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.

1. CENTER FOR PHYSIOTHERAPYAND REHABILITATION
SCIENCE JAMIA MILLIA ISLAMIA
Topic: Phase -1 Cardiac Rehabilitation in CABG patients.
Shagufa Amber
MPT- 3rd Semester
Roll no.- 19MPC0006

2. 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.

3. PHASE -1 (INPATIENT REHABILITATION) IN CABG:
The main purpose of this phase is to counteract the deconditioning effects of prolonged bed
rest, return to normal daily activities and maintenance of work capacity, strength and
flexibility.
CABG patients, being weak cannot tolerate long bouts of exercise in this phase so prolonged
warm up and cool down period is observed and the necessary exercise therapy, activities in
daily living and counselling is done.
1. Firstly we need to do physical assessment of the patient, reviewing the medical records and
drugs taken, assessment of the incision and sternum and patient’s mental status in regard to
the rehabilitation program.
2.Range of motion exercises: It includes the shoulder flexion, abduction, internal and
external rotation, elbow flexion, hip flexion, abduction, external and internal rotation, ankle
dorsiflexion, plantarflexion, eversion and inversion.Upper limb Range of motion is more
important pertaining to enhanced blood flow and healing.
(10 -16 repetitions two times a day, and progressing with 0.5-1.5kg wrist weights)

4. ACSM and AACVPR contraindications prior to exercise therapy:
-Unstable angina
-Resting bp(systolic greater than 200mmHg and diastolic greater than 100mmHg)
-Orthostatic BP drop of more than 20mmHg
-Uncontrolled CHF
-Third degree atrioventricular block
-Recent embolism
-Thrombophlebitis
-Uncontrolled diabetes
-Orthopaedic problems hindering exercise
-Moderate to severe aortic stenosis
-ST depression( greater than 3mm)
-Uncontrolled sinus tachycardia
- Active pericarditis
-Active systemic illness or fever
-Uncontrolled ventricular or atrial dysrhythmias

5. 3.Ambulation:In CABG surgery patient the ambulation may start as early as the first day. But due
to prolonged bed rest orthostatic hypotension and reflex tachycardia is very common. The blood
pressure measurement is taken in sitting and standing after 30sec. The drop of 20mmHg systolic
BP or more is contraindicated. It needs to be maintained for 90mm Hg.
Ambulation shall include 1.5-3 MET self care activities progressing to slow walking, range of
motion exercises, and in later part stair climbing, stationary cycling.
(It is done twice daily under supervision and extended till 20 minutes depending on the
patient.)
4.Exercise intensity: In CABG patients, the intensity donot exceed 2-3 MET in the first phase,
and is determined by calculating the target heart rate .
The target heart rate is calculated by adding 10-20 beats/min to the resting standing heart rate
and not by the fixed low level heart rate.
Borg rating of perceived exertion scale is used and upto 10-12(light) points.
Heart rate responses during exercises and ambulation donot rise more than 5-10 beats/min from
the resting standing levels.
The systolic blood pressure donot rise more than 5mmHg during exercises and 10-20mmHg
during ambulation.

6. 5.Frequency: Its recommended twice to thrice daily.
6.Duration: The CABG patients extends for 10-20 minutes each time.
7.Discharge planning: The predischarge plan should include strategies for risk modification,
exercise prescription, counselling, dietary and medical planning.
The exercise prescription includes the range of motion exercises, walking, stair climbing,
stationary cycling and extended warm up and cool down period.
The patient shall know to interpret RPE, heart rate responses and need to be alert.

7. ACSM guidelines to terminate exercise session
-Fatigue
-Onset of angina with exercise
-Failure of monitoring equipment
-Excessive hypotension
-Inappropriate bradycardia( drop greater than 10beats/min)
-Light headedness, confusion, ataxia, cyanosis, nausea, peripheral circulatory
insufficiency.
-Symptomatic supraventricular tachycardia
-Ventricular tachycardia
-ST displacement(3mm) horizontal or down sloping from rest.
-Exercise induced left bundle branch block.
-Onset of second or third degree atrioventricular block

8. Progression of training among different group of individuals.
The CABG patient’s rate of progression is higher than MI in the first 6 weeks as it takes time
for healing and scar tissue of the myocardium. Beyond 6 weeks the rate of progression is
equal in both.
From Pallock, M.L. And J.H.Wilmore, 1990.

9. Inpatient physical activity, Education programme schedule and Guidelines for CABG
patients.( Guidelines are modified from the outlines by Wenger and Hellerstein )

10. These guidelines were designed so that at Step 6 of the CABG protocol, the patient goes to an
inpatient centre once a day for physical activity. Patient shall progress one step a day ,however it
is individualised accordingly.

11. Author/Jou
rnal’s
name/Impa
ct factor
Title Methodology Result Conclusion
Dejan et
al,.2016
Clinical
Cardiology
Impact
factor:2.4
Very
short/short-term
benefit of
inpatient/outpati
ent cardiac
rehabilitation
programs after
coronary artery
bypass grafting
surgery
They studied 54 consecutive
patients with myocardial
infarction (MI) treated with
CABG surgery referred for
rehabilitation. The study
population consisted of 50 men
and 4 women,who participated
in a 3-week clinical and 6-
month outpatient cardiac
rehabilitation program. The
Inpatient program consisted of
cycling 7 times/week and daily
walking for 45 minutes. The
outpatient program consisted
mainly of walking 5
times/week for 45 minutes and
cycling 3 times/week. All
patients performed symptom-
limited CPET on a bicycle
ergometer with a ramp protocol
of 10 W/minute at the start, for
3 weeks, and for 6 months.
After 3 weeks of an
exercise-based cardiac
rehabilitation program,
exercise tolerance
improved as compared
to baseline, as well as
peak respiratory
exchange ratio. Most
importantly, peak
VO2, peak VCO2
peak ventilatory
exchange and peak
breathing reserve were
also improved. The
same improvement
trend continued after 6
months.No major
adverse cardiac events
were noted during the
rehabilitation program.
Very short/short-
term exercise
training in
patients with MI
treated with
CABG surgery
was safe and
improved
functional
capacity as well
as test duration,
workload, and
HR response.

12. Author/Journa
l’s
name/Impact
factor
Title Methodology Result Conclusion
Yuji et al., 2017
Heart Vessels
Impact factor-
1.6
Predictors
of improveme
nts in exercise
capacity
during cardiac
rehabilitation
in the recover
y phase
after coronary
artery bypass
graft surgery
versus acute
myocardial
infarction
They studied 152
patients (91 after AMI
and 61 after CABG)
who participated in a 3-
month CR program. All
patients underwent a
cardiopulmonary
exercise test, blood
tests, maximal
quadriceps isometric
strength (QIS)
measurement, and
bioelectrical impedance
body composition
measurement at the
beginning and end of
the 3-month CR
program.
At baseline, the (%pred-
PVO2), maximal QIS, and
hemoglobin (Hb) were
significantly lower, while
C-reactive protein (CRP)
was significantly higher, in
the CABG than the AMI
group. After the 3-month
CR, %change in PVO2 was
significantly greater in the
CABG than AMI group .At
univariate analysis, change
in plasma hemoglobin
(ΔHb) significantly
correlated with %ΔPVO2 in
the CABG group, whereas
only baseline %pred-PVO2
did so in the AMI group.
In the CABG
patients both
enhancing QIS
(quadriceps
isometric
sstrength)and
correcting
anemia may
contribute to
greater
improvements
in exercise
capacity after
CR, whereas in
AMI baseline
%PVO2 is the
dependent
reason.

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15. THANK YOU !!!