Download EACPR Policy Statement 1 Referral order form for in-patient program.

EACPR Policy Statement
1
Table I. Referral order form for in-patient program.
Sample tool for referring to an in-patient secondary prevention program [Tool to be considered for use
with the CR/PC Performance Measurement - Table 1]
Inclusion Criteria
•
Order applies to patients >18 years of age with CVD:
•
Persistent clinical instability because of complications after the acute event, or serious
concomitant diseases;
•
Clinically unstable with advanced heart failure (NYHA class III-IV), needing intermittent or
continuous drug infusion and/or mechanical support;
•
After a recent heart transplantation or ventricular assist device implantation;
•
Discharged very early after the acute event, even uncomplicated, at high risk of instability (i.e.
aging, co-morbidities)
• Unable to attend a formal outpatient CR program for any logistic reasons.
Exclusion Criteria
It does not apply to patients considered ineligible for CR/PC programs, including those in long-term
nursing home placement, homebound patients, or with severe dementia
Referral Process.
Responsibility of Patient’s primary cardiologist/ cardiovascular provider to
1.
Patient: to be informed of the importance of the CR/PC program
-
2.
Provide patients with information on the selected CR program
Arrange for in-patient CR contact prior to discharge:
-
Document the CR program in the hospital discharge summary
-
Send hospital discharge summary and appropriate information to the CR Centre
EACPR Policy Statement
2
Table II. Referral order form for out-patient program.
Sample tool for referring to an out-patient secondary prevention program. [Tool to be considered for
use with the CR/PC Performance Measurement Set – Table 2]
Inclusion Criteria
Order applies to patients >18 years of age with CVD:
a. ACS
b. Chronic CAD
c.
Recent cardiac surgery and intervention (coronary artery or structural heart disease including
heart valve)
d. CHF
e. Cardiac transplantation
f.
Diabetes mellitus, and metabolic syndrome
g. Peripheral arterial diseases, vascular surgery and intervention
h. Ventricular assist device recipient
i. Pacemaker, ICD, and CRT implantation
Exclusion Criteria
It does not apply to patients considered ineligible for CR/PC programs, including those in long-term
nursing home placement, homebound patients, or with severe dementia
Referral Process.
Responsibility of Patient’s primary cardiologist/ cardiovascular provider to
1.
Patient: to be informed of the importance of the CR/PC program
•
2.
Provide patients with information on the selected CR program
Arrange for in-patient CR contact prior to discharge:
•
•
Document the name of the CR program in the hospital discharge summary, with date and
time of the appointment
Send hospital discharge summary and appropriate information to the CR Centre
EACPR Policy Statement
Table III. Check-list to assess the comprehensiveness of the prevention therapies after acute
coronary event for hospitalised patients
(adapted from American Heart Association. Multidisciplinary Cardiac Discharge Checklist/
Instructions. Get With The Guidelines Web site. Available at:
http://www.americanheart.org/downloadable/heart/1055429944221
GWTG_CAD_Discharge_Template.doc. Accessed March 14, 2007)
Insert Patient Information here
Insert hospital Identification/logo here
……………………………………..
………………………………………………...
Multidisciplinary Cardiac Discharge Checklist/Instructions
To be completed by physician, nurse, or other care provider at patient’s discharge
Admission Date: ____________________
Discharge Date: _____________________
Diagnosis: ____________________________
Check each condition and therapy prescribed or check contraindication reason:
•
Education on the prescribed pharmacological therapy: when and how to be taken, importance of
correct compliance, positive and side effects
•
Cardiac rehabilitation referral made, patient information communicated to the CR program and
program information/appointment communicated to patient
•
Exercise prescription
•
Smoking cessation advice and pharmacological therapy given (if patient is a current smoker or
former smoker of less than 1 year)
•
Smoking cessation advice and pharmacological therapy not required (if patient is non-smoker or
former smoker of greater than 1 year).
•
Education on warning signs of cardiac failure and what to do if symptoms, given
•
Vocational support
•
Psychosocial management: depression/anxiety, coping with lifestyle changes, normalization of
daily life activities (self-care, return to work, driving, sexual activity), health-related quality of life.
•
Mediterranean Diet: low-fat, low-cholesterol, no added salt
Follow-up appointment documented in medical record:
Date: ___________________Time: ___________ OR
Call _______________Cardiac Rehabilitation Program within _______ days. Phone #
If condition worsens, new symptoms develop, or questions arise, call your physician.
I hereby acknowledge receiving the explanation of the above instructions:
Patient’s signature: ______________________________________ Date: ______________
3
EACPR Policy Statement
4
TABLE IV. Exercise activity and training: pre-program assessment.
ELEMENT
CONSIDERATION
SKILL MIX
Safety
Risk stratification
Cardiologist,
Exclusion criteria
Dedicated nurse,
Safety procedures
Exercise physiologist,
Occupational therapist,
Physiotherapist
Exercise/Physical Activity History
Medical prescription, adherence
Cardiologist, Psychologist
Activities prior to event (work,
Cardiologist,
household, leisure)
Dedicated nurse,
Exercise history
Exercise physiologist,
Current activity level
Occupational therapist,
Limiting symptoms
Physiotherapist.
Target exercise/activity level
Patient needs and goals
Exercise testing results
Exercise physiologist,
Barriers to exercise
Physiotherapist.
Access to exercise equipment
Physical activity
Occupational therapist,
Work demands
Physiotherapist,
Task analysis of work
Psychologist.
Energy conservation techniques
EACPR Policy Statement
5
TABLE V. Exercise activity and training: intervention strategies.
ELEMENT
CONSIDERATION
SKILL MIX
Prescription
Components of fitness
Exercise physiologist,
Considerations
Warm up/cool down
Occupational therapist,
Stretching
Physiotherapist
Mode of activity/method of training (aerobic
continuous, interval)
Cardiovascular conditioning (duration,
frequency, intensity)
Muscular conditioning (strength, endurance,
flexibility)
Progression program
Home program
Safety issues
Personal Considerations
Simulated work/home/leisure tasks
Occupational therapist,
Work conditioning
Physiotherapist
Encourage
Cardiologist,
Self-efficacy
Dedicated nurse,
Empowerment
Exercise physiologist,
Motivation
Occupational therapist,
Provide information and educate as
Physiotherapist,
appropriate
Psychologist.
EACPR Policy Statement
6
TABLE VI. Exercise activity and training: monitoring strategies.
ELEMENT
CONSIDERATION
SKILL MIX
Standard Monitoring
Rate of perceived exertion
Cardiologist,
Techniques
Talk test
Dedicated nurse,
Self-monitoring
Exercise physiologist,
Symptoms
Occupational therapist,
General observations (i.e. breathing, Physiotherapist,
colour, behaviour, sweating)
Psychologist.
Technique correction
Psychosocial symptoms
Additional Monitoring
Techniques
Blood pressure
Cardiologist,
Heart rate
Exercise physiologist,
Nurse
Occupational therapist,
Physiotherapist.
ECG
Cardiologist,
Exercise physiologist,
Nurse,
Physiotherapist.
Functional capacity by metabolic
Exercise physiologist,
equivalents (METS)
Occupational therapist,
Non invasive oxygen saturation
Physiotherapist.
Monitoring of home based activity
Personal Factors
Compliance
Cardiologist,
Progression
Exercise physiologist,
Motivation
Occupational therapist,
Physiotherapist,
Psychologist.
EACPR Policy Statement
7
Table VII. Education topics and health professionals.
TOPICS
SKILL MIX
Cardiovascular Disease
Cardiologist,
Exercise physiologist,
Dietician
Nurse,
Occupational therapist,
Physiotherapist,
Psychologist.
Risk Factors
Cardiologist,
Exercise physiologist,
Dietician,
Nurse,
Occupational therapist,
Physiotherapist
Psychologist.
Physical Activity/Exercise Training
Cardiologist,
Exercise physiologist,
Nurse,
Occupational therapist,
Physiotherapist.
Activities of daily life
Cardiologist,
Exercise physiologist,
Nurse,
Occupational therapist,
Physiotherapist,
Psychologist.
Nutrition
Cardiologist,
Dedicated nurse,
Dietician.
Exercise physiologist,
Physiotherapist
Psychologist.
Smoking Cessation
Psychologist,
Cardiologist,
Dedicated nurse,
Dietician,
Exercise physiologist,
EACPR Policy Statement
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Occupational therapist,
Pharmacist
Physiotherapist,
Social services expert.
Medication
Cardiologist,
Nurse,
Pharmacist.
Psychological Issues
Psychologist,
Cardiologist,
Dedicated nurse,
Occupational therapist,
Social services expert.
Stress Management
Psychologist,
Cardiologist,
Dedicated nurse,
Dietician,
Exercise physiologist,
Occupational therapist,
Physiotherapist,
Social services expert.
EACPR Policy Statement
9
Table VIII. Secondary prevention program structure-based measurement set
The cardiac rehabilitation (CR) / secondary prevention program has policies in place to demonstrate
that:
1)
A physician-director (cardiologist - see text) is responsible for the oversight of CR program
policies and procedures and ensures that policies and procedures are consistent with
evidence-based guidelines, safety and regulatory standards. This includes appropriate
policies and procedures for the provision of alternative CR program services, such as homebased CR.
2)
A multidisciplinary team/approach is provided (see text)
3)
An emergency response concept is available to respond to medical emergencies.
a. In a hospital setting, physician supervision is presumed to be met when services are
performed on hospital premises
b. In the setting of a free-standing outpatient CR program (owned/ operated by a hospital,
but not located on the main campus), a physician-directed emergency response team
must be present and immediately available to respond to emergencies
c.
In the setting of a physician-directed clinic or practice, a physician-directed emergency
response team must be present and immediately available to respond to emergencies.
4)
All non-medical professional staff have successfully completed a recognised course for basic
life support (BLS) with at least one staff member present who has completed such a course
for advanced cardiac life support (ACLS) and meets state and hospital or facility medico-legal
requirements for defibrillation and other related practices.
5)
Functional emergency resuscitation equipment and supplies for handling emergencies are
immediately available.
6)
Periodic educational courses for health professionals are undertaken (see text).
Numerator
The number of CR programs in the health care system that meet these structure based performance
measure criteria
Denominator
All CR programs within a health care system
Period of Assessment: per reporting year
Method of Reporting: Inclusive data collection tracking sheet
Sources of Data: Written program policies
EACPR Policy Statement
10
Table IX Check-list to assess the comprehensiveness of the prevention therapies after a CR program.
List to be considered in conjunction with Table 3. “Core components and objectives common to all
clinical conditions.”
Insert Patient Information here
……………………………………….
Insert hospital Identification/logo here
………………………………………………….
Multidisciplinary Cardiac Discharge Checklist/Instructions
To be completed by physician, nurse, or other care provider at patient’s discharge
Admission Date: ____________________
Discharge Date: ______________________
Diagnosis: ____________________________
Check each condition and therapy prescribed or check contraindication reason.
1. Full risk assessment
o
Formulation of ‘tailored’, patient-specific, counselling regarding the objectives of the
secondary preventive program
o
No counselling provided with reason in discharge summary
2. Cardiac rehabilitation
o
Referral made, patient information communicated to the CR program and program
information/appointment communicated to patient
o
No cardiac rehabilitation referral with reason in discharge summary
3. Physical activity
o
Counselling made
o
No Physical activity counselling with reason recorded in discharge summary
4. Exercise training prescription
o
Prescription made
o
Exercise prescription not given, reason documented in discharge summary.
5. Diet/nutritional counselling
o
Counselling made
o
Diet/nutritional counselling not given, reason documented in discharge summary.
6. Weight control management (patient is obese or overweight)
o
Management made
o
Weight control management not given, reason documented in discharge summary
7. Lipid management
o
Management made
o
Lipid management not given, reason documented in discharge summary
8. Blood pressure monitoring
o
Management made
o
Blood pressure monitoring not given, reason documented in discharge summary
9. Smoking cessation
o
Teaching and pharmacological therapy (when necessary) given
EACPR Policy Statement
o
11
Smoking cessation teaching and pharmacological therapy not required (patient is non-smoker
or former smoker of greater than 1 year).
10. Psychosocial management
o
Management made
o
Psychosocial management not given, reason documented in discharge summary
11. Vocational management
o
Management made
o
Vocational management not given, reason documented in discharge summary
12. Education on warning signs of instability and self management.
o
Education made
o
Education not given, reason documented in discharge summary.
13. Education on appropriate medical therapy given
14. Referral to a phase 3 or to community program (Coronary Club)
15. Follow-up appointment documented in medical record.
o
Date: _______________Time: ___________ or Call _______________
o
Expected time to appointment within _______ days. Phone # _________
If condition worsens, new symptoms develop, or questions arise, call your physician.
I hereby acknowledge receiving the explanation of the above instructions:
Patient’s signature: ________________________Date: ______________
Patient left w/o signing: ______________________________________
EACPR Policy Statement
12
Table X Core components in CAD
Components
Patient - risk
assessment
Physical
activity
counselling
Exercise
training
Diet /
Nutritional
counselling
Weight control
management
Lipid
management
Established/Agreed issues
• Clinical history: Review clinical course
• Physical examination: inspect puncture site of PCI, and extremities for the
presence of arterial pulses
• Exercise capacity and ischemic threshold: the exercise stress testing by
bicycle ergometry or treadmill maximal stress test (cardiopulmonary exercise
test if available) must be symptom-limited test within 4 weeks after the acute
event. A submaximal test should be considered in particular cases such as
after extensive myocardial infarction or with complications, while a maximal
testing should be performed afterwards. Exercise or pharmacological imaging
technique in patients with un-interpretable ECG should be considered.
• Exercise stress test guide: in the presence of exercise capacity >5METS
without symptoms, patient can resume routine physical activity; otherwise, the
patients should resume physical activity at 50% of maximal exercise capacity
and gradually increase
• Physical activity: a slow gradual and progressive increase of moderate
intensity aerobic activity, such as walking, climbing stairs and cycling
supplemented by an increase in daily activities (such as gardening, or
household work).
• The program should include supervised medically prescribed aerobic exercise
training:
• Low risk patients: at least 3 sessions of 30-60 min /week aerobic exercise at
55 – 70% of the maximum work load or HR at the onset of symptoms; >1500
kcal/week to be spent by low risk patients
• Moderate to high risk patients: similar to low risk group but starting with
<50% maximum work load
• Resistance exercise: at least 1 hour/ week (2 sets, with an intensity of a 10 –
15 repetition maximum [RM])
• Medication: prophylactic nitro-glycerine can be taken at the start of exercise
training session in chronic stable angina
[see table 3]
[see table 3]
•
•
•
Blood pressure
monitoring
Smoking
cessation
Psychosocial
management
Vocational
management
Assess fasting lipid profile in all patients, preferably within 24 h of an acute
event. Initiate lipid lowering medication as recommended below as soon as
possible:
Statin therapy for all patients. Consider ezetimibe, fibrate and niacine in statin
intolerant patients
High Triglycerides: emphasise weight management and physical activity,
alcohol abstention, smoking cessation
[see table 3]
[see table 3]
[see table 3]
[see table 3]
EACPR Policy Statement
13
Table XI. Core components following cardiac surgery/intervention (coronary arteries or structural
heart disease including heart valves)
Components
Patient - risk
assessment
Physical
Activity
Counselling
Exercise
training
Diet /
Nutritional
counselling
Tobacco
cessation
Psychosocial
management
Vocational
management
Established/Agreed issues
Assess: wound (chest and legs) healing and stability, co-morbidities, complications
and disabilities
ECG: heart rate, rhythm, repolarisation and possible new Q waves
Chest X Ray: infection, pleural effusion, diaphragm paralysis
Blood testing: anemia, fasting blood glucose, (HbA1C if fasting blood glucose is
elevated), renal function and electrolytes
Echocardiography: pleural or pericardial effusion, prosthetic function and/ or
valvular heart disease, when appropriate
Exercise capacity and to determine basal level, screen for residual ischemia or
arrhythmias and to guide exercise prescription
Patient education: about anticoagulation, including drug interactions and selfmanagement if appropriate; in-depth knowledge on endocarditic prophylaxis;
secondary prevention medication for CAD; how to progress in order to normalize
daily life activities.
• Wound healing and exercise capacity should be considered [see also Table X]
• To be started early in the in-hospital phase
• In-patient and/or out-patients programs immediately after discharge lasting 8-12
weeks are indicated
• Upper-body training can begin when the chest is stable, i.e. usually after 6
weeks.
• Individually tailored according to the clinical condition, baseline exercise
capacity, ventricular function and different valve surgery [see also Table X]:
• After mitral valve replacement exercise tolerance is much lower than that after
aortic valve replacement, particularly if there is residual pulmonary hypertension
• Note interaction between anticoagulation and K-vitamin rich food and other
drugs, in particularly amiodarone. Special emphasis on the Mediterranean diet
• Risk of complications depends on how long before surgery the smoking habit
has been changed, whether smoking was reduced or stopped completely
• Sleep disturbances, anxiety, depression and impaired quality of life (including
erectile dysfunction) may occur after surgery.
[see table 3]
EACPR Policy Statement
14
Table XII. Core components in CHF
Components
Patient – risk
assessment
Physical
activity
counselling
Exercise
training
Established/agreed issues
• Hemodynamic and fluid status: signs of congestion, peripheral and central
edema
• Chest X Ray: lung edema, pleural effusion
• Echocardiography: left ventricular filling profile, pulmonary pressures, when
appropriate
• Cachexia signs: nutritional status, reduced muscle mass, muscle strength and
endurance
• Blood testing: serum electrolytes, creatinine, BUN and BNP
• Peak exercise capacity: symptom-limited cardiopulmonary exercise test with
metabolic gas exchange. For testing protocol small increments 5-10W per min
on bicycle ergometer or modified Bruce or Naughton protocols are indicated.
• Six minute walk test is accepted as a test to assess exercise tolerance
• Other tests: coronary angiography, invasive hemodynamic measurements,
endomyocardial biopsy, screening for sleep apnea is recommended for
selected patients or cardiac transplantation candidates.
• At least 30min/day of moderate-intensity physical activity to be gradually
increased to 60 min/day
Progression of aerobic ET for stable patients:
• Initial stage: intensity should be kept at a low level (40-50% of peak VO2),
increasing duration from 15 to 30 min, 2-3 times / week according to perceived
symptoms and clinical status for the first 1-2 weeks.
• Improvement stage: a gradual increase of intensity (50%, 60%, 70% to 80% of
peak VO2, if tolerated) is the primary aim. Prolongation of exercise session to
30 min is a secondary goal. Resistance training and inspiratory muscle training
are optional training modalities which can be added to endurance training [44]
Supervised program: Supervised, in-hospital training program may be
recommended, especially during the initial phases, to verify individual responses
and tolerability, clinical stability and promptly identify signs and symptoms indicating
to modify or terminate the program.
Diet/Nutritional •
counselling
•
•
Weight control •
management,
•
Lipid
management
Tobacco
cessation
Psychosocial
management
Vocational
management
•
Prescribe specific dietary modifications according to
Fluid intake: < 2 litres per day
Sodium intake: severe restriction should usually be considered in severe HF
Weight monitoring: The patients must be educated to weight themselves
daily. Weight gain is commonly due to fluid retention, which precedes the
appearance of symptomatic pulmonary or systemic congestion. A gain > 1.5 kg
over 24 hours or >2.0 kg over two days suggest developing fluid retention.
Weight reduction: In moderate-severe HF, weight reduction is not
recommended since unintentional weight lost and anorexia are common
complications. It may be due to loss of appetite, induced by renal and hepatic
dysfunction or hepatic congestion, or be a marker of depression.
Statins should be considered only in patients with established atherosclerotic
disease.
(see table 3)
(see table 3)
(see table 3)
EACPR Policy Statement
15
Table XIII. Core components in cardiac transplantation
Components
Patient – risk
assessment
Physical
Activity
Counselling
Exercise
training
Diet /
Nutritional
counselling
Weight control
management
Established /Agreed issues
• Clinical: Wound healing, symptoms of rejection
• Chest X Ray: infection, pleural effusion, diaphragm paralysis
• Echocardiography: right and LV function, pericardial effusion
• Exercise capacity: cardiopulmonary exercise stress test 4 weeks after surgery
to guide detailed exercise recommendations. For testing protocols, small
increments of 10W per min on bicycle ergometer, or modified Bruce protocols
or Naughton protocols on treadmill are appropriate.
• Patient education on the risk of acute rejection. Patients should be instructed
to practice self-monitoring: unusually low BP, change of HR, unexplained
weight gain, fever or fatigue may be early signs of rejection even in the
absence of major symptoms. Exercise training should be stopped and prompt
intervention is needed.
• Physician knowledge of the anatomical and physiological reasons for limited
exercise tolerance: e.g. the immune-suppression therapy side effect
(impairments of inflammatory response, metabolism, osteoporosis),
chronotropic incompetence, diastolic dysfunction
• Patients and physiotherapists should be educated to adhere to the
recommendations concerning personal hygiene and general measures to
reduce the risk of infection
• Chronic dynamic and resistance exercises prevent the side-effects of
immunosuppressive therapy
• Exercise intensity relies more on perceived exertion than on a specific HR.
Borg scale: scores of 12-14 to achieve. E.g.: instruct the patients to start
walking 1.5 or 2 km five times weekly at a pace resulting in a perceived exertion
of 12 to 14 on the Borg scale. The pace should be increased slowly over time
• Early training program can be beneficial in the early post-operative period as
well as in the long-term. Respiratory physiotherapy (to prevent respiratory
infection) and kinesiotherapy of the upper and lower limbs are advisable in
order to achieve early mobilization
• Supervised exercise program at least during the initial phase may be advisable
to verify individual responses (given the chronotropic incompetence in these
patients) and tolerability as well as adaptability to exercise and clinical stability
• Aerobic exercise may be started in the second or third week after transplant but
should be discontinued during corticosteroid bolus therapy for rejection.
Resistance exercise should be added after 6 to 8 weeks
• Regimen: At least 30-40 min/day of combined aerobic (walking) and resistance
(muscle strength) training at moderate level, slowly progressing warm-up,
closed-chain resistive activities (e.g. bridging, half-squats, toe raises, use of
therapeutic bands) and walking/Nordic Walking/cycling
• Resistance training: 2-3 sets with 10-12 repetitions per set at 40-70% 1-RM
with a full recovery period (>1 min) between each set. The goal is to be able to
do 5 sets of 10 repetitions at 70% of 1-RM
• Aerobic training: the intensity of training should be defined according to peak
VO2 (<50% or 10% below Ventilatory Anaerobic Threshold [VAT] determined
by cardiopulmonary exercise testing) or peak work load (<50%)
• Dietary infection prophylaxis – food to be avoided:
• Raw meat
• Raw seafood
• Un-pasteurised milk
• Cheese from un-pasteurised milk
• Mouldy cheese
• Raw eggs
• Soft ice
• Avoidance of overweight is mandatory to balance the side-effects of
immunosuppressants, to limit the classical cardiovascular risk factors.
• Obesity increases the risk of cardiac allograft vasculopathy. It should be
EACPR Policy Statement
Lipid
management
•
•
Blood pressure •
monitoring
•
Tobacco
cessation
•
Psychosocial
management
Vocational
management
•
16
controlled by daily exercise and healthy diet
Hyperlipidaemia increases the risk of CVD. It should be controlled by statins,
daily exercise and healthy diet
Statins (pravastatin, simvastatin) not only lower LDL-C levels but also decrease
the incidence of CAV and significantly improved survival.
Hypertension is linked to immunosuppressive therapy and denervation of
cardiac volume receptors
It is sensitive to a low-sodium diet. Treatment with diltiazem, amlodipine and
ACE inhibitors are first choice, usually completed by diuretics. Beta-blockers
are contra-indicated as they hamper the already delayed chronotropic response
of the denervated heart
Cessation of smoking is a prerequisite for transplantation. Psychological
support may be needed so patient does not resume smoking posttransplantation.
Support coping strategies, i.e. guilt, high levels of anxiety and
apprehensiveness, may be needed
(see table 3)
EACPR Policy Statement
17
Table XIV. Core components in diabetes mellitus and metabolic syndrome
Components
Patient – risk
assessment
Physical
Activity
Counselling
Exercise
training
Established/Agreed issues
• Suspected type 2 diabetes: combination of risk score tools (e.g. FINDRISK
questionnaire), HbA1c and Oral glucose tolerance test (OGTT), 2 hour post-load
plasma glucose level)
• Patients with CAD and unknown diabetes: HbA1c
• Functional capacity and exercise induced ischemia by maximal symptom-limited
exercise stress testing
• Daily walking for> 30 min
•
•
•
Diet /
Nutritional
counselling
•
•
•
Weight control
management
Lipid
•
management
•
Blood pressure •
monitoring
•
•
Tobacco
cessation
Psychosocial
management
•
•
Vocational
management
≥150 min/week of moderate-intensity aerobic exercise (≥4.5 METs) and/or ≥90
min/week of vigorous aerobic exercise (≥7.5 METS)
It should last at least 30 min; no more than two consecutive days without exercise
training.
Resistance training 3 times/week, targeting all major muscle groups, 1-3 sets of 712 repetitions with heavy (60-70% 1-RM) workload (to induce hypertrophy) or 3040 repetitions with low (30-40% 1-RM) workload (for endurance type training).
In case of overweight, caloric restriction to approx. 1500 kcal/day
anti-atherogenic diet: low fat, i.e. 30-35% of daily energy uptake (10% for
monounsaturated fatty acids, e.g. olive oil); avoidance of trans fats; high fibre, i.e.
30g/day; low in industrialised sugars; 5 servings of fruits / vegetables per day
diet is more effective when combined with exercise training (see above)
(see table 3)
statins for all aiming at LDL < 80 mg/dl (<2.0 mmol/L)
if monotherapy with a statin is not sufficient it can be combined with ezetimibe
Angiotensin converting enzyme (ACE) inhibitors or Angiotensin receptor blockers
(ARBs) are first choice therapy
Usually combination therapy is required; choice according to concomitant
diagnoses
Anti-hypertensive therapy is more important than glucose control
(see table 3)
Health psychology interventions with a special focus on supporting changing
lifestyle (i.e. motivational interviewing)
(see table 3)
(see table 3)
EACPR Policy Statement
18
Table XV Core components in peripheral artery disease (PAD), vascular surgery / interventions
Components
Patient – risk
assessment
Physical activity
counselling
Exercise
training
Diet / Nutritional
counselling
Blood pressure
monitoring
Smoking
cessation
Psychosocial
management
Vocational
management
Established/Agreed issues
Clinical:
• Any exercise limitation of the lower extremity muscles or any history of walking
impairment, i.e. fatigue, aching, numbness, or pain.
• Primary site(s) of discomfort: buttock, thigh, calf, or foot.
• Any poorly healing wounds of the legs or feet.
• Any pain at rest localised to the lower leg or foot and its association with the
upright or recumbent positions.
• Reduced muscle mass, strength and endurance
Vascular status:
• Bilateral arm BP, palpation of peripheral arteries and abdominal aorta with
annotation of any bruits and inspection of feet for trophic defects
Ankle-brachial index measurement:
• values 0.5 - 0.95: claudication range; 0.20 - 0.49: rest pain; <0.20: tissue
necrosis.
Functional capacity:
• markedly impaired (peak O2 consumption is 50% of the predicted value).
• Difficulty in walking short distances, even at a slow speed, associated with
impairment in the performance of activities of daily living.
• To exclude occult CAD, perform treadmill or bicycle exercise testing to monitor
symptoms, ST–T wave changes, arrhythmias, claudication thresholds, HR and
BP responses, useful for exercise prescription.
• Exercise activities, such as walking, lasting >30 min, ≥3 times/ week, until nearmaximal pain
• Supervised hospital- or clinic-based ET program to ensure that patients are
receiving a standardised exercise stimulus in a safe environment is effective and
recommended as initial treatment modality for all patients
• Exercise-rest-exercise: Each training session consists of short periods of
treadmill walking interspersed with rest throughout a 60-min exercise session, 3
times weekly.
• Treadmill exercise: more effective - the initial workload is set to a speed and
grade that elicit claudication symptoms within 3 to 5 min. Patients are asked to
continue to walk at this workload until they achieve claudication of moderate
severity. This is followed by a brief period of rest to permit symptoms to resolve.
The exercise-rest-exercise cycle is repeated several times during the hour of
supervision.
• Resistance training: appropriately prescribed, is generally recommended
• To achieve a serum LDL concentration <100 mg/dL (2.5mmol/L)
• Treatment with statin to achieve a target LDL < 80 mg/dL (2.0 mmol/L) in high
risk patients.
• A statin should be given as initial therapy, but niacin and fibrates may play an
important role in patients with low serum HDL or high serum triglyceride
concentrations (>150 mg/dL or 1.7 mmol/L)
• The use of ACE-Inhibitors in patients with PAD may confer protection against
cardiovascular events beyond that expected from BP lowering
• Stopping smoking is exceptionally important in PAD. Smoking-cessation
programs involving nicotine-replacement therapy, and the use of medications
such as bupropion or varenicline should be encouraged
(see table 3)
(see table 3)
EACPR Policy Statement
19
Table XVI. Core components in patients with ventricular assist devices (VAD)
Components
Established/agreed issues
Devices allowing
outpatient care
- VADs assist either right (RVAD), left (LVAD) or both ventricles (BiVAD),
depending on heart disease and pulmonary resistance.
- VADs either work as pulsatile systems pneumatically or electrically driven or
they work as continuous flow systems supporting regular actions of the
native heart. Taking into account the less susceptible technique and
safety, continuous flow techniques actually are preferred [38]
- intracorporal systems:
Heartmate II (continuous flow)
Jarvik2000 (continuous flow supporting pulsative flow of native heart)
Berlin Heart Incor (continuous flow)
deBakey (continuous flow supporting pulsative flow of native heart)
Dura Heart (continuous flow)
HeartWare (continuous flow)
Novacor (pulsatile flow)
- paracorporal systems, for outpatient care only suitable with restrictions:
Thoratec pVAD (pulsatile flow)
Berlin Heart Excor (pulsatile flow)
Structural preconditions and managing
Patients - risk
assessment and
clinical control [39]
General rules:
- see table XI. and XII
Special considerations and needs:
- Patients should start cardiac rehabilitation not before being trained for
certainty to independently handle the device, especially to be able to
change batteries and controller.
- The rehabilitation team has to be trained on the specific assist device
before starting rehabilitation.
- The rehabilitation centre should be in short distance to the heart centre,
and a close cooperation is mandatory
- NOTE: VAD-patients are completely dependent on power supply.
- Batteries may serve as bridging only for some hours. An emergency
power supply therefore should be available.
- Rehabilitation centres should provide an emergency room with bed and
monitoring devices
- At least two persons of the rehabilitation team should be specialized in
handling VAD and in correctly solving potential functional problems
- The rehabilitation team has to be regularly trained in dealing with the
systems and potential complications.
Assessment and nursing:
- Anticoagulation and thrombo-embolism:
- A close control of anticoagulation is mandatory: daily self control of
anticoagulation by the patient (coagucheck-device), supplemented by
regular laboratory controls. Anticoagulation also has to be checked daily
by rehabilitation nurses or physicians. Dose adaption should be done in
close communication with the patient.
- Watch for signs of potential systemic thrombo-embolism
Avoidance of infections:
- Daily watch wound healing, early treat local infections, regularly screen
for systemic infections.
- Nursing of the driveline-outlet has to follow strictly sterile conditions!
Arrhythmias:
- Rapid atrial arrhythmias compromise filling of pulsatile devices. These
devices then have to be switched from volume mode to fixed rate
- Ventricular tachycardia has to be converted immediately, although often
is haemodynamically well tolerated.
Function of assist device and interplay with native heart:
EACPR Policy Statement
-
20
Closely watch fluid balance.
Closely watch the function of the native right and left ventricle, watch for
aortic valve regurgitation (echocardiogram).control of serum lactate
concentration, electrolytes, creatinine, BUN and BNP
Control of pulsatile assist devices [40-41]:
- In the outpatient setting pulsatile devices usually are used in the “volume
mode”, and then are strictly dependent on preload volume. In the volume
mode
- bradycardia is a consequence of volume depletion (bleeding? excess
diuresis? tamponade? Right ventricular failure?)
- tachycardia reflects volume overload (general fluid overload? inflow valve
regurgitation? native aortic valve regurgitation? shunting?)
- Inadequate filling of LVAD may be the consequence of right ventricular
failure but also of left ventricular recovery
- closely watch the function of inflow and outflow valves (regurgitation?
distortions of the conduits?)
- Opening of the native aortic valves with “normal” excursions may be the
consequence of either malfunction of LVAD or LV-recovery.
Decompression of left ventricular is normal in patients with pulsatile
LVAD. If decompression does not occur, there may be inadequate LVemptying by LVAD.
Medical treatment:
- Anticoagulation with warfarin/phenprocoumon in combination with acetylic
salicylic acid in most systems
- Guideline adjusted medical treatment of heart failure [42]
- Close adaptation of diuretics to the individual needs (especially watch
volume load of pulsatile devices).
- Right ventricular failure: induce inotropic support, call implantation centre
- Signs of left ventricular recovery, call implantation centre
Assessment of
cardiac function
and exercise
capacity
Exercise training
Expected outcomes:
- correct clinical and technical guidance and avoidance of clinical and
technical complications.
- training of the patients in their self guidance
General rules:
- see also table XII
Special considerations:
- Cardiac function (right and left ventricular function and valve function):
Echocardiogram
- Determination of peak exercise capacity by peak oxygen consumption (use
small increments of 5-10 W per minutes on bicycle ergometer or modified
Bruce or Naughton protocols) or 6 minutes walk test
- Continuous ECG monitoring
- Control of serum lactate concentration
General rules:
- See table XII
- Exercise training may improve the functional status of VAD recipients
even at a later period after implantation. It therefore may have additional
importance in cases of destination therapy.[43]
Special considerations:
Mechanisms to adapt cardiac output during exercise:
• Pulsatile flow devices: device rate and cardiac output depends upon
passive filling of the device
• Continuous flow devices: increase of cardiac output by increase of heart
rate. Device flow rate may be automatically adapted to the native cardiac
cycle.
Modes of exercise and exercise intensity:
• Combination of aerobic endurance and dynamic resistance training with
EACPR Policy Statement
•
•
21
similar restrictions as in other patients after cardiac surgery
Include activities to develop flexibility, coordination and body awareness
NOTE: Avoid exercise programs that irritate driveline-outlet. Avoid shaking
movements or strong vibrations
Expected outcomes:
• Increased fitness, flexibility and rebuild muscular mass and strength
• Improved psychosocial well-being and social participation
Diet, nutritional
counselling
•
•
Watch fluid regulation and insure a daily weight control by the patient.
Reduce salt intake and watch vitamin K intake by nutrition
Weight control
management
Lipid management
•
See table XII •
•
See table XII
Lipid management depends on the baseline disease leading to chronically
heart failure, and has to be individually adjusted.
Statins should only be given in patients with atherosclerotic disease and
no cardiac cachexia.
•
Blood pressure
management
•
Smoking cessation
See table XIII
Psychosocial
management
• Patients should be psychologically stable before starting rehabilitation
Expected outcomes:
• Improved coping
• Improved long-term outcome
Social support
•
Systemic blood pressure should be regulated according to the
recommendations of the individual assist device
Include patient’s partner and close family members in the rehabilitation
process according to individual needs
Expected outcomes:
• Improve social support of the patient and thereby improve quality of life
EACPR Policy Statement
22
Table XVII. Core components in Pacemaker, ICD, and CRT recipient
Components
Patient – risk
assessment
Established /Agreed issues
• Clinical: Wound healing both in terms of skin and heart muscle wire insertion.
Clarification of route taken by device wires (uncomplicated or complicated).
• X Ray: not routinely carried out but could be required to check the route of the
ICD-CRT leads
• Echocardiography: LV function as part of inclusion-selection for ICD and is
used pre and post implant for CRT as part of optimisation of function. A
relatively large proportion of patients fitted with an ICD or ICD-CRT secondary
to a cardiac event and with arrhythmia will have heart failure. Rehabilitation
practitioners should take account of specific issues relating to this sub
population as they are at higher risk of a future cardiac event. This often
influences the staffing numbers required to offer safe exercise.
• Exercise capacity: For ICD and CRT/ICD ensure details of device firing are
known: these include ATP and shock thresholds (e.g. ATP 170bpm or shocks
220 bpm), mode (VT or VF), rapid onset setting (e.g. 30 beats rise in one
minute), sustained arrhythmia period before device firing commences (e.g. 40
to 60 seconds). Also note use and dose of beta blockade. Exercise heart
rates should not exceed ICD therapy thresholds and ideally be set between 10
to 20 beats below first line therapy thresholds. For example, a patient who is
taking beta blockade, has a VF setting of 190bpm with a rapid onset setting of
25 beats and set for shock therapy (defibrillation) is unlikely to experience
shock therapy due to moderate intensity exercise.
• Pacemakers: rate responsive devices (i.e. allow heart to increase in
proportion to the exercise intensity) present no limits to exercise. Rate-limited
devices will hinder exercise capacity but generally allow moderate intensity
activity.
• Patient education: Where the ICD has been fitted following a cardiac event
then the underlying heart condition (i.e. the cause of arrhythmia and therefore
the reason for the ICD being implanted) is likely to have more influence on the
patient’s ability to exercise than the presence of an ICD. The underlying heart
condition may limit exercise capacity due to shortness of breath, fatigue or
chest pain and it is important for patients to be aware of these factors. For most
patients the likelihood of arrhythmia is no greater during moderate intensity
aerobic exercise than during resting but certain types and approaches to
exercise do carry greater risk. For instance when patients exercise hard, from
rest, without a warm-up and immediately cease exercise, without a cool down
or active recovery period.
• CR practitioner knowledge: Inappropriate therapy from an ICD occurs in
some patients and patients should be made aware of this at the scheduled
review clinics.
• Patients should be briefed on the potential side effects of anti arrhythmia
medications
• A note of caution is required for those few patients who are at risk of ICD
electrical-lead failure. This situation is rare, but often known immediately
postoperatively and exists because the only viable route to the ventricle
required the ICD wire to bend slightly more than normal. During exercise it is
important to avoid excessive shoulder range of movement and/or highly
repetitive vigorous shoulder movements. Light to moderate resistance activities
performed within a normal range of movement that closely match functional
activities have been used successfully in patients with an ICD.
• Activities involving moderate to high aerobic challenge with associated low to
moderate hemodynamic response should be encouraged (e.g. walking, cycling
etc). Due to the associated HF in many patients with ICD, activities that involve
large muscle groups working together with breath holding or large static
(isometric) muscle work (e.g. full body press ups) should be avoided. If such
activities are carried out in ICD patients without HF they should be performed
with caution
Physical
•
Physical fitness is soon lost if training is not continued at a level sufficient to
EACPR Policy Statement
Activity
Counselling
•
•
•
•
Exercise
training
•
•
•
•
•
•
•
•
23
maintain the effect. Moderate physical activity as well as leisure and sport are
known to benefit health and where possible these should be pursued most days
of the week. Continuous physical activity of 30 minutes or more is considered
most effective, although multiple activity sessions of 10 to 15 minutes, on the
same day, have also demonstrated significant health improvement.
Patients should not undertake hard contact sports. Although the ICD device is
very tough, bruising or breaking the skin over the site where the device is
implanted may lead to infection, which can then become very troublesome to
treat and resolve.
Swimming can be undertaken once the implant wound has healed fully. It is
advisable to ensure that patients are accompanied at all times during swimming
or water sports by someone able to assist in helping them out of the water
should the ICD go off or in case they lose consciousness or feel unwell. Some
ICDs are implanted for arrhythmias, which may be triggered specifically by
swimming (some Long QT Syndromes) – patients should check with their
cardiologist if they are unsure. Snorkelling is not recommended and SCUBA
diving should not be undertaken.
Patients should recognise that they are unlikely to be able to obtain insurance
for winter sports such as skiing or, indeed any other “extreme” sports where the
effects of a shock may put them or others at risk.
In setting up the exercise classes close proximity to powerful electricalmagnetic equipment is to be avoided. In terms of electro-magnetic interference
patients are safe to use powered ergometers (e.g. treadmills) and telemetry
heart rate monitoring devices.
Training program duration of 12 weeks or more has been found to be beneficial.
Exercise prescription should utilize one of the standard best-practice
approaches of monitoring, e.g. VO2, measured heart rate or rating of perceived
exertion (e.g. RPE 6 to 19 or the CR 10 scale 0 to 10).
Aerobic training: the intensity of training should be defined according to peak
VO2 or heart rate determined by cardiopulmonary exercise testing or peak work
load.
A note of caution is required when prescribing exercise intensity based on
estimated heart rate approaches. The use of standard 75% target heart rate in
ICD patients with slow ventricular tachycardia will often mean that the target
exercise heart rate is above the detection threshold of the ICD. This could, for
some patients, lead to inappropriate ICD therapy or fear of such events. We
recommend that maximum or peak heart rates are measured rather than
estimated in this patient population.
In situations where patients have low threshold settings for ICD therapy, CRT
limits or rate-limited pacemakers, training heart rates should be adjusted to the
appropriate device settings.
For patients with ICD-CRT and associated heart failure the intensity of exercise
is often lower (e.g. 40 to 60%) and care should be taken with planning the
setting and progression of exercise intensity. The use of rate pressure product
(peak systolic x peak heart rate x 0.01) is encouraged as a way of establishing
the burden on the heart during exercise in this patient sub group.
All exercise sessions should start with a warm-up and finish with a cool-down
period, both of which should last for 10 to 15 minutes, so that the
cardiovascular system has time to adjust to the alteration in circulatory and
respiratory demand. The sequence of exercise should vary from arm work to
trunk and leg work, with flexibility and coordination exercises following the more
strenuous exercises. The main part of the training program should consist of
graded aerobic circuit training exercises lasting 30 to 40 minutes and
incorporating multi-joint movements with part bodyweight and moderate
resistance.
In general, most exercises should be performed standing, with horizontal and
seated arm exercises kept to a minimum. Seated arm exercise, especially at or
above shoulder height, is associated with reduced venous return, reduced enddiastolic volume, a concomitant decrease in cardiac output and increased
likelihood of arrhythmia. If seated exercise is to be performed then the intensity
EACPR Policy Statement
•
•
Diet /
Nutritional
counselling
Weight control
management
•
•
•
Lipid
management
Blood pressure
monitoring
Tobacco
cessation
Psychosocial
•
management
•
Vocational
management
•
24
of exercise should be lowered and the emphasis placed on muscular
endurance.
Resistance training: 2-3 sets with 10-12 repetitions per set at 40-70% 1-RM
with a full recovery period (>1 min) between each set. The range of movement
during shoulder resistance training should take account of ICD lead issues and
be kept within safe and tolerable ranges (e.g. avoid excessive shoulder flexion).
Progression is based on the patient’s ability to carry out 10 repetitions in a
skilled and comfortable way, at which point the load can be increased.
Regular skilled, low emotive exercise, incorporating a warm-up with a self
monitored moderate exercise intensity followed by a graded cool down is the
proven way to gain the most whilst reducing the risk of future cardiac events.
In general there are no specific dietary issues for patients with an ICD other
than those of patients with cardiac disease and those in the pursuit of a healthy
diet (see Diet / Nutritional counselling section in table 3).
There are no specific weight management issues for patients with an ICD other
than those of patients with cardiac disease and those in the pursuit of a healthy
diet (see weight control management section in table 3).
The only exception is for patients with associated heart failure (NYHA class III
and IV) in which case daily weight measurement is required as a means of
monitoring fluid retention and overload. Rapid weight gain in the order of 1.5kg
in one day is a sign of increasing burden and exercise should not be carried
out.
(see table 3)
(see table 3)
(see table 3)
Every effort should be made to reduce patient anxiety which is known to be
raised in patients fitted with an ICD. Awareness of stress and stress
management approaches should be introduced early in the CR program. Group
or one-to one sessions should be offered to support patient preference.
Depression in patients with arrhythmia and heart failure is associated with poor
long term outcome and poor compliance with exercise programs. These
patients should be assessed and supported with evidence based approaches
that often require medication and counselling.
ICDs used for the management of ventricular arrhythmias may hinder return to
work but with appropriate education and support for the patient and employer
most patients, with a history of working, should eventually return to work.
EACPR Policy Statement
25
Table XVIII Core components in older patients
Components
Patient – risk
assessment
Physical activity
counselling
Exercise training
(ET)
Diet/Nutritional
counselling
Weight control
management
Lipid management
Blood pressure
monitoring
Smoking cessation
Psychosocial
management
Established/Agreed Issues
• Clinical history: cardiovascular disease (e.g. CAD, HF, atrial fibrillation,
PAD, renal failure) and risk factors as well as concomitant diseases (e.g.
stroke, neurological dysfunction, COPD, visual/hearing impairment, arthritis,
osteoporosis, urinary incontinence, cognitive impairment, dementia)
• Education: Take into account the fact that older patients typically more
often have visual, hearing and cognitive impairments
Expected outcomes: formulation of a therapeutic regime with a high level of
individual care and support, with the aim of preserving mobility, independence
and mental function
• Emphasise participation in supervised group activities to advance social
integration and social support
Tailored exercise recommendations: prescriptions for a given patient should:
• Depend on existing co-morbidities and on the baseline level of physical
capacity as well as existing activity limitation,
• Include activities to develop endurance, strength, flexibility, coordination
(balance skills) and body awareness,
• start at a very low level and gradually progress to a goal of moderate
activity
Frailty:
• For frail patients stationary cycling may provide a greater degree of stability
and less risk of injury than walking exercise; specially adapted balance and
resistance exercise programs may enhance functional capacity and prevent
falls
• Recommended intensity for resistance exercise <30%-60% of 1RM.
• Select exercise appropriate to musculoskeletal conditions in older patients
• Avoid exercises that require rapid postural variations for orthostatic
hypotension risk.
• Greater benefits from shorter single exercise session with prolonged
duration of the CR/ET programs
(see table 3)
•
•
•
•
•
Less likely to be severely obese than younger patients, especially those
with CHF which are at higher risk of developing cardiac cachexia.
BMI 28-29 kg/m2 is the target value
Benefit from lipid lowering medication (statins) as for other patients
A careful management of hypertension in older patients is mandatory
including pharmacological and non-pharmacological interventions (weight
reduction, exercise and low salt intake).
(see table 3)
Treatment should focus on identifying and reducing depression and anxiety,
improving social adaptation and reintegration as well as overall quality of
life
EACPR Policy Statement
26
Table XIX. Core components in women
Components
Patient - risk
assessment
Physical Activity
Counselling
Exercise training
Diet/Nutritional
counselling
Weight control
management
Lipid
management
Blood pressure
monitoring
Smoking
cessation
Psychosocial
management
Established/Agreed Issues
- Clinical history: (see also table 3)
- Patient education: crucial to provide comprehensive information on the
contents and the basic purpose of the CR program to improve adherence and
reduce possible barriers.
- Expected outcomes: formulation of a therapeutic regime with a high level of
individual care and support considering their specific characteristics and needs
as well as individual convenience
- advise and encourage to perform regular physical activities (e.g. walking or
biking > 30 min 5-7 days a week).
- women who need to lose weight or sustain weight loss should accumulate a
minimum of 60 of moderate-intensity physical activity (e.g., brisk walking) on
most, and preferably all, days of the week
- emphasise participation in supervised group activities to advance social
integration and support.
- Exercise recommendations and prescriptions (see also table 3):
- incorporate individual preferences which might be different from those of male
patients,
- include combined program of endurance (cycle, walking, nordic walking) and
resistance exercise (major functional, postural and pelvic floor muscle)
- include callisthenics to develop flexibility, coordination (balance skills) and
body awareness
- include activities and games which enhance communication and social
integration, like dancing.
- a diet rich in fruits and vegetables, whole-grain, high-fibre foods; fish,
especially oily fish, ≥ twice a week;
- limit intake of saturated fat to <10% of energy (<7% if possible), cholesterol
to<300 mg/d, alcohol intake to ≤1 drink/day, sodium intake to <2.3 g/d
(approximately 1 tsp salt).
- In obese women, weight reduction and maintenance is mandatory through
appropriate caloric intake, physical activity and exercise as well as behavioural
programs
- older women with CHF and other chronic diseases are at risk of developing
cardiac cachexia.
- Encourage optimal lipid management through lifestyle approaches and lipid
lowering medication (statin therapy, unless contraindicated)
(see table 3)
-
Women may need more individual counselling (see table 3)
-
Focus on identifying and treating anxiety and depression, improvement in
social adaptation and reintegration as well as overall quality of life
Younger women need special attention
Emphasize emotionally supportive approaches. Female patients respond
positively to reassurance, encouragement and listening
(see table 3)
Vocational
management
EACPR Policy Statement
27
Table XX. Core components in patients with history of TIA / stroke
Components
Established / Generally agreed issues
Patient - risk
assessment
-
-
-
Physical Activity
Counselling
Exercise training
-
-
Diet/Nutritional
counselling
Weight control
management
Lipid
management
Blood pressure
monitoring
Smoking
cessation
Psychosocial
management
Severe neurological deficits should go for specialized neurological
rehabilitation.
Otherwise, all patients with history of minor TIA or stroke should be
encouraged to participate in exercise based CR, firstly to improve
coordination and balance skills.
These patients can also be integrated in a normal CR exercise program, but
they would profit from participation in a special group of patients with a history
of TIA or minor stroke. Group activities may improve social functioning and
communication skills particularly in patients with speech difficulties.
Prescriptions should depend on the baseline level of physical capacity as well
as existing exercise-limiting neurological deficits and/or disabilities.
The implementation of relaxation training must take into account possible
motor deficits and consider if participation in the sitting position might fit better
To avoid cardiac overload consideration must be given to patients with motor
deficits or disabilities (e.g. caused by spasticity) who have higher energy
demands for a given activity.
(see table 3)
(see table 3)
(see table 3)
•
•
Check for unsafe hypotension episodes
see table 3
(see table 3)
•
Consider an increased risk of depression, appropriate counselling and
possible appropriate pharmacological therapy to increase motor function and
adherence to CR program
Neuropsychological assessment and training if indicated.
see table 3
(see table 3)
•
•
Vocational
management
Risk factors and (a history of) neurological symptoms and deficits (e.g.
amaurosis fugax, diplopic images, aphasia, hemiparesis, paresthesia,
dementia, vertigo)
Gait ability, sitting balance, standing balance and functional mobility (eg. Berg
Balance Scale (www.strokecenter.org), Clinical Outcome Variables Scale
(COVS ) (www.rehab.onca/irrd/covs).
Residual neurological deficits especially those which might affect the patient’s
ability to participate in the CR-program (e.g. paresis, motor deficits,
movement deficits, impaired sensibility, cognitive deficits, and/or neuropsychological symptoms, such as attention deficits, apraxia, aphasia)
In patients with residual and severe deficits, consider if participation in the
usual educational program can be of benefit.
(see table 3)
EACPR Policy Statement
28
Table XXI. Core components in patients with COPD
Components
Established/agreed issues
Patient - risk
assessment
-
Risk factors and symptoms (dyspnea, chronic cough, chronic sputum
production)
- Spirometry (for classification of COPD severity; specific cut points e.g. postbronchodilator FEV1/FVC ratio or FEV1)
- Exercise capacity by cardio pulmonary stress test and/or 6 min walk test
- Echocardiography (exclusion/diagnosis of pulmonary hypertension; cor
pumonale)
Introduction to peak flow-based self management
Physical activity
counselling
Exercise training •
•
Educational
program
Diet/Nutritional
counselling
Weight control
management
Lipid
management
Blood pressure
monitoring
Smoking
cessation
Psychosocial
management
Vocational
management
Prescriptions should depend on the baseline level of physical capacity as well
as the COPD severity. The program should include endurance (interval
training), resistance exercise (especially lower body exercise), breathing
exercise, as well as instruction in postures to help shift and cough up phlegm
Patients with measurable obstruction should be advised to use a
bronchodilator medication before starting the exercise. In case of postbronchodilator FEV1
• >75%, the patient can be integrated into the regular CR exercise training
regime.
• <75% >50% the level of endurance exercise should be reduced by 1015%.
• < 50%, participation in low dose endurance/interval cycle ergometer
training as well as gymnastics (Borg-Dyspnea-Scale value ≤ 5, breathing
rate ≤ 20/min) is advisable
• < 30%, O2 saturation should not exceed values < 90%
(see table 3)
(see table 3)
•
Patients with severe COPD are at risk of developing cachexia. Weight loss
may impair respiratory performance so their diet should cover increased
energy needs
•
Some evidence of benefit from statin therapy
•
Beta-blockers should be used with caution in severe COPD
•
Stopping smoking is the main intervention and all forms of treatment program
should be offered
(see table 3)
(see table 3)
EACPR Policy Statement
29
Table XXII. Core components in patients with renal failure (RF)
Components
Patient - risk
assessment
Physical activity
counselling
Exercise training
Diet/Nutritional
counselling
Established/Agreed Issues
Clinical history:
• see table XX:
• etiology of chronic renal failure
Assessment:
• actual status of renal function, electrolytes, proteinuria
• cardiovascular risk factors and risk diseases especially hypertension,
diabetes, hyperlipidemia.
Advanced renal failure, hemodialysis:
• concomitant disease: lack of 1,25-(OH)2-D3, secondary hyperparathyroidism,
renal osteopathy, renal anemia, metabolic acidosis, hypertension?
• fluid retention? dehydration? oliguria? anuria?
• establish a close cooperation with dialysis centre
Expected outcomes:
• correct clinical guidance and avoidance of clinical complications during
rehabilitation
See table XX and watch the additional recommendations for patients under
hemodialysis or after kidney transplantation (see below).
Modes of exercise and exercise intensity:
- Combination of aerobic endurance and dynamic resistance training
- Include activities to develop flexibility, coordination and body awareness
- Training intensity depends on the individual exercise capacity and the
severity of renal failure.
- The exercise program usually is not affected by chronic renal failure in
stage 1-3
Patients under hemodialysis:
- If possible low intensity endurance training during hemodialysis (bed side
ergometer) should be performed and supplemented by gymnastics to
increase muscular strength, flexibility and co-ordination. In addition, an
individually adjusted exercise training is performed on the days between
hemodialysis.
- avoid pressure and injury of shunt/arteriovenous fistula, protect puncture
area with dressing
- blood pressure must not be measured on the shunt arm
- avoid exercises (gymnastics or resistance exercises) which include
pressing on the arms and/or holding the arms in head up position
- avoid wristwatches and wrist bands
Patients after kidney transplantation:
- strictly avoid any external trauma of the kidney transplant, which is
positioned within the iliac fossa directly below the abdominal wall
- avoid dehydration and any risk of infection
- avoid medications with pharmacokinetic interaction with
immunosuppressants
- avoid exercises performed in face down position
- avoid extreme stretching of the upper part of the body
Expected outcomes:
- increased fitness, flexibility and muscular strength
- improved psychosocial well-being and social participation
- reno-protective effect
•
•
Watch fluid regulation and strongly recommend daily weight control by the
patient. Fluid and sodium intake has to be individually adjusted according to
the stage of renal failure and the degree of fluid retention
in patients with stable chronic renal failure stage 1-3 a daily fluid intake of
approx. 1,5 l is recommended. Extraordinary fluid loss by sweating, diarrhoea
etc. has to be replaced.
EACPR Policy Statement
Weight control
management
Lipid
management
Blood pressure
monitoring
Smoking
cessation
Psychosocial
management
Vocational
management
30
Patients at stage 4 or above:
• Avoid food rich in phosphate (e.g. milk products, eggs, meat)
• reduce intake of food rich in potassium (fresh fruits, nuts, fruit juice)
• consider supplementation with vitamin D3 (Colecalciferol)
• stage 5: consider supplementation of water soluble vitamins
Expected outcomes:
• renoprotective effect
• risk reduction and avoidance of acute on chronic renal failure, fluid overload
and hyperkalemia.
• daily weight control
• in patients under hemodialysis the anticipated weight has to be considered for
control of fluid intake
Expected outcomes:
• simple way of improving patient’s self management
(see table 3)
treatment of hypertension has to start early and has to be effectively
controlled. In patients with proteinuria the resting blood pressure should be
below 125/75 mmHg
• inhibitors of the renin-angiotensin system are preferred, but plasma
potassium concentration has to be controlled
Expected outcomes:
• renoprotective effect
(see table 3)
•
•
•
See table 3;
psychosocial management especially should address the limited participation
of patients under hemodialysis and support individual coping mechanisms
Expected outcomes:
• improved coping
(see table 3)
References
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