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cardiac rehabilitation

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presented in the 2nd International and the 29th Annual Physiotherapy Congress of the Iranian Physiotherapy Association.

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cardiac rehabilitation

  1. 1. CARDIAC REHABILITATION Reza Nejat, M.D., Anesthesiologist, FCCM, ex-Assistant Professor, SBMU Bazarganan Hospital
  2. 2. Cardiac Rehab  Cardiac Rehabilitation (CR) is an interdisciplinary team approach to patients with functional limitations secondary to heart disease.
  3. 3. Cardiac Rehab  WHO definition of Cardiac Rehab:  the activities required to influence:  the underlying cause of the disease,  the best possible physical, mental, and social conditions:  so that the patient may, by their own efforts, preserve or resume, as normal a place as possible in the society.  Rehabilitation:  cannot be regarded as an isolated form of therapy,  must be integrated within the entire treatment.
  4. 4. Cardiac Rehab  Cardiac Rehab:  A progressive program with a goal of helping patients to restore and maintain optimal health while helping to reduce the risk of future heart problems.
  5. 5. Cardiac Rehab  Early mobilization:  helps to decrease the effects of bed rest,  enables the patients to return to their activities of daily living (ADL), within the limits of the disease,  identifies patients at risk of cardiovascular and physical impairments,  prepares the patient and the support system at home to optimize recovery
  6. 6. Cardiac Rehab CR staffing:  Medical Director- MD  Available for consult  Assist in program development  Approve all policies/procedures  Be involved in therapeutic aspects of program  Coordinator- RN, Phys, RD, MBA  Administrative duties  Direct patient care
  7. 7. Cardiac Rehab  Cardiac Rehab phases:  phase-1: in the hospitalized period of the patient following an acute MI, (3- 5 days)  phase-2: the immediate post discharge period, (2-6 weeks)  phase-3: the stage of a structured exercise program, (6-12 weeks)  phase-4: the maintenance phase
  8. 8. Cardiac Rehab  CR core components: 1. Baseline patient assessment, 2. Nutritional counseling, 3. Risk factor modification, 4. Psychosocial interventions, 5. Physical activity counseling, 6. Exercise training.
  9. 9. Cardiac Rehab • What CR does • cardiac morbidity and relieve symptoms • Modifying risk factors and secondary prevention • Anxiety and increase knowledge • Increase fitness and restores normal activities
  10. 10. Cardiac Rehab • The benefit of CR: 1) Increased cardiovascular endurance 2) Endurance training = activity using large muscle groups, 3) Increase in maximal oxygen uptake 4) Maximal oxygen uptake (VO2 max) is limited: I. Centrally by cardiac output II. peripherally by the capacity of muscles to extract oxygen from the blood
  11. 11. Cardiac Rehab  In healthy people: endurance training: increase in CO due to increase in SV increase in SV: 1) LV mass and size 2) Increased total blood volume 3) Reduced peripheral resistance
  12. 12. Cardiac Rehab  What happens to the muscles in CR: A. Increased number and size of mitochondria B. Increased oxidative enzyme activity C. Increased capillarization D. Increased myoglobin
  13. 13. Cardiac Rehab  In patients with IHD: increase inVO2 max should be mostly achieved by: peripheral changes Note: high intensity exercises needed for central changes – inappropriate.
  14. 14. Cardiac Rehab  In patients with IHD: Repeated submaximal daily activities with less physiological stress: 1) Decreased heart rate, 2) Decreased blood pressure and 3) Decreased plasma catecholamine concentrations
  15. 15. Cardiac Rehab How you might describe your exertion Borg RPE Examples (for most adults <65 years old) None 6 Reading a book, watching television Very, very light 7 to 8 Tying shoes Very light 9 to 10 Chores like folding clothes that seem to take little effort Fairly light 11 to 12 Walking through the grocery store or other activities that require some effort but not enough to speed up your breathing Somewhat hard 13 to 14 Brisk walking or other activities that require moderate effort and speed your heart rate and breathing but don’t make you out of breath Hard 15 to 16 Bicycling, swimming, or other activities that take vigorous effort and get the heart pounding and make breathing very fast Very hard 17 to 18 The highest level of activity you can sustain Very, very hard 19 to 20 A finishing kick in a race or other burst of activity that you can’t maintain for long
  16. 16. Cardiac Rehab  A high correlation exists between a person's perceived exertion rating times 10 and the actual heart rate during physical activity
  17. 17. Cardiac Rehab  A MET, the resting metabolic rate:  the amount of oxygen consumed at rest like sitting quietly in a chair,  approximately 3.5 ml 02/kg/min  1.2 kcal/min for a 70-kg person
  18. 18. Cardiac Rehab In early stages of acute heart diseases like MI, post-CABG, Acute HF: First 24-48 hours: 1. Breathing maneuvers 2. Simple arm and leg exercises 3. Limited self-care activities Over the next 2-3 days: 1. RBR, 2. Take short walks 3. Take shower and dressing with help
  19. 19. Cardiac Rehab  CR programming:  Warm up  Aerobic exercises  Resistive exercises  Cooling down
  20. 20. Cardiac Rehab  Be careful! stop training in case of: 1) Fever, acute systemic illness 2) Unresolved/unstable angina 3) Blood pressure systolic > 200 mmHg and diastolic > 110 mmHg 4) Unexplained drop in blood pressure
  21. 21. Cardiac Rehab  Be careful! stop training in case of: 1) Symptomatic hypotension 2) Tachycardia 3) Arrhythmias 4) Breathlessness, lethargy, palpitations, dizziness 5) Unstable heart failure, weight gain > 2 kg in 2 days 6) Unstable/uncontrolled diabetes
  22. 22. ABG in Cardiac Rehab  Accurate and timely interpretation of ABG and an acid–base disorder can be lifesaving,  The establishment of a correct diagnosis may be challenging
  23. 23. ABG in Cardiac Rehab  Assessment of ABG 1. careful clinical evaluation 2. determine the primary acid–base disorder 3. consider the metabolic component 4. consider the possibility of a mixed metabolic acid–base disturbance 5. note the serum osmolal gap in any patient with an unexplained high anion-gap acidosis 6. evaluate the respiratory component 7. determine the cause of the identified processes
  24. 24. ABG in Cardiac Rehab  Assessment of ABG 1. careful clinical evaluation 2. determine the primary acid–base disorder 3. consider the metabolic component 4. consider the possibility of a mixed metabolic acid–base disturbance 5. note the serum osmolal gap in any patient with an unexplained high anion-gap acidosis 6. evaluate the respiratory component 7. determine the cause of the identified processes
  25. 25. ABG in Cardiac Rehab  Respiratory insufficiency:  Low FiO2  Hypoventilation  PaCO2= VCO2/VA, VCO2  V/Q mismatch  Shunt  (PAO2-PaO2)/20  Diffusion  DLCO
  26. 26. ABG in Cardiac Rehab  𝑷𝑷𝒂𝒂 𝑶𝑶𝟐𝟐 < 𝟓𝟓𝟓𝟓 𝒎𝒎𝒎𝒎𝒎𝒎𝒎𝒎  Memory defect, impaired judgement  𝑷𝑷𝒂𝒂 𝑶𝑶𝟐𝟐 < 𝟒𝟒𝟒𝟒 𝒎𝒎𝒎𝒎𝒎𝒎𝒎𝒎  Tissue damage  𝑷𝑷𝒂𝒂 𝑶𝑶𝟐𝟐 < 𝟑𝟑𝟑𝟑 𝒎𝒎𝒎𝒎𝒎𝒎𝒎𝒎  Unconsciousness  𝑷𝑷𝒂𝒂 𝑶𝑶𝟐𝟐 < 𝟐𝟐𝟐𝟐 𝒎𝒎𝒎𝒎𝒎𝒎𝒎𝒎  Death
  27. 27. ABG in Cardiac Rehab Clinical features of Hypoxemia Hypercapnia Cyanosis Flapping tremor of hands Tachypnea Tachypnea Tachycardia→arrhythmia→bradycardia Tachycardia Peripheral vasoconstriction Peripheral vasodilation warm hands/ headache Restlessness→confusion→coma drowsiness→hallucination→coma Sweating
  28. 28. ABG in Cardiac Rehab  In normal subjects:  𝑷𝑷𝒂𝒂 𝑶𝑶𝟐𝟐 = 𝑭𝑭𝒊𝒊 𝑶𝑶𝟐𝟐 × 𝟓𝟓  PaO2/FiO2  Normal 100/0.21=500  200< PaO2/FiO2<300 MILD ARDS  100< PaO2/FiO2<200 MODERATE ARDS  PaO2/FiO2<100 SEVERE ARDS  (on PEEP=5cmH2O)
  29. 29. ABG in Cardiac Rehab  SpO2/FiO2=235  PaO2/FiO2=200 Moderate ARDS: PaO2/FiO2<200  SpO2/FiO2=315  PaO2/FiO2=300 Mild ARDS: PaO2/FiO2<300
  30. 30. ABG in Cardiac Rehab  Assessment of ABG 1. careful clinical evaluation 2. determine the primary acid–base disorder 3. consider the metabolic component 4. consider the possibility of a mixed metabolic acid–base disturbance 5. note the serum osmolal gap in any patient with an unexplained high anion-gap acidosis 6. evaluate the respiratory component 7. determine the cause of the identified processes
  31. 31. ABG in Cardiac Rehab  Acidosis  the hydrogen-ion concentration ↑  Alkalosis  the hydrogen-ion concentration ↓
  32. 32. ABG in Cardiac Rehab  the plasma concentration of hydrogen ions normally  very low 40 nmol/L  the pH  the negative logarithm of the hydrogen-ion concentration,  is generally used in clinical medicine to indicate acid–base status.  “acidemia”  Plasma pH is abnormally low (acidic)  “alkalemia”  Plasma pH is abnormally high (alkaline)
  33. 33. ABG in Cardiac Rehab  the Henderson–Hasselbalch equation  pH = pK + log10 ([HCO3−] / [0.03 × (PaCO2)])  HCO3− = proton acceptor = BASE (KIDNEY)  CO2 = proton donor = ACID (LUNG)  pH = pK + log10 ([BASE] / [ACID])  pH = pK + log10 ([kidney] / [lung])
  34. 34. ABG in Cardiac Rehab  pH = pK + log10 ([kidney] / [lung])  ACIDOSIS:  Respiratory  Metabolic  ALKALOSIS:  Respiratory  Metabolic
  35. 35. ABG in Cardiac Rehab  Met Acidosis:  low pH (<7.35) and low bicarb (<22 meq/l)  Met Alkalosis:  high pH (>7.45) and high bicarb (>26 meq/l)  Resp Acidosis:  low pH and high PCO2 (>42mmHg)  Resp Alkalosis:  high pH and low PCO2 (<38mmHg)
  36. 36. ABG INTERPRETATION
  37. 37. ABG INTERPRETATION  Metabolic acidosis  pH <7.38 and [HCO3−] <22 mmol/liter  Secondary (respiratory) response:  PaCO2 = 1.5 × [HCO3−] + 8±2 mm Hg or  PaCO2 = [HCO3−] + 15 mm Hg  Complete secondary adaptive response within 12–24 hr
  38. 38. ABG INTERPRETATION  Metabolic alkalosis  pH >7.42 and [HCO3−] >26 mmol/liter  Secondary (respiratory) response:  Paco2 = 0.7 × ([HCO3−] − 24) + 40±2 mm Hg or  Paco2 = [HCO3−] + 15 mm Hg or  Paco2 = 0.7 × [HCO3−] + 20 mm Hg  Complete secondary adaptive response within 24–36 hr
  39. 39. ABG INTERPRETATION  Respiratory acidosis  pH <7.38 and Paco2 >42 mm Hg  Secondary (metabolic) response  Acute: [HCO3−] is increased by 1mmol/liter for each Paco2 increase of 10 mm Hg above 40 mm Hg  Chronic: generally [HCO3−] is increased by 4–5 mmol/liter for each Paco2 increase of 10 mm Hg above 40 mm Hg  Complete secondary adaptive response within 2–5 days
  40. 40. ABG INTERPRETATION  Respiratory alkalosis  pH >7.42 and Paco2 <38 mm Hg  Secondary (metabolic) response  Acute: [HCO3−] is decreased by 2 mmol/liter for each Paco2 decrease of 10 mm Hg below 40 mm Hg  Chronic: [HCO3−] is decreased by 4–5 mmol/liter for each Paco2 decrease of 10 mm Hg below 40 mm Hg  Complete secondary adaptive response within 2–5 days
  41. 41. ABG INTERPRETATION  www.rezanejat.com

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