Cardiac Rehabilitation

1. By
Dr. Doaa Salah Atta

3. - Up until the 1950s, strict bed rest was
thought to be the best medicine after a
heart attack.
- Following discharge moderately
stressful activity such as climbing
stairs was discouraged for a year or
more.
- The patient is to be guarded by day and
night nursing and helped in every way
to avoid voluntary movement or effort.
Introduction

4. - Cardiac rehabilitation has been defined as:
The sum of activities required to ensure
cardiac patients the best possible physical,
mental and social conditions so that they
may, by their own efforts, resume and
maintain as normal a place as possible in the
community.
- Cardiac rehabilitation has also been described
as: The combined and coordinated use of
medical, psychosocial, educational,
vocational and physical measures to
facilitate return to an active and satisfying
lifestyle.

5. - Coordinated, multifaceted interventions
designed to optimize a cardiac patient’s
physicial, psychological, and social
functioning, in addition to stabilizing,
slowing or even reversing the
progression of the underlying
atherosclerotic process, thereby
reducing morbidity and mortality.

6. • Post-MI
• Post-CABG
• Angina
• PCI
• Valve replacement or repair
• Heart transplant
• Indications for CHF continue to be
evaluated

7. • Benefits of exercise
• Recent studies
• Components of exercise class
• Health and Safety
recommendations

8. 8
- Offset deleterious pyschologic and
physiologic effects of bed rest during
hospitalization
- Provide additional medical surveillance of
patients
- Enable patients to return to activities of daily
living within the limits imposed by their
disease
- Prepare the patient and the support system at
home to optimize recovery followed by
hospital discharge

9. • Reduces cardiovascular and total
mortality
• Does not increase non-fatal reinfarction
rate
• Improves myocardial perfusion
• May reduce progression of
atherosclerosis when combined with
aggressive diet
• No consistent effects on hemodynamics,
LV function or visible collaterals

10. • No consistent effects on cardiac
arrhythmias
• Improves exercise tolerance without
significant CV complications
• Improves skeletal muscle strength and
endurance in clinically stable patients
• Promotes favorable exercise habits
• Decreases angina and CHF symptoms

11. 1. Smoking cessation
2. Lipid management
3. Weight control
4. Blood pressure control
5. Improved exercise tolerance
6. Symptom control
7. Return to work
8. Psychological well-being/stress management

12. • Physical activity:
• improves glucose metabolism
• reduces body fat
• lowers blood pressure
• improves musculoskeletal strength
• controls body weight
• reduces symptoms of depression

13. - A Cochrane review in 2004 concluded that
exercise only cardiac rehabilitation reduced
all cause mortality by 27% and cardiac
mortality by 31%
- The Canadian Co-ordinating Office for Health
Technology Assessment reported reductions
of all cause mortality of 24% and cardiac
mortality of 23%.
- A study by Witt et al in 2004 found that not
only was participation in cardiac rehab
associated with decreased mortality after MI
but also with lower risk of recurrent MI

14. - Clinical risk stratification is suitable for low
to moderate risk patients undergoing low
to moderate intensity exercise
- Exercise testing and echocardiography are
recommended for high risk patients
and/or high intensity exercise
- Functional exercise capacity should be
evaluated before and on completion of
exercise testing.

15. • Absolute Acute myocardial infarction (within two
days)
• Unstable angina
• Uncontrolled cardiac arrhythmias causing symptoms
or homodynamic compromise
• Symptomatic severe aortic stenosis
• Uncontrolled symptomatic heart failure
• Acute pulmonary embolus or pulmonary infarction
• Acute myocarditis or pericarditis
• Active endocarditis
• Acute aortic dissection
• Acute noncardiac disorder that may affect exercise
performance or be aggravated by exercise
• Inability to obtain consent

16. - Left main coronary stenosis or its equivalent
- Moderate stenotic valvular heart disease
- Electrolyte abnormalities
- Severe hypertension (systolic 200 mmHg
and/or diastolic 110 mmHg)
- Tachyarrhythmias or bradyarrhythmias,
including atrial fibrillation with uncontrolled
ventricular rate
- Hypertrophic cardiomyopathy and other forms
of outflow tract obstruction
- Mental or physical impairment leading to
inability to cooperate
- High-degree atrioventricular block

18. - Conditioning from acute event/ post-
CABG
- To make patient functionally
independent
- To adjust with discharge from the
hospital
- Psychological counselling
- Nutritional counselling
- Secondary prevention targetting

19. - Phase I relates to the period of hospitalization
following an acute cardiac event. The duration of this
phase may vary depending on the initial diagnosis,
the severity of the event and individual institutions,
usually one week acute event/post-operative.
- During this phase,
- Early mobilization and adequate discharge planning.
- Individuals typically undergo a risk factor assessment
and risk stratification
- Receiving information regarding their diagnosis, risk
factors, medications and work/ social issues.
- Involvement and support of the partner and family is
facilitated and encouraged.

21. - Functional goals
- Exercise training under supervision/at
home
- Psychosocial goals
- Anxiety/depression management
- Secondary preventive targets

22. - Phase II: This phase encompasses the
- Immediate post discharge period, which is typically a
period of four to six weeks.
- It focuses on
- health education and
- resumption of physical activity, however the
structure of this phase may vary dramatically from
centre to centre.
- It may take the format of
- telephone follow up,
- home visits, or
- individual or group education sessions.
- Either way, some form of contact is maintained with
the patient, facilitating ongoing education and
exchange of information.

24. Functional goals
– Exercise training under supervision
Psychosocial goals
– Return to work
– Return to hobbies and lifestyle
– Anxiety/depression management
Secondary preventive targets

25. • Phase III: This phase is sometimes
erroneously referred to as the ‘Exercise’
phase.
• It incorporates
– Exercise training in combination with
ongoing education and psychosocial and
vocational interventions.
– The duration of Phase 3 may vary from six
to 12 weeks, with patients required to
attend a CR unit two to three times weekly
for structured exercise and other lifestyle
interventions.

27. • Functional goals
– Exercise training
• Psychosocial goals
– Return to work
– Return to hobbies and lifestyle
– Anxiety/depression management
• Secondary preventive targets

28. • Phase IV: This phase constitutes the
components of long-term maintenance of
lifestyle changes and professional
monitoring of clinical status.
• It is when patients leave the structured Phase
3 programme and continue exercise and
other lifestyle modifications indefinitely.
• This may be facilitated in the CR unit itself or
in a local leisure centre.
• Alternatively, individuals may prefer to
exercise independently and
• Phase 4 may involve helping them set a safe
and realistic maintenance programme.

29. • Exercise capacity
• Quality of life surveys (SF-12, SF-36)
• BP
• Weight
• Waist circumference
• Lipids
• Glucose/HbA1C
• Telemetry monitoring occurs during
exercise sessions
• Nutritional survey tool

31. 31
• Frequency
–Early mobilization:
• 3-4 times/day (days 1-3)
–Later mobilization:
• 2 times/day (beginning on day 4)
• Progression:
–Initially increase duration up to 10-15
min, then increase intensity.

32. 32
• By hospital discharge, the patient
should:
–Demonstrate a knowledge of
inappropriate exercises
–Have a safe, progressive plan of
exercise formulated for them to take
home

33. 33
• Selected moderate to high risk patients
should be encouraged to participate in
outpatient cardiac rehabilitation
programs &/or
• Manage their discharge rehabilitation
plan and report any cardiovascular
symptoms promptly (should they
occur).

34. 34
• Goals are to:
– Provide appropriate patient monitoring
and supervision to detect a
deterioration in clinical status and to
provide timely feedback to the referring
physician to enhance effective medical
feedback,
– Contingent upon patient clinical status,
return patient to pre-morbid vocational
&/or recreational activities, modify or
find alternative activities.

35. 35
• Goals are to:
–Develop and help the patient to
establish and implement a safe and
effective home exercise program and
recreational lifestyle,
–Provide patient and family education
and therapies to maximize secondary
prevention.

36. 36
• In general, patients should engage in
multiple activities to promote total
conditioning including aerobic and
resistance exercises.
• Principles of prescription are those for
healthy adults but adjusted to take into
account the patients clinical status.

37. 37
• Use of RPE. Particularly useful when
GXT has not been performed or
medications change.
• Normally 11-13 (fairly light to somewhat
hard) for Phase II.
• Later (Phase III or IV) may use 12-15
(Approximately 60-80% VO2R

38. 38
• RPE can be used with beta-blockers
BUT
• Should remember that significant and
serious ST segment and/or arrhythmias
can still occur at low intensities and
RPE’s

39. 39
• Some patients: need to know when
abnormalities occur to enable exercise
below anginal or ischemic threshold
• Use of HR monitor with alarms
• Peak exercise HR 10 bpm below
appropriate threshold.
• Need to allow for medication effects on
exercise tolerance and HR.

40. 40
• Signs and symptoms below which an upper
limit for exercise should be set:
– Onset of angina or other symptoms of CV
insufficiency
– Plateau or decrease in SBP, SBP > 240 or
DBP > 110 mmHg.
≥ 1mm ST-segment depression
– Increasing frequency of ventricular
arrhythmias
– Other significant ECG changes
– Other signs or symptoms of intolerance to
exercise

41. 41
• Desire to have 20-60 min of continuous
or intermittent activity
• Inversely proportional to intensity
• May be able to accumulate in short (10-
15 min) bouts.

42. 42
• Depends upon patient functional capacity and
prognosis
• Generally, progress over 3-6 months to 1000
kcal/week
• Follow principles of initial, conditioning and
maintenance phase
• Generally progress every 1-3 weeks with goal of
achieving 20-30 min of continuous exercise.
• Patients requiring intermittent program (eg.
Peripheral vascular disease, low functional
capacity) should progress according to
symptoms and clinical status

43. 43
• Functional capacity ≥ 8 METS or twice
occupational level
• Appropriate hemodynamic response to
exercise
• Appropriate ECG response
• Adequate management of risk factor
intervention strategy and safe exercise
participation
• Demonstrated knowledge of disease process,
abnormal signs and symptoms, medication
use and side effects

44. 44
• Initial intensities determined according
to length of time from acute cardiac
event and associated complications,
duration since discharge and patient
information (ADL’s current home
program, associated signs and
symptoms)
• Use of Duke Activity Status Index

45. 45
• Previously required abstinence from
resistance training for several months
post MI.
• Now many patients can start by
carrying up to 13 kg by 3 weeks post
MI.
• Generally use approx. 50% 1RM or use
of other modes such as bands, hand
weights etc. in Phase II.

46. 46
• Should not begin until 2-3 weeks post
MI.
• After 4-6 weeks post MI, may start bar
bells and/or weight machines
• Note: surgical patients need to adjust
program to accommodate sternotomy
• Normally begin resistance program 2-3
weeks after initiating aerobic program.

47. 47
• Advocate 1 set of 8-10 different
exercises that focus on large muscle
groups, 2-3 days/week. Will result in
significant improvements
• Additional sets/reps do not seem to
result in substantial improvements.

48. 48
• Initially start with 1 set of 10-15 reps to
moderate fatigue using 8-10 different
exercises
• Increase 1-2 kg/week for arms and 3-5
kg/week for legs.
• Check rate, pressure product.
Shouldn’t exceed that for endurance
exercise
• RPE: 11-14.
• Avoid Valsalva

49. • Hypertension
-<140/90, 130/85 in high risk groups
• Diabetes
– HbA1C <7
• Obesity
– Set weight goals
– 5 lbs in the 3 months of phase 2

58. THANKTHANK
YOUYOU