Cardiac Rehabilitation

واحدی هوشنگ دکترامیرتوانبخشی و فیزیکی متخصصطب

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BackgroundCVD are the leading cause of mortality and

morbidity in the industrialized world, accounting for almost 50% of all deaths annually.

CR aims to reverse limitations experienced by patients who have suffered the adverse pathophysiologic and psychological consequences of cardiac events.

CR has been provided to somewhat lower-risk patients who could exercise without getting into trouble.

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History In 1912→Herrick first described a MI.→Bed rest for 2

months . In the 1930s, patients with MI→observe 6w of bedrest. In the 1940s, and by the early 1950s→ Chair therapy & 3-

5 minutes of daily walking , (beginning at 4 weeks). Clinicians gradually recognized → early ambulation.

→safety of unsupervised exercise ?→ development of structured, physician-supervised rehabilitation programs, which included clinical supervision, &ECG monitoring.

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History In the 1950s, Hellerstein presented his methodology for

the comprehensive rehabilitation of patients recovering from an acute cardiac event.

He advocated a multidisciplinary approach to the rehabilitation program.

His approach was adopted by ‘CR programs’ throughout the world. Despite multiple advances, Hellerstein's original ideas have not been

improved upon significantly. However, due to changing patient demographics, many more patients

now have the opportunity to receive the benefits offered by CR. Multifactorial intervention, including aggressive risk factor

modification, has become an integral part of present day CR.

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Goals of cardiac rehabGreater physical activity.Improved risk profile.Improved quality of life.Better social functioning.Less hospital admission.Improved survival.Reduced recurrent events.

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Indication of cardiac rehab

Patient with MI.Post CABG Patients.Post PTCA Patients.Stable angina patients.HF (stable patient in class II &III of NYHA)Post valvular surgery patients.Post heart transplantation.

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NYHA-New York Heart Association classification:

Class 1: Heart disease without symptoms

Class 2: Heart disease with symptoms during ordinary activity

Class 3: Heart disease with symptoms during less than ordinary activity

Class 4: Heart disease with symptoms at rest

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PRESENT PROBLEMS WITH CARDIAC REHABILITATION

The major present problem with exercise-based cardiac rehabilitation is its underutilization.

(25 to 30 percent of men and 11 to 20 percent of women)

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INSURANCE COVERAGEStarting March 22, 2006*1.    Have had an acute AMI within the preceding 12

months   * 2.    Have undergone CAGB    *3.    Have stable angina pectoris    4.    Have undergone a cardiac valve repair or replacement    5.    Have undergone PTCA    6.    Have received a heart or heart-lung transplant 7. HF???

Routine coverage is for a total of 36 exercise sessions.9

Contraindication of CR

UA.Uncontrolled atrial or ventricular

arrhythmia. Uncontrolled HF.Moderate to severe AS.Resent thrombophelebitis or PE.Non cardiac reasons(orthopedic or other

disease).10

Cardiac rehabilitation:

Exercise:

Monitoring

Non monitoring

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Criteria for ECG monitoring during exercise

1-Severely depressed LV function (EF<30%).

2-Resting complex ventricular arrythmia.

3-Ventricular arrythmias appearing or

increasing with exercise.

4-Survivors of sudden cardiac death.

5-Decrease in systolic blood pressure with

exercise. 12

Criteria for ECG monitoring during exercise

6-Survivors of MI complicated by CHF, cardiogenic shock, serious ventricular arrythmias or some combination of three.

7-Severe CAD and marked exercise-induced ischemia(ST segment depression greater than or equal 2mm).

8-Initially to self-monitor HR because of physical or intellectual impairment.

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Risk stratification

Acute event.

Clinical stability.

Residual ventricular function.

Functional capacity.

Myocardial ischemia & arrythmias.

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Risk stratification

Low

Intermediate

high

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Low risk patients

Uncomplicated in acute phase.

EF>=50%

No detectable residual ischemia.

No complex arrythmias.

Functional capacity>6 METs.16

Intermediate risk patients

31< EF >49%.

Exercise ST segment depression below 2 mm.

No sustained ventricular arrythmias.

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High risk patients

Survivors sudden cardiac death.

Complications during acute phase.

EF<30%.

Myocardial ischemia with ST segment

depression greater than 2 mm.

Complex ventricular arrythmia at rest.

Decrease in SBP>15mmHg during exercise. 18

Readiness for cardiac rehab.:To begin rehab.

• No new or reccurent chest pain in past 8 hours.

• Ck or troponin levels are not rising.

• No new sign of uncompensated HF (dyspnea at rest & basilar rals.)

• No new significant abnormal rhythm or ECG changes in past 8 hours.

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Progression of rehab.

Adequate HR increase.Adequate SBP rise to within 10-40 mmHg

from rest.No new rhythm or ST change on telemetry

rhythm strip.No cardiac symptoms such as palpitation,

dyspnea, excessive fatigue or CP.

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RECOMMENDATION FOR MONITORING

Lowest risk for exercise prescription

Moderate risk for exercise prescription

Highest risk for exercise prescription

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Lowest risk for exercise prescription

Direct staff suppervision for 6-18 exercise session or 30 days post event or procedure,beginning with continuous EKG monitoring and decreasing to intermittent EKG monitoring (at 6-12 session)

For a patient to remain at Lowest risk normal ECG & hemodynamic, no sign or symptoms and progression of exercise should be normal.

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Moderate risk for exercise prescriptionDirect staff suppervision for 12-24 exercise session

or 60 days post event or procedure,beginning with continuous EKG monitoring and decreasing to intermittent EKG monitoring (at12-18 sessions)

For a to patient move to lowest risk normal EKG & hemodynamic,no sign or symptoms and progression of exercise should be normal.

Abnormal EKG & hemodynamic during exercise, abnormal sign & symptom within or away from exercise & need to severely ↓ exercise level → remain in moderate risk or move to ↑ risk category. 23

Highest risk for exercise prescription

Direct staff suppervision for 18-36 exercise session or 90 days post event or procedure,beginning with continuous EKG monitoring and decreasing to intermittent EKG monitoring (at18-24 sessions)

For a patient move to moderate risk category: normal EKG & hemodynamic,no sign or symptoms within or away from exercise, and progression of exercise should be appropriate.

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ET before starting cardiac rehab.ET is useful, especially those after recent MI,

but not all patients, undergo such testing. Patients who did not undergo exercise testing before the

program can exercise at a heart rate 20 beats faster than their resting value.

• their resting HR plus a specified additional percent of rest.

month 1→ rest HR+20 to 30 percent rest HR;month 2→ rest HR+20 to 40 percent rest HRmonth 3→ rest HR+20 to 50 percent rest HR

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Four step of cardiac rehab.

Phase 1: Inpatient rehabilitation

Phase 2: outpatient rehabilitation

Phase 3: Supervised rehabilitation

Phase 4: Maintenance

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Phase 1

Inpatient rehabilitation, usually lasting for the

duration of hospitalization. It emphasizes a

gradual, progressive approach to exercise and

an education program that helps the patient

understand the disease process, the

rehabilitation process, and initial preventive

efforts to slow the progression of disease.28

Phase 1 goals;Clear the patient for any skeletal, muscle, and

orthopedic problems.Clear the patient for any pulmonary problems that

would limit activityReturn the patient home and workplace→safe

activity (without reinjuring their hearts)Decrease the patient pain & fear of living.Increase the patient,s physical work capacity.Help the patient to modify their coronary risk factor.Give objective information back to all member of

CR team. 29

Component of CR P1

The rehabilitation specialist →risk factor for CAD and reduce them.

The physical therapists→early mobilization

The registered dietitation→dietery change

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Phase 1 exerciseInclude ROM activity, walking, exercise to

stretch muscle and stair climbing.

This is done to: enhance recovery, decrease deconditioning associated with bed rest(muscle atrophy, blood clot formation...)& improve confidence for long term lifestyle change.

The exercises are individualized for patient depending on medical condition.

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General guidelines for exercise priscription(for recommendation)

Week 1:walk 3-5 min. Continuously 3-4 times daily.

Week 2:walk 6-10 min. Continuously 3 times daily.

Week 3:walk 11-15 min. Continuously 2 times daily.

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Plan exercise into one dayDont exceed a 20 min. Continuously without your

doctor,s okey.May add a few extra walks if you can tolerate it,

avoid doing too much; avoid fatigue.Rest 20 min.before & after walking.Walk at a pace that feels fairly easy( should be able

to talk)Wait at least 1 h. after a meal before you go walking

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Walking often with assistant→target heart rate <20 beat above the resting heart rate.

At discharge the patient should undrestand what activities are safeand which activities should be avoided for the next several weeks.

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Phase 1.5 (post discharge phase)Begin after the patient returns home from the

hospital.Team member check the patient’s medical status.This phase of recovery include low-level exercise &

physical activityRisk reduction strategies are emphasized again.

After 2-6 weeks of recovery at home the patient is ready to start CR phase 2.

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Phase 2

Multifaceted outpatient rehabilitation, lasting 2-3 mo.

Emphasizes safe physical activity to improve conditioning with continued behavior modification aimed at smoking cessation, weight loss, healthy eating, and other factors to reduce disease risk.

Initiate an exercise prescription37

Exercise program design

Warm-up period

Conditioning period

Cool-down period

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Warm-up period

Static stretching

Dynamic R.O.M

Low level dynamic aerobic activity

(25-40% of pt's F.C)

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Conditioning period(focus on following activity)

To increase caloric expenditure(weight management)

To improve overall F.CTo delay the onset of symptomsTo maintain current fnnctional abilityTo improve muscle tone or strenghtTo obtimize job or avocational abilities. To obtimize recreational activities performance.To obtimize activities of A.D.L(activity of daily

living)40

In conditioning period cosider:

Frequency

Intensity

Mode

Duration

Rate of progression.41

Frequency affected by:

Overall goal of CR program.

Functional ability of the patient

The type and intensity of activity

The patient interests.

Level of personal commitment &recent activity

history.42

Averrage rehab. Program frequency:

Begin with 3 time per week at least 3to6 months and after this time the program can be extended to 4-5 time per week.

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Intensity–Can be determined by:

• Work load, MET’s & exercise intensity

• Heart rate and & exercise intensity

• RPE & exercise intensity

• Oncet of symptom & exercise intensity

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Work load, MET’s & exercise intensity

ACSM recommended VO2 Reserve as a method to prescribe exercise intensity.

Gaskell et. al (2004) demonstrated %HRR is better related to %VO2max than to VO2R in 630 initially sedentary individuals (ages 17 to 65 years).

Gaskell concludes %VO2max is the better measure for prescribing exercise intensity.

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Heart rate and & exercise intensityThe Karvonen Formula:220 - Age= Predicted MHR- RHR(average of 3

mornings)= HRRHRRx.50( )+ RHR= Minimum Training ThresholdHRRx .85 ( )+ RHR= Maximum Training Threshold

=========================================

Target heart rate:50( )%-85( )% MHR is Target HR

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Borg Scale for Rating Perceived Exertion

15-grade scale 10-grade scale

6 0 Nothing

7 Very, very light 0.5 Very, very weak (just noticeable)

8 1 Very weak

9 Very light 2 Weak (light)

10 3 Moderate

11 Fairly light 4 Somewhat strong

12 5 Strong (heavy)

13 Somewhat hard 6

14 7 Very strong

15 Hard 8

16 9

17 Very hard 10 Very, very strong (almost maximum)

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19 Very, very hard ° Maximum

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RPE OF 12-16 = 60-85%H.R Responce

(somewath hard to hard)

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Oncet of symptom & exercise intensity

Oncet of symptom should be an absolute determinat of the upper limit of exercise intensity;

Drop in SBP/Exaggerated BP response/>2mm ↓ST segment/↑Chest pain/Fatigue/Shortness of breath/ Wheezing/Leg cramps/Intermittent claudication/ CNS symptom/Arrythmia/ Patient request to stop.

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ModeDepend on the;

• Specific goal• Needs• Ability of the patient.

P.F.C of cycle ergometry=85% P.F.C of treadmillP.F.C of arm ergometry=60% of cycle ergometry

• (P.F.C= peak functional capacity)

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Rate of progression

Must be determined by;

–Current level of fitness

–Prior activity history

–Health status

–Age

– sex

–Personality

–Goal of rehabilitation 50

Cool-down period: 1. Active aerobic exercise

2. Static stretching

3. Gentle R.O.M • 3-10 min. Low level rhythmic, aerobic activities.

• Enhance venous return

• Minimize postexercise hypotention

• Help to removing lactate

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قلب اساسضربان بیماران CAD بر در ورزش تجویز

Phase 3

Supervised rehabilitation, lasting 6-12 mo. Establishes a prescription for safe exercise that can be performed at home or in a community service facility, and continues to emphasize risk factor reduction

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Policies and Procedures Admission Process

Referral from Phase 2New Exercise Prescription

Assign Care Coordinator

Orientation to Phase 3

Direct AdmitsNursing Assessment

Monitored Exercise Session

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Policies and Procedures

Forms

Exercise Log

Risk Factor Management Report

Emergency Sheet

Annual Physician Letter

Support Person

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EventsPicnic

Golf

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Phase 4

Maintenance, indefinite

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Many patients cannot attend supervised exercise training sessions because a CR program is not available or because it is not convenient to attend supervised sessions.

•Patients without lower limb orthopedic problems should be encouraged to use brisk walking as their exercise training modality.

•exercise to the onset of mild dyspnea for the reasons mentioned earlier. Such an approach obviates the need for pulse monitoring.

•using the “talk test” (comfortable conversation58

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