CARDIAC REHABILITATION Manal Osman Professor of physical Medicine

CARDIAC REHABILITATION Manal Osman Professor of physical Medicine , Rheumatology and Rehabilitation Faculty of Medicine Ain Shams University 2018

GENERAL OUTLINE • Rehabilitation: • Rehab team : physiatrist Rehab nurse SLP Ocupational rehab therapist Physiotherapist vocational rehab therapist educational rehab therapist orthosis and prosthesis rehab therapist dietation social worker psychologist psychiatrist other doctor specialities as needed

ILOS • Defination • Aim • Benefits • Inclusions • Exclusions • Phases • Components • Risks and Complications • Exercise prescription

DEFINITION • Development (restore) and maintenance of a desirable level of physiological, physical, social, mental , vocational and psychological functioning after the onset of CVD

AIM short term goals: Relive the symptoms long term goals: improve cardiovascular performance improve quality of life

BENEFITS=OUTCOME • Counteract the effect of inactivity • Improve in exercise tolerance and improve the functional capacity • Early return to work • Improve psychological well being • Risk factors modifications

INCLUSION : VALVOPLASTY ANOMALIES ACUTE MI, ANGINA, HF POST OP CABGS PTCA VALVE REPAIR, REPLACEMENT, CORRECTION OF CONGENITAL CARDIOPULMONARY TRANSPLANT

EXCLUSION: Uncontrolled HF Recent embolism ST depression 3 mm 3 rd degree heart block Resting BP 200 -110 Significant drop of 20 mm. Hg of systolic BP Symptoms at rest Unstable angina Uncontrolled ventricular arrhythmias Uncontrolled supraventricular arrhythmias

PHASES • Phase I ( supervised, inpatient) 0 -14 days. • Phase II ( supervised, 3 -6 ms) • Phase III ( supervised, > 6 ms) • Phase VI ( unsupervised , maintenance > 6 ms)

RISKS AND COMPLICATIONS • Risk factors of CAD: I -modifiable : HTN Cig smoking Hyperlipidemia DM Obesity Sedentary life II – Non modifiable : age , sex (male), family and past history

COMPONENTS • Exercise conditioning • Patient education • Vocational rehab • Avocational rehab • Risk factor modification

EDUCATION • Patient and family education individual meeting , group meeting , family meeting, pamph, lectures , booklets …. Physiology of heart, pathology of diseases, rheumatic or CAD , risk factors , cardiac rehab, prophylaxis, treatment surgery postoperative care , ….

VOCATIONAL REHAB OR HOUSE HOLD ACTIVITIES • Slow walk 3 -3 mets • Regular speed walk 3 -4 mets • Brisk walk 4 -5 mets • Very brisk walk 5 -6 mets • Sexual intercourse 3 -4 mets • Out door work 7 mets • Jog , walk 9 mets • mop floor 2 -4 mets

AVOCATIONAL REHAB • Golf 3 -5 mets • Volleyball 3 -4 mets • Ping pong 3 -6 mets • Tennis 4 -7 mets • Swimming 8 -12 mets

RISK FACTOR MODIFICATION • Obesity (BMI , weight reduction , diet reg , ex, gastric ballon. Gastric surgery) • Hyperlipidemia( Diet , medication, ex, • HTN ( medication , stress mangment, behavior treatment) • Cig smoking cessation ( education, group therapy, medication, acupuncture, behavioral therapy) • DM( diet control, medication, follow up)

EVALUATION • History • Examination • Investigation Lab Resting ECG Exercise stress test Functional classification NYHA Echo Exercise nuclear image pharmacological stress testing Plan of rehab and Ex prescription

NYHA • Class I low risk : ( > 7 Mets). • Class II mild risk : (>5 -7 Mets). • Class III : moderate risk ( >2 -5 Mets). • Class IV : high risk (<2 Mets).

EXERCISE STRESS TEST Types: Bruce protocol modified Bruce Nughton Modified Naughton Data : Resting HR Mx HR METs VO 2 Max Arrythmia Provok symptoms

RESPONSE TO EX • Ex duration= ex tolerance • Mx pulse reached • HRPr product • Presence or absence of pain • Ex capacity ( MET to duration)

EXERCISE PRESCRIPTION(DOSAGE) • Type • Mode • Frequency • Duration • Intensity • Home ex

TYPE • Aerobic • Isotonic ( >5 Mets) • Resistance (avoid in arryhtmias, HTN 160/100 and Met < 5)

MODE • Rowing machine • Bike • Treadmill • Stretching • Shoulder wheel

FREQUENCY • 3 -5 sessions /wk

DURATION 5 min warm up 5 -10 min/session Increase 5 min /wk 5 min cool down

INTENSITY • Age predicted HR( healthy) • Mx HR achieved = Clearance HR • Target HR …………… 60 -85% of mx achieved • Karvonen method +resting HR 10 beats / min/wk . . ( 70 -85%(mx HR for age –resting HR) )

HOME EX • Modified Borg scale 0 -10 scale • RPE 6 -20 -Borg scale • 6= No exertion • 9 = V. light • 11 Light • 13= somewhat hard • 15= hard-heavy • 20=Mx exertion

QUESTIONS

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