Please read the assigned case study and answer the questions in a thorough and detailed manner.
Case Study A – Module 2 (Ch. 13, pages 257-258 in course textbook)
MEDICAL HISTORY
Ms. RW is a 58-year-old Caucasian woman with no prior history of heart disease. She has hypertension under good control with medications and was diagnosed with diabetes 15 years ago. Her last fasting blood sugar was 234, and her HbA1c was 8.7. She is a former smoker (quit 10 years ago) and leads a rather sedentary lifestyle as a computer analyst for a large local corporation. Over the past 3 months she has started to notice increased shortness of breath when climbing two flights of stairs at work; at the top of the stairs, she feels some moderate chest pressure that resolves in a couple of minutes after she sits down at her desk. Her primary care physician sends her for a routine exercise test.
EXERCISE TEST RESULTS
Exercise Stress Test
Resting ECG: appears normal
Heart rate: 65 beats per minute
Blood pressure: 138/92mmHg
Heart and lung sounds: within normal limits
She exercises on a standard Bruce protocol. At 4:30 min there is some horizontal ST depression, about 1 mm in inferior and lateral leads; by peak exercise (5:20 min) it is about 2 mm downsloping in the same leads, and she is developing chest pressure she described in her symptom history. ECG changes resolve by 10 min of recovery, and symptoms resolve in about 5 min of recovery.
DIAGNOSIS
Principal diagnosis: Severe two-vessel CAD. Stenting was performed to 95% proximal left anterior descending coronary artery (LAD) lesion; Ms. RW’s 75% distal left circumflex lesion was not a candidate for revascularization at the time of procedure.
Medications: Metoprolol 50 mg twice daily, lisinopril 10 mg once daily, aspirin, Plavix, and simvastatin.
CARDIAC REHABILITATION
A referral for cardiac rehabilitation was placed by her cardiologist and was to start as soon as she was able to set up after hospitalization.
EXERCISE PRESCIPTION
Resting heart rate: 54 beats per minute
Resting blood pressure: 112/64mm Hg
Initial exercise program:
Treadmill walking = 2.0 mph (3.2 kph), 0% grade for 10 min
Combined arm and leg ergometry = 100 W for 10 min
Upright stationary leg ergometry = 30 to 50 W for 10 min
Short circuit resistance machines = one set of six exercises for 10 repetitions
Patient completed 6 weeks in the program at the following workloads:
Treadmill walking = 2.7 mph (4.0 kph), 3% grade for 10 min
Combined arm and leg ergometry = 100 to 125 W for 10 min
Upright stationary leg ergometry = 100 to 125 W for 10 min
Rowing = 50 to 75 W for 10 min
Short circuit resistance machines = two or three sets of eight exercises for 10 repetitions
Exercise heart rate: 100 to 110 beats per minute
Exercise rating of perceived exertion: 12 to 14
The remainder of her program was uneventful. The patient completed a total of 12 weeks from the start of the program and returned to her home exercise program and activities of daily living.
DISCUSSION QUESTIONS
- What changes may have to be made to this patient’s exercise regimen in view of the residual 75% blockage in her left circumflex coronary artery.
- If she hits a plateau in her ability to increase her intensity of cardiovascular exercise that is not due to further complications with her heart, what issues may be limiting her ability to increase exercise intensity?
