Cardiac Comorbidities in Outpatient Settings: Implications for Assessment and Treatment 2/20/2012 Property of A. Lynn Millar, Do not copy without permission 1 – Implications for Assessment and Treatment A. Lynn Millar, PT, PhD, FACSM Winston-Salem State University Combined Sections Meeting 2012 Chicago, IL ◊ February 8 – 11, 2012 Objectives ♥ Identify the most common cardiovascular comorbidities or treatments that may present in an outpatient setting ♥ Select appropriate assessment techniques based upon cardiovascular co-morbidity ♥ Select appropriate modifications to physical therapy interventions based upon selected cardiovascular co- morbidities or medical treatment Relevance to PT ♥ Heart disease 2 nd only to arthritis in limiting activity ♥ ―leading cause of premature, permanent disability‖ (CDC, 2004) ♥ Common as a co- morbidity Cardiovascular Disease Categories • Coronary heart disease • Hypertension • Heart failure • Vascular disease Epidemiology of Cardiac Disease • 2010 CDC – 27.1 million individuals with heart disease • Hypertension - >74 million: ―1in 3‖ • Heart failure - 5.8 million, with 670,000 new cases per year • Peripheral Arterial disease – 8 million • Atrial fibrillation – 2.66 million Hypertension • ―Almost one fifth (21.3%) of the people with high blood pressure don't know that they have it.‖ CDC, 2006 • 28% have pre-hypertension • ―because essential hypertension is manifest at varying ages and is usually asymptomatic, otherwise healthy patients need regular and ongoing blood pressure screening‖ Joint agenda for ACS, ADA & AHA, 2004
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Cardiac Comorbidities in Outpatient Settings: Implications for Assessment and Treatment
2/20/2012
Property of A. Lynn Millar, Do not copy without permission 1
Cardiac Co-
Morbidities in
Outpatient Settings
– Implications for
Assessment and
Treatment
A. Lynn Millar, PT, PhD, FACSM
Winston-Salem State University
Combined Sections Meeting 2012
Chicago, IL ◊ February 8 – 11, 2012 Objectives
♥ Identify the most common cardiovascular comorbidities
or treatments that may present in an outpatient setting
♥ Select appropriate assessment techniques based upon
cardiovascular co-morbidity
♥ Select appropriate modifications to physical therapy
interventions based upon selected cardiovascular co-
morbidities or medical treatment
Relevance to PT
♥ Heart disease 2nd only to arthritis in limiting activity
♥ ―leading cause of premature, permanent disability‖ (CDC, 2004)
♥ Common as a co-morbidity
Cardiovascular Disease
Categories
• Coronary heart disease
• Hypertension
• Heart failure
• Vascular disease
Epidemiology of Cardiac
Disease
• 2010 CDC – 27.1 million individuals with heart disease
• Hypertension - >74 million: ―1in 3‖
• Heart failure - 5.8 million, with 670,000 new cases per
year
• Peripheral Arterial disease – 8 million
• Atrial fibrillation – 2.66 million
Hypertension
• ―Almost one fifth (21.3%) of the people with high blood
pressure don't know that they have it.‖ CDC, 2006
• 28% have pre-hypertension
• ―because essential hypertension is manifest at varying ages
and is usually asymptomatic, otherwise healthy patients need
regular and ongoing blood pressure screening‖
Joint agenda for ACS, ADA & AHA, 2004
Cardiac Comorbidities in Outpatient Settings: Implications for Assessment and Treatment
2/20/2012
Property of A. Lynn Millar, Do not copy without permission 2
PREVALENCE
Variations in Prevalence
• Age
• Gender
• Race
• Heart disease – Pacific Islanders > Am. Indian >White
• HTN – Black > Am. Indian > White
% HTN by Race and Gender From: Health, US, 2004, CDC/NCHS.
0
5
10
15
20
25
30
35
40
45
Caucasion African
American
Hispanic
27.5
40.4
26.7 28.4
43.4
27.8
Males
Females
Co-morbidities in OP
• Jette & Jette, 1996
• 27 – 30 % with 1 co-morbidity category; 13% with 2 co-
• Lloyd-Jones D, Adams RJ, Brown TM, et al. Heart Disease and Stroke Statistics—2010 Update. A Report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2010;121:e1-e170.
• Pickering TG, Hall JE, Appel LJ, et al. Blood pressure measurement in humans: A statement for the professional from the subcommittee of professional and public education of the American Heart Association Council on High Blood Pressure Research. Hypertension. 2004;45:142-161.
• National Center for Health Statistics. Health, United States, 2008 [PDF 8.4M]. Hyattsville, MD: National Center for Health Statistics; 2008.
• Scherer S, Noteboom J, Flynn TW. Cardiovascular assessment in the orthopedic practice setting . J Orthop Sports Phys Ther. 2005;35:730-737.
Cardiac Comorbidities in Outpatient Settings: Implications for Assessment and Treatment
2/20/2012
Property of A. Lynn Millar, Do not copy without permission 15
• US Department of Health and Human Services. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. 2004.
• Thompson WR (ed). ACSM’s Guidelines for Exercise Testing and Prescription. 8th Ed. Philadelphia, PA: Lippincotte Williams and Wilkins; 2010.
• Ehrman JK (ed). ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription. 6th ed. Philadelphia, PA: Lippincotte Williams and Wilkins; 2010.
• Goodman C, Snyder T. Differential Diagnosis for Physical Therapists: Screening for Referral. 2007.
• Bonow RO, Bennett S, Casey DE, et al. ACC/AHA Clinical Performance Measures for Adults With Chronic Heart Failure. J Amer C Cardiol. 2005;46:1144-78.
• Hirsch et al. Peripheral Arterial Disease: ACC/AHA 2005 Guidelines for the Management of Patients With (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic): A Collaborative Report From the AAVS/SVS, SCAI, SVMB, SIR, and the ACC/AHA Task Force on Practice Guidelines Accessed at: http://www.acc.org/qualityandscience/clinical/topic/topic.htm#guidelines
• 2009 Focused Update Incorporated Into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults. Accessed at: http://content.onlinejacc.org/cgi/content/full/j.jacc.2008.11.013
• Fuster V, Ryden LE, Cannom DS, et al. ACC/AHA/ESC 2006 Guidelines for management of patients with atrial fibrillation. J Am Coll Cardiol. 2006;48:854-906. Available at: http://www.acc.org/qualityandscience/clinical/topic/topic.htm#guidelines
• Boissonnault, WG. Prevalence of comorbid conditions, surgeries, and medication use in a physical therapy outpatient population: A multicentered study. J Ortho Sports Phys Ther. 1999;29:506-525.
• Guccione AA, Felson DT, Anderson JJ, et al. The effects of specific medical conditions on the functional limitations of elders in the Framingham Study. Am J Pub Health. 1994;84:351-358.
• Jette DU, Jette AM. Physical therapy and health outcomes in patients with spinal impairments. Phys Ther. 1996;76:930-941.
• Ritzwoller DP, Crounse L, Shetterly S, Rublee D. The association of comorbidities, utilization and costs for patients identified with low back pain. BMC Musculoskeletal Disorders. 2006;7:72. Accessed at: http://www.biomedcentral.com/1471-2474/7/72
• 7th Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure. 2004. Accessed at: http://www.nhlbi.nih.gov/guidelines/hypertension/index.htm
• The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents. Accessed at: http://www.nhlbi.nih.gov/health/prof/heart/hbp/hbp_ped.htm