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Transcript
Cardiac Rehabilitation and the High Risk Patient Ma. Paz Mildred F. Luque, MD, FPCP, FPCC HEART INSTITUTE St. Luke's Medical Center Quezon City ♥ Global City High-risk patients Severe LV dysfunction Severe exercise-induced ischemia, ST-segment depression of greater than 0.2 mV on an ECG, multiple perfusion defects on exercise nuclear stress testing, or multiple dyskinetic LV segments on stress echocardiography Complex ventricular arrhythmias or a history of previous sudden cardiac arrest Hypotensive response to exercise Low functional capacity Patient's inability to self-monitor his/her heart rate Components of a program Medical evaluation Prescribed exercise Education Counselling of patients with cardiac disease Short term goals "Reconditioning" the patient sufficiently enough to allow him/her to resume customary activities Limiting the physiologic and psychological effects of heart disease Decreasing the risk of sudden cardiac arrest or reinfarction Controlling the symptoms of cardiac disease Long term goals Identification and treatment of risk factors Stabilizing or reversing the atherosclerotic process Enhancing the psychological status of the patients Risk stratification Assessment of the patient's functional capacity Educational and psychosocial status Whether alternatives to traditional cardiac rehabilitation can be used Whether the patient is suffering from myocardial ischemia, ventricular dysfunction, or arrhythmias Heart Failure Limited exercise capacity Low cardiac output Reduced muscle blood flow Skeletal muscle dysfunction Deconditioning Effects of exercise Clinical Enhanced peak VO2, possibly peak cardiac output due to a higher workload achieved, and leg blood flow during exercise Improved muscle energetics Improvement in symptoms Effects of exercise Pathophysiologic Reduced sympathetic tone and increased vagal tone at rest Reduced neurohumoral activity with decreased resting levels of angiotensin, aldosterone, vasopressin and natriuretic peptide Improvement in endothelial function Reduction in plasma levels of proinflammatory cytokines No ventilatory, hemodynamic, autonomic, or clinical factor at baseline predicts the outcome with exercise training in patients with heart failure Effects of exercise training Hemodynamics Functional capacity Improves measures of left ventricular function and hemodynamics Improvement in maximal exercise tolerance Patient outcome Reduce heart failure related hospitalization Improve health-related quality of life HF Action Trial 2331 patients with left ventricular ejection fraction ≤35 percent and NYHA class II to IV HF Randomly assigned to either a supervised exercise training program or usual care including education and recommendation of regular exercise Background medical therapy was optimized Median follow-up was 30 months HF Action Trial Modest but significant decrease in allcause mortality or all cause hospitalization (after adjusting for baseline prognostic variables) with the exercise training program Significant reduction in cardiovascular mortality or HF hospitalizations High level of safety during and after the training sessions Significant improvement in health status Exercise recommendations Patients with stable class II to class III HF who do not have advanced arrhythmias, and who do not have other limitations to exercise Exercise intensity of 70 percent of heart rate reserve, three days per week for six to eight weeks Exercise guidelines Longer warm-up period Begin at 40 to 60 percent VO2max for intervals of two to six minutes separated by one to two minutes of rest Gradually increase length of the exercise interval by one to two minutes until the patient tolerates 30 minutes of continuous exercise Self care Actions aimed at maintaining physical activity, avoidance of behaviors that can worsen the condition and detection of the early symptoms of deterioration Linked to symptom control, functional capacity, QOL, hospital admissions, prognosis, reduced mortality Precipitating factors in deterioration: nonadherence to diet or medication regimen, inappropriate use of medications, infections arrhythmia, ischemia Cardiac Transplantation Abnormal levels of functional capacity Marked deconditioning prior to transplant due to heart failure Surgical denervation Corticosteroid therapy Peripheral vasoconstriction Pre-transplantatiion For stable outpatients, exercise as an adjunct to pharmacologic therapy during the entire waiting period Preferred timing of referral is during the hospital stay for the transplant event For patients on home inotropic therapy, a monitored program in a cardiac rehabilitation center Pre-transplantation For patients on inotropic support who are being monitored hemodynamically, activity will vary depending upon patient mobility Limited data suggest that exercise training may be beneficial in patients who receive a left ventricular assist device (LVAD) as a bridge to transplantation Immediate post-op Prior to removal of the chest tubes and pacer wires, passive and active range of motion plus incentive spirometry Once out of bed in a chair, leg raising and hip girdle exercises Once the patient is able to stand, ambulation is initiated Prior to discharge, exercise on a stationary bicycle ergometer and/or treadmill. Predischarge cardiopulmonary exercise test Post-hospital prescription Intensity Duration Frequency Progression Resistance exercise Exercise guidelines Exercise in 15 to 30 minute sessions three to five times per week Avoid repetitive lifting of greater than a few pounds Maintain RPE at 10 to 13 ICD Baseline information ICD detection threshold setting in beats per minute Whether the device is set for ventricular tachycardia or ventricular fibrillation Rapid onset setting Sustained ventricular tachycardia settings ICD mode of therapy Beta-blockers Exercise Avoid contact sports Swimming possible unless arrhythmia is triggered by swimming; must be accompanied at all times Snorkeling not recommended SCUBA diving should not be undertaken Avoid exposure to strong magnetic or electrical fields or a powerful radio source Physical activity & exercise Aerobic skilled flowing movement, muscular endurance, flexibility Progress slowly Monitor intensity using heart rate or perceived effort Warm up and cool down Avoid static exercise when you are holding tight or resisting strongly and holding your breath Most exercise should be performed standing Physical activity & exercise Most exercise should be performed standing Avoid excessive shoulder range movement and or highly repetitous vigorous range movements Continuous physical activity of 30 minutes or more most days of the week Chronic Kidney Disease Cardiovascular Disease Leading cause of death regardless of CKD stage As renal function declines, all cause and cardiovascular mortality increases exponentially 40% of patients with established CVD have concomitant CKD Worse prognosis Worse revascularization outcomes Higher procedural complication rates CVD risk factors and CKD Traditional risk factors are rampant in the CKD population U-shaped mortality curve associated with cholesterol and hypertension levels with an increased risk of death for both extremes of measurement Qualitatively and quantitatively different risk factor exposure Burden of CKD-associated non-traditional risk factors Physical fitness and CKD Limited physical function across amny subjective and objective domains Deficits in measures of cardiopulmonary fitness (walking distance/time, treadmill, cycle ergometry) and strength Association between declining exercise performance and creatinine over time, independent of hemoglobin level Beneficial effects Physical fitness Blood pressure Psychosocial function Lipid parameters Hemoglobin levels Measures of arterial stiffness Quality of life Cardiorespiratory parameters Renal functional parameters Barriers to participation Socio-economic Logistic Patient-related Biased referral patterns Special considerations Hemoglobin Direct relationship with exercise capacity Treatment with erythropoesis-stimulating agents (i.e., erythropoietin) improves exercise capacity and VO2 peak Strength training and resistance exercises Intrinsic muscle changes contribute more to poor performance than do limitation in oxygen supply 1997 study showed strength training alone can improve VO2 peak in CKD patients Psychological stressors and adjustments Higher stress levels Alteration in social and role responsibilities, dependence and interdependence issues and uncertainty about the future Intensify as CKD progresses and need for renal replacement therapy draws nearer Cardiac rehabilitation provides an opportunity to foster coping skills and help patients adjust to these stressful changes Dietary counseling Maintenance of optimal nutrition Prevent or minimize metabolic derangements of CKD Retard the progression of renal failure Cardiac rehabilitation & CKD Regular structured exercise Dietary intervention Psychosocial counselling Life skills and coping skills retraining Pharmacologic intervention Elderly Elderly High risk of disability after coronary event or hospitalization for heart failure Complications of MI and myocardial revascularization are more frequent at an advanced age Prolonged hospitalization leads to deconditioning Less referral to and participation in cardiac rehabilitation Physical activity Improvements in gait, balance, overall functional capacity and bone health Increase quality of life Physical activity Cardiovascular fitness At least 30 minutes of moderate intensity exercise on most, if not all, days of the week Exercise mode that does not impose excessive orthopedic stress; and is accessible, convenient enjoyable Start low and individually progress according to tolerance and preference Measured peak heart rate preferable to agepredicted heart rate because of underlying CAD Physical activity Resistance training Begin first 8 weeks with little resistance One-set of 8-10 multi-jointed exercises that include all major muscle groups Set should include 15 repetitions at RPE of 1213 Number of repetitions increased before the resistance Physical activity Flexibility Improvement in ability to perform ADL, balance and agility Reduction in injury potential For every major joint of the body, at least 2 to 3 times per week Thank you for your kind attention
