Cardiac Rehabilitation Cardiac rehabilitation programs aim to limit the psychological and physiological stresses of CVD, reduce the risk of mortality secondary to CVD, and Improve cardiovascular function to help patients achieve their highest quality of life possible.

1. Overview of Phases of Cardiac
Rehabilitation
Nihal Ashraf
MPT 3rd Sem.
Jamia Millia Islamia

2. • Cardiac rehabilitation programs aim to limit the psychological
and physiological stresses of CVD, reduce the risk of mortality
secondary to CVD, and Improve cardiovascular function to
help patients achieve their highest quality of life possible.

3. • They require a team approach, including a multidisciplinary
the multidisciplinary team including:
– Cardiologist/Physician and co-coordinator to lead cardiac
rehabilitation
– Clinical Nurse Specialist
– Physiotherapist
– Clinical nutritionist/Dietitian
– Occupational Therapist
– Pharmacist
– Psychologist
– Smoking cessation counselor/nurse
– Social worker
– Vocational counselor
– Clerical Administration

4. • Indication
• Cardiac rehabilitation should be offered to all cardiac patients
who would benefit
• Recent myocardial infarction
• Acute coronary artery syndrome
• Chronic stable angina
• Congestive heart failure
• Cardiac transplantation
• CR begins as soon as possible in intensive care units (only if
the patient is in stable medical condition). Intensity of
rehabilitation depends on the patient's condition and
complications in the acute phase of disease

5. Phases of Cardiac Rehabilitation
• Cardiac rehabilitation consists of 3 phases.
• Phase I: Inpatient phase or Clinical phase
• Phase II: Outpatient cardiac rehab
• Phase III: Post-cardiac rehab. Maintenance

6. Phases Of Cardiac Rehabilitation
Phase I
Or
Inpatient
phase
Phase II
Or
Early
outpatient,
Clinic or
Home based
Phase III
Or
Late
outpatient,
Community
based or
Home based
Phase IV
Or
Community
based
maintenance
phase

7. Phase I: Inpatient phase or Clinical phase
• Involves immediate inpatient exercise rehabilitation that emphasizes:
a) Patient education (informal discussions with nurses and physicians)
and
b) Counselling.
• Exercise therapy-
a) Musculoskeletal ROM activities.
b) ADLs (sitting, standing, and walking).
• Purpose:
a) Counter the deconditioning effects of prolonged bed rest,
b) Prepare patient for a return to normal daily activities.

8. • Each cardiac patient is faced with unique set of physiological,
medical, and psychological characteristics that affect his or her
readiness to safely begin the exercise portion of the rehabilitation
program.
• Thorough medical, nursing, and physical therapy assessment,
including review of medical records (admission, operative, and
progress notes and reports from diagnostic studies, including
cardiac catheterization, electrophysiology, echocardiography, and
nuclear tests), form the basis of an appropriate exercise
prescription.

9. CONTRAINDICATIONS
• Unstable angina
• Resting systolic BP > 200mmHg or resting diastolic BP > 100
mmHg
• Orthostatic BP drop 20mmHg or more
• Moderate to severe aortic stenosis
• Acute systemic illness or fever
• Uncontrolled atrial or ventricular dysrhythmias
• Uncontrolled sinus tachycardia (>120bpm)

10. • Uncontrolled CHF
• 3rd degree atrioventricular block
• Active pericarditis or myocarditis
• Recent embolism
• Thrombophlebitis
• Resting ST displacement (> 3mm)
• Uncontrolled diabetes
• Orthopaedic problems that would prohibit exercise.

11. EXERCISE PRESCRIPTION FOR PHASE I
1. ROM EXERCISES:
• Due to surgical trauma to muscle and bones of upper body,
these area may become atrophied and are vulnerable to
development of adhesions.
• Upper extremity ROM exercises may enhance blood flow to
the damaged areas and accelerate tissue repair. In addition to
increasing muscular strength and flexibility.

12. • ROM exercises include:
• Shoulder flexion, abduction and internal & external rotation
• Elbow flexion
• Hip flexion, abduction, internal and external rotation
• Ankle PF and DF
• Initially 5 repetitions of each should be perform once or twice daily with a
gradual progression to 10-15 repetitions twice daily.
• When patients can comfortably execute 10-15 repetitions, 1-3 lb wrist
weights may be added.

13. 2. AMBULATION:
• Two commonly encountered medical problems associated with
reduction in blood volume found following bed rest or CABG
surgery are orthostatic hypotension and reflex tachycardia.
• Ambulatory activities in phase 1 should be low in intensity
(approx. 1.5-3 METS) and initially include self care activities
(eating, sitting), which are gradually progressed to slow
walking, ROM exercises and activities of daily living.
• Later stair climbing can also be introduced.

14. • The duration of ambulatory part of the exercise session may be
progressively extended to up to 20mins.
• When patients are physically stronger they can participate in
formalized physical activity program including stationary
cycling and treadmill walking.

15. 3. EXERCISE INTENSITY:
• Exercise performed in phase 1 typically do not exceed 2-3 METS.
• There is no set rule in determining training (target) HR for the in patient, two
methods are generally used:
i. The use of fixed low level HR- may not be appropriate
because of wide range of resting heart rates among patients.
ii. A specified no. of beats above the patients standing resting
HR.
• The use of Borg Rating of Perceived Exertion Scale is encouraged after first
few days in the hospital.
• Patient should aim to achieve levels of 10-12 (light) on the 15 point category
RPE Scale.

16. 4. DISCHARGE PLAN:
• During the final days in hospital patient should be prepared for the
continuation of rehabilitation program after discharge.
• The pre discharge plan should include:
– Strategies for risk factor modification,
– Dietary counselling,
– Education on medications,
– An emergency plan,
– Exercise prescription for use at home (ROM exercise,
information on walking and stationary cycling and
recommendations for stair climbing and other ADLs).

17. FITT PRINCIPLE FOR PHASE I
• Frequency 2-3 times/day
• Intensity MI: RHR + 20
CABG: RHR + 20
• Duration MI: 5-20 min
CABG: 10-20 min
• Activity
ROM, treadmill, bike, one flight of stairs

19. Phase II of Cardac Rehabilitation
• individualized treatment plan is developed, incorporating an
exercise prescription and realistic goals for secondary
prevention.
• Session typically take place three times a week for up to 36
sessions; usually, options are available for less-frequent
weekly attendance for a longer period to achieve a full course.

20. • Exercise. As part of the initial evaluation, AACVPR
guidelines suggest an exercise test —
• e.g., a symptom-limited exercise stress test, a six-minute walk
test, or use of a Rating of Perceived Exertion scale.
• Prescribed exercise generally targets moderate activity in the
range of 50 to 70 percent of peak estimated functional
capacity. In the appropriate clinical context, high-functioning
patients can be offered high-intensity interval training instead
of moderate exercise, as they confer similar benefits.5

21. Phase III of Cardiac Rehabilitation
• In phase 3, patients independently continue risk-factor
modification and physical activity without cardiac monitoring.
• Most cardiac rehabilitation programs offer transition-to-
maintenance classes after completion of phase 2; this may be a
welcome option, particularly for those who have developed a
good routine and rapport with the staff and other participants.
• Others may opt for an independent program, using their own
home equipment or a local health club.

23. Thank you