Scenario: An 80-year-old female presents with shortness of breath and chest pain with exertion and cough. She states that she has to sleep with four pillows at night or she gets short of breath. She has a history of long-standing hypertension and noncompliance with her medication. Vitals are: Pulse: 120, Respiration: 22, Temperature: 97.8° F, Blood Pressure: 150/80, and SpO2% of 94%. The patient appears diaphoretic with cool pale extremities. There are audible rales in the lungs bilaterally and +2 edema of the legs bilaterally. There is an audible S3 gallop. EKG shows some left ventricular strain. Chest X-ray shows fluid in the bases of the lungs bilaterally and enlargement of the heart. Brain natriuretic peptide (BNP) level in the blood is 500 pg/mL. 

Question: What systolic blood pressure  would be considered a high risk for exercise

Potential answers: 

a.      Stop exercising if your systolic blood pressure surpasses 200 mm Hg

b.      Stop exercising if your systolic blood pressure surpasses 180 mm Hg

c.    Patient should be referred back to primary care physician as they are unfit for physical therapy if the systolic blood pressure is 140 mm HG.  

d.    If the patient has a referral for Physical Therapy, the Physical Therapist does not need to access vital signs.  

Answer with rationale:   A. Unless previously cleared by a physician stop exercising if your systolic blood pressure surpasses 200 mm Hg. Vital signs need to be assessed regularly, closely monitored aerobic and resistance exercises may be beneficial, and patient education on disease management is key.¹  

Vital signs must be assessed regularly because the heart is no longer working efficiently so it is important to monitor for signs and symptoms of worsening. Also, fatigue and energy conservation will need to be considered. Monitoring should include before, during, and after exercise whether at home or in physical therapy.^1,2 

Aerobic and resistance exercises have proven to be beneficial for congestive heart failure because they help maintain or improve oxygenation in the body as well as decreasing blood pressure and heart rate. They must be closely monitored because the patient may experience excessive fatigue or other symptoms due to the heart having trouble working efficiently.^1,2 

Patient education on disease management plays an important role in maintenance and improvement of congestive heart failure. Teaching the patient about monitoring vital signs, energy conservation, activity modifications, and red flags to watch out for can be integral in adding to quality of life. 

For more information see Chapter 9 Congestive Heart Failure in the Color Atlas of Physical Therapy.