PET4551 Exam 2

Ejection fraction equation

(SV/EDV ) x 100 Percent of blood pushed out with each contraction. Below 40%: Heart failure 40-49%: Borderline heart failure / cardiomyopathy 50%+: Ideal

Vigourous exercise

>60% HRR or VO2R >6 METS, RPE >14 activity that causes substantial increases in HR / breathing.

Physical fitness

A set of attributes that relate to a person's ability to perform physical activities (PA) and activities of daily living (ADL).

Exercise

A type of physical activity, consisting of planned structured, and repetitive bodily movement done to improve or maintain one or more components of physical fitness

Stance

Back erect Knees: slightly bent Head and shoulders: in line with hips Feet: Shoulder width apart

Dyanmic vs. static

Strength can be assessed: •Statically •Grip strength test •Cable tensiometry •Dynamically •1‐RM •Multiple RM tests •5-10 RM: needs to be performed to failure

exertional hypotension

decrease in sbp of >10 after increase in exercise

Pre Participation

******•identifies those who are at risk for adverse exercise-related CV events and which individuals should be referred for medical clearance.*** •The recommendations are intended to reduce or remove barriers to adopting and maintaining habitual PA or exercise. Medical clearance refers to approval from a health care provider to engage in exercise.

Exercise Frequency

-For most adults, spreading the exercise sessions across 3-5 d · w−1 may be best to reach the recommended amount of PA. -The frequency of exercise can vary, as can the intensity and duration, as these three variables are interdependent on each other. -The current evidence on PA frequency/ intensity is not conclusive to state that 5 d · w−1 of 30 min of aerobic exercise is superior to 3 d · w−1 of 50 min. -Aerobic exercise performed at a frequency of only 1-2 d · w−1 at moderate-to-vigorous intensity can still bring substantial health/fitness benefits, particularly for deconditioned individuals.

neuromotor exercise

...involves motor skills, such as balance, coordination, gait, and agility, and proprioceptive training and is sometimes called functional fitness training. •NM training results in improvements in balance, agility, and muscle strength and reduces the risk of falls and the fear of falling among older adults •The optimal effectiveness of the various types of neuromotor exercise, doses (i.e., FIT), and training regimens are not known for adults of any age. Studies that have resulted in neuromotor improvements have mostly employed training frequencies of ≥2-3 d wk−1 with exercise sessions of ≥20-30 min duration for a total of ≥60 min of neuromotor exercise per week Neuromotor exercises involving balance, agility, coordination, and gait are recommended on ≥2-3 d ∙wk−1 for older individuals and are likely beneficial for younger adults as well. The optimal duration or number of repetitions of these exercises is not known, but neuromotor exercise routines of ≥20-30 min in duration for a total of ≥60 min of neuromotor exercise.

Order of blood flow through the heart

1) From body 2) superior/inferior vena cava 3) right atrium 4) tricuspid valve 5) right ventricle 6) pulmonary semilunar valve 7) pulmonary artery -deoxygenated- 8) into the lungs -oxygenation- 9) pulmonary vein 10) left atrium 11) bicuspid valve 12) left ventricle 13) aortic valve 14) aorta 15) body

EKG reading

1. Begins with atrial depolarization -This looks like a small nipple, known as the p-wave - Positive deflection portion is the right atrial component of contraction (depolarizing) -Following downward deflection is the left atrial component. 2. Conduction pause -Return to the baseline (PR segment) 3. Ventricular depolarization -QRS complex -Downward deflection, followed by large spike in amplitude, then a return to baseline. -First downward deflection is Q - Upward deflection is R -First downward after upward, - usually Below baseline, then back to baseline- is S 4. Ventricular repolarization -Going back to original negative state to restart cardiac cycle -T wave (rounded wave following QRS complex) *This could look differently due to anatomical / medical differences or electrode postions* *Instead of QRS could have: RSR prime RS QR QS R

Electrical pathway of the heart

1. SA node, pacemaker, initiates impulses. Top right of atrium. 2. Impulses pause 0.1s at AV node. 3. The AV bundle connects atria to ventricles 4.Bundle branches conduct the impulses through inter-ventricular septum. 5. Subendocardial conducting network depolarizes the contractile cells of both ventricles. Intercalated disks The intercalated disks have two types of membranous junctions: - • The desmosomes -provide mechanical support • The gap junctions -areas of low electrical resistance allowing action potential to spread from one cell to the other. No gap junctions between the atrial and ventricular contractile cells Autorhythmic cells /Pace makers • Specialized myocardial cells which set the rate of the heart beat. • Ability to contract without any outside signal. • Smaller and have few contractile fibers • Initiate and conduct the action potential •The sinoatrial node (SA node): a small specialized region in the right atrial wall near the opening of the superior vena cava • The AV node a small bundle located at the base of the right atrium near the septum • The bundle of His : a tract of specialized cells originating at the AV node and enters the interventricular septum • The Purkinje fibers: small terminal fibers that extend from the bundle of His and spread throughout the ventricular myocardium.

Conduction blocks

1. Sinus node block—sinus node fires normally, but the wave of depolarization is immediately blocked and is not transmitted into the atrial tissue. 2. AV block—block between the sinus node and the terminal Purkinje fibers. 3. Bundle branch block—conduction block in one or both of the ventricular bundle branches. •only a part of the left bundle branch is blocked: fascicular block or a hemiblock. First-degree AV block is characterized by a delay in conduction at the AV node or His bundle (recall that the His bundle—or bundle of His, depending on your grammatical preference—is the part of the conducting system located just below the AV node. A routine 12-lead EKG cannot distinguish between a block in the AV node and one in the His bundle). The wave of depolarization spreads normally from the sinus node through the atria but upon reaching the AV node is held up for longer than the usual one-tenth of a second. As a result, the PR interval—the time from the start of atrial depolarization to the start of ventricular depolarization, a time period that encompasses the delay at the AV node—is prolonged. The diagnosis of first-degree AV block requires only that the PR interval be longer than 0.2 seconds

Order of muscle strengthening

1.Endurance 2.Hypertrophy 3.Strength 4.Power

1.What is the difference in the QRS widening of bundle branch block vs WPW? 2.What causes an escape rhythm? 3.Which arrhythmia is pre-terminal? 4.How do you know if the ECG is showing a ventricular arrhythmia?

1.QRS complex is widened because of delayed ventricular activation, in WPW it is widened because of premature activation 2.Rate of electrical discharge reaching the AV node or ventricles falls below the base rate due to failure of the SA node to generate one or more impulses 3.Ventricular fibrillation 4.Wide QRS > 0.12 s

light exercise

30-39% HRR or VO2R 2-2.9 METS, RPE 9-11, an intensity that causes slight increases in HR and breathing.

moderate exercise

40-59% HRR or VO2R 3-5.9 METS, RPE 12-13, an intensity that causes noticeable increase in HR and breathing.

ADL's

ADLs: Activities of daily living (ADLs) are routine activities people do every day without assistance. Basic ADLs include eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet.

Heart axis

AVR: -150 AVL: -30 AVF: +90 Normal QRS axis: Flow of electric lies between 0 and +90 because heart points down to the right. Can extend from -30 to +90/ Normal axis: -30 to -110 Left axis deviation: -30 to -90 Right axis deviation: +90 to +180 Extreme axis deviation: -90 to -180

Demographic barriers

Age goes up PA goes down education goes up PA goes up income goes up PA goes up

Pacing of heart

Atrial pacemaker: 60-75bpm Junctional pacemaker: 50-60bpm, no atrial depolarization ventricular pacemaker: 30-45bpm. no atrial depolarization

cardiovascular risk factors

Age: Men Greater Then to Equal to 45 and Women Greater then or Equal to 55. Family history: -Myocardial Infarction -Coronary Revascularization -Sudden Death in Father or other male 1st degree relative before age 55.OR-Sudden Death in Mother or other 1st Degree relative before age 65. Cigarette use: -Current Smoker OR -Quit in the last 6 months OR -Exposure to second hand smoke Sedentary lifestyle: Not participating in at least 30 minutes of moderate intensity physical activity on at least 3 days of the week for at least 3 months Obesity: -BMI of 30 or higher OR-Waist Girth in Men of 40 inches or more-Waist Girth in Women of 35 inches or more Hypertension -SBP Greater or equal to 140 mmHg AND/OR-DBP Greater or equal to 90 mmHg**Both of these need to be confirmed by measurements on 2 separate occasions. OR- On anti-hypertensive medications Dyslipidemia: -LDL's Greater than or equal to 130 mg/dL OR- HDL's Less than or equal to 40 mg /dL OR - On lipid- lowering medication* *IF total serum cholesterol is all we have and it's greater then or equal to 200 mg/dL its a risk factor. Prediabetes: -Impaired Fasting Glucose (IFG) = If fasting plasma glucose is Greater or equal to 100 mg/dL and between greater to equal to 125 mg/dL OR -Impaired Glucose Tolerance Test (IGTT) of greater than or equal to 140 mg/dL and between 199 mg/dL.* *Both confirmed by measurements on 2 separate occasions. HBA1C: greater than or equal to 5.7% (good measure of long term) most used clinically HDL Cholesterol: (Negative Risk Factor) - Greater than or equal to 60 mg/dL.**Cancels out one of the other risk factors.

Activity recommendations

All healthy adults 18-65 should participate in moderate intensity aerobic PA for a min. of 30 min 5 days a week OR vigorous activity for a minimum of 20 minutes a week 3 days a week Combinations of moderate and vigorous intensity exercise can be performed to meet this recommendation. Moderate intensity aerobic exercise can be accumulated to the total 30 min minimum by performing bouts of 10+ min. Every adults should perform activities that maintain or increase muscle strength and endurance for a minimum of two days a week Because of the dose response relationship between PA and health, individuals who wish to further improve their fitness, and reduce disease risk may benefit from exceeding minimums.

EKG what do we look for / why is calibration important

Amplitude, Shape, Duration

Premature beats

An atrial premature beat can be distinguished from a normal sinus beat by the contour of the P wave and by the timing of the beat. Contour. Because an atrial premature beat originates at an atrial site distant from the sinus node, atrial depolarization does not occur in the usual manner, and the configuration of the resultant P wave differs from that of the sinus P waves. If the site of origin of the atrial premature beat is far from the sinus node, the axis of the atrial premature beat will also differ from that of the normal P waves. Timing. An atrial premature beat comes too early; that is, it intrudes itself before the next anticipated sinus wave. With junctional premature beats, there is usually no visible P wave, but sometimes, a retrograde P wave may be seen. This is just like the case with the junctional escape beats seen with sinus arrest. R waves seem late

Physical activity

Bodily movement produced by the contraction of skeletal muscles that results in an increase in caloric requirements over resting energy expenditure.

Health and skill components

CR endurance: HEALTH RELATED-The ability of the circulatory and respiratory system to supply oxygen during sustained physical activity. Body composition: -HEALTH RELATEDThe relative amounts of bone, muscle, fat and other vital parts of the body. Muscular strength: HEALTH RELATED-The ability of a muscle to exert force. Muscular endurance: HEALTH RELATED-The ability of a muscle to continue to perform without fatigue. Flexability: HEALTH RELATED-The range of motion available at a joint. Agility: SKILL RELATED-The ability to change the position of the body in space with speed and accuracy. Balance: SKILL RELATED-The maintenance of equilibrium while stationary or moving. Coordination: SKILL RELATED-The ability to use the senses, such as hearing, together with body parts in performing tasks smoothly and accurately Power: SKILL RELATED-The ability or rate at which one can perform work. Reaction time: SKILL RELATED-The time elapsed between stimulation and the beginning of the reaction to it. Speed: SKILL RELATED-The ability to perform a movement in a short period of time.

Pacemaker

Can be in atria or ventricles When a pacemaker fires, a small spike can be seen on the EKG. With a ventricular pacemaker, the ensuing QRS complex will be wide and bizarre, just like a PVC. An atrial pacemaker will generate a spike followed by a P wave, a normal PR interval, and a normal QRS complex. Clinical evidence strongly supports their use in patients with third-degree (complete) AV block a lesser degree of AV block or bradycardia (e.g., sick sinus syndrome) if the patient is symptomatic (especially in atrial fibrillation) the sudden development of various combinations of AV block and bundle branch block in patients who are in the throes of an acute myocardial infarction (this situation usually only requires a temporary pacemaker that can be removed after the acute incident has resolved) recurrent tachycardias that can be overdriven and thereby terminated by pacemaker activity a strong indication for therapy with an AV nodal blocker, for example, a high burden of PVCs, but who are unable to use these drugs without developing a clinically intolerable bradycardia (shortness of breath, dizziness, etc.).

Cardiac cycle

Cardiac Cycle 1.Ventricular Filling -atrial contraction (phase 1) -rapid filling (phase 6) - reduced filling (phase 7) 2.Isovolumetric Contraction (phase 2) 3.Ventricular ejection - Rapid ejection (phase 3) - Reduced ejection (phase 4) 4.Isovolumetric relaxation (phase 5) End diastolic volume (EDV): volume of blood in each ventricle at end of ventricular diastole​. LV EDV refers to volume of blood at end of diastole in left ventricle. End systolic volume (ESV): volume of blood remaining in each ventricle after systole. Stroke volume: Difference between EDV and ESV.

What do we screen for

Cardiovascular: Peripheral vascular, cerebral vascular, cardiac Metabolic: Type 1 or 2 diabetes Renal diseases (Blood pressure) Conditions aggravated by exercise: Pregnancy Orthopedic injury Arthritis Hypertension

Contextual motivation

Contextual motivation involves how the client generally views exercise. Contextual motivation pertains to one's usual. motivational orientation toward a distinct context, such as sport, •Empower perception of control over participation. •Teach, not manipulate, a client to act. •Teach self-sufficiency and autonomy can help facilitate intrinsic motivation. •Client independence •Failing to build client independence is related to less-motivated clients who may ultimately drop out.

Right bundle branch block

Criteria for Right Bundle Branch Block1. QRS complex widened to > 0.12 seconds2. RSR′ (rabbit ears) or a tall R wave in V1 and V2 with ST-segmentdepression and T-wave inversion3. Reciprocal changes in V5, V6, I, and aVL

delivery / utilization

Delivery •cardiac output oblood volume; Hgb ovenous returno resistance to blood flow •muscle capillary density Utilization •amount of lean mass •#/size of mitochondria •#/activity of oxidative enzymes •muscle fiber type

EKG deflections

Depolarization wave --> Positive electrode = positive deflection Depolarization wave --> Negative electrode = negative deflection Depolarization wave --> perpendicular to positive electrode = biphasic.

Factors Influencing Participation and Adherence

Determinants: factors that influence a person's decision to engage in exercise. •Determinants for PA: •Personal attributes •Environmental factors •Physical-activity factors (Picorelli et al., 2012) •For obese individuals, the degree of overweight is the one of the most consistent predictors of drop-out! (Kopelman et al., 2010).

AV valves

Diastole (ventricular filling): 1. Blood returning to the heart fills atria, pressing against the AV valves. The increased pressure forces AV valves open. 2. As ventricles fill, AV valve flaps hang limply into ventricles 3. Atria contract, forcing additional blood into ventricles 4. AV valves force any additional blood into ventricles and snap shut.

Calculating intesity

Direct measurement of the physiologic responses to exercise through an incremental (graded) cardiopulmonary exercise test is the preferred method for Ex Rx whenever possible. Methods of estimating the absolute intensity of exercise -Caloric expenditure (kcal · min−1) -Absolute oxygen uptake (VO2; mL ∙ min−1 or L ∙ min−1) -Metabolic equivalents (METs)

Acute ST segment Elevation MI's (STEMI)

During an acute infarction, the EKG evolves through 3 stages: 1)T wave peaking followed by T wave inversion - indicates ischemia not infarction 2)ST segment elevation - indicates injury 3)Appearance of new Q waves - indicates irreversible myocardial cell death

Left Atrial Enlargement

Dx: -the terminal (left atrial) portion of the P wave should drop more than 1 mm below the isoelectric line in lead V1 -Increase terminal portion of P wave duration > 0.04 s (one small block) - No significant axis With left atrial enlargement, the second portion of the P wave may increase in amplitude. The diagnosis of left atrial enlargement requires that the terminal (left atrial) portion of the P wave should drop more than 1 mm below the isoelectric line in lead V1 (remember that lead V1 overlies the right heart, so when an enlarged left atrium depolarizes, the result will be a larger negative deflection in lead V1). However, a more prominent change in the P wave is an increase in its duration. This occurs because left atrial depolarization represents the terminal portion of the P wave, and prolonged depolarization can be readily seen (with right atrial enlargement, prolonged depolarization of the right atrium is hidden by the left atrial portion of the P wave). The diagnosis of left atrial enlargement, therefore, also requires that the terminal portion of the P wave should be at least 1 small block (0.04 second) in width. The electrocardiographic picture of left atrial enlargement has been called Pmitrale because mitral valve disease is a common cause of left atrial enlargement. Left atrial enlargement is characterized by the following: 1. The amplitude of the terminal (negative) component of the P wave may be increased and must descend at least 1 mm below the isoelectric line in lead V1. 2. The duration of the P wave is increased, and the terminal (negative) portion of the P wave must be at least 1 small block (0.04 second) in width. 3. No significant axis

Submax assumptions

Estimates of VO2 max from HR Response: -A steady state HR is obtained for each exercise work rate -A linear relationship exists between HR and work rate-Difference between actual and predicted max HR is minimal -Subject is not on any medications that may alter HR response to exercise-Subject is not using high quantities of caffeine, ill, or in a high temperature environment, all of which may alter HR response

Causes of RAD (right axis deviation)

Four main causes: 1. Right ventricular hypertrophy •Right ventricular overload syndromes (acute or chronic) •Conditions that cause right ventricular strain (e.g., pulmonary embolism, pulmonary stenosis, pulmonary hypertension, chronic lung disease, and resultant cor pulmonale 2. Reduced muscle mass of left ventricle 3. Altered conduction pathways •Conduction defects: left posterior fascicular block, right bundle branch block •Lateral wall myocardial infarction •Preexcitation syndromes (e.g., Wolff-Parkinson-White syndrome) •Ventricular ectopic rhythms (e.g., ventricular tachycardia) 4. Change in the position of the heart in the chest •Mechanical shift, such as with inspiration or emphysema •Congenital heart disease (e.g., secundum atrial septal defect) •Left pneumothorax RAD may be a normal variation (e.g., children, young adults) or Limb-lead reversal (left- and right-arm electrodes). Right ventricular hypertrophy is far less common and requires a huge change in the proportions of the right ventricle in order to overcome the electrical forces generated by the normally dominant left ventricle. It can occur, however, in patients with chronic obstructive pulmonary disease sufficiently severe to cause pulmonary artery hypertension or in patients with uncorrected congenital heart disease associated with profound volume or pressure overload of the right ventricle. If the right ventricle greatly hypertrophies, it can be detected on the EKG as a shift in the QRS axis. The mean electrical axis of current flow is drawn rightward, and the result is right axis deviation. Cor pulmonale is RV enlargement secondary to a lung disorder that causes pulmonary artery hypertension. RV failure follows. Pneumothorax is a collapsed lung.

diabetes mellitus

Four types of diabetes are recognised based on etiologic origin: •Type 1: typically occurs before the age of 40 yr; peak diagnosis age 10-14 yrs •Type 2: typically occurs after the age of 40 yr; South Asian after the age of 25 yr •Gestational (i.e., diagnosed during pregnancy): due to an increase in hormones during pregnancy the insulin receptors do not uptake glucose to allow for the baby. This is likely due to pregnancy related factors such as the presence of human placental lactogen that interferes with susceptible insulin receptors. This in turn causes inappropriately elevated blood sugar levels. •Other specific origins (i.e., genetic defects and drug induced) •Prediabetes is a condition characterized by (a) elevated blood glucose in response to dietary carbohydrate, termed impaired glucose tolerance (IGT); and/or (b) elevated blood glucose in the fasting state, termed impaired fasting glucose •Individuals with prediabetes are at very high risk to develop diabetes because the capacity of the β cells to hypersecrete insulin diminishes over time and becomes insufficient to restrain elevations in blood glucose.

top six risk factors

HBP Tobacco High glucose Physical inactivity Obesity High cholesterol

Test order

HR, BP, ECG, Height, Weight, Body Composition •Optimal testing order for multiple health-related components of fitness has not been established, but sufficient time should be allowed for HR and BP to return to baseline between tests conducted serially. •Medications should be noted•i.e., β-blockers which lower HR, will affect some physical fitness test results

Resting normal limits ekg

HR: 60-100 P-Wave: <0.11s. if not, could be left atrial hypertrophy <2.5mm tall. if not, could be right atrial hypertrophy PR interval: .12-.20 Less than .12 = preexcitation More than .20 = 1st degree AV block QRS duration: up to .1 second If not, could be a conduction abnormality QT interval: Rate dependent Too long caused by ischemia, drugs, etc Too short caused by hypercalcemia, etc Normal QT = K sqrt(RR) K =0.37 for men and kids, K=.4 for women. QRS axis: -30 to +110 degrees Less than 30, Left deviation More than 110 Right deviation

Fox equation

HRmax = 220-age

Supine five points of contact

Head Shoulders Lower back Ass Feet

Supraventricular arrythmias

High atrial heart rates (200-500) •Atrial Premature Beats (PACs) •Junctional Premature Beats •Atrial Flutter (1 re-enter) •Atrial Fibrillation (multiple Re-enter) •Multifocal Atrial Tachycardia (MAT) Paroxysmal atrial tachycardia AV reciprocating tachycardia

EKG axis / scales

Horizontal: Time Vertical: Amplitude ( Millivolts ) Horizontal scale: Small boxes: 0.04s Large boxes: 0.2s Vertical scale: One large box: amplitude = 0.5mV Two large boxes: amplitude = 1mV

Q-Waves

How to determine normal Q waves from abnormal ones. •Q wave greater than 0.04 sec in duration •Depth of Q wave at least a third of the R wave •Never use aVr

Gelish equation

Hrmax = 207 - (0.7 x age)

Dyslipidemia

Hyperlipidemia refers to high levels of LDL or triglycerides Dyslipidemia can refer to levels that are either higher or lower than the normal range for those blood fats. Blood lipids are fatty substances: HDL LDL Triglycerides Very LDL deliver triglycerids

Categories of vascular disease

Hypertension (BP > 130/80 mmHg)* •Coronary Heart Disease, CHD (Ischemic Heart Disease manifests as Angina or Myocardial Infarction) •Angina•Cerebrovascular Disease (Strokes: Ischemic, Blood clots, Hemorrhagic) •Peripheral Vascular disease: PVD, PAD (Intermittent Claudication) •Heart Failure (Heart cannot supply sufficient blood to body due to impaired left ventricular function) •Rheumatic Heart Disease (valve defects) •Cardiomyopathies (Disorders due to structural changes such as HCM) •Myocardial Infarction (Acute MI)

What causes arrhythmia

H—Hypoxia: A myocardium deprived of oxygen is an irritable myocardium. Pulmonary disorders, whether severe chronic lung disease or an acute pulmonary embolus, are major precipitants of cardiac arrhythmias. I—Ischemia and Irritability: We have already mentioned that myocardial infarctions are a common setting for arrhythmias. Angina, even without the actual death of myocardial cells that occurs with infarction, is also a major precipitant. Occasionally, myocarditis, an inflammation of the heart muscle often caused by routine viral infections, can induce an arrhythmia. S—Sympathetic Stimulation: Enhanced sympathetic tone from any cause (e.g., hyperthyroidism, congestive heart failure, nervousness, exercise) can elicit arrhythmias. D—Drugs: Many drugs can cause arrhythmias. They do so by a variety of mechanisms. Ironically, the antiarrhythmic drugs are among the leading culprits. E—Electrolyte Disturbances: Hypokalemia and hyperkalemia are notorious for their ability to induce arrhythmias, but imbalances of calcium and magnesium can also be responsible. B—Bradycardia: A very slow heart rate seems to predispose to arrhythmias. One could include the bradytachycardia syndrome (also called the sick sinus syndrome) in this category. S—Stretch: Enlargement and hypertrophy of the atria and ventricles can produce arrhythmias. This is one way in which congestive heart failure, cardiomyopathies, and valvular disease can cause arrhythmias. In order to identify an arrhythmia correctly, it is often necessary to view the heart rhythm over a much longer period of time than the few complexes present on the standard 12-lead EKG. When an arrhythmia is suspected, either clinically or electrocardiographically, it is standard practice to run a rhythm strip, a long tracing of a single lead or multiple leads. Any lead can be chosen, but it obviously makes sense to choose the lead that provides you with the most information. One or more leads are preprogrammed to run automatically when you hit the Rhythm button on modern EKG machines. The rhythm strip makes it much easier to identify

Risks with high cholesterol

Increases resistance Atherosclerosis: disease of the arteries characterized by the deposition of plaques of fatty material on their inner walls. Ischemia: lack of blood flow Angina: chest pain associated with the lack of blood flow to the heart muscle Intermittent claudication: muscle pain on mild exertion (ache, cramp, numbness or sense of fatigue), classically in the calf muscle, which occurs during exercise, such as walking, and is relieved by a short period of rest Activity helps: Benefits to blood lipids •Decreased concentrations of small-density LDL particles •Increased number or larger sizes LDL particles •Higher HDL-C concentrations •Lower triglyceride levels •Reduced postprandial lipemia STATINS reduce cholesterol

Insulin sensitivity

Insulin sensitivity refers to how sensitive the body's cells are in response to insulin. High insulin sensitivity allows the cells of the body to use blood glucose more effectively, reducing blood sugar. Insulin resistance, by contrast, decreases cellular energy uptake in most somatic tissues, and antagonizes "anabolic" glycogen and triglyceride storage. During insulin resistance (IR), the Insulin receptor signaling to the GLUT 4 is inhibited, preventing GLUT 4 from transporting glucose. Thus, in IR, glucose is prevented from entering muscle and fat cells.

Types of motivation

Intrinsic motivation refers to performing an activity for itself, in order to experience pleasure and satisfaction inherent in the activity. On the other hand, extrinsic motivation pertains to a wide variety of behaviors where the goals of action extend beyond those inherent in the activity itself (Deci & Ryan, 1985). •Intrinsic motivation •Being physically active because a person truly enjoys it •Associated with positive attitudes and emotions, maximal effort, and persistence when faced with barriers •Very few adults are completely intrinsically motivated. •Personal trainers should maximize enjoyment and engagement, but do not expect clients to always demonstrate intrinsic motivation. •Extrinsic motivation •The engagement in exercise for any benefit other than for the joy of participation •Being physically active because of some external factor •Associated with feelings of tension, guilt, or pressure related to participation

Pulse measuring

It is a measure to: •Determine how well the heart is functioning •Assess cardiovascular fitness •Assess rhythm Bradycardia and Tachycardia are types of heart rhythm disorder. Bradycardia can be caused by: Sinus node dysfunction: The heart's natural pacemaker isn't working properly. Heart block: The electrical connection between the upper and the lower chambers of the heart doesn't work as it's supposed to. This causes the lower chamber that pumps blood out of the heart to beat slowly. Causes of tachycardia include: •Heart-related conditions such as high blood pressure (hypertension) •Poor blood supply to the heart muscle due to coronary artery disease (atherosclerosis), heart valve disease, heart failure, heart muscle disease (cardiomyopathy), tumours, or infections •Other medical conditions such as thyroid disease, certain lung diseases, electrolyte imbalance, and alcohol or drug abuse •Emotional stress or drinking large amounts of alcoholic or caffeinated beverages. This is why we need to control for this prior to testing.

Krotkoff sounds

K-1 (Phase 1): The appearance of the clear "tapping" sounds as the cuff is gradually deflated. The first clear "tapping" sound is defined as the systolic pressure. K-2 (Phase 2): The sounds in K-2 become softer and longer and are characterized by a swishing sound since the blood flow in the artery increases. K-3 (Phase 3): The sounds become crisper and louder in K-3 which is similar to the sounds heard in K-1. K-4 (Phase 4): As the blood flow starts to become less turbulent in the artery, the sounds in K-4 are muffled and softer. Some professionals record diastolic during Phase 4 and Phase 5 K-5 (Phase 5): In K-5, the sounds disappear completely since the blood flow through the artery has returned to normal. The last audible sound is defined as the diastolic pressure.

Absolute intensity

L/min

influences on vo2 max

Largely genetically determined •Training can improve it 5-20%, depending on initial fitness level •Males score ~ 15-30% higher than females•Differences between gender due to: •Muscle mass •Hemoglobin concentration •However, many trained women can score higher than average men

12 Lead EKG

Limb leads: I, II, III Augmented leads: avR, avL, avF Precordial leads: V1 to V6. Lead I: Across Lead II: Right diagonal Lead III: Left diagonal AVF: straight down AVR: Up right AVFL: Up left AVR: Only lead that goes opposite direction of heart, therefore its wave form is upside down.

Golgi tendon organs (gtos)

Located at the muscle-tendon junction, not within the tendon. Main function is to monitor muscle tension.

Height vs. Weight bmi tables

MEASURE OF CARDIOVASCULAR RISK. NOT FOR INDIVIDUALS WHO RESISTANCE TRAIN. Developed from: •unvalidated estimates of frame size •data primarily from white populations •mortality data that may not reflect obesity-related comorbidities - provide no assessment of body composition -Doesn't account for FFM -Take Home message: BMI misses more than half of the people with BF% defined obesity. -should be used along with waist circumference. Body weight should be measured using a calibrated balance beam or electronic scale. Individual should wear minimal clothing with empty pockets and shoes removed.

Determining the axis

Main leads: I, II, AVF If all these leads have positive QRS complex axis is normal Lead 1, and AVF positive? Normal Positive means that the R is greater than the S on the EKG

Healthy body composition

Main structural components of man: Skeleton, organs, muscle and fat Essential Fat Fat present in bone marrow, nerve tissue and organs Needed for normal physiological function 3% in men; 12% in women Storage Fat In adipose tissue, beneath skin & around organs Three basic functions: insulation, energy, and padding Distribution pattern differs between sexes Males (abdomen); Females (hips & thighs) 12% in men; 15% in women Sarcopenia - degenerative loss of muscle mass and strength as a result of aging can be estimated with measures of body composition.

Technique

Maintain regular breathing pattern - exhaling during the lifting phase (concentric) and inhaling during the lowering phase (eccentric) •BP can increase dramatically (MacDougall et al. 1985; Mazzeo & Tanaka 2001) •Avoid Valsalva Manuevre? •Full range of motion (FROM)

Risk by waist circumference

Men: <70:Very Low 70-89: Low 90-110:High >110:Very high Women: <80: Very Low 80-99:Low 100-120:High >120:Very high

Exercise intensity

Methods for measuring require a specific percentage: •Heart Rate Reserve (HRR) •Oxygen Uptake Reserve (VO2R) •Oxygen Consumption (VO2) •Metabolic Equivalents (METs) 1 MET = 3.5 ml/kg/minVO2 Adults: 2.0-2.9 METs: light intensity 3.0-5.9 METs: moderate intensity > 6.0 METS: vigorous intensity In addition to defining PA, it is important to clearly define the wide range of intensities associated with PA and with different methods of estimating intensities. METs are a useful, convenient, and standardized method for quantifying the absolute intensity of various behaviors and activities. Because of age-related declines in maximal aerobic capacity, when older and younger individuals work at the same MET level, the relative exercise intensity will usually be different. In other words, the older individual will be working a greater relative percentage of maximal oxygen consumption (VO2max) than their younger counterparts (i.e., it will be harder for the older person!). Nonetheless, physical active older persons may have aerobic capacities comparable to or greater than those of physically inactive younger adults.

relative intensity

Methods of Estimating Relative Intensity: %HRR %HRmax %VO2R %VO2 %METs Methods of measuring intensity: Rating of perceived exertion (RPE) Affective valence OMNI Scale Talk test Feeling Scale

what happens when we stretch

Most theories: increase in length of the stretched muscle •Biomechanically, muscle does increase in length when stretched due to viscoelasticproperties of the muscle-tendon units. •However, this is transient depending on the magnitude, duration and type of stretching applied. Recent theory: increases in muscle extensibility are due to a modification of sensation only. •Decreased muscle activation and altered reflex sensitivity

muscular fitness

Muscular strength and endurance are health-related fitness components that may improve or maintain the following: •Bone mass, which is related to osteoporosis •Muscle mass, which is related to sarcopenia •Glucose tolerance, which is pertinent in both the prediabetic and diabetic state •Musculotendinous integrity, which is related to a lower risk of injury including low back pain •The ability to carry out the ADLs, which is related to perceived quality of life and self-efficacy among other indicators of mental health •Fat free mass (FFM) and resting metabolic rate, which are related to weight management

Premature ventricular contractions

No p-wave, wide QRS, R to R looks early Premature ventricular contractions (PVCs) are certainly the most common of the ventricular arrhythmias. The QRS complex of a PVC appears wide and bizarre because ventricular depolarization does not follow the normal ventricular conduction pathways. However, the QRS complex may not appear wide in all leads, so scan the entire 12-lead EKG before making your diagnosis. The QRS duration must be at least 0.12 seconds in most leads to make the diagnosis of a PVC. A retrograde P wave may sometimes be seen, but it is more common to see no P wave at all. A PVC is usually followed by a prolonged compensatory pause before the next beat appears. Less commonly, a PVC may occur between two normally conducted beats without a compensatory pause. These are called interpolated PVCs. Isolated PVCs are common in normal hearts and rarely require treatment. An isolated PVC in the setting of an acute myocardial infarction, however, is more ominous because it can trigger ventricular tachycardia or ventricular fibrillation, both of which are life-threatening arrhythmias. PVCs typically occur randomly, but they may alternate with normal sinus beats in a regular pattern. If the ratio is one normal sinus beat to one PVC, the rhythm is called bigeminy. Trigeminy refers to two normal sinus beats for every one PVC, and so on. A run of three or more consecutive PVCs is called ventricular tachycardia. The rate is usually between 120 and 200 beats per minute and, unlike AVNRT, may be slightly irregular (although it may take a very fine eye to see this). Both sustained ventricular tachycardia—defined as lasting more than 30 seconds—or ventricular tachycardia associated with hemodynamic instability are emergencies, presaging cardiac arrest and requiring immediate treatment. The morphology of ventricular tachycardia may be uniform, with each complex appearing similar to the one before it, as in the picture above, or it may be polymorphic, changing appearance from beat to beat. Polymorphic ventricular tachycardia is more commonly associated with acute coronary ischemia, infarction, profound electrolyte disturbances, and conditions causing prolongation of the QT interval. PVCs typically occur randomly, but they may alternate with normal sinus beats in a regular pattern. If the ratio is one normal sinus beat to one PVC, the rhythm is called bigeminy. Trigeminy refers to two normal sinus beats for every one PVC, and so on.

Blood pressure catagories

Normal = less than 120 and less than 80. Treatment: Promote health lifestyle and reassess yearly Elevated = 120-129 and less than 80. Treatment: Non-pharmological treatment, reassess 3-6 months High Blood Pressure Stage 1 = 130-139 or 80-89. Estimate 10yr CVD risk, if less than 10% start with lifestyle changes and reassess in 3-6 months. If greater than 10% or other disease, lifestyle changes AND drugs. Reassess monthly. High Blood Pressure Stage 2 = 140 or higher or 90 or higher. Drugs and lifestyle changes reassessing monthly. Hypertensive Crisis (call your doctor immediately) = Higher than 180 and/or higher than 120.

Finding heart rythm

Normal sinus rhythm: SA node is pacemaker, as denoted by presence of P-wave, and HR is between 60-100. Sinus bradycardia: P-wave present, HR is less than 60. Sinus Tachycardia: P-wave present, HR is greater than 100. Atrial fibrillation: Atria is beating rapidly, not just SA node. Baseline quivers, chaotic QRS. Supra-ventricular tachycardia:

exercise program

Optimal Ex Rx should address: -cardiorespiratory (aerobic) fitness, -muscular strength and endurance, -flexibility,-body composition, and -neuromotor fitness.

1st degree av block

PR interval > 0.2sec

Mobitz Type I (Wenckebach) (2nd degree block)

PR interval becomes progressively longer, until one QRS is dropped (DROPPED BEAT)

Exercise participation

Performing planned structured PA at least 30min at moderate intensity at least 3d a week for last 3 months

VO2 max test criteria

Plateau in VO2 w/ increased intensity: change < 150 ml/min (absolute VO2) RER > 1.15 HR max ± 10 bpm RPE > 19 Blood lactate > 8 mmol. Volitional exhaustion

Lowered due to

Preload: -Decreased thyroid hormones -Decreased calcium ions -High or low potassium ions -High or low sodium -Low body temp -Hypoxia -Abnormal pH -Drugs Decreases SV Decreases EDV Contractility: -Parasympathetic activation -Acetylcholine -Hypoxia -Hyperkalimia Increases ESV Decreases SV Afterload: -Decreased vascular resistance Decreases ESV Increases Sv

Raised due to

Preload: -Fast filling -Increased venous return Increases EDV Increases SV Contractility: -Sympathetic stimulation -Epinephrine and norepinephrine -High intracellular calcium ions -High blood calcium level -Thyroid hormones -Glucagon Decreases ESV Increases SV Afterload: -Increased vascular resistance -Semilunar valve damage Increases ESV Decreases SV

Stroke volune

Preload: Degree to which cardiac muscle cells are stretched just before they contract •Increased preload → increased EDV → increased SV Frank Starling Mechanism: Cardiac muscle exhibits a length-tension relationship -At rest, cardiac muscle cells are shorter than optimal length →dramatic increase in contractile force Contractility: tension developed and velocity of shortening (strength of contraction) of myocardial fibers at a given preload and afterload. -Independent of load or stretch (preload) applied Afterload: pressure that ventricles must overcome to eject blood (peripheral resistance)

Evaluation for participation

Prior to engaging in physical activity or structured exercise programs •Informed consent •Exercise preparticipation health screening •Health history •Cardiovascular (CV) risk factor analysis Medical history and CV risk factor analysis are not part of the preparticipation health screening procedures for the purpose of reducing acute risk. Insufficient evidence is available to suggest that the presence of CVD risk factors without underlying disease confers substantial risk of adverse exercise-related CV events. However, medical and CV screening provides valuable information for designing individualized exercise programs to lower or reduce known health risks. Medical and CV screening may also uncover a need for other health or medical referrals.

Exercise volume and quantity

Product of Frequency, Intensity, and Time (duration) or FIT of exercise. •Exercise volume may be used to estimate the gross EE of an individual's Ex Rx. •MET-min ∙ wk−1 and kcal ∙ wk−1 can be used to estimate exercise volume in a standardized manner. A total EE of ≥500-1,000 MET-min ∙ wk−1associated with lower rates of CVD and premature mortality.

PNF stretching

Proprioceptive neuromuscular facilitation (PNF): technique in which muscles are stretched out sequentially with intermittent isometric contractions. •Partner stretching - some combination of altering contraction and relaxation of both agonist and antagonist muscles. •Different techniques: slow reversal hold, contract relax, and hold relax. •PNF stretching usually involves a 10 second push phase followed by a 10 second relaxation phase, typically repeated a few times.

Right Ventricular Hypertrophy

Pulmonic origins 1. Right axis deviation is present, with the QRS axis exceeding +100°. 2. The R wave is larger than the S wave in V1, whereas the S wave is larger than the R wave in V6. The most common feature associated with right ventricular hypertrophy is right axis deviation; that is, the electrical axis of the QRS complex, normally between 0° and +90°, veers off between +90° and +180°. This reflects the new electrical dominance of the usually electrically submissive right ventricle. Many cardiologists feel that the QRS axis must exceed +100° in order to make the diagnosis of right ventricular hypertrophy. Therefore, the QRS complex in lead I (oriented at 0°) must be more negative than positive. Right ventricular hypertrophy is characterized by the following: 1. Right axis deviation is present, with the QRS axis exceeding +100°. 2. The R wave is larger than the S wave in V1, whereas the S wave is large than the R wave in V6.

Cardiac equations

Pulse Pressure = (SBP - DBP) Direct Measure of MAP, MAP = CO x TPR Indirect Measure of MAP HR < 100 b/min MAP = (1/3(SBP - DBP)) + DBP or 1/3 (SBP) + 2/3(DBP) HR ≥ 100 b/min MAP = (1/2(SBP - DBP)) + DBP Pulse pressure: SBP increases with age due to increased resistance in the arteries (decreased LV ejection, decrease elasticity in the central arteries, and intensity of backward wave originating at refection sites in the peripheral circulation). DBP levels off or even reverses in the fifth decade of life. Rate pressure product RPP = (HR x SBP)/100 Cardiac Output CO = HR x SV Changes in cardiac output with body positions Pulse pressure < 40 mmHg in adults is normal (typically 30-40 mmHg), > 40 mmHg is abnormal, >60 mmHg is a risk factor for CVD, particularly for > 60 years of age. MAP < 60 mmHg can lead to hypoperfusion, potentially resulting in renal failure, neurologic abnormalities, and shock.

Left Bundle Branch Block

QRS complex widened to greater than 0.12 seconds.2. Broad or notched R wave with prolonged upstroke in leads V5, V6, I, and aVL, with ST-segment depression and T-wave inversion.3. Reciprocal changes in V1 and V2.4. LAD may be present.rabbit

Flexibility exercises

ROM is improved acutely and chronically following flexibility exercises. Flexibility exercises are most effective when the muscles are warm. Static stretching exercises may acutely reduce power and strength - perform after exercise and sports where strength and power are important

Cardiac equations meanings

Rate Pressure Product: RPP is defined by resting heart rate (RHR) multiplied by systolic blood pressure (SBP). Any total value greater than 10,000 indicates an increased risk for heart disease. What RPP really illustrates is the oxygen demands of the heart. HR, SBP and RPP increases with the increase workload on the heart to provide the adequate blood supply to the active myocardium during exercise. The higher the RPP the increased oxygen demand on the heat, increased stress on the heart and increased rating of perceived exertion - leading to early fatigue and fatiguing of the respiratiory muscles. Cardiac output: The amount of blood the heart pumps through the circulatory system in a minute. The amount of blood put out by the left ventricle of the heart in one contraction is called the stroke volume. The normal range for cardiac output is about 4 to 8 L/min, but it can vary depending on the body's metabolic needs. Factors affecting cardiac output HR: autonomic innervation, hormones, fitness levels, age Stroke volume: heart size, fitness level, gender, contractility, duration of contraction, preload (EDV) and afterload (resistance) Preload can be defined as the initial stretching of the cardiac myocytes prior to contraction. Preload, therefore, is related to muscle sarcomere length. Contractility: intrinsic strength of the muscle independent of preload

Relapse preparation

Relapse Prevention •Relapse is common and should be expected. • •Plan ahead and be prepared! •Educate clients about the potential occurrence of a relapse •Prepare clients in advance for relapses and resuming exercise • •Preparation allows clients to get back on track with their activity/ behavior change program soon after experiencing a relapse.

Muscular strength recommendation

Resistance training of each major muscle group 2-3 d ∙wk−1 with at least 48 h separating the exercise training sessions for the same muscle group is recommended for all adults. Many types of resistance training equipment can effectively be used to improve muscular fitness including free weights, machines with stacked weights or pneumatic resistance, and even resistance bands.

Heart sounds

S1 (lub): Isovolumetric contraction Closure of mitral and tricuspid (av) valves S2 (dub): Isovolumetric relaxation Closure of aortic and pulmonic valves -semilunar- S3: normal children; adults - represents ventricular dilation, systolic ventricular failure - Due to tension in chordae tendinae S4: stiff, low compliant ventricle; ventricular hypertrophy - Due to vibrations on ventricle wall during atrial contractions When a stethoscope is placed on the chest over different regions of the heart, there are four basic heart sounds that can be heard (listening to heart sounds is called cardiac auscultation). The sounds waves responsible for heart sounds (including abnormal sounds such as murmurs) are generated by vibrations induced by valve closure, abnormal valve opening, vibrations in the ventricular chambers, tensing of the chordae tendineae, and by turbulent or abnormal blood flow across valves or between cardiac chambersHeart sounds are the sounds of blood pushing through the heart and/or when the heart valves close. Heart sounds 1 and 2 are normal in healthy adults. Hearing sounds 3 and 4 (aka heart murmurs) may be indicative of heart or valvular disease. S1 is caused by closure of the mitral and tricuspid valves at the beginning of isovolumetric ventricular contraction. S1 is normally slightly split (~0.04 sec) because mitral valve closure precedes tricuspid valve closure; however, this very short time interval cannot normally be heard with a stethoscope so only a single sound is perceived. S2 is caused by closure of the aortic and pulmonic valves at the beginning of isovolumetric ventricular relaxation. S2 is physiologically split because aortic valve closure normally precedes pulmonic valve closure. This splitting is not of fixed duration. S2 splitting changes depending on respiration, body posture and certain pathological conditions. The third heart sound (S3), when audible, occurs early in ventricular filling, and may represent tensing of the chordae tendineae and the atrioventricular ring, which is the connective tissue supporting the AV valve leaflets. This sound is normal in children, but when heard in adults it is often associated with ventricular dilation as occurs in systolic ventricular failure. The fourth heart sound (S4), when audible, is caused by vibration of the ventricular wall during atrial contraction. This

Atrial flutter

Sawtooth baseline •Atrial Flutter Regular, saw-toothed •2:1, 3:1, 4:1, etc., block •Atrial rate: 250-350 bpm •Ventricular rate: one-half, one-third, onequarter, •etc., of atrial rate •Carotid massage: increases block

EKG intervals and segments

Segment: Straight line connecting two waves PR segment: End of P-wave to beginning of QRS complex. Measures the AV conduction pause. Ventricular filling occurs. ST Segment: End of QRS complex wave to beginning of T wave. Measures end of ventricular depolarization to beginning of ventricular re-polarization. Interval: Straight line encompassing at least one wave. PR interval: Beginning of P wave to beginning of R wave. Measure of atrial depolarization to ventricular depolarization. QT interval: Beginning of Q wave to end of T wave. Measures ventricular depolarization to end of ventricular re-polarization QRS interval: Encompasses QRS complex. Measures ventricular depolarization. RR interval: R wave to R wave. Can be used to measure heart rate.

self-efficacy

Self-efficacy: One of the strongest and most consistent cognitive correlates of activity level Self-efficacy for PA: individual's confidence in his or her own ability to be PA on a regular basis (Trost et al., 2002). •positively related to motivation (Sallis et al. 1988). •Task efficacy: individual's confidence in the ability to perform the elements of a task •leads to more positive attitude, effort and persistence. •Exercise barrier self-efficacy: belief they can overcome barriers. Exercise professionals can use the sources of self-efficacy to help influence efficacy levels. •short-term success by designing a workout/challenge that the client can master. •Each workout/challenge should build on previous accomplishments.

Muscle spindles

Sensory Receptors Related to StretchingMuscle spindles (myotatic or stretch reflex)Primary stretch receptors in muscle, encased in a spindle-shaped capsule which is attached at both ends to the muscle fibers

BMI classifications

Severely underweight - BMI less than 16.5kg/m^2 Underweight - BMI under 18.5 kg/m^2 Normal weight - BMI greater than or equal to 18.5 to 24.9 kg/m^2 Overweight - BMI greater than or equal to 25 to 29.9 kg/m^2 Obesity - BMI greater than or equal to 30 kg/m^2 Obesity class I - BMI 30 to 34.9 kg/m^2 Obesity class II - BMI 35 to 39.9 kg/m^2 Obesity class III - BMI greater than or equal to 40 kg/m^2 (also referred to as severe, extreme, or massive obesity) Asian and South Asian population overweight - BMI between 23 and 24.9 kg/m^2 obesity - BMI greater than 25 kg/m^2 Risk given bmi category and waist size: Men < 102, Women <88: Overweight: Increased Obese I: High Obese II: Very High Obese III: Extremely high Men >102, Women >88 Overweight: High Obese I: Very High Obese II: Very High Obese III: Extremely high

Choice of exercises

Should relate to biomechanical goals! •Primary exercises train the prime movers in a particular movement and are typically major muscle group exercises (e.g., leg press, bench press, hang pulls). •Assistance exercises train predominantly a single muscle group (e.g., triceps press, bicep curls) that aid (synergists) in the movement produced by the prime movers. •Multi-joint exercises require the coordinated action of several muscle groups and joints. -Power cleans, hang power cleans, power snatches, dead lifts, bench presses, lateral pulldowns, military presses, and squats •Single-joint exercises involve single joints and/or single muscle groups. -Bicep curls, knee extensions, and knee curls

sinus arrest

Sinus arrest occurs when the sinus node stops firing. If nothing else were to happen, the EKG would show a flat line without any electrical activity. With junctional escape, depolarization originates near the AV node, and the usual pattern of atrial depolarization does not occur. As a result, a normal P wave is not seen. Most often, there is no P wave at all. Occasionally, however, a retrograde P wave may be seen, representing atrial depolarization moving backward from the AV node into the atria. The mean electrical axis of this retrograde P wave is reversed 180° from that of the normal P wave. Thus, whereas the normal P wave is upright in lead II and inverted in lead aVR, the retrograde P wave is inverted in lead II and upright in lead aVR.

Situational motivation

Situational motivation refers to the motivation individuals experience when they are currently engaging in an activity. It refers to the here-and-now of motivation (Vallerand, 1997).Contextual motivation involves how the client generally views exercise. -Perceived competence -Positive affect and vitality -Regulation -Monetary rewards decreases situational motivation •Creating mastery •Providing consistent and clear feedback •Including the client in aspects of program design •Creating a workout environment that is aesthetically pleasing

Calculating HR using EKG

Small box method: 1500 / small boxes between R-waves. Large box method: 300 / large boxes between R-waves 6-second method: (Hard with a 12-lead) Good for running lead.

Transition zones

Somewhere usually around V3 / V4 a transition occurs. Should see R-wave progression up until V6. Wave becomes biphasic, then almost entirely positive. (Progressing V1 to V6) If its in V1 / V2 = Counterclock (left) If its in V5/V6 = clockwise Normally, in lead V1, there is a small R wave with a deep S wave; the R-wave amplitude should increase in size with the transition zone, normally in leads V2 to V4. Poor or late R-wave progression consists of a transition zone in lead V5 or V6, and it can be a sign of a previous anterior myocardial infarction

Finding exact axis

State actual angle of the axis with fair precision: •Look for the limb lead in which the QRS complex is most nearly biphasic (positive and negative deflections extended equally on both sides of the baseline - deflections are so small that the wave appears flat, or isoelectric). •The axis must then be oriented approximately perpendicular to this lead because an electrode oriented perpendicularly to the mean direction of current flow records a biphasic wave.

u-wave

The U wave is a small (0.5 mm) deflection immediately following the T wave. U wave is best seen in leads V2 and V3. •The U wave normally goes in the same direction as the T wave •U -wave size is inversely proportional to heart rate: the U wave grows bigger as the heart rate slows down •U waves generally become visible when the heart rate falls below 65 bpm •The voltage of the U wave is normally < 25% of the T-wave voltage: disproportionally large U waves are abnormal •Maximum normal amplitude of the U wave is 1-2 mm Prominent U waves U waves are described as prominent if they are >1-2mm or 25% of the height of the T wave. Causes of prominent U waves Prominent U waves most commonly found with: Bradycardia Severe hypokalaemia. Prominent U waves may be present with: Hypocalcemia Hypomagnesemia Hypothermia Raised intracranial pressure Left ventricular hypertrophy Hypertrophic cardiomyopathy Drugs associated with prominent U waves: Digoxin Phenothiazines (thioridazine) Class Ia antiarrhythmics (quinidine, procainamide) Class III antiarrhythmics (sotalol, amiodarone) Inverted U waves U-wave inversion is abnormal (in leads with upright T waves) A negative U wave is highly specific for the presence of heart disease Common causes of inverted U waves Coronary artery disease Hypertension Valvular heart disease Congenital heart disease Cardiomyopathy Hyperthyroidism In patients presenting with chest pain, inverted U waves: Are a very specific sign of myocardial ischaemia May be the earliest marker of unstable angina and evolving myocardial infarction Have been shown to predict a ≥ 75% stenosis of the LAD / LMCA and the presence of left ventricular dysfunction

cardiorespiratory fitness testing

The ability to perform large muscle, dynamic, moderate-to-vigorous intensity exercise for prolonged periods of time. Low levels of CRF: markedly increased risk of premature death from all causes and specifically from cardiovascular diseaseIncreases in CRF fitness: reduction in death from all causesHigh levels of CRF fitness: higher levels of habitual PA; many health benefitsImportant part of a primary or secondary prevention and rehabilitative programs

ECG

The cardiac cycle begins with atrial systole and progresses to ventricular systole, atrial diastole, and ventricular diastole, when the cycle begins again. P wave: depolarization of the atria results in contraction (atrial systole) QRS wave: ventricular depolarization T wave: repolarization of the ventricles

Screening algorithm

The screening algorithm begins by classifying individuals who do or do not participate in exercise. Participants classified as current exercisers should have a history of performing, planned, structured, PA of at least moderate intensity for at lest 30 min or more on 3 d/wk during the past 3 mos. Algorithm components •Classifying individuals who do (Yes) or do not (No) currently participate in regular exercise •Identifying individuals with known CV, metabolic, or renal diseases or those with signs or symptoms suggestive of cardiac, peripheral vascular, or cerebrovascular disease, Types 1 and 2 diabetes mellitus (DM), and renal disease •Identifying desired exercise intensity

Normal Body Composition

There are no universally accepted norms for body composition; however: •A range of 12%-23% and 17%-26% for men and women, respectively, has long been viewed as satisfactory for health. •More recent data support this range, although age and race, in addition to sex, impact what may be construed as a healthy percent body fat.

assessing rhythm

These four questions should become an intrinsic part of your thinking: 1. Are normal P waves present? 2. Are the QRS complexes narrow or wide? 3. What is the relationship between the P waves and the QRS complexes? 4. Is the rhythm regular or irregular (remember, though, that a sinus arrhythmia is normal)?

VO2 max vs. VO2 peak

VO2 peak: highest level of oxygen consumption that can be achieved during a mode of exercise •VO2 max: the largest VO2 peak for an individual •Mode of exercise impacts VO2max/peak achieved; typically achieved in running or stair stepping (Keren et al. 1980) •For individuals trained at a specific mode of exercise, it usually matches the mode of the training

VO2 max

VO2max: represents the maximal rate of delivery of oxygen from the inspired air to the working tissues (skeletal muscle). VO2max: • is the greatest rate at which oxygen can be consumed during exercise or •the maximal rate at which oxygen can be taken up, distributed, and used by the body during physical activity.

Valsalva maneuver

Valsalva Manuever ‐Forced Expiration against Closed Glottis ‐Need to avoid holding breath when performing maximal movements ‐Increase blood pressure and pressure behind the eye Procedure: 1. Adjust the grip bar so the second joint of the fingers fit snugly under the handle and takes the weight of the instrument. Set the dynamometer to zero. 2.The subject holds the handgrip dynamometer in line with the forearm at level of the thigh, away from body. 3. The subject squeezes the handgrip hard as possible without holding breath (avoid valsalva). Neither the hand or handgrip should touch the body or any other object. 4.Repeat the test TWICE WITH EACH HAND. The score is the highest of the two reading (to the nearest KG) for each hand added together.

Lipid types

Very low-density lipoproteins (VLDL) VLDL is a lipoprotein class synthesized by the liver that is analogous to the chylomicrons secreted by the intestine. Its purpose is also to deliver triglycerides, cholesteryl esters, and cholesterol to peripheral tissues. VLDL is largely depleted of its triglyceride content in these tissues and gives rise to an intermediate-density lipoprotein (IDL) remnant, which is returned to the liver in the bloodstream. As might be expected (see table), the same proteins are present in both VLDL and IDL. Low-density lipoproteins (LDL) Low-density lipoproteins are derived from VLDL and IDL in the plasma and contain a large amount of cholesterol and cholesteryl esters. Their principal role is to deliver these two forms of cholesterol to peripheral tissues. Almost two-thirds of the cholesterol and its esters found in plasma (blood free of red and white cells) is associated with LDL. High-density lipoproteins (HDL) Lipoproteins of this class are the smallest, with a diameter of 10.8 nm and the highest protein-to-lipid ratio. The resulting high density gives this class its name. HDL plays a primary role in the removal of excess cholesterol from cells and returning it to the liver, where it is metabolized to bile acids and salts that are eventually eliminated through the intestine. LDL and HDL together are the major factors in maintaining the cholesterol balance of the body. Because of the high correlation between blood cholesterol levels and atherosclerosis, high ratios of HDL to cholesterol (principally as found in LDL) correlate well with a lower incidence of this disease in humans. Triglycerides are a type of fat (lipid) found in your blood. When you eat, your body converts any calories it doesn't need to use right away into triglycerides. The triglycerides are stored in your fat cells. Later, hormones release triglycerides for energy between meals. If you regularly eat more calories than you burn, particularly from high-carbohydrate foods, you may have high triglycerides (hypertriglyceridemia).

Body fat distribution

Waist Circumference High risk: >102 cm for men >88 cm for women Waist-Hip Ratio High risk: >0.96 for men >0.85 for women The pattern of body fat distribution is recognized as an important indicator of health and prognosis. Android obesity that is characterized by more fat on the trunk (abdominal fat) increases the risk of hypertension, metabolic syndrome, T2DM, dyslipidemia, CVD, and premature death compared with individuals who demonstrate gynoid or gynecoid obesity (fat distributed in the hip and thigh). Individuals with increased visceral fat (i.e., fat within and surrounding thoracic and abdominal cavities) confer a higher risk for development of the metsyn compared to distribution of fat within the subcutaneous compartment. Waist circumference The waist circumference can be used alone as an indicator of health risk because abdominal obesity is the primary issue. Although BMI and waist circumference are correlated, waist circumference is a better measure of visceral adiposity which can be varied within a given BMI. Waist-to-hip ratio (WHR) The waist-to-hip ratio is the circumference of the waist (above the iliac crest) divided by the circumference of the hips (buttocks/hips measure). WHR has traditionally been used as a simple method for assessing body fat distribution and identifying individuals with higher and more detrimental amounts of abdominal fat. Health risk increases as WHR increases, and the standards for risk vary with age and sex.

components of exercise session

Warm-up: at least 5-10 min of light-to-moderate intensity cardiorespiratory and muscular endurance activities, including movements that mimic what will be done in exercise. Conditioning: at least 20-60 min of aerobic, resistance, neuromotor, and/or sports activities (exercise bouts of 10 min are acceptable if the individual accumulates at least 20-60 min · d−1of daily aerobic exercise) Cool-down: at least 5-10 min of light-to-moderate intensity cardiorespiratory and muscular endurance activities. Highest risk for myocardial infarction occurs at most intense point, and during cooldown. The longer the workout, the longer the cooldown. Each single exercise session should be designed with a training goal in mind.

Transition zone

almost biphasic, roughly equal R and S. - If R wave progression not present, no transition zone If given 12 lead, look at V1-V6

Calibration

comparing a known against a standard

Exercise BP limits

dbp: 115 sbp:250

relative intensity

ml/kg/min

Third degree block

no relationship between p-wave and QRS. Complete block at AV node. normal p wave and normal QRS just disconnected.

Mobitz type II 2nd degree block

normal pr interval, but still a dropped beat.

Wolf-Parkinson-White Syndrome

type of pre-excitation bypasses AV node Characteristics of WPW •PR interval < 0.12 s •QRS complex > 0.1 s with the presence of a delta wave (huge spike wide R wave) -No pause between P and R Symptoms include: palpitations, dyspnea, and predisposes patient to V tachyarrhythmias.

VO2 direct measurement

• Graded exercise test provides most accurate assessment •Increases in workload by increasing speed/grade of treadmill or resistance on bike until subject cannot continue RAMP: Not good because we need steady heart rate Incremental: Gradually increase difficulty to reach steady states.

field tests

•1-mile and 1.5 mile run tests •12-minute Walk/Run test•1-mile walk test •Bleep test; Yo-yo test •Queen's College Step Test •Advantages: practical, inexpensive, less time consuming than laboratory tests, easy to administer for large groups, and quite accurate.

Weight management

•150 min/week of moderate-intensity PA may not be sufficient for preventing weight gain. •≥ 300 min/week (60 min/day) is recommended for weight management. •Aerobic Exercise •Elevates metabolism during & after exercise •Strength Training •Helps to build lean muscle •Good eating & good exercise = success! •1-2 pounds/week safely (this equates to a caloric deficit of 3500-7000 per week) •Set realistic goals & start slowly

Atherosclerosis

•A build up of cholesterol plaque in the walls of arteries causing obstruction of blood flow. Plaques may rupture causing acute occlusion of the artery by clot. •Atherosclerosis is often considered a heart problem, it can affect arteries anywhere in your body. •Arteriosclerosis the thickening and hardening of the walls of the arteries, occurring typically in old age.

type 2 diabetes mellitus

•A group of metabolic diseases characterized by an elevated blood glucose concentration (i.e., hyperglycemia) as a result of defects in insulin secretion and/or an inability to use insulin. •Sustained elevated blood glucose levels place patients at risk for microvascular and macrovascular diseases as well as neuropathies (sensory, motor, peripheral and autonomic).

Environmental barriers

•Access to facilities •Perceived lack of time •The most common excuse for not exercising and for dropping out of an exercise/PA program. •Social Support Perceived lack of time •The most common excuse for not exercising and for dropping out of an exercise/PA program. •This perception is likely due to: •Not being interested in or enjoying the activity •Not being committed to the activity program •Need to help change their perception through proper goal setting, time management, and prioritizing. • Social support from family and friends is an important predictor of PA behavior. • •Support from a spouse is an important and reliable predictor of program adherence. • •Exercise/PA professionals must be proactive in creating and establishing a support network for the client/participant.

Factors that effect heart rate

•Air temperature: 5-10 bpm increase in high temperature/humidity. •Body Temperature: 10 bpm increase for every 1 degree C increase. •Body position: Orthostatic increase for first 15 to 20 seconds. •Emotions: Anxiety, stress, excitement may increase heart rate. •Body size: obesity may increase resting heart rate. •Medication use: some medications may increase heart rate (e.g., thyroid medications) and some may suppress heart rate (e.g., beta blockers)

Frequency of resistance training

•All muscle groups to be trained may be done so in the same session (i.e., whole body), or each session may "split" the body into selected muscle groups so that only a few of groups are trained in any one session. •This split weight training routine entails 4 d ∙ wk−1 totrain each muscle group 2 times ∙ wk−1 •The split and whole-body methods are effective as long as each muscle group is trained 2-3 d ∙ wk−1.

Progression of Resistance Training

•As adaptations to a resistance exercise training program occur, the individual should continue to subject the muscles to greater stimuli for continued increases in muscular fitness. •The most common approach is to increase the amount of resistance lifted during training. •Other ways to progressively overload muscles include performing more sets per muscle group and increasing the number of days per week the muscle groups are trained.

SL valves

•As ventricles contract and intraventricular pressure rises, blood is pushed up against semilunar valves, forcing them OPEN. •As ventricles relax and intraventricular pressure falls, blood flows back from arteries, filling the cusps of semilunar valves and forcing them to CLOSE.

Overload principle

•Exercise below a minimum intensity, or threshold, will not challenge body sufficiently to result in changes in physiologic parameters, including increase VO2max. •Minimum threshold of intensity for benefit •vary depending on an individual's CRF level •other factors such as age, health status, physiologic differences, genetics, habitual physical activity, and social and psychological factors.

Heart rate

•Average range is 60 -100 bpm •Intrinsic rate of SA node ~100 times/min ARRYTHMIA: •Bradycardia = <60 bpm •Adaptation to chronic exercise •Tachycardia = >100 bpm Normal sinus rhythm: electrical impulse coming from the SA node is being properly transmitted. In the absence of any influence, SA node would be ~ 100bpm. Parasympathetic nervous system via the vagus nerve has a negative chronotropic effect (by releasing Acetylcholine to bind to pacemaker receptors) to reduce resting HR down to 60-75 bpm. SNS has a positive chronotropic effect (by releasing norepinephrine from nerve terminals) in that it increases HR. Chronotropic refers to changes in heart rate. Bradycardia and Tachycardia are types of heart rhythm disorder. Bradycardia can be caused by: Sinus node dysfunction: The heart's natural pacemaker isn't working properly. Heart block: The electrical connection between the upper and the lower chambers of the heart doesn't work as it's supposed to. This causes the lower chamber that pumps blood out of the heart to beat slowly. Causes of tachycardia include: •Heart-related conditions such as high blood pressure (hypertension) •Poor blood supply to the heart muscle due to coronary artery disease (atherosclerosis), heart valve disease, heart failure, heart muscle disease (cardiomyopathy), tumours, or infections •Other medical conditions such as thyroid disease, certain lung diseases, electrolyte imbalance, and alcohol or drug abuse •Emotional stress or drinking large amounts of alcoholic or caffeinated beverages. This is why we need to control for this prior to testing.

Shape and size

•Body Size: refers to stature (height) and body mass (weight) of an individual •Short or tall •Heavy or light •Body Composition: body's chemical composition •Body Build: refers to morphology. (shape / somatotypes)

Health related fitness

•Cardiovascular Fitness •Muscular Strength •Muscular Endurance •Flexibility •Body Composition

other tests

•Cycling Ergometer •Step Tests •Treadmill Tests

Max vs. Submax Testing

•Decision: reasons for the test, risk level of the client, and availability of appropriate equipment and personnel •Maximal tests: point of volitional fatigue•may be inappropriate for some individuals (8-12min) •may require the need for emergency equipment •Submaximal exercise tests •maximal exercise testing is not always feasible in the health/fitness setting

Body composition

•Definition: relative proportion of fat (FM) and fat free mass (FFM) in the body. Body composition can be expressed as the relative percentage of mass that is fat (FM) and fat-free (FFM) using a two-component model. Fat free: Muscle, bone, organ •Clinical significance: Obesity is correlated to an increased risk of: •Coronary artery disease (CAD) •Non-insulin dependent diabetes mellitus (NIDDM) •Hypertension (HTN) •Certain cancers •Hyperlipidemia (high blood cholesterol)

Rate of progression

•Dependent on individual's health status, exercise tolerance, and exercise program goals •Any component of FITT may be increased •Initially, gradual increase in duration (5-10 minutes) every 1 to 2 weeks over first 4 to 6 weeks is reasonable •After 1 month or more, frequency and intensity may be gradually adjusted until recommended quality and quantity of exercise are met. •Following adjustments, monitor individual for adverse effects (adjust downward if not well tolerated).

direct measurement

•Direct measurement•Gas analysis to measure VE and expired gases. •Most accurate

distance run tests

•Distance Run Tests •Cooper 12-min test •1.5-mi (2.4 km) test for time •Rockport One-Mile Fitness Walking Test

Blood pressure during exercise

•During exercise SBP increase HR & SV (CO) DBP remains the same or Slight decrease(if diastolic goes up by more than 10 its abnormal. If systolic goes up by more than 10 per MET of exercise) . -Needs to stay under 250 to continue •Recall that BP determined by CO & TPR •During Exercise CO goes up and TPR goes down (TPR goes down to improve blood flow -vasodilation-)

diagnosing right atrial enlargement

•Dx: presence of P waves with an amplitude exceeding 2.5 mm in at least one of the inferior leads II, III, and aVF. •No change in duration of P wave •Possible RAD The normal P wave is less than 0.12 second in duration, and the largest deflection, that is, voltage, whether positive or negative, should not exceed 2.5 mm. The first part of the P wave represents right atrial depolarization and the second part left atrial depolarization. Check Lead II and V1: Lead II is useful because it is oriented nearly parallel to the flow of current through the atria (i.e., parallel to the mean P-wave vector).Lead V1 is useful because it is oriented perpendicularly to the flow of electricity and is therefore biphasic, allowing easy separation of the right and left atrial components. With right atrial enlargement, the amplitude of the first portion of the P wave increases. The width does not change because the terminal component of the P wave is left atrial in origin, and this remains unchanged. Enlargement of the right atrium may also cause the right atrium to dominate the left atrium electrically. The vector of atrial depolarization may swing rightward, and the P-wave axis may move rightward toward or even beyond +90°. The tallest P wave may therefore appear no longer in lead II, but in lead aVF or lead III. The classic picture of right atrial enlargement is illustrated in leads II and V1, below, and has been called P pulmonale because it is often caused by severe lung disease. Right atrial enlargement is characterized by the following: 1. P waves with an amplitude exceeding 2.5 mm in the inferior leads 2. No change in the duration of the P wave 3. Possible right axis deviation of the P wave

Risks associated with exercise

•Exercise Related Musculoskeletal Injury • - most common •- Related to exercise intensity, pre-existing conditions, MSK anomalies •Sudden Cardiac Death among Young Individuals • -risk is low •- Prescreening for congenital heart abnormalities is advised for athletes •Exercise Related Cardiac Events in Adults •- Related to absence or presence of occult CVD, exercise intensity, age and PA. •- risk of AMI during or immediately following vigorous intensity exercise was 50x higher for the habitually sedentary compared to individuals who exercised vigorously for 1-h sessions > 5 d/wk ​ Although the benefits of regular PA are well established, participation in exercise is associated with an increased risk for musculoskeletal injury (MSI) and cardiovascular complications such as sudden cardiac death (SCD) and acute myocardial infarction (AMI) ​ MSI is the most common exercise-related complication and is often associated with exercise intensity, the nature of the activity, preexisting conditions, and musculoskeletal anomalies​ SCD and AMI are associated with vigorous intensity are much less common than MSI but may lead to long-term morbidity and mortality​ Absolute annual risk of exercise-related death among high school and college athletes:​ One per 133,000 men​ One per 769,000 women​ It should be noted that these rates, although low, include all sports-related nontraumatic deaths. Of the 136 total identifiable causes of death, 100 were caused by CVD. In general, exercise does not provoke cardiovascular events in healthy individuals with normal cardiovascular systems.​ Risk is related to the absence or presence of occult CVD, exercise intensity, age and PA.​ The Onset Study showed that the risk of AMI during or immediately following vigorous intensity exercise was 50 times higher for the habitually sedentary compared to individuals who exercised vigorously for 1-h sessions > 5 d × wk -1

Exercise mode

•Exercise should be: •rhythmic, •aerobic type, and• large muscle groups. •Exercise and sports requiring skill to perform or at higher levels of fitness are recommended only for individuals possessing adequate skill and fitness to perform that activity.

Order of tests

•Fill out paper-work informed consents, health history, PAR-Q, etc •Cardiovascular: resting heart rate, blood pressure, oxygen saturation •Blood Tests: hemoglobin, glucose, lipids •Anthropometric: body mass, stature, BMI, girths, % body fat •Pulmonary Function: spirometry •Aerobic Measurements •Strength Measurements •Flexibility • •Next steps: Prepare a report of the information, reschedule next meeting to review results and discuss training plan.

Flexibility

•Flexibility is the ability to move a joint through its complete range of motion (ROM). •Flexibility depends on a number of specific variables including •distensibility of the joint capsule, •adequate warm-up, and •muscle viscosity. •Compliance ("tightness") of various other tissues such as ligaments and tendons affects the range of motion. Can be measured with goniometer or sit and reach

indirect measurement

•HR •Time to exhaustion •Protocol

Karvonen Formula heart rate

•HRR method (Karvonen formula): Target HR (THR) = [(HRmax/peak — HRrest) × % intensity desired] + HRrest •HRmax/peak is the highest value obtained during maximal/peak exercise or it can be estimated by 220 — age or some other prediction equation

Blood variables

•Hemoglobin (g/dL): men 13.5-17.0; women 11.5-15.5 * Good measures for anemia, VO2max, etc. Measure of bloods oxygen carrying capacity. Blood doping. •Hematocrit (%): men 40-52; women 36-48 *percent of RBC in plasma. Also effects oxygen capacity. Blood doping •Fasting Glucose (mg/dL): 60-99 •Kidney Tests - Blood Urea Nitrogen (BUN); Creatinine •Liver Tests: Bilirubin; ALT: Alanine transaminase; AST: Aspartate Transaminase •C-reactive protein (proinflammatory state): > 3.0 mg/L •Fibrinogen (prothrombotic): ≥ 350 mg/dL

identifying MI

•History and physical examination •Cardiac enzymes •Creatine Kinase MB (up 6 hrs)•Troponin I or T (up 2-3 hrs) •EKG

Catagories of vascular disease

•Hypertension (BP > 130/80 mmHg)* •Coronary Heart Disease, CHD (Ischemic Heart Disease manifests as Angina or Myocardial Infarction) •Angina •Cerebrovascular Disease (Strokes: Ischemic, Blood clots, Hemorrhagic) •Peripheral Vascular disease: PVD, PAD (Intermittent Claudication) •Heart Failure (Heart cannot supply sufficient blood to body due to impaired left ventricular function) •Rheumatic Heart Disease (valve defects) •Cardiomyopathies (Disorders due to structural changes such as HCM) •Myocardial Infarction (Acute MI) During pre-participation health screening, hypertension should be considered a CVD risk factor and not a cardiac disease (Ch 2, p.35). Rheumatic heart disease is caused by rheumatic fever, an inflammatory disease that can affect many connective tissues, especially in the heart, joints, skin, or brain. The heart valves can be inflamed and become scarred over time. Cardiomyopathy: An acquired or hereditary disease of heart muscle, this condition makes it hard for the heart to deliver blood to the body and can lead to heart failure. Symptoms include breathlessness, swollen legs and feet, and a bloated belly. Hypertrophic cardiomyopathy (HCM) is a disease in which the heart muscle becomes abnormally thick (hypertrophied).

Hypertrophy and enlargement

•Hypertrophy increase in muscle mass, caused by pressure overload •Enlargement dilation of chamber, caused by volume overload •Enlargement and Hypertrophy cause changes in EKG EKG: Longer durations, increased amplitudes, shift in axis Axis shifts: Ventricular hypertrophy Checking for hypertrophy: Limb leads: - Right axis deviation (QRS in lead 1 is negative) Precordial leads: - No normal R wave progression ( R should start small and get bigger, vice versa for S) -V1 R is bigger than S -V6 R is bigger than S Checking for enlargement: -Check p-wave -Check leads II and V1 -Amplitude higher than 2.5 = RA enlargement -P-wave is duration is larger than .12s (3 boxes) = LA enlargement

Hypertrophy / enlargement

•Hypertrophy increase in muscle mass, caused by pressure overload •Enlargement dilation of chamber, caused by volume overload. Sign that the heart may be overworked •Enlargement and Hypertrophy cause changes in EKG -Left ventricular hypertrophy shifts axis leftward, and vice versa

Common exercise barriers

•I feel awkward when I exercise •I don't know how to do it •I might get hurt •It's not safe •No one will watch my child if I exercised •There is no one to exercise with me •I don't have enough time •I don't have enough energy •I'm just not motivated •It costs too much •I'm sick or hurt •There's nowhere for me to exercise

Informed consent

•Important ethical and legal consideration and should be completed prior to (a) the collection of any personal and confidential information, (b) any form of fitness testing, or (c) exercise participation. •ensure that individuals know and understand the purpose(s) and risks associated with screening, assessment, and the exercise program. •Should be verbally described, and the individual be given every chance to ask questions before signing.

Dyslipidemia - Special Considerations

•Individuals taking lipid-lowering medications (i.e., statins and fibric acid) may experience muscle weakness and soreness termed myalgia. •Although rare, these medicines can cause direct and severe muscle injury. A health care provider should be consulted if an individual experiences unusual or persistent muscle soreness when exercising while taking these medications. Fibric acid derivatives (fibrates) are a class of medication that lowers blood triglyceride levels. Fibrates lower blood triglyceride levels by reducing the liver's production of VLDL (the triglyceride-carrying particle that circulates in the blood) and by speeding up the removal of triglycerides from the blood.

VO2-Fick equation

•Influenced by amount of O2supplied to muscles and ability of muscles to utilize available O2 •VO2 = Q x (a-vO2diff)•Q = Cardiac Output (L Blood/min) •a-vO2 diff. = difference between arterial and venous oxygen content (L O2/L Blood). This is the amount of O2extracted from the blood."Uptake, Distribution, and Utilization"

1-rm testing

•The greatest resistance that can be moved through the full ROM in a controlled manner with good posture •1‐RM may vary between different types of equipment •Multiple (3,5, or 10) RM can also be used. Prediction accuracy increases with the least number of repetitions. •Use tables and prediction equations to estimate 1‐RM.

Interval training

•Interval training typically consists of alternating bouts of vigorous-to-supramaximal intensity exercise followed by equal or longer bouts of light-to-moderate intensity exercise. •Interval training elicits physiologic adaptations similar to traditional endurance training despite a lower total workload and superior physiologic adaptations when total exercise dose is matched. •Interval training can be classified as either high intensity interval training (HIIT) or sprint interval training (SIT). •Resistance-based interval training can also be implemented via a combination of body weight exercises, plyometrics, and resistance training equipment.

atrial fibrillation

•Irregular •Undulating baseline •Atrial rate: 350-500 bpm •Ventricular rate: variable •Carotid massage: may slow ventricular rate •Look for P waves The key to diagnosing a supraventricular tachyarrhythmia is to look for P waves. They are most likely to be prominent in leads II and V1.

Connective tissue and flexibility

•Joint capsule and associated ligaments contribute approximately 47% to restriction of ROM; muscles contribute 41%, the tendons 10%, and skin 2% •Stretching exercises help to cause minor distensions in connective tissue and summation of these small changes can improve ROM (Biomechanical change) •Increase in stretch tolerance (Sensory change)

Grip strength

•Measure of muscular strength or the maximum force/tension generated by one's forearm muscles. •Uses: •screening tool for the measurement of upper body strength and overall strength. •multiple measurements are taken over time to track performance. •Decreases with age, impacts ADL's •i.e., opening jars, carrying groceries, and turning doorknobs. Procedure:

Blood pressure

•Measurement of the force of blood against the arterial wall -2-5mmHgrelease. •Units are millimeters of mercury (mmHg) •Systolic (SBP) •Maximum pressure in the arteries during heart contraction (systole) •Diastolic (DBP) •Minimum pressure during heart relaxation (diastole)

medical history

•Medical diagnosis •Previous findings on physical examinations •History of symptoms, allergies •Recent illnesses and surgical procedures •Orthopedic problems •Medications •Other habits •Exercise history •Work history •Family history

Steady state

•Metabolic demands of tissue are satisfied •Operationally defined as two HRs ± 5 BPM HR response with incremental exercise is to increase with increasing workloads at a rate of 10 beats per minute per 1 MET. HR max decreases with age HR is attenuated in patients on B-adrenergic blocking agents.

PAR-Q self test

•Minimal standard for entry into moderate-intensity exercise program. •Yes/No questions •Answer 'yes' - client should see physician. Physical activity readiness questionnaire should be done on all individuals wishing to initiate an exercise program. This update PAR-Q+ was designed to reduce barriers for exercise and false positive screenings. Uses follow up questions to better tailor pre-exercise recommendations. The cognitive ability to complete the form may require assistance. Screening: Don't lose your clients -They are inconvenienced by screening -Died because you didn't screen them. -If using this with clients, then need to verbally ask the questions again.

Magnitude of the Adherence Problem

•More than 50% of people who start a new program will drop out within the first three to six months (Dishman 1988, Boyette et al. 2002). •75% of population dropout of exercise in 3 years •20-80% dropout in dieting •80% do not achieve desired weight goals Existing programming models may not be effective for exercise adherence. There is no exact formula for helping people continue with a program. Personal trainers must create: Well-rounded programs that get people fit and healthy An exercise experience that is positive and worthwhile

Motivation and adherence

•Motivation •The psychological drive that gives behavior direction and purpose •Exercise adherence •Refers to maintaining an exercise/PA regimen for a prolonged period of time following the initial adoption phase (Pearson, 1988). •Voluntary, self-regulated and largely a psychological issue •Established exercisers have few problems with adherence. What populations are at a higher risk of not engaging in or dropping out and why? Older adults (take into account intermittent illness, understand how their medical health affects their exercise, clear exercise prescription), ethnic and racial minorities (take into account cultural concerns, values; address unique barriers, church-based programs), low socioeconomic status (increased provision of outdoor leisure facilities or home based exercise programs, telephoned and mailed counselling), women (take into account family and caregiving responsibilities, incorporate social support from peers and family members).

muscle endurance

•Muscular endurance is the ability of a muscle group to execute repeated muscle actions over a period of time sufficient to cause muscular fatigue or to maintain a specific percentage of the 1-RM for a prolonged period of time •Push-up endurance test •Does not include the curl-up test in light of recent research suggesting that the test may not be sensitive enough to grade performance and may cause lower back injury

Muscular Strength

•Muscular strength refers to the muscle's ability to exert force. •3 < repetition to fatigue •Muscular endurance is the muscle's ability to continue to perform successive exertions or many repetitions. •12 > repetition to fatigue •Muscular power is the muscle's ability to exert force per unit of time.

So, how can we support clients/ participants?

•New exercisers may be intimidated by exercise testing, the recommended volume of PA, or find it difficult to break old habits. •The exercise/PA professional must break down recommendations into a manageable and achievable program. •Remember: recommended PA guidelines should only guide us in creating exercise programs. •Taking a "one size fits all" approach to program design is detrimental to long-term adherence.

Causes of LAD

•Normal variation (physiologic, often age-related change) •Left ventricular hypertrophy •Conduction defects: left bundle branch block, left anterior fascicular block •Inferior wall myocardial infarction •Preexcitation syndromes (e.g., Wolff-Parkinson-White syndrome) •Ventricular ectopic rhythms (e.g., ventricular tachycardia) •Congenital heart disease (e.g., primum atrial septal defect, endocardial cushion defect) •Hyperkalemia •Emphysema •Mechanical shift, such as with expiration or raised diaphragm (e.g., pregnancy, ascites, abdominal tumor, organomegaly) •Pacemaker-generated rhythm or paced rhythm

Risks Associated with PA and Exercise

•Participation in exercise is associated with an increased risk for: •musculoskeletal injury (MSI) •cardiovascular complications (acute myocardial infarction) • sudden cardiac death (SCD) (Sudden Cardiac Death Absolute annual risk of exercise-related death among high school and college athletes: One per 133,000 men One per 769,000 women It should be noted that these rates, although low, include all sports-related nontraumatic deaths. Of the 136 total identifiable causes of death, 100 were caused by CVD) •acute myocardial infarction (AMI). •MSI is the most common exercise-related complication and is often associated with exercise intensity, the nature of the activity, preexisting conditions, and musculoskeletal anomalies •SCD and AMI are associated with vigorous intensity and are much less common than MSI but may lead to long-term morbidity and mortality.

Test preparation

•Perform the informed consent process •Perform exercise preparticipation health screening •Complete pre-exercise evaluation •Ensure consent and screening forms, data recording sheets, and any related testing documents are available in the client's file and available for the test's administration. •Room temperature between 68° F and 72° F, humidity < 60% with adequate airflow •Calibrate all equipment

Specificity (SAID principle)

•Physiological and metabolic responses and adaptations to training are SPECIFIC to the type of exercise and muscle groups involved• SAID principle (Specific Adaptation to Imposed Demand) - specific adaptations take place in the body in responses to specific stimuli

exercise intensity

•Positive dose response of health/fitness benefits with increasing exercise intensity. •Moderate to vigorous intensity is recommended in most individuals.• Light to moderate for individuals who are deconditioned. VO2 < 19ml/kg/min increase in risk of mortality

Exercise duration

•Prescribed as a measure of the amount of time PA is performed •It is recommended that most adults accumulate 30-60 min ∙ d−1 (≥150 min ∙ wk−1) of moderate intensity exercise, 20-60 min ∙ d−1 (≥75 min ∙ wk−1) of vigorous exercise, or a combination of moderate and vigorous exercise per day. •A general guideline for aerobic Ex Rx is that 2-min of moderate intensity aerobic exercise is equivalent to 1-min of vigorous intensity aerobic exercise. •The recommended time/duration of physical activity may be performed continuously (i.e., one session) or intermittently and can be accumulated over the course of a day in one or more sessions of physical activity that total at least 10 min ∙ session−1. •Exercise bouts of less than 10 min are associated with favorable health-related outcomes, thus engaging in PA, regardless of length of the bout, has health-enhancing effects, reinforcing the benefits of PA regardless of the duration.

measuring heart rate

•Radial pulse •Carotid pulse? •Resting = 30-60 seconds •Exercise = 15 seconds •Start at 0!

Rest intervals

•Rest between sets and exercises •3-5 min recommended for large muscle mass multi-joint exercises (such as squat, power clean, or dead lift), •1-2 min may be sufficient for smaller muscle mass exercises or single-joint movements. •For a novice-to-intermediate resistance exercise protocol, rest periods of 2-3 min may suffice for large muscle mass multi-joint exercises.

Pre-excitation syndromes

•Signal is conducted too quickly •Accessory pathways bypass AV node and arrive at ventricles ahead of time •<1% individuals

Five basic rhythm disturbances

•Sinus Arrhythmias •Ectopic Rhythms •Reentrant arrhythmias •Conduction Blocks •Pre-excitation syndromes In order to identify an arrhythmia correctly, it is often necessary to view the heart rhythm over a much longer period of time than the few complexes present on the standard 12-lead EKG. When an arrhythmia is suspected, either clinically or electrocardiographically, it is standard practice to run a rhythm strip, a long tracing of a single lead or multiple leads. Any lead can be chosen, but it obviously makes sense to choose the lead that provides you with the most information. One or more leads are preprogrammed to run automatically when you hit the Rhythm button on modern EKG machines. The rhythm strip makes it much easier to identify arrythmias.

sport related fitness

•Speed •Power •Balance •Coordination •Reaction Time •Agility

when to stretch

•Static stretching exercises can have a negative effect on subsequent muscle strength and power and sports performances (McHugh & Cosgrave 2010). •stretches performed >60 s have a deleterious effect on exercise performance (i.e., sprinting, maximal contractions, etc.).ACSM (2018) recommendation: •Flexibility exercise after cardiorespiratory or resistance exercise-or alternatively-as a stand-alone program.•A dynamic, cardiorespiratory endurance exercise warm-up is superior to flexibility exercise for enhancing cardiorespiratory or resistance exercise (especially with high duration and repetitions) performance (Beedle et al. 2007, Fradkin et al. 2010). •A pre-event warm-up, CV and flexibility exercise has benefits for specific recreational sports such as dancing (Gremion 2005).

left ventricular hypertrophy

•The R wave in V5 or V6 plus the S wave in V1 or V2 exceeds 35 mm. •The R wave in aVL is 11 mm. •The R wave in aVL plus the S wave in V3 exceeds 20 in women and 28 in men. •Left axis deviation exceeding −15° is also often present. The diagnosis of left ventricular hypertrophy is somewhat more complicated. Left axis deviation beyond −15° is often seen, but by and large, this is not a very useful diagnostic feature. Instead, increased R-wave amplitude in those leads overlying the left ventricle forms the basis for the EKG diagnosis of left ventricular hypertrophy. Unfortunately, there are almost as many criteria for diagnosing left ventricular hypertrophy on the EKG as there are books about EKGs. Nevertheless, all the criteria reflect a common theme: There should be increased R-wave amplitude in leads overlying the left ventricle and increased S-wave amplitude in leads overlying the right ventricle. The various criteria vary in their sensitivity and specificity. Left ventricular hypertrophy is characterized by voltage criteria and, not infrequently, secondary repolarization abnormalities. The most useful criteria are the following: 1. The R wave in V5 or V6 plus the S wave in V1 or V2 exceeds 35 mm. 2. The R wave in aVL is 11 mm. 3. The R wave in aVL plus the S wave in V3 exceeds 20 in women and 28 in men. 4. Left axis deviation exceeding −15° is also often present.

myocardial infarction ekg

•The most common symptom of a heart attack is severe chest pain. •The pain may spread down the left shoulder and arm and to other areas, such as the back, jaw, neck, or right arm. •Pain in the upper belly, often mistaken for heartburn •Sweating •Nausea and vomiting •Trouble breathing •A feeling that the heart is racing or pounding (palpitations) •Feeling weak or very tired •Feeling dizzy or fainting

skinfold measurements

•The principle behind skinfold measurements is that the amount of subcutaneous fat is proportional to the total amount of body fat. •The exact proportion of subcutaneous to total fat varies with sex, age, and race. •The accuracy of predicting percent body fat from skinfolds is approximately ±3.5%, assuming appropriate techniques and equations have been used.

Karvonen formula Vo2 reserve

•VO2R method: Target VO2R = [(VO2max/peak − VO2rest ) × % intensity desired] + VO2rest •VO2max/peak is the highest value obtained during maximal/peak exercise or it can be estimated from a submaximal exercise test.

Factors Affecting Participation:

•Vigorous-intensity exercise •The drop-out rate is almost twice as high as in moderate-intensity activity programs. •Approximately half of all people who engage in high-intensity activities are injured each year. •Injuries that occur as a result of program participation are directly related to program dropout. •Vigorous-intensity exercise - more experienced exercises fare better with higher intensity exercise. Whereas novice exercises prefer moderate intensity - implications for •The drop-out rate is almost twice as high as in moderate-intensity activity programs. •Most people choose to start moderate-intensity programs rather than vigorous-intensity programs. •This is true regardless of whether intensity is measured physiologically or psychologically. Particularly with unsupervised! •Approximately half of all people who engage in high-intensity activities are injured each year. •Injuries that occur as a result of program participation are directly related to program dropout. •Injured exercisers •Are able to participate in modified exercise programs •Often report engaging in significantly more walking than non-injured exercisers

Order of exercises

•When training all major muscle groups in a workout, perform: -Large muscle group before small muscle groups. -Multi-joint exercises before single-joint exercises. -Rotate upper- and lower-body exercises. •When training individual muscle groups, perform -Multi-joint exercises before single-joint exercises -Higher intensity exercises (i.e., those that require a greater percentage of one's 1-RM) before lower intensity exercises. -An alternative technique sometimes used by bodybuilders is to perform single-joint exercises (i.e., triceps) before multi-joint exercises (i.e., bench press) to pre-fatigue the assistance muscles, thus increasing the overload on the primary muscles.

Internal factors affecting flexibility

•joint type and internal resistance •bony structures; elasticity of connective tissue, muscle mass and skin •the temperature of the joint and associated tissues •the ability of a muscle to relax and contract

External influences on flexibility

•the temperature •the time of day •the stage in the recovery process of a joint (or muscle) after injury (injured joints and muscles will usually offer a lesser degree of flexibility than healthy ones) •age •gender •ability •commitment •restrictive clothing or equipment •Water?