Cardiac Rehabilitation

Dr.ramiza khalid
Physiotherapist
Lecturer GCUF
 Definition of
Cardiac Rehabilitation

“The sum of activities required to ensure

patients the best possible physical, mental
and social conditions so that they may
resume and maintain as normal a place as
possible in the community”.
World Health Organisation
 Goal of rehabilitation
 Return to independent living situation
 Nursing home patients generally return to
that environment
Rehabilitation in general
 Comprehensive
 Multidisciplinary
 Long term
 Medical evaluation
 Prescribed exercise
 Risk factor modification
 Counseling/Education
Cardiac rehab outcomes
 Improved psychosocial well-being
 Mortality reduction of approximately
25% at three years (similar to B-
blockers and ACEI Rx)
 No increase in morbidity or mortality

Cardiol J. 2008; 15(5): 481-7

Cardiac rehab outcomes
 Improved exercise tolerance for CAD
and CHF
 Decreased symptoms in CAD and CHF
 Multi-factorial interventions improve
lipids
 Multi-factorial rehab reduces cigarette
smoking (16-26% will quit)
AHRQ Technical Reviews and Summaries, AHRQ Supported Clinical Practice
Guidelines, Chapter 17. Cardiac rehabilitation
Cardiac Rehabilitation
Saves Lives!
 No treatment in cardiac disease has stronger scientific
evidence or a significantly greater impact on survival.

 The scientific evidence has been reviewed by many

scientific and expert bodies over the last 30 years.
Every review has come to the same conclusion that
cardiac rehabilitation is an essential treatment.

 CR is only form of chronic disease management with

an evidence base.
The Evidence

Comprehensive help with lifestyle modification

involving education and psychological input as
well as exercise training can reduce mortality by
20-25% over 3 years.

Oldridge et al 1988;
O’Connor et al 1989
Cost of Cardiac Rehabilitation

 The average cost per patient in 2006-7 was £413

 Single day in a CCU costs £1,400

 Angioplasty (does not reduce mortality) costs

£3,000

 Bypass surgery costs £8,000.

Who Makes Up The Cardiac
Rehabilitation Team
 Physician
 Physical Therapist
 The nurse
 The occupational Therapist
 Psychologist
 The Dietician or Nutritionist
 The Exercise Physiologist
Who should be involved?
Exercise instructor
Physiotherapy
GP District Nurses Consultant

Secondary care
Psychologist
Dietician

Practice nurses Smoking cessation advisor

Nurse
Pharmacist
Health Visitor
Target Groups
Coronary heart disease (CHD)
– Exertional angina .
– ACS (unstable angina or NSTEMI or STEMI)
following medical/surgical management.
– Revascularisation
– Stable heart failure and cardiomyopathy
Those at high risk of developing CVD: total
CVD risk > 20% over 10 years or diabetes
mellitus.
 Structure of
Cardiac Rehabilitation
 Phase 1: In-patient (1st contact)
 Phase 2: Immediate post discharge
 Phase 3: 2-4 weeks post discharge
 Phase 4: Long-term, on-going
Phase I Cardiac
Rehabilitation
What do we do
with these very sick people ?
 Phase 1
 Understanding of condition
 Information & education
 Risk factor assessment
 Personalised health plan
 Psychological assessment/support
 Referral
 Drug therapy
 Outcomes
Diagnosis Functional QOL Morbidity Mortality
Capacity
AMI +++ +++ ++ +++
CABG +++ +++ ++ ++
Stable +++ +++ + +
angina
PCI +++ ++ + ?
CHF +++ ++ + +
Cardiac +++ ++ ? ?
Transplant
Valve +++ ++ ? ?
replacement

Am Heart J. 2006; 152: 835-41

 Functional decline during
hospitalization

Hospital admission
B Post Recovery
Function

A
Rehabilitation

Threshold of
Independence
No rehabilitation

Am J Phys Med Rehab, 2009,

Time 88(1):66-77
Etiology of deconditioning
Consequences of
deconditioning
 Strength and Functional Status

Normal
Healthy
Adults
“Function” Near
Frail
THRESHOLD
Poor Frail
Adults

“Strength”
Low High
Established Populations for Epidemiologic Studies of the Elderly (EPESE) . J
Gerontology, 1994;49(3):M109-15
 Objectives of Phase I
Cardiac Rehabilitation

I .Patient & Family Education

II. Prevent Deleterious
Effects Of Bedrest
III. Provide A Safe
Discharge To Home
 Objectives of Phase I
Cardiac Rehabilitation
I. Patient & Family
Education
 Modification of risk factor
profile
 treatment of hyperlipidemia
 smoking cessation
 treatment of hypertension
 control of diabetes
 regular exercise
 dietary changes
Education
 Challenges for the Pt and Family

•Frightening, life threatening event (MI, major surgery)

•A chronic illness, reduced life expectancy, symptoms
•Altered identity - an invalid, walking time bomb
•Fears for family and partner being left alone
•Threat to employment and financial status
•Medication side effects (lethargy, impotence)
•Being treated differently by other people
•Neurological impairement (esp. cardiac arrest pats.)
•Making lifestyle changes, smoking, diet, activity
 Objectives of Phase I
Cardiac Rehabilitation
 Behavior modification
 stress management at
home
 stress management at
work
 creation of hobbies -
time out
 conflict resolution skills
 Objectives of Phase I
Cardiac Rehabilitation
II. Prevent Deleterious
Effects Of Bedrest
 Mobilize the patient
soon
 Prevent muscle
atrophy
 Prevent blood clot
formation
 Prevent pneumonia
 Prevent lethargy
INTERVENTIONS IN ACUTE CARE
 1-Mobilizations and exercises
 2-Body Positioning
 3-Clinical application of airways clearance
techniques
 4-Coughing techniques facilitating airways
clearance
 5-Facilitating ventilation patterns and
breathing strategies
 Mobilization and exercise
 Mobilization is defined as therapeutic and
prescriptive application of low-intensity
exercises in the management of
cardiopulmonary dysfunction
 Mobilization and exercises are the
physical therapist’s (PT’s) “drug”
 Termed as DRUG because it includes
indications, contraindications, &side
effects for each patients
 Objectives of Phase I
Cardiac Rehabilitation

III. Provide A Safe

Discharge To Home
 Provide enough physical stamina to
go home and perform ADL’s
 Reduce fear
Patient Assessment
 Patient Assessment

 In order for a patient to enter

Phase I Cardiac Rehab, they
must be medically stable.
 Patient Assessment
Who Should Be Enrolled In
Phase I Cardiac Rehab ?
 Stable myocardial infarcts
 CABG patients
 Patients who have had angioplasty
 Patients who have had cardiac transplantation
 Patient with Other cardiac patients
 Patient with noncardiac diseases and have
several risk factors
Patient Assessment
Who Should Not Do Phase I ?

 Patients with unstable angina

 Patients with acute CHF
 Patient’s with uncontrolled rhythms
 Patients with a systolic BP >200 mm Hg
Patient Assessment
Who Should Not Do Phase I ?

 Patients with acute pericarditis

 Patients with recent emboli or clots
 Patients with severe cardiomyopathies
 Patients with uncontrolled DM
 Patints with severe AS
 Patient with third degree AV Block
Evaluation
 Phase II

 Phase II is the next stage in

cardiac rehabilitation for the
patient
 It begins after discharge from the
hospital.
 It usually occurs in a hospital
setting where the patient can be
constantly monitored.
 Goals Of Phase II
Cardiac Rehab
 Give the patient a safe, monitored
environment in which to exercise
 Increase the patient’s work
capacity through exercise
conditioning
 Relieve anxiety and fear : reassure
the patient that they can live a
more normal life
 Teach the patient to monitor their
own responses to exercise -
monitor HR and learn to use
subjective feelings to assess work
intensity - use of the Borg Scale
 Phase II continues to be a time for
patient education - seminars on
food preparation, medications,
smoking cessation, sexual activity,
cardiopulmonary anatomy, risk
factor modification and what to do
when symptoms return
The patient is monitored
during Phase II with :
 blood pressure
 heart rate

 telemetry EKG

 anginal scale

 dyspnea scale

 Borg scale
 Blood pressure at rest should be
less than 160 mm Hg at rest.
 Heart rate at rest should be less
than 140 bpm.
EKG rhythms that prevent
exercise in Phase II :
 atrial flutter
 atrial fibrillation

 supraventricular

tachycardia
 Mobitz Type II 2nd AV

block

3rd degree AV block

couplets

triplets

sick sinus syndrome
 Anginal Scale
1+ : faint pain is present - patient
can continue
2+ : pain clearly present - patient
can continue
3+ : pain is very bad - patient
must stop exercise soon
4+ : Pain is the worse ever -
exercise must stop now !
 Dyspnea Scale
1+ : slight breathlessness - patient
can continue
2+ : moderate breathlessness - patient
can continue
3+ : moderately severe breathlessness -
patient must stop exercise soon
4+ : severe breathlessness - exercise
must stop now !
Borg Scale
 The Exercise Program
 Mode
 Determined by the patient’s
pathology - stationary bike,
treadmill, Nu-Step Bike,
UBE or an UE Monarch bike
 Mode is also determined by the
intensity or level of monitoring
required for the patient’s well
being.
 Frequency
 Usually 3 times per week
for 12 weeks - insurance
will pay for Phase II
 Duration Of Exercise Bout
 minimum of 15-20 minutes
 10-15 minute warm-up

period
 10-15 minute cool-down

period
 Cool-down periods are
important
 allows for heart to decelerate
 lactic acid disposal

 heat dissipation

 re-uptake of catecholamines
 When cool-downs are too short or
non-existent, cardiac events are
more likely to happen at the end of
vigorous aerobic exercise.
 Intensity
 Intensity is calculated from
the GXT data that the
patient’s doctor generated
at the end of phase I
cardiac rehab
 GXT DATA
 GXT data is comprised of :
 Resting HR

 Resting blood pressure

 Maximum exercise heart rate

 Maximum exercise blood

pressure

Maximimum MET’s achieved.
 Rate of Progression
 Rate of progression is
determined by the patient’s
starting fitness level,
progression of disease, and
time since diagnosis.
 A Reasonable
Rate Of Progression
 Week 1-2 : treadmill @ 0% x 3.5 mph
HR @ 135 x 20 min
 Week 2-4 : treadmill @ 0% x 3.8 mph
HR @ 140 x 30 min
 Week 4-6 : treadmill @ 2% grade x 3.8 mph
HR @ 140 x 40 min
 Week 6-8 : treadmill @ 4% grade x 3.8 mph
 HR @ 140 x 45 min
 After 12-Weeks Of
Phase II, What Next ?
 Once A PERSON has graduated
from 12-weeks of Phase II cardiac
rehab,he/ she will enter Phase III
cardiac rehab.
 Phase III Cardiac Rehab
 Phase III is an exercise program
that is usually held at a athletic
club or the YMCA
 It is characterized by a much lower
level of monitoring.
 Personnel present in a Phase III
program are the exercise leader
and a nurse with a crash cart
 Monitoring may involve :
 An initial BP taken before
warm-up exercises or...
 An initial defibrillator

paddle look at the heart -

analysis of the resting EKG
 Fifteen minutes of stretching and
light exercises will begin the
exercise session
 Patients will then exercise for 30-
60 minutes doing walk-jog, easy
basketball, or whatever exercise
routine they have planned out -
rowing, biking, rebounding, etc.
 Cool-down is a much lower level of
exercise activity decelerating to a
slow, ambling walk and followed
by a few minutes of stretching
exercises.
 In Phase III, the patient is largely
responsible for self monitoring HR,
subjective feelings and
symptomatology.
 Phase IV Cardiac Rehab
 Phase IV is a lifelong commitment
to regular exercise. It is generally
run as a club experience.
 The Phase IV club experiences
could involve swimming,
badminton, tennis, walk-jog,
biking, hiking, Tai-Chi in the park,
etc.
 ClassificationClass 0: Asymptomatic
 Class 1: Angina with strenuous Exercise
 Class 2: Angina with moderate exertion
 Class 3: Angina with mild exertion
– Walking 1-2 level blocks at normal pace
– Climbing 1 flight of stairs at normal pace
 Class 4: Angina at any level of physical
exertion
Cardiac Initial Rise To Back To
marker Rise Peak Baseline
CK 4-6 h 24-36 h 3-4 d

CKMB 3-12 h 24 h 2-3 d

Troponin I 3-12 h 12-48 h 5-10 d

Metabolic equivalent of energy expenditure for
varying levels of activity
Modified Bruce Exercise Test
Protocole
Stage Speed Grade Time METs
One 1.7 0% 3 min 2.3
mph
Two 1.7 5% 3 min 3.5
mph
Three 1.7 10% 3 min 4.6
mph
Four 2.5 12% 3 min 6.8
mph
With

Thanks
General Recommendations
Ischemic Heart Disease
 When stable, regular physical activity
 Contra-indications
– Recent MI
– Unstable angina
– Exercise induced arrhythmia
 Intensity
– Below anginal threshold
– “Talk-test”
 Duration and Frequency = 30 min most days
General Recommendations
Heart Failure
 All (almost) CHF patients should be
considered
 Elderly not excluded
 Intensity initially = “talk test”
 Duration and Frequency = 30 min most
days
 Notes on total dose and
volume for cardiac patients
 For stable cardiac patients progress to expenditure of
1000kcal/week over 3-6 months
 Higher level than this is associated with
atherosclerotic regression (1500-2200kcal/week) (15-
20 miles per week)
 Typical cardiac program is <300kcal per session and
<200 on non-program days
 19-43% of patients in rehab programs reach these
levels
 Traditional exercise rx falls short of this goal!
Exercise considerations for the
angina patient
 Goal: increase anginal and ischemic threshold
 Prolonged warm-up & cool down (gradual rise)
 Target HR below ischmic level (± 10 bpm)
 Caution with exertion in the cold
 Monitor blood pressures before and after
exercise.
 Alternative exercise: frequent, short,
intermittent sessions
Exercise considerations for the
CHF patient
 Must be on stable medical therapy
 Monitor hypokalemia and hemodynamic
response
 Malignant dysrhythmia
 THR 40-70%
 Long warm-up and cool down
 Interval exercise training
 RPE may be used
Exercise considerations for the
pacemaker/ICD patient
 Fixed vs. adjustable rate
 Monitor systolic pressures
 Extended warm-up and cool down
 ICD: ECG monitoring/pulse to titrate
intensity
Exercise considerations for the
cardiac transplant patient
1-3 year survival rates of 86% and 80%
 Train wreck physically and metabolically
 Rx from data from testing, graded protocols
 Long warm up & cool down
 Denervated heart = no angina, low EKG sensitivity for ischemia,
delayed cardioacceleratory (and deceleratory) response
 Stress echo or radionuclide testing
 Intensity:

 50-75% of VO2peak
 RPE of 11-15 on the 6-20 scale
 Dyspnea
Exercise considerations for the
CABG and PTCI patient
CABG
ROM and mobility exercises
 Light hand weights
 Stretching and flexibility
 Avoid resistance training until sternum healed (3
months)
 Initial aerobic training (resting HR +30bpm)
 Valve patients: longer recovery, slower rate, more
limitations
 PTCI
 Aerobic and resistance after access site
healed
 May progress rapidly if no myocardial
damage
Benefits of Exercise Training
  work capacity  fatigue
  Heart rate during Exercise
  symptoms of CHF
  Atherogenicity by maintaining body weight
 HDL  TG  platelet aggregation
 Improve blood glucose level
 Improves coronary blood flow and myocardial
perfusion
Benefits of Exercise Training
contd.
 Endurance Training
  VO2 max 10-40%,  BP,  HR
 Positive changes in body composition
  body weight (1-3 kg),  % fat (1-3%)
 Positive metabolic changes
  insulin sensitivity,  cholesterol
 Resistance Training
  strength
 references
 Thomas RJ, King M, Lui K, et al. AACVPR/ACC/AHA 2007 performance
measures on cardiac rehabilitation for referral to and delivery of cardiac
rehabilitation/secondary prevention services. J Cardiopulm Rehabil Prev
2007;27:260-90
 Giannuzzi P, Saner H, Björnstad H, et al. Secondary prevention through
cardiac rehabilitation: position paper of the Working Group on Cardiac
Rehabilitation and Exercise Physiology of the European Society of
Cardiology. 
 Piepoli MF, Corrà U, Benzer W, et al. Secondary prevention through
cardiac rehabilitation: from knowledge to implementation. A position
paper from the Cardiac Rehabilitation Section of the European
Association of Cardiovascular Prevention and Rehabilitation.