1) The document discusses special considerations for cardiac rehabilitation programs for patients with heart failure. 2) It outlines three main types of heart failure and explains the muscle hypothesis, which links reduced cardiac function to peripheral skeletal muscle abnormalities. 3) Key factors for exercise programs discussed include extensive medical screening, monitoring drug regimens, using low-intensity exercise testing and prescriptions, and providing education to patients about symptom recognition and disease management.

1. CENTER FOR PHYSIOTHERAPY AND REHABILITATION
SCIENCE
JAMIA MILLIA ISLAMIA
Topic:Special consideration of cardiac rehabilitation in heart failure patients
Submitted by:Qurat ul aein
19mpc005

2. Special consideration of
cardiac rehabilitation in
heart failure patients
By;Qurat ul aein
MPT3rd sem

3. Types of heart failure
• Systolic heart failure
• Dysystolic heart failure
• Congestive heart failure

4. • Systolic heart failure their is reduced ejection fraction {less
than35%}
• Dysystolic heart failure their is filling insufficiency but
ejection fraction is maintained
• Eventually left side heart failure leads to right side heart
failure also called congestive heart failure

5. • People with heart failure experience breathlessness and restricted
activities of daily living because of their restricted heart capacity.
• This can reduce their amount of exercise, which can further reduce
fitness, making their symptoms worse.
• Peripheral factors such as blood flow, intrinsic skeletal muscle
abnormalities, and neurohormonal alterations are primarily responsible for
the poor exercise tolerance. The muscle hypothesis provides a connection
between left ventricular dysfunction and peripheral abnormalities that
include skeletal muscle myopathy and dyspnea. The peripheral
abnormalities have been associated with reduced ability to perform ADL
leading to a reduced quality of life in patients with HF

6. Muscle hypothesis
• The muscle hypothesis states that reduced left ventricular function
results in low perfusion to the skeletal muscle. The low muscle
perfusion leads to a reduced metabolic state in the skeletal muscle,
causing skeletal muscle myopathy. The skeletal muscle myopathy
results in an accumulation of metabolic by-products, causing muscle
fatigue and activating ergoreceptors in the skeletal muscle.
• Ergoreceptors are afferent nerve endings that transmit signals to the
central nervous system. These signals result in increased ventilation
and sympathetic nervous system (SNS) stimulation, causing
increased dyspnea and peripheral resistance, respectively. The long-
term negative consequences of the increase in SNS activity is an
increase in vasoconstriction and afterload, both of which perpetuate
the HF cycle.

8. History, and Physical
Examination
• Extensive medical history and physical activity history is
required
• Presence of comorbidities
• Medical screening examination
• Physical examination
• Echocardiogram to determine ejection fraction

9. Drug regime
• The drug regimen is extensive and should be assessed and side effects should be considered before
implementing any exercise program.
• Standard medical therapy includes diuretics (loop, thiazide, potassium sparing) to reduce blood volume and
edema,
• vasodilators (e.g., ACE inhibitors or angiotensin receptor blockers) to reduce afterload and restore
neurohumoral balance and systemic vascular resistance
• β-adrenergic receptor blockers to interrupt the “toxic effects” of the overactive SNS
• Combination drugs such as sacubitril/valsartan (angiotensin receptor blocker plus a medication to reduce BP,
are increasingly popular because of their effectiveness and lower patient burden.
• The use of digoxin in patients with HF and atrial fibrillation may be appropriate in patients who cannot tolerate β-
blockers for rate control because of intractable HF.
• Other agents that may be used with this population include antiplatelet and anticoagulation therapies and an
aldosterone antagonist.
• Use of implantable cardioverter defibrillators (ICDs) and wearable defibrillator devices is also becoming more
common in this population of patients. The exercise professional should be aware of the upper limits in terms of
HRs for these individuals that could potentially precipitate the delivery of an electrical shock.

10. Exercise Testing Considerations
• A symptom-limited cardiopulmonary exercise test using a low-
intensity protocol with small, 1 MET increments in work
requirements/stage such as a modified Naughton may be performed
prior to exercise prescription.
• The Bruce protocol is never appropriate for patients with HF unless
the patient clearly already has a more normalized exercise capacity.
• Other modes of testing include 6-minute walk and pharmacological
stress testing .
• The most common concerns related to exercise testing and specific
to HF include postexercise hypotension, arrhythmias, and worsening
HF symptoms.

11. • Postexercise symptoms including hypotension, arrhythmias, and
disproportionate dyspnea need to be monitored closely.
Symptoms for patients with HF will occur at lower workloads,
and thus, exercise tests need to be low level with modest MET
increments between stages; ramped protocols are appropriate.
• Six-minute walk tests may be used in this population.
• Ventilatory measures, although not available to all patients with
HF, can provide valuable data for clinicians regarding patient
status and prognosis.
Test termination criteria should be more focused on symptoms
rather than target HRs.

12. Chronic Medical
Condition
Frequency (How
often?)
Intensity Time Type Resistance Flexibility
Special
considerations
Heart Failure 3–5 d ∙ wk−1
If HR data is
available from a
recent GXT, set
intensity between
60% and 80% of
HRR. In the absence
of data from a GXT
or if atrial
fibrillation is
present, use RPE of
11–14 on a 6–20
scale.
Progressively
increase to 30 min ∙
d−1
and then up to 60
min ∙ d −1
Treadmill or free
walking and
stationary cycling
1-2 days a
week.Begin at 40%
1RM for upper body
and 50% for lower
body exerciseTwo
sets of 10 to 15
repetitions focussing
on major muscle
group
2-3 days a wk,10 to
30s for static
stretching,2 to 4
repetitions
Exercise is
especially important
for patients with HF
who may exhibit
exerc intolerance d
to skeletal muscle
myopathy.
Resistance training
is needed to as with
ADL. HIIT, althou
popular, is o
appropriate f a
selected subsection
of this population

13. Safety Exercise Education
• Uncompensated heart
failure is contraindication
to start exercise program
• Decompensated is
reason to discontinue
exercise program
• A thorough assessment
should be done with each
visit
• Exercise stress testing
should be done
• Progression should be
done by 1 METper stage
• Longer warm up and cool
down period
• Use interval exercise 1 to
6 min as needed
• Encourage weight bearing
for ADL
• Use ECG and bp
monitoring during
exercise
• Educate about signs and
symptoms of recognition ,
including fatigue ,
weakness , dysnea ,
orthopnea, edema ,
weight gain
• Heart healthy diet [low
sodium diet[eg1500mg]
• Educate patient about
drug regime
• Psychological
consultation
• Basic information about
disease process

14. Thank you