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1. Cardiac rehabilitation
following coronary artery
bypass graft surgery
By- Aditi shah
MPT Neurology
SVNIRTAR, cuttack, Odisha

2. OUTLINES-
Indications for CABG
Contraindications to CABG
What surgical procedure takes place in
CABG
Exercise testing- principles?
indications
contraindication
procedure
interpretation
Exercise prescription writing
Cardiac rehabilitation

4. Indications for CABG
 Over 50% left main coronary artery stenosis
 Over 70% stenosis of the proximal left anterior
descending (LAD) and proximal circumflex arteries
 Three-vessel disease in asymptomatic patients or those
with mild or stable angina
 Three-vessel disease with proximal LAD stenosis in
patients with poor left ventricular (LV) function
 One- or two-Vessel disease and a large area of viable
myocardium in high-risk area in patients with stable
angina
 Over 70% proximal LAD stenosis with either an ejection
fraction (EF) below 50% or demonstrable ischemia on
noninvasive testing

5. Contd..
Other indications for CABG include the following:
 Disabling angina (class I)
 Ongoing ischemia in the of a non–ST segment elevation
myocardial infarction (MI) that is unresponsive to medical
therapy (class I)
 Poor LV function but with viable, nonfunctioning
myocardium above the anatomic defect that can be
revascularized
 CABG may be performed as an emergency procedure in
the context of an ST-segment elevation MI (STEMI) in
cases where it has not been possible to perform
percutaneous coronary intervention (PCI) or where PCI
has failed and there is persistent pain and ischemia
threatening a significant area of myocardium despite
medical therapy.

6. Contraindications to CABG
 CABG is not considered appropriate in
asymptomatic patients who are at a low
risk of MI or death. Patients who will
experience little benefit from coronary
revascularization are also excluded.
 Although advanced age is not a
contraindication, CABG should be
carefully considered in the elderly,
especially those older than 85 years. These
patients are also more likely to experience
peri-operative complications after CABG.

7. CABG procedure

8. Exercise physiology and testing:
principles
Two basic principles of exercise
physiology are:
 Myocardial oxygen consumption(MVO2) = heart rate
x systolic blood pressure
 Ventilatory oxygen consumption(VO2) = cardiac
output x Arteriovenous oxygen difference

9. Myocardial oxygen
consumption(MVO2):
 At rest, the myocardium extracts 70% to 80% of the oxygen from the
blood flowing in the coronary vessels.(other muscles could make upto
25%)
 In general, there is a linear relationship between CBF and MVO2. In
vigorous exercise, coronary blood flow increases four to six times
above the resting level.
 Rate-Pressure Product: An Estimate of Myocardial Work
 Exercise studies of people with coronary heart disease have linked the
RPP to the onset of angina or electrocardiographic (ECG)
abnormalities.
 In nine patients who were followed over 7 years of exercise training,
RPP increased 11.5% before ischemic abnormalities appeared.(indirect
evidence for a training-induced improvement in myocardial
oxygenation)

10. Ventilatory oxygen
consumption(VO2) :
VO2 = C.O. x a-v O2 difference
Stroke vol. heart rate arterial o2 mixed
(preload, content venous O2
Contractility,
Afterload)

11. Cardiovascular response to
aerobic exercise

12. Exercise heart rate
•There is a direct ,almost
linear relationship between
HR and external workload.
•Heart rate for the
untrained person accelerates
relatively rapidly with
increasing exercise demands;
a much smaller heart rate
increase occurs for the
trained person.
• The trained person achieves
a higher level of exercise
oxygen uptake at a particular
submaximal heart rate than a
sedentary person.

13. Blood pressure: CO * Total peripheral
resistance
At rest:
systolic BP 120 mm Hg
Diastolic BP: 80 mm Hg
During exercise:
1.Rhytmic exercise: The alternate
rhythmic contraction and relaxation
of skeletal muscles forces blood
through the vessels and returns it to
the heart. Increased blood flow
during moderate exercise increases
systolic pressure in the first few
minutes; it then levels off, usually
between 140 and 160 mm Hg.
Diastolic pressure remains relatively
unchanged.

14. 2.Resisted exercise:
Straining-type exercise (e.g., heavy
resistance exercise, shoveling wet
snow) increases blood pressure
dramatically because sustained
muscular force compresses
peripheral arterioles, considerably
increasing the resistance to blood
flow.
In Recovery
After a bout of sustained light- to
moderate-intensity exercise,
systolic blood pressure temporarily
decreases below pre-exercise
levels for up to 12 hours in normal
and hypertensive subjects.
(By Pooling of blood in the visceral
organs and lower limbs)

15. Exercise stroke volume
Stroke volume increases
progressively with exercise
to about 50% VO2max and
then gradually levels off
until termination of exercise.
Stroke volume and VO2max:
Since heart rate increases
linearly in almost all
conditions. Stroke vol.
(in cardiac output) is the
determining factor for
VO2max.

16. Cardiac output : heart rate x
stroke volume
Blood flow from the heart increases
in direct proportion to exercise
intensity for both trained and
untrained individuals.
From rest to steady-rate exercise,
cardiac output increases rapidly,
followed by a more gradual
increase until it plateaus as blood
flow matches exercise metabolic
requirements.
At rest
During exercise

17. CARDIAC OUTPUT AND
OXYGEN TRANSPORT
At Rest
 Each 100 mL of arterial blood normally carries about 20 mL of
oxygen( 200 mL of oxygen per liter of blood)
 1000 mL of oxygen becomes available during 1 minute (5 L
blood 200 mL O2).
 Resting oxygen uptake averages only about 250 mL/min; this
means 750 mL of oxygen returns “unused” to the heart(which
serves as reserve for when neded).
During exercise
 3200 mL of oxygen circulate each minute via a 16-L (200* 0.08)
cardiac output (16 L 200 mL O2). If the body extracted all of
the oxygen delivered in a 16-L cardiac output, VO2max would
be equal 3200 mL. This represents the theoretical upper limit
for this person because the oxygen needs of tissues such as the
brain do not increase greatly with exercise, yet they require an
uninterrupted blood supply.

18. The a–v–O2 Difference During
Rest and Exercise
Arterial blood oxygen content varies
little from its value of 20 mLdL1 at rest
throughout the full exercise intensity
range. In contrast, mixed-venous
oxygen content varies between 12 and
15 mLdL1 at rest to a low of 2 to 4
mLdL1 during maximum exercise. The
difference between arterial and
mixed-venous blood oxygen content
(a–vO2 difference) at any time
represents oxygen extraction from
blood as it circulates through the
body’s tissues. At rest, for example,
a–vO2 difference equals 5 mL of
oxygen, or only

19. CARDIOVASCULAR ADJUSTMENTS
TO UPPER-BODY EXERCISE
Arm (upperbody) exercise requires a greater oxygen uptake compared with leg
(lower-body) exercise at any power output throughout the comparison range.
The largest differences occur during intense exercise.

22. Need for exercise testing:
 To determine the functional aerobic capacity of the
individual, commonly expressed as metabolic
equivalents(METs; 1 MET = 3.5 mL O2/kg/min);
 To assess the efficacy of interventions such as
coronary artery bypass graft (CABG) surgery,
percutaneous transluminal coronary angioplasty
(PTCA), medications, or physical conditioning;
 To clarify the safety of vigorous physical exertion;
 To formulate an effective exercise prescription;
 To ascertain work-related capabilities;
 To aid in clarifying prognosis via risk stratification.

23. Equipment used:
1.Cycle ergometer
2.Treadmill
The equipment used is connected to 12-
lead ECG throughout the test and
recovery

24. Treadmill vs cycle ergometer:

25. Ramping test: ramp protocols are characterized
by a gradual increase of work rate, evenly distributed within each
minute of the exercise phase
 The choice of ramp protocol steepness should be
tailored to the subject’s exercise tolerance, aiming at a
test duration ranging between 8 and 12 minutes.
 The advantage of ramp protocols:
1. the work rate increase is devoid of brisk step
increases typical of step protocols (e.g., 25 W every 3
minutes);
2.the trend of parameters changes over time is not
affected by protocol steps, making physiological
responses linear and more readable for the operators.

26.  Ramp incremental (left panel)
and 2-minute incremental
(right panel) protocols for cycle
ergometry. Red dashed
lines represent protocols
reaching an equal work rate of
150 W after 10 minutes of
exercise; blue solid
lines represent protocols
reaching an equal work rate of
100 W after 10 minutes of
exercise. The work rate
increment is added at the start
of each 2-minute stage for the
conventional incremental test,
whereas the increment is equal
to 1 W every 6 seconds and 1.5
W every 6 seconds for the 10
W/min and 15 W/min ramp
protocols, respectively,
beginning from Time 0 of the
exercise period.

27. Indications for termination of
exercise testing:
 Acute MI or suspection of MI
 Onset of moderate to severe angina
 Drop in SBP with increasing workload
 Serious arrythmia
 Signs of poor perfusion( pallor, cyanosis, cold, clammy
skin)
 Shortness of breath
 CNS symptoms(ataxia, vertigo, gait problems)
 On ECG – ST segment > 2mm below horizontal
 Leg cramps
 HTN( SBP > 260 ,DBP > 115 )
 Technical issues
 Patient request

28. Interpretation of exercise
testing:
 Positive ETT: Indicates that there is a point at
which the myocardial supply is inadequate to
meet the myocardial oxygen demands;test is
therefore positive for ischaemia.
 Negative ETT: indicates that at every tested
physiological workload there is a balanced
oxygen supply and demand.
 False-negative ETT: Interpreted as negative
but the patient has ischemia.
 False-positive ETT: interpreted as positive
but the patient doesn’t have ischemia.

31. Exercise prescription
 GOALS:
 To limit physiological and pyschological
effects of cardiac illness
 To reduce risk of sudden death
 Control cardiac symptoms
 Stabilize or reverse atherosclerotic disease
 Enhance patient`s pyscho-social and
vocational status

32. Components of exercise
prescription
Warm-up
Conditioning phase
Cool-down

33. Warm-up phase
 Prepares the body for more intense activity by
stretching the large muscle groups and
gradually increasing blood flow.
 warm-up has preventive value and enhances
performance capacity.
 should include musculoskeletal and
cardiorespiratory activities, sufficient to evoke
a heart rate response within 20 beats/min of
the prescribed heart rate for endurance
training. This can be achieved by performing
the same activity that will be used during the
conditioning phase, but at a reduced intensity
(e.g., brisk walking before slow jogging).

34. Cool-down phase:
 permits appropriate circulatory readjustments after
vigorous activity;
 enhances venous return, thereby reducing the
potential for postexercise lightheadedness;
 facilitates the dissipation of body heat;
 promotes more rapid removal of lactic acid than
stationary recovery
 combats the potential deleterious effects of the
post-exercise rise in plasma catecholamines .

35. Conditioning phase : This phase should
be prescribed in specific terms of intensity, frequency,
duration, and mode of exercise training
1.Intensity
 The prescribed exercise intensity should be above a
threshold level required to induce a "training effect,"
yet below the metabolic load that evokes abnormal
signs or symptoms.
 3 techinques used to prescribe and monitor exercise
intensity: HR, MET OR VO2max , RPE

36. a. Metabolic equivalents or VO2 max.
60-70% VO2max is taken as the baseline.
b. Heart Rate
Prescribed heart rate can be obtained by three
methods:
(1) the heart rate versus VO2max regression method ,
where THR = heart rate that occurred at a given
oxygen uptake during exercise testing;
(2) the maximal heart rate reserve method of Karvonen
and associates, in which
THR = (maximal heart rate - resting heart rate) X 50 to
80% + resting heart rate; and
(3) the percentage of maximal heart rate method (70-85
% 0f HRmax)

37.  c. Rating of Perceived Exertion
 Upper limit of prescribed training heart rates during
the early stages of outpatient cardiac rehabilitation
(e.g., phase II)-Exercise rated as 11 to 13 (6-20 scale) or
3 to 4 (0-10 scale), between "fairly light" and
"somewhat hard" (6-20 scale), or between "moderate"
to "somewhat strong"(0-10 scale),.
 Later, for higher levels of training, ratings of 12 to 14
(6-20 scale) or 4 to 5 (0- 10 scale) may be appropriate,
corresponding to 70% to 85% of the HRmax, which is
equivalent to —60 to 80% VO2max.
 TALK TEST: patient to be able to talk without
becoming breathless while exercising. This provides
fair indication that the patient is appropriately
exercising below his or her anaerobic threshold.

38. Rating of perceived exertion
Modified Borg Dyspnoea
Scale
 0 Nothing at all
 0.5 Very, very slight (just
noticeable)
 1 Very slight
 2 Slight
 3 Moderate
 4 Somewhat severe
 5 Severe
 6
 7 Very severe
 8
 9 Very, very severe (almost
maximal)
 10 Maximal
Category scale
 6 – No exertion at all
 7 – Extremely light
 8
 9 – Very light
 10
 11 – Light
 12
 13 – Somewhat hard
 14
 15 – Hard
 16
 17 – Very hard
 18
 19 – Extremely hard
 20 – Maximal exertion

39. 2.Frequency
 Improvement in VO2max with low-to-moderate training
intensities suggests that the interrelation among the
training intensity, frequency, and duration may permit a
decrease in the intensity to be partially or totally
compensated for by increases in the exercise duration or
frequency, or both.
 Depends on individual functional capacities- for patients
with functional capacities < 3 METs; short session of 5
mins performed several times a day can be prescribed.
 For patient`s with functional capacities > 5 METs – 3-5
times/ week maybe prescribed.

40. 3.Duration:
 Warm-up – 10-15 mins
 Conditioning – 20- 60 mins (either
continuous or intermittent, both has equal
effects)
 Cool-down – 5-15 mins
4. Mode of aerobic exercise:
For cardiac patients mostly low grade/non-wt
bearing modality is used.

41. Cardiac
Rehabilitation

42. The major goals of a cardiac rehabilitation
program are:
 Curtail the patho-physiologic and
psychosocial effects of heart disease
 Limit the risk for re-infarction or sudden
death
 Relieve cardiac symptoms
 Retard or reverse atherosclerosis by instituting
programs for exercise training, education,
counseling, and risk factor alteration
 Reintegrate heart disease patients into
successful functional status in their families
and in society

43. Phases of cardiac
rehabilitation:
 Phase I Inpatient
 Phase II immediate outpatient
 Phase III intermediate outpatient
 Phase IV maintainence

44. Phase I Inpatient prescription
 PRE-OP DAY : Main goals will be
 Patient education and explaining our role to them.
 Teaching the importance of deep breathing ,use of incentive
spirometry, early ambulation.
 POD zero: Main goal will be directed towards preventing the
pulmonary complications of surgery.
 patient will be supine and ventilated or atleast still intubated,
untill they have stabilised and warmed-up.
 Patient canbe made to sit up in bed and deep breathing has to
be encouraged.
 If airway and blood gas levels are maintained- extubation can
be considered.

45.  POD 1 : Main goals will be
 assessing the cardio-respiratory status (post-
operative atelectasis and sputum retention)
 Teaching positioning to the patient.
Interventions :
Deep breathing and use of spirometer every
hourly.(humidification and nebulization if
required)
Forward sitting with elbow supported on bent
knees or table infront.(fixing shoulder enables
expansion of lower lobes and minimise sternal
wound pain)
Expectoration with sternal support

46.  POD2 : main goals will be to Mobilise the
patient
Interventions :
Patient can be made to sit in a bedside chair
several times in a day.
If drain is insitu – attached to the wall
suction; patient can be stoodup and
encouraged to mobilize on spot or with in
the confine of suction tubing.
If not, and oxygen saturation being
maintained, can be mobilised upto 30 m for
the first walk and progressed upto 60 m in
the late afternoon.

47.  POD 3 : goal is to increase mobilisation
Interventions:
Drips and drains are removed
If patient’s chest is clinically clear, he or
she can mobilise independently.
If patient is hypoxemic- mobilise with
oxygen cylinder.(use of pulse oximeter in
such cases is recommended)
A flight of stairs can be climbed at this
stage.(keeping a check on any symptoms
like dizziness)

48.  POD4 - discharge: goal is to prepare
the patient for coping up at home.
Intervention:
equilateral arm ROM exercises can be
done as tolerated by the patient.
Active lowerlimb range of motion
exercises canbe done.
NOTE: Opposing arm movements put
strain on the sternum so has to be
avoided.( unilateral activity canbe
considered appropriate at approx.8
weeks after discharge.

49. Phase II- immediate outpatient
 It involves closely supervised and carefully
monitored exercise program with a
structured education series.
 Begins with 5-12 weeks after surgery( six
weeks being the most common)
 Continues for 6-8 weeks
 Low level exercise testing(2/3- 6/7 METs)-
to decide whether the patient is a
candidate for physical therapy(phase II)
and if so , What intensity of ex. Appears to
be indicated.

50. Purpose of phase II programs:
 Increase exercise capacity and endurance in a
safe and progressive manner.
 Ensure the continuity of the exercise program
with a transition to the home environment.
 Assess the cardiovascular responses of mild to
moderate external workloads and give
feedback to the referring physician
 Teach the patient to apply techniques of self-
monitoring to home activities.
 Relieve anxiety and depression.
 Increase the patient’s knowledge of the
atherosclerotic disease process and how
personal health habits affect it.

51. Low level treadmill protocol
Stage Speed(mph) %grade Duration(mi
n)
Estimated
MET
I 1.7 0 3 2.3
II 1.7 5 3 3.5
III 1.7 10 3 4.6
IV 2.5 12 3 6.8

52. Contra-indications to low level
exercise testing:
 Patient less than 5 days after acute MI OR
CABG surgery
 Incomplete pretest database
 Acute congestive heart failure
 Recent episodes of chest pain suggestive
of unstable angina
 Hypotension (80/50 mm Hg)
 Hypertension(170/100 mmHg) at rest
 Uncontrolled dysarrythmias before
exercise.

53. End points for low level treadmill
test:
 Achievement of heart rate equivalent to
75-80% of age predicted max.heart rate.
 Hypoadaptive systolic blood pressure
response
 Onset of symptoms consistent with
mild angina pectoris
 >2 mm of ST segment depression
 fatigue/ leg cramps
 Patient’s request

54.  Intensity : mostly patients are able to tolerate
80-95% of HRmax on Low level testing(HR
increased by 10 beats every week)
 Duration : 10-15 mins of continuous low-
intensity training tolerated initially.
later on progressed to 30-45 mins. of
continuous lower extremity exercise and 10-15
mins of upper-extremity exercise.
5 mins of warm-up and cooldown.
• Frequency :5-6 sessions/week
• Type : combination of upper and lower
extremity training.(to reduce the myocardial
oxygen demand in both UE and LE)

55. Contd…
 Maximal ex testing: common to
perform as early as 6-8 weeks after the
CABG Surgery.(at completion of early
outpatient phase.

56. Phase III- outpatient cardiac
rehabilitation
 During this phase, the patient
continues on an individually designed
exercise program based on periodic
formal reevaluations.(symptom limited
ex tests conducted at 6 months)
 At the end of this phase a maintainence
level is achieved (no further changes in
exercise intensity or duration are
required)

57. Purpose of phase III
 To improve the physical fitness and
endurance level in coronary patients
 To produce long-term reductions in
coronary risk factors.
 To enhance patient’s quality of life.
 Emphasizing distance goals and not of
speed is primarily important.

58. TRAINING PROGRAM
 Patient is interviewed and goals are established
 We required our patient to have a lipoprotein
profile –including total serum cholesterol
,total serum triglycerides ,HDL Cholesterol
,LDL and VLDL cholesterol before beginning
the exercise .
 Through maximum exercise testing
establishing a training intensity high enough
to produce peripheral and central
improvements(peripheral effects attained at
atleast 60% of total chronotropic reserve and
central at 90%).

59.  Intensity and duration of exercise are
interrelated, with the total volume of training
accomplished being an important factor . As
long as the participant is above the minimal
intensity threshold, the total volume of
training (kcal) is the key to the development
and maintenance of fitness/health . This total
kcal concept appears acceptable, whether the
exercise program is continuous or intermittent
 Frequency and duration of training are usually
greater for cardiac patients since most training
is conducted at the lower end of the intensity
target range (i.e., 50 to 70% of HRRIMX).

60. REEVALUATION IN PHASE III
 Periodic assessment is required for those who
participate longer than 6 months.
 Lipid profile is routinely repeated after 3 months
and 6-12 months thereafter.
 If lipid values are worse than at admission changes
appeared to be the result of an improper diet .-
counselling with the team dietitian.
 To monitor disease stability 1)periodic ECG
monitoring during exercise.2)recording of hospital
and home exercise in a monthly diary.
 Blood pressure changes during each session
 Maximal symptom-limited exercise test every 6
months-1 year.

61. PHASE IV :MAINTENANCE
 Goal: facilitate long term maintenance of
lifestyle changes, monitoring risk factor
changes and secondary prevention.
 Includes
• Educational sessions
• Support groups
• Telephone follow up
• Review in clinics
• Outreach programmes

63. References
 Cardiopulmonary physical therapy by Scot
Irwin,DPT,CCS,and Jan Stephen Tecklin,MS (2nd
edition)
 Essentials of exercise physiology, Victor
L.Katch,William D. McArdie,Frank I. Katch(4th
edition)
 Cash’s textbook of chest,heart and vascular
disorders for physiotherapist(4th edition)
 Physical rehabilitation ; Susan B O’ sullivan (6th
edition)
 CARDIAC REHABILITATION,A guide to practice
in the 21st century -Nanette K wenger et al
 ACSM’s guidelines for exercise testing and
prescription( 10th edition)