Sue Scherer, PT, PhD 1

Echocardiography Is my Patient at Risk for Heart Attack? Assessing Cardio-Vascular Risk in the Physical Therapy Setting We want healthy heart function Susan Scherer, PT, PhD Associate Professor Regis University Background APTA s Vision 2020 states that consumers will have direct access to PT in all environments. As direct access increases, clinicians need to adopt current best practice by identifying a variety of risk factors, including those to the cardiovascular system. Cardiovascular disease is leading cause of death in the U.S. Over 150,000 deaths each year < 65 y.o.a. Sudden death not always preceded by symptoms Objectives Review practice patterns of Orthopedic physical therapists Describe the major risk factors associated with CV disease Describe components of screening for risk factors prior to physical fitness participation Discuss the role of physical therapists in identifying CV risk and adjusting plan of care Guidelines CV risk assessment is component of primary prevention CV risk assessment is recommended prior to implementation of a physical activity program according to the following guidelines: American Heart Association (AHA) American College of Sports Medicine (ACSM) Guide to Physical Therapist Practice (APTA) Sue Scherer, PT, PhD 1

Lack of evidence to guide practice There is little data indicating current practice patterns and knowledge of PT regarding CV risk Eason (Cardiopulm. Phys. Ther., 10(4), 15-22, 2000). Recommended that all PTs, regardless of practice setting, should assess vital signs as a component of the examination. Knowledge of vital signs enables a therapist to determine appropriate goals and progress a patient s plan of care (Eason, 2000). Purpose To address the following questions: Are physical therapists performing CV risk assessments, and if so, are they performing to the standards of established guidelines? Are therapists monitoring patients CV response to exercises, and if so, what methods are being used? Are therapists measuring baseline aerobic capacity prior to starting a physical activity program? Are variables such as therapist s gender, type of degree, years of experience, and practice setting associated with clinical practice patterns? Methods Instrumentation: Survey (WebSurveyor, Herndon, VA 20170) Subjects: Random sample of 1,600 members of the Orthopedic section of the APTA Methods Survey Questions Demographics Ex: gender, degree, setting, years of experience Knowledge of CV risk assessment Five scenarios inquiring about need for medical clearance Clinical practice patterns Methods of monitoring during exercise Frequency of assessment prior to prescribing aerobic exercise Methods Procedure: Email message requesting participation Electronic link to survey Anonymous Multiple follow-up requests Data Analysis: SPSS 11.5 (SPSS Inc., Chicago, IL 60606) Frequency distributions ANOVA Results Response Rate: 32% (n=483) Reliability of instrument: 0.76, indicating good consistency (Cronbach's alpha) Demographics Gender Degree Males (52.1%) Bachelor s (44.3%) Females (47.9%) Master s (44.3%) Setting Hospital OP (35%) Private OP (55.1%) Sue Scherer, PT, PhD 2

ACSM Risk Stratification Low Risk Moderate Risk Men < 45, women < 55 yr. Men 45, women 55 yr. Asymptomatic or No more than one risk factor 2 or more risk factors High Risk 1 or more signs/symptoms suggestive of CV and pulmonary disease, or Known cardiovascular, pulmonary, or metabolic disease (ACSM, 2000) Survey Scenarios Male, age 35-44, with no family history of CAD Female, age 45-54, with no family history of CAD Male, age 45, with HTN and high cholesterol Female, age 50, with obesity and Type II diabetes Male, age 44, with shortness of breath while climbing stairs Risk Stratification Low risk Low risk Mod. risk High risk High risk Results cont Risk Knowledge by Degree Type Cardiovascular screening was performed by 75% of the survey respondents, similar to other types of screening 5 72% of respondents correctly identified patients requiring medical clearance However, of this group, 75% also recognized low-risk individuals as needing medical clearance Respondents were over-conservative Only 18% of all survey participants correctly identified the need for medical clearance in all five scenarios. # of Scenarios Correct 4 3 2 1 0 p =.02 Cert BS MS DPT Vital Sign Monitoring Aerobic Exercise Prescribed vs. Assessed 30 100 % of Respondents 25 20 15 10 5 0 HR BP RPE Pt Report % of Respondents 80 60 40 20 0 Aerobic Exercise Prescribed Aerobic Capacity Assessed Sue Scherer, PT, PhD 3

Discussion PTs and CV risk assessment Aware of importance and performing some form of it, yet. Falling short of guidelines Barriers to standardized risk assessment Physicians also below expected level (Mosca, 2005) Exercise prescription w/o baseline assessment Direct access and autonomous practice Significance of comprehensive screen Appropriate measurement and monitoring of aerobic function Limitations Completeness and clarity of survey Hawthorne effect Low response rate Conclusions Guidelines exist to assist physical therapists in decision-making for CV risk assessment. Physical therapists may not be using the most safe and effective methods to determine CV risk, assess aerobic capacity, or monitor aerobic exercise. The data indicate that although orthopaedic physical therapists are performing CV risk and exercise assessments, the frequency and accuracy of these assessments fall below the expectations of established guidelines. Conclusions Generally accurate view of CV risk, but lack of specific knowledge of ACSM guidelines HR and BP are underutilized as monitoring tools during physical therapy Baseline measurement of aerobic capacity is infrequently used. Physical therapists need information about: CV risk prevalence CV risk management Aerobic capacity measurement and monitoring CV disease prevalence Heart disease is the leading cause of death for both women and men in the United States.* In 2001, 700,142 people died of heart disease (52% of them women), accounting for 29% of all U.S. deaths. The age adjusted death rate was 246 per 100,000 population. Heart disease is the leading cause of death for American Indians and Alaska Natives, blacks, Hispanics, and whites. Although cancer is the leading cause of death for Asians and Pacific Islanders (accounting for 26.4% of all deaths), heart disease is a close second (25.4%). Heart disease death rates per 100,000 population for the five largest U.S. racial/ethnic groups are as follows: Hispanics, 73; Asians and Pacific Islanders, 77; American Indians, 79; blacks, 210; and whites, 263. In 2004, heart disease was projected to cost $238.6 billion, including health care services, medications, and lost productivity. Sue Scherer, PT, PhD 4

Coronary Artery Mortality Risk of Death from CHD CDC, 2000 Coronary Heart Disease (CHD) Risk Factor Categories Involves degenerative changes in the intima of the larger arteries that supply blood to the myocardium Angina (ischemia) Myocardial infarction MI Inherited/Biological Age Gender Race Susceptibility to disease Environmental Physical (air, water) Socioeconomic Family Behavioral Smoking Poor nutrition Alcohol Inactivity Fast driving Seat belts Risk Factors for Acute Myocardial Infarction Risk Factors for Acute MI INTER-HEART study 14,000 with Acute MI, 18,000 controls 46 countries Questionnaires, physical measurements, blood samples Sponsored by the World Health Organization and World Heart Federation Current smoking and abnormal ApoB/ApoA ratio predict 66% of global heart disease 1. Blood lipids (ApoB/ApoA-1) 2. Current smoking 3. Diabetes 4. Hypertension 5. Abdominal obesity 6. Psychosocial 7. Lack of Vegetables/fruits daily 8. No Exercise 9. No Alcohol intake Predict 2/3 of risk Sue Scherer, PT, PhD 5

Other findings INTER-HEART (ApoB/ApoA-1) better than cholesterol Abdominal obesity better predictor than BMI The risk factors more predictive in younger people than older Smoking has negative effect even at low levels 1-5 cigarettes/day increased risk by 40% More than 20 cigarettes/day increased risk 4x All types of tobacco increase risk (compared to non-smokers) INTER-HEART Conclusions 8/10 individuals have at least 1 risk factor for developing heart disease or stroke These risk factors are all modifiable Should be able to prevent the majority of heart attacks in the future American College of Sports Medicine Risk Factors Family History Cigarette smoking Hypertension High Cholesterol Impaired fasting glucose Obesity Sedentary lifestyle Negative high HDL cholesterol Risk Thresholds ACSM Table 2-1 Family history MI, bypass or sudden death before 55 years in father or male 1 st degree relative OR Before 65 in mother or female 1 st degree relative Hypertension > 140/90 Body mass index > 30 or waist girth > 100 cm Sedentary Not meeting minimum physical activity requirements Risk Factor for CHD HTN Silent killer Creates cellular changes in heart and blood vessels Affects the development of atherosclerosis Damages vascular endothelial cells Increases filtration of lipids into atherosclerotic lesion Classification of BP Adults Systolic Diastolic Category <120 and <80 Normal 120-139 or 80-89 Prehypertensive* 140-159 or 90-99 Stage 1 Hypertension > 160 or > 100 Stage 2 Hypertension (Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, JAMA 2003; 289(19)) Sue Scherer, PT, PhD 6

Major Lipoproteins Relationships between Cholesterol and Heart Disease VLDL Diam = 80 nm D < 1 IDL Diam = 50 nm D 1.05 LDL D ~1 Good HDL Diam= 8nm D = 1.15 Marked increase incidence of myocardial infarction with total cholesterol > 200 mg/dl LDL considered the most atherogenic LDL and MI correlation stronger than total cholesterol Elevated apob (LDL like) also associated with Coronary Heart Disease Low levels of High density lipoprotein (HDL) < 35 mg/dl associated with CHD Obesity and Lipids Increased abdominal fat associated with a decrease in LPL activity in liver impairs breakdown of triglycerides This stimulates production of small, dense lipoproteins atherogenic 10% decrease in weight typically decreases cholesterol by 11 mg/dl Body Mass Index Formula: weight (kg) / [height (m)]2 Example: Height = 165 cm (1.65 m), Weight = 68 kg Calculation: 68 (1.65)2 = 24.98 BMI Below 18.5 18.5 24.9 Weight Status Underweight Normal 25.0 29.9 Overweight 30.0 and Above Obese ACSM Risk Stratification Low Risk Men < 45, women < 55 yr. Asymptomatic No more than one risk factor Moderate Risk Men 45, women 55 yr. or 2 or more risk factors High Risk 1 or more signs/symptoms suggestive of CV and pulmonary disease, or Known cardiovascular, pulmonary, or metabolic disease (ACSM, 2000) Sue Scherer, PT, PhD 7

Applications for PT CV risk factor assessment should be part of initial medical screening form in all PT settings Physical therapists part of primary and secondary prevention strategy Risk factor stratification improves decision making Patients with risk factors encouraged manage risk with primary care physician Safe practice regarding exercise testing and prescription Physical Activity Low cardiovascular fitness was a strong and independent risk factor for CVD and all-cause mortality Moderate and high levels of fitness provide protection against other risk factors Fit people with any of the following risk factors (smoking, HTN, high cholesterol) had lower death rates than low fit people with no risk factors (Blair, et al. 2002) Physical Therapy and Physical Activity Promote ourselves as experts Promote physical activity in all patient groups Specific expertise in management of orthopedic dysfunction Benefits of Aerobic Exercise Aerobic and strength training decreased neck pain and disability in women with chronic neck pain. (Nikander, 2006) Fitness classes gave better improvement in disability scale for patients with chronic back pain compared to back exercises. (Frost, 1995) 6-month weight loss and walking program improved measures of physical functioning and pain in overweight and obese postmenopausal women with knee OA. (Martin, 2001) Baseline Exercise Testing Procedures Risk Stratification Low Moderate Exercise Goals Moderate Vigorous Moderate Vigorous Exercise Test Submax Max Submax Max MD supervision NO NO No Yes Measure baseline HR & BP Determine need for baseline exercise testing Musculoskeletal assessment Results of exercise testing Exercise prescription High Moderate Vigorous Submax Max Yes Yes Sue Scherer, PT, PhD 8

Role of Physical Therapist Understand current guidelines Identify risk factors for disease Refer for appropriate medical management Suggest physical activity for health benefits Prescribe physical activity /exercise for therapeutic benefits (SAFE & EFFECTIVE) Thank You----Questions? References American College of Sports Medicine (2000). ACSM s guidelines for exercise testing and prescription (6th ed.). Philadelphia: Lippincott Williams & Wilkins. American Physical Therapy Association (2001). Guide to physical therapist practice (2nd ed.). Alexandria, VA: American Physical Therapy Association. Eason, J.M. (2000). Cardiopulmonary Assessment. Cardiopulmonary Physical Therapy Journal, 10(4) or 11(1), 15-22. Gibbons, R. J., Balady, G. J., Bricker, J. T., Chaitman, B. R., Fletcher, G. F., & Froelicher, V.F. (2002). ACC/AHA 2002 guideline update for exercise testing: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing). American College of Cardiology Foundation-Medical Specialty Society AMA Professional Association. Mosca, L., Linfante, A.H., Benjamin, E. J., Berra, K., Hayes, S.N., Walsch, B.W., Fabunmi, R.P., Kwan, J., Mills, T. & Simpson, S. L. (2005). National study of physicians awareness and adherence to cardiovascular disease prevention guidelines, Circulation, 111, 499-510 References Nikander R, Malkia E, Parkkari J, Heinonen A, Starck H, Ylinen J. Dose- Response Relationship of Specific Training to Reduce Chronic Neck Pain and Disability. Med Sci Sports Exerc. Dec 2006;38(12):2068-2074. Frost H, Klaber Moffett JA, Moser JS, Fairbank JC. Randomised controlled trial for evaluation of fitness programme for patients with chronic low back pain. BMJ. Jan 21 1995;310(6973):151-154. Martin K, Fontaine KR, Nicklas BJ, Dennis KE, Goldberg AP, Hochberg MC. Weight Loss and Exercise Walking Reduce Pain and Improve Physical Functioning in Overweight Postmenopausal Women with Knee Osteoarthritis. J Clin Rheumatol. Aug 2001;7(4):219-223. Sue Scherer, PT, PhD 9