Questions/ Case studies

Name: Mikhaila Amres [0759324]

Date: Tuesday, November 25 th, 2014
Supervisor: Joanne Berardi

1. List modifiable and non-modifiable risk factors for cardiovascular disease.

Unlike non-modifiable risk factors, modifiable risk factors can be treated and/or
controlled. Non-modifiable risk factors for cardiovascular disease include: age, male
gender, ethnicity, and family history (genetics). Modifiable risk factors for cardiovascular
disease include: smoking, physical inactivity, poor diet, stress, dyslipidemia, hypertension,
diabetes and obesity (Stone, J. A., et al, 2009).
2. Describe the influence of exercise on cardiovascular risk factors.
Exercise can decrease your risk of cardiovascular disease and help slow down the
progression of certain symptoms. Exercise training was found to increase VO2max by
2.2ml/kg/min, increase the length in time in which a person is able to exercise by 2 min
and 38 seconds and increase work capacity by 15.1 watts in a study dealing with heart
failure patients. In the same study, exercise was also shown to increase the distance
covered in a six minute walk test by 41 meters (Taylor, et al., 2004). These improvements
have the potential to positively affect quality of life, as well as morbidity and mortality
rate of an individual. Not only does exercise increase exercise tolerance, it also reduces
body weight-which is many times a concern for diabetic patients. Diabetic patients can
increase their insulin sensitivity by exercising. Exercise also promotes a reduction in
blood pressure and bad cholesterol (LDL and TC) but also an increase in the good
cholesterol (HDL) (Stone, J. A., et al, 2009).
3. Examine the role of diet on cardiovascular risk factors such as hypertension, blood lipids
and body weight.
Diet is just as important as exercise when it comes to cardiovascular risk factors. The
goal is to have an overall healthy diet. The focus should not be what to exclude form your
diet but rather what to include. Intake of saturated fat, cholesterol, and sodium are
important to monitor (World Heart Federation, 2014). Specifically, The American Heart
Association recommends that saturated fat should be no more than 7% of a persons total
energy intake. They also recommend that individuals should consume no more than
300mg of cholesterol a day (The American Heart Association, 2011). A Health Survey
conducted in 2004, found that 90% of men and 66% of women were exceeding the upper
tolerable limit for sodium (Statistics Canada, 2007). These findings suggest that more
emphases needs to be placed on a healthy diet as a means of reducing the amount of
people developing cardiovascular disease in Canada.
4. Mr. Heart presents to the Emergency Department with chest pain. What are possible
diagnostic tests he may undergo?
Immediate tests that Mr. Heart would undergo include:
Electrocardiogram (ECG or EKG): a test the measures the electrical activity of the heart,

which gives insight on how the heart is functioning.

Blood tests: looking at his cholesterol levels- Total Cholesterol (TC), Triglycerides (TG),
High Density Lipoproteins (HDL) Cholesterol, Low Density Lipoproteins (LDL)
Cholesterol, TC/HDL ratio. As well as his fasting blood sugars (FBS)-this tells us the
amount of glucose in his blood. Troponin levels are also observed to see if a heart attack
has occurred. This test is usually repeated two more times over the next 6 to 24 hours.
Follow-up testing (which is dependent on the results from the immediate tests) include:
Echocardiogram: determines how the heart is beating and pumping blood by using sound
waves to produce images of the heart.
Computerized Tomography (CT scan): x-ray technique which combines multiple x-ray
images with the help of a computer, in order to create cross-sectional views of the body.
Stress Tests: conducted by a technician in order to determine the amount of stress the heart
can withstand before either developing an abnormal rhythm or signs of ischemia (chest
pain, jaw or neck pain, arm or shoulder pain, fast heartbeat, shortness of breath, nausea or
vomiting).
Coronary catheterization (angiogram): A catheter is threaded through the blood vessels to
the heart through an opening either at the arm, groin or neck. The catheter can be used for
diagnosing or treating heart conditions.
(Mayo Clinic Staff, 2011).
5. What is the difference between STEMI (ST elevation myocardial infarction) and NSTEMI
(non-ST elevation myocardial infarction)? How is treatment different?
Both a STEMI and a NSTEMI are commonly known as heart attacks. A NSTEMI is a
partial thickness damage of heart muscle, caused by the coronary arteries previously being
affected by atherosclerosis. On an EKG, a NSTEMI would not show an elevation in its ST
segments, and they are non-Q-wave-MIs. A STEMI is a full thickness damage of heart
muscles which is visible by an elevation in ST segments and they are Q-wave MIs.
STEMIs are more urgent and usually affect a major blood vessel compared to a branch.
NSTEMIs account for 30% of all heart attacks, whereas STEMIs account for 70% of all
heart attacks. Drugs such as beta blockers, statins and ACE inhibitors are given in both
NSTEMI and STEMI treatments. The primary treatment for STEMI is PCI (percutaneous
coronary intervention). A PCI is a non-surgical procedure which uses a catheter in order to
insert a stent at the blockage site to reopen the artery. NSTEMI can also be treated by PCI
as well as by Coronary Artery Bypass Grafting (CABG). CABG is a procedure in which a
healthy artery or vein is taken from one part of the individuals body to the heart in order to
make a bypassing pathway of oxygen-rich blood around the blockage site (Abdul, 2014).

6. Mr. Heart is a 56 year old South Asian male who presents to CR program post MI and
PTCA procedure 6 weeks ago. He has a history of hypertension and dyslipidemia. He is a
lifetime non-smoker. His does not have any family history of premature CAD. During the
intake assessment appointment he reported bilateral knee discomfort due to osteoarthritis.
He is currently walking at home and reported no limitations with this.
As part of the program, he attends the education classes on heart health and presents for
his intake assessment appointment with the following:

Blood work: TC/HDL==6.8 mmol/L, TC=4.6 mmol/L, Triglycerides= 1.5 mmol/L,

HDL=1.2 mmol/L, LDL=2.5 mmol/L, TC/HDL=3.83

BP=120/80 mmHg

Anthropometric measurements
o Height=178 cm
o Body weight=210 lbs
o Waist girth=106 cm

FFQ score=60

HADS score (A=10, D=12, T=22)

Current exercise at home: walking 20 min, 3x/week

Medications: Plavix 75 mg daily, ASA 81 mg daily, Lipitor 10 mg daily, Ramipril 5

mg daily

Questions:
(A) What CAD risk factors does Mr. Heart present with?
Mr. Heart has many CAD risk factors including :
-his age (men>45) 1 point
-high FBS (pre-diabetic)
-low HDL levels (<40mg/dl)
-obesity (WC>102cm for men), BMI: 95kg/1.78m^2 = 30
-sedentarism (less than 3x30 min bouts of PA/wk)
-low FFQ score
-high HADS scores- eligible to be referred to social worker (HADS score >14)
-coronary heart disease are the highest is South Asian communities
(Stone, J. A., et al, 2009)

Good to note:
-post MI and PTCA- (more susceptible to have another)
-history of hypertension and dyslipidemia (make sure has been treated)
(B) Are there any concerns with his blood work results? If so, how would you counsel
Mr. Heart what other actions would you take?
Mr. Hearts FBS is high and classifies him at pre-diabetic. In order to change this,
I would talk to Mr. Heart about his exercise, diet and medications- all of which have
influence on the amount of glucose present in his blood. I would encourage Mr. Heart
to follow up with his doctor and get more blood work done (perhaps a 2hr glucose
tolerance test). Also, Mr. Heart appears to be very inactive according to his recorded
exercise amount, so I would encourage him to walk more and build an exercise
routine that works for him. I would also place an emphasis on weight lost, which
would help reduce his WC number as well as BMI classification (Stone, J. A., et al,
2009).
(C) Would you recommend any dietary changes given his FFQ score
It would be beneficial for me to talk to Mr. Heart about his diet, especially based
on his low FFQ score. We would discuss what he is not getting enough of in his diet
as well as what he is getting too much of. Also the type of oils he is using in his foods
would be helpful to know and I can recommend better alternatives. I would remind
Mr. Heart that we do have a dietitian on staff in which he can book an appointment
with or attend education electives on the subject.
(D) Are you concerned about his HADS score?
Unfortunately, I am concerned with Mr. Hearts HAD score because of how high it
is. This indicates that he has high levels of stress and anxiety as well as depression in
his life. Fortunately, there are ways we can help decrease these numbers. The most
appropriate method being counselling. Based on his score, Mr. Heart is eligible to see
the social worker that can work one on one with him to figure out what is causing him
all this stress and anxiety and work with him to come up with solutions to lower his
levels (The Credit Valley Hospital, 2008). Exercise increases your levels of
endorphins, improves mood and is a form of meditation in motion which can also
help with this issue.
(E) What are some factors you need to consider when setting Mr. Hearts exercise
prescription? Based on his current walking regimen, would you make any

recommendations?
It is important to take in to consideration Mr. Hearts current exercise procedure
as well as any limitations he might have. The mode, intensity, frequency, and duration
of exercise are all factors that need to be considered (ACSM, 2011). Since he reported
that walking does not hold any limitations for him, despite his osteoarthritis, I would
recommend that he continues to walk. Right now he is doing 20min/day, 3x/week;
this is good because at least he is moving, but it can be greatly improved. I would
advise Mr. Heart to progress up to at least 30min/day- to get him out of that
sedentarism classification. If however, Mr. Heart does experience bi-lateral knee
discomfort due to his osteoarthritis, I would then advise him to move to a cycle
ergometer which is non-weight bearing.
7. Identify orthopedic limitation (eg., gout, foot drop, specific joint problems) as they relate
to modifications of exercise testing and programming.
Exercise testing uses two forms of machinery, the treadmill or the bike ergometer. The
treadmill is used most of the time as the bike is non-weight bearing and therefore gives a
lower VO2max value (ACSM, 2013). Although the treadmill is the preferred method by
the technician, it is not always preferred by the patient who may have orthopedic
limitations. For example, patients with a history of gout, (a sudden, severe attack of pain
on the base of the big toe), may not want to walk on the treadmill for an extended period
of time, which can encourage the symptoms to rebirth. Foot drop is another limitation
which makes it difficult to lift the front part of the foot. This in turn, causes the patient to
drag their foot along the ground and affects their gait motion. Walking may also put stress
on joints such as the hips and knees which can then reduce their test time and produce
inaccurate results. For these individuals, a bike would be more recommended as they are
not applying stress to their lower body (American Heart Association, 2011). This
modification from the treadmill to the bike can them be translated in to the exercise
program as they can use the bike modality as a form of aerobic exercise during class.
Also, walking aids such as canes and walkers, should be brought to class and practiced in
a control environment where if such help is needed, it can be provided.
8. Provide summary of general exercise program for CR patients (cardiorespiratory,
resistance, flexibility).
The patients are able to target their cardiorespiratory system by using any of the
machines available in the gym (including: the treadmill, bikes, ellipticals, rowing
machines, arm ergometer etc.) These machines are full-body, cardiovascular and aerobic
targeting workouts which strengthen their heart and lungs. An aerobic exercise has the

potential to reduce blood pressure and improve the patients breathing, which puts less
stress on the heart during exercise (ACSM, 2013). The CR patients start off on one
machine with a 5-10 min warm up at a low intensity and then increase to a speed, incline
and or resistance that is able to get their HR within their target heart rate zone (which was
determined based on their GXT results). After about 45minutes or so, the CR patients are
then asked to slow down and eventually stop their workouts on the machines and
participate in some strength training. Bands or weights can be used during the strength
training portion as resistance. This period lasts about 10 minutes. The last five minutes of
the class are devoted to stretching the large muscle groups. This is where flexibility is
incorporated. When the patient is on their own, it is recommended that cardio be
performed a minimum of 30min/day, resistance/strength training should be performed 23x/wk and flexibility/stretching can be performed daily
9.

Describe factors to consider when setting CR patients exercise intensity.

The safety of the patient is the most important factor to consider when prescribing their
intensity. Based on their GXT results, the report gives insight to the patient physical work
capacity and a target heart rate is established. It is important that the patient stays in this
range when he/she is doing work. Working above this range can place too much stress on
the heart and evidently put the patient at risk to experience chest pain. For the cardiac
patients, their ideal heart rate training zone is between 40% - 75% of the maximum heart
rate, limited by symptoms, as determined from a graded exercise treadmill test (ACSM,
2011). At this intensity, patients can get to their target heart rate zone and get the benefits
of the workout without putting themselves at risk. Also, their weight may play a role in the
amount of intensity they are able to place on their bodies. As they lose body weight, they
can increase their workout intensity as the heart is less stressed at a higher state (Franklin,
B. A. et al, 1996).

References

Abdul, W. (2014). NSTEMI vs. STEMI. Retrieved from: http://nstemi.org/nstemi-vs-stemi/

American College of Sports Medicine (2011). Exercise for Persons with Cardiovascular Disease.
Retrieved from: http://www.acsm.org/docs/current-comments/exercise-for-persons-withcardiovascular-disease.pdf
American College of Sports Medicine. (2013). ACSMs Guidelines for Exercise Testing and
Prescription. Philadelphia: Lippincott Williams and Wilkins.
American Heart Association. (2011). Exercise Stress Test. Retrieved from:
http://www.heart.org/HEARTORG/Conditions/HeartAttack/SymptomsDiagnosisofHeartAttack/E
xercise-Stress-Test_UCM_307474_Article.jsp
Frabklin, B. A., Khan, J. K. (1996). Delayed Progression or Regression of Coronary
Atherosclerosis with Intensive Risk Factor Modification: Effects of diet, drugs and exercise.
Sports Medicine 22(5), 306-20.
Mayo Clinic Staff. (2011). Tests and Diagnosis. Retrieved from:
http://www.mayoclinic.org/diseases-conditions/chest-pain/basics/tests-diagnosis/con-20030540
Statistics Canada. (2007). Recommended Sodium Intake. Retrieved from: http://www.statcan.gc.ca/pub/82-003-x/2006004/article/sodium/4148995-eng.htm
Stone, J. A. et al. (2009). Canadian Guidelines for Cardiac Rehabilitation and Cardiovascular
Disease Prevention: Translating Knowledge into Action. Winnipeg, Man: Canadian Association
of Cardiac Rehabilitation.
Taylor, R. S., Brown, A., Ebraham, S., Jolliffe, J., Noorani, H., Rees, K. et al. (2004). Exercisebased Rehabilitation for Patients with Coronary Heart Disease: Systematic Review and Metaanalysis of Randomized Controlled Trials. Journal of Medicine 116(10), 682-92.
The Credit Valley Hospital. (2008). Referrals to Psychology and Social Work for Cardiac
Outpatients. Retrieved from: http://thphub/search/pages/results.aspx?k=HADS
World Heart Federation. (2014). Diet and Cardiovascular Disease. Retrieved from:
http://www.world-heart-federation.org/cardiovascular-health/cardiovascular-disease-riskfactors/diet/