Acute Myocardial Infarction

Patient’s information

• Gender  Male
• Age 64
• Height 183cm or 1.83m
• Weight 116kg
• BMI 35.8 (Obese)
• Waist circumference 40.2 inches
• Medical history Smoking for 15 years, 1 incident of Acute Myocardial Infarction (AMI)
• Hypertension/Blood pressure Stage 2 hypertensive = 160/120 mm Hg
• Family history Obesity, Father had AMI
• Maximum Heart Rate (MHR) 220-64 = 156bmp
• Resting Heart Rate (RHR) 100bmp
• Fitness level Sedentary
• Medication ACE-inhibitors Ramipril/perindopril, DCA-nifedipine, N-DHCA-verapamil and diltiazem

Medical Background

The selected disease that will be focused on is Acute Myocardial Infarction (AMI). AMI is caused by a build of cholesterol and white blood cells (plaque rupture) that cut off blood flow to one or more coronary arteries, causing tissue damage and irregular heartbeat (Frøbert et al., 2009). Coronary Heart Disease (CHD) is a leading cause of high mortality rates and premature deaths (Kerr, Holden, Smith, Bunker, 2006).  AMI contributes to a large factor of CHD as restoring the amount of blood flow (reperfusion) to the heart is a key factor to survival and quality of life, the longer reperfusion takes, the increased changes of continuation of CHD occurring (Kerr et al, 2006).

Methods that are used to treat patients that have AMI, high blood pressure (hypertensive) and obesity are; medications, exercise programs and nutritional diet plans. Variety of medications that can be used to treat hypertensive and cardiovascular risk (CV) must focus on the goal of achieving goal blood pressure of 130/80 mm Hg (White, 2005). White (2005) states that initial therapy includes diuretics in combination with other medical agents to reduce BP, resulting in maximal effectiveness of medication to reduce chances of another AMI incident. Systolic Blood Pressure (SBP) control is most important to reducing blood pressure, due to having earlier results of a drop in BP compared to Diastolic Blood Pressure (DBP) (White, 2005). Exercise programs are just as important as medication use, as exercise helps to reduce BP and reduces changes of cardiovascular risks such as AMI (Habibzadeh et al., 2010). Exercises that focus on aerobic activities, aiming to achieve 40-60% of maximum heart rate in 30-45-minute intervals over 5 days per week, is optimal to result in a decrease chance of CV risk and a decrease in BP. Dietary programs are also just as important as exercise and medication, due to a drastic change in weight loss, BP and a decreased BMI (White, 2005). White (2005) states that high calcium diets are effective against preventing AMI and stroke, as well as an increase in whole grains, carbohydrates and vegetables contribute to prevention of AMI.

Medication is focused on due to be a boost and supportive method to help with exercise, survival and quality of life (White, 2005). Beta-blockers and ACE inhibitor Ramipril have shown to significantly reduce chances of AMI and reduce BP (White, 2005). Long-term use of these medications combined with other medical agents, can result in significant change and a positive outcome from the risk of AMI, reduce BP and reduce RHR. BP has a large input to high-risk patients of AMI risk; this is due to large amount of stress on the heart muscle (White,2005) Further prevention with losartan significantly decreased BP, therefore, resulting in a decreased chance of AMI (White, 2005).

Contraindications that can be involved with the selected methods above are; overuse of prescribed medication which can result in the opposite effect, prescribed wrong medication, dietary plan not accounting for other medical problems (allergic reactions, diabetes etc.), exercise program planned to be too vigorous or strenuous for the individual.

AMI is still prevalent in Australia, due to the increase rates of scientific studies that have been shown. Over the course of the 17-year period, 714,262 incidents of MI occurred across Australia (Wong et al., 2013). The result demonstrated a 1.98% increase annually, and the age group affected the most were between 50-80 years old (Wong et al., 2013). In another case study, metropolitan areas have a decrease in AMI, while regional and remote areas have increase (Davies et al., 2017). The significance of AMI in Australia is that it still contributes to the leading cause of death that is CHD (Kerr et al., 2006).

Pre-exercise screening

A pre-screening tool that’ll be optimal for the patient prescribed is the APSS as it determines medical history, fitness level, and current medical status resulting in a professional prescribing the patient the best fit exercise program (see appendix). APSS can also help the professional prescribing the exercise is aware of their limitations and their current medicine intake, therefore, being aware of how to prescribe the exercise program. APSS is important prior to exercising, due to professionals being aware of the patient’s history of AMI, this can further help professional prescribing an exercise program based on the dangers of AMI, and the dangers the patient has.

A pre-screening exercise to determine the fitness level of the participant can be called a graded exercise testing (GXT). GXT is used post AMI to determine prognosis and functional status of the heart (Habibzadeh et al., 2010). The GXT is often performed within the first few weeks of AMI; it includes a variety of exercises to determine fitness level and limitations of the patient (Ehrman, Gordon, Visich & Keteyian, 2018). The best GXT used for the Male patient is the Rockport Walk Test. Rockport Walk Test is a submaximal test to determine VO2 at a cheaper cost and easily to accessible method. It is tested over 1.6km distance and the patient needs to walk 1.6km as fast as possible, HR will be recorded and other factors such as height, weight (pounds), age. At the end VO2 max is calculated and compared to on a normative table provided. The importance of this submaxim test determines the patient’s potential maximal output in an exercise, as well as, the patient performs the exercise in a safe environment. in a case study that tested if the Rockport Walk test is accurate (Weiglein, Herrick, Kirk & Kirk 2011), compared results between 1-Mile walk test vs 1.5 – mile run with U.S air force males as participants. Weiglein et al., (2011) states that the walk test is a valid predictor of VO2 max in fitness levels.

Medication

White (2005) concludes his case study stating that patients with hypertension and cardiovascular risk require multiple medical prescriptions to achieve a healthy BP and reduced chances of AMI. Angiotensin-converting enzyme inhibitor (ACE inhibitor) is medication used to treat high BP and cardiovascular risk. As stated, prior, ACE inhibitor Ramipril has been shown to result is reduce risk to AMI. Ramipril achieves this by preventing the creation of angiotensin II, therefore widening blood vessels and reducing the amount of water absorbed back into the body (Kleinert, 1999). Further medication of ACE inhibitor Perindopril reduces cardiovascular incidents such as myocardial infarction as well as, protecting the heart from further AMI (White, 2005). Perindopril works in conjunction with Ramipril by preventing angiotensin II, causing blood vessels to widen and reducing how much water is put back in the body (Leenen, Tanner & McNally, 2000). In long term treatment Dropyridine Calcium Antagonist (DCA) nifedipine, Non-Dihydropyridine Calcium Antagonist (N-DHCA) verapamil and diltiazem have been shown to reduce risk of AMI while having similar results from diuretics or beta-blockers (White, 2005). DCA relax arteriolar smooth muscle therefore reducing BP, in contrast N-DHCA is an arteriolar dilator reducing BP and peripheral resistance (White, 2005).

Exercise plan

The patient has filled out the APSS and performed the Rockport walk test. The medication, fitness level, medical/family history and physical characteristics, are addressed on the patients table. Hypertension and AMI can be in conjunction with the exercise plan. As stated, the patient has both stage II hypertension and a history of AMI, for this process, the exercise program will focus on prescribing exercise to AMI risk. The exercise program will state the Mode, frequency, Intensity and duration of the exercises. Mode is split into two types of training aerobic and resistance training. Aerobic is focused on due to increase lung capacity therefore cycling the body with fresh oxygenated blood (ELshazly, Khorshid, Hanna & Ali, 2018). Exercises such as walking, jogging, cycling, and water aerobics are optimal for safety and are accessible everywhere. Resistance training helps with fluctuation of lactic acid and removal of waste around the body (ELshazly et al., 2018). Exercises such as machine weight and light free weight help to increase muscle strength and endurance. Frequency is determined how many sessions per week the patient will be attending (Gassner, Dunn & Piller, 2003). Intensity is how intense the patient will be working out through the training program. Duration is how long each session will be going for. Progression is weekly progress to the optimal goal of being at a healthier fitness level (Gassner et al., 2003)

Mode:

The patient for the 8-week training period on aerobic days will focus on cycling, walking, swimming and step work, while resistance days will be focusing on machine work and light free weight

Frequency:

Aerobic is to be starting off at 3-4 days a week, optimally achieving 7 days a week, while adding 1/2 sessions per day. While resistance training will be maintained at 2-3 days a week as it’s not as important as aerobic training.

Intensity:

Aerobic training is to maintain and achieve a 40-60% HRR in each workout, optimally achieving 70-80% in end of the 8 weeks, RPE should stay at a consist 11-13 throughout the 8 weeks. Resistance training is to be kept at 40-60% of 1RM of any exercise; RPE should be 12-13

Duration:

Patient is to start at 30-60 minutes a session for aerobic activity, optimally achieving 60-90 minutes a session in the end of the 8-week training program. Patient is to start on 5-7 exercises, 1 set per exercise and 10-15 repetitions, optimally achieving 8-10 exercises, maintaining 1 set and 10-15 repetitions.

Progression:

Patient is to progress through each week and reaching new goals, as well as, having physical change in a healthy outcome. This can come in the form of pushing to new limits or 40-60% of HRR is not achieved (adapting to workout).

Methods to monitor:

Methods that can monitor the individual for exercise adherence can be a daily check on the individual; this can be done through an app or in person. Having the patient work with someone can boost motivation and help exercise adherence (Gassner et al., 2003). Changing environments when working out and setting achievable short-term goals are methods to increase exercise adherence. Supervision throughout workouts and in person training sessions increase adherence due to motivation of the environment (Picorelli, Pereira, Pereira, Felício & Sherrington, 2014). Though exercise adherence is not at its strong point with the elderly due to, physiological, medical, environmental and mental factors, resulting in exercise adherence to still be in a grew area (Picorelli et al., 2014). To overcome this obstacle of exercise adherence, group or community sessions are strongly advised due to not being isolated in the sessions (Picorelli et al., 2014)

Conclusion

Improvements the patient will have after the 8-week training program is significantly reduced BP and RHR, lower cholesterol levels, loss of weigh and less smoking (Gassner et al., 2003). The patient will be improving on each week, if exercise adherence is near 100%, this will result in a lower BMI, therefore decreasing any risk of AMI (Gassner et al., 2003). Further improvements include less medication or reliability of medication, healthier diet and a high chance of no smoking. Focusing on aerobic exercise enhances quality of life and an increase to the patient’s mental well-being (Gassner et al., 2003). Furthermore, VO2 max reduces 9% over a decade, though aerobic exercise can slow it down to half (Gassner et al., 2003). Long-term recommendations are healthier diet, less/no smoking, including higher resistance load, increase intensity of aerobic exercise.

In conclusion, the report illustrates the prevalence of AMI and suggesting methods to reduce changes of AMI and other risk diseases. This can result in a decrease of AMI occurring in individuals and decreasing premature death.

Reference list:

1. Picorelli, A. M. A., Pereira, L. S. M., Pereira, D. S., Felício, D., & Sherrington, C. (2014). Adherence to exercise programs for older people is influenced by program characteristics and personal factors: a systematic review. Journal of Physiotherapy, 60(3), 151–156.
2. Gassner, L.-A., Dunn, S., & Piller, N. (2003). Aerobic exercise and the post myocardial infarction patient: a review of the literature. Heart & Lung: The Journal of Acute and Critical Care, 32(4), 258–265.
3. Elshazly, A., Khorshid, H., Hanna, H., & Ali, A. (2018). Effect of exercise training on heart rate recovery in patients post anterior myocardial infarction. The Egyptian Heart Journal.
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10. Weiglein, L., Herrick, J., Kirk, S., & Kirk, E. P. (2011). The 1-Mile Walk Test is a Valid Predictor of VO2maxand is a Reliable Alternative Fitness Test to the 1.5-Mile Run in U.S. Air Force Males. Military Medicine, 176(6), 669–673.
11. Wong, C. X., Sun, M. T., Lau, D. H., Brooks, A. G., Sullivan, T., Worthley, M. I., … Sanders, P. (2013). Nationwide Trends in the Incidence of Acute Myocardial Infarction in Australia, 1993–2010. The American Journal of Cardiology, 112(2), 169–173.
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