Sharing a brief and physiotherapy interventions in patient with myocardial infarction

1. Exercise prescription for patients
with myocardial infarction
By – Dhwani Suthar

2. Contents
• Introduction
• Diagnostic test
• Risk Stratification
• Contraindications
• Phases
• Exercise prescription
• Home Exercise program
• Article

3. INTRODUCTION
• Cardiovascular Disease (CVD) encompasses
all disorders of the heart and blood vessels and
is the leading cause of global mortality
accounting for over 17 million deaths each
year.
• Advances in diagnosis, revascularisation,
pharmacotherapy and treatment of acute illness
have contributed to these reductions in
mortality.

4. • This places a growing and unsustainable burden on
healthcare resources and consequently the demand for
effective secondary prevention is intensifying.
• Cardiac rehabilitation is considered an integral part of
the regular medical management of patients with
coronary heart diseases and is widely recommended
in international guidelines.

5. • Without systematic access to cardiac rehabilitation,
these individuals may experience multiple recurrent
acute care events and suffer unnecessarily premature
death.
• Survivors are at very high risk of a recurrence, with
one-quarter likely to be readmitted to hospital within
1 year.

6. • In 1993 the World Health Organization (WHO)
defined cardiac rehabilitation as –
‘The coordinated sum of activities required to influence
favourably the underlying cause of cardiovascular disease, as
well as to provide the best possible physical, mental and social
conditions, so that the patients may, by their own efforts,
preserve or resume optimal functioning in their community
and through improved health behaviour, slow or reverse
progression of disease.’

7. Ischaemic heart disease
• Ischaemic heart disease (IHD) is
used synonymously with the term
'coronary heart disease‘ and refers
to impairment of the cardiac muscle
due to imbalance between coronary
blood flow and myocardial needs
caused by changes in the coronary
circulation.

8. • Atherosclerosisis a chronic and
progressive inflammatory disease of
the arterial endothelial.
• The characteristic lesion seen in
coronary atherosclerosis is the
formation of atheromatous or
atherosclerotic ‘plaques’ resulting
from a combination of intimal
thickening and accumulation of
lipid.

9. • Modifable Factors
o Smoking
o Hypertension
o Diabetes metlitus
o Dyslipidaemia
o Diet
o Physical inactivity
o Obesity
o Social isolation- depression
•Non-modifiable
factors
oAdvanced age
oMale gender
oFamily history of
ischaemic heart disease
opoor socioeconomic
status
Risk factors

11. Symptoms and Signs of Ischaemic
Heart Disease
• The primary clinical manifestations of are stable angina,
unstable angina pectoris and acute myocardial infarction .
• Stable angina occurs when coronary perfusion fails to meet
increased metabolic demand, which may occur during exercise
or tachycardia.

12. • Stable angina is ‘associated with a disturbance in myocardial
function, without myocardial necrosis’, and typically presents
as retrosternal pain (angina pectoris).
• Unstable angina pectoris and Acute myocardial infarction,
collectively referred to as ‘acute coronary syndromes’, can be
life-threatening and occur when physical disruption of an
atherosclerotic plaque triggers thrombosis.

13. • The formation of thrombus within the artery leads to
subtotal or total occlusion.
• Unstable angina pectoris typically presents as
frequent and prolonged episodes of retrosternal pain
or discomfort, often at rest or with minimal exertion;
myocardial necrosis is absent.

14. • Acute myocardial infarction may also occur without
symptoms, but typically presents as prolonged ‘chest,
upper extremity, jaw or epigastric discomfort with
exertion or rest’ and dyspnoea, diaphoresis, nausea
and syncope.

15. Diagnosis
• Electrocardiogram (ECG)
• Blood test - CPK & Troponin
• In the absence of an acute coronary syndrome, a
progressive exercise or ‘stress’ test with ECG monitoring.
• Coronary angiography is used in both stable acute
myocardial infarction and acute coronary syndromes to
assess coronary artery anatomy.

16. RISK STRATIFICATION
• The patients are risk stratified into low-,
medium- and high-risk groups depending on
their current cardiac status.
• This includes the extent of myocardial
damage, previous history of MI, complications
and associated signs and symptoms.

17. • The risk classification given below is based on the
guidelines from the American Association of
CardioVascular and Pulmonary Rehabilitation .
Low
risk
Medium
risk
High
Risk
Risk
Stratification

18. High Risk
• Decreased left ventricular function (ejection fraction <40%) .
• Complex arrhythmias at rest or appearing or increasing during
exercise testing and recovery
• Presence of angina or other significant. Symptoms, such as
unusual shortness of breath or dizziness at low levels of
exertion <5MET or recovery high level of silent ischaemia
(ST segment depression ≥ 2 mm from baseline) during
exercise testing or recovery.

19. High Risk
• Abnormal haemodynamics with exercise (especially
decrease in SBP during exercise or recovery – severe
post-exercise hypotension)
• MI or revascularisation procedure complicated by
congestive heart failure, cardiogenic shock and
complex arrhythmias.
• Survivor of cardiac arrest or sudden death.

20. Moderate risk
• Moderately impaired left ventricular function (ejection fraction
40–49%).
• Presence of angina or other significant symptoms such as
unusual shortness of breath or dizziness occurring only at high
levels of exertion (≥7 mets).
• Mild-to-moderate level of silent ischaemia (ST segment
depression ≤2 mm from baseline) during exercise testing or
recovery.
• Functional capacity <5 MET.

21. Low risk
• No left ventricular dysfunction (ejection fraction >50%)
• No resting or exercise-induced complex arrhythmias
• Absence of angina or other significant symptoms, such as unusual
shortness of breath or dizziness during exercise testing and recovery
• Uncomplicated MI, CABG, PTCA
• Normal haemodynamics with exercise testing and recovery
• Functional capacity ≥7 METS
• Absence of clinical depression

22. Contra-indications to exercise
• Unstable angina
• Severe uncontrolled hypertension (resting hypertension over 200/100)
• Orthostatic BP drop of more than 20mmhg with symptoms
• Uncontrolled arrhythmias
• Severe aortic stenosis
• Uncontrolled diabetes
• Complicated acute myocardial infarction
• Untreated heart failure

23. Contra-indications to exercise
• Shortness of breath on low exertion Resting heart rate over
100 beats per minute
• Hypertrophic cardiomyopathy
• Third degree heart block
• Acute febrile illness
• Viral infections

24. Phases of rehabilitation.
CARDIAC
REHABILITATION
Phase II:
Immediate post-
discharge period
Phase IV: Long-
term follow-up/
maintenance in
primary care
Phase I: Inpatient
period
Phase III: Supervised
outpatient
programme,
including structured
exercise

25. PHASE I
• The aim is to avoid inactivity, maintain and improve
pulmonary function and endurance and maintain global muscle
strength.

26. American Association Of Cardiovascular And Pulmonary
Rehabilitation (AACVPR) Parameter For Inpatient Cardiac
Rehabilitation Daily Ambulation:
• No new or recurrent chest pain in previous 8 hours.
• Stable or falling creatine kinase and troponin values.
• No indication of decompensated heart failure.
• Normal cardiac rhythm and stables electrocardiogram for
previous 8 hours.

27. Intensity RPE below 13 on Borg Breathing Scale (scale 6-20)
Post AMI: HR below 120 bpm or resting HR + 20 bpm
Up to tolerance if non-symptomatic
Duration Intermittent sessions lasting from 3 to 5 min
Resting periods: As the patient wishes - lasting from 1 to 2 min
Resting period should be shorter than the time of the exercise
sessions
Total duration of 20 min
Frequency Early mobilization: 3 to 4 times per day (1st to 3rd days)
Subsequent mobilization: twice per day (As from the 4th day)
Type Mobility, Breathing , walking , stair climbing.
Progression Initially increase the duration by up to 10 to 15 min of exercise
time and then increase the intensity
Presentation of the ACSM recommendations for the
prescription of exercises in phase I of cardiac rehabilitation

28. STEPS CARDIAC
REHABILITATION/
PHYSICAL THERAPY
WARD
ACTIVITY
PATIENT
EDUCATION
STEP
1:
1-1.5
METs
Deep breathing ex, Sitting
with feet supported, AAROM
to AROM exercise of major
muscles, active scapular
elevation/ depression,
protraction/ retraction 3-5
repetitions
Begin sitting in
chair (when
stable) several
times a day for
10-30 mins. May
ambulate 100-
200 feet with
assistance, 1-2
times daily.
Orient to Cardiac ICU,
reinforce purpose of
physical therapy and deep
breathing exercise. Orient
to exercise component of
rehabilitation program.
Answer patient and family
questions regarding
progress.
STEP
2:
1.5
METs
Sitting: repeat exercise from
step 1 and increase repetitions
to 5-10, deep breathing twice
daily, monitored ambulation
of 200ft with assistance as
tolerated (stress on correct
posture) twice daily.
Continue
activities
from step 1
As step 1

29. STEP
S
CARDIAC
REHABILITATION/
PHYSICAL THERAPY
WARD
ACTIVITY
PATIENT
EDUCATION
STEP
3:
1.5-2
METs
Standing: begin active UL and
trunk exercise without resistance
(shoulder flexion, abduction,
internal/ external rotation,
circumduction backward, elbow
flexion, trunk flexion, lateral
flexion and rotation, knee
extension (if appropriate), ankle
exercise; 5-10 repetitions and
twice daily.
Increase ambulation
to 300ft at slow
pace with assistance
twice daily
Begin pulse- taking
instruction when
appropriate and
explain RPE scale,
answer all questions
STEP
4: 1.5-2
METs
Standing- active exercise as step
3; 10 15 reps, twice daily.
Monitored ambulation.
Increase ambulation
to 1 lap at slow pace
with assistance twice
daily
Same as above

30. STEPS CARDIAC REHABILITATION/
PHYSICAL THERAPY
WARD ACTIVITY PATIENT
EDUCATION
STEP 5:
1.2 - 2.5
METs
Active exercise from step 3, 15
repetitions, once daily. Monitored
ambulation for 5-10 mins as
tolerated. Monitored ROM/
strengthening exercise from step 3,
15 reps, leg stretching (hamstring
and gastrocnemius); treadmill or
bicycle 5-10 min
Increase ambulation
up to 3 laps daily as
tolerated. Begin
participating in daily
ADL and personal
care as tolerated,
encourage chair sitting
with legs crossed.
Continue instruction in
pulse taking and use of
RPE scale. Explain
value of exercise.
STEP 6:
1.5-2.5
METs
Standing- active exercise from step
3 with 1-lb weight each UL, 15
repetitions, once daily, leg
stretching, treadmill/bicycle 15-20
mins and stair climbing (6-12 stairs)
with assistance.
Increase ambulation
up to 5 laps daily.
Encourage
independence in ADL,
encourage chair sitting
with legs elevated.
Discuss about
discharge instructions
to patient and family

31. STEP
S
CARDIAC
REHABILITATION/
PHYSICAL THERAPY
WARD
ACTIVITY
PATIENT
EDUCATION
STEP 7:
2-3
METs
Standing: Active exercise from
step 3 with 0.5kg weight each
UL, 15 reps, once daily, leg
stretching, treadmill/bicycle 20-
30 mins and stair climbing (up to
14 stairs) with assistance
Continue activities
from step 6.
increase
ambulation up to 8
laps daily.
Discuss and initiate
referral to phase 2
program if
appropriate. Give
instructions for home
exercise program.
Explain pre discharge
graded exercise test
and upper limit HR.
STEP 8:
2-3
METs
Standing- Exercise from step 3
with 1 kg weight each UL, 15
reps, once daily. Leg stretching,
10 reps, treadmill/bicycle 20-30
mins and stair climbing (up to 16
steps)
Continue activities
from step 7,
increase
ambulation up to 9
laps daily
Reinforce prior
teaching

32. STEPS CARDIAC
REHABILITATION/
PHYSICAL THERAPY
WARD ACTIVITY PATIENT
EDUCATION
STEP
9: 2-3
METs
Standing: Exercise from step 3
with 1 kg weight each UL, 15
reps, once daily, leg stretching,
treadmill/bicycle 20-30 mins,
stair climbing (up to 18 stairs)
Continue activities
from step 8, increase
ambulation up to 10-
11 lap (5060 ft)
Finalize
discharge
instructions.
Complete referral
to Phase 2
STEP
10: 2- 3
METs
Standing: Exercise with 1.5kg
weight each UL, 15 reps, once
daily, leg stretching, treadmill or
bicycling 20-30 mins, stair
climbing (up to 24 steps or
more). A symptom limited graded
exercise test) is recommended at
this time.
Continue activities
from step 9, increase
ambulation up to 12
lap (5936 ft) or more

33. Phase 2
• Immediate post-discharge, normally lasts for 4-6
weeks.
• Home and Hospital Outpatients .

34. • This phase generally happens at home, immediately following
discharge.
• The aim within this phase is for the patient to gradually return
to their normal activities of daily living both personal
(washing, dressing etc.) and domestic (cooking, cleaning,
shopping) and to progress their mobility (distance and speed)
walking outside.

35. • It is recommended, that the patient mobilise/physically active
for 20-30 minutes per day.
• INTENSITY: normally 11-13 (fairly light to somewhat hard)
for phase II.
• Later (phase III or IV) may use 12-15.
• DURATION: 20-60 min of continuous or intermittent activity

36. • If a 12-lead exercise tolerance test is not possible to complete,
then one of the following exercise tests should be chosen and
completed:
a. Walk test (6-minute Walk Test)
b. Step test
c. Cycle ergometer test
d. Arm ergometer test
e. Graded exercise test
A qualitative measure such as the 12-item Duke Activity Survey
Index can also be administered.

37. 10 meter walking
Biceps curls
Cycling
Sit-to-stand
Triceps press-ups against wall
Marching on the spot/ alternate hand to
opposite knee
Lateral arm raises
Calf exercises
Step ups
Floor mats: Sit-ups placing hands on bridging
exercise

38. • The FITT Principle for Increasing Aerobic Capacity
Frequency Two to three times weekly (e.g. two
rehabilitation classes and one home
circuit) Other days – walk/ leisure
activities
Intensity HRR/VO2max/ METmax = 40–70% RPE
2–4 (CR 0–10 Borg scale), 11–14 RPE
(Borg scale) HRmax = 60–80%
Time 20–30 minutes conditioning period (not
inclusive of warm-up and cool-down
periods
Type Aerobic , endurance training
CR, Cardiac rehabilitation; HRmax, maximal heart rate; HRR, heart rate reserve;
MET, metabolic equivalent; RPE, rating of perceived exertion; VO2R, oxygen
uptake reserve. Benefits may occur at lower intensities (e.g. 35% HRR/VO2max in
deconditioned patients).

39. Strength Training and Resistance Exercise
Prescription
Frequency Minimum 2 times per week
Intensity Upper body *30–40% 1 rep max
Lower body *50–60% 1 rep max
Time 1 set min (2–4 sets optimal) of 10–15
reps
Type 8–10 different muscle groups( Large
group muscles)

40. HOME BASED CIRCUIT TRAINING
PROGRAM
• Warm up for
• Time: 15 minutes
• Intensity: very light, light (up to 9-11 using the Borg scale

41. • Walk on spot x 1 minute
• Heel digs x 16
• Walk on spot x 1 minute
• Side taps x 16
• Walk on spot x 1 minute
• Side steps x 16
• Walk on spot as you lift and lower the shoulder x 4
• Walk on spot as you circle your shoulders x 4

42. • Stand with your feet shoulder width apart
o Side bends x 2 each side
• Walk on spot x 1 minute
• Trunk twist x 2 each side
• Walk on spot x 1 minute

43. Warm up stretches
• Hold the stretches without bouncing for 8-10 seconds
• Keep the feet moving when stretching the arms and upper
body.
• Keep the feet moving between stretches where possible
• Breathe normally during the stretch.

44. Front of chest
Back of upper arm
Calf stretch
Front of thigh

45. • Circuit Time: Up to 20 minutes
• Intensity: Moderate (Borg 11-13) “Exertion without
discomfort
Sit to stand – high
chair
Sit to stand – low
chair
Squats

46. Arm curl (sitting down)
Arm curl (standing)
Side steps
Side steps with arm curls,
light weights

47. Forward arm lift
using light weight
Knee lifts
Knee lifts with arm
raise

48. Step-up – low step
Step-up – high step
Step-up – high step with
arm raise

49. Wall press-ups
Chest Press
March on spot
Jog on the spot / Jog on
Trampette

50. Step-up – low step
Step-up – high step
Step-up – high step with
arm raise
Do each exercise for ___ minutes
Complete the circuit ___ times (Set according to each patient )

51. • Cool - down and stretch Time: Minimum 10
minutes
• Intensity: Light to extremely light
o Gentle marches on the spot x 1 minute
o Side steps x 8
o Gentle marches on the spot x 1 minute
o Side taps x 8
o Gentle marches on the spot x 1 minute
o Heel digs x 8
o Gentle walks on the spot x 1 minute

52. • Cool down stretches
o Keep your feet gently moving whilst performing the upper
body stretches.
o Keep your feet gently moving between the standing stretches
o Hold the stretches without bouncing for 20 to 30 seconds

53. Front of chest
Back of upper arm
Calf stretch
Front of thigh

54. ARTICLE
Improvement in cardiac dysfunction with a novel
circuit training method combining
simultaneous aerobic-resistance exercises. A
randomized trial
Horesh Dor-Haim1 , Sharon Barak, Michal Horowitz , Eldad
Yaakobi1 , Sara Katzburg1 , Moshe Swissa , Chaim Lotan

55. • Introduction Exercise is considered a valuable nonpharmacological
intervention modality in cardiac rehabilitation (CR) programs in patients
with ischemic heart disease. The effect of aerobic interval exercise
combined with alternating sets of resistance training (super-circuit training,
SCT) on cardiac patients’ with reduced left ventricular function, post-
myocardial infarction (MI) has not been thoroughly investigated.
• Aim of study to improve cardiac function with a novel method of
combined aerobic-resistance circuit training in a randomized control trial
by way of comparing the effectiveness of continuous aerobic training
(CAT) to SCT on mechanical cardiac function. Secondary to compare their
effect on aerobic fitness, manual strength, and quality of life in men post
MI. Finally, to evaluate the safety and feasibility of SCT

56. • Methods 29 men post-MI participants were randomly assigned to either
12-weeks of CAT (n = 15) or SCT (n = 14). Both groups, CAT and SCT
exercised at 60%-70% and 75–85% of their heart rate reserve, respectively.
The SCT group also engaged in intermittently combined resistance training.
Primary outcome measure was echocardiography. Secondary outcome
measures were aerobic fitness, strength, and quality of life (QoL). The
effectiveness of the two training programs was examined via paired t-tests
and Cohen’s d effect size (ES)

57. Eight Exercise
Horizontal rowing
chest press
Leg press
 Shoulder press
 Leg extension
lateral pull down,
leg flexion
 Assisted squat

58. Exercise protocol–continuous aerobic training
group.
• The CAT group participants exercised continually at 60%-70%
of their heart rate reserve.
• The speed and inclination of the treadmill, or resistance and
cadence of the cycle ergometer were adjusted continuously to
ensure that every training session was carried out at the
assigned heart rate.
• Each session lasted 45 minutes.

59. Exercise protocol–super-circuit training
group.
• The SCT group preformed moderate to high intensity
exercise, alternating between resistance and aerobic training
.
• Each SCT set included one resistant training set, 3 minutes
of aerobic interval and a resting period.
• This sequence was repeated eight times.
• In the first two weeks of the program, the training intensity
was light [(30% of one-repetition maximum (1RM)] and
progressively increased to 50% of 1RM.

60. Exercise protocol–super-circuit training
group
• Aerobic intensity was designed to be 75%-85% of heart
rate reserve.
• Resting periods between the resistance set and the aerobic
interval and between the aerobic interval and the
resistance set were monitored and gradually decreased
from two minutes in the first two weeks to one minute in
weeks 7-12.

61. Results Post-training, only the SCT group presented significant changes in
echocardiography. Similarly, only the SCT group presented significant
changes in aerobic fitness (an increase in maximal metabolic equivalent,
P<0.05). In addition, SCT improvement in the physical component of QoL
was greater than this observed in the CAT group.
• Conclusion Men post-MI stand to benefit from both CAT and SCT.
However, in comparison to CAT, as assessed by echocardiography, SCT
may yield greater benefits to the left ventricle mechanical function as well
as to the patient's aerobic fitness and physical QoL. Moreover, the SCT
program was found to be feasible as well as safe.

62. References books
• ACSM guidelines for exercise testing and prescription 8th edition by
williams
• Tidy`s Physiotherapy 12th edition (chapter 8 ) By Ann thomson.
• Physiotherapy for respiratory and cardiac problems adult and
paediatrics 4th edition (chapter 12) By Jennifer Pryor.
• Rehabilitation guideline after myocardial infarction WHO
guidelines.
• https://pubmed.ncbi.nlm.nih.gov/29377893/.