Glimpse of Cardiac rehabilitation for health care professionals to update themselves, with aim of helping people with or without disease. Focus on primary, secondary, tertiary prevention.
1. Dr. Vinod K. Ravaliya
Cardiothoracic Physiotherapy
Shree Krishna Hospital
KMPIP, Karamsad
2.
3. Introduction
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.
4. "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
5. Cardiac rehabilitation has been defined as
The 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 as
The combined and coordinated use of
medical, psychosocial, educational, vocational
and physical measures to facilitate return to an
active and satisfying lifestyle.
6. 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
7. Post-MI
Post-CABG
Angina
PCI
Valve replacement or repair
Heart transplant
Indications for CHF continue to be evaluated
8. Benefits of exercise
Recent studies
Components of exercise class
Health and Safety recommendations
9. 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
HM734 Exercise Testing and Prescription: Cardiorespiratory 9
10. 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
11. 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
12. 1. Smoking cessation
2. Lipid management
3. Weight control
4. Blood pressure control
5. Improved exercise tolerance
6. Symptom control
7. Return to work
8. Psychological well-being/stress management
13. Physical activity:
improves glucose metabolism
reduces body fat
lowers blood pressure
improves musculoskeletal strength
controls body weight
reduces symptoms of depression
14. 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
15. 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
testing.
16. 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
17. 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;
18.
19. 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
20. 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.
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.
21.
22. Functional goals
– Exercise training under supervision/ at
home
Psychosocial goals
– Anxiety/depression management
Secondary preventive targets
23. 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.
24.
25. Functional goals
– Exercise training under supervision
Psychosocial goals
– Return to work
– Return to hobbies and lifestyle
– Anxiety/depression management
Secondary preventive targets
26. 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.
27.
28. Functional goals
– Exercise training
Psychosocial goals
– Return to work
– Return to hobbies and lifestyle
– Anxiety/depression management
Secondary preventive targets
29. 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.
30. 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
31.
32. 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.
32
33. 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
33
34. 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).
34
35. 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,
35
36. 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.
36
37. 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.
37
38. 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
38
39. 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
39
40. 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.
40
41. 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
41
42. 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.
42
43. 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.
43
44. Patients requiring intermittent program (eg.
Peripheral vascular disease, low functional
capacity) should progress according to
symptoms and clinical status
44
45. 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
45
46. 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
46
47. 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.
47
48. 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.
48
49. 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.
49
50. 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
50
51. Hypertension
-<140/90, 130/85 in high risk groups
Diabetes
– HbA1C <7
Obesity
– Set weight goals
– 5 lbs in the 3 months of phase 2