Cardiovascular/pulmonary systems physical therapy interventions and their applications for rehabilitation, health promotion, and performance according to current best evidence Cardiac rehabilitation (4 Phases) is now outdated but may still be on the NPTE. The major concerns are how the patient is monitored, where the patient is located. Other concerns are the workload measured in metabolic equivalents and the patient’s functional goal. Contraindications to cardiac rehabilitation and active exercise: 1 Unstable angina Resting systolic blood pressure > 200 mm Hg. Resting diastolic pressure > 110 mmHg. Orthostatic blood pressure drop > 20 mm Hg. Critical aortic stenosis Acute systemic illness or fever Unstable blood sugar level due to uncontrolled diabetes Uncontrolled high thyroid level Uncontrolled hydration level or electrolyte imbalances Recent embolism Thrombophlebitis Severe orthopedic conditions that prevent exercise Other severe or uncontrolled medical conditions Active pericarditis or myocarditis Uncontrolled cardiac arrhythmia: o Uncontrolled atrial or ventricular arrhythmia o Uncontrolled tachycardia with rates over 120 at rest o Third degree atrial-ventricular (AV) blocks o Third degree AV block without a functioning pacemaker o Resting ST-segment depression or elevation of greater than 2 mm on the ECG Initial inpatient care: Most of the time the first few visits are in the ICU/CCU or NNICU. Indications: Medically stable patients with post myocardial infarction (MI) at rest. This should be approved by the physician by a stable EKG at rest and blood enzyme levels declining. Angina should be stable and not the unstable/uncontrolled form Following open heart surgery such as coronary bypass graft surgery, heart transplant, or implantation of a ventricular assist device.
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Cardiovascular/pulmonary systems physical therapy
interventions and their applications for rehabilitation, health
promotion, and performance according to current best
evidence
Cardiac rehabilitation (4 Phases) is now outdated but may still be on the NPTE.
The major concerns are how the patient is monitored, where the patient is located.
Other concerns are the workload measured in metabolic equivalents and the patient’s
functional goal.
Contraindications to cardiac rehabilitation and active exercise:1
Unstable angina
Resting systolic blood pressure > 200 mm Hg.
Resting diastolic pressure > 110 mmHg.
Orthostatic blood pressure drop > 20 mm Hg.
Critical aortic stenosis
Acute systemic illness or fever
Unstable blood sugar level due to uncontrolled diabetes
Uncontrolled high thyroid level
Uncontrolled hydration level or electrolyte imbalances
Recent embolism
Thrombophlebitis
Severe orthopedic conditions that prevent exercise
Other severe or uncontrolled medical conditions
Active pericarditis or myocarditis
Uncontrolled cardiac arrhythmia:
o Uncontrolled atrial or ventricular arrhythmia
o Uncontrolled tachycardia with rates over 120 at rest
o Third degree atrial-ventricular (AV) blocks
o Third degree AV block without a functioning pacemaker
o Resting ST-segment depression or elevation of greater than 2 mm on the ECG
Initial inpatient care: Most of the time the first few visits are in the ICU/CCU or NNICU.
Indications:
Medically stable patients with post myocardial infarction (MI) at rest. This should be
approved by the physician by a stable EKG at rest and blood enzyme levels declining.
Angina should be stable and not the unstable/uncontrolled form
Following open heart surgery such as coronary bypass graft surgery, heart transplant, or
implantation of a ventricular assist device.
Following a balloon angioplasty or coronary endarterectomy with stent placement of
the transmural coronary arteries.
Heart valve replacement surgery where the myocardium was cut through.
Surgery to correct congenital heart defects that involved incision through the
myocardium.
Sudden cardiac death syndrome
Phase I or with patients in the ICU,CCU or NNICU2
Patient monitoring: the patient is in the hospital intensive care unit (ICU) or coronary
care unit (CCU). They need to be monitored 24 hours a day, both during activity and at rest.
Electronic monitoring through telemetry or wall mounted ECG and other vital functions such as
O2 saturation and ventilation rate are used.
Goals: Minimal assistance levels with activities of daily living. Ideally to allow the patient
to go home (homebound level) with assistance. Ideally the patient should be able to tolerate a
stress level of 2.5 to 3 Mets. They need to be stable at rest to be released to phase II.
Activities: Therapeutic exercise, starting with the lower extremities and progressing to
the upper extremities to permit dressing. Exercise is focused on strength with active and active
assistive exercises. Few repetitions are used with frequent rest breaks. Use a low target 65-75%
of maximal effort. Transfer training bed to chair. Ambulation 10-20 ft. to permit bathroom use.
Patient education can be introduced during rest breaks.
Phase II or with patients that are not in intensive care, they are on a hospital floor such as the
subacute unit or in a skilled nursing facility or at home in a homebound status.3
Indications here can include:
Usually following an ICU stay for cardiac complications
Any cardiomyopathy, damage to the heart muscle by trauma or infection.
Patient monitoring: the patient is home in homebound status or in a subacute unit. The
length of this phase is 4-6 weeks to allow the muscle of the myocardium to heal. Cardiac
monitoring during exercise, not at rest. Vital signs are most often used to monitor, but a pulse
oximeter is now in use as well.
Goals: The patient should be able to tolerate 5-6 Mets by the end of this phase. This will
allow the patient to enter the community, get to outpatient cardiac rehabilitation. This is the
same level that is needed for sedentary work, such as an office job.
Activities: Exercise of both lower and upper extremities with a concentration on
strength. Ambulation of at least 200ft. by the end of this phase. Patient education on their
condition and lifestyle changes. Energy conservation and the solving of problems that are
concerned with their house are addressed during rest breaks.
Phase III Outpatient cardiac rehabilitation4
Indications:
After initial pacemaker insertion or implantable cardiac defibrillator insertion
Angiography or Balloon angioplasty not related to an acute myocardial infarction.
At high risk for coronary disease due to multiple or severe risk factors such as diabetes.
End stage renal disease
Peripheral vascular disease
Cardiac disease that cannot be medically or surgically corrected that is impacting the
patient’s function.
Patient monitoring: During exercise patients are closely monitored by a professional
(usually an exercise physiologist, specially trained nurse or physical therapist [often a
cardiopulmonary certified specialist]). Telemetry is commonly used. Monitoring is done prior to
exercise, during exercise and after exercise to determine recovery time.
Goals: The heart muscle (myocardium should be healed now. Goals here focus more on
improving endurance to enhance the patient’s quality of life. The patient should tolerate their
expected maximal heart rate. They should be able to tolerate the workload as indicated by
their employment or recreational activities that they have been doing. Self-monitoring of vital
signs. This phase terminates when a patient can reliably monitor their own vital signs and
demonstrate that they can increase workloads to an appropriate stress level and recognize
when they are exceeding a targeted training level.
Activities: Exercise (5 times a week) often takes the form of graded exercise testing. The
focus is on improving endurance. Upper and lower extremities are exercised with exercises that
incorporate both to achieve higher workload levels (elliptical trainers and ski machines). Patient
education focuses on teaching the patient to monitor their own vital signs to determine how
much exercise they can tolerate. Education on exercise and diet as a lifestyle change.
Phase IV5
This form of cardiac rehabilitation is not professionally supervised. Here the patient is
able to monitor their own heart rate before, during and after exercise. There are many classes
that a patient can attend or exercise on their own. The best choice is an activity that the patient
likes to do which is within their target training intensity level. This increases compliance with
regular exercise.
Patient monitoring: Here the patient is able to monitor themselves during exercise and
at rest. No professional monitoring is needed. They exercise at a health club or any facility.
Many cardiac rehabilitation programs allow patients that have graduated from phase III to
continue to come and use the equipment, although they are not monitored. The YMCA has
developed programs for this phase of cardiac rehabilitation.
Goals: are to maintain (3 times a week) or improve (5 times a week) cardiac muscle
function. Improvement may be needed if a patient cannot tolerate a workload, or stress level
that is required by either a job or recreational activity that they need to or want to participate.
Activities: are focused on aerobic activities that are integrated into a patient’s lifestyle.
They may be seasonal sport activities or cross training types of exercise programs that interest
a patient. Compliance is a major factor in selecting good activities. When a patient participates
in the activity their heart rate should be within a training level for at least 20 minutes.
(Reference: ACSM, (2010), ACSM’s Guidelines for Exercise Testing and Prescription, 8th edition.
P. 209)
The NPTE will focus more on phase I and II cardiac rehabilitation as entry level
therapists are commonly involved in these phases. To treat a patient with cardiac precautions,
even with another diagnosis, the phase II of cardiac rehabilitation should be used to ensure a
safe and effective treatment. Geriatric patients, infants and those with anemia, neurological
impairments and pulmonary dysfunction should use this concept. Aerobic and anaerobic
elements should be addressed in all treatment plans.
Calculations:
The maximal heart rate is calculated by computing 220- the patient’s age.
A target heart rate is calculated by using Karvonen formula
Target heart rate = [(heart rate maximal - heart rate at rest) X % intensity] + heart rate
at rest. Generally, for most patients that are in the early phases of cardiac rehabilitation an
intensity percentage of 60-70 % is used. In outpatient rehabilitation with professional
monitoring a higher 80-95% can be used, this causes endorphin production that will reward the
patient for their effort and lead to better compliance and more likely a lifestyle change.6
Graded exercise:
Principles to follow:
Initially use low intensity work load
o Start with smaller muscle groups and progress to larger muscle groups
o Start with lower extremity exercise first as this does not affect the barrow
receptors as greatly so vital signs will elevate more slowly
o Start in supine and progress to sitting then standing
Functional activities have lesser and greater workloads
o Start in supine with bed mobility progress to sitting then standing and finally
walking
Give at least 5 minutes before increasing the workload to allow them to adjust to the
demand on the cardiopulmonary system.
o Monitor vital signs and O2 saturation levels at least every 5 minutes during a
treatment session
o Use current vital signs to make the decision to advance to the next level of
workload
o Use Karvonen formula to calculate a target heart rate
Conducting a treatment session with cardiac precautions:
Initial baseline vital signs (heart rate, respiratory rate, blood pressure and sometimes
oxygen saturation) should be measured.
Make decision to exercise if vital signs are within parameters that will allow for safe
exercise.
Calculate target heart rate for the exercise session.
o Initial intensity should be low. Duration to steady state (5-7 minutes of
contentious exercise). Patient history should indicate what intensity has been
tolerated previously which serves as a guide on what intensity to start. It is
recommended that the intensity should be at least a level below the level that
the patient previously tolerated.
Observe the patient during exercise for signs of intolerance (Stridor, the use of
accessory muscles of respiration, skin color or diaphoresis (excessive sweating)
decreasing level of consciousness or complaints of chest and/or arm pain).
Retake the vital signs to determine patient tolerance.
o Make a decision to increase exercise intensity if the vital signs are within
expected parameters.
This process is repeated until the goal of the treatment has been achieved.
Low target intensity levels (65-75% of maximal effort) are safer in that it is unlikely to
exceed maximal heart rate that is determined through calculation of the maximal expected
heart rate or better from a maximal stress test.
High target intensity levels are 85-95% of maximal effort. Using this level will gain
better patient compliance, but are not as safe to use.
Monitoring a Patient
The therapist needs to know how to monitor a patient’s vital signs and what is expected
as a normal and abnormal reaction to a stressful work load. This is used to adjust the work
load so that an effective treatment is accomplished.
An example is initial ambulation or a patient immediately after a myocardial infarction.
GUIDELINES FOR HELPING PATIENTS RESUME WALKING SOON AFTER
MYOCARDIAL INFARCTIONS7
Before Exercise
Ask about chest discomfort, dyspnea, and faintness (if present, check with physician before
proceeding).
Measure blood pressure and heart rate (if greater than160/100 or less than 90/60 mm Hg or if
heart rate is greater than110 or less than 60 bpm, check with physician before starting)
Check orthostatic blood pressure before beginning standing range-of-motion exercise or
walking. If blood pressure falls more than 20 mm Hg or if fall is associated with symptoms of
faintness, have patient lie down and notify physician.
During Exercise
Ask patient to report symptoms, particularly chest discomfort, dyspnea, or faintness. If
symptoms occur, discontinue exercises until checking with physician.
Ask for rating of perceived exertion.
Immediately After Exercise
Ask patient about symptoms.
Measure heart rate, blood pressure, and rating of perceived exertion. If symptoms occur,
blood pressure falls more than 20 mm Hg, or heart rate rises more than 20 bpm over resting
rate, check with physician before continuing.
Response to Stress/Exercise
As a patient begins to exercise vital signs normally change. Accommodation to a
workload takes up to 3-5 minutes normally, but with debilitated patients it may take up to 7
minutes. If it is longer than 7 minutes it may mean that the patient should not be exercised.
After an exercise session, or functional mobility training, vital signs should be checked
again (5-7 minutes) to see if they tolerated the treatment. If their vital signs are not near the
starting vital sign levels after treatment it means that they did not tolerate the treatment.
Initially all patients with any cardiopulmonary involvement should be treated as if they
have a cardiopulmonary problem. If after several treatments, you see that the vital signs are
responding as expected you can just take vital signs before and after treatment.
Monitoring the cardiopulmonary status of a patient
To adequately monitor a patient using vital signs the therapist must know what changes
and when it changes in response to exercise or functional training. With this knowledge you can
spot if there is an abnormal response indicating that the intensity of the activity is too great for
it at this time.
Patients with cardiac precautions should have their vital signs taken before, during
treatment every time the intensity is to be increased or every 5 minutes and after exercise to
see if they tolerated the treatment.
All patients with diagnoses and secondary diagnoses that can lead to cardiopulmonary
problems should have their vital signs assessed at the beginning, and end of treatment.
All patients should have their vital signs assessed in their initial assessment.
Response to Exercise
Period Factor Expected
Response
to
Exercise
Normal
Maximum Values
Danger Signs
Initial 30
seconds
Increased
tidal
volume
Increases Facial grimace with
sub sternal retractions
May decrease when
other factors
accommodate
Response to Exercise
Period Factor Expected
Response
to
Exercise
Normal
Maximum Values
Danger Signs
30-60 seconds Increased
respirations
Increases Adult
normal 12
Maximum 30
Infant 40- 60
Child under 3 years
20-30
Child over 3 years
15-20
Adult
Abnormal greater
than 30, less than 6
May slightly decrease
when other factors
(HR and cardiac
output)
accommodate to
workload
Infant
Abnormal high more
than 60
Abnormal low less
than 40
Child under 3 years
Abnormal high more
than 30
Abnormal low less
than 20
Child over 3 years,
less than 15 years
Abnormal more than
20
Abnormal less than
15
Response to Exercise
Period Factor Expected
Response
to
Exercise
Normal
Maximum Values
Danger Signs
First Minute Ventilation
output
Increases Initially increases
then may slightly
decrease when other
factors
accommodate
60-120 seconds Increased
stroke
volume
Systolic
blood
pressure
increases
Adult
Rest 120 mmHg
Maximum 280
mmHg
Infant 60-90 mm
Hg
Child under 3 years
75-130 mm Hg
Child over 3
years 90-140 mm
Hg
Adult
Abnormal Less
than 100
mmHg
Greater than 280
mmHg
Falling with increased
work load
Infant
Abnormal high more
than 90 mmHg
Abnormal low less
than 60 mmHg
Child under 3 years
Abnormal high more
than 130 mmHg
Abnormal low less
than 75 mmHg
Child over 3 years
Abnormal more than
140 mmHg
Abnormal less than
90 mmHg
Response to Exercise
Period Factor Expected
Response
to
Exercise
Normal
Maximum Values
Danger Signs
Over 1 minute Increased
heart rate
Increases Adult normal 80
BPM
Maximum 220
BPM
Infant 120-200
BPM
Child under 3
years 100-180
BPM
Child over 3 years
70-150 BPM
Adult
Greater than 220
BPM
Less than 60 BPM
Infant
Abnormal high more
than 200 BPM
Abnormal low less
than 120 BPM
Child under 3 years
Abnormal high more
than 180 BPM
Abnormal low less
than 100 BPM
Child over 3 years
Abnormal more than
150 BPM
Abnormal less than
70 BPM
Pulse
Stroke
volume +
Heart Rate
Increases
pulse
pressure =
systolic BP
-diastolic
Adult
40 mmHg
All patients Falling
with increased work
over 10 mmHg is
significant
BP
Response to Exercise
Period Factor Expected
Response
to
Exercise
Normal
Maximum Values
Danger Signs
Steady state:
at 2.5 - 3
minutes
Diastolic
blood
pressure
No change Adult 80 mmHg
Infant 30-60
mmHg
Child under 3
years 45-90 mmHg
Child over 3
years 50-80
mmHg
Maximum 100
mmHg
Abnormal
CNS response is
falling or elevating
Over 90-100 mmHg
Change greater than
10 mm Hg
Abnormal Adult less
than 50 mmHg
greater than 90
mmHg
Infant
Abnormal high more
than 60 mmHg
Abnormal low less
than 30 mmHg
Child under 3 years
Abnormal high more
than 90 mmHg
Abnormal low less
than 45 mmHg
Child over 3 years
Abnormal more than
80 mmHg
Abnormal less than
50 mmHg
Target Range:
Target ranges are used to maintain a specific training intensity or workload. Active
exercises should have the intensity level set to a target range. The target is 65% to 90% of a
patient’s maximal effort. To determine a specific level a maximal effort must be first
determined. Studies have shown that there is not a significant difference in the adaptation of
tissue (gains) due to training at either 65 or 90% of a patient’s maximal effort. Since 65 to 90 %
is a large range the consideration of safety or motivation needs to be considered.
Training at 65% is safer (debilitated patients can be started at as little as 40% of maximal
effort) in that there is a considerable range that would have to be bridged for a patient to
exceed 100% and cause additional tissue damage. The problem is that training at 65% is not
motivating to the patient as little stress is felt by the patient, thus they would not gain a sense
of accomplishment.
Physiologically there is little to no additional endorphin release in response to this low
intensity level of exercise. Exercising at 90% of maximal level does provide the patient with a
sense of accomplishment of overcoming a stress, thus is motivating. In addition a significant
amount of endorphins are produced so that the patient is better satisfied with their
performance.
Aerobic activities that are popular among people with heart failure are walking and
stationary cycling. Remember to first exercise at low intensity. They can gradually increase the
intensity and duration of the exercise sessions as long as the tolerance improves with no
symptoms. Teach patients to listen to their body.
An example of a walking and cycling program for people with heart failure is shown below.
Aerobic Exercises8
Mode Intensity Duration Frequency Progression
Walking Slow to moderate
pace
RPE: 11 to 14
THR: 40% to
70% of HR max
Until tolerance if
asymptomatic
Interval training
Exercise 1 to 6
min.
Rest 1 to 2 min.
Total exercise
time
10 to 20 min.
3 to 7 days a
week
5 -7 times a week
to improve
aerobic capacity.
3 times a week to
maintain aerobic
capacity
Gradual increase
in duration starts
at 7-15 minutes
and increases to
20-30 minutes
Gradual increase
in intensity; RPE:
11 to 14
Aerobic Exercises
Mode Intensity Duration Frequency Progression
Cycling
(stationary)
Little to moderate
resistance
Comfortable revs
per min. RPE: 11 to
14
THR: 40% to
70% of HR max
Until tolerance if
asymptomatic
Interval training
Exercise 1 to 6
min.
Rest 1 to 2 min.
Total exercise
time
10 to 20 min.
3 to 7 days a
week
5 -7 times a week
to improve
aerobic capacity
3 times a week to
maintain aerobic
capacity
Gradual increase
in duration
Gradual increase
in resistance;
RPE: 11 to 14
Stop exercising if the patient experience angina (chest pain or discomfort), shortness of
breath, unexplained dizziness, or significant pain or discomfort.
GUIDELINES FOR EXERCISE and EXERCISE TESTING
Metabolic equivalents (METs) are workloads. This is the stress that is put upon a patient
to do an activity or exercise.
1 MET=3.5 ml O2 / ml per minute
1 MET= 1 kcal / kg per minute
1 L O2 / min = 5 kcal
MET VALUES OF COMMON PHYSICAL ACTIVITIES CLASSIFIED AS LIGHT, MODERATE, OR
Beta blockers such as Inderal is used to prevent sudden increase in blood pressure. They also
prevent a sudden rise in heart rate. When exercising a patient on these medications will not
experience a rise in heart rate or systolic blood pressure. Since heart rate is the major way of
showing the intensity of exercise, other ways need to be used to show the tolerance of exercise
or functional training. The rate of perceived exertion and the BORG scale will provide you with
a subjective picture of the intensity of a treatment. It is better to look at the oxygen saturation
level because it is a more objective measure in most patients unless they have undergone
training on the subjective scales. The therapist should still check vital signs as a decrease in
blood pressure or heart rate still indicate intolerance.
Generic name Common brand names
Acebutolol Sectral*
Atenolol Tenormin*
Betaxolol Kerlone*
Bisoprolol fumarate Zebeta*
Carteolol hydrochloride Cartrol*
Metoprolol tartrate Lopressor*
Metoprolol succinate Toprol-XL*
Nadolol Corgard*
Penbutolol sulfate Levatol*
Pindolol* Visken*
propranolol hydrochloride* Inderal*
Solotol hydrochloride Betapace*
Timolol maleate* Blocadren*
Combination beta-blocker/diuretic Side effects:
Neuromuscular o Insomnia o Tiredness or depression
Cardiovascular o Cold hands and feet, a symptom of left sided heart failure o Slow heartbeat, bradycardia o Impotence may also occur
Pulmonary o Symptoms of asthma
If they have diabetes and are taking insulin, their responses to therapy should be monitored closely.
Pregnancy. If they have been prescribed beta-blockers, they should consult their healthcare provider as soon as possible to determine the safest medication at this time.
Hydrochlorothiazide and bisoprolol Ziac*
Ace inhibitors
These medications gradually lower blood pressure, but it can take 6-9 months to start to be
effective. They relax and allow the arterial walls to atrophy which undoes some of the damages
that the high blood pressure caused. To be maximally effective it may take 2 years or more.
Usually they are started along with a calcium channel blocker to initially control the
hypertension thus decreasing the damage and decreasing the associated risk factors for stroke,
myocardial infarction and renal failure.
The therapist treating a patient should always monitor blood pressure at the start of
each therapy session as they are at risk for developing hypotension. If they are found to
develop hypotension they should be referred to a physician.
Generic name Common brand names
Benazepril hydrochloride Lotensin*
Captopril Capoten*
Enalapril maleate Vasotec*
Eosinophil sodium Monopril*
Lisinopril Prinivel*, Zestril*
Moexipril Univasc*
Perindopril Aceon*
quinapril hydrochloride Accupril*
Ramipril Altace*
Trandolapril Mavik*
Side effects often prevent their continued use in many patients:
Pregnancy: These drugs have been shown to be dangerous to both mother and baby
during pregnancy. They can cause low blood pressure, severe kidney failure, excess
potassium and even death of the newborn.
Most common problems:
Skin rash
Loss of taste
Chronic dry, hacking cough
In rare instances, kidney damage
Diuretics
For a therapist there are two classes, those that are not potassium sparing, where you need to
be checking for signs of abnormal potassium levels (usually too low) and those that spare the
potassium. These drugs lower blood pressure and are used to decrease excess water to treat
edema, commonly from heart failure.
If the patient is taking digitalis and a diuretic, they have a significant chance of heart failure. In
this case you should decrease the intensity of treatments that increase the cardiac work load. It
is also unlikely that they will progress to the point that they can tolerate an age appropriate
work load.
These drugs cause the kidneys to excrete excess sodium and usually potassium as well. They
remove water thus placing a patient at risk for dehydration.
Potassium sparing diuretics, there is no increased risk of hypokalemia
Amiloride hydrochloride Midamar*
Spironolactone Aldactone*
Triamterene Dyrenium*
Side effects:
Neuromuscular and musculoskeletal system: Some of these drugs may decrease your
body's supply of potassium. Symptoms such as weakness, leg cramps or fatigue may
result. Eating foods containing potassium may help prevent significant potassium loss.
Many patients are also placed on a potassium supplement to prevent potassium loss.
Diuretics such as amiloride (Midamar)*, spironolactone (Aldactone)* or triamterene
(Dyrenium)* are called "potassium sparing" agents. They don't cause the body to lose
potassium. They might be prescribed alone, but are usually used with another diuretic.
Some of these combinations are Aldactazide*, Dyazide*, Maxzide* and Moduretic*.
Musculoskeletal system: Some patients may suffer from attacks of gout after prolonged
treatment with diuretics. This is a side effect of dehydration.
Endocrine system: Patients with diabetes may find that diuretic drugs increase their
blood sugar level. Again this is a side effect of dehydration. A change in medication,
diet, insulin or oral anti-diabetic dosage corrects this in most cases.
Vascular due to low blood pressure Impotence may occur.
Nitroglycerine (nitrates)
This is used as a vasodilator to relieve chest pain (angina), reduce blood pressure and the work
load on the heart. A therapist needs to understand the two common forms.
The short acting form which is a tablet that the patient should be carrying with them.
o When they start to feel chest pain they should stop activity and sit.
o If the chest pain continues, over 5 minutes, they should place a tablet under the
tongue, while seated with adequate support.
o The effect of the nitroglycerine peaks within 2-3 minutes and their chest pain
should be relieved.
o If the pain is not relieved after 5 minutes they should take another nitroglycerine
tablet.
o If they have used 4 tablets and still have chest pain it is considered to be a
myocardial infarction instead of angina so activate the emergency medical
system.
Nitroglycerine effect on vital signs.
o Vasodilation should cause a drop in the diastolic blood pressure, they can
experience dizziness and syncope with this.
o The heart rate should increase significantly which decreases the cerebral
hypotension and the dizziness.
o They should develop a headache. This is a normal side effect of the
nitroglycerine.
Patch or cream nitroglycerine is used for long term administration of nitroglycerine. It
can be used to treat unstable angina. The most common side effect is a skin rash.
o If a patient wearing a patch develops chest pain when exercising, do not use the
activity intensity that caused the chest pain until you consult with the physician.
References
1. Cardiac Rehabilitation: Overview, History and Definition of Cardiac Rehabilitation, Patient Selection and Risk Stratification. March 2016. http://emedicine.medscape.com/article/319683-overview?pa=v1Jn6oFFsNcZo0bY7AAcAChI2Jn1uLsRz0CsEUtMfcC%2Ba%2BSJfhX%2Fp%2Bu7TTF9a295LCEJNCrbkqLWYvqLrhntWA%3D%3D. Accessed November 11, 2016.
2. de Macedo RM, Faria-Neto JR, Costantini CO, et al. Phase I of cardiac rehabilitation: A new challenge for evidence based physiotherapy. World J Cardiol. 2011;3(7):248-255. doi:10.4330/wjc.v3.i7.248.
3. Pinto BM, Goldstein MG, Papandonatos GD, et al. Maintenance of exercise after phase II cardiac rehabilitation: a randomized controlled trial. Am J Prev Med. 2011;41(3):274-283. doi:10.1016/j.amepre.2011.04.015.
4. Seki E, Watanabe Y, Shimada K, et al. Effects of a phase III cardiac rehabilitation program on physical status and lipid profiles in elderly patients with coronary artery disease: Juntendo Cardiac Rehabilitation Program (J-CARP). Circ J Off J Jpn Circ Soc. 2008;72(8):1230-1234.
5. Woolf-May K, Bird S, MacIntyre P. Physical activity levels during phase IV cardiac rehabilitation in a group of male myocardial infarction patients. Br J Sports Med. 2005;39(3):e12. doi:10.1136/bjsm.2003.010983.
6. PT SHRS, FAHA SLWPPF, OCS DASPP. The Rehabilitation Specialist’s Handbook. 4 edition. Philadelphia, PA: F.A. Davis Company; 2012.
7. Antman EM, Hand M, Armstrong PW, et al. 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: developed in collaboration With the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee. Circulation. 2008;117(2):296-329. doi:10.1161/CIRCULATIONAHA.107.188209.
8. Ainsworth BE, Haskell WL, Whitt MC, et al. Compendium of physical activities: an update of activity codes and MET intensities. Med Sci Sports Exerc. 2000;32(9 Suppl):S498-504.
9. Chung F, Mueller D. Physical Therapy Management of Ventilated Patients with Acute Respiratory Distress Syndrome or Severe Acute Lung Injury. Physiother Can. 2011;63(2):191-198. doi:10.3138/ptc.2010-10.