Cardiac rehabilitation is the coordinated sum of interventions
required to ensure the best physical, psychological and social
conditions so that patients with chronic or post-acute
cardiovascular disease may, by their own efforts, preserve or
resume optimal functioning in society and, through improved
health behaviors, slow or reverse progression of disease.
Aims of cardiac rehabilitation
• Maximize physical, psychological and social functioning to enable people with
cardiac disease to lead fulfilling lives with confidence.
• Introduce and encourage behaviors that may minimize the risk of further cardiac
events and conditions.
• Facilitate and shorten the period of recovery after an acute cardiac event.
• Promote strategies for achieving mutually agreed goals of ongoing prevention.
• Develop and maintain skills for long-term
• behavior change and self-management.
• Promote appropriate use of health and community services, including
concordance with prescribed medications and professional advice.
• Medical evaluation and risk stratification
• Psychological and social support.
• myocardial infarction (ST elevation MI, non-ST elevation MI)
• revascularization procedures
• stable or unstable angina
• controlled heart failure
• other vascular or heart disease.
• 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.
• 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
Epidemiological studies of exercise and mortality
• Regular exercise is associated with lower mortality from both cardiovascular
disease and all causes.
• Risk of coronary artery disease was less than half in the most active compared to
the most sedentary individuals (>20 vs. <2 MET. hours/week respectively)
• No clear consensus on the health benefits of vigorous and prolonged exercise
compared to more moderate physical activity.
• Exercise energy expenditure of greater than 2000 kcal/week (~8360kJ/week)
provides no additional health benefit.
• Most evidence is for aerobic exercise, but recent observational studies suggests
resistance training also has favorable effects on cardiovascular risk.
• regular exercise associated with a signiﬁcant 28% reduction in all-
cause mortality and a possible but nonsignificant 24% reduction in
recurrent myocardial infarction.
• Risks of exercise-
• Vigorous exercise may trigger myocardial infarction or sudden death but regular
exercise protects against this.
• the risk of myocardial infarction is on average six times higher during and for one
hour after vigorous exercise.
• risk is higher in persons with impaired left ventricular function, severe coronary
artery disease with inducible myocardial ischemia, recent myocardial infarction
and in individuals with significant ventricular arrhythmia.
Exercise in specific cardiac conditions
• Angioplasty and stenting-
• Although regular exercise is likely to reduce long term risk, no studies reliably assess
whether exercise training influences outcomes following PTCA.
• There is also limited information on the safety of exercise early after coronary
angioplasty and stenting.
• Coronary artery bypass grafting and other cardiac surgery-
• Cardiac rehabilitation with exercise may more rapidly improve functional capacity
following coronary artery bypass surgery, particularly in patients with physical
• Exercise is normally limited during the early weeks until there is adequate healing of the
sternotomy and surgical incisions, but low level activities, eg- walking, can usually begin
48 hours following surgery with gradual progression.
• In the long term, regular exercise is likely to reduce cardiovascular risk.
• The effects of exercise training in persons with arrhythmias is uncertain.
• The presence of exercise induced high grade ventricular ectopy is usually a contraindication to
• For persons with benign arrhythmias, exercise training is not contraindicated.
• should not restrict physical activity.
• For many patients with pacemakers heart rate is not a reliable guide to exercise intensity.
• indicators such as perceived exertion need to be used to guide appropriate levels of exercise.
• Older people
• much less likely to be referred for cardiac rehabilitation than younger groups.
• both male and female older persons with established coronary disease, can
improve exercise capacity with training comparable to younger groups.
• An individual approach is needed because of the wide range of age, fitness level, disease severity,
risk factor profile and medications.
• five major components to consider when prescribing exercise
• type of exercise
• intensity, warm-up
The intensity and duration of exercise sessions should start at a low level and gradually increase.
• Most exercise prescriptions are modified from a 3 session per week model.
• Patients with low (< 5 METS) functional capacity are encouraged to take part in several, brief (<
10 minutes) exercise sessions each day.
• Patients with higher functional capacities will benefit from fewer, longer sessions.
• Patient’s program may start out with several short sessions each day and gradually increase into
three-to-five, 30 – 45 minute sessions per week as functional capacity improves.
• duration can be adapted from a baseline value of 30 minutes per session.
• Type of exercise
• To achieve the best aerobic training effect, prolonged continuous low to moderate intensity.
• exercise (40 – 75% VO2max), using large muscle groups is indicated like walking, running, cycling
and swimming. .
• Exercise intensity-
• low-to-moderate intensity exercise is beneficial and increased benefit may be achieved with
more intense exercise
• Nutritional assessment
• Evaluation of food and nutrient intake
• Evaluation of physical activity levels and exercise tolerance
• Identification of diet-related diseases or conditions that contribute to CVD
• Evaluation of smoking habits
• Evaluation of current medication use
• Measurement of height
• Measurement of body weight and waist circumference
• Measurement of blood pressure
• Measurement of blood lipid levels.
• aim of nutrition education in cardiac rehabilitation is to facilitate the adoption of more
healthy food-related behaviors.
• The ‘stages of change model’ is promoted by the Heart Foundation for the management
of patients with dyslipidemia.
• change is cyclical, individuals who intentionally change behavior do so through a series of
stages. These stages have been termed:
• 1 pre-contemplation
• 2 contemplation
• 3 preparation
• 4 action
• 5 maintenance
• 6 relapse.
Benefits of smoking cessation
• reduce the risk of a recurrent myocardial infarct or death by half if they stop smoking.
• beneficial to stop smoking at any age.
• major and immediate health benefits for smokers of all ages
• Within one day of quitting, the chance of a heart attack decreases.
• excess risk of heart disease is reduced by half after one year’s abstinence. The risk of a major
coronary event reduces to the level of a never smoker within five years.
MANAGING PSYCHOSOCIAL ISSUES
• Up to one in four patients will experience a disabling level of anxiety or depression
following a myocardial infarction.
• A patient's illness perception may determine the degree of anxiety and depression
experienced and may delay or substantially reduce social and leisure activities.
• Depression is associated with a five-fold increase in mortality at six months and a three-
fold increase in one year cardiac mortality.
• Major depression following a coronary event runs a long term course with the majority
of those affected remaining depressed at one year.
• Most patients will return to work or primary activity following myocardial infarction. The
return to work is associated with an improvement in emotional well being.
• Marital status, emotional and social support and social networks are likely to have a
protective effect and reduce risk of future fatal and non-fatal coronary heart disease and
• Anxiety and depression
• 15-30% of post-myocardial infarction patients and 14-18% of post CABG patients experience moderate
to severe levels of anxiety and depression
• Depression and anxiety increased overall number of primary care visits, rehospitalisation or recurrent
• associated with a five fold increase in mortality at six months and over three fold increase in one year
• oxygen requirements during sexual activity are moderate .
• Heart rate levels during intercourse are similar to those found in everyday life
• sexual activity for those with coronary heart disease is associated with low risk of cardiac
Potential impact of medications on sexual
• PHASES OF CARDIAC REHABILITATION
• Phase I - Inpatient rehabilitation
• Phase II - Outpatient rehabilitation
• Phase III - Long-term maintenance
Objectives of Phase I Cardiac Rehab
• Conditioning from acute event/ post-CABG
• To make patient functionally independent
• To adjust with discharge from the hospital
• Psychological counselling
• Nutritional counselling
• Secondary prevention targeting.
• Phase II: This phase encompasse Immediate post discharge period,
which is typically a period of four to six weeks.
• It focuses on
• health education
• 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.
Objectives of Phase II Cardiac Rehab
• Functional goals
– Exercise training under supervision/ at home
• Psychosocial goals
– Anxiety/depression management
• Secondary preventive targets
• Phase III: 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 program 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 program.
• Exercise capacity
• Quality of life
• Waist circumference
• Telemetry monitoring occurs during exercise sessions
• Nutritional survey tool
Outcomes in Cardiac Rehabilitation
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