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Exercise Prescriptions: Cardiac Rehab and Frail Adults. Brian K. Unwin, M.D. Colonel, Medical Corps, USA Uniformed Services University. Cardiac Rehab. Only 15-25% of eligible patients participate!. The Evidence Fewer events, reduced all cause mortality 20-34%.

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Exercise prescriptions cardiac rehab and frail adults l.jpg

Exercise Prescriptions:Cardiac Rehab andFrail Adults

Brian K. Unwin, M.D.

Colonel, Medical Corps, USA

Uniformed Services University


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Cardiac Rehab

Only 15-25% of eligible patients

participate!

Am Heart J 2006; 152:835-841


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The Evidence

Fewer events, reduced

all cause mortality

20-34%

Am Heart J. Nov. 2006. 152(5):835-41


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Core components of Cardiac Rehab

  • Patient assessment

  • Nutritional counseling

  • Lipid management

  • Hypertension management

  • Smoking cessation

  • Diabetes management

  • Psychosocial management

  • General education (meds, procedures, condition)

  • Physical activity counseling

  • Exercise training



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NICE Guidance

  • Lifestyle

    • Regular activity

    • Stop Smoking

    • Mediterranean Diet

    • 7 gm of Omega-3 fatty acids/week

    • Healthy weight

    • 14 “units” of alcohol per week

    • No beta-carotene

    • No evidence for antioxidants and folic acid

Heart 2007; 93: 862-864


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NICE Guidance

  • Cardiac Rehab

    • Exercise offered

    • Includes: exercise, education, stress management

    • Involves partners/carers

    • Can be home based (Edinburgh Heart Manual)

    • Advice for return to activities

    • Sexual activity okay

    • Consider wider social and health needs


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NICE Guidelines

  • Drug Treatment

    • ACE

    • Aspirin

    • Beta-blocker

    • Statin

    • Clopidogrel x12 months (after non-ST MI), at least 1 month after ST elevation MI.

    • Aldosterone with CHF and LV dysfunction

    • Consider moderate intensity coumadin (INR 2-3)

  • Cardiological assessment


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General RecommendationsIschemic Heart Disease

  • When stable, regular physical activity

  • Contra-indications

    • Recent MI

    • Unstable angina

    • Exercise induced arrhythmia

  • Intensity

    • Below anginal theshold

    • “Talk-test”

  • Duration and Frequency = 30 min most days


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General RecommendationsHeart Failure

  • All (almost) CHF patients should be considered

  • Elderly not excluded

  • Intensity initially = “talk test”

  • Duration and Frequency = 30 min most days

Heart, Lung and Circulation 2007; 16: S83-S87


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American Association of Cardiovascular Rehabilitation (AACVPR) (Card Clin 2001; 19: 415-431)

Lowest Risk

Moderate Risk

High Risk

American Heart Association (Circulation 2001; 104:1694-1740)

Class A

Class B

Class C

Class D

Risk Stratification

AHA Guidelines include activity

guidelines and supervision requirements

See handout…


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Returning to work (AACVPR)

Many factors

Non-exercise variables are important

Gradual exposure to outdoor exercise program

See ACSM Guide Appendix E


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Notes on total dose and volume for cardiac patients (AACVPR)

ACSM Guide to Exercise Rx 7th Edition

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!


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Exercise considerations for the angina patient (AACVPR)

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

Upper body exercise may precipitate symptoms due to higher pressor response

NTG

Monitor blood pressures before and after exercise (or NTG use)

Alternative exercise: frequent, short, intermittent sessions


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Exercise considerations for the CHF patient (AACVPR)

Must be on stable medical therapy

Monitor hypokalemia and hemodynamic response

Malignant dysrhythmia

THR 40-70% VO2max 3-7days per week, 20-40 minutes per session

Long warm-up and cool down

Interval exercise training

RPE may be used


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Exercise considerations for the pacemaker/ICD patient (AACVPR)

  • Fixed vs. adjustable rate

  • Monitor systolic pressures

  • Extended warm-up and cool down

  • ICD: ECG monitoring/pulse to titrate intensity

  • Rate modulated pacemakers intensity:

    • MHRR method of Karvonen

    • Fixed percentage of MHR

    • RPE

    • METs


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Exercise considerations for the cardiac transplant patient (AACVPR)

  • 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


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Exercise considerations for the CABG and PTCI patient (AACVPR)

CABG

PTCI

Aerobic and resistance after access site healed

May progress rapidly if no myocardial damage

  • 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



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Why push our frail elders? (AACVPR)

People live longer with chronic diseases.

10% of nondisabled adults 75 years+ lose independence in 1 or more ADL’s each year.

Exercise and physical activity can improve health, functional capacity, QOL, and independence.


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Exactly What is Frailty? (AACVPR)

Aging, high burden of chronic disease, malnutrition and extreme lack of activity.

Muscle weakness and low muscle mass (sarcopenia), low bone density, cardiovascular deconditioning, poor balance and gait.

Inactivity with low energy intake, weight loss or low BMI.


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Frailty in Relation to Other End of Life States (AACVPR)

Lunney et al. JAMA; 289:2387-92, 2003


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Physiology of Frailty (AACVPR)

Sarcopenia = decreased quality of muscle

Strength decline: diminished walking speed and balance difficulties as a result

Grip strength: inversely related to IADL deficits

Spinal mobility: affects many functional tasks


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Exercise (AACVPR) (Activity) Prescription for Older Adults Fitness 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


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Aging (AACVPR)

Decreased taste

Poor dentition

Dementia and depression

Chronic illness

Multiple hospitalizations

Aging

Weight loss

Chronic inflammation

Illness

Chronic

Malnutrition

Frailty

Cycle

Decreased

appetite

Sarcopenia

Osteopenia

Decreased strength

Immobility

Dependency

Impaired balance and falls

Chronic illness

Hospitalization

Medications

Stressful life events

Falls

Decreased

metabolic rate

and activity

AM J Med. 2007. 120(9):748-753


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Associations with (AACVPR) co-morbidity and disability

If identified as Frail:

27% reported ADL

disability

46% had co-morbid

disease

22% had ADL disability

and com-morbid illness

27% had neither disability

or co-morbidity

Overall: 2,762 subjects with comorbidity and/or disability and/or frailty


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Pathways to Frailty (AACVPR)

Genetic Factors, atherosclerosis,

chronic inflammation

Prevention

Low level of exercise,

malnutrition

Clinical Disease

Primary Frailty

Palliation

Secondary Frailty

Disability

Lancet. 2007. 369: 1328-29


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Frailty Predicted: (AACVPR)

Predictor of death within 3 yrs (6x mortality)

3x mortality at 7years

Increased falls, decreased mobility, injury and ADL disability

Hospitalization/institutionalization risk

Pre-frail had 2x the risk of progression to being frail

Dependency


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How to Quantify Frailty: (AACVPR)

From the Cardiovascular Health Study, three or more of the following:

Shrinking

>10 pounds (or 5%) of body weight in prior year

Weakness

Lowest 20% adjusted for gender and BMI

Self report of exhaustion

Correlates with VO2 max and cardiovascular disease

Slowness

Slowest 20% based on time to walk 15 feet, gender and standing height adjusted

Low physical activity level

Weighted score of kcals expended per week, lowest 20% adjusted to gender

Fried. J Gerontol. 2001. 56A(3): M146-156


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Quantifying Frailty: (AACVPR)

Frailty

3 or more criteria met

Pre-frailty

1-2 criteria met

Fried, Tangen, et al. Frailty in Older Adults: Evidence for a Phenotype. J of Gerontology. 2001: 56A(3): M146-M156.


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Criteria #1: Weight loss (AACVPR)

  • Weight loss

    • Patients asked if they experienced 10 pounds of unintentional weight loss in last one year


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Criteria #2: Exhaustion (AACVPR)

  • Self-report of exhaustion

    • Two statements provided

      • “I felt that everything I did was an effort”

      • “I could not get going.”

    • “How often in the last week did you feel this way?”

      • 1= some or a little of the time (1-2 days)

      • 2= a moderate amount of time (3-4 days)

      • 3= most of the time


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Criteria #3: Walk time (AACVPR)

Time to walk 15 feet:

6.5 secs


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Criteria #4: Grip strength (AACVPR)

MEN:

WOMEN:

<30 Kg

<18 Kg


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Criteria #5: Low activity (AACVPR)

  • Leisure-time physical activity

    • Males < 383 kcal/week

    • Females < 270 kcal/week

Perspective:

159# person walking at 5kph

burns 280kcal/HOUR


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Frailty: An operational definition (AACVPR)

The aged person with unintended weight loss

Weakness

Self-report of exhaustion

Slowness

Low activity

WASTING SYNDROME


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Evidence for Exercise (AACVPR)

Regular physical activity reduces age-related loss of muscle mass.

Resistance training increases muscle mass, counteracts sarcopenia, and improves function.

Chronic disease and syndromes respond favorably to exercise.

Small improvements in physiological capacity = substantial effect on functional performance.


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Studies (AACVPR)

Cochrane Collaboration: falls reduction

Fiatarone et al: increased muscle strength = increased daily function

FICSIT Trials: balance exercises lowered falls

FAST trial: diminished pain and disability in OA patients

NEJM Oct 2002: 45% reduction in disability

Health ABC Study: exercise = better function


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Exercise Goals for the Frail Elder (AACVPR)

Improve ADL and IADL function

Improve QOL

Enhance: flexibility, balance/postural stability, endurance, coordination, movement speed, strength, and bone health

Prevent/decrease the burden of disease

Improve patient education


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Exercise History (AACVPR)

What is the patient’s lifelong pattern of activities and interests?

Patient’s investment in plan

What has been the patient’s activity level in the past 2-3 months?

Determines current baseline

What are the patient’s concerns and perceived barriers regarding exercise?

Opportunity for education


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Evaluating Function (AACVPR)

Physical Performance Test (PPT)

Timed Get Up and Go (TUG)

Vulnerable Elders Survey (VES-13)

Functional Status Questionnaire (FSQ)

EPESE study: Physical performance measures

Others: LLFDI, PF-10 and LHS


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Contraindications for Exercise (AACVPR)

Frailty or extreme age is not!

Caution: acute illness; unstable CP; uncontrolled DM, HTN, asthma, CHF; musculoskeletal pain, weight loss and falling

Not during treatment: hernias, cataracts, retinal bleeding or joint injuries

Stop!: enlarging AAA, end stage CHF, malignant ventricular arrhythmias, severe AS


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Risks of exercise for the frail elder (AACVPR)

Main risk = musculoskeletal injury

Higher: vigorous exercise, higher volume, obesity

Lower: higher fitness, supervision, protective gear and well designed exercise environment

Risk of exercise related MI and sudden death: greatest in least active elders


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Disease Specific Exercise Rx’s (AACVPR)

OA: aquatic; flexibility training; isometric exercises

Osteoporosis: weight bearing; improve balance

Obesity: rotation to minimize orthopedic injury

HTN: aerobic activity, large muscle groups

COPD: walking; PRT of shoulder girdle, inspiratory and UE muscles. Bronchodilators reduce dyspnea

CHF: aerobic and resistance training; improves VO2 max, dyspnea, work capacity and LV function; muscle strength and muscle endurance


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The “MD FITT” Prescription (AACVPR)

(for the older adult)

  • Mode:

    Aerobic+Strength +Balance+Flexibility

  • Duration

  • Frequency

  • Intensity:

  • Touch > No Touch > Eyes Closed for balance

  • 5-6/10 self-perceived exertion

  • Timely Follow Up

  • Therapy (Preventive and/or Therapeutic)


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TOOL TIME! (AACVPR)


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REHAB TOOLS! (AACVPR)

  • The Kansas City Cardiomyopathy Questionnaire

  • The Patient Knowledge Questionnaire

  • Medical Outcomes Study: 36-Item Short Form Survey Instrument

  • 6 Minute Walking Test

  • ACSM’s Guidelines for Exercise Testing and Prescritpion (7th Edition)


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Vulnerable Elder Survey (AACVPR) VES-13

Saliba et al. JAGS ; 49: 1691-99, 2001


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Timed Up and Go (AACVPR) “TUG”

Patient sits in a straight-backed high-seat chair

Instructions for patient:

Get up (without using the armrests)

Stand still momentarily

Walk forward (10 ft or 3 m)

Turn around and walk back to chair

Turn and be seated

>15 seconds higher risk for fall


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PPT (AACVPR)

Reuben DB, Siu AL. JAGS; 38(10): 1105-12, 1990


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Exercise (AACVPR) (Activity) Prescription for Older Adults

http://www.nia.nih.gov/NR/rdonlyres/8E3B798C-237E-469B-A508-94CA4E537D4C/0/NIA_Exercise_Guide407.pdf


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Useful web sites (AACVPR)

Exercise: A Guide from the NIA http://www.nia.nih.gov/HealthInformation/Publications/ExerciseGuide

ACSM Fit Society Page http://www.acsm.org

CDC Physical Activity for Everyone http://www.cdc.gov/nccdphp/dnpa/physical/index.htm


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