctio n a n d b lo od r h eo lo gy Im pro ved p sy ch oso cia l f u nctio n ( le ss d ep re ssio n, a n xie ty , so m atiz atio n, h ostility ) Rep eate d s u rv eilla n ce o f b lo od p re ssu re , s y m pto m s, a rrh yth m ia s, a n d so o n, l e ad in g t o e arlie r t r e atm en t Im pro ved p atie n t c o m plia n ce w ith t a k in g c ard io pro te ctiv e med ic atio ns Red uced r e h osp ita liz atio ns Red uced h ealth c are c o sts Red uced m orta lity Str e n gth t r a in in g r e su lts i n s ig nif ic an t g ain s i n s k ele ta l m usc le s tr e n gth . Sym pto m s r e la te d t o c o ro nary d is e ase u su ally i m pro ve with c ard ia c re h ab ilita tio n. L eft v en tr ic u la r f u nctio n m ay i m pro ve. I m pro vem en t i n co ro nary r is k f a cto rs i s o bse rv ed . A th ero gen esis is s lo w ed , e n doth elia l fu nctio n i s i m pro ved , a n d m yocard ia l i s c h em ia m ay b e l e sse n ed . Psy ch oso cia l f u nctio n m ay i m pro ve ( 7 5, 76, 7 7, 7 8). A m eta -a n aly sis o f se v era l r a n dom iz ed t r ia ls d em onstr a te d a 3 1% r e d uctio n i n m orta lity f o r patie n ts w ho p artic ip ate d in c ard ia c r e h ab ilita tio n ( 7 9). For m y o w n pro gra m , l o cate d a t a n a cad em ic m ed ic al c en te r, w e h av e d em onstr a te d a 56% , 4 5% , a n d 4 6% r e d uctio n i n a ll- c au se morta lity f o r p artic ip an ts w ith eith er a cu te m yocard ia l i n fa rc tio n, P C I, o r C A BG , r e sp ectiv ely , c o m pare d with n onpartic ip an ts (8 0, 8 1a, 8 1b). In a d ditio n, i n a l a rg e s a m ple o f Med ic are b en efic ia rie s, a d ose – re sp onse r e la tio nsh ip b etw een t h e n um ber 482 of c ard ia c r e h ab ilita tio n se ssio ns a tte n ded a n d v ario us c ard io vasc u la r outc o m es w as d ete rm in ed ( i.e ., t h e m ore s e ssio ns a tte n ded , t h e b ette r t h e outc o m es) (8 2). Underu tiliz a tio n o f C ard ia c R eh ab ilit a tio n S erv ic es In s p ite o f t h e i m pre ssiv e b en efits o f e x erc is e -b ase d c ard ia c r e h ab ilita tio n, most p atie n ts d o n ot a tte n d a fte r a n a cu te c o ro nary sy ndro m e. A m ong Med ic are b en efic ia rie s, o nly 1 9% o f e lig ib le p atie n ts p artic ip ate i n outp atie n t c ard ia c r e h ab ilita tio n ( 8 3). Old er a d ults , n onw hite s, p atie n ts with c o m orb id itie s, p atie n ts w ith l o w s o cio eco nom ic s ta tu s, t h e unem plo yed , s in gle p are n ts , an d w om en a re l e ss l ik ely t o p artic ip ate ( 8 4, 85, 8 6). S uggeste d s te p s t o i m pro ve t h e e n ro llm en t r a te i n c ard ia c re h ab ilita tio n pro gra m s i n clu de a u to m atin g t h e r e fe rra l p ro cess, desig natin g r e fe rra l a n d e n ro llm en t i n c ard ia c r e h ab ilita tio n a s a q uality in dic ato r i n c ard io vasc u la r c are , d esig nin g p ro gra m s t h at u tiliz e t h e te le p hone o r I n te rn et f o r p atie n ts w ho l iv e i n a re as with out p ro gra m s, dete rm in in g h ow b est t o i n clu de u nders e rv ed p opula tio ns, a n d d ev elo pin g a m ultim ed ia e d ucatio n p ro gra m o n th e b en efits o f c ard ia c r e h ab ilita tio n dir e cte d a t b oth p atie n ts a n d h ealth c are p ro vid ers ( 8 7). Con clu sio n Acu te c o ro nary s y ndro m es a re t h e r e su lt o f a th ero sc le ro tic p la q ue dev elo pm en t, w ith s u bse q uen t p la q ue d is ru ptio n a n d t h ro m bus fo rm atio n le ad in g t o m yocard ia l i s c h em ia a n d p ote n tia l n ecro sis . U nsta b le a n gin a pecto ris i s t h e r e su lt o f t r a n sie n t c o ro nary arte ry o cclu sio n w ith sp onta n eo us c lo t d is so lu tio n a n d n o d em onstr a b le m yocard ia l n ecro sis . Vesse l o cclu sio n p ers is tin g f o r more t h an 1 h r e su lts i n m yocard ia l necro sis , w hic h i s t h e h allm ark o f a cu te m yocard ia l i n fa rc tio n. M yocard ia l in fa rc tio ns are c ate g oriz ed , b ase d o n e le ctr o card io gra p hic f in din gs, a s eith er S T -s e g m en t e le v atio n o r n on-S T -s e g m en t e le v atio n. P re fe rre d tr e atm en t i s p ro m pt r e p erfu sio n o f t h e o cclu ded v esse l, a n d t h is r e su lts i n le ss m yocard ia l d am ag e. S ev era l c la sse s o f c ard io pro te ctiv e med ic atio ns are g iv en t o s u rv iv ors o f a cu te c o ro nary s y ndro m es. I n a d ditio n t o t h ese med ic atio ns, c o m pre h en siv e c ard ia c r e h ab ilita tio n, in clu din g e x erc is e tr a in in g, f o rm s t h e b asis f o r s e co ndary p re v en tio n o f f u tu re c ard ia c e v en ts fo r t h ese p atie n ts . C ard ia c re h ab ilita tio n r e su lts i n i m pre ssiv e b en efits f o r patie n ts , i n clu din g r e d uced m orta lity . 483 Go o nlin e t o r e v ie w t h e w eb r e so urc e c ase s tu dy a n d d is c u ssio n q uestio ns fo r t h is c h ap te r. 484 Chap te r 1 4 Rev asc u la riz a tio n o f t h e H ea rt Neil A . S m art, P hD A ckn ow le d gm en t: M uch o f t h e w ritin g i n t h is c h ap te r w as a d ap te d f ro m t h e t h ir d e d itio n o f Clin ic a l Exerc is e P hysio lo gy . T hus, w e w is h t o g ra te fu lly a ck now le d ge t h e p re v io us e ffo rts o f a n d t h an k Mark P atte rs o n, P hD . H eart d is e ase r e m ain s t h e l e ad in g c au se o f d eath a cco rd in g t o t h e C en te rs f o r D is e ase C ontr o l a n d P re v en tio n. C onsid erin g th is r e ality i s o f u pm ost i m porta n ce i n u nders ta n din g t h e p ro ced ure s u se d t o p ote n tia lly a lle v ia te s y m pto m s, r e d uce r is k o f sig nif ic an t h eart i n ju ry , o r e v en s a v e t h e l iv es o f t h ose a fflic te d w ith h eart d is e ase . I t i s a ls o i m porta n t t o k now h ow t o u tiliz e e x erc is e a s a t h era p y, a fte r r e v asc u la riz atio n, t o m ain ta in o r i m pro ve p hysic al f u nctio nin g o f t h e h eart a n d b ody to m ain ta in l o w er r is k o f f u rth er a d vers e c ard ia c e v en ts a n d i m pro ve a p ers o n’s q uality o f l if e . Defin it io n T he t e rm re va sc u la riz a tio n r e fe rs t o a s u rg ic al p ro ced ure t o h elp p ro vid e n ew o r a d ditio nal b lo od s u pply t o a b ody p art o r o rg an . S ev era l o rg an s, s u ch as t h e h eart, l u ngs, k id ney s, l iv er, a n d m usc le s ( in s itu atio ns s u ch a s g an gre n e), c an b en efit f ro m t h is p ro ced ure . T ypic ally , dia g nostic t e sts m ay i n volv e u sin g m ag netic r e so nan ce i m ag in g ( M RI), C T s c an s, o r X r a y f lu oro sc o py t o i d en tif y t h e n eed f o r re v asc u la riz atio n o r h elp i n g uid an ce o f t h e p ro ced ure . A lth ough t h ere a re m ultip le p arts o f t h e b ody a n d o rg an s f o r w hic h r e v asc u la riz atio n m ay b e i n dic ate d , t h e f o cu s o f t h is c h ap te r is o n p ro ced ure s c o ncern in g t h e h eart. Y ou w ill s e e t e rm s s u ch a s perc u ta neo us t r a nslu m in al c o ro nary a ngio pla sty ( P T C A ) a n d perc u ta neo us c o ro nary i n te rv en tio n ( P C I), w ith o r w ith out s te n tin g, a n d co ro nary a rte ry b yp ass s u rg ery ( C A BS), a ll t e ch niq ues f o r e sta b lis h in g p ro per b lo od f lo w b ack t o t h e h eart. 485 Sco p e When a p ers o n h as c o ro nary a rte ry d is e ase , c lin ic al p ro ced ure s m ay b e ele cte d t o r e sto re m yocard ia l b lo od f lo w , w ith t h e s p ecif ic in te n t o f sy m pto m r e lie f a n d i m pro ved m orb id ity a n d m orta lity . T he t w o m ost co m monly u se d t e ch niq ues a re c o ro nary a rte ry b ypass su rg ery ( C A BS) an d p erc u ta n eo us t r a n slu m in al c o ro nary a n gio pla sty ( P T C A ) o r perc u ta n eo us c o ro nary i n te rv en tio n ( P C I), w ith or w ith out s te n tin g. T he Natio nal C en te r f o r B io te ch nolo gy I n fo rm atio n e stim ate d r a te s o f C A BS an d P C I i n t h e a d ult U .S . p opula tio n in 2 008. M ore t h an 2 40,0 00 C A BS an d 8 17,0 00 P C I w ere p erfo rm ed . Recen t w ork f ro m t h e U nite d K in gdom s h ow s p atte rn s o f r e fe rra l t o card ia c r e h ab ilita tio n h as i n cre ase d t o a lm ost 5 0% o f e lig ib le patie n ts ( 6 0). Today , b ecau se o f a d van ces i n c o ro nary i n vasiv e t e ch nolo gy, c ard ia c re h ab ilita tio n p ro gra m s a re s e ein g a g ro w in g num ber o f p eo ple w ho h av e ex perie n ced p erc u ta n eo us i n te rv en tio ns, i n clu din g p erc u ta n eo us tr a n slu m in al c o ro nary an gio p la sty a lo ne a n d, m ore f re q uen tly , i n co m bin atio n w ith ste n t t h era p y, w hic h i n volv es t h e p la cem en t o f a m esh tu be a lo ng t h e a rte ry w all t o p re v en t r e o cclu sio n ( 2 , 5 3). E ven t h ough min or co nvale sc en t d if fe re n ces e x is t a m ong t h e d if fe re n t p erc u ta n eo us in te rv en tio nal p ro ced ure s, t h e s ta n dard s o f p ra ctic e a n d e x pecte d outc o m es fo r c ard ia c r e h ab ilita tio n a re s im ila r ( 3 2, 8 3); t h us, t h is c h ap te r f o cu se s o n patie n ts w ho h av e u nderg one C A BS o r PT C A w ith o r w ith out s te n t th era p y. An i m porta n t n ote c o ncern s t h e e m erg in g i n fo rm atio n r e g ard in g mech an ic al r e v asc u la riz atio n v ers u s a g gre ssiv e m ed ic al m an ag em en t. In a 2008 p ap er, D r. B arry F ra n klin , P hD , o utlin ed s e v era l a rtic le s t h at in dic ate d q uestio nab le m orta lity b en efit f o r t h ose who u nderw en t C A BS o r PC I v ers u s m ed ic al m an ag em en t. I t w as s till a d van ta g eo us f o r t h ose w ith ev olv in g m yocard ia l i n fa rc tio n or u nsta b le a n gin a t o u nderg o re v asc u la riz atio n, b ut f o r t h ose w ith s ta b le a n gin a, t h e b en efit i s n ot a s cle ar ( 3 1). S om e ev id en ce d oes e x is t s u ggestin g t h at r e g ula r e x erc is e tr a in in g m ay r e su lt i n s u perio r e v en t- fre e s u rv iv al a n d e x erc is e c ap acity , co m pare d w ith P C I, i n p eo ple w ith c o ro nary a rte ry d is e ase ( 4 3). Reg ard le ss o f w heth er p atie n ts w ith c o ro nary a rte ry d is e ase are re v asc u la riz ed o r n ot, m ultip le s tu die s h av e d em onstr a te d t h at f o r e ach 1 MET ( m eta b olic e q uiv ale n t) i m pro vem en t i n e x erc is e cap acity , t h ere ap pears t o b e b etw een a n 8 % a n d 1 7% r e d uctio n i n m orta lity ( 1 0). 486 Path op hysio lo gy Coro nary a rte ry d is e ase ( C A D) i n volv es a b uild up o f l ip id s, m acro phag es, pla te le ts , c alc iu m , a n d f ib ro us c o nnectiv e t is su e with in t h e c o ro nary arte rie s. T his r e su lts i n t h e f o rm atio n o f a p la q ue t h at p ro gre ssiv ely narro w s t h e l u m en . T his m ay e v en tu ally cau se a l im ita tio n o r o bstr u ctio n of n orm al b lo od f lo w . W hile s y m pto m s o r c h an ges o n a n ele ctr o card io gra m ( E C G ) d urin g a s tr e ss te st m ay n ot o ccu r u ntil a co ro nary a rte ry h as a 7 5% o r g re ate r s te n osis , l e sio ns t h at c o m pro m is e 50% o r m ore o f t h e l u m en in a m ajo r c o ro nary a rte ry m ig ht b e c o nsid ere d clin ic ally s ig nif ic an t. M ultip le f a cto rs s u ch a s l o catio n o f t h e l e sio n, sta b ility of t h e p la q ue, s y m pto m s, s h ort- a n d l o ng-te rm p ro gnosis , a n d quality o f l if e m ay a ll i n flu en ce t h e d ecis io n o n w heth er a p artic u la r patie n t i s a c an did ate f o r r e v asc u la riz atio n p ro ced ure s. Coro n ary A rte ry B yp ass S urg ery Coro nary a rte ry b ypass s u rg ery i n volv es r e v asc u la riz atio n u sin g a v en ous gra ft f ro m a n a rm o r l e g o r a n a rte ria l g ra ft— both en ds f re e o r f ro m a re g io nal i n ta ct n ativ e v esse l ( e .g ., i n te rn al m am mary ; gastr o ep ip lo ic arte ry )— to p ro vid e b lo od f lo w t o t h e m yocard iu m b ey ond t h e s ite o f t h e occlu ded o r n early o cclu ded a re a i n a c o ro nary a rte ry . A lth ough CA BS h as tr a d itio nally i n volv ed a ste rn oto m y an d t h e u se o f a hea rt a n d l u ng byp ass , t e ch nic al a d van ces n ow p erm it a g ro w in g n um ber o f p ro ced ure s t o be p erfo rm ed . R ecen t a d van ces i n C A BS i n clu de: 1 . Pre fe re n tia l u se o f t h e l e ft i n te rn al m am mary a rte ry f o r l e ft a n te rio r desc en din g ( L A D) a rte ry g ra ftin g, a s o ppose d t o t h e sa p hen ous v ein . The f o rm er h as s h ow n t o h av e s u perio r 1 0 y r p ate n cy f o r L A D g ra fts (4 1). 2 . A r e cen t m eta -a n aly sis h as s h ow n t h at a v oid an ce o f o n-p um p b ypass su rg ery w ith a n o ff-p um p t e ch niq ue r e d uces t h e i n cid en ce of posto pera tiv e a tr ia l f ib rilla tio n b y 1 3% t o o dds r a tio 0 .8 7, a s w ell a s decre ase s v en tila tio n t im e m ean d if fe re n ce, I C U sta y , a n d h osp ita l sta y . 3 . A m in is u rg ery p ro ced ure p erfo rm ed t h ro ugh s m all p ort i n cis io ns usin g m ic ro sc o pic t e ch niq ues. 4 . Pro ced ure s p erfo rm ed w ith r o botic t e ch nolo gy 5 . Surg ery p erfo rm ed o n t h e b eatin g h eart w ith out t h e u se o f 487 card io pulm onary b ypass Subse q uen t t o t h ese t e ch nic al a d van ces, p osto pera tiv e m orb id ity h as sig nif ic an tly d ecre ase d . T he p osts u rg ic al h osp ita l s ta y fo r C A BS p atie n ts with out c o m plic atio ns i s n ow l e ss t h an 5 d . A s a r e su lt o f t h e e v olu tio n o f re v asc u la riz atio n p ro ced ure s (p artic u la rly p erc u ta n eo us i n te rv en tio n), t h e ro le f o r C A BS h as c h an ged ; i t i s n ow r e se rv ed f o r t h e f o llo w in g p atie n ts : 1 . Patie n ts w ho a re p ost- P T C A o r s te n tin g ( o r b oth ) w ith r e ste n osis 2 . Patie n ts w ho a re n o l o nger c an did ate s f o r a n gio pla sty b ut s till h av e ta rg et v esse ls o ffe rin g p re se rv atio n o f l e ft v en tr ic u la r sy sto lic fu nctio n 3 . Those w ith m ultiv esse l d is e ase n ot a m en ab le t o a n gio pla sty o r ste n tin g 4 . Those w ith t e ch nic ally d if fic u lt v esse l l e sio ns ( e .g ., a l e sio n o n t h e cu rv e o f a v esse l o r i n a d is ta l l o catio n n ot r e ad ily am en ab le t o an gio pla sty o r s te n tin g) The n um ber o f s u rg ic al r e v asc u la riz atio n p ro ced ure s h as d eclin ed , b ut th ese p ro ced ure s s till p la y a n e sse n tia l r o le i n h ig her-ris k occlu siv e dis e ase . S uccessfu l C A BS r e su lts i n m yria d i m pro ved e x erc is e r e sp onse s; an d w hen c o m bin ed w ith m ed ic al t h era p y, CA BS m ay m ore e ffe ctiv ely re lie v e s ig nif ic an t r e sid ual e x erc is e -in duced s y m pto m atic o r s ile n t myocard ia l i s c h em ia . T here i s als o s o m e e v id en ce t h at i n p ers o ns w ith dia b ete s, t h e n eed f o r f u tu re r e v asc u la riz atio n p ro ced ure s i s l e ss w ith CA BS t h an with P T C A o r s te n tin g ( 1 4, 4 2). T hus, t h e s y m pto m r e lie f, im pro ved f u nctio nal c ap acity , a n d i m pro ved q uality o f l if e m ay b e th e most p ra ctic al a n d i m porta n t p atie n t b en efits o f C A BS. Percu ta n eo u s I n te rv en tio n s Coro nary a n gio pla sty , w hic h i s a ls o c alle d p erc u ta n eo us t r a n slu m in al co ro nary a n gio pla sty ( P T C A ), i s l e ss i n vasiv e t h an C A BS. Sev era l te ch niq ues h av e b een d ev elo ped f o r u se i n r e sto rin g a d eq uate b lo od f lo w in d is e ase d c o ro nary a rte rie s. O fte n t h e p ro ced ure is c o m bin ed w ith s te n t th era p y t o r e d uce t h e l ik elih ood t h at t h e a rte ry w ill r e o cclu de. Perc u ta n eo u s T ra n slu m in al C oro n ary A ngio pla sty 488 PT C A i s a w ell- e sta b lis h ed , s a fe , a n d e ffe ctiv e r e v asc u la riz atio n p ro ced ure fo r p atie n ts w ith s y m pto m s a ttr ib uta b le t o C A D. The p ro ced ure m ay u se one o r m ore t e ch niq ues a lo ne o r i n c o m bin atio n t o o pen t h e v esse l: 1 . Ballo on d ila tio n i s m ost c o m monly u se d i n c o nju nctio n w ith s te n t pla cem en t ( fig ure 1 4.1 ). 2 . Rota tio nal a th ere cto m y, a r o ta tio nal d ev ic e u se d f o r r e m ovin g p la q ue, may b e a p plie d t o c en tr a l b ulk y l e sio ns i n a m in ority of c ase s. 3 . Dir e ctio nal a th ere cto m y a n d l a se r m ay b e u se d t o d eb ulk l a rg e le sio ns, b ut t h e r is k o f v esse l w all p erfo ra tio n o r d is se ctio n may b e gre ate r. T he u se o f t h ese d ev ic es i s l im ite d t o a f e w c en te rs i n co nte m pora ry p ra ctic e. The c o m plic atio ns o f a n gio pla sty a re a cu te v esse l c lo su re ( re b ound vaso co nstr ic tio n) o r c h ro nic r e ste n osis , t h ro m botic d is ta l em bolis m , myocard ia l i n fa rc tio n ( M I), a rrh yth m ia s, d is se ctio n o f t h e c o ro nary a rte ry , an d b le ed in g. 489 Fig u re 1 4.1 Perc u ta n eo us t r a n slu m in al c o ro nary a n gio pla sty b allo on c ath ete r a n d t w o t y pes o f s te n ts : l a ttic ed s te el ( le ft) a n d c o ile d ste n t ( rig ht) . S te n t T hera py T o r e d uce t h e r is k o f a cu te c lo su re a n d r e ste n osis o f c o ro nary a rte rie s a fte r P T C A ( 3 7), s e v era l m odels o f i n tr a co ro nary s te n ts hav e b een a d vocate d . S te n t t h era p y i s f re q uen tly u se d i n c o nju nctio n w ith o ne o f t h e p re v io usly d esc rib ed t e ch niq ues t o p re se rv e th e p ate n cy o f t h e v esse l. S te n ts a re s ta in le ss s te el m esh t u be b rid ges t h at a re a d van ced o n t h e e n d o f a b allo on c ath ete r, passe d a cro ss t h e c u lp rit l e sio n, a n d e x pan ded . T he s te n t, s e rv in g a s a p erm an en t i n tr a v asc u la r p ro sth esis , c o m pre sse s t h e le sio n, r e su ltin g i n a n o pen v esse l. T his i s t h e f in al t r e atm en t f o llo w in g b allo on a n gio pla sty o r d eb ulk in g i n o ver 9 5% o f case s. A fte r r e m oval o f t h e b allo on c ath ete r, t h e s te n t r e m ain s p erm an en tly i n t h e c o ro nary a rte ry a n d i s e v en tu ally c o vere d w ith e n doth eliu m , b eco m in g p art o f t h e l u m in al w all s tr u ctu re . I n t h e l a st d ecad e, d ru g-e lu tin g s te n ts h av e b eco m e a v aila b le . T he m eta l s c affo ld in g p re v en ts a cu te c lo su re a n d a ls o p ro vid es a v eh ic le f o r l o cal d ru g d eliv ery . T his i n novatio n p lu s t h e u se o f a sp ir in a n d t h ie n opyrid in es ( c lo pid ogre l a n d p ra su gre l) has r e d uced t h e p ro ble m o f i n -s te n t r e ste n osis t o a g re at e x te n t ( 1 , 6 6, 8 0, 8 8). M an y s te n t p ro ced ure s r e q uir e a o ne-n ig ht h osp ita l s ta y o r a re a s a m e-d ay p ro ced ure . T he l o ss i n f u nctio nal c ap acity f o llo w in g PC I i s l e ss t h an t h at f o llo w in g a b ypass p ro ced ure . S ubse q uen tly , P C I p atie n ts b eg in c ard ia c 490 re h ab ilita tio n a t h ig her f u nctio nal cap acity , q uality o f l if e , a n d se lf – effic a cy ( 3 6, 5 7). The H is to ry a n d F utu re o f P T C A S urg ery The f ir s t P T C A s u rg erie s u se d o nly a b allo on a n d n o s te n t; t h is re su lte d i n p oor r e ste n osis r a te s c o m pare d w ith t o day . B are meta l ste n ts w ere f ir s t u se d i n t h e e arly 1 980s, a n d d ual a n tip la te le t med ic atio ns w ere r e q uir e d i n a n a tte m pt t o p re v en t re ste n osis . T he in tr o ductio n o f n ew a n tip la te le t d ru gs, s u ch a s p ra su gre l, r e d uced en doth elia l h yperp la sia ( s c arrin g a ro und th e s te n t, l e ad in g t o partia l o r c o m ple te r e ste n osis ). A dm in is tr a tio n o f a n tic an cer d ru gs to r e d uce m ito sis a ro und t h e s te n t so lv ed t h e p ro ble m o f r e ste n osis but i n tr o duced a n ew p ro ble m : S te n ts w ere d esig ned t o b eco m e part o f t h e e n doth eliu m , a n d an tim ito tic m ed ic atio n s to pped t h e en doth elia liz atio n o f t h e s te n ts , c au sin g l a te s te n t t h ro m bosis . A re cen t m eta -a n aly sis has s h ow n t h at a sk in g p atie n ts t o c o ntin ue an tip la te le t m ed ic atio n b ey ond 3 m o, p re fe ra b ly f o r 1 2 m o, r e d uces th is c o m plic atio n (7 8). T he n ex t g en era tio n o f s te n ts a re l ik ely t o be b io deg ra d ab le p oly m er r e sin s, w hic h w ill r e d uce t h e t h re at o f en doth elia l hyperp la sia a n d a ls o l a te s te n t t h ro m bosis ( 9 0). A 2 013 m eta -a n aly sis s u ggests t h at P C I w ith d ru g-e lu tin g s te n ts i s a s a fe a n d d ura b le a lte rn ativ e t o C A BS f o r t h e r e v asc u la riz atio n of unpro te cte d l e ft m ain c o ro nary a rte ry s te n osis i n s e le ct p atie n ts a t lo ng-te rm f o llo w -u p ( 1 5). Clin ic a l C on sid era tio n s The s u ccess r a te o f a r e v asc u la riz atio n p ro ced ure m ay b e p re d ic te d , i n part, b y t h e p atie n t’ s a g e, e x is tin g c o m orb id itie s, an d s e v erity a n d l o catio n of t h e l e sio n. Coro n ary A rte ry B yp ass S urg ery 491 Ele ctiv e C A BS i m pro ves t h e l ik elih ood o f l o ng-te rm s u rv iv al i n p atie n ts who h av e t h e f o llo w in g: Sig nif ic an t l e ft m ain C A D Thre e-v esse l d is e ase Tw o-v esse l d is e ase w ith a p ro xim al l e ft a n te rio r d esc en din g s te n osis Tw o-v esse l d is e ase a n d i m pair e d l e ft v en tr ic u la r f u nctio n ( 2 ) In p atie n ts e x perie n cin g f a ile d a n gio pla sty w ith p ers is te n t p ain o r hem odynam ic i n sta b ility , a cu te M I w ith p ers is te n t o r r e cu rre n t is c h em ia re fra cto ry t o m ed ic al t h era p y, ca rd io gen ic s h ock , o r f a ile d P T C A w ith a n are a o f m yocard iu m s till a t r is k , r e v asc u la riz atio n b y C A BS o ffe rs effe ctiv e r e lie f o f a n gin a p ecto ris an d i m pro ves t h e q uality o f l if e ( 2 ). T he occlu sio n r a te o f g ra fts i s a p pro xim ate ly 1 0% , 2 0% , a n d 4 0% a fte r 1 , 5 , an d 1 1 y r, re sp ectiv ely ( 1 0). T he C A BS p atie n t’ s p osto pera tiv e e d ucatio n sh ould i n clu de w ound c are , a p pro pria te m an ag em en t o f r e cu rrin g sy m pto m s, a n d r is k f a cto r m odif ic atio n. Percu ta n eo u s T ra n slu m in al C oro n ary A ngio p la sty In s e le ct c ase s o f u nsta b le a n gin a, P T C A h as a n a cu te s u ccess r a te o f o ver 84% . F ollo w in g s u ccessfu l P T C A , r e ste n osis o ccu rs in a p pro xim ate ly 2 5% of p atie n ts , a lm ost a lw ay s w ith in t h e f ir s t 6 m o ( 2 , 4 ). F ollo w in g t h e dev elo pm en t o f d ru g-e lu tin g s te n ts , re ste n osis r a te s h av e d ro pped dra m atic ally i n m an y c ase s, t o b elo w 5 % a fte r 2 y r ( 3 3). Tab le 1 4.1 l is ts se v era l p re d ic to rs o f r e ste n osis ( 6 7). 492 O th er v ery i m porta n t p ote n tia l p re d ic to rs i n clu de c o m orb id itie s s u ch a s d ia b ete s m ellitu s a n d w heth er p atie n ts a re o n o ptim al med ic al t h era p y t h at i n clu des u se o f a sp ir in a n d t h ie n opyrid in es s u ch a s P la v ix a n d E ffie n t ( 1 , 3 3). P atie n ts w ho h av e h ad P T C A i n t h e s e ttin g o f u nsta b le a n gin a s h ould h av e c lo se s u rv eilla n ce f o llo w in g h osp ita l d is c h arg e a n d sh ould b e a d vis e d t o s e ek p ro m pt m ed ic al a tte n tio n i n t h e e v en t o f a r e cu rre n ce o f t h e s y m pto m s t h at w ere o ccu rrin g b efo re th eir P T C A ( 1 9). S te n t T hera p y I m pro ved t e ch nolo gy c u rre n tly c o nfe rs p ro ced ura l s u ccess r a te s i n e x cess o f 9 5% i n m ost c en te rs . A cu te c lo su re a n d r e ste n osis re m ain a s l im ita tio ns t o s h ort- a n d l o ng-te rm s u ccess, r e sp ectiv ely , a lth ough t h e i n cid en ce o f b oth t h ese c o m plic atio ns h as decre ase d d ra m atic ally i n r e cen t y ears . T he i n cid en ce o f t h ro m bosis a n d a cu te c lo su re i s i n t h e r a n ge o f 1 % t o 2 % w ith 493 use of t h ie n opyrid in es ( c lo pid ogre l o r t ic lo pid in e); t h ere fo re , c h ro nic an tic o agu la tio n t h era p y i s n o l o nger r e q uir e d . R este n osis r a te r a n ges fro m 2 5% t o 4 0% w ith b are m eta l s te n ts a n d l e ss t h an 1 0% w ith d ru g- elu tin g ste n ts ( 4 , 5 8). T hese r e su lts v ary d ep en din g o n c o m orb id itie s a n d effic acy o f a g gre ssiv e m ed ic al m an ag em en t a s w ell a s o n su rg ic al t im e, ty pe o f s u rg ery , a n d o n- o r o ff-p um p s u rg ic al m eth ods. Hyb rid C oro n ary A rte ry R ev asc u la riz a tio n Hybrid c o ro nary a rte ry r e v asc u la riz atio n ( H CR) r e fe rs t o c o m ple te o r near-c o m ple te r e v asc u la riz atio n u sin g t h e c o m bin atio n of s in gle -v esse l co ro nary a rte ry b ypass g ra ft ( C A BG ), w ith t h e l e ft i n te rn al m am mary arte ry ( L IM A) p la ced t o t h e l e ft a n te rio r desc en din g c o ro nary a rte ry (L A D), a n d p erc u ta n eo us c o ro nary i n te rv en tio n ( P C I) o f s ig nif ic an t co ro nary l e sio ns i n o th er v esse ls . The l a rg est o bse rv atio nal s tu dy co m pare d 2 00 p atie n ts w ho u nderw en t H CR w ith 9 8 p atie n ts w ho underw en t m ultiv esse l P C I ( 3 9a). At 1 2 m o, t h ere w as n o d if fe re n ce i n t h e ra te o f m ajo r a d vers e c ard ia c a n d c ere b ro vasc u la r e v en ts . H CR i s a re aso nab le a p pro ach to m ultiv esse l c o ro nary a rte ry r e v asc u la riz atio n i n se le cte d p atie n ts a t f a cilitie s w ith s ig nif ic an t e x pertis e . Tab le 1 4.2 p ro vid es a s u m mary o f m ed ic atio ns c o m monly p re sc rib ed . 494 E xercis e T estin g T he g ra d ed e x erc is e t e st ( G XT) i s c o m monly u se d f o r c o ntin ued d ia g nosis o f p ossib le i s c h em ic m yocard iu m , p ro gnostic atio n, an d t h e e sta b lis h m en t o f f u nctio nal s ta tu s f o r e x erc is e p re sc rip tio n p urp ose s. A lth ough a n i n te g ra l c o m ponen t f o r e x erc is e pre sc rip tio n, t h e t im in g o f t h e G XT i s s o m ew hat c o ntr o vers ia l. S ta n dard a d m in is tr a tio n p ro ced ure s a n d c o ntr a in dic atio ns t o te stin g, d is c u sse d i n c h ap te r 5 , s h ould b e f o llo w ed . P ra ctic al a p plic atio n 1 4.1 o utlin es e x erc is e t e stin g f o r r e v asc u la riz ed p atie n ts . Pra ctic a l A pplic a tio n 1 4.1 495 Exercis e T estin g R ev ie w f o r S urg ery P atie n ts Testin g p ro ced ure s o utlin ed i n AC SM ’s G uid elin es f o r E xerc is e Testin g a nd P re sc rip tio n, T en th E ditio n , i n dic ate t h at f o r s e v ere re g urg ita n t ( le ak in g) o r s te n otic ( n arro w in g) v alv e d is e ase , v alv e re p la cem en t m ay b e e sse n tia l fo r s y m pto m r e lie f a n d i m pro ved ex erc is e t o le ra n ce. R eg ard in g t h e o pen -h eart s u rg ic al p ro cess, pre cau tio ns s im ila r t o t h ose fo r t h e b ypass s u rg ery p atie n t s h ould be f o llo w ed , w ith a tte n tio n t o a f e w s p ecia l c o nsid era tio ns. T he in tr o ductio n o f t r a n sc ath ete r ao rtic v alv e i m pla n ta tio n ( T A VI) h as re d uced t h e i n cid en ce o f o pen -h eart v alv e s u rg ery . T A VIs a re in tr o duced v ia a f e m ora l arte ry i n cis io n o r b y m in im ally i n vasiv e su rg ery . A n i n itia l p ro ble m w ith i n se rtio n w as d if fic u lty p la cin g th e T A VI d ue t o movem en t a sso cia te d w ith t h e b eatin g h eart. A pacin g w ir e i s u se d t o c re ate v en tr ic u la r t a ch ycard ia ; p erh ap s co unte rin tu itiv ely , in cre asin g h eart r a te r e d uces c ard ia m ovem en t an d a llo w s p re cis e i n se rtio n o f t h e T A VI. O nce t h e T A VI i s co rre ctly p la ced it i s d ep lo yed . M in im ally i n vasiv e s u rg ery r e d uces tim e s p en t i n t h e i n te n siv e c are u nit ( 2 3). 496 Specia l c o nsid era tio ns: S ym pto m r e so lu tio n m ay n ot o ccu r im med ia te ly f o llo w in g s u rg ery . S ym pto m s m ay g ra d ually r e so lv e becau se of h eart r e m odelin g a fte r v alv e r e p la cem en t ( e .g ., f o r ao rtic s te n osis ). A void s tr e n gth t r a in in g f o r s e v ere s te n otic o r re g urg ita n t valv ula r d is e ase . S ev era l m eta -a n aly se s h av e s h ow n is o m etr ic e x erc is e m ay o ffe r a n o pportu nity t o m an ag e hyperte n sio n i n p atie n ts who c an not p erfo rm , o r w is h t o u se a n ad ju nct t o , a ero bic e x erc is e ( 4 5). C om mon e x erc is e -in duced sy m pto m s i n clu de s h ortn ess of b re ath , f a tig ue, a n d d iz zin ess o r lig ht- h ead ed ness. Exerc is e p re sc rip tio n: F ollo w p ro ced ure s s im ila r t o t h ose f o r re v asc u la riz atio n s u rg ery . C oro n ary A rte ry B yp ass S urg ery R eq uir in g a ll p atie n ts t o h av e a n e x erc is e t e st a fte r s u ccessfu l b ypass s u rg ery f o r t h e p urp ose o f b eg in nin g a s u perv is e d an d m onito re d e x erc is e 497 pro gra m i s o f q uestio nab le c lin ic al b en efit a n d a n u nnecessa ry f in an cia l burd en ( 6 1). T he p atie n t’ s co ro nary a n ato m y i s k now n, a n d u nle ss s u rg ic al co m plic atio ns o r p osts u rg ic al s y m pto m s a re p re se n t, t h e c h an ce o f dete ctin g unknow n i s c h em ia i s e x tr e m ely l o w . I n a d ditio n, b ecau se o f t h e acu te c o nvale sc en t p erio d, t h e p atie n t m ay n ot b e a b le t o g iv e a physio lo gic al m ax im al e ffo rt, s a crif ic in g t e st s e n sitiv ity . A m ore o pportu ne t im e f o r t e stin g t h e p atie n t i s a fte r i n cis io nal p ain h as re so lv ed , b lo od v olu m es a n d h em oglo bin c o ncen tr a tio ns hav e n orm aliz ed , an d s k ele ta l m usc u la r s tr e n gth a n d e n dura n ce h av e i m pro ved f ro m partic ip atin g i n l o w -le v el e x erc is e a n d a ctiv ity . At l e ast 4 w k p osts u rg ery , th e p atie n t w ill b e a b le t o g iv e a n ear-m ax im al p hysio lo gic al e ffo rt, pro vid in g t e st r e su lts w ith gre ate r d ia g nostic a ccu ra cy f o r a sse ssin g fu nctio nal c ap acity , d ete rm in in g r e tu rn -to -w ork s ta tu s, o r r e co m men din g th e r e su m ptio n of p hysic ally v ig oro us r e cre atio nal a ctiv itie s. F or p atie n ts whose s u rg ic al r e v asc u la riz atio n w as n ot s u ccessfu l o r w ho a re ex perie n cin g s y m pto m s s u ggestiv e o f i s c h em ia , a c lin ic al e x erc is e t e st befo re s ta rtin g a n e x erc is e p ro gra m i s r e co m men ded . All t e stin g pro ced ure s s h ould f o llo w p ro fe ssio nal g uid elin es ( 8 , 9 , 1 1) a s n ote d i n ch ap te r 5 . Perc u ta n eo u s T ra n slu m in al C oro n ary A ngio pla sty Deb ate e x is ts r e g ard in g t h e p ro per t im in g o f s tr e ss t e stin g i n P T C A patie n ts . S ev era l r e p orts o f a cu te t h ro m botic o cclu sio n asso cia te d w ith ex erc is e t e stin g s h ortly a fte r s u ccessfu l P T C A h av e b een r e p orte d , alth ough t h ese h av e n ot b een b orn e o ut as r e le v an t i n c lin ic al p ra ctic e. Alth ough n o c h est p ain i s r e p orte d d urin g t h e t e st, i s c h em ia w ith in 1 h afte r t e stin g h as been r e p orte d ( 2 0, 7 1). T he m ech an is m s f o r t h e a p pare n tly ab norm al t e st r e sp onse s a re u ncle ar b ut a re p ossib ly r e la te d t o th e fo llo w in g: 1 . Hig her l e v els o f pla te le t a ggreg atio n durin g e x erc is e t e stin g 2 . An i n cre ase i n t h ro m boxan e A 2 3 . Pla te le t a ctiv atio n a n d h yperre activ ity i n cre ase d urin g e x erc is e 4 . In cre ase d a rte ria l w all s tr e ss a sso cia te d w ith i n cre ase d c o ro nary b lo od flo w 5 . The h ig her b lo od p re ssu re t h at o ccu rs d urin g e x erc is e , w hic h m ay tr a u m atiz e a n a lr e ad y d is ru pte d in tim a ( 2 0, 5 1) 498 On t h e o th er h an d, e x erc is e t e stin g o f p atie n ts w ith P T C A h as b een accep te d s ta n dard p ra ctic e, p artic u la rly f o r t h ose w ith in co m ple te re v asc u la riz atio n. A l a rg e b ody o f e v id en ce s u pports t h e u se o f e arly postp ro ced ure e x erc is e t e stin g ( 1 o r 2 d ) to e v alu ate t h e f u nctio nal s ta tu s o f th e P T C A p atie n t ( 5 , 6 , 1 7, 1 9, 7 5). Ste n t T hera py Contr o vers y w ith r e g ard t o s a fe ty o f e arly t e stin g a fte r s te n t p la cem en t h as esse n tia lly b een l a id t o r e st. M ost a u th oritie s now a ccep t t h at p erfo rm in g a str e ss t e st a fte r c o ro nary s te n tin g i s s a fe . R ecen tly , t h ere h as b een in cre asin g s u pport f o r ex erc is e t e stin g b efo re t h e s ta rt o f a n e x erc is e pro gra m ( 1 3, 1 9, 2 4, 4 8, 4 9). T he a ccu ra cy o f t h ese t e sts , h ow ev er, c an still be d eb ate d . I n p artic u la r, t h ere h av e b een r e p orts o f f a ls e -p ositiv e str e ss t e st r e su lts e arly o n a fte r c o ro nary s te n tin g. As w ith C A BS a n d PT C A , t h e n eed t o t e st a ll p atie n ts a fte r s te n t t h era p y b efo re s ta rtin g card ia c r e h ab ilita tio n i s d eb ata b le . One s c en ario f o r w hic h i t m ig ht b e use fu l i s f o r p atie n ts w ho e ith er c an not p artic ip ate i n a s u perv is e d p ro gra m or c h oose to e x erc is e i n dep en den tly a n d n eed s o m e r e assu ra n ce a n d i n itia l guid an ce. I n g en era l, f o r t h e s u ccessfu lly r e v asc u la riz ed patie n t, a n ex erc is e t e st m ay b e r e d undan t a n d m ay n ot p ro vid e a n y f u rth er u se fu l clin ic al i n fo rm atio n b efo re t h e p atie n t sta rts a s u perv is e d e x erc is e pro gra m . T he p rim ary c o ncern s w ith P T C A a n d s te n t a re reo cclu sio n a n d reste n osis . S ubse q uen t r e ste n osis m ay n ot b e d ete cte d i m med ia te ly fo llo w in g t h e p ro ced ure . T he p atie n t c an e x erc is e i n a s u perv is e d ex erc is e pro gra m a n d b e t e ste d a t a l a te r d ate i f s y m pto m s r e cu r o r f o r a sse ssm en t of f u nctio nal c ap acity b efo re r e tu rn t o work . A dditio nally , a p oor r e sp onse to e x erc is e t r a in in g, d em onstr a tin g n o i m pro vem en t i n f u nctio nal c ap acity , may b e i n dic ativ e of r e ste n osis ( 5 , 6 , 5 6). Pra ctic al a p plic atio n 1 4.2 p ro vid es a d vic e o n h elp in g r e v asc u la riz ed patie n ts a d here t o a l o ng-te rm e x erc is e p ro gra m . Pra ctic a l A pplic a tio n 1 4.2 Clie n t– C lin ic ia n I n te ra ctio n 499 Med ic al a d van ces h av e c o m e a l o ng w ay t o a ssis t t h e c lin ic al ex erc is e p ro fe ssio nal i n h elp in g i n div id uals r e tu rn t o e x erc is e an d more a ctiv e l if e sty le s s o oner. D esp ite a ll t h ese a d van ces, m ost re v asc u la riz ed p atie n ts e v en tu ally r e tu rn t o a m ore s e d en ta ry lif e sty le . T he f ie ld o f b eh av io r c h an ge h as s ta rte d t o b eco m e a n in cre asin gly i m porta n t p art o f h elp in g t h ese i n div id uals main ta in th eir e x erc is e p ro gra m s a n d m ore a ctiv e l if e sty le s. One o f t h e m ost i m porta n t t o ols y ou c an u se t o i n cre ase e x erc is e ad here n ce i s y our e ars . T ak e t h e t im e t o l is te n t o y our p atie n ts . Unders ta n d w hat i t i s t h ey h av e g one t h ro ugh. L is te n t o t h eir f e ars an d c o ncern s w hen y ou a re t e stin g o r d esig nin g e x erc is e pro gra m s. Unders ta n d t h eir p hysic al, e m otio nal, a n d e n vir o nm en ta l b arrie rs . If y ou t a k e t h e t im e t o c o nsid er t h eir s o urc es of s u pport a n d t h eir re so urc es f o r a ctiv ity a n d e x erc is e , a n d t h en r e m em ber t o r e asse ss th eir g oals , t o b e f le x ib le , a n d t o fo llo w u p i n a t im ely f a sh io n, t h ey will b e m ore l ik ely t o s u cceed . Isc h em ic P re co n ditio n in g Recen tly a n um ber o f m eta -a n aly se s h av e n ote d t h e b en efits o f i s c h em ic pre co nditio nin g b efo re p la n ned c ard ia c s u rg ery . I s c h em ic pre co nditio nin g is e x posu re t o f o ur c y cle s o f 5 m in o f c u ff i n fla tio n a t s u pra sy sto lic pre ssu re ( o fte n 2 00 m mHg), w ith 3 t o 5 m in o f r e co very b etw een in fla tio ns. R ed uced i n cid en ce a n d s iz e o f p eri- a n d p osto pera tiv e myocard ia l i n fa rc ts h av e b een re p orte d , a m ong o th er a cq uir e d b en efits . Rep eate d e x posu re t o i s c h em ic p re co nditio nin g h as a ls o b een i n vestig ate d fo r m an ag in g hyperte n sio n a n d w ound h ealin g ( 2 6). Exercis e P resc rip tio n a n d T ra in in g Over t h e p ast d ecad e, t h e a v era g e l e n gth o f h osp ita l s ta y f o r c ard io vasc u la r patie n ts h as d ecre ase d d ra m atic ally . C urre n tly , th e h osp ita l s ta y f o r unco m plic ate d c ase s o f C A BS i s u su ally 2 t o 5 d . F or P T C A s te n ts , t h e sta y i s 1 o r 2 d ; t h is p ro ced ure is a ls o d one o n a n o utp atie n t b asis , w ith t h e patie n t m an ag ed i n a n a cu te r e co very s u ite a n d d is c h arg ed o n t h e s a m e day . A lth ough card ia c r e h ab ilita tio n b eg in s a s s o on a s p ossib le d urin g hosp ita l a d m is sio n, t h e s h orte r l e n gth o f h osp ita l s ta y h as c h an ged th e 500 in patie n t p ro gra m t o b asic r a n ge o f m otio n e x erc is e s a n d a m bula tio n; a n d th e e d ucatio nal f o cu s i s o n d is c h arg e p la n nin g— te ach in g ab out med ic atio ns, h om e a ctiv itie s, a n d f o llo w -u p a p poin tm en ts . E ducatio nal to pic s p re v io usly c o vere d i n t h e i n patie n t s e ttin g are n ow t h e r e sp onsib ility of t h e o utp atie n t p ro gra m . M ore o ver, c ard ia c r e h ab ilita tio n p ro fe ssio nals must m ak e e v ery e ffo rt to e n ro ll p atie n ts i n a n o utp atie n t p ro gra m . I n te rv al tr a in in g m ay o ffe r a n a lte rn ativ e t o c o ntin uous e x erc is e i n s e v ere ly deco nditio ned p atie n ts . L ate r, i n p hase I I a n d b ey ond, h ig h-in te n sity in te rv al e x erc is e ( H IIT ) m ay o ffe r s u perio r b en efits to m odera te -in te n sity co ntin uous e x erc is e ( 4 6). A h ybrid a p pro ach t o c ard ia c r e h ab ilita tio n m ay offe r a c o m pro m is e i n t h ose cau tio us a b out u sin g H IIT ( 5 2). Tab le 1 4.3 re v ie w s t h e e x erc is e p re sc rip tio n f o r t h e r e v asc u la riz ed p atie n t. 501 502 W ith in t h e f ir s t f e w d ay s o f b ed r e st, m an y b ody c o m positio n c h an ges ( lo ss o f l e an b ody m ass) o ccu r ( 7 9), s u pportin g t h e n eed fo r e arly e x erc is e i n te rv en tio n d urin g h osp ita l a d m is sio n. P atie n ts w ho p erfo rm t y pic al w ard a ctiv itie s a n d m odera te , s u perv is e d am bula tio n d o n ot s u ffe r t h e m ag nitu de o f l o ss i n l e an b ody t is su e s e en i n t h ose w ho r e m ain i n activ e. E arly s ta n din g a n d l o w -le v el activ itie s, i n clu din g r a n ge o f m otio n a n d s lo w a m bula tio n, m ay b e a ll t h at i s r e q uir e d t o d ete r p osts u rg ic al l e an b ody m ass lo ss w hile t h e p atie n t i s i n t h e h osp ita l ( 7 9). A fte r h osp ita l d is c h arg e, m an y p ositiv e p hysio lo gic al a d ap ta tio ns o ccu r i n r e v asc u la riz ed p atie n ts w ho p artic ip ate i n a s u perv is e d ex erc is e p ro gra m ( 8 3): Im pro ved c ard ia c p erfo rm an ce a t r e st a n d d urin g e x erc is e Im pro ved e x erc is e c ap acity ( a ero bic a n d s tr e n gth ) Gre ate r t o ta l w ork p erfo rm ed Im pro ved a n gin a-fre e e x erc is e t o le ra n ce, m uch o f w hic h i s attr ib uta b le t o p erip hera l m usc u la r a d ap ta tio ns ( 4 0) Im pro ved n eu ro hum ora l t o ne ( 5 4) P atie n ts i n s u ch a p ro gra m g ain i n s e v era l w ay s: They m ore o fte n a ch ie v e f u ll w ork in g s ta tu s. They h av e f e w er h osp ita l r e ad m is sio ns. They a re l e ss l ik ely t o s m oke a t 6 m o f o llo w in g c o m ple tio n o f 503 ex erc is e t h era p y ( 9 ). When w e c o m pare t h e p hysio lo gic al a n d p sy ch oso cia l o utc o m es b etw een CA BS, P T C A –ste n t, a n d M I p atie n ts a t t h e b eg in nin g a n d en d o f 1 2 w k o f card ia c r e h ab ilita tio n, s o m e g ro up t r e n ds a re a p pare n t. C A BS p atie n ts m ay beg in w ith l o w er f u nctio nal c ap acitie s an d l o w er r a tin gs o f q uality o f l if e an d s e lf -e ffic acy a ttr ib uta b le t o t h e s u rg ic al r e cu pera tiv e p ro cess ( 8 4), b ut th ey s h ow gre ate r i m pro vem en t d urin g t h e p ro gra m a n d o bta in s im ila r o r gre ate r v alu es c o m pare d w ith o th er c ard ia c p atie n ts a t p ro gra m co m ple tio n, r e g ard le ss o f a g e ( 2 5, 3 6, 5 7). T his r e su lt m ay r e fle ct l o w er ra te s o f is c h em ia t h an i n M I p atie n ts , g re ate r c o nfid en ce i n t h eir o w n ab ility , a n d t h e p ote n tia l p sy ch olo gic al f e elin g t h at s o m eth in g w as done ab out t h eir h eart d is e ase a n d t h at t h ey a re “ cu re d .” R eg ard le ss o f a g e, t h e CA BS p atie n ts d em onstr a te f u nctio nal i m pro vem en t but m ay r e q uir e a lo nger t r a in in g p erio d t o o bta in t h e s a m e m ag nitu de o f e ffe ct ( 7 0). T he PT C A –ste n t g ro ups h av e n ot s u ffe re d th e l o ss i n f u nctio nal c ap acity becau se o f t h e m ore p ro lo nged r e cu pera tiv e p ro cess f o llo w in g a n M I o r bypass s u rg ery a n d h av e gre ate r f u nctio nal c ap acity w hen s ta rtin g c ard ia c re h ab ilita tio n ( 3 6, 5 7). Exerc is e p re sc rip tio n g uid elin es f o r rev asc u la riz a tio n p atie n ts h av e b een publis h ed b y t h e A m eric an C olle g e o f S ports M ed ic in e ( 1 1), A m eric an Asso cia tio n o f C ard io vasc u la r a n d Pulm onary R eh ab ilita tio n ( 9 ), a n d Am eric an H eart A sso cia tio n ( 8 ). Specia l E xercis e C on sid era tio n s Alth ough r e v asc u la riz ed p atie n ts a re j u st a s k now le d geab le a b out r is k fa cto rs a s p ost- M I p atie n ts , t h ey a re l e ss c o m pelle d to m ak e c h an ges ( 3 7). Post- M I p atie n ts i n itia te c o nsid era b ly g re ate r l if e sty le c h an ges t h an re v asc u la riz ed p atie n ts d o ( 6 5). Patie n ts u nderg oin g r e v asc u la riz atio n m ay be l e ss m otiv ate d t o a d here t o r is k f a cto r b eh av io r c h an ge b ecau se o f a perc ep tio n of t h at t h ey a re l e ss s ic k o r h av e b een c u re d , w hic h h as a neg ativ e e ffe ct o n c o m plia n ce w ith r is k f a cto r m odif ic atio n ( 3 8, 47, 6 4). Rev asc u la riz ed p atie n ts m ay e n co unte r, o r a n tic ip ate , r e str ic tio ns dif fe re n tly t h an o th er c ard ia c p atie n ts d o. M ost P T C A –ste n t patie n ts a re cap ab le o f r e su m in g n orm al a ctiv itie s o f d aily l iv in g f o llo w in g h osp ita l dis c h arg e, b ut p atie n ts f re q uen tly p erc eiv e co nsid era b le r e str ic tio ns a fte r th e p ro ced ure w ith r e sp ect t o a ll a ctiv itie s o f d aily l iv in g— le is u re activ itie s, s e x ual a ctiv ity , an d e arly r e tu rn t o w ork ( 2 8, 6 8, 7 3). 504 Dep re ssio n r e m ain s p re v ale n t i n p atie n ts w ith c o ro nary h eart d is e ase a fte r majo r c ard ia c e v en ts ( C A BS a n d P T C A i n clu ded ). Card ia c r e h ab ilita tio n does r e d uce t h e p re v ale n ce a n d s e v erity o f d ep re ssio n. T here fo re , c ard ia c patie n ts s h ould b e r o utin ely sc re en ed a n d o ffe re d t h e b en efits o f co m pre h en siv e c ard ia c r e h ab ilita tio n, i n clu din g p sy ch oso cia l s u pport a n d pasto ra l c are (6 2). T here h as a ls o b een s o m e r e se arc h o n p re p ro ced ure ex erc is e a n d c o unse lin g ( p re h ab ilita tio n) a n d e x te n ded t e le p hone co unse lin g afte r t h e p ro ced ure a n d r e h ab ilita tio n s e ssio ns h av e e n ded ; th ese s tu die s h av e s h ow n p ro m is e i n r e d uctio n i n d ep re ssio n s u rro undin g re v asc u la riz atio n p ro ced ure s ( 3 5, 7 4). Spouse s m ay b e m ore l ik ely t o s e ek i n fo rm atio n a b out t h e p atie n t’ s psy ch olo gic al r e actio ns a n d r e co very , w here as p atie n ts are m ore l ik ely t o se ek i n fo rm atio n a b out t h eir p hysic al c o nditio n a n d r e co very ( 6 4). P atie n ts te n d t o b e m ore p ositiv e t h an sp ouse s, w ho t e n d t o b e m ore f e arfu l o f t h e fu tu re ( 3 9b). A ls o , p atie n ts a n d s p ouse s d if fe r i n t h eir v ie w s o n t h e c au se s of CA D a n d a b out t h e r e sp onsib ility f o r l if e sty le c h an ges a n d t h e man ag em en t o f h ealth a n d s tr e ss ( 6 9). T here fo re , a sse ssin g both t h e patie n t’ s a n d t h e s p ouse ’s e d ucatio nal n eed s i s i m porta n t. H ealth C are Check lis t f o r P C I/S te n t P atie n ts l is ts i m porta n t co ncern s i n t h e re h ab ilita tio n o f t h e p ost- P T C A p atie n t, t a k in g i n to a cco unt t h at e x erc is e may b e c o ntr a in dic ate d f o r p atie n ts who c o ntin ue t o b e s y m pto m atic poste v en t o r p ostp ro ced ure , p artic u la rly a t l o w w ork lo ad s ( < 5.0 M ETs). Anoth er c o nsid era tio n i s t h e p ote n tia l u nco verin g o f c la u dic atio n i n perip hera l a rte ry d is e ase ( P A D) w ith a m bula tio n a fte r re v asc u la riz atio n. I t is w ell e sta b lis h ed t h at p ers o ns w ith C A D a re a t h ig her r is k t h an o th ers f o r PA D ( a n d v ic e v ers a ). T his may b e m ore o f a n i s su e w ith p atie n ts w ho hav e b een v ery s e d en ta ry a n d t h en s ta rt a n ew e x erc is e r e g im en a fte r t h e pro ced ure an d d ev elo p s y m pto m s o f c la u dic atio n. Hea lt h C are C heck lis t f o r P C I/S te n t P atie n ts Contr o l o f h yperte n sio n, o besity , a n d s m okin g Pro gre ssiv e e x erc is e a n d w eig ht r e d uctio n Aware n ess o f o th er c ard ia c r is k f a cto rs Id en tif ic atio n o f s tr e ssfu l f a cto rs Counse lin g s e rv ic es f o r w eig ht r e d uctio n, s tr e ss m an ag em en t, 505 an d s m okin g c essa tio n Main ta in in g c lo se c o nta ct b etw een h ealth p ro fe ssio nals Org an iz in g a n d m ain ta in in g l o ng-te rm f o llo w -u p r e co rd s Rein fo rc in g t h e n oncu ra tiv e n atu re o f P C I/s te n t a s c ard ia c tr e atm en t m odality Enco ura g in g r e v asc u la riz atio n p atie n ts a n d P C I/s te n t p atie n ts to t a k e a p ro activ e a p pro ach t o i m pro ve h ealth o utc o m es Coro n ary A rte ry B yp ass S urg ery Prim ary c o ncern s f o r t h e C A BS p atie n t w hen e n te rin g o utp atie n t c ard ia c re h ab ilita tio n a re t h e s ta te o f i n cis io nal h ealin g an d s te rn al s ta b ility , hypovole m ia , a n d l o w h em oglo bin c o ncen tr a tio ns. D urin g t h e i n itia l patie n t i n te rv ie w , t h e r e h ab ilita tio n pro fe ssio nal n eed s t o e n su re t h at t h e su rg ic al w ound h as n o s ig ns o f i n fe ctio n, s ig nif ic an t d ra in in g, o r in sta b ility . Q uestio ns sh ould f o cu s o n t h e f o llo w in g: Excessiv e o r u nusu al s o re n ess a n d s tif fn ess Cra ck in g, g rin din g, o r m otio n i n t h e s te rn al r e g io n Wheth er t h e p atie n t i s s le ep in g a t n ig ht How t h e p atie n t’ s c h est a n d l e g i n cis io ns a re r e sp ondin g t o c u rre n t activ itie s o f d aily l iv in g s in ce d is c h arg e Als o , k now in g h ow p atie n ts p erfo rm ed d urin g t h e i n patie n t p ro gra m m ay help d ete rm in e h ow s o on t h ey c an b eg in t h e o utp atie n t pro gra m a n d a t what l e v el t h ey c an b eg in e x erc is in g. F or e x am ple , w as t h e p atie n t o ut o f bed , u prig ht, a n d w alk in g s o on a fte r su rg ery w ith out p ro ble m s? I f n ot, w as th e p atie n t’ s l a ck o f a ctiv ity a ttr ib uta b le t o e x tr e m e p hysic al d is c o m fo rt, clin ic al or o rth oped ic d if fic u ltie s, o r l a ck o f m otiv atio n? R ecen t r e se arc h has s h ow n t h at c h est s o re n ess c an r e d uce w alk in g d is ta n ce, whic h c an hav e a n i m pact o n f u nctio nal f itn ess ( 1 6). His to ric ally , s u rg ic al p atie n ts d id n ot b eg in c ard ia c r e h ab ilita tio n f o r 4 t o 6 wk p osts u rg ery o r l o nger a n d a v oid ed u pper ex tr e m ity e x erc is e f o r e v en lo nger p erio ds. T oday , s ta n dard p ra ctic e i s f o r p atie n ts t o b eg in t h e outp atie n t p ro gra m p rio r to , o r s o on a fte r, d is c h arg e, o fte n w ith in a w eek of s u rg ery . F or t h e u nco m plic ate d r e v asc u la riz ed p atie n t, l ig ht u pper ex tr e m ity ex erc is e s a re n ow p re sc rib ed , i n clu din g r a n ge o f m otio n ex erc is e s, l ig ht h an d w eig hts p ro gre ssin g t o l ig ht r e sis tiv e m ach in ery , an d 506 gra d ually p ro gre ssiv e u pper e x tr e m ity e rg om etr y b eg in nin g a t z ero re sis ta n ce. R ecen t r e se arc h i n dic ate s t h at w om en t e n d not t o r e sp ond t o in patie n t c ard ia c r e h ab ilita tio ns a s m uch a s m en ( 2 9). Perc u ta n eo u s T ra n slu m in al C oro n ary A ngio pla sty The p rim ary c o ncern f o r t h e P T C A o r s te n t p atie n t i s r e ste n osis . A t t h e patie n t’ s i n itia l o rie n ta tio n s e ssio n, q uestio nin g sh ould a d dre ss t h e pre se n ce o f s ig ns o r s y m pto m s i n dic ativ e o f a n gin a o r t h e p ers o n’s partic u la r a n gin al e q uiv ale n t. E ducatio n sh ould i n clu de i n fo rm atio n a b out sy m pto m s, i n clu din g a n gin al e q uiv ale n ts ; m an ag em en t o f a n gin a ( e .g ., how t o u se n itr o gly cerin , goin g t o t h e e m erg en cy d ep artm en t) ; pre cip ita tin g f a cto rs ( e x ertio n o r a n xie ty r e la te d ); a n d c are o f t h e c ath ete r in se rtio n site . P atie n ts w ith P T C A s a n d s te n ts m ay b eg in t h e o utp atie n t pro gra m a s s o on a s t h ey a re d is c h arg ed f ro m t h e h osp ita l o r im med ia te ly fo llo w in g t h e p ro ced ure i f i t h as b een p erfo rm ed o n a n o utp atie n t b asis (8 2). Exerc is e t r a in in g m ay a lle v ia te t h e p ro gre ssio n o f c o ro nary a rte ry s te n osis afte r P T C A b y i n hib itin g s m ooth m usc le c ell p ro lif e ra tio n, lo w erin g s e ru m lip id s, i m pro vin g i n su lin r e sis ta n ce a n d g lu co se i n to le ra n ce, a n d c au sin g hem osta tic c h an ges ( 5 5, 8 5). T ra d itio nal aero bic t r a in in g f o r 3 0 t o 4 0 m in , fo ur t o s ix t im es p er w eek f o r 1 2 w k, i m pro ves t r e ad m ill t im e a n d myocard ia l p erfu sio n an d r e d uces t h e r e ste n osis r a te a t 3 m o f o llo w in g PT C A ( 5 5, 5 7). R ecen tly t h e u se o f r e p eate d , s h orte r i n te rv als o f v ig oro us or h ig h-in te n sity e x erc is e h as b een t r ia le d w ith p ro m is in g r e su lts ( 6 3). As a r e su lt o f a n gio pla sty w ith i m pro ved t e ch niq ues o f r e v asc u la riz atio n, more p atie n ts w ith l o w -ris k p ro file s a re b ein g r e fe rre d to c ard ia c re h ab ilita tio n ( i.e ., p atie n ts w ith a g re ate r e x erc is e c ap acity , n o e v id en ce o f is c h em ia , n orm al l e ft v en tr ic u la r fu nctio n, a n d n o a rrh yth m ia s). S pecif ic ex am ple s i n clu de p atie n ts w ho a re y ounger, h av e s in gle -v esse l d is e ase , an d d id n ot ex perie n ce a n M I b efo re t h eir P T C A . R eg ard in g e x erc is e pre sc rip tio n, t h ese i n div id uals m ay b e t r e ate d s im ila rly t o a p pare n tly health y i n div id uals w ith t h e a d ditio n o f e d ucatio n c o ncern in g t h e re co gnitio n o f a n gin al e q uiv ale n ts , s e lf -m onito rin g, s e lf -c are , an d r is k fa cto r m odif ic atio n. O ptim iz ed m ed ic al t h era p y a lo ng w ith a p pro pria te ly pre sc rib ed e x erc is e t r a in in g c an b e a n a lte rn ativ e ap pro ach t o in te rv en tio nal s tr a te g ie s i n s e le cte d p atie n ts w ho a re a sy m pto m atic ( 4 3). When P C I i s t h e t h era p y o f c h oic e, i t sh ould b e c o m bin ed w ith d aily 507 physic al e x erc is e a n d i n cre ase d p hysic al a ctiv ity t o o ptim iz e s u ccess ( 4 3). Card ia c r e h ab ilita tio n re su lts i n e arly a n d s u sta in ed i m pro vem en t i n quality o f l if e a n d i s h ig hly c o st- e ffe ctiv e ( 9 1). I n a d ditio n, a n gio pla sty patie n ts c o m monly e x perie n ce r e ste n osis . S uperv is e d e x erc is e t r a in in g a n d ed ucatio n i m pro ve r e co gnitio n o f s ig ns a n d s y m pto m s asso cia te d w ith clo su re . M ost i m porta n t, a n gio pla sty p atie n ts n eed i n str u ctio n c o ncern in g ap pro pria te e x erc is e t r a in in g, d ie ta ry modif ic atio ns, m ed ic atio ns, a n d gen era l r is k f a cto r r e d uctio n t o s lo w o r r e v ers e t h e c o ro nary d is e ase pro cess. Becau se t h e P T C A p atie n t r e m ain s o n c o m ple te b ed r e st w hile t h e s h eath is i n s itu f o r a p pro xim ate ly 1 8 t o 2 4 h , t h e i m mobiliz atio n ofte n c au se s back p ain . A ppro pria te f le x ib ility e x erc is e s t h at e n han ce r a n ge o f m otio n ofte n h elp t o r e so lv e l o w b ack p ain . Ste n t T hera py Pla cem en t o f s te n ts u se s t h e s a m e c ath ete r p ro ced ure a s i n t h e P T C A , s o th e s a m e c o nsid era tio ns e x is t. B ut t h e r is k f o r t h ro m bosis is g re ate r fo llo w in g s te n t t h era p y. C onse q uen tly , p atie n ts a re o fte n p la ced o n an tic o ag ula n t t h era p y f o r p re v en tiv e p urp ose s. Alth ough n o s p ecif ic co ntr a in dic atio ns p re clu de e x erc is e f o llo w in g r e cen t s te n t p la cem en t, pro ceed in g w ith s im ila r c au tio n is p ru den t. Card io vasc u la r E xercis e The m ultip le i m pro vem en ts i n p atie n ts ’ t o le ra n ce t o a cu te b outs o f ex erc is e a fte r r e v asc u la riz atio n i n clu de t h e f o llo w in g (3 6, 5 7): Im pro ved m yocard ia l b lo od f lo w In cre ase d f u nctio nal c ap acity Im pro ved c y cle e rg om ete r o r t r e ad m ill p erfo rm an ce Varia b le i m pro vem en ts i n l e ft v en tr ic u la r f u nctio n In cre ase d m ax im al h eart r a te In cre ase d r a te – pre ssu re p ro duct Red uctio n i n S T -s e g m en t d ep re ssio n Relie f o r i m pro vem en t i n a n gin al s y m pto m s w ith e x erc is e Im pro ved h eart r a te r e co very Red uctio n i n e x ertio nal h ypote n sio n 508 The i n itia l e x erc is e p re sc rip tio n i s b ase d o n i n fo rm atio n g ain ed f ro m t h e patie n t’ s o rie n ta tio n i n te rv ie w f o r t h e o utp atie n t card ia c r e h ab ilita tio n pro gra m . P atie n ts a re q uestio ned c o ncern in g t h e p re se n ce o f s ig ns o r sy m pto m s, t h eir a ctiv ity w hile in t h e h osp ita l, a n d t h eir a ctiv ity l e v el s in ce th eir r e tu rn h om e f ro m t h e h osp ita l. O f e q ual i m porta n ce a re t h eir l e v el an d co nsis te n cy o f c o nditio nin g b efo re t h eir c ard ia c e v en t. D ep en din g o n how l o ng t h ey w ere i n t h e h osp ita l a n d t h e a m ount o f deco nditio nin g, bette r-c o nditio ned , h ig her-fu nctio nin g p atie n ts m ay b e a b le t o r e tu rn t o hig her l e v els o f e x erc is e v olu m e an d i n te n sity m ore q uic k ly t h an m ost patie n ts . I n itia lly , p atie n ts a re c lo se ly o bse rv ed a n d m onito re d t o e sta b lis h ap pro pria te ex erc is e i n te n sitie s a n d d ura tio ns t h at a re w ith in t h eir to le ra n ce. A s ta rtin g p ro gra m m ay i n clu de t r e ad m ill w alk in g ( 5 -1 0 m in ), c y cle erg om etr y ( 5 -1 0 m in ), c o m bin ed a rm a n d l e g e rg om etr y ( 5 -1 0 min ), a n d upper b ody e rg om etr y ( 5 m in ). I n itia l i n te n sitie s m ay a p pro xim ate 2 t o 3 METs ( m ultip le o f r e stin g o xygen u pta k e of 3 .5 m L · k g −1 · m in −1 ), b ut sta rtin g M ET l e v els m ay b e a b it h ig her d ep en din g o n e x erc is e h is to ry a n d prio r c o nditio nin g. A s m an y c ard ia c p atie n ts hav e l o w f u nctio nal c ap acity , esp ecia lly a fte r c ard ia c s u rg ery , t h eir d aily g en era l l iv in g a ctiv itie s pro bab ly e x ceed t h eir max im um c ard io re sp ir a to ry f itn ess ( p eak O 2 ). F or th is r e aso n, H IIT m ay b e i n dic ate d t o q uic k ly i m pro ve f itn ess; o ver t im e, fre q uen t e x posu re t o v ig oro us h ig h-in te n sity activ ity h as b een s h ow n t o re d uce M I r is k ( 8 6). A c o m mon e x erc is e p re sc rip tio n i s f o ur w ork in te rv als o f 4 m in w ith 3 m in re st o r r e co very b etw een e ach w ork i n te rv al. An i n te n sity o f 8 5% t o 9 5% p eak O 2 i s c o m monly u tiliz ed ( 8 9), w ith a 5 to 1 0 m in w arm -u p, 5 m in c o ol- d ow n, a n d r e co very b outs a ll c o m ple te d a t ab out 5 5% t o 65% p eak O 2 . The p atie n t’ s h eart r a te , b lo od p re ssu re , r a tin g o f p erc eiv ed e x ertio n, a n d sig ns a n d s y m pto m s a re m onito re d a n d r e co rd ed . Pro gra m s a re g ra d ually titr a te d d urin g t h e i n itia l s e ssio ns t o a r a tin g o f p erc eiv ed e x ertio n o f 1 1 t o 14 i n t h e a b se n ce o f an y a b norm al s ig ns o r s y m pto m s. In g en era l, e x erc is e i n te n sity i s p ro gre sse d b y 0 .5 t o 1 .0 M ET i n cre m en ts (i.e ., 0 .5 m ph [ 0 .8 k ph] o r 2 .0 % g ra d e o n t h e t r e ad m ill or 1 2.5 -2 5.0 W atts on t h e c y cle ). T he r a te o f p ro gre ssio n i s b ase d o n t h e p atie n t’ s s y m pto m s, sig ns o f o vere x ertio n, r a tin g of p erc eiv ed e x ertio n, i n dic atio ns o f a n y ex erc is e -in duced a b norm alitie s, a n d p ru den t c lin ic al j u dgm en t o n t h e p art of t h e card ia c r e h ab ilita tio n s ta ff. P atie n ts w ith g re ate r e x erc is e c ap acitie s (P T C A –ste n t p atie n ts w ith n o M I) a re s ta rte d a cco rd in g to t h eir e x erc is e 509 cap acitie s a n d p ro gre sse d m ore r a p id ly . T he s e le ctio n o f e x erc is e m odality dep en ds o n t h e p ers o n’s p ro gra m obje ctiv es. F or e x am ple , t h ose w ho a re em plo yed i n a l a b or-ty pe o ccu patio n o r p erfo rm m an y u pper e x tr e m ity activ itie s a t h om e sp en d a g re ate r p ortio n o f t h eir e x erc is e t im e d oin g upper e x tr e m ity e x erc is e s. I f s p ecif ic l im ita tio ns p re clu de c erta in e x erc is e modalitie s, p ro gra m m odif ic atio ns a re m ad e t h at a llo w m ore t im e o n to le ra b le e q uip m en t t o o bta in t h e g re ate st c ard io vasc u la r an d m usc u la r ad van ta g e. F or p atie n ts w ho h av e a n e x erc is e t e st, s ta n dard r e co m men ded pro ced ure s f o r e x erc is e p re sc rip tio n are f o llo w ed ( 8 , 9 , 1 1). Resis ta n ce T ra in in g Musc u la r s tr e n gth a n d e n dura n ce e x erc is e t r a in in g s h ould b e i n co rp ora te d eq ually w ith c ard io vasc u la r e n dura n ce a n d f le x ib ility ex erc is e t r a in in g durin g t h e e arly o utp atie n t r e co very p erio d. F ollo w in g r e v asc u la riz atio n, lo w -ris k p atie n ts c an p erfo rm musc u la r s tr e n gth a n d e n dura n ce e x erc is e tr a in in g s a fe ly a n d e ffe ctiv ely ( 5 0). D ep en din g o n t h e p atie n t’ s c lin ic al a n d physic al sta tu s, s u ccessfu l a p pro ach es f o r u pper a n d l o w er e x tr e m ity str e n gth e n han cem en t i n clu de 1 0 t o 1 2 r e p etitio ns w ith a v arie ty of t y pes of e q uip m en t t h at m ay i n clu de e la stic b an ds, V elc ro -s tr a p ped w ris t a n d an kle w eig hts , h an d w eig hts , a n d v ario us m ultis ta tio n mach in es. U su al guid elin es i n clu de m ain te n an ce o f r e g ula r b re ath in g p atte rn s ( a v oid in g t h e Vals a lv a m an eu ver ), s e le ctio n o f w eig hts s o t h at t h e l a st r e p etitio n o f a se t i s m odera te ly o r s o m ew hat h ard , a n d p ro gre ssio n w hen t h e p erc ep tio n of d if fic u lty d ecre ase s. C A BS p atie n ts m ay s ta rt r a n ge o f m otio n e x erc is e s with l ig ht w eig hts o f 1 t o 3 l b ( 0 .5 -1 .5 k g) w ith in 4 w k o f s u rg ery a s l o ng as s te rn al s ta b ility i s e n su re d a n d e x cessiv e i n cis io nal d is c o m fo rt i s n ot pre se n t. P T C A –ste n t p atie n ts may s ta rt r e sis ta n ce t r a in in g i m med ia te ly . Exerc is e s s h ould b e s e le cte d t h at w ill s tr e n gth en m usc le g ro ups u se d durin g n orm al activ itie s o f d aily l iv in g f o r l if tin g a n d c arry in g a n d occu patio nal o r r e cre atio nal t a sk s ( 2 ). Weig hts a re s e le cte d t h at a llo w t h e c o m ple tio n o f 1 2 t o 1 5 r e p etitio ns in itia lly ; t h e p atie n t t h en p ro gre sse s t o h ig her w eig hts an d 1 0 t o 1 2 re p etitio ns, w ith t h e l a st t h re e r e p etitio ns f e elin g m odera te ly h ard . T hose who c an not s e cu re ly h old h an d w eig hts sh ould u se w ris t w eig hts w ith Velc ro s tr a p s. T ypic ally , e x erc is e s a re s e le cte d t h at u se u pper a n d l o w er ex tr e m ity m usc le g ro ups in volv ed i n r o utin e l if tin g a n d c arry in g a n d o th er activ itie s o f d aily l iv in g. P atie n ts a re p ro gre sse d f ro m s tr e tc h b an ds an d lig ht h an d w eig hts t o r e sis ta n ce m ach in es, a g ain u sin g r e sis ta n ces t h at 510 re su lt i n a p erc ep tio n o f d if fic u lty o f m odera te ly hard f o r t w o o r t h re e s e ts of 1 0 t o 1 2 r e p etitio ns. Fig ure s 1 4.2 t h ro ugh 14.4 o utlin e p ossib le ex erc is e s f o r a r e h ab ilita tiv e e x erc is e p ro gre ssio n f o r r e v asc u la riz ed patie n ts . Pro gre ssio n o f e x erc is e i s b ase d o n p atie n ts w ith o pen -h eart p ro ced ure s; patie n ts u nderg oin g P T C A a n d s te n tin g c an p erfo rm all e x erc is e s l is te d f o r th e b eg in nin g o f t h e p ro gra m w ith p ro per p ro gre ssio n b ase d o n p rio r ex erc is e h is to ry a n d c lin ic al ju dgm en t o f t h e c ard ia c r e h ab ilita tio n t e am . The l is t t h at f o llo w s i s b ase d p artly o n i n fo rm atio n f ro m A dam s a n d co lle ag ues (7 ). Early -P hase R eh ab ilit a tiv e E xercis e s ( 2 -4 w k P ostd is c h arg e) Tra d itio nally p atie n ts a t t h is p hase h av e b een t o ld t o a v oid s tr e n gth tr a in in g a n d d o o nly r a n ge o f m otio n o r v ery l ig ht, if a n y, s tr e n gth t r a in in g. You m ay c o nsid er h av in g p atie n ts s ta rt t h ese e x erc is e s e arlie r i n t h eir re co very i f s te rn al h ealin g is g oin g w ell a n d t h ey a re a m bula to ry : Seate d l e g e x te n sio n Seate d o r s ta n din g l e g c u rl ( s u pin e l a te p hase o nly ) Sta n din g c alf r a is e ( w ith out s ig nif ic an t w eig ht o n s h ould ers ) Dum bbell c u rl Tric ep s p ush -d ow n 511 F ig u re 1 4.2 Early -p hase r e h ab ilita tiv e e x erc is e s: ( a ) s e ate d l e g e x te n sio n, ( b ) s ta n din g l e g c u rl, ( c ) s ta n din g c alf r a is e , ( d ) d um bbell c u rl, a n d ( e ) tr ic ep s p ush -d ow n. 512 513 Photo s c o urte sy o f M ark A . P atte rs o n. Mid phase R eh ab ilit a tiv e E xercis e s ( 4 -6 w k P ostd is c h arg e) Dum bbell b en t- o ver r o w Seate d r o w Late ra l d um bbell r a is e Should er p re ss Tric ep s k ic k back 514 Fig u re 1 4.3 Mid phase r e h ab ilita tiv e e x erc is e s: ( a ) d um bbell b en t- o ver ro w , ( b ) s e ate d r o w , ( c ) l a te ra l d um bbell r a is e , ( d ) s h ould er p re ss, a n d ( e ) tr ic ep s k ic k back . 515 Photo s c o urte sy o f M ark A . P atte rs o n. Late -P hase R eh ab ilit a tiv e E xercis e s ( 6 w k o r M ore P ostd is c h arg e) Lat p ull- d ow n Dum bbell b en ch p re ss Dum bbell f ly Fro nt r a is e 516 Fig u re 1 4.4 Late -p hase r e h ab ilita tiv e e x erc is e s: ( a ) l a t p ull- d ow n, ( b ) dum bbell b en ch p re ss, ( c ) d um bbell f ly , a n d ( d ) f ro nt r a is e . 517 Photo s c o urte sy o f M ark A . P atte rs o n. The p ote n tia l b en efits o f r e sis ta n ce t r a in in g i n t h e r e v asc u la riz ed popula tio n i n clu de i m pro vin g m usc u la r s tr e n gth a n d e n dura n ce an d possib ly a tte n uatin g t h e h eart r a te a n d b lo od p re ssu re r e sp onse t o a n y giv en w ork lo ad ( lo w er w ork lo ad o n t h e h eart) . G en era l re sis ta n ce t r a in in g guid elin es f o r c ard ia c r e h ab ilita tio n a re p re se n te d i n P atie n t’ s G uid e f o r Resis ta n ce T ra in in g. R is k s tr a tif y in g patie n ts t o d ete rm in e e lig ib ility i s im porta n t. Patie n t’s G uid e f o r R esis ta n ce T ra in in g Choose a n i n itia l w eig ht y ou c an c o m fo rta b ly l if t f o r 1 2 t o 1 5 re p etitio ns; a s y ou p ro gre ss o ver t im e, i n cre ase t h e w eig ht acco rd in gly s o t h at y our m usc le s w ill g et s ig nif ic an tly t ir e d by 1 0 t o 1 2 r e p etitio ns b ut y ou a re n ot s tr u gglin g t o c o m ple te th em . Avoid t ig ht g rip pin g d urin g p ush in g, p ullin g, a n d l if tin g ex erc is e s. Do n ot h old y our b re ath d urin g t h e a ctiv ity . E xhale d urin g t h e ex ertio n p hase , a n d a v oid s tr a in in g. Perfo rm t w o o r t h re e s e ts o f e ach e x erc is e , a n d t r a in t h re e tim es p er w eek . Rest 3 0 t o 4 5 s b etw een s e ts . In cre ase w eig ht m odestly ( 1 -2 l b , o r 0 .5 -1 .0 k g) a fte r y ou c an easily p erfo rm 1 2 t o 1 5 r e p etitio ns o f a g iv en w eig ht. 518 Ran ge o f M otio n Each e x erc is e s e ssio n b eg in s w ith a s e rie s o f r a n ge o f m otio n a n d fle x ib ility e x erc is e s d esig ned t o m ain ta in o r i m pro ve t h e ra n ge o f m otio n aro und j o in ts a n d m ain ta in o r i m pro ve f le x ib ility o f m ajo r m usc le g ro ups ( fig ure 1 4.5 ). T he e x erc is e s b eg in i n t h e s ta n din g p ositio n ( o r s e ate d i n a ch air , i f t h e p ers o n h as d if fic u lty s ta n din g) w ith t h e n eck , pro gre ssin g dow nw ard t o t h e s h ould ers a n d t r u nk a n d e v en tu ally t o t h e l o w er ex tr e m itie s. T he f in al s tr e tc h es f o r t h e i m pro vem en t of p oste rio r l e g musc le s a n d l o w er b ack f le x ib ility m ay b e p erfo rm ed o n t h e f lo or, o r i n a ch air f o r t h ose w ith d if fic u lty gettin g t o t h e f lo or. 519 F ig u re 1 4.5 Str e tc h in g e x erc is e s: ( a ) h ead t o s h ould er, ( b ) a rm c ir c le s, ( c ) l a te ra l a rm o ver h ead , ( d ) s h ould er s h ru g, ( e ) s e ate d h am str in g s tr e tc h , a n d ( f ) c alf s tr e tc h in g. 520 521 Photo s c o urte sy o f M ark A . P atte rs o n. The f o llo w in g a re e x am ple s o f s tr e tc h es f o r t h e r e v asc u la riz ed p atie n t. Patie n ts w ho u nderw en t a n o pen -h eart p ro ced ure s h ould perfo rm s tr e tc h es with c au tio n i n t h e e arly s ta g es a fte r h osp ita l d is c h arg e. P atie n ts s h ould d o th e s tr e tc h es d aily , a n d i d eally multip le t im es a d ay , b ut s h ould t a k e e ach str e tc h o nly t o t h e p oin t w here t h ey m ay f e el s o m e m ild t u ggin g o n t h e ste rn oto m y site ; t h e s tr e tc h s h ould n ot b e p ain fu l. Head t o s h ould er Arm c ir c le s Late ra l a rm o ver h ead Should er s h ru g Seate d h am str in g s tr e tc h Calf s tr e tc h in g Tab le 1 4.4 o utlin es e x erc is e p re sc rip tio n f o r r e v asc u la riz ed p atie n ts . 522 Pra ctic a l A pplic a tio n 1 4.3 Rese a rch F ocu s: E arlie r P ro gressio n a n d F ew er Restr ic tio n s C on cern in g S tr en gth T ra in in g Guid elin es f o r s ta rtin g a n d p ro gre ssin g s tr e n gth t r a in in g a fte r re v asc u la riz atio n m ay o ccasio nally b e c o nsid ere d o verly re str ic tiv e, as m an y t a sk s o f d aily l iv in g d em an d l if tin g o r p ullin g obje cts t h at e x ceed t h e s u ggeste d s tr e n gth t r a in in g w eig ht l im its . Clin ic ia n s m ay u se c lin ic al j u dgm en t t o s ta rt s tr e n gth t r a in in g a t earlie r s ta g es w hile t a k in g i n to c o nsid era tio n t h e p atie n t’ s prio r co nditio nin g a n d e x perie n ce w ith s tr e n gth t r a in in g e x erc is e s, a s well a s t h e k now le d ge t h at n o a b so lu te c o ntr a in dic atio ns to str e n gth t r a in in g a re p re se n t. A r e cen t p ositio n s ta n d s u ggests e arly pro gre ssiv e u se o f s tr e n gth t r a in in g e v en f o r c ard ia c patie n ts w hen ex erc is e s a re s e le cte d i n div id ually , w ith s a fe ty a n d e ffic acy o f re sis ta n ce e x erc is e i n m in d ( 7 7). T his m eth od puts v ario us s tr e n gth tr a in in g e x erc is e s i n to c ate g orie s b y t h eir p ote n tia l t o c au se h arm to t h e p atie n t ( s u ch a s d am ag e t o th e s te rn um o f t h e C A BS patie n t) . Rev asc u la riz a tio n E xercis e K ey P atie n t A dvic e CA BS p atie n ts a re v ery p ro te ctiv e o f t h eir s te rn oto m y s ite s an d a re s o m etim es r e lu cta n t t o d o r a n ge o f m otio n a n d 523 str e tc h in g ex erc is e s. B e v ery p ers is te n t i n e n su rin g t h ey a re perfo rm in g e x erc is e s t o r e sto re n orm al f u nctio n t o u pper b ody movem en ts as s o on a s p ossib le t o l im it f u tu re i s su es w ith upper b ody s tr e n gth a n d f le x ib ility . Red uced a rm s w in g w ill r e d uce s tr id e l e n gth a n d h en ce walk in g s p eed ; i f n ot c o rre cte d r e la tiv ely q uic k ly , t h is c o uld hav e an a d vers e e ffe ct o n w eek ly e x erc is e . Access t o e q uip m en t t h at c an b e t itr a te d a t m in ute i n cre m en ts in w ork lo ad i s v ery i m porta n t a s c ard ia c p atie n ts h av e l o w le v els of f itn ess, e sp ecia lly i n t h e i m med ia te p osto pera tiv e perio d, s o e q uip m en t s u ch a s s ta tio nary c y cle s m ay n eed t o b e ad ju ste d in t in y 2 W att i n cre m en ts i n w ork lo ad t o acco m modate s e v ere ly d eco nditio ned p atie n ts . Rev asc u la riz ed p atie n ts s o m etim es f e el c u re d o f t h eir d is e ase ; th e r e h ab ilita tio n t e am n eed s t o r e in fo rc e p ro per l if e sty le an d med ic al m an ag em en t t o e n su re c o ntin ued l o w er r is k o f f u tu re card ia c e v en ts a n d h osp ita liz atio ns. Man y r e v asc u la riz ed p atie n ts a re o n β -b lo ck er m ed ic atio ns, whic h m ak es e x erc is e p re sc rip tio n b y h eart r a te d if fic u lt i f n ot im possib le . I t i s b ette r t o u se r a tin g o f p erc eiv ed e x ertio n; sp en d t im e h elp in g t h em “ fe el” h ow h ard t o b e e x erc is in g when th ey a re o n t h eir o w n, a n d h elp t h em g et s o m e p ra ctic al ex perie n ce i n u nders ta n din g t h e s e n sa tio n o f p ro per e x erc is e in te n sity . While m an y r e v asc u la riz ed p atie n ts s tr u ggle w ith d ep re ssio n, so m e a re o n t h e o th er e n d o f t h e s p ectr u m a n d f e el b ette r t h an th ey h av e i n y ears ; t h ese p atie n ts m ay b e t o o a g gre ssiv e i n pro gre ssin g e x erc is e . Con clu sio n Advan ces i n c o ro nary r e v asc u la riz atio n p ro ced ure s a n d a n a g in g popula tio n h av e l e d t o a g re ate r n um ber o f p atie n ts p re se n tin g fo r re h ab ilita tio n f o llo w in g C A BS, P C TA , a n d s te n tin g. P re h ab ilita tio n a n d oth er i n te rv en tio ns m ay b ette r p re p are p atie n ts fo r s u rg ery a n d r e su lt i n bette r a d here n ce t o p osts u rg ery e x erc is e r e h ab ilita tio n ( 7 6). I n a d ditio n t o ex erc is e p ro gra m min g, ris k f a cto r m odif ic atio n i s e sse n tia l f o r p re v en tio n of r e cu rre n t e v en ts ( 2 1, 5 9). F urth erm ore , b arrin g n o n ew s y m pto m s, t h e GXT, a lth ough a g ood p ro gnostic t o ol, m ay b ette r s e rv e i ts p urp ose o f 524 asse ssin g f u nctio nal s ta tu s i f i t i s p ostp oned u ntil la te r i n t h e r e h ab ilita tio n pro gra m . P ro vid ed t h at n o u nto w ard e v en ts o ccu r o ver t h e c o urs e o f re h ab ilita tio n, C A BS a n d P T C A patie n ts u su ally o utp erfo rm t h eir M I co unte rp arts , a ch ie v in g g re ate r f itn ess i m pro vem en ts a t a f a ste r r a te . Go o nlin e t o r e v ie w t h e w eb r e so urc e c ase s tu dy a n d d is c u ssio n q uestio ns fo r t h is c h ap te r. 525
Case study (Attached) Answer the 7 Questions. Clearly and thoroughly describe your thought process and rationale for your answer/decision. Topic: Exercise in Chronic Disease: Cardiopulmonary and Met
Chapter 14 Case Study A Subjective Medical History Ms. RW is a 58 yr old white woman with no prior history of heart disease. She has hypertension under good control with medications and was diagnosed with diabetes 15 yr ago. Her last fasting blood sugar was 234, and her HbA1c was 8.7. She is a former smoker (quit 10 yr ago) and leads a rather sedentary lifestyle as a computer analyst for a large local corporation. Over the past 3 mo she has started to notice increased shortness of breath when climbing two flights of stairs at work; at the top of the stairs, she feels some moderate chest pressure that resolves in a couple of minutes after she sits down at her desk. Her primary care physician sends her for a routine exercise stress test. Objective and Laboratory Data Exercise Test Results Resting ECG: appears normal Heart rate: 65 beats · min–1 Blood pressure: 138/92 mmHg Heart and lung sounds: within normal limits Ms. RW exercises on a standard Bruce protocol. At 4:30 there is some horizontal ST depression, about 1 mm in inferior and lateral leads; by peak exercise (5:20) it is about 2 mm downsloping in the same leads, and she is developing the chest pressure she described in her symptom history. ECG changes resolve by 10 min of recovery, and symptoms resolve in about 5 min of recovery. Assessment and Plan Diagnosis Principal diagnosis: Severe two-vessel CAD. Stenting was performed to 95% proximal left anterior descending coronary artery (LAD) lesion; Ms. RW’s 75% distal left circumflex lesion was not a candidate for revascularization at the time of the procedure. Medications: Metoprolol 50 mg twice daily, lisinopril 10 mg once daily, aspirin, Plavix, and simvastatin. Exercise Prescription A referral for cardiac rehabilitation was placed by her cardiologist and was to start as soon as she was able to set it up after hospitalization. Resting heart rate: 54 beats · min–1 Resting blood pressure: 112/64 mmHg Initial exercise program: Treadmill walking = 2.0 mph (3.2 kph), 0% grade for 10 min Combined arm and leg ergometry = 100 W for 10 min Upright stationary leg ergometry = 30 to 50 W for 10 min Short circuit of resistance machines = one set of six exercises for 10 repetitions Ms. RW completed 6 wk in the program at the following workloads: Treadmill walking = 2.7 mph (4.0 kph), 3% grade for 10 min Combined arm and leg ergometry = 100 to 125 W for 10 min Upright stationary leg ergometery = 100 to 125 W for 10 min Rowing = 50 to 75 W for 10 min Short circuit of resistance machines = two or three sets of eight exercises for 10 repetitions Exercise heart rate: 100 to 110 beats · min–1 Exercise rating of perceived exertion: 12 to 14 The remainder of the program was uneventful. The patient completed a total of 12 wk from the start of the program and returned to her home exercise program and activities of daily living. Case Study Discussion Questions What changes may have to be made to Ms. RW’s exercise regimen in view of the residual 75% blockage in her left circumflex coronary artery? If she hits a plateau in her ability to increase her intensity of cardiovascular exercise that is not due to further complications with her heart, what issues may be limiting her ability to increase exercise intensity? Case Study B Subjective Medical History Mr. XN, a 60 yr old SE Asian male, was referred via dialysis unit for cardiac rehabilitation after PCI. He had severe dyspnea and chest pain on mild exertion. He had a 6 mo dialysis history. Body mass was 70 kg. Resting echo revealed left ventricular ejection fraction of 12%. Hemoglobin was 10g · dL–1. Medications: Carvedilol 25 mg daily, enalnopril 20 mg once daily, aspirin, Plavix, and atorvastatin. Objective and Laboratory Data Stress Echo Baseline: Cycled at 60 rpm starting at 10 W, increasing 10 W min–1. Finished after 6.15 min at 70 W. Peak V̇O2 12.9 mL · kg–1 · min–1. Baseline: Severe LV dysfunction 12.1%, Diastology E/A 0.66, DT 355 ms, E/e’ 19.1 Assessment and Plan Exercise Prescription and Interventions Exercise rehabilitation, EPO administration to address anemia due to renal failure, revascularization (PCI). We know that mean peak V̇O2 (for a 70 kg person this is only a peak of 840 mL O2!) of heart failure patients in exercise studies is around 12-13 mL · kg–1 · min–1 or 3.7-4.0 METs* (Smart 2004 AJM). So moderate intensity @40-60% would require the patient to exercise at 5.0-7.2 mL · kg–1 · min–1 or 1.4-2.1 METs, which for a 70 kg person is equivalent to cycling at a low wattage of 25 W. However to obtain benefits we would like the person to cycling continually for 15-20 min, building over several weeks to perhaps 30 min. Mr. XN, however, could only manage 5-6 min continuous cycling at the outset so we adopted another approach. High [email protected] 85-95% would be 10.9 mL · kg–1 · min–1 (85% peak V̇O2) or 3.1 METs, this is equivalent to cycling at 42 W (illustrating the importance of having cycling equipment that can be titrated to within 2 W accuracy). Difference between moderate and high intensity is approximately 1.0 MET (which is relatively small). With recovery between intervals in HIT—to attenuate physical stress of 3 min at rest or preferably recovery at about 30-40% peak V̇O2 (initially), as Mr. XN improves we would challenge them to recover at 40-60% peak V̇O2. Easily below the requirements of independent living (5.5 METs) so training at high intensity will not likely expose people (with chronic disease) to efforts they are not already routinely experiencing multiple times daily. Patient Progress Base 8 wk 16 wk 52 wk EDV (mL) 232 201 166 193 ESV (mL) 204 153 89 102 LVEF (%) 12.1 24.3 46.7 47.2 Peak V̇O2 12.9 15.8 17.8 16.2 Minnesota Living with Heart Failure Total Score Max 30 27 23 20 21 Case Study Discussion Questions Do you think Mr. XN would be eligible for a heart transplant? Please justify your answer. Do you think Mr. XN should have had CABS? Please justify your answer. With respect to his change in cardiac function baseline to 52 wk, do you think this is typical? What might explain why relative change in peak V̇O2 at 52 wk was much less than the relative change in cardiac function? Was the change in Minnesota score clinically significant? From J.K. Ehrman, P.M. Gordon, P.S. Visich, and S.J. Keteyian, Clinical Exercise Physiology Web Resource, 4th ed. (Champaign, IL: Human Kinetics, 2019).

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