CAD

1. JAMIA MILLIA ISLAMIA
PHYSIOTHERAPY IN CARDIOPULMONARY CONDITIONS
(BPT402)
CORONARY ARTERY DISEASE
Submitted to- Dr. Jamal Moiz
Submitted by- Saiha Alina
BPT 4th YEAR
Roll no.-17BPT030
CPRS

2. Introduction
• Coronary artery disease is a condition of diverse
etiologies, all having in common a disturbance of
cardiac function due to involvement of coronary
arteries.
• There is imbalance between oxygen supply and
demand.
• Most common form of heart disease and single
most common cause of morbidity and premature
death after the age of 35.
• Disease is more common in males than females.

3. Causes
• Atherosclerosis (focal or patchy disease of arterial
intima) of the coronary arteries with thrombus
formation in one or more of them is main cause of
CAD.
• Subintimal collections of abnormal fat, cells and debris
form the atherosclerotic plaque, which forms at
irregular rate at different segment of coronary arteries,
eventually leading to reduction in cross-sectional area.
• Narrowing of arteries can also occur occasionally due
to congenital anomalies, aortitis, polyarteritis etc.
causing ischemia of heart muscles.

4. Pathophysiology of Atherosclerosis
• ( any injury to the arterial wall)
• Circulating monocytes migrate into intima forming fatty streaks.
• These take up oxidized low density lipoprotein from the plasma and become fat
laden foam cells.
• After death of foam cells, there is liberation of their lipid content forming extra
cellular lipid pools.
• Smooth cells migrate into it and proliferate within the plaque.
• As the process precedes, it becomes a mature plaque, which has core of lipid
surrounded by smooth muscle cells and separated from lumen by a thick cap of
collagen rich fibrous tissue.
• Such plaques are prone to fissuring, hemorrhage and thrombosis

5. Risk factors
• Risk factors of coronary artery disease are as follows:
– Non-Modifiable
• Age
• Gender
• Race
• Family history
– Modifiable
• Type 2 diabetes mellitus
• Hypertension
• Smoking
• Hyperlipidemia
• Chronic kidney disease
• Obesity and metabolic syndrome

6. Clinical consequences of coronary
artery disease
• CAD can present in a variety of ways. The following are the most
frequent clinical consequences of CAD:
– Stable angina
– Unstable angina
– Non ST segment elevation MI
– ST segment elevation MI
– Silent ischemia/asymptomatic ischemia
– Sudden cardiac death
• Most common symptom of coronary artery disease is angina.
Described as chest discomfort, heaviness, tightness, pressure,
aching, numbness, fullness or squeezing. It can also be felt in left
shoulder, arms, neck, back or jaw.
• Other symptoms include: shortness of breath, palpitations (irregular
heart beats), faster heartbeat, dizziness, nausea, weakness, sweating
ACUTE CORONARY
SYNDROME

7. Diagnostic measures
• In evaluating patients with ACS, an emphasis on the Evaluation Triad takes place.
Evaluating the patient’s complaints, ECG changes, and cardiac enzyme levels are
the three major components of the Evaluation Triad.
• 1. Patient Complaints: usually reports of intense pressure or feeling of heaviness in
chest.
• 2. ECG Changes:
– If ischemia is present- ST segment depression, T wave inversion
– Large acute MI with subsequent injury to myocardial tissue- ST segment elevation
– STEMI- pathological Q waves appear.
• 3. Enzyme levels:
– Increase in total CK(creatinine kinase)
– Increase in troponin levels
• Echocardiogram.
• Exercise stress test.
• Cardiac catheterization and angiogram: There is insertion of a catheter into an
artery or vein in groin, neck or arm and heart. X-rays are used to guide the catheter
to the correct position. Sometimes, dye is injected through the catheter.
• Cardiac CT scan

8. Prevention and management
• Treatment for coronary artery disease involves reducing your risk factors, taking medications,
possibly undergoing invasive and/or surgical procedures and seeing your doctor for regular visits.
1. Reduce your risk factors.
– This involves making lifestyle changes.
– If you smoke, you should quit.
– You will need to make changes in your diet to reduce your cholesterol, keep your blood pressure in check, and
keep blood sugar in control if you have diabetes. Low fat, low sodium, low cholesterol foods are
recommended. Limiting alcohol is also important.
– You should increase your exercise/activity level to help achieve and maintain a healthy weight and reduce
stress. But, check with your doctor before starting an exercise program.
– It is also important to control high blood pressure and maintain tight control of diabetes to reduce your risk of
coronary artery disease.
2. Pharmacological Management:
Beta blockers
Calcium channel blockers
Anti platelet agent
3. Surgical management:
– Coronary artery Bypass Graft Surgery
– Percutaneous Transluminal Coronary Angioplasty (PTCA)
– Atherectomy
– Laser Ablation

9. Pre and Post Surgical physiotherapy
• Pre-surgical physiotherapy:
• Pre-surgical physiotherapy interventions aim to assess patient’s functional capacity
and educate on the exercises
• Physiotherapists educate patients on how to get out of bed and chair, demonstrate
and inform them about huffing, coughing techniques, breathing exercises and lower
limb mobilization.
• Common techniques that are currently applied, include deep breathing exercises,
such as incentive spirometry , hyperinflation therapy (intermittent positive pressure
breathing [IPPB], continuous positive airway pressure [CPAP], and
insufflation/exsufflation, and chest physical therapy (CPT).
• Wound management and protection necessary immediately after the operation,
should be taught to the patient.
• Benefits:
– improves the functional capacity of the lungs
– reduces the hospitalization.
– improve inspiratory muscle strength
– reduce post-surgery pulmonary complications.
– Reduce incidence of atelectasis.

10. Inpatient Program
• Phase 1 refers to an inpatient rehabilitation, which is mainly utilized
for assessment of risk factors, the ability to carry out daily activities,
activity counseling and education of the patient and the family
• During the first 48 hours, following MI and/or cardiac surgery,
physical activity should be restricted to self care activities, arm and
leg range of motion exercises and postural change.
• Simple exposure to orthostatic or gravitational stress, such as
intermittent sitting or standing, may help in preventing deterioration
in exercise performance that follows an acute cardiac event.
• The patient gradually starts walking for 50 to 100 feet, three times a
day which can be increased to 250 to 500 feet, 3 to 4 times per day.

11. Outpatient Program
• Phase 2 refers to the first 12 weeks of rehabilitation after a
cardiac event or interventional procedure.
• Phase 3 refers to patients who have completed the initial 12
- 24 weeks but elect to remain in a supervised setting .
• Phase 4 refers to cardiac rehabilitation done at other places
away from an organized rehabilitation centre.
• The outpatient program aims to return the patient to his
vocational activity. The patient is helped in developing an
exercise program that can be safely implemented at home.
Patients should be encouraged to engage in multiple
activities, including flexibility exercises and strength
training in addition to the aerobic exercises, with a view to
promote total physical conditioning.

12. Exercise for Aerobic/Cardio
Respiratory Fitness
• The exercise can be prescribed on the basis of the ‘FITT’ factors:
• Frequency : In the early weeks of phase II cardiac rehabilitation, two exercise
sessions in a week may be effective. This can be increased up to five times weekly.
• Intensity : For most deconditioned cardiac patients, the threshold intensity for
exercise training lies between 40-50% of heart rate reserve (HRR). For higher
levels of training (phase III and IV) intensity is gradually increased to 80% of HRR
under supervision. The rating of perceived exertion (RPE) provides a useful adjunct
to heart rate as an intensity guide for exercise training. In the phase II of cardiac
rehabilitation, exercise rated as 11-13 on the RPE scale is prescribed, which can be
gradually be increased to rating of 15.
• Time : The duration of exercise varies inversely with the degree of desired
improvement in aerobic fitness. The recommended duration is 20 to 60 minutes of
continuous or intermittent activity. The exercise duration can be broken into shorter
periods of activity.
• Type : The primary aerobic exercises are running, jogging, brisk walking,
swimming, cycling etc. The endurance sports like racquetball (singles), tennis,
basketball etc constitute secondary exercises.

13. Exercise for Strength Training
• Strength training improves muscular strength and endurance. The increased muscle
mass leads to an increased basal metabolic rate (BMR), thus strength training
complements aerobic exercise for weight control. It also attenuates the rate-pressure
product when lifting any load, thus strength training appears to decrease cardiac
demands during daily activities. Low and moderate risk patients should be
encouraged to include resistance training into their physical conditioning program.
• During the inpatient phase most of the cardiac patients should begin with range-of-
motion i.e. flexibility or stretching exercises for the upper and lower extremities.
Low-level resistance training using elastic bands (exer-tubes or thera-bands) or very
light (1 to 5 pounds) hand weights can begin in two to three weeks post MI phase.
• Once patients complete the convalescence stage, regular barbell, dumbbell and/or
weight machines may be initiated.
• Once the patient is able to perform more than the prescribed number of repetitions
of an exercise comfortably, the weight should be increased by 5-10%. Light aerobic
exercises and stretching exercises can be performed during the warm-up and cool-
down.

14. • Flexibility exercises must be carried out with up to four repetitions per muscle
group two to three days per week. It includes stretching the muscle beyond its
normal length to the point of tension or slight discomfort, not pain. Hold the stretch
for 30 seconds or longer (10-15 seconds stretch for warm up). The dynamic and
static range-of-motion stretching should be assumed slowly and gradually.
Flexibility exercises are best carried out as part of cooling down process.
• The absolute contraindications for entry into inpatient and outpatient exercise
training are unstable angina, resting systolic blood pressure >200 mm Hg, resting
diastolic pressure >100 mm Hg, significant drop (≥ 20 mm Hg) in resting systolic
blood pressure from average level, moderate to severe aortic stenosis, acute
systemic illness or fever, uncontrolled tachycardia (>100 bpm), symptomatic
congestive heart failure, third degree heart block without pacemaker, active
pericarditis or myocarditis, recent embolism, thrombophlebitis, resting ST segment
displacement (>3mm), uncontrolled diabetes and orthopedic problems that would
prohibit exercise

15. Summary
• Coronary artery disease is the disease caused by narrowing of coronary arteries
which supply oxygen, blood and nutrients to heart muscle.
• This narrowing can be in the form of development of atherosclerotic plaque in the
intima of blood vessels.
• There are various risk factors identified which are associated and are classified into
modifiable and non-modifiable risk factors.
• There are various presentations of CAD; stable angina, unstable angina,
NSTEMI,STEMI, sudden cardiac death, silent ischemia etc. Shortness of breath and
chest discomfort is the hallmark of disease.
• Various diagnostic procedures can be implemented in the detection of CAD. These
are ECG, electrocardiogram, catheterization, exercise stress test, blood test, CT
scan etc.
• Lifestyle modification is the best way to prevent and reduce risk factors of CAD.
Medical and surgical treatment are also available.
• PT management and cardiac rehabilitation is implemented in both pre and post
surgical phases. There are four phases of cardiac rehabilitation which involves
range of techniques to monitor patient’s overall activity and improve cardiac
function. PT management is also beneficial in preventive phase of disease.

16. References
• National Institutes of Health Consensus
Development Panel on Physical Activity and
Cardiovascular Health Physical activity and
cardiovascular health. JAMA. 1996;276:241–
246. [PubMed] [Google Scholar]
• Thompson PD. Exercise Rehabilitation for
Cardiac patients: A Beneficial but underused
therapy. The Physician and Sports
Medicine. 2001;29:69–75. [PubMed] [Google
Scholar]