MEDICAL HISTORY
Ms. RW is a 58-year-old Caucasian woman with no prior history ofheart disease. She has hypertension under good control withmedications and was diagnosed with diabetes 15 years ago. Her lastfasting blood sugar was 234, and her HbA1c was 8.7. She is a formersmoker (quit 10 years ago) and leads a rather sedentary lifestyleas a computer analyst for a large local corporation. Over the past3 months she has started to notice increased shortness of breathwhen climbing two flights of stairs at work; at the top of thestairs, she feels some moderate chest pressure that resolves in acouple of minutes after she sits down at her desk. Her primary carephysician sends her for a routine exercise test.
EXERCISE TEST RESULTS
Exercise Stress Test
Resting ECG: appears normal
Heart rate: 65 beats per minute
Blood pressure: 138/92mmHg
Heart and lung sounds: within normal limits
She exercises on a standard Bruce protocol. At 4:30 min there issome horizontal ST depression, about 1 mm in inferior and lateralleads; by peak exercise (5:20 min) it is about 2 mm downsloping inthe same leads, and she is developing chest pressure she describedin her symptom history. ECG changes resolve by 10 min of recovery,and symptoms resolve in about 5 min of recovery.
DIAGNOSIS
Principal diagnosis: Severe two-vessel CAD. Stenting was performedto 95% proximal left anterior descending coronary artery (LAD)lesion; Ms. RW’s 75% distal left circumflex lesion was not acandidate for revascularization at the time of procedure.
Medications: Metoprolol 50 mg twice daily, lisinopril 10 mg oncedaily, aspirin, Plavix, and simvastatin.
CARDIAC REHABILITATION
A referral for cardiac rehabilitation was placed by hercardiologist and was to start as soon as she was able to set upafter hospitalization.
EXERCISE PRESCIPTION
Resting heart rate: 54 beats per minute
Resting blood pressure: 112/64mm Hg
Initial exercise program:
Treadmill walking = 2.0 mph (3.2 kph), 0% grade for 10 min
Combined arm and leg ergometry = 100 W for 10 min
Upright stationary leg ergometry = 30 to 50 W for 10 min
Short circuit resistance machines = one set of six exercises for 10repetitions
Patient completed 6 weeks in the program at the followingworkloads:
Treadmill walking = 2.7 mph (4.0 kph), 3% grade for 10 min
Combined arm and leg ergometry = 100 to 125 W for 10 min
Upright stationary leg ergometry = 100 to 125 W for 10 min
Rowing = 50 to 75 W for 10 min
Short circuit resistance machines = two or three sets of eightexercises for 10 repetitions
Exercise heart rate: 100 to 110 beats per minute
Exercise rating of perceived exertion: 12 to 14
The remainder of her program was uneventful. The patient completeda total of 12 weeks from the start of the program and returned toher home exercise program and activities of daily living.
DISCUSSION QUESTIONS (limit of 500 words perquestion)
- What changes may have to be made to this patient’s exerciseregimen in view of the residual 75% blockage in her left circumflexcoronary artery.
- If she hits a plateau in her ability to increase her intensityof cardiovascular exercise that is not due to further complicationswith her heart, what issues may be limiting her ability to increaseexercise intensity?
