This document provides information on exercise prescription for cardiac rehabilitation. It discusses assessing patient risk and stratifying them before creating an individualized exercise plan. The goals of a cardiac rehabilitation program are to improve exercise capacity and reduce cardiac ischemia through aerobic and resistance training 3 times per week for 30 minutes each session at a target heart rate of 70-85% of maximum. Contraindications include unstable angina or new symptoms during exercise. Baseline testing establishes work capacity and excludes issues before developing a safe prescription.
Exercise Prescription for Cardiac Patientsnihal Ashraf
Cardiovascular disease (CVD) is the leading cause of death and a major cause of disability worldwide. (WHO., 2003)
Cardiac rehabilitation is the process of restoring psychological, physical and social function in the people with manifestations of coronary artery disease( CAD).
Exercise testing is a non invasive procedure that provides diagnostic and prognostic information and evaluates an individual’s capacity for dynamic exercises
This PPT share the principles used in exercise prescription and the parameters which should be kept in mind while prescribing and progressing the exercise regimen
Exercise Prescription for Cardiac Patientsnihal Ashraf
Cardiovascular disease (CVD) is the leading cause of death and a major cause of disability worldwide. (WHO., 2003)
Cardiac rehabilitation is the process of restoring psychological, physical and social function in the people with manifestations of coronary artery disease( CAD).
Exercise testing is a non invasive procedure that provides diagnostic and prognostic information and evaluates an individual’s capacity for dynamic exercises
This PPT share the principles used in exercise prescription and the parameters which should be kept in mind while prescribing and progressing the exercise regimen
What does cardiac rehab involve? Cardiac rehabilitation doesn't change your past, but it can help you improve your heart's future. Cardiac rehab is a medically supervised program designed to improve your cardiovascular health if you have experienced heart attack, heart failure, angioplasty or heart surgery.
this power point presentation provides main emphasis on the phases of the rehabilitation post op. it will enhance the knowledge about do's and dont's during the rehabilitation phases in brief. U may ask the questions if you have in your mind in the comment section. this ppt includes upper extremity as well as lower extremity exercises and also provides easy understanding with the help of suitable and intresting diagrams
PRE PARTICIPATION EXAMINATION I Dr.RAJAT JANGIR JAIPUR
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The 6-minute walk test (6MWT) is an easy to perform and practical test that has been used in the assessment of patients with a variety of cardiopulmonary diseases including pulmonary arterial hypertension (PAH). It simply measures the distance that a patient can walk on a flat, hard surface in a period of 6 minutes.
Aerobic means "with oxygen," and anaerobic means "without oxygen." Anaerobic exercise is the type where you get out of breath in just a few moments, like when you lift weights for improving strength, when you sprint, or when you climb a long flight of stairs.
CHEST MOBILIZATION EXERCISES, COUNTER-ROTATION TECHNIQUE, BUTTERFLY TECHNIQUE, BREATH CONTROL DURING WALKING. These Mobilization Techniques are useful to improve Chest Wall Mobility and Expansion in Patients with Restricted Chest wall movements and also Postoperative patients
What does cardiac rehab involve? Cardiac rehabilitation doesn't change your past, but it can help you improve your heart's future. Cardiac rehab is a medically supervised program designed to improve your cardiovascular health if you have experienced heart attack, heart failure, angioplasty or heart surgery.
this power point presentation provides main emphasis on the phases of the rehabilitation post op. it will enhance the knowledge about do's and dont's during the rehabilitation phases in brief. U may ask the questions if you have in your mind in the comment section. this ppt includes upper extremity as well as lower extremity exercises and also provides easy understanding with the help of suitable and intresting diagrams
PRE PARTICIPATION EXAMINATION I Dr.RAJAT JANGIR JAIPUR
knee injury, ligament injury knee, pcl injury, sports injury, Acl injury in football player surgery, Acl injury in football players, Acl injury in taekwondo, Acl reconstruction in jaipur, Acl reconstruction in taekwondo, Acl reconstruction surgery in football, Acl surgery in jaipur, Acl surgery ke baad physiotherapy, Best acl surgeon in india, Best acl surgeon in jaipur, Best knee surgeon in jaipur, Best ligament doctor in hindi, Meniscus repair surgery in jaipur, Sports injury doctor, acl surgery, acl surgery recovery, acl tear
The 6-minute walk test (6MWT) is an easy to perform and practical test that has been used in the assessment of patients with a variety of cardiopulmonary diseases including pulmonary arterial hypertension (PAH). It simply measures the distance that a patient can walk on a flat, hard surface in a period of 6 minutes.
Aerobic means "with oxygen," and anaerobic means "without oxygen." Anaerobic exercise is the type where you get out of breath in just a few moments, like when you lift weights for improving strength, when you sprint, or when you climb a long flight of stairs.
CHEST MOBILIZATION EXERCISES, COUNTER-ROTATION TECHNIQUE, BUTTERFLY TECHNIQUE, BREATH CONTROL DURING WALKING. These Mobilization Techniques are useful to improve Chest Wall Mobility and Expansion in Patients with Restricted Chest wall movements and also Postoperative patients
Cardiac rehabilitation is a broad term. It includes physical activities for cardiac patients as well as risk stratification, management of risk factors, occupational rehabilitation and patient education and counselling. This presentation deals with the prescription of physical activity and exercise for patients with acute coronary syndrome, chronic coronary syndrome, heart failure etc.
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
Exercise Training Recommendation for Individual with Chronic Stable Angina an...nihal Ashraf
For patients with cardiovascular disease, exercise is a critically important intervention and should be prioritized to slow the progression of disease and prevent or reverse physical deconditioning.
Overview of phases of cardiac rehabilitationnihal Ashraf
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. Phase -1 Cardiac Rehabilitation in CABG patients.ShagufaAmber
Cardiac Rehabilitation refers to the process of restoring psychological, physical, and social functions in people with manifestations of coronary artery diseases(CAD).Why do we need Cardiac Rehabilitation?-Effect upon the mortality and morbidity.-An approach to other risk factor modification.-Impacting the quality of life-Combating stress, depression and behavioural changes-In CABG, the post surgical stiffness and complications are overcome with physical activity.The Cardiac Rehabilitation program is individually tailored depending upon the risk stratification, prognosis ,functional capacity and specific needs. The ACSM classifies it into four distinct phases.
Its leftover homework of our physician scientist & health care providers for the last 75 years indeed. Contemporary challenges are numerous , but there is a will there is a way ,today or tomorrow some body some where has to start .
Currently heart failure is being treated by every physician ,any where from community to academic institution ,and is based on old system of payment ( FFP ) fee for service ,we need to switch from FFS to Value based payment ( VBP ) .
Million Heart, ticking time bomb can we predict or preventasadsoomro1960
There are different stages of HF syndromes , stage B HF is grossly neglected by cardiology community ,which is a ticking bomb to prevent symptomatic HF
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
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Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
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2 Case Reports of Gastric Ultrasound
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
2. Objectives
• To understand the process of assessment
& exercise prescription, patients for
Cardiac Rehabilitation Program.
• To define risk of progression &
stratification
• To understand the exercise prescription
process for Cardiac Rehabilitation
Program.
3. Introduction
In 1772,william heberden described a patient with
angina who “ set himself a task of sawing wood for
half an hour every day, and was nearly cured.
Before 1930 immobilization and extended bedrest
were encouraged for up to 6 weeks after CV event,
leading to significant deconditioning.
In 1940 things slowly began to change ,Levine
introduced up to chair therapy.
In 1950 short daily walk in the ward was introduced.
2019 era exercise and cardiac rehabilitation is class 1
indication indeed.
4. What is Cardiac
Rehabilitation
Cardiac rehabilitation mean physician supervised
program, that furnishes physician prescribed :
• Exercise
• Cardiac risk factors modification
• Psychosocial assessment
• Outcome assessment
Multidisciplinary & multifactorial Intervention
( including education and cardio-protective
therapies to control symptoms and overall quality
of life)
7. Definitions
• Physical activity, defined as any bodily movement.
• Exercise, defined as physical activity
performed to stress primarily the oxygen
transport system ( Aerobic exercise), muscular
skeletal system ( Resistance exercise )
• Exercise training, defined as exercise
performed repetitively to increase the maximal
capacity of the oxygen transport ( Aerobic
exercise training/ resistance exercise training) .
8. Exercise Training
Exercise training in patients with CV disease increases
exercise capacity ,reduces cardiac ischemia, delays the onset
of or elimination of angina, and improves endothelial
function, thus reduces CAD and related mortality .
Despite these benefits , inexpensive and generally safe is
being rarely prescribed especially amongst women and
older patients.
The reasons for this underutilization are not defined but
probably include health professionals underestimation of
the benefits of exercise, lack of awareness and training
among many healthcare workers and last not the least lack
of large randomized clinical trials.
9. Assessment &
Risk Stratification
Clinical examination :
– The site & size infarct & operation details
– Current cardiac status
– Any complications
– Current medication
– Progress since Discharge
– Current exercises level – including the recent results
– Any symptoms, exercise chest pain, shortness of breath,
dizziness
– Relevant past medical history
– Risk factor for Coronary Heart Disease.
– Weight/ BMI
– Psychological status/ mood
– Orthopedic limitations
10. Assessment &
Risk Stratification
Risk Stratification
Process of assessing the risk of patients
having a further event depend upon.
The main risk factors :
•Extensive cardiac damage
•Residual ischaemia
•Ventricular arrhythmias on exercise
11. Assessment &
Risk Stratification
Risk Stratification
1. History of :
- more than one previous infarct
- An anterior rather than inferior infarct
- ↑ cardiac enzyme levels at the time of infarct
- complications ie: LV failure/ Cardiogenic Shock
2. Symptoms severe exertional breathlessness &
orthopnea.
3. Finding of large heart/ Pulmonary venous congestion & low
Ejection Fraction.
4. A low capacity on the exercise. Test with significant ECG
changes/ poor HR/BP response.
5. Current angina
12. Assessment &
Risk Stratification
Uncomplicated MI.CABG,
Angioplasty
FC equal or greater than
6METs
3 or more weeks after event
FC less than 5-6 Mets 3 or
more weeks after event
Mild – moderately depressed
LVF (EF 31to 49%)
Severely depressed LVF
(≤30%). Complex ventricular
arrhythmias at rest/
appearing/ increasing
with exercise
No resting/ exercise induced
myocardial ischemia
manifested as angina & or ST
segment displacement.
Failure to comply with
Exercise Prescription
↓ SBP of › 15mmHg during
exercise or failure to rise.
MI complicated by CHF,
cardiogenic shock .
No resting/ exercise induced
complex arrhythmias
No significant LV dysfunction
(EF = / ↑ than 50%)
Exercise induced ST-segment
depression of 1-2mm/
reversible
ischemic defects (echo/
nuclear radio)
Patients with severe CAD &
marked (›2mm) exercise
induced ST segment
depression. Survivor of
cardiac arrest
Low Risk Moderate Risk High Risk
13. Phases of exercise
Cardiac Rehabilitation
Phase 1
Inpatient ( last few days
before discharge)
Exercise may involve simple
ward ambulation
mild activities of daily living ,
Referral to phase 2
enrollment.
Phase 11
Outpatient/ hospital based
or home based
Comprehensive secondary prevention
model
Individual treatment plan
Exercise prescription Education
classes.
Risk modification, smoking,
hypertension, diabetes, obesity, lipid
and nutrition counseling.
Psychosocial counseling
Phase 111
Maintenance Cardiac monitoring no longer
needed.
Independent continuation of risk
factors modification and
exercise, with periodic physician
evaluation.
14.
15. Exercise
Recommendation
Aerobics
• Large muscle
activities
(arm/leg ergometry
Increase aerobic
capacity
• Decreased BP & HR
response to sub max
exercise
40-85 VO2max/ HRR
• Intensity to be kept
below ischemic
threshold
• 3-7 days a week
• 20-60 mins continuous
exercises• 5-10 mins
warm up/down
4-6 months
Strength
• Circuit training
Increase ability to
perform leisure,
occupational & daily
living activities
• Increased muscular
strength
40-50% maximal
voluntary contraction
(avoid vasalva)
• 2-3 days/ week
• 1-3 sets, 10-15
repetitions• Resistance
should begradually
increased over time (1-2 lbs)
4-6 months
Flexibility
• Upper & lower body
ROM
Decreased risk of
injury
• Improved ROM in
post sternotomy
2-3 days/ week 4-6 months
Modes Goals Intensity Time to goal
16. Exercise Prescription
FITT Principles
F
FREQUENCY
2 – 3 TIMES WEEKLY / >3 TIMES WEEKLY ( Total 36 visits )
(2 REHABILITATION CLASSES & 1 HOME CIRCUIT)
OTHER DAYS WALK/ LEISURE ACTIVITIES
I
INTENSITY
70% - 85% OF PREDETERMINED PEAK HEART RATE
12 – 13 RPE (BORG SCALE)
60% - 75 % OF VO2 max ( Prescription is standard for most exercise training programs )
T
TIME / DURATION
20 – 30 MINUTES per session
(not inclusive of warm/up or cool down ) 5 min
T
TYPE/ MODE
AEROBIC, ENDURANCE TRAINING
Resistance exercise 30 to 50% RM 12-15 repetitions, 1 set 2-3 times weekly
17. Heart Rate
Karvonen Formula
THR = ((HRmax − HRrest) × % intensity) + HR rest
Example for someone with a HRmax of 180 and a HRrest of 70:
50% Intensity: ((180 − 70) × 0.50) + 70 = 125 bpm
85% Intensit
Predicted maximal HR
e.g. if patient is 40 years of age and is required to work at 60% - 75% of MHR
220 – Age =
220 – 40 = 180 (MHR)
180 x 60% = 108
180 x 75% = 135
Therefore the THR is (108 -135)
Note: Remember that Beta Blockers reduces the heart rate @ rest & during
exercise. Please take off 20- 30 BPMy: ((180 − 70) × 0.85) + 70 = 163 bpm
18. Indications of exercise &
Cardiac Rehabilitation
1) Myocardial infarction in past 12 months. ( Class 1 )
2) Coronary artery bypass grafting ( Covered by US center medicated services 2006)
3) Post Percutaneous coronary intervention.
4) Heart Valve repair or replacement.
5) Chronic stable angina.
6) Compensated heart Failure with FC11 -1V, symptoms,
EF <35% and stable on medications or no planned
procedure in past 6 weeks. ( Class 11a, added in 2014)
7) Heart/ heart lung transplant
8) Peripheral arterial Disease ( added in 2017 )
19. Base line
Exercise Test.
Objective:
- Assess the patient response to
exercise
- Enable risk stratification for
future events
- Determine medical & rehab management
Info from the result:
- Duration & rate of work achieved
- HR & BP response via exercise
- HR, BP & exercise level at peak/
changes
- Medication during test
- RPE (rate perceive exertion )
20. Base line Exercise
Test
CAD patients should undergo
symptom limited exercise testing on
their usual medications , before
referral ,to establish a baseline
maximal heart rate ,and to exclude
important ischemia , symptoms or
arrhythmias because that would alter
the therapeutic approach.
21. Exercise
Prescription & Proscription
Prescription, Virtually all patients
with known CAD,& PAD if stable
should engage in regular physical
activity. The simplest approach for
clinicians prescribing exercise is to
refer patients to an established
cardiac rehabilitation program.
3 times a week for at least 30 min.
Prescription , Historically exercise
training was prohibited in patients
with HF, with the feeling that it
will compromised LV function.
Different meta analysis conclude
that exercise training improves
exercise tolerance in HF, is safe,
and may reduce mortality.
Proscription, There are few exercise
proscription for CAD patients like during
first week of acute MI, unstable angina ,
exercise induced arrhythmias, ist week of
cardiac surgary, wound infection &
thrombophlebitis. PAD with resting symptoms
Proscription
Advanced HF NYHA class 111 &
1V should refrain from exercise
training until their symptoms
permit exercise.
Coronary artery disease Heart Failure
22. Contraindications
of exercise & CR
Unstable or unresolved angina.
• Fever and acute systemic illness.
• Patient in severe pain.
• Resting blood pressure: SBP>
180mmHg, DBP> 100mmHg
• Significantly unexplained drop
in blood pressure.
• Tachycardia > 100bpm.
• New or recurrent symptoms of
breathlessness, palpitation,&
dizziness.
• Significant lethargy Your Heart… Our Passion
23. Exercise Termination
Criteria
Any angina symptoms
or feeling too breathless to continue
• Feeling dizzy or faint
• Leg pain limiting
further exercise
• Exceeds level of
perceived exertion >
15 (Borg Scale)
• Increased Heart Rate
> 85% as of THR
Your Heart …Our Passion
24. 10 Rules Of Exercise
1. Choose a form of exercise that suits patients
2. Always build up gradually
3. If patients have a break for whatever reason, build up
gradually again
4. Always warm up & cool down
5. Do not allow patients to exercise if they are ill
6. Stop exercise if patients c/o of pain/ feel dizzy/
uncomfortable/ palpitation/ irregular
7. Patients should be able to talk & exercise @ the same time
8. Do not exercise patients immediately after a meal
9. Make sure patients wear suitable clothing & good footwear
10. If in doubt consult your colleague.
25. General
Considerations
Content must be simple & adaptable
• Adopt educational approach
• Monitor type A behavior
• Ensure that goals are
agreed upon rather than
imposed & readily achievable
• Exercise prescription
must reflect individual
differences, patients will differ
greatly in most other
Respects.
Your Heart …….our Passion
26. Clinical
Characteristics
1) Patient population ( Post PCI, Acute MI,CABG )
2) What about heart failure ( Yes Stable HF included )
3) How many training sessions are schedule for each
patient .( 9 -36 sessions)
4) What is the graduation rate ( 75% phase 11 CR )
5) What is the functional capacity goal at the end of
rehabilitation program ?
6) Are baseline stress test performed before the exercise
prescription is written. ( No ,depend upon physician choice
7) Who is writing exercise prescription for CR Patients.
( certified clinical exercise physiologist )
27. Aerobic Exercise
Prescription
1) How often is aerobic exercise performed each week
for each patient?. ( 3 days per week)
2) How is intensity for aerobic training prescribed
3) How is intensity prescribed in absence of baseline
exercise test. ( 11 -14 RPE )
4) How long does each aerobic training last. ( 40 min )
5) What types of training modes are used for aerobic
exercise. ( Treadmill , ergometer)
6) Which type of training is used for aerobic exercise
( Continuous, interval )
7) How are patients progressed throughout their
program. ( combination of intensity & duration)
28. Resistance Exercise
Prescription
1) How many strength training session are performed
each week? ( 1-3 days per week)
2) How is training intensity determined ( Trial & error
RPE )
3) On average , How many sets are performed for each
strength exercise? ( one )
4) On average ,how many strength exercises are
performed each session? ( 6-12 )
5) Which type of resistance training is used ? ( Free
weights, elastic bands, resistance machines, body
weight. )
29. Conclusion
In Clinically stable CAD patients ,who respond to
treatment ,the benefits of physical activity far
outweight the risk .
Indeed regular exercise appears similarly effective
in secondary prevention as many drug interventions
without significant side effects.
Both aerobic and resistance training are safe for
people with stable CAD, as long as they are
assessed properly with suitable exercise
prescription.
30. References
• British Heart Foundation (2002) British Heart
Foundation CHD Statistics
British Heart Foundation
• Campble, N.C , Grimshaw, J.M , Ritchie, L.D and Rawles
,JN ( 1996)
`Outpatient` Cardiac Rehabilitation ; are the potential
benefits being
realised?’ Journal of the Royale College of Physicians,30,
pp.514-19
• Ewart , C.K , Taylor , C.B, Reese, L.B and de busk , R.F
(1983) ` Effects of
Early post-myocardial infraction exercise testing on self-
perception and
subsequent Physical Activity’ American journal
Cardiology ,51, pp.1076-80