cardiac rehabilitation

Dr. Vinod K. Ravaliya, MPTCardiothoracic Physiotherapy

Shree Krishna HospitalKMPIP, Karamsad

Objectives

Definition Members of CR Benefits of CR Assessment of risk factors and

system-wise examination Phases of CR Principles of exercise program for

cardiac patients

Question yourself ????

Up until the 1950s, strict bed rest was thought to be the best medicine after a heart attack.

Following discharge moderately stressful activity such as climbing stairs was discouraged for a year or more.

Introduction

Introduction

"The patient is to be guarded by day and night nursing and helped in every way to avoid voluntary movement or effort."

Thomas Lewis, 1933

Definition of CR

Cardiac rehabilitation has been defined asThe sum of activities required to ensure

cardiac patients the best possible physical, mental and social conditions so that they may, by their own efforts, resume and maintain as normal a place as possible in the community.

Cardiac rehabilitation has also been described asThe combined and coordinated use of

medical, psychosocial, educational, vocational and physical measures to facilitate return to an active and satisfying lifestyle.

Definition of CR

The Coordinated, multifaceted interventions designed to optimize a cardiac patient’s physicial, psychological, and social functioning, in addition to stabilizing, slowing or even reversing the progression of the underlying atherosclerotic process, thereby reducing morbidity and mortality

AHA Scientific Statement, Circ 2005;111:369-76

Current Indications for Cardiac Rehabilitation (Medicare)

Post-MI Post-CABG Angina PCI Valve replacement or repair Heart transplant Indications for CHF continue to be

evaluated

HM734 Exercise Testing and Prescription: Cardiorespiratory 9

Benefits of Cardiac Rehab

Offset deleterious pyschologic and physiologic effects of bed rest during hospitalization

Provide additional medical surveillance of patients

Enable patients to return to activities of daily living within the limits imposed by their disease

Prepare the patient and the support system at home to optimize recovery followed by hospital discharge

Benefits of CR

Reduces cardiovascular and total mortality

Does not increase non-fatal reinfarction rate

Improves myocardial perfusion May reduce progression of

atherosclerosis when combined with aggressive diet

No consistent effects on hemodynamics, LV function or visible collaterals

Benefits of CR

No consistent effects on cardiac arrhythmias

Improves exercise tolerance without significant CV complications

Improves skeletal muscle strength and endurance in clinically stable patients

Promotes favorable exercise habits Decreases angina and CHF

symptoms

Outcomes in Cardiac Rehabilitation1996 AHCPR Guidelines

1. Smoking cessation2. Lipid management3. Weight control4. Blood pressure control5. Improved exercise tolerance6. Symptom control7. Return to work8. Psychological well-being/stress

management

Desirable to KNOW…..

A Cochrane review in 2004 concluded that exercise only cardiac rehabilitation reduced all cause mortality by 27% and cardiac mortality by 31%

The Canadian Co-ordinating Office for Health Technology Assessment reported reductions of all cause mortality of 24% and cardiac mortality of 23%.

A study by Witt et al in 2004 found that not only was participation in cardiac rehab associated with decreased mortality after MI but also with lower risk of recurrent MI

Assessment before exercise training

Clinical risk stratification is suitable for low to moderate risk patients undergoing low to moderate intensity exercise

Exercise testing and echocardiography are recommended for high risk patients and/or high intensity exercise

Functional exercise capacity should be evaluated before and on completion of exercise training.

On Examination

Vitals:PR, RR, BP, SpO2, ECG findings RS Examination Circulatory Examination MS Examination CNS Examination

Measurements

Exercise capacity Quality of life surveys (SF-12, SF-36) BP Weight Waist circumference Lipids Glucose/HbA1C Telemetry monitoring occurs during

exercise sessions Nutritional survey tool Stress level

Absolute Contraindication to Exercise Absolute Acute myocardial infarction (within two days) Unstable angina Uncontrolled cardiac arrhythmias causing symptoms or

homodynamic compromise Symptomatic severe aortic stenosis Uncontrolled symptomatic heart failure Acute pulmonary embolus or pulmonary infarction Acute myocarditis or pericarditis Active endocarditis Acute aortic dissection Acute noncardiac disorder that may affect exercise performance or

be aggravated by exercise Inability to obtain consent

Exercise standards for testing and training: a statement for healthcare professionals from the American Heart Association. Circulation 2001; 104:1694

Relative Contraindication to Exercise Left main coronary stenosis or its equivalent Moderate stenotic valvular heart disease Electrolyte abnormalities Severe hypertension (systolic 200 mmHg and/or diastolic 110

mmHg) Tachyarrhythmias or bradyarrhythmias, including atrial

fibrillation with uncontrolled ventricular rate Hypertrophic cardiomyopathy and other forms of outflow tract

obstruction Mental or physical impairment leading to inability to cooperate High-degree atrioventricular block

Exercise standards for testing and training: a statement for healthcare professionals from the American Heart Association. Circulation 2001; 104:1694;

Phase I

Objectives of Phase I Cardiac Rehab

Conditioning from acute event/ post-CABG

To make patient functionally independent

To adjust with discharge from the hospital

Psychological counselling Nutritional counselling Secondary prevention targetting

Phase I

Phase I relates to the period of hospitalization following an acute cardiac event. The duration of this phase may vary depending on the initial diagnosis, the severity of the event and individual institutions, usually one week acute event/post-operative.

Contd….

During this phase, Early mobilization and adequate

discharge planning. Individuals typically undergo a risk factor

assessment and risk stratification Receiving information regarding their

diagnosis, risk factors, medications and work/ social issues.

Involvement and support of the partner and family is facilitated and encouraged.

Phase II

Objectives of Phase II Cardiac Rehab

Functional goals– Exercise training under supervision/ at home

Psychosocial goals – Anxiety/depression management

Secondary preventive targets

Phase II

Phase II: This phase encompasses the Immediate post discharge period, which is typically a

period of four to six weeks. It focuses on

health education and resumption of physical activity, however the structure of

this phase may vary dramatically from centre to centre. It may take the format of

telephone follow up, home visits, or individual or group education sessions.

Either way, some form of contact is maintained with the patient, facilitating ongoing education and exchange of information.

Phase III

Objectives of Phase III Cardiac Rehab

Functional goals– Exercise training under supervision

Psychosocial goals – Return to work – Return to hobbies and lifestyle– Anxiety/depression management


Phase III

Phase III: This phase is sometimes erroneously referred to as the ‘Exercise’ phase.

It incorporates Exercise training in combination with ongoing

education and psychosocial and vocational interventions.

The duration of Phase 3 may vary from six to 12 weeks, with patients required to attend a CR unit two to three times weekly for structured exercise and other lifestyle interventions.

Phase IV

Objectives of Phase IV Cardiac Rehab

Maintenance of achieved functional status

Return to work – Return to hobbies and lifestyle modifications


Phase IV

Phase IV: This phase constitutes the components of long-term maintenance of lifestyle changes and professional monitoring of clinical status.

It is when patients leave the structured Phase 3 programme and continue exercise and other lifestyle modifications indefinitely.

This may be facilitated in the CR unit itself or in a local leisure centre.

Alternatively, individuals may prefer to exercise independently and

Phase 4 may involve helping them set a safe and realistic maintenance programme.

EXERCISE GUIDELINES FOR

CARDIAC PATIENTS


General Inpatient Prescription Guidelines

Frequency Early mobilization:▪ 3-4 times/day (days 1-3)

Later mobilization:▪ 2 times/day (beginning on day 4)

Progression: Initially increase duration up to 10-15

min, then increase intensity.



By hospital discharge, the patient should: Demonstrate a knowledge of

inappropriate exercises Have a safe, progressive plan of exercise

formulated for them to take home



Selected moderate to high risk patients should be encouraged to participate in outpatient cardiac rehabilitation programs &/or

Manage their discharge rehabilitation plan and report any cardiovascular symptoms promptly (should they occur).


Outpatient Programs

Goals are to: Provide appropriate patient monitoring

and supervision to detect a deterioration in clinical status and to provide timely feedback to the referring physician to enhance effective medical feedback,

Contingent upon patient clinical status, return patient to pre-morbid vocational &/or recreational activities, modify or find alternative activities,


Outpatient Programs

Goals are to: Develop and help the patient to

establish and implement a safe and effective home exercise program and recreational lifestyle,

Provide patient and family education and therapies to maximize secondary prevention.


Outpatient Programs

In general, patients should engage in multiple activities to promote total conditioning including aerobic and resistance exercises.

Principles of prescription are those for healthy adults but adjusted to take into account the patients clinical status.


Intensity

Use of RPE. Particularly useful when GXT has not been performed or medications change.

Normally 11-13 (fairly light to somewhat hard) for Phase II.

Later (Phase III or IV) may use 12-15 (Approximately 60-80% VO2R


Intensity

RPE can be used with beta-blockers BUT

Should remember that significant and serious ST segment and/or arrhythmias can still occur at low intensities and RPE’s


Intensity

Some patients: need to know when abnormalities occur to enable exercise below anginal or ischemic threshold

Use of HR monitor with alarms Peak exercise HR 10 bpm below

appropriate threshold. Need to allow for medication effects

on exercise tolerance and HR.


Intensity

Signs and symptoms below which an upper limit for exercise should be set: Onset of angina or other symptoms of CV

insufficiency Plateau or decrease in SBP, SBP > 240 or DBP

> 110 mmHg. 1mm ST-segment depression Increasing frequency of ventricular arrhythmias Other significant ECG changes Other signs or symptoms of intolerance to

exercise


Duration

Desire to have 20-60 min of continuous or intermittent activity

Inversely proportional to intensity May be able to accumulate in short

(10-15 min) bouts.


Rate of Progression

Depends upon patient functional capacity and prognosis

Generally, progress over 3-6 months to 1000 kcal/week

Follow principles of initial, conditioning and maintenance phase

Generally progress every 1-3 weeks with goal of achieving 20-30 min of continuous exercise.


Rate of Progression

Patients requiring intermittent program (eg. Peripheral vascular disease, low functional capacity) should progress according to symptoms and clinical status


Guidelines for Progression to Independent Exercise with Minimal or No Supervision

Functional capacity 8 METS or twice occupational level

Appropriate hemodynamic response to exercise

Appropriate ECG response Adequate management of risk factor

intervention strategy and safe exercise participation

Demonstrated knowledge of disease process, abnormal signs and symptoms, medication use and side effects


Exercise Prescription Without a Preliminary Exercise Test

Initial intensities determined according to length of time from acute cardiac event and associated complications, duration since discharge and patient information (ADL’s current home program, associated signs and symptoms)

Use of Duke Activity Status Index


Resistance Training

Previously required abstinence from resistance training for several months post MI.

Now many patients can start by carrying up to 13 kg by 3 weeks post MI.

Generally use approx. 50% 1RM or use of other modes such as bands, hand weights etc. in Phase II.


Resistance Training

Should not begin until 2-3 weeks post MI.

After 4-6 weeks post MI, may start bar bells and/or weight machines

Note: surgical patients need to adjust program to accommodate sternotomy

Normally begin resistance program 2-3 weeks after initiating aerobic program.


Resistance Training

Advocate 1 set of 8-10 different exercises that focus on large muscle groups, 2-3 days/week. Will result in significant improvements

Additional sets/reps do not seem to result in substantial improvements.


Resistance Training

Initially start with 1 set of 10-15 reps to moderate fatigue using 8-10 different exercises

Increase 1-2 kg/week for arms and 3-5 kg/week for legs.

Check rate, pressure product. Shouldn’t exceed that for endurance exercise

RPE: 11-14. Avoid Valsalva

cardiac rehabilitation

Health & Medicine

cardiac mortality

exercise inability

exercise performance

cardiac patientsphysicial

favorable exercise habits

improved exercise tolerance6

low tomoderate risk

stable patients