Cardiac rehabilitation II Dr Rehab F Gwada Contraindication

Cardiac rehabilitation II Dr/ Rehab F. Gwada

Contraindication to exercise program ü Unstable angina. ü Hypertension, ( B. P ≥ 200/100 at rest). ü Moderate to severe aortic stenosis. ü Orthostatic blood pressure drop of > 20 mm. Hg. ü Uncontrolled ventricular or atrial arrhythmia. ü Uncontrolled sinus tachycardia (> 120 b/min. ) ü Decompensated heart failure. ü S-T segment displacement more than 3 mm. ü 3 rd degree of A - V block. ü Acute systemic illness. ü Acute pericarditis, myocarditis or endocarditis. ü Thrombophlebitis. ü Recent embolism. ü Other disorder that may be aggravated by exercise (Severe orthopedic problems.

Effects of Exercise Cardio protective Effects Antiatherosclerotic Lipids ↓ adiposity ↑insulin sensitivity ↓ inflammation Psychologic Depression↓ Stress↓ ↑Social support Antithrombotic Antiischemic Myocardial O 2 demand Platelet adhesiveness Coronary flow ↓ fibrinogen ↓ blood viscosity ↓ endothelial dysfunction Antiarrhythmic ↓ adrenergic activity

Risk Stratification • American Association of Cardiovascular &pulmonary Rehabilitation (AACVPR) (Card Clin 2001; 19: 415 -431) – Lowest Risk – Moderate Risk – High Risk • American Heart Association (Circulation 2001; 104: 1694 -1740) – – Class A Class B Class C Class D

Risk Stratification for Exercise according to AHA Class D: unstable disease for whom exercise is contraindicated. Class C: moderate or high risk of cardiac complications (multiple myocardial infarctions or cardiac arrest, NYHA class III or IV, Exercise capacity of < 6 METs, or significant ischemia on the exercise test Class B: established CHD that is clinically stable. Overall low risk of cardiovascular complications of vigorous exercise Class A: apparently healthy and no clinical evidence of increased cardiovascular risk of exercise.

Risk Stratification for Exercise according to (AACVPR) LOW RISK • if ALL low risk factors are present(indicated for CR) MODERATE RISK • if they meet neither High Risk nor Low Risk standards HIGH RISK • if ANY ONE OR MORE of the high risk factors are present

Risk factors Left ventricular ejection fraction Complex ventricular dysrhythmias Ex. Induced cardiac ischemia hemodynamics with exercise Maximal functional capacity Clinical data low Moderate high >50% 40 -50% <40% No(at rest or during exercise) no at rest or with exercise Yes at moderate level of ex. at low level of 5 -6. 9 METs ex. <5 METs Or in recovery Normal at least 7. 0 METs -Uncomplicated MI, CABG, angioplasty, - Absence of CHF or signs/symptomsindicating post-event ischemia NYHA class II flat or decreasing SBP or HR with increase load 5 -6. 9 METs less than 5. 0 METs NYHA class II MI or cardiac surgery complicated by cardiogenic shock, CHF, and/or signs/symptoms of post-procedure ischemia NYHA class III_IV

New York Heart Association Functional Classification NYHA Class Symptoms I Cardiac disease, but no symptoms and no limitation in ordinary physical activity, e. g. no shortness of breath when walking, climbing stairs etc. II Mild symptoms (mild shortness of breath and/or angina) and slight limitation during ordinary activity. III Marked limitation in activity due to symptoms, even during less-than-ordinary activity, e. g. walking short distances (20– 100 m). Comfortable only at rest. IV Severe limitations. Experiences symptoms even while at rest. Mostly bedbound patients.

Cardiac Rehab Phases Phase III- maintenance program – long term-in which physical fitness and additional risk-factor reduction are emphasized - Phase II- (supervised ambulatory outpatient program spanning 6 -12 weeks or more) exercise, risk factor reduction, reduce morbidity/mortality, improve function and quality of life and build confidence Phase 1: Inpatient Rehab - A program that delivers preventive and rehabilitative services to hospitalized patients following an index CVD event

Phase I Cardiac Rehabilitation

Objectives of Phase I Cardiac Rehabilitation • 1) To initiate early physical therapy activities to : • a) Return to the activities of ADL. • b) To offset the prolonged bed rest effects. • c) To decrease anxiety and depression. • d) To determine the effects of prescribed medications during activities.

The deconditioning effects of prolonged bed rest ü pulmonary complications: Decrease in Lung Volumes and capacities & atelectasis ü Circulatory complications: DVT, Decreased in the circulating blood volume, Orthostatic hypotension ü Musculoskeletal complications: Decrease in the contractile strength of body musculature, joint dysfunction ü Decrease in the physical work capacity.

Objectives of Phase I Cardiac Rehabilitation offset the prolonged bed rest effects ¤Mobilize the patient soon ¤Prevent muscle atrophy ¤Prevent blood clot formation ¤Prevent pneumonia ¤Prevent lethargy

Objectives of Phase I Cardiac Rehabilitation • 2. Patient & Family Education • To outline the course of cardiac rehabilitation and plan for resumption of life at home. • To modify risk factors of atherosclerosis as dietary changes, stop smoking • For Behavior modification as stress management at home &work, creation of hobbies - time out, conflict resolution skills

Education

Objectives of Phase I Cardiac Rehabilitation 3 - Provide A Safe Discharge To Home ü Provide enough physical stamina to go home and perform ADL’s ü Reduce fear

Criteria for termination of inpatient exercise programs: ü Excessive fatigue. ü Failure of the monitoring equipment. ü Peripheral circulatory insufficiency as : pallor, cyanosis, significant exertional dyspnea, ataxia, confusion, nausea and headedness. ü Inappropriate bradycardia (drop of the heart rate more than 10 b/m with increase or no change in the exercise intensity). ü Hypertensive response to exercise. q S. B. P raises about 50 mm. Hg from resting, more than that is hypertensive response. q The D. B. P raises very little about 15 mm. Hg from resting, more than that up to 20 mm. Hg is considered critical. ü Exercises induced hypotension (drop of S. B. P more than 20 mm. Hg).

Cont. ü Exercise induced angina. ü Exercise induced left bundle branch block. ü Exercise - induced 2 nd or 3 rd degree of A-V block. ü S-T segment displacement about 3 mm or downsloping from rest. ü Ventricular tachycardia: ü Three or more consecutive premature ventricular contractions. ü Multifocal premature ventricular contractions. http: //www. youtube. com/watch? v=s 7 c. Jyoa. M-Yg

Principles of Training ü The exercises in phase I should be Low intensity, gradually increasing the metabolic cost, safe and of dynamic nature. ü Activities are described in METs or metabolic equivalents. ü METs : measures energy requirement for basal homeostasis, when the subject is in the resting position (a wake or sitting position) METs = 3. 5: 4 ml of O 2/Kg/minute ü Most inpatient programs begin with activities 2 -3 METs and progress to 5 - METs before discharge

Specific exercise progressions within program ü Passive to active Resistive ex. ü Distal to intermediate to proximal joint exercises. ü From extremities to trunk. ü From supine to sitting then standing. ü Progressive increase in the ambulation distance then stair climbing (down) and then progression to stair up. ü Initially, the patient does the ex for short duration and high frequency (several times) per day until the patient's condition improves and vice versa will occur.

For the post surgical patients ü Graduated mobilization is initiated early in acute units. ü Activities in the first 24 -48 are usually included breathing ex. , ARM of armleg, and limited self care activities. ü Activity progression is faster and the patient works at slightly higher intensity. ü Emphasis is placed on the upper extremity R. O. M to counteract shoulder and chest pain

Monitoring exercise responses: In phase I: ü HR ü BP ü ECG ü Rating of Perceived exertion (R. P. E); (Handout I ü) ü Signs and symptoms of exertional intolerance: 1) Excessive fatigue. 2) Persistent dyspnea. 3) Severe leg claudication. 4) Ataxia. 5) Anginal pain. 6) Dizziness or confusion. 7) Pallor or cold sweating.

Exercise prescription Frequency =2 -3 times/day Intensity : resting HR+20 bpm post MI resting HR+30 bpm post CAPG • RPE<11 or to individual tolerance • Timing: 5 -20 mins • • • Type of ex. : • Sitting/standing functional activity ; ROM ex; walking ; circulatory ex. Breathing ex. ……. . act

Phase 1. 5: post discharge phase ü This phase begins after the patient returns home from the hospital. ü Better understanding of how to keep the heart healthy and strong is emphasized. Team members work with patients and family members. ü Team members check the patient's medical status and continuing recovery; they should offer reassurance as the patient regains health and strength. ü This phase of recovery includes low-level exercise and physical activity, as well as instruction regarding changes for the resumption of an active and satisfying lifestyle. ü Risk reduction strategies are emphasized again. ü After 2 -6 weeks of recovery at home depend on local protocols and patient’s fitness , the patient is ready to start phase 2 of his/her cardiac rehabilitation.

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