CARDIAC REHABILITATION (MANJU).pptx

TOPIC
ON
“CARDIAC REHABILITATION ”
Presented by:
Mr. Manjunath. Beth
Associate professor
&
HOD OF MSN DEPARTMENT

CARDIAC REHABILITATION: DID YOU KNOW: WITH EVERY HEART BE AT,
BLOOD IS PROPELLED THROUGH THE 60,000-MILE NETWORK OF VESSELS MAKING
UP THE CIRCULATORY SYSTEM. ABOUT 100,000 TIMES A D AY, THE CARDIAC CYCLE
REPEATS AND SUSTAINS LIFE.
AMAZING!!
 Review
 Blood flow
 Conduction
System

Introduction
 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."
Thomas Lewis, 1933

CARDIAC REHABILITATION
A successful rehabilitation begins with the moment
the client enters the coronary care unit for emergency
care & continues for months and even years after
discharge from the health care facility.
The overall goal of rehabilitation is to help the
client live as full vital and productive a life as possible
while remaining within the limits of the heart’s ability
to respond to increase in the activity and stress.

DEFINITIONS
Cardiac rehabilitation is a comprehensive
long term program that involves periodic medical
evaluation, prescribed exercises & education &
counselling about cardiac risk factor modification.
Cardiac rehabilitation is a multifactorial
program that begins when the client is still
hospitalized and continues throughout recovery.

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.

Cardiac rehabilitation is the process that restores
optimal medical, physiological, social & vocational
performance following recovery from an acute cardiac
event (AACVPR –1995)
Cardiac rehabilitation is described by the American
College of cardiology as “those exercise and counseling
services which reduce symptoms or improve cardiac
function”
Cardiac rehabilitation is defined by the U.S. Public
Health Service as “comprehensive, long-term
programs involving medical evaluation, prescribed
exercise, cardiac risk factor modification, education
and counseling.

Aims / goals
1. Cardiac rehabilitation aims to reverse limitations
experienced by patients who have suffered the adverse
pathophysiologic and psychological consequences of
cardiac events.
2. The goals of cardiac rehabilitation or cardiac rehab is to
help you regain strength, to control your risk factors, to
prevent your condition from worsening and to reduce your
risk of future heart problems.

COMPONENTS OF
CARDIAC REHABILITATION

WHO ARE ELIGIBLE
TO PARTICIPATE
IN THE CARDIAC
REHABILITATION
PROGRAM ?

INDICATIONS FOR CARDIAC REHAB
• MI
• Angina (stable)
• Coronary artery bypass Sx
• Compensated heart failure
• Cardiac surgery
• High risk for CAD
• High risk for diabetes
• High risk for high blood
pressure
• End stage renal failure
• Cardiomyopathy PVD
• Heart transplant
• Status post pacemaker
insertion

CONTRAINDICATIONS FOR CARDIAC REHAB
 Uncontrolled atrial/ventricular arrythmias
 Recent diagnosis embolism/DVT
 Resting diastolic >110
 Resting systolic >200mm Hg
 Uncompensated CHF
 Thrombophlebitis
 Orthostatic BP >20mm HG drop
 Acute infection
 Unstable angina
 Resting ST segment displacement >2mm

BENEFITS OF ROUTINE EXERCISE
 Decrease myocardial  Decrease serum
O2 cost triglycerides
 Decrease HR/BP  Decrease risk of heart
disease
 Increase Max O2
uptake  Decrease % body fat
 Decrease minute  Improve glucose
ventilation tolerance
 Decrease in  Increase HDL
depression/anxiety cholesterol

Who Can Benefit From
Cardiac Rehabilitation
And
How Is It Determined?

• A cardiac rehab program is designed for patients
newly diagnosed with a heart issue, or patients with
a heart transplant, or acute coronary syndrome, or
ventricular assist device, or confirmed with the
diagnosis of exertional angina, heart valve
replacements, or patients who have undergone
surgery for implantation of an intra-cardiac
defibrillator.
• The patient's cardiac rehab program depends upon
the health disorder and medical history. Therefore,
the rehab team will take the patient's medical history
into keen consideration, do a physical exam, and
perform various tests before starting the program.

Possible tests may include
• cardiac imaging tests, electrocardiogram (EKG),
and a stationary bike or treadmill exercise test.
• The patient may also have tests to measure the blood
sugar and cholesterol levels.
• During cardiac rehab, the patient learns to perform
exercises safely and increases the daily physical
activity day by day.
• The period that the patient spends in cardiac rehab
program depends on the condition's nature and its
intensity.

 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
training.

 Vitals:PR, RR, BP, SpO2, ECG findings
 RS Examination
 Circulatory Examination
 MS Examination
 CNS Examination

 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
 Stress level

PHASES
OF
CARDIAC
REHABILITATION

PHASES
PHASE I : IN PATIENT
PHASE II : OUT PATIENT
PHASE III : LONG-TERM
CONDITIONING
PHASE IV : LONG-TERM
MAINTENANCE

There are typically 4 phases and 4 components in a
cardiac rehab program:
• Phase 1 – guidance and counseling during
hospitalization (the rehab team will meet you and
provide clarification about your health condition)
• Phase 2 – monitoring and support during the
recovery period (which might be just a few days for
a stent procedure and about 6 weeks for bypass
surgery)

• Phase 3 – supervised exercise cum education
sessions (where you will attend two or three sessions
a week for 6-12 weeks at Cardiac Wellness Institute)
• Phase 4 – maintenance and follow-up (you will
continue the lifestyle changes at home and visit the
rehab centre periodically)
• During the rehab program, you will be clinically
evaluated and then guided through a series of
sessions involving various components of exercise,
an appropriate nutritional plan, stress management
techniques and professional counseling.

A cardiac rehabilitation begins as soon as you are
hospitalized for a heart surgery or treatment, or soon
after you've had a stroke. The ideal program consists of
following 4 phases:
• Phase 1: It is an in-patient phase in the hospital, also
called recuperation phase, which generally lasts up to 6
weeks in which a patient receives help in a range of
motion activities, intermittent standing or sitting, and
walking. The phase aims at reducing the de-
conditioning that normally co-occur with prolonged bed
rest.

• Phase 2: It is an outpatient phase that commences
immediately upon phase 1 and lasts up to 4-6 weeks in
which exercise bouts are of short duration and low
intensity. The patient begins with activities of equal
strength as normal daily activities.
• Phase 3: Also called a long-term conditioning phase,
the patient progresses and reaches to a more advanced
exercise program during the phase.
• Phase 4: Also known as maintenance phase, the
patient enters after 4 to 6 months following the
commencement of the cardiac rehab program.

 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

 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.

 Functional goals
– Exercise training under supervision/ at
home
 Psychosocial goals
– Anxiety/depression management
 Secondary preventive targets

 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.

 Functional goals
– Exercise training under supervision
 Psychosocial goals
– Return to work
– Return to hobbies and lifestyle
– Anxiety/depression management

 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.

 Maintenance of achieved functional status
 Return to work
– Return to hobbies and lifestyle
modifications

 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.

 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.
HM734 ExerciseTesting and Prescription:Cardiorespiratory 34

 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

 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).

 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,

 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.

 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.

 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%VO R
2

 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

 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.

 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.
. 1 mm ST-segment depression
. Increasing frequency of ventricular arrhythmias
. Other significant ECG changes
. Other signs or symptoms of intolerance to exercise

 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.

 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

 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

 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

 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.

 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.

 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.

 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.
 AvoidValsalva

CARDIAC
REHABILITATION HOME
EXERCISE
PROGRAM

GUIDELINES FOR EXERCISE
♥ Try to walk on level surfaces. Walk slower if
you do walk on hilly terrain.
♥ Space your activities. Wait at least 1 hour after
you eat a heavy meal or bathe before exercising.
♥ Avoid exercising in extremely hot/humid
weather: greater than 80°F/75 percent humidity.
♥ Avoid exercising in extremely cold/damp
weather: less than 32° F unless you cover your
face with a scarf or mask.
♥ If you are feeling ill, do not exercise. When
you are feeling better, start your program again
slowly.

What Are The Basic
Elements Of Cardiac
Rehabilitation?

• Cardiac Rehabilitation is a secondary
prevention program recognized as
integral to the overall wellbeing and
care of patients with stroke or
cardiovascular issue.

The program usually comprises of following basic elements:
1. Health Behavior Education and Lifestyle Risk Factor
Management
2. Psychological Health
3. Medical Risk Factor Management
4. Long-Term Management
5. Cardio protective Therapies
6. Audit and Evaluation

1. Health Behavior Education and Lifestyle Risk
Factor Management
• Health behavior education is often synonymously
used with different aspects of lifestyle directly
related to overall health, life expectancy and a heart
condition.
• Guidance regarding nutrition, training on physical
activities and exercise, and education on factors
causing cardiovascular issues can help a patient
improve overall lifestyle and alleviate the symptoms
of the health disorder.

• Physical Activity And Exercise: Physical activity
has various physical, psychological and emotional
health benefits that can be from supervised activities
to a daily walk in the park.
When it comes to cardiac rehabilitation, a
physiotherapist helps you perform physical activities
and exercises under its keep supervision.

The idea is mainly to get moving, and the physical
exercises primarily deliver following benefits:
• Strengthening the heart muscles
• Increasing stroke volume for better heart pumping
• Increasing hemoglobin concentration in the blood
• Enlarging and increasing the number of arteries that
supply the heart with blood, consequently,
increasing oxygen supply and decreasing the
tendency for blood clots.
• Boosting the body's metabolism, thus ensuring
improved body weight. It benefits obese and
overweight individuals suffering from heart issues.

• Reducing and aiding with the control over
cardiac risk factors, like diabetes, high
cholesterol and high blood pressure
• Improving overall muscle strength, endurance
and flexibility
• Alleviating psychological stress

Diet: Adopting a heart-healthy diet that includes a
meal with low in salt and rich in fruits, vegetables,
whole grains, low-fat meat, and fish. Choice of right
foods aimed at reducing fat, cholesterol level and
sodium in your diet are beneficiary for heart
patients. A health nutritionist or dietitian can help
you develop a better diet plan meeting your health
needs.
Smoking cessation: Smoking injures nearly every
organ of your body, including your heart. Most of
the cardiac rehab programs offer practical methods
to help patients kick off the harmful habit.

2. Psychological Health
• Cardiac patients often experience anxiety and
depression causing reduced quality of life and
mortality. Therefore, cardiac rehab program
incorporates the mental and psychological
treatments for stress and anxiety.
3. Medical Risk Factor Management
• Diabetes, high cholesterol, hypertension, blood
circulation issues, atrial fibrillation, and obesity are
leading medical risk factors to a stroke. Therefore,
cardiac rehab team helps patients be able to manage
such factors if they are already affected by them.

4. Long-Term Management
• The rehab team aims for a long term treatment and
healing within the heart by helping patients improve
their lifestyle, avoid risk factors, become habitual of
doing daily exercises, and prefer healthy foods.
5. Cardio-protective Therapies
• To prevent a problem is far easier than to solve it.
Similarly, cardio-protective therapies aim at
preventing the recurrence of a cardiovascular issue,
which are the combination of above-described
cardiac rehab elements.

6. Audit and Evaluation:
• Initial and ongoing medical evaluation helps the
cardiac team determine physical abilities and
limitations, and other conditions, and keep track of
the progress over time.
• During the assessment, the healthcare team looks at
different risk factors for heart disorder or stroke.
• It helps them tailor the program to each individual
situation, ensuring safety and effectiveness.
• Delivery of services mentioned above requires
expertise from a range of different specialists and
professionals.

• The team may include a cardiologist,
community cardiologist, nurse specialist,
physician, physiotherapist, a general
practitioner with a special interest, nutritionist,
psychologist, occupational therapist, clerical
administrator, and exercise specialist.

What Are The Barriers To Cardiac Rehabilitation
Participation?
Despite the documented proof of the
benefits associated with a cardiac
rehabilitation in enhancing recovery,
reducing mortality and improving overall
health following a heart surgery or stroke,
just nearly one-third of the patients
participate in such programs.

Mentioned below are some of the barriers to cardiac
rehab participation:
1. Poor referral rates, especially for certain groups
including women, elderly people, people living in rural
settings, people from ethnic minorities, and people in
low socioeconomic classes.
2. Lack of endorsement by a doctor.
3. Lack of patient adherence, resulting in low enrollment
with high dropout rates.

4. Cigarette smoking addiction with lack of
interest in physical exercises.
5. Poor social support, depression, obesity.
6. Transportation issues and
7. lack of leave from job to attend the sessions.

OVERALL BENEFITS OF CARDIAC
REHABILITATION
• Cardiac rehab has several benefits for the individual
as well as for the family members and caregivers.
• By giving some time and thought to your rehab
program, you will enjoy freedom from symptoms,
higher energy levels, ability to control your risk
factors, better understanding of your health
condition, healthy food choices, better sleep and
mental relaxation, all within a few sessions of
starting the program.

CARDIAC REHABILITATION (MANJU).pptx

CARDIAC REHABILITATION (MANJU).pptx

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