A classroom presentation on cardiac rehabilitation

1. Cardiac
Rehabilitation
Presented by-
Dr. Jheelam Biswas
Resident, Phase A
Palliative Medicine, BSMMU

2. What is cardiac rehabilitation
 The term cardiac rehabilitation refers to
coordinated, multifaceted interventions
designed to optimize a cardiac patient’s
physical, psychological, and social
functioning, in addition to stabilizing,
slowing, or even reversing the progression
of the underlying atherosclerotic processes,
thereby reducing morbidity and mortality.

3. Core components
Source: British Association for Cardiovascular Prevention and

4. Outcomes: 1996 AHCPR
Guidelines
 Smoking cessation
 Lipid management
 Weight control
 Blood pressure control
 Improved exercise tolerance
 Symptom control
 Return to work
 Psychological well-being/ stress
management

5. Members of a cardiac rehab
team
 Cardiologist
 Specialist Nurse
 Physiotherapist
 Dietitian
 Psychologist
 Exercise specialist
 Occupational therapist

6. Indications
 Post-MI
 Post-CABG
 Angina
 PCI, PTCA
 Valve replacement or repair
 Heart transplant
 Compensated CHF
(Source: Medcare, American Heart
Association)

7. Phases of cardiac
rehabilitation
 Acute Phase (Phase I)
 Convalescent Phase (Phase II)
 Training Phase (Phase III)
 Maintenance Phase (Phase IV)

8. Phase I
Acute phase

9. Definition
 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.

10. Objectives
 Early mobilization and adequate discharge
planning.
 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.

11. Mobilization- Post MI
 The classic Wenger cardiac rehabilitation
program was to get individuals from bed
rest to climbing 2 flights of stairs in 14 days.
 Under current practices, clinicians have
modified the classic program of cardiac
rehabilitation in of 3–5 days .

12. Steps of mobilization
 Day 1-2 : bed rest, bed mobility, sitting on
the bed, breathing exercises
 Day 3: short distance ambulation and
bathroom privileges with monitoring
 Day 4-5: home exercise program, climbing
stairs, and increasing duration of
ambulation.
 Intensity: Post MI HR 20bpm and SBP
20mmhg from base line, RPE <13 in a 6-20
Borg scale (old scale)

13. Mobilization – Post PTCA
◦ May ambulate at comfortable pace
following surgery
◦ Avoid aerobic training for 2 weeks post-op
◦ Exercise prescription to be based on post-
op ETT results
◦ Often progress faster than MI patients

14. Patient and family education

15. Cardio-protective therapies
 Anti-platelet therapy
 Lipid-lowering therapies
 Beta-blockers (Post myocardial infarction)
 ACE inhibitors/ARBs
 Calcium channel blockers
 Anticoagulants if necessary
 Diuretics if necessary (e.g. heart failure)
( Source: British Association for Cardiovascular
Prevention and Rehabilitation)

16. Risk factors management
Initially-
 Lipid management
 Hypertension management
 Diabetes management
Advice about-
 Smoking / Tobacco cessation
 Lifestyle modification
 Stress management

17. Lipid management
 Goal: LDL<100 mg/dl (<70 mg/dl is
desirable), HDL >40 mg/dl, TC >200 mg/dl,
TG <150 mg/dl
 Intervention: If LDL > 100 mg/dl, advice
nutritional counseling and weight reduction
and Statins are prescribed.
If HDL < 40 mg/dl, advice exercise, smoking
cessation.

18. Hypertension management
 Goal: Optimal BP is < 120/80 mmHg
 Intervention: If BP >130/80 mmHg advice
about lifestyle modification before
discharge . Add drug therapy for patients
with diabetes, heart failure, or renal failure.
If BP > 140/90 mmHg advice lifestyle
modification and initiate drug therapy.

19. Diabetes management
 Goal: Near normal fasting plasma
glucose(< 7 mmol/l) and near normal HbA1
C (<7)
 Intervention: Appropriate hypoglycemic
therapy e.g. diet modification, oral
hypoglycemic agents and/or insulin

20. Psychosocial management

21. Survival kit before discharge
 Clear information about medication
 Clear advice on managing chest pain and
reassurance
 Advice and information on ‘what and when
they can do’ (work, travel, exercise etc)

22. Phase II
Convalescent Phase

23. Definition
 This phase encompasses the immediate
post discharge period, which is typically a
period of four to six weeks.

24. Objectives
 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.

25. Assessment before phase II
rehabilitation
 Vitals (HR, BP, RR and rhythm, RPE, O2 sats,
pulses)
 Dyspnea
 Auscultation of lungs
 Edema
 Surgical sites
 Heart rhythm via ECG if monitored
 Pain
 Posture
 Strength
 Medications and effects

26. Exercise guidelines
 Frequency: 3 times /wk,
 Duration: 30-60 minutes (5-10 min of warm-
up and cool down)
 Mode: walking and/or cycle/arm ergometer
and strength training
 Intensity: Submaximal, or determined by
ETT data upto a level of 70% maximum HR
or MET level 5 or RPE 7 in modified Borg
scale.

27. Exercise guidelines (cont..)
• Strength training
begin at 3 weeks cardiac rehab, 5 weeks
post MI, 8 wks post CABG
Begin with bands and light weights (1-3
lbs)
Progress to moderate loads, 12-15 reps

28. Risk factor management
 It includes the risk factors addressed as in
the phase I.
 Lipid, hypertension and diabetes
management must be continued as in
phase 1.
 Active initiation of smoking cessation, and
weight reduction.

29. Psycho-Social Rehabilitation
 Common psychological reactions: low
mood, tearfulness, sleep disturbance,
irritability, anxiety, acute awareness of
minor somatic sensations or pains, poor
concentration and memory.
 Proper counseling must be done. Seek
professional help if needed.

30. Phase III
Training Phase

31. Definition
 This phase is sometimes erroneously
referred to as the ‘Exercise’ phase. The
duration of Phase 3 may vary from six to 12
weeks.
 It incorporates exercise training in
combination with ongoing education and
psychosocial and vocational interventions.

32. Objectives
 Functional goals – Exercise training under
supervision
 Psychosocial goals – Return to work, return
to hobbies and lifestyle, anxiety/depression
management
 Secondary preventive targets

33. Components

34. Assessments before phase III
rehab
 Clinical risk stratification is suitable for low
to moderate risk patients undergoing low to
moderate intensity exercise.
 Low level ETT and ECHO are
recommended for high risk patients and/or
high intensity exercise.

35. Assessments (cont…)
 Vitals: PR, RR, BP, SpO2, ECG findings
 Respiratory, cardiovascular, CNS system
examination
 Weight
 Waist circumference
 Lipids
 Blood Glucose/HbA1C

36. Risk stratification before exercise
 Ischemic risk-
 Postoperative angina
 LVEF (EF <35%)
 NYHA grade III or IV CHF
 Ventricular tachycardia of fibrillation in the
postoperative period
 SBP drop of 10 points or more with
exercise
 Excessive ventricular ectopic with exercise
 Myocardial ischemia with exercise

37. Risk stratification before exercise
 Arrhythmic risk-
 Acute infarction within 6 weeks
 Active ischemia by angina or exercise
testing
 Significant left ventricular dysfunction (LVEF
<30%)
 History of sustained VT
 History of sustained life-threatening SVT
 Initial therapy of a patient with a rate
adaptive cardiac pacemaker

38. Exercise prescription
 The Modified Borg RPE (rate of perceived
exertion) scale and % HRmax (220- age of
the person) are considered during
prescription of exercise.
 In low risk patients, a program to achieve
85% of the maximum HR is safe. But in the
patients with risk of angina or arrhythmia,
achievement of HRmax as low as 60% is
safe.

39. Rate of Perceived Exertion (RPE)*
Sing – Talk –Gasp Test
Gasp: breathing heavily
Talk: enough breath to carry a conversation
Sing: Enough breath to sing
*Modified Scale adapted by Borg
Maximal
10 very, very hard
9
8
7 very hard
6
5 hard
4 somewhat hard
3 moderate
2 easy
1 very easy
0.5 very, very easy
0 nothing at all

40. Heart Failure
 Criteria for exercise-
Medically stable
Exercise capacity >3 METS
 Exercise training-
Prolonged Warm up and cool down
Low intensities (40-60%)
Increase duration as tolerated
Maintain HR below 115 bpm
Monitor RPE: fairly light
Avoid isometrics
May include light resistance

41. Exercise Modalities in Heart Failure
(2013 Candian Heart failure management guideline)
Discharged with
Heart Failure NYHA I-III NYHA IV
Flexibility Exercises Recommended Recommended Recommended
Aerobic Exercises
•Selected population only
•Supervision by an expert
team needed
• Walk
• Treadmill
• Ergocycle
• Swimming
•Selected population only
•Supervision by an expert
team needed
Continuous training:
Moderate intensity:
• RPE scale 3-5,or
• 65-855 HRmax, or
• 50-75% peak VO2
Moderate intensity aerobic interval may be incorporated in
selected patients
• Intervals of 15-30 seconds with a RPE scale of 3-5
• Rest intervals of 15-30 seconds
• Intensity
• Starting with 2-3 days/week
• Goal: 5 days/week
• Frequency
• Selected population only
• Supervision by an expert
team needed
• 10-20 repetitions of 5-10 pounds free weights
•Selected population only
•Supervision by an expert
team needed
Isometric/Resistance
Exercises
• Starting with 10-15 minutes
• Goal: 30 minutes
• 2-3 days/week• Frequency
• Suggested modality
• Intensity

42. STOP Exercise
◦ Persistent dyspnea
◦ Dizziness/confusion
◦ Onset of angina
◦ Leg claudication
◦ Excessive fatigue, pallor, cold sweat
◦ Ataxia, incoordination
◦ Bone/joint pain
◦ Nausea/vomiting
◦ Systolic BP>200 mmHg, Diastolic BP >110
mmHg
◦ Significant changes in ECG

43. Contraindications of exercise
training Unstable angina
 Resting systolic BP (SBP) > 200 mm Hg or resting
Diastolic BP (DBP) > 110 mm Hg . Orthostatic BP
drop of >20 mm Hg with symptoms.
 Critical aortic stenosis
 Uncompensated CHF.
 3rd degree atrioventricular (AV) block wihout
pacemaker.
 Active pericaditis or myocarditis.
 Recent embolism
 Thrombophlebitis
 Resting ST-segment depression or elevation (>
2mm)..

44. Lifestyle modification
 Patients must be regularly monitored for
DM, HTN control in very visit, and change in
drug therapy and exercise as needed.
Blood lipids must be monitored 2 months
after initiation of drug therapy.
 Diet modification, smoking cessation and
weight reduction, stress management must
be addressed.

45. Nutritional Counseling
 Recommended diet low in fat (especially
saturated fat), and high in complex
carbohydrates.
 Diet should consist of 50-60% calories from
carbohydrates, up to 30% from fat (with
saturated fat forming 10% or less), and 10-
15% from protein.
 Individualized plans should be formulated,
depending on the presence of other risk
factors.

46. Weight management
 Goal: BMI 21-25 kg/m2 , waist < 35 inches
in men and < 31 inches in women.
 Intervention: Advice a reduction in total
caloric intake, and increase in energy
expenditure through a combined program of
diet, and exercise.
Initially reduction of weight 10% from
baseline is indicated. If successful, then
further reduction can be advised.

47. Smoking/ Tobacco cessation
 Goal: Complete cessation
 Intervention: Provide individual education
and counseling. Encourage patient to quit
in every visit.
Provide nicotine replacement and
pharmacological therapy as appropriate.

48. Return to Work
 Although improvement in functional
capacity and the associated reduction in
cardio-respiratory symptoms may enhance
a cardiac patient’s ability to return to work.
 The time to return to work, after an MI can
vary greatly from about two weeks, to
upwards of six weeks.

49. Phase III
Maintenance Phase

50. Definition
 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 program and continue exercise
and other lifestyle modifications indefinitely.

51. Objectives
 Maintenance of achieved functional status
 Return to work
 Return to hobbies and lifestyle
modifications
 Secondary preventive targets

52. Exercise
 The exercises need to be integrated into
the patient’s lifestyle and interests to assure
compliance.
 The ongoing exercises should be
performed at the target HR for at least 30
minutes, three times a week, if at a
moderate level. If at a low level, exercises
need to be performed five times a week.

53. Secondary prevention
 The secondary prevention measures also
need to be integrated into the patient’s
lifestyle.
 The continued control and monitoring of
DM, HTN, lipids must be ensured.

54. Patient and family
responsibilities
 Self care and self management in
emergency situations
 Family must help the patients to adhere to
their long term managements.
 Patients are often encouraged to join-
 local heart support groups
 community exercise and activity groups
community dietetic and weight
management services
 smoking cessation services.

55. Special conditions

56. Stable angina
 Full-level ETT should be done in order to
determine the maximum HR, and angina
threshold.
 The program of rehabilitation can begin at
phase III (training).
 The primary goal of rehabilitation in this
group of patients is aimed at increasing
work capacity and education in
primary/secondary prevention strategies.

57. Post-CABG
 Cardiac rehabilitation after CABG has two
stages:
 Immediate postoperative period
 Later maintenance stage.
• In-hospital period lasts 5–7 days.
• At-home program is usually conducted as
an outpatient procedure, and intensity of
exercise is determined according to risk
stratification.

58. Valvular Heart Disease
 In valvular heart disease, the major problem
is often deconditioning along with CHF.
 In patients receiving surgical correction of
the valvular disease, a post-CABG-type
program is used.
 In uncorrected valvular heart disease with
heart failure, the program resembles the
program for CHF.

59. Cardiomyopathy
 Dynamic exercise is preferred with a target
HR 10 bpm. Isometric exercise should be
avoided where possible, and limited to 2-
minute intervals when performed.
 Unstable angina, decompensated CHF,
and unstable arrhythmias are
contraindications to cardiac rehabilitation.

60. Pacemakers
 Should know setting for HR limit
 Use RPE
 ST segment changes may be common
 Avoid aerobic or strengthening exercises
initially after implant

61. Cardiac Transplant
 HR alone is not an appropriate measure of
exercise intensity (heart is denervated).
◦ Use RPE, METS, dyspnea scale, BP
 Use longer periods of warm-up and cool-
down because the physiological responses
to exercise and recovery take longer

62. Benefits
 Reduces cardiovascular and total mortality
 Improves myocardial perfusion
 May reduce progression of atherosclerosis
when combined with aggressive diet
 Improves exercise tolerance without
significant CV complications
 Improves skeletal muscle strength and
endurance in clinically stable patients
 Promotes favorable exercise habits
 Decreases angina and CHF symptoms

63. Thank You…