Download Cardiac rehabilitation - دکتر امیر هوشنگ واحدی متخصص طب

‫‪Cardiac Rehabilitation‬‬
‫دکترامیر هوشنگ واحدی‬
‫متخصص طب فیزیکی و توانبخشی‬
‫‪1‬‬
Background
CVD 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 & 35 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 rehab
Greater 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 COVERAGE
 Starting March 22, 2006
 *1. Have had an acute AMI within the preceding 12
months
 * 2.
 *3.
 4.
 5.
 6.
 7.
Have undergone CAGB
Have stable angina pectoris
Have undergone a cardiac valve repair or replacement
Have undergone PTCA
Have received a heart or heart-lung transplant
HF???
 Routine coverage is for a total of 36 exercise sessions.
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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).
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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.
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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.
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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.
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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 prescription
Direct 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 HR
month 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.
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Phase 1 goals;
Clear the patient for any skeletal, muscle, and
orthopedic problems.
Clear the patient for any pulmonary problems that
would limit activity
Return 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
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CR team.
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 exercise
Include 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 day
Dont 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 activity
Risk 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 prescription
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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.C
To delay the onset of symptoms
To maintain current fnnctional ability
To improve muscle tone or strenght
To obtimize job or avocational abilities.
To obtimize recreational activities performance.
To obtimize activities of A.D.L(activity of daily
living)
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In conditioning period cosider:
Frequency
Intensity
Mode
Duration
Rate of progression.
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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.
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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 intensity
 The Karvonen Formula:
 220 - Age= Predicted MHR- RHR(average of 3
mornings)= HRR
 HRRx.50( )+ RHR= Minimum Training Threshold
 HRRx .85 ( )+ RHR= Maximum Training Threshold
=========================================
Target heart rate:
50( )%-85( )% MHR is Target HR
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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)
18
19 Very, very hard
° Maximum
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Borg Scale for Rating Perceived Exertion
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.
48
Mode
Depend on the;
• Specific goal
• Needs
• Ability of the patient.
P.F.C of cycle ergometry=85% P.F.C of treadmill
P.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
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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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‫تجویز ورزش در بیماران ‪ CAD‬بر اساس ضربان قلب‬
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
53
Policies and Procedures
 Admission Process
Referral from Phase 2
New Exercise Prescription
Assign Care Coordinator
Orientation to Phase 3
Direct Admits
Nursing 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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Events
Picnic
 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 conversation 58
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