Physical therapists (PTs) and physical therapist assistants (PTAs) promote heath and wellness and the prevention and management of cardiovascular and pulmonary conditions. Regardless of the clinical setting, PTs and PTAs may treat patients with cardiac and pulmonary conditions as primary or secondary diagnoses. Significant advances in the diagnosis and treatment of cardiovascular and pulmonary conditions during the past 30 years, coupled with positive changes in modifiable risk factors, have resulted in a decline in the number of deaths. As individuals with these conditions are living longer lives, PTs and PTAs play a major role in improving functional performance, enhancing quality of life, and increasing the chances of living an independent life after disease. Despite the remarkable progress, cardiovascular and pulmonary conditions remain leading causes of morbidity and mortality.

Cardiovascular disease (CVD) remains the number one cause of death in the United States, claiming over 830,000 lives in 2006 (last full data set available).¹ This represents 26% of the more than 2.4 million people who died that year (Figure 10-1). The economic impact and prevalence of this disease are extensive. Estimated direct and indirect costs for 2010 were $485.6 billion for the 81.1 million American adults that had CVD. The prevalence of two or more risk factors for adults 18 years of age or older varies with ethnicity, education, income, and employment status. Data from the 2003 Centers for Disease Control and Prevention Behavioral Risk Factor Surveillance System indicate that these factors were highest among blacks (48.7%) and American Indians/Alaska Natives (46.7%) and lowest among Asians (25.9%). Multiple risk factors ranged from 25.9% for college graduates to 52.5% for those with less than a high school diploma (or equivalent). Individuals with household income of $10,000 or less had the highest prevalence (52.5%), whereas those with $50,000 or more had the lowest prevalence (28.8%). Adults who were unable to work had the highest prevalence (69.3%), followed by retired persons (45.1%), unemployed adults (43.4%), homemakers (34.3%), and employed persons (34.0%).

Coronary heart disease (CHD), disease specifically of the heart and its vascular supply, is responsible for 51% of all deaths caused by CVD (Figure 10-2).¹ This represents 1 of every 6 deaths in the United States in 2006. Approximately every 25 seconds an American undergoes a coronary event, and about every minute someone dies of a cardiac event. For 2010, an estimated 785,000 Americans had a new heart attack (myocardial infarction [MI]) and 470,000 had recurrent attacks. Besides attempts to alter the lifestyle of a person who is at risk for heart disease to decrease the risk factors, direct intervention is commonly used to manage heart disease. In 2006, an estimated 1,313,000 percutaneous coronary interventions (PCIs, previously referred to as angioplasties) were performed. The most common PCI procedure requires inserting a tube into a coronary vessel and inflating a balloon on the end of the tube to open up a blockage in the vessel to restore normal blood flow. Nearly half a million coronary artery bypass procedures were performed, 418,000 pacemaker procedures were completed, and 2163 heart transplantations were performed in 2006.¹

Chronic obstructive pulmonary disease (COPD) comprises a group of lung diseases that are characterized by obstruction of airflow through the bronchial system and in some cases destruction of lung parenchyma. Emphysema and chronic bronchitis are the two most common COPD conditions and are often found together in the same patient. Asthma is not included in this definition of COPD.

In 2008 (last full data set available), 12.1 million people in the United States aged 18 or over had a diagnosis of COPD.² COPD is the fourth leading cause of death in the United States, and for the last 7 years more women than men died of COPD. As in CVD, gender, race, and age affect the population in which COPD develops. In 2008 the highest percentage of individuals with chronic bronchitis consisted of non-Hispanic white females from the South, ranging from 45 to 64 years of age. The greatest percentage of individuals with emphysema also consisted of non-Hispanic white females from the South, but over the age of 65. In 2010, the projected annual cost of COPD to the nation was $49.9 billion. This included $29.5 billion in direct health care costs, $8 billion in indirect morbidity costs, and $12.4 billion in indirect mortality costs.

As the profession is moving toward direct patient access, PTs must have a thorough understanding of the normal anatomy and physiology of the cardiac and pulmonary systems. With this knowledge, the therapist can evaluate these systems, determine if the patient is appropriate to treat, and develop optimal rehabilitation programs.

Cardiovascular System

Heart

The heart is positioned left of center in the chest cavity (mediastinum), with the base located superiorly and the apex inferiorly and left of center. A fibrous tissue known as the pericardial sac surrounds the heart. The major portion of the heart is made up of muscle tissue referred to as the myocardium. This tissue is cross-striated with layers of muscle fibers arranged in multiple directions.³

The heart has two pairs of matched chambers. The two atria are thin-walled chambers, whereas the two ventricles have much thicker muscular walls (Figure 10-3).⁴ These chambers are separated by valves that direct the blood through the chambers in a specific pattern.

The right atrium receives venous blood from the body through the superior and inferior venae cavae. With atrial contraction (atrial systole) the blood then passes through the tricuspid valve into the right ventricle (Figure 10-4, A).⁴ The left atrium receives oxygenated blood through the pulmonary veins coming from the lungs. During atrial systole, this oxygenated blood passes through the bicuspid (mitral) valve into the left ventricle (Figure 10-4, B).⁴

Once the right and left ventricles have received blood from their respective atria, ventricular contraction (ventricular systole) occurs. This contraction results in an increase in pressure in the ventricular chambers, which causes the tricuspid and bicuspid valves to close tightly and prevents blood from passing back into the atria. As ventricular contraction continues, venous blood leaves the right ventricle through the pulmonic or semilunar valve and flows into the lungs to be reoxygenated. Oxygenated blood leaves the left ventricle through the aortic valve into the aorta to be transported to the body through the systemic circulation.

It is significant that the ventricles have thicker muscular walls than the atria. This greater muscle mass, especially in the left ventricle, must provide enough force to overcome the resistance to flow that blood encounters as it moves through the peripheral arteries.⁵

Conduction

The myocardium contains special types of tissue responsible for conducting the electrical impulse that causes the myocardium to contract in a synchronized pattern. The synchronized depolarization and repolarization of cardiac muscle result in efficient movement of blood through the chambers of the heart and through the coronary and peripheral vessels.

The specialized tissues are called nodal and Purkinje fibers (Figure 10-5).⁶ The sinoatrial (SA) node initiates the impulse (sinus rhythm) and is referred to as the pacemaker of the heart. Once a signal is initiated by the SA node, it travels quickly through the walls of the atria on special tracts to the atrioventricular (AV) node. The impulse also travels to the muscle fibers of the atria and causes them to contract. The AV node transports the signal to the bundle of His, which is where the Purkinje fibers start to spread out into the muscle fibers of the ventricles. For every heartbeat or contraction, the depolarization signal that causes the myocardium to contract must travel through this conduction system of the heart.

Both the SA and AV nodes receive autonomic nerve fibers via the sympathetic and parasympathetic systems. These nerve fibers release special neurotransmitters that influence the rate of contraction and myocardial contractility. The ability to influence the heart’s rate and contractility is extremely important because this mechanism allows the central nervous system to tell the heart how to respond to increases in demand, such as those made during exercise.⁵

Coronary Arteries

The myocardium receives its blood supply from two major vessels: the right and left coronary arteries (Figure 10-6).⁷ These arteries arise from the ascending aorta, which is the major artery leaving the left ventricle and carrying blood to the body (see Figure 10-3). In general, the right and left coronary vessels supply the right and left sides of the heart, respectively; however, this arrangement can vary a great deal among individuals. If something occurs that causes blockage of a coronary vessel, it is important to determine exactly how that blockage alters blood flow to the individual’s myocardium. A blockage that prevents oxygen supply to the heart, causing permanent damage to the heart cells, is known as a heart attack (myocardial infarction or MI).

Peripheral Circulation

The blood vessels that make up the peripheral circulation are arteries, capillaries, and veins, and disorders in these vessels can result in cardiovascular and pulmonary dysfunction. PTs and PTAs work with a variety of patients who have disabilities caused by pathologic changes in the peripheral circulation.

The arteries, of which the aorta has the largest diameter, and the arterioles have elastic fibers and smooth muscle in their walls. If the smooth muscle contracts, the diameter of the vessel is decreased, which causes an increase in the resistance to blood flow through the vessels. Arterioles are often referred to as “resistance vessels.” Changes in resistance to blood flow in the peripheral circulation directly affect how hard the heart has to work to pump blood through the body. A disease called arteriosclerosis, which is often referred to as “hardening of the arteries,” causes plaque to build up on the inner wall and decreases the elasticity of the vessel, with subsequently higher resistance to blood flow.

Capillaries are the smallest vessels in the peripheral circulation. They connect arteries to veins and can be so small that they allow only one red blood cell to pass through at a time. Their walls are only one cell thick, which permits efficient exchange of oxygen and carbon dioxide. Nutrients and waste products also pass through the wall. Capillaries are often referred to as “exchange vessels.”

The veins, which return blood to the heart from the body, have much less elastic fiber and smooth muscle in their walls. The larger veins can act as a blood reservoir and are often called “capacitance vessels.”

Pulmonary System

Respiration

Respiration is the process of exchanging oxygen and carbon dioxide between the air we breathe and blood cells that pass through the lungs. Ventilation is the process of exchanging air between the atmosphere and the lungs through inspiration and expiration.⁸ The mechanics of inspiration and expiration depend on many factors, including the structure of the lungs, chest, and muscles. Inspiration occurs when the muscles of ventilation, the most important being the diaphragm, contract to cause an increase in the space within the thoracic cavity. This expansion causes air pressure to drop inside the lungs, which causes air to move into the lungs. Expiration is the reverse of this process.

If the body needs increased amounts of oxygen, such as during exercise, the amount of air that must flow into and out of the lungs must markedly increase. When this situation occurs, the muscles of ventilation must work extensively. When disease affects the lungs, the results can be the same. In this case, however, the body is not requiring more oxygen. The ability of air to move normally into and out of the lungs is compromised because of blockage of the tubes that conduct the air. This obstruction results in high resistance to airflow and increased work for the muscles of ventilation.⁹

Conducting Airways and Lungs

Conducting airways are the passageways and tubes that transport air into and out of the lungs. The upper conducting airway includes the nose, pharynx, and larynx. This component of the air transport system cleans and humidifies the air and terminates at the beginning of the trachea. The lower conducting airway is made up of the trachea and bronchiole system (Figure 10-7).⁹ The bronchiole system consists of tubes branching from the main bronchus out to the terminal bronchioles. It is here that the conduction system ends and air enters into the alveolus, where gas exchange takes place. The alveoli are surrounded by capillaries that contain deoxygenated blood coming from the right ventricle of the heart. It is at this junction that oxygen and carbon dioxide are exchanged, with the reoxygenated blood returning to the left atrium. The lungs are compartmentalized into a system of lobes, which are present because of the structure of the bronchial airway system (Figure 10-7). A special membrane, the pleura, covers the outer surface of the lungs and the inner surface of the chest wall. The pleura is extremely important to the process of ventilation and maintenance of the continuity of the lungs.³

Two major categories of disease processes influence the myocardium: ischemic conditions and cardiac muscle dysfunction.¹⁰

Principles of Examination

The examination performed by PTs and PTAs is an inclusive process that involves not only the patient, but also the family and other caregivers who are participating in the overall care of the patient. It includes a review of the patient’s past medical and social history, review of the body systems, and tests and measures to gather data about the patient’s condition. Areas reviewed include not only physical parameters, but also functional, psychological, social, and employment conditions. The tests and measures that are selected to examine a patient/client depend on various parameters, including the age of the patient/client; severity of the problem; stage of recovery (acute, subacute, chronic); phase of rehabilitation (early, intermediate, late, return to activity); and home, community, and work status.¹³ Table 10-1 describes tests and measures commonly performed in the examination of patients with cardiovascular and pulmonary conditions.¹³

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