208 Cases
REFERENCES
1. Harrison TR. Harrison's principles of internal medicine. New York: McGraw-Hill; 2001.
(A good text to derive information about mitral valve prolapse)
2. http://www.merck.com/pubs/mmanual/
CASE
Acute Myocardial
11 Infarction—Good Recovery
HISTORY/CHART NOTES
• HPI: Mr. G is a 75-year-old man complaining of left-sided chest pain radiating to his axillary area. The
chest discomfort was described as if somebody was sitting on his chest. The pain came on just after sup-
per about an hour ago.
• Dx: Non Q-wave anterior myocardial infarct.
• Investigation: Serial EKG showed ST segment depression in the precordial leads. Serial troponin I showed
an increase to 10 mg/L at 6 hours and 20 mg/L at 18 hours. HR is 112 and in sinus rhythm. BP is 145/100.
• PMH: Appendectomy. Cancer of the prostate.
Mr. G's cardiac risk factors:
• Smoker 4 cigarettes a day and up to a half a pack a day in the past
• Occasional glass of wine
• No diabetes
• No hypertension
• No known cholesterol problems
• Moderately obese and "does not like to work up a sweat"
Questions
1. Assess the cardiac risk factors for this patient and outline your plan for secondary prevention.
ELECTROCARDIOGRAM
Review the V2 and V3 leads in the EKG (Figure 11-1) of this patient. What are the main features consis-
tent with an MI shown by these leads?
PHYSICAL THERAPY MANAGEMENT
1. On day 2 post-MI, the patient is stable and transferred to the step down cardiac unit. You were asked to
see Mr. G for rehabilitation. Outline your in-patient rehabilitation plan for this patient.
Acute Myocardial Infarction—Coronary Artery Bypass Graft 209
Figure 11-1. Electrocardiogram.
CASE
Acute Myocardial Infarction—
12 Coronary Artery Bypass Graft
HISTORY/CHART NOTES
• HPI: Mr. F developed chest pain during an exercise stress test. He was subsequently transferred to the
coronary care unit and then to the cardiac catheterization laboratory. Angioplasty and stenting were per-
formed. However, the patient continued to have cardiac symptoms over night and emergency CABG x3
were done early this morning.
• Stress test report: Using the Bruce protocol, the patient exercised for 8 minutes reaching a target heart rate
of 128 beats per minute which is submaximal of his age-predicted target. Three minutes into exercise, his
ST segments began elevating in the inferior leads. He therefore had an acute inferior infarct. His stress
test was stopped. He complained of vague chest pain.
Questions
1. After CABG, what are the wound and sternal precautions taught to patients and why are these instruc-
tions provided?
ELECTROCARDIOGRAM
1. Identify the acute EKG changes.
PHYSICAL THERAPY MANAGEMENT
1. On day 2 post-CABG, the patient is stable and transferred to the step down cardiac unit. You were asked
to see Mr. G for rehabilitation. Outline your in-patient rehabilitation plan for this patient.
Answer Guides: Cases 249
CASE
Acute Myocardial
11 Infarction—Good Recovery
HISTORY/CHART NOTES
1. Assess the cardiac risk factors for this patient and outline your plan for secondary prevention.
Advise the patient to modify the lifestyle to decrease the risk of a future myocardial infarct. Provide links
to local support groups, Web sites, the local heart association, reading materials, and videotapes. Smoking
cessation is paramount for this patient. Dietary changes and consultation are needed. Encourage the
patient to increase his or her activity level in a walking program, in an air-conditioned indoor shopping
mall, or outdoor walking.
Contraindications for exercising cardiac patients:
o Unstable angina
o Resting systolic BP >200 mmHg or diastolic >110 mmHg
o Symptomatic drop of BP >20 mmHg during exercise
o Moderate to severe aortic stenosis
o Other acute illness or fever
o Uncontrolled atrial or ventricular arrthymias
o Uncontrolled tachycardia or third degree heart block
o Uncontrolled CHF, diabetes
o Active pericarditis, myocarditis, recent embolism, or thrombophlebitis
o Resting ST segment changes >2 mm
o Clinical signs such as pallor, cold sweats, dizziness, severe dyspnea
ELECTROCARDIOGRAM
Review the V2 and V3 lead EKG of this patient. What are the main features consistent with an MI shown by
these leads?
The main features of the EKG consistent with an MI are ST segment depressions in leads V2, and V3 and
that it is a non Q-wave infarct. The findings are indicative of an anterior myocardial infarct. See Chapter
19, Table 19-5 for the site of myocardial infarct, diagnosis, and clinical significance.
PHYSICAL THERAPY MANAGEMENT
1. On day 2 post-MI, the patient is stable and transferred to step down cardiac unit. You were asked to see Mr. G
for rehabilitation. Outline your in-patient rehabilitation plan for this patient.
Details of the contraindications to exercise and phases of exercise during cardiac rehabilitation in these
patients are outlined under “History/Chart Notes” above, and phases of cardiac rehabilitation are:
• Phase I—Acute/In-patient Phase
Start once patient is deemed medically stable
o Level 1 (1 METs)
Bed rest but allow gentle upper and lower extremities active range-of-motion exercises. However,
those patients who have sternotomy following open-heart surgery need to follow sternal precau-
tions
250 Answer Guides
o Level 2 (2 METs)
Allow sitting up in a chair for meals and walking to the bathroom or inside the room (up to 50 ft)
a few times a day. Allow performing activities of daily living. Increase repetitions of active range-
of-motion exercises
o Level 3 (3 METs)
Allow a sitting shower. Ambulate up to 250 ft 3 to 4 times per day
o Level 4 (4 METs)
Perform activities of daily living independently and ambulate up to 1000 ft 3 to 4 times per day.
Allow climbing 1 flight of stairs
• Phase II—Subacute/Post-Discharge Conditioning Phase
Usually begins after the discharge from the hospital during the first 6 weeks. Conditioning exercises are
done with close cardiac monitoring. Start education on risk factor reduction if not already initiated.
• Phase III—Intensive Rehabilitation
After completion of phase II, patient proceeds to exercise in large groups. Resistance training is often
initiated during this phase.
• Phase IV—Maintenance Phase
Ongoing exercise training in a group setting or self-monitored program.
See Chapter 9 for more details.
In general:
• Familiarize yourselves with the patient's resting vital signs including the EKG.
• During activity, watch the bedside monitor or alert the cardiac nurse if the patient is on telemetry for
any unusual EKG changes.
• Explain the purpose of the visit, benefits and risks of rehabilitation. Reassure patient that the rehabil-
itation program is done in a safe environment with close supervision and medical help is readily avail-
able if needed.
• Take into account of the patient's previous functional level and customize the rehabilitation program
to the patient's ability.
• Watch for signs of activity intolerance.
• Provide details of the rehabilitation program for the patient to do. Include type, frequency, intensity,
and duration.
• During exercise, other than the heart rate and EKG, use additional objective measures such as an angi-
na pain scale, a dyspnea scale, pulse oximetry, and blood pressure level as indicated.
• Liaison with the health care team to provide outpatient cardiac rehabilitation.
BIBLIOGRAPHY
American College of Sports Medicine. Guidelines for Exercise Testing and Prescription. 5th ed. Philadelphia: Lea
& Febiger; 1995.
