Dr. Vinod K. RavaliyaCardiothoracic Physiotherapy Shree Krishna Hospital KMPIP, Karamsad
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 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.
Coordinated, multifaceted interventions designed to optimize a cardiac patient’s physicial, psychological, and social functioning, in addition to stabilizing, slowing or even reversing the progression of the underlying atherosclerotic process, thereby reducing morbidity and mortality AHA Scientific Statement, Circ 2005;111:369-76
Post-MI Post-CABG Angina PCI Valve replacement or repair Heart transplant Indications for CHF continue to be evaluated
Benefits of exercise Recent studies Components of exercise class Health and Safety recommendations
Offset deleterious pyschologic and physiologic effects of bed rest during hospitalization Provide additional medical surveillance of patients Enable patients to return to activities of daily living within the limits imposed by their disease Prepare the patient and the support system at home to optimize recovery followed by hospital discharge HM734 Exercise Testing and Prescription: Cardiorespiratory 9
Reduces cardiovascular and total mortality Does not increase non-fatal reinfarction rate Improves myocardial perfusion May reduce progression of atherosclerosis when combined with aggressive diet No consistent effects on hemodynamics, LV function or visible collaterals
No consistent effects on cardiac arrhythmias 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
Physical activity: improves glucose metabolism reduces body fat lowers blood pressure improves musculoskeletal strength controls body weight reduces symptoms of depression
A Cochrane review in 2004 concluded that exercise only cardiac rehabilitation reduced all cause mortality by 27% and cardiac mortality by 31% The Canadian Co-ordinating Office for Health Technology Assessment reported reductions of all cause mortality of 24% and cardiac mortality of 23%. A study by Witt et al in 2004 found that not only was participation in cardiac rehab associated with decreased mortality after MI but also with lower risk of recurrent MI
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 testing.
Absolute Acute myocardial infarction (within two days) Unstable angina Uncontrolled cardiac arrhythmias causing symptoms or homodynamic compromise Symptomatic severe aortic stenosis Uncontrolled symptomatic heart failure Acute pulmonary embolus or pulmonary infarction Acute myocarditis or pericarditis Active endocarditis Acute aortic dissection Acute noncardiac disorder that may affect exercise performance or be aggravated by exercise Inability to obtain consentExercise standards for testing and training: a statement for healthcare professionals from the American Heart Association. Circulation 2001; 104:1694
Left main coronary stenosis or its equivalent Moderate stenotic valvular heart disease Electrolyte abnormalities Severe hypertension (systolic 200 mmHg and/or diastolic 110 mmHg) Tachyarrhythmias or bradyarrhythmias, including atrial fibrillation with uncontrolled ventricular rate Hypertrophic cardiomyopathy and other forms of outflow tract obstruction Mental or physical impairment leading to inability to cooperate High-degree atrioventricular block Exercise standards for testing and training: a statement for healthcare professionals from the American Heart Association. Circulation 2001; 104:1694;
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 Secondary preventive targets
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.
Functional goals – Exercise training Psychosocial goals – Return to work – Return to hobbies and lifestyle – Anxiety/depression management Secondary preventive targets
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.
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
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. 32
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 33
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). 34
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, 35
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. 36
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. 37
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% VO2R 38
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 39
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. 40
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. 1mm ST-segment depression Increasing frequency of ventricular arrhythmias Other significant ECG changes Other signs or symptoms of intolerance to exercise 41
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. 42
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. 43
Patients requiring intermittent program (eg. Peripheral vascular disease, low functional capacity) should progress according to symptoms and clinical status 44
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 45
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 46
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. 47
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. 48
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. 49
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. Avoid Valsalva 50
Hypertension -<140/90, 130/85 in high risk groups Diabetes – HbA1C <7 Obesity – Set weight goals – 5 lbs in the 3 months of phase 2