Cardiac Rehabilitation

Prepared by:
Md. Yeasir Arafat Alve
Lecturer in Occupational Therapy MDM(BRACU), BSOT(DU);
Department of Occupational Therapy
Bangladesh Health Professions Institute (BHPI)
Centre for the Rehabilitation of the Paralysed (CRP)
Savar, Chapain, Dhaka- 1343
Email: alve_crp@yahoo.com
alve.ot.bd@outlook.com
5/16/2017 1BHPI/2nd Year/Cardiac Rehab/Alve

What is Cardiac disease?
• Cardiac disease is a broad term used to
describe a range of diseases that affect heart.
The various diseases that fall under the
umbrella of heart disease include:
– diseases of blood vessels, such as coronary artery
disease; heart rhythm problems (arrhythmias);
– heart infections; and
– heart defects born with (congenital heart defects)
that can lead to a heart attack, chest pain (angina)
or stroke.

Prevalence of Cardiovascular Diseases in American
Men and Women, Ages 20 and Older

Death Rates for Cardiovascular Disease, Including
CHD and Stroke for Selected Countries

Percentage Breakdown of Deaths from
Cardiovascular Disease in the United States, 2001

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6

Anatomy of the Heart

Common Blood Vessel Disorders

Myocardial infarction
• The heart requires its own constant supply of oxygen and
nutrients, like any muscle in the body. Two large, branching
coronary arteries deliver oxygenated blood to the heart
muscle.
Symptom:
Pressure, tightness, pain, or a squeezing
or aching sensation in your chest or arms
that may spread to your neck, jaw or back
Nausea, indigestion, heartburn or
abdominal pain
Shortness of breath
Cold sweat
Fatigue
Lightheadedness or sudden dizziness

Dressler's syndrome
• Dressler's syndrome is a type
of pericarditis, inflammation of
the sac surrounding the heart
(pericardium). Inflammation
associated with Dressler's
syndrome is believed to be an
immune system response
following damage to heart
tissue or the pericardium, such
as a heart attack, surgery or
traumatic injury.

Symptoms
• Symptoms are likely to appear weeks to
months after a heart attack, surgery or other
heart injury. Dressler's syndrome symptoms
may include:
– Chest pain
– Fever
5/16/2017 11BHPI/2nd Year/Cardiac Rehab/Alve Constrictive pericarditis

Angina Pectoris
• Angina, or angina pectoris, is the medical
term used to describe the temporary chest
discomfort that occurs when the heart is
not getting enough blood.
• The heart is a muscle (myocardium) and
gets its blood supply from the coronary
arteries.
• Blood carries the oxygen and nutrients the
heart muscle needs to keep pumping.

• When the heart does not get enough blood, it
can no longer function at its full capacity.
• When physical exertion, strong emotions,
extreme temperatures or eating increase the
demand on the heart, a person with angina
feels temporary pain, pressure, fullness, or
squeezing in the center of the chest or in the
neck, shoulder, jaw, upper arm, or upper back.
5/16/2017 BHPI/2nd Year/Cardiac Rehab/Alve 13
Angina Pectoris continue…

Symptom:
• sweating
• weakness
• faintness
• numbness or tingling or
• nausea
• Pain that does not go
away after a few minutes
Pain that is of concern in
any way

Congenital heart disease/defects
• A congenital heart defect is a problem with the
structure of the heart. It is present at birth.
Congenital heart defects are the most common type
of birth defect. The defects can involve the walls of
the heart, the valves of the heart, and the arteries
and veins near the heart.
• Symptoms of severe defects in newborns include
– Rapid breathing
– Cyanosis - a bluish tint to the skin, lips, and fingernails
– Fatigue
– Poor blood circulation

Holes in the Heart (Septal Defects)
• The septum is the wall that separates the chambers on left
and right sides of the heart. The wall prevents blood from
mixing between the two sides of the heart. Some babies are
born with Holes in the septal. These holes allow blood to mix
between the two sides of the heart.

Aortic valve stenosis
• Aortic valve stenosis is an uncommon and serious
type of congenital heart defect. It accounts for
around 5% of cases of congenital heart disease.
• In aortic valve stenosis, the aortic valve that
controls the flow of blood out of the main
pumping chamber of the heart (the left ventricle)
to the body's main artery (the aorta) is narrowed.
This affects the flow of oxygen-rich blood away
from the heart towards the rest of the body and
means the muscle thickens because the pump
has to work harder.

Coarctation of the aorta
• Coarctation of the aorta (CoA) is where the main
artery (the aorta) has a narrowing, which means
that less blood can flow through it.
• CoA accounts for around 10% of cases of
congenital heart disease. It can occur by itself or in
combination with other types of heart defects,
most commonly a ventricular septal defect or a
type of defect known as a patent ductus
arteriosus.
• In around half of all cases, the narrowing can be
severe and will require treatment shortly after
birth.

Patent ductus arteriosus
• Patent ductus arteriosus (PDA) is a rare type of
congenital heart disease, affecting around 5 in
every 100,000 babies. It is where a connection
between the main body artery and lung artery
(the ductus arteriosus) doesn't completely
close after birth as it's supposed to.
• This means extra blood is pumped into the
arteries of the lungs, forcing the heart and
lungs to work harder.

Pulmonary valve stenosis
• Pulmonary valve stenosis is a
defect where the pulmonary
valve, which controls the
flow of blood out of the right
heart pumping chamber (the
right ventricle) to the lungs,
is narrower than normal.
This means the right heart
pump has to work harder to
push blood through the
narrowed valve to get to the
lungs.
• Pulmonary valve stenosis
accounts for around 10% of
cases of congenital heart
disease.5/16/2017 BHPI/2nd Year/Cardiac Rehab/Alve 23

Hypoplastic left heart syndrome
• Hypoplastic left heart syndrome
(HLHS) is a rare type of
congenital heart disease where
the left side of the heart doesn't
develop properly and is too
small. This means not enough
oxygenated blood can get
through to the body.
• Without treatment HLHS can be
fatal within a few weeks of
birth, but nowadays complex
heart operations can be
performed to try to change this.

Tetralogy of Fallot
• Tetralogy of Fallot is a combination of several
defects, affecting about 30 in every 100,000
babies.
• The defects making up tetralogy of Fallot are:
• ventricular septal defect – a hole between the left
and right ventricle
• pulmonary stenosis – narrowing of the
pulmonary valve
• right ventricular hypertrophy – where the heart
muscle is thick
• displaced aorta – where the aorta is not in its
usual position coming out of the heart

Total anomalous pulmonary venous connection
(TAPVC)
• Total anomalous pulmonary venous connection
(TAPVC) occurs when veins taking oxygenated blood
from the lungs to the heart are connected in the
wrong place. They connect to the right side of the
heart when they should be connected to the left
side. Sometimes veins are also narrowed, and the
condition can be fatal within a month after birth.
• TAPVC is an uncommon type of congenital heart
disease, affecting around 7 in every 100,000 babies.

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27

Truncus arteriosus
• Truncus arteriosus is an uncommon type of
congenital heart disease, affecting around 5 in
every 100,000 babies.
• It is where the development of the two main
arteries (the pulmonary and aorta) does not
happen properly and remains a single vessel.
• This results in too much blood being sent to the
lungs which, over time, can cause breathing
difficulties and damaged blood vessels inside the
lungs.
• The condition is usually fatal within a year of birth
if not treated.

New Weapons Against Heart Disease
• Techniques for diagnosing heart disease
– Electrocardiogram (ECG)
– Angiography
– Positron emission tomography (PET)
– Single positron emission color tomography
(SPECT)
– Radionuclide imaging
– Magnetic resonance imaging (MRI)
– Ultrafast CT
– Digital cardiac angiography (DSA)

Angioplasty Versus Bypass Surgery
Angioplasty – a thin catheter is
threaded through the blocked
arteries. The catheter has a
balloon on the tip which is
inflated to flatten the fatty
deposits against the wall of
the artery
Coronary bypass surgery – a
blood vessel is taken from
another site and implanted to
bypass blocked arteries and
transport blood

Aspirin For Heart Disease?
Research shows that 80
milligrams of aspirin every
other day is beneficial to heart
patients due to its blood
thinning properties
Thrombolysis
Thrombolysis involves
injecting an agent such as
tissue plasminogen activator
(TPA) to dissolve the clot and
restore some blood flow.

Heart transplant
Valve replacement/repair
Valve replacement/repair
Valve replacement/repair5/16/2017 33BHPI/2nd Year/Cardiac Rehab/Alve

SYMPTOMS
 Uncomfortable pressure, fullness or squeezing pain in the
center of the chest
 Prolonged pain in the upper abdomen
 Discomfort or pain spreading beyond the chest to the
shoulders, neck, jaw, teeth, or one or both arms
 Shortness of breath
 Lightheadedness, dizziness, Sweating, Nausea
 Numbness, weakness or coldness in legs or arms
 A racing heartbeat (tachycardia)
 A slow heartbeat (bradycardia)
 Fainting (syncope) or near fainting
 Pale gray or blue skin color (cyanosis)
 Swelling in the legs, abdomen or areas around the eyes
 Shortness of breath during feedings, leading to poor weight
gain

CAUSES OF CARDIC DISEASE
• The causes of cardiac disease are varying from
conditions to conditions. These are following:
– High blood pressure
– Diabetes
– Smoking
– Excessive use of alcohol or caffeine
– Drug abuse
– Stress
– Bacteria
– Viruses
– Parasites

RISK FACTORS OF CARDIAC DISEASE
• Smoking
• Family history
• Sex
• Age
• Poor hygiene
• High stress
• Physical inactivity
• Obesity
• Diabetes
• High blood cholesterol levels
• High blood pressure
• Poor diet

COMPLICATIONS
• Heart failure
• Heart attack
• Stroke
• Peripheral artery disease
• Sudden cardiac arrest

FUNCTIONAL CLASSIFICATION OF CARDIAC DISEASE (Subjective)
• Class I: Patients with cardiac disease but without resulting
limitations of physical activity. Ordinary physical activity does
not cause undue fatigue, palpitation, dyspnea (shortness of
breath).
• Class II: Patients with cardiac disease resulting in slight
limitation of physical activity. They are comfortable at rest.
Ordinary physical activity results in fatigue, palpitation,
dyspnea or anginal pain.
• Class III: Patients with the cardiac disease resulting in marked
limitation of physical activity. They are comfortable at rest. Less
than ordinary physical activity causes fatigue, palpitation,
dyspnea or anginal pain.
• Class IV: Patient with cardiac disease resulting in inability to
carry on any physical activity without discomfort. Symptoms of
cardiac insufficiency or of the anginal syndrome may be
present even at rest. If any physical activity is undertaken,
discomfort is increased.

Class Objective Assessment
A
No objective evidence of cardiovascular disease. No symptoms and no
limitation in ordinary physical activity.
B
Objective evidence of minimal cardiovascular disease. Mild symptoms and
slight limitation during ordinary activity. Comfortable at rest.
C
Objective evidence of moderately severe cardiovascular disease. Marked
limitation in activity due to symptoms, even during less-than-ordinary
activity. Comfortable only at rest.
D
Objective evidence of severe cardiovascular disease. Severe limitations.
Experiences symptoms even while at rest.
FUNCTIONAL CLASSIFICATION OF CARDIAC DISEASE (Subjective)

MANAGEMENT
• FIRST AID
– Call local emergency medical assistance number
– Chew and swallow an aspirin
– Take nitroglycerin
– Begin CPR if the person is unconscious
• Medications:
• Surgery
– Medical procedures or surgery
– Pacemakers or implantable cardioverter-defibrillators
(ICDs)
– Open-heart surgery
– Heart transplant

• Rehabilitation
• Lifestyle changes:
• Stop smoking:
• Control blood pressure
• Check cholesterol:
• Keep diabetes under control:
• Get moving
• Eat healthy foods:
• Maintain a healthy weight:
• Manage stress
• Practice good hygiene habits

Cardiac Rehabilitation Team
• A comprehensive cardiac rehabilitation program
will include a wide range of skilled health
professional including-
– dietician
– doctors
– nurse
– occupational therapist
– physiotherapist
– psychologist and
– social worker

Occupational Therapy Assessment
• Initial Interview
• Physical assessment
• Cognitive assessment
• Psychosocial assessment
• Endurance and Activity Test
• Functional Assessment

METs Value in Functional Assessment
• The Metabolic Equivalent of Task (MET), or
simply metabolic equivalent, is a Physiological
measure expressing the energy cost of
physical activities and is defined as the ratio
of metabolic rate (and therefore the rate of
energy consumption) during a specific
physical activity to a reference metabolic rate,
set by convention to 3.5 ml O2·kg−1·min−1 or
equivalently.

MET VALUES FOR SOME OCCUPATIONAL PERFORMANCE AREA
MET’
s
Oxygen
consumed
(mL/kg/min)
Level of
activity
Self care activities Work activities Play and leisure
activities
1.5-
2.0
4-7 Very light
Minimal
Eating, shaving,
grooming, getting in
and out of bed,
dressing,
undressing,
standing, walking 1
km/h or 1.6 mph
Working at desk, type
writing
Playing cards, sewing,
knitting
2-3 7-11 Light Showering in warm
water, level walking
2 km/h or 3.25 mph
Ironing, light wood
working, using riding
lawnmower
Level bicycling 8 km/h or
5 mph, playing billiards,
bowling, golfing with
power cart
3-4 11-14 Moderate Walking 5 km/h or
3.5 mph
Cleaning windows,
making beds, mopping
floors, vacuuming,
bricklaying, doing
machine assembly
Bicycling 10 km/h or 6
mph, fly fishing standing
in waders, horseshoe
pitching
4-5 14-18 Heavy Showering with hot
water, walking 5.5
km/h or 3.5 mph
Scrubbing floors,
hoeing, raking leaves,
doing light carpentry
mph, table tennis, double
tennis
5-6 18-21 Heavy Walking 6.5 km/h or
4 mph
Digging in garden,
shoveling light earth
mph, canoeing 6.5 km/h
or 4 mph, Ice skating or
roller skating 15 km/h or
9 mph
6-7 21-25 Very heavy Walking 8 km/h or 5
mph
Shoveling snow,
splitting wood
Bicycling 17.5 km/h or 11
mph, light downhill skiing,
ski touring 4 km/h or 2.5
mph5/16/2017 BHPI/2nd Year/Cardiac Rehab/Alve 45

METs Rating in Bicycling

Occupational Therapy goals of cardiac rehabilitation:
• The major goal of a comprehensive cardiac
rehabilitation program is the achievement of
an optimal health status for each patient and
the maintenance of this status.
– To ensure limitation of adverse effects of illness
– To ensure efficient and effective symptom
management
– Stratification of risk for a further cardiac event to
assist in clinical decision making regarding further
treatment
– Modification of cardiac risk factors to prevent
progression of cardiac disease

Phase I cardiac rehab program: Inpatient Care
• Therapists treat each patient at least once a day
and usually twice daily as soon as the patient’s
medical status has stabilized, often within the first
24-48 hours after admission. The goals of inpatient
cardiac rehabilitation are:
To prevent muscle loss from bed rest
To monitor and assess patient’s ability to function
To instruct the patient in appropriate home activities
To educate the patient about individual risk factors
To teach methods for lessening these risks
• Clinical pathway
• Home program
• Discharge planning

Phase II cardiac rehab program: Outpatient Care
• Patients are usually started in outpatient cardiac
rehabilitation 1-2 weeks after discharge from the
hospital. The program runs 3 days a week for 4-8
weeks. Outpatient cardiac rehabilitation is a
multifaceted program of EKG-monitored exercise
and education for secondary prevention of heart
disease. The goals for outpatient cardiac
rehabilitation are:
– Continue medical surveillance and assessment of an
individual’s cardiovascular response to exercise
– Limit the physiological and psychological effects of heart
disease
– Instruct on risk factors for heart disease and how to
reduce their impact
– Maximize psychosocial and vocational status

• The program consists of following activities:
– Close monitoring and supervision during the early
part of exercise program
– Preparing the patient to return to work
– Educate the patient about to work safely and in a
timely manner
– Providing education and supporting counseling
for patient and his or her family member about
maintain a healthy lifestyle that will lower risk of
having further heart problems

Phase III Cardiac Rehabilitation program: community based
• Phase III is a community based cardiac rehabilitation
with larger groups of patients and fewer staff
members per participant. Its programs are often
located in community centers, school gyms. A
physician must refer a patient to this program.
Phase-III is often referred to as the maintenance
phase of cardiac rehab because it emphasizes long-
term lifestyle issues. This program will help the
patient to practice and keep healthy behaviors and
habits to continue to improve existing heart
condition or to keep risk of heart disease low.
During this phase, exercise habits are established and
risk factor modification is ongoing. Educate the
patient to increased activity tolerance by maintain of
energy conservation technique.

ADL evaluation and training
• Patients with pulmonary disease are often
limited in their ability to perform their ADLs
due to dyspnea. It is common to have
significant muscle wasting from disuse. The
therapist should note during the ADL
evaluation the patient’s breathing pattern.
The treatment guideline for ADL training
should consider oxygen saturation with
activity.
• Breathing techniques

Use energy conservation principles
Plan ahead
– Gather all items needed
– Spread heavy and light tasks throughout the day and
week
Pace yourself
– A moderate steady pace is most productive
– Plan rest periods throughout the day, 5-10 minutes out of
every hour
– Use pulse and level of dyspnea as guidelines
Avoid fatigue
– Get enough rest
– Avoid large meals
– Avoid activities 1 hour after meals
– Don’t wait until you are tired, before you stop and rest

Breathe Easy
– Apply you pursed lip and abdominal breathing
during activities
– Have adequate ventilation, cooking odors, cleaning
products and steam can make breathing more
difficult
– Slow deep breathing is relaxing and helps slow body
motions
– Do not hold your breath
– When is doubt breath out
Sit when possible
– Sitting eliminates considerable fatigue
– Use a seat in the shower when dressing

Minimize arm movements
– Especially above shoulder level
– Keep elbows low and close to your body
– Support elbows on a surface when working in one
place
Avoid bending, reaching, twisting
– Organize, so items are within reach
– Instead of twisting, move your feet to turn your
body
– Use long handled equipment

Use good posture
– Sit and stand straight
– Proper body alignment balances muscles and
decreases stress
– A stooped posture cause the diaphragm to fold
over onto itself making breathing more difficult
Use good body mechanics
– Push or pull, rather than lift
– Stand close to the object to be moved
– Slide objects along the counter
– Inhale before lifting and exhale during the lift
– If you must lift, it should be done with your legs
muscles rather than your back

Incorporating energy conservation techniques in self
care activities:
Important to remember
– When in doubt breathe out
– Rest frequently, avoid over exertion
– Never hold your activity during activities

Grooming
–Sit when possible
–Avoid aerosols and strong scent
–Short, easier care haircuts simplify hair
grooming
–Wash hair in shower, keep elbows low and chin
tucked
–Have hair done professionally
–Support elbows on counter while grooming
–Do not hold breathe, such as when shaving

Bathing and showering
–Consider taking a bath in the evening
–Gather all the necessary items that you will
need, including your clothes. Keep items in
easy to reach places
–Use a shower in your shower

Pursed lip breathing
• Pursed lip breathing is one of the simplest ways
to control shortness of breath. It provides a quick
and easy way to slow your pace of breathing,
making each breath more effective.
• What does pursed lip breathing do?
– Improves ventilation
– Releases trapped air in the lungs
– Keeps the airways open longer and decreases the
work of breathing
– Prolongs exhalation to slow the breathing rate
– Improves breathing patterns by moving old air out of
the lungs and allowing for new air to enter the lungs
– Relieves shortness of breath
– Causes general relaxation
5/16/2017 BHPI/2nd Year/Cardiac Rehab/Alve
64

• When should I use this technique?
• Use this technique during the difficult part of any
activity, such as bending, lifting or stair climbing
• Practice this technique 4-5 times a day at first so you
can get the correct breathing pattern
• Relax your neck and shoulder muscles
• Breathe in (inhale) slowly through your nose for two
counts, keeping your mouth closed. Don't take a
deep breath; a normal breath will do. It may help to
count to yourself: inhale, one, two
• Pucker or "purse" your lips as if you were going to
whistle or gently flicker the flame of a candle
• Breathe out (exhale) slowly and gently through your
pursed lips while counting to four. It may help to
count to yourself: exhale, one, two, three, four.

Relaxing Breath Exercise
• This exercise is utterly simple, takes almost no time,
requires no equipment and can be done anywhere.
Although you can do the exercise in any position, sit
with your back straight while learning the exercise.
– Exhale completely through your mouth, making a whoosh
sound.
– Close your mouth and inhale quietly through your nose to
a mental count of four.
– Hold your breath for a count of seven.
– Exhale completely through your mouth, making a whoosh
sound to a count of eight.
– This is one breath. Now inhale again and repeat the cycle
three more times.

Diaphragmatic breathing technique
• Lie on your back on a flat surface or in bed, with
your knees bent and your head supported. You can
use a pillow under your knees to support your legs.
Place one hand on your upper chest and the other
just below your rib cage. This will allow you to feel
your diaphragm move as you breathe.

• Breathe in slowly through your nose so that your
stomach moves out against your hand. The hand on
your chest should remain as still as possible.
• Tighten your stomach muscles, letting them fall
inward as you exhale through pursed lips (see
"Pursed Lip Breathing Technique").The hand on your
upper chest must remain as still as possible.

The Stimulating Breath (also called the Bellows Breath)
The Stimulating Breath is adapted from a yogic
breathing technique. Its aim is to raise vital energy
and increase alertness.
– Inhale and exhale rapidly through your nose, keeping your
mouth closed but relaxed. Your breaths in and out should
be equal in duration, but as short as possible. This is a
noisy breathing exercise.
– Try for three in-and-out breath cycles per second. This
produces a quick movement of the diaphragm, suggesting
a bellows. Breathe normally after each cycle.
– Do not do for more than 15 seconds on your first try. Each
time you practice the Stimulating Breath, you can increase
your time by five seconds or so, until you reach a full
minute.

• If done properly-
– you may feel invigorated
– comparable to the heightened awareness
– you feel after a good workout
– You should feel the effort at the back of the neck,
the diaphragm, the chest and the abdomen
– try this breathing exercise the next time you need
an energy boost and feel yourself reaching for a
cup of coffee.

Breath Counting
• If you want to get a feel for this challenging work, try your hand at
breath counting, a deceptively simple technique.
• Sit in a comfortable position with the spine straight
• head inclined slightly forward
• Gently close your eyes and take a few deep breaths.
• Then let the breath come naturally without trying to influence it.
• To begin the exercise, count "one" to yourself as you exhale.
• The next time you exhale, count "two," and so on up to "five."
• Then begin a new cycle, counting "one" on the next exhalation.
• Never count higher than "five," and count only when you exhale.
You will know your attention has wandered when you find yourself
up to "eight," "12," even "19."
• Try to do 10 minutes of this form of meditation.

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