Cardiac Rehabilitation


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Definition, epidemiology, physiology, effects of physical inactivity, benefits of habitual physical activity, contraindications, phases, physical assessment, exercise sessions, description of cardiac rehabilitation program phase II @ University Hospital University of Puerto Rico School of Medicine

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Cardiac Rehabilitation

  1. 1. Cardiac Rehabilitation Margarita Correa MD Director Cardiac Rehabilitation Program Professor Department of Physical Medicine and Rehabilitation and Sports Health Department University of Puerto Rico School of Medicine (1984 - 2008)
  2. 2. Effects of Prolonged Bed Rest <ul><li>20-25% decrement in physical work capacity after 3 weeks </li></ul><ul><li>700-800 ml reduction in circulating blood volume after 7-10 days producing orthostatic hypotension and a reflex tachycardia </li></ul><ul><li>Blood viscosity increases, predisposing to thromboembolic events </li></ul>
  3. 3. Effects of Prolonged Bed Rest <ul><li>10-15% reduction per week in muscle mass and muscle contractile strength </li></ul><ul><li>Increases the oxygen demand imposed on an already impaired oxygen transport system and potentially ischemic myocardium </li></ul>
  4. 4. At Rest <ul><li>Decreased venous return – diminished preload </li></ul><ul><li>Stroke volume is reduced </li></ul><ul><li>Heart rate increases with prolonged immobilization </li></ul><ul><li>Cardiac output (4-6 lt/min) </li></ul><ul><li>Oxygen uptake (0.2 – 0.3 lt/min) </li></ul>
  5. 5. Horizontal to Passive Feet Down Position <ul><li>Cardiac output falls to 4-5 lt/min (venous pooling) </li></ul><ul><li>Stroke volume is reduced </li></ul><ul><li>Heart rate increases </li></ul><ul><li>Oxygen uptake is unchanged </li></ul><ul><li>Arteriovenous oxygen difference is increased </li></ul>
  6. 6. With exercise <ul><li>Increases venous return (VR) </li></ul><ul><li>Increases cardiac output (CO) </li></ul><ul><li>Increment in preload causes acceleration of heart rate and improves stroke volume </li></ul><ul><li>Increases the oxygen uptake </li></ul><ul><li>Increases the arteriovenous oxygen difference </li></ul>
  7. 7. Epidemiology <ul><li>Framingham Study: the cardiovascular mortality and morbidity related inversely to physical activity in men. This relation was independent of age, blood pressure, smoking and cholesterol level. </li></ul><ul><li>PR Heart Health Program: physical activity was a protective factor against hear attacks in Puerto Rico. </li></ul>
  8. 8. Epidemiology <ul><li>Reduction in age-adjusted all-cause mortality rates in the most-fit men and women primarily due to lowered rates of cardiovascular disease and cancer </li></ul><ul><li>Coronary stenosis regressed in the group 1-year after engaging in low-fat vegetarian diet (10% total fat, 2% sat. fat), stopping smoking, stress management training and moderate exercise </li></ul>
  9. 9. Epidemiology <ul><li>Lower rates of death from all causes and coronary diseases were separately associated with: </li></ul><ul><ul><li>Moderate physical activity </li></ul></ul><ul><ul><li>Quitting cigarette smoking </li></ul></ul><ul><ul><li>Maintaining normal blood pressure </li></ul></ul><ul><ul><li>Avoiding central obesity </li></ul></ul>
  10. 10. Why Exercise?
  11. 11. Effects of Habitual Physical Activity <ul><li>Increase in maximal oxygen uptake and cardiac output and stroke volume </li></ul><ul><li>Reduced heart rate at given oxygen uptake </li></ul><ul><li>Reduced systolic and diastolic blood pressure </li></ul><ul><li>Improved efficiency of heart muscle </li></ul><ul><li>Decreased myocardial electrical irritability </li></ul>
  12. 12. Effects of Habitual Physical Activity <ul><li>Reduce mortality (26%) and morbidity (non-fatal MI’s, CABG & PTCA) * </li></ul><ul><li>Increased capillary density in skeletal muscle </li></ul><ul><li>Increased activity of aerobic enzymes in skeletal muscle </li></ul><ul><li>Reduced lactate production at given percentage (%) of maximal oxygen uptake </li></ul><ul><li>*Exercise-based rehabilitation for coronary heart disease (Cochrane Review) </li></ul>
  13. 13. Effects of Habitual Physical Activity <ul><li>Enhanced ability to utilize free fatty acid as substrate during exercise-glycogen saving </li></ul><ul><li>Improved endurance </li></ul><ul><li>Increased metabolism </li></ul><ul><li>Increased in the HDL/LDL ratio </li></ul><ul><li>Improved structure and function of ligaments, tendons and joints </li></ul>
  14. 14. Effects of Habitual Physical Activity <ul><li>Increased muscular strength </li></ul><ul><li>Reduced rate of perceived exertion (RPE) at given work rate </li></ul><ul><li>Increased release of endorphins </li></ul><ul><li>Provides a sense of well-being </li></ul><ul><li>Enhanced tolerance to hot environment – increased rate of sweating </li></ul>
  15. 15. Effects of Habitual Physical Activity <ul><li>Reduced platelet aggregation </li></ul><ul><li>Counteracts osteoporosis </li></ul><ul><li>Can normalize glucose tolerance </li></ul><ul><li>Improves endogenous and exogenous insulin sensitivity </li></ul><ul><li>Decreased percent of body fat </li></ul><ul><li>Increased lean body mass </li></ul>
  16. 16. Cardiac Rehabilitation <ul><li>Phase I (Inpatient) </li></ul><ul><li>Phase II (Outpatient) </li></ul><ul><li>Phase III (Long-term community based or home </li></ul>
  17. 17. Phase I <ul><li>Early ambulation to prevent stiffness, pulmonary atelectasis, reduction in anxiety and depression </li></ul><ul><li>1-3 days post MI or surgical procedure </li></ul><ul><li>Low intensity activities 2-3 METs </li></ul>
  18. 18. Phase I - Exercises <ul><li>Passive </li></ul><ul><li>Active </li></ul>
  19. 19. Phase I - Exercises <ul><li>Resistive </li></ul>
  20. 20. Phase I - Education <ul><ul><li>Cardiac Rehabilitation Home Program </li></ul></ul><ul><ul><li>Early Warning Symptoms of a Heart Attack </li></ul></ul><ul><ul><li>Living with angina pectoris, CHF </li></ul></ul><ul><ul><li>Relaxation skills, home diet </li></ul></ul><ul><ul><li>Stop smoking </li></ul></ul><ul><ul><li>Sex and the cardiac patient </li></ul></ul>
  21. 21. Phase II <ul><li>Can start immediately after hospital discharge, incremental physical activity based on general physical status, medical conditions and tolerance </li></ul><ul><li>Goals: Resumption of habitual and occupational activities and promotion of positive lifestyle changes </li></ul>
  22. 22. Contraindications for Exercise <ul><li>Unstable angina pectoris </li></ul><ul><li>BP at rest >200/100 </li></ul><ul><li>Orthostatic BP drop >20 mmHg with symptoms </li></ul><ul><li>Critical aortic stenosis – peak systolic pressure gradient >50 mmHg, orifice area <0.75 cm ² in an average adult </li></ul><ul><li>Acute systemic illness or fever </li></ul>
  23. 23. Contraindications for Exercise <ul><li>Uncontrolled atrial or ventricular arrhythmias </li></ul><ul><li>Uncontrolled sinus tachycardia (>120 b/m), except for post heart transplant patients due to heart denervation </li></ul><ul><li>Uncompensated congestive heart failure </li></ul><ul><li>3 rd degree AV block w/o pacemaker </li></ul><ul><li>Active pericarditis or myocarditis </li></ul><ul><li>Recent pulmonary embolism </li></ul>
  24. 24. Contraindications for Exercise <ul><li>Deep venous thrombosis (DVT) </li></ul><ul><li>Resting ST segment displacement >2mm </li></ul><ul><li>Uncontrolled diabetes mellitus > 400mg/dl </li></ul><ul><li>Severe musculoskeletal conditions that would prohibit exercise </li></ul><ul><li>Other metabolic conditions, such as acute thyroiditis, hypo or hyperkalemia, acute renal failure, hypovolemia, etc. </li></ul>
  25. 25. Evaluation <ul><li>Past & present history </li></ul><ul><li>Family History </li></ul><ul><li>- emphasis on CV diseases, arterial hypertension, diabetes mellitus, hyperlipidemia, deaths related to CV <50 y/o </li></ul><ul><li>Physical Examination </li></ul><ul><li>Laboratories </li></ul><ul><li>Diagnostic Studies </li></ul><ul><li>- resting ECG </li></ul><ul><li>- exercise test </li></ul><ul><li>- echocardiography </li></ul><ul><li>- myocardial perfusion </li></ul><ul><li>- coronary angiography </li></ul>
  26. 26. Health Related Fitness Evaluation <ul><li>Body Composition Assessment: subcutaneous skin fold for determination of body fat – approx. ½ of the total body fat is located beneath the skin </li></ul>
  27. 27. Health Related Fitness Evaluation Body Fat % <ul><li>Nomogram that relates age and the sum of 3 skinfolds: </li></ul><ul><li>-Females (triceps, thigh, suprailium) </li></ul><ul><li>-Males (chest, abdomen, thigh) </li></ul>
  28. 28. Health Related Fitness Evaluation <ul><li>Height and weight </li></ul><ul><li>Resting heart rate </li></ul><ul><li>Resting blood pressure </li></ul><ul><li>Pulmonary function test, if necessary </li></ul>
  29. 29. Health Related Fitness Evaluation <ul><li>Sit and reach flexibility </li></ul>
  30. 30. Exercise Test <ul><li>Patient’s tolerance to exercise </li></ul><ul><li>ECG abnormalities in response to exercise </li></ul><ul><li>Hemodynamic changes related to exercise </li></ul><ul><li>Determination of HRmax </li></ul><ul><li>Estimate VO2max and exercise capacity METs </li></ul><ul><li>Determine functional class </li></ul>
  31. 31. Exercise Test
  32. 32. Exercise Test <ul><li>Predicted HR max = 220 – age </li></ul><ul><li>VO2 max: highest level of oxygen consumption that the individual can achieve by dynamic exercise of a large fraction of a major muscle mass </li></ul><ul><li>MET: a multiple of the resting rate of O2 consumption (VO2 rest) </li></ul><ul><li>1 MET = VO2 rest = 3.5 ml/kg x min </li></ul>
  33. 33. Exercise Prescription <ul><li>Heart rate </li></ul><ul><li>Rating of Perceived Exertion (RPE) </li></ul><ul><li>METs </li></ul><ul><li>VO2 max </li></ul><ul><li>Based on the participant’s health status and level of fitness </li></ul>
  34. 34. Exercise Prescription
  35. 35. Factors Affecting Training <ul><li>Initial level of fitness </li></ul><ul><li>Intensity </li></ul><ul><li>Duration </li></ul><ul><li>Frequency </li></ul>
  36. 36. Exercise Session
  37. 37. Exercise Session <ul><li>Warm-up period (5 – 10 mins) </li></ul><ul><li>- Stretching exercises </li></ul><ul><li>Aerobic phase (20 – 45 mins) </li></ul><ul><li>- Intensity: 60 – 80% of HRmax </li></ul><ul><li>55 – 85% VO2 max </li></ul><ul><li>- Duration: 20 – 45 mins </li></ul><ul><li>- Frequency: 2 – 3 X per week </li></ul><ul><li>Resistive exercises </li></ul><ul><li>Cool-down period (5 – 10 mins) </li></ul>
  38. 38. Exercise Session <ul><li>Target Heart Rate in the training-sensitive zone (60% - 90%) </li></ul><ul><li>Peak rate – age-predicted maximum heart rate </li></ul>
  39. 39. Facts <ul><li>In USA from about 2 millions of potential candidates for cardiac rehabilitation, just 38% participate, now estimated in 10-20%. </li></ul><ul><li>Although, the physicians consider that physical training is important for the comprehensive care of these patients, the referral is very scarce </li></ul><ul><li>3 rd party payer issues, limitation in health care coverage </li></ul><ul><li>Wenger NK et al (1995) AHCPR Publication No. 96-0672 </li></ul>
  40. 40. Cardiac Rehabilitation Phase II - University Hospital
  41. 41. Cardiac Rehabilitation Program Phase II - University Hospital
  42. 42. Cardiac Rehabilitation Program Phase II - University Hospital
  43. 43. Cardiac Rehabilitation Program Phase II - University Hospital
  44. 44. Cardiac Rehabilitation Program Phase II - University Hospital <ul><li>Flexibility, vital capacity and estimated energy expenditure significantly increased (p<0.05) </li></ul><ul><li>Estimated resting energy expenditure and LDL significantly decreased (p<0.05) </li></ul><ul><li>Carmen A Padro, Margarita Correa (1997) A clinical study of a cardiac rehabilitation program (phase II), 245-50. In P R Health Sci J. 16 (3) </li></ul>
  45. 45. Cardiac Rehabilitation Program Phase II - University Hospital <ul><li>Conclusion </li></ul><ul><li>The patients improved some parameters of health-related fitness, physical activity level and a positive tendency on the remaining measured variables </li></ul><ul><li>Carmen A Padro, Margarita Correa (1997) A clinical study of a cardiac rehabilitation program (phase II), 245-50. In P R Health Sci J. 16 (3) </li></ul>
  46. 46. Cardiac Rehabilitation Program Phase II - University Hospital <ul><li>Conclusion </li></ul><ul><li>These results suggest that a multifactorial intervention in Cardiac Rehabilitation can help improve and/or maintain the health status of these patients, especially the risk factors associated to health-related fitness and physical activity level </li></ul><ul><li>Carmen A Padro, Margarita Correa (1997) A clinical study of a cardiac rehabilitation program (phase II), 245-50. In P R Health Sci J. 16 (3) </li></ul>
  47. 47. Thanks!