Cardiac Post MI Rehabilitation.

1. Cardiac Rehabilitation
By Prof. Mahendra Lamba

2. Cardiac rehabilitation describes all measures
used to help people with heart disease return to
an active and satisfying life and to prevent
recurrence of cardiac events.
Cardiac rehabilitation services should be
provided in collaboration with the patient’s
cardiac specialist, general practitioner and
other health professionals who retain overall
responsibility for the patient’s management.

3. Definition
It’s a Coordinated, multifaceted interventions
designed to optimize a cardiac patient’s physical,
psychological, and social functioning, in addition to
stabilizing, slowing or even reversing the
progression of the underlying atherosclerotic
process, thereby reducing morbidity and mortality
-AHA Scientific Statement, Circ 2005;111:369-76

4. Aims of cardiac rehabilitation
i.Maximize physical, psychological and
social functioning to enable people with
cardiac disease to lead fulfilling lives with
confidence.
ii.Introduce and encourage behaviors that
may minimize the risk of further cardiac
events and conditions.

5. iii. Facilitate and shorten the period of
recovery after an acute cardiac event.
iv. Promote strategies for achieving mutually
agreed goals of ongoing prevention.
v. Develop and maintain skills for long-term
behavior change and self-management.
vi. Promote appropriate use of health and
community services, including concordance
with prescribed medications and professional
advice.

6. Benefits of CR
Limit the adverse physiologic effects of cardiac illness
Limit the adverse psychological effects of cardiac illness
Reduce the risk of sudden death or reinfarction
Control cardiac symptoms
Stabilize or reduce atherosclerosis
Improve functional capacity
Enhance psycho-social and vocational status

7. Eligible patients
The core group of people eligible for cardiac
rehabilitation are those who have had:
• myocardial infarction (ST elevation MI, non-
ST elevation MI)
• re-vascularisation procedures
• stable or unstable angina
• controlled heart failure
• other vascular or heart disease.

8. Staffing requirements
A multidisciplinary team of health professionals,
with one nominated coordinator, should
deliver cardiac rehabilitation services. In some
instances, for example in rural and remote
areas, a program may function adequately
with only one trained health professional
provided there is access to medical guidance
and the availability of referral for medical
opinion.

9. A trained health professional has a
degree, diploma or certificate of
registration in medicine, nursing,
physiotherapy, occupational therapy,
should have additional training or work
experience encompassing adult
education principles and physical
activity programs as set out in these
recommendations.

10. Recommended role and responsibilities of
the coordinator
Coordinators are responsible for managing the overall
program. This involves:
1. Developing a system that supports referral of all
eligible persons to cardiac rehabilitation.
2. Liaising with the patient’s cardiac specialist, general
practitioner, other primary care provider/s and
relevant community services.
3. Coordinating input from other rehabilitation
practitioners and facilitating communication
between team members.

11. 4. Establishing systems to ensure that the
structure, content and delivery of
services remains appropriate.
5. Establishing systems for maintenance of
an adequate patient database and
evaluation and monitoring mechanisms.
6. Promoting cardiac rehabilitation to
medical practitioners to encourage
referral.

12. Phases of Cardiac
Rehabilitation
Phase I : Inpatient
Phase II: Outpatient EKG monitored
Phase III: Outpatient with decreasing
monitoring
Phase IV: Community based, independent
exercise

13. Inpatient Cardiac
Rehabilitation Principles
Goals:
1)Normal cardiovascular response to changes in position
and ADLs (Activities of Daily Living)
2)Reach 3-4 MET activity level by discharge
Activity:
1)Slow progression of activity intensity (increase by 1
MET/day)

14. Initiating Inpatient
Cardiac Rehab
Post-MI, Post-surgery, Post-stent (no MI), CHF,
heart transplant
Patient may begin if:
No chest discomfort (8 hours)
No new signs of decompensated heart failure
No abnormal EKG changes (8 hours)

15. Cardiac Rehab
Phase II
Supervised outpatient program 6-8 wks.
Exercise test performed prior to rehab
EKG monitoring every session
Goals - increase exercise capacity to 5 METS
Patient education on HR, exercise, symptoms

16. Phase III
Outcomes
Functional capacity goals > 8 METS or 2x energy
requirements of work
Training effects expected
No cardiac symptoms
EKG monitoring happens occasionally, or when increasing
activity parameters
Patients learn self-monitoring of HR and symptoms

17. Cardiac Rehab
Phase IV
Unsupervised program
Community Based

18. Exercise Training
Program
Exercise training is defined as a sub-category of physical
activity in which planned, structured, and repetitive
bodily movements are performed to maintain or
improve one or more attributes of physical fitness and
thus it is a structured intervention over a defined period
of time.

19. The Benefits of Exercise
Primary Prevention
Brisk walking, 30mins/day, 5 times/week
30% ↓vascular events in 3.5 years follow-up
3 hours of brisk walking/week = 1.5 hours of
vigorousexercise per week.
Resistance exercise and weight training were
also beneficial.

20. The Benefits of Exercise
Secondary Prevention
Physical activity with 1000kcal/wks.
 20-30% ↓ all cause mortality1
For patients without revascularization
 Exercise training improves SBP, angina symptoms and exercise
tolerance2
For patients with revascularization



Improvement in exercise tolerance
↓29% cardiac events
↓re-admissions (18.6 vs 46%)3

21. Absolute Contraindication to Exercise
 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 non-cardiac disorder
that may affect exercise
performance or be
aggravated by exercise
Inability to obtain consent

22. Relative Contraindication to Exercise
 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

23. General Inpatient Prescription
Guidelines
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.
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24. General Inpatient Prescription
Guidelines
1)Selected moderate to high risk patients should be
encouraged to participate in outpatient cardiac
rehabilitation programs
&/or
2) Manage their discharge rehabilitation plan and report any
cardiovascular symptoms promptly (should they occur).
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25. Programme management
•All staff competent, appropriate skills and training,
regularly updated
•Appropriate emergency equipment, checked regularly,
policy for handling emergency situations, appropriate
venue
•Patient education important - aims and exercise goals
safety
use of equipment

26. Programme management
Patients and families should know the following:
•Signs and symptoms of exertion
•Importance of warm-up and cool-down
•Caution with isometric activities
•Issue e.g. excessive heat/cold, dehydration
•Avoid exercising after heavy meal, if ill an when tired
•Remain for 30 min after exercise for observation
•Excessive use of arm/upper body work results in higher
systolic and diastolic blood pressure than the same work
by legs