Exercise Prescription for Cardiac Patients

1. Exercise Prescription for Cardiac Patients Prof. Warren Payne HM734 Exercise Testing and Prescription: Cardiorespiratory

2. Benefits of Exercise for Cardiac Patients • Offset deleterious pyschologic and physiologic effects of bed rest during hospitalization • Provide additional medical surveillance of patients HM734 Exercise Testing and Prescription: Cardiorespiratory

3. Benefits of Exercise for Cardiac Patients • Enable patients to return to activities of daily living within the limits imposed by their disease • Prepare the patient and the support system at home to optimize recovery followed by hospital discharge HM734 Exercise Testing and Prescription: Cardiorespiratory

4. Traditional Classification of Programs • Phase I: Inpatient • Phase II: Up to 12 weeks of supervised exercise and/or education following discharge • Phase III: Variable length program, intermittent or no ECG monitoring • Phase IV: No ECG monitoring and limited supervision HM734 Exercise Testing and Prescription: Cardiorespiratory

5. Contemporary Approaches • Background • Changes in risk stratification • New data on exercise safety • Financial pressures • Changes to traditional approach to cardiac rehabilitation HM734 Exercise Testing and Prescription: Cardiorespiratory

6. Contemporary Approaches • Movement towards individualized: • program according to patient recreational and occupational needs, • length of program, • degree of ECG monitoring, • level of clinical monitoring. HM734 Exercise Testing and Prescription: Cardiorespiratory

7. Inpatient Programs • Most patients will benefit from some form of inpatient intervention including risk factor assessment, activity counseling and patient and family education. • Follow a risk stratification approach taking into account contraindications to exercise (eg. Unstable angina, resting SBP > 200 mmHg or resting DBP > 110, acute illness or fever, uncontrolled PVC’s) HM734 Exercise Testing and Prescription: Cardiorespiratory

8. Inpatient Programs • First 48 Hours: • Logically restrict activities to ADL’s, arm and leg mobilization and postural change. HM734 Exercise Testing and Prescription: Cardiorespiratory

9. Inpatient Programs • Structured, formalized, in-hospital exercise programs after acute MI appear to offer little additional physioligic or behavioral benefits over routine medical care. • Use of formal exercise 3-5 days post MI may assist in quantifying exercise tolerance HM734 Exercise Testing and Prescription: Cardiorespiratory

10. Activity Classification Guide for Inpatient Activities • Class I • Sit up in bed with assistance • Does own self care activities • Sit in chair 15-30 min, 2-3 times/day • Class II • Sit in bed without assistance • Walks in room and to bathroom HM734 Exercise Testing and Prescription: Cardiorespiratory

11. Activity Classification Guide for Inpatient Activities • Class III • Sits and stands independently • Walks in halls with assistance short distances (15-30 meters) as tolerated, up to 3 times/day • Class IV • Does own self care and bathes • Walks in halls (50-70 meters) with minimal assistance, 3-4 times/ day HM734 Exercise Testing and Prescription: Cardiorespiratory

12. Activity Classification Guide for Inpatient Activities • Class V • Walks in halls independently (80-150 meters) 3-4 times/day • Class VI • Independent ambulation on unit 3-6 times/day. (ACSM Guidelines 2000 pp. 168) HM734 Exercise Testing and Prescription: Cardiorespiratory

13. General Inpatient Prescription Guidelines • Intensity • RPE: < 13 • Post MI: • HR < 120 bpm or HRrest + 20 bpm • Postsurgery: • HRrest + 30 bpm • To tolerance if asymptomatic HM734 Exercise Testing and Prescription: Cardiorespiratory

14. General Inpatient Prescription Guidelines • Duration • Intermittent bouts lasting 3-5 min • Rest Periods • At patient’s discretion, lasting 1-2 min, shorter than exercise bout • Total duration of up to 20 min HM734 Exercise Testing and Prescription: Cardiorespiratory

15. General Inpatient Prescription Guidelines • Frequency • Early mobilization: • 3-4 times/day (days 1-3) • Later mobilization: • 2 times/day (beginning on day 4) • Progression: • Initially increase duration up to 10-15 min, then increase intensity. HM734 Exercise Testing and Prescription: Cardiorespiratory

16. General Inpatient Prescription Guidelines • By hospital discharge, the patient should: • Demonstrate a knowledge of inappropriate exercises • Have a safe, progressive plan of exercise formulated for them to take home HM734 Exercise Testing and Prescription: Cardiorespiratory

17. General Inpatient Prescription Guidelines • Selected moderate to high risk patients should be encouraged to participate in outpatient cardiac rehabilitation programs &/or • Manage their discharge rehabilitation plan and report any cardiovascular symptoms promptly (should they occur). HM734 Exercise Testing and Prescription: Cardiorespiratory

18. Outpatient Programs • Goals are to: • Provide appropriate patient monitoring and supervision to detect a deterioration in clinical status and to provide timely feedback to the referring physician to enhance effective medical feedback, HM734 Exercise Testing and Prescription: Cardiorespiratory

19. Outpatient Programs • Goals are to: • Contingent upon patient clinical status, return patient to pre-morbid vocational &/or recreational activities, modify or find alternative activities, HM734 Exercise Testing and Prescription: Cardiorespiratory

20. Outpatient Programs • Goals are to: • Develop and help the patient to establish and implement a safe and effective home exercise program and recreational lifestyle, • Provide patient and family education and therapies to maximize secondary prevention. HM734 Exercise Testing and Prescription: Cardiorespiratory

21. Outpatient Programs • In general, patients should engage in multiple activities to promote total conditioning including aerobic and resistance exercises. • Principles of prescription are those for healthy adults but adjusted to take into account the patients clinical status. HM734 Exercise Testing and Prescription: Cardiorespiratory

22. Intensity • Above training threshold but below that which induces abnormal clinical signs and symptoms • For deconditioned cardiac patients: 40-50% of VO2 Reserve (VO2R). • Normally approximated by the HRR method of Karvonen (also can be applied to MET reserve) HM734 Exercise Testing and Prescription: Cardiorespiratory

23. Intensity • Use of RPE. Particularly useful when GXT has not been performed or medications change. • Normally 11-13 (fairly light to somewhat hard) for Phase II. • Later (Phase III or IV) may use 12-15 (Approximately 60-80% VO2R HM734 Exercise Testing and Prescription: Cardiorespiratory

24. Intensity • RPE can be used with beta-blockers BUT • Should remember that significant and serious ST segment and/or arrhythmias can still occur at low intensities and RPE’s HM734 Exercise Testing and Prescription: Cardiorespiratory

25. Intensity • Some patients: need to know when abnormalities occur to enable exercise below anginal or ischemic threshold • Use of HR monitor with alarms • Peak exercise HR 10 bpm below appropriate threshold. • Need to allow for medication effects on exercise tolerance and HR. HM734 Exercise Testing and Prescription: Cardiorespiratory

26. Intensity • Signs and symptoms below which an upper limit for exercise should be set: • Onset of angina or other symptoms of CV insufficiency • Plateau or decrease in SBP, SBP > 240 or DBP > 110 mmHg. •  1mm ST-segment depression • Increasing frequency of ventricular arrhythmias • Other significant ECG changes • Other signs or symptoms of intolerance to exercise HM734 Exercise Testing and Prescription: Cardiorespiratory

27. Duration • Desire to have 20-60 min of continuous or intermittent activity • Inversely proportional to intensity • May be able to accumulate in short (10-15 min) bouts. HM734 Exercise Testing and Prescription: Cardiorespiratory

28. Rate of Progression • Depends upon patient functional capacity and prognosis • Generally, progress over 3-6 months to 1000 kcal/week • Follow principles of initial, conditioning and maintenance phase • Generally progress every 1-3 weeks with goal of achieving 20-30 min of continuous exercise. HM734 Exercise Testing and Prescription: Cardiorespiratory

29. Rate of Progression • Patients requiring intermittent program (eg. Peripheral vascular disease, low functional capacity) should progress according to symptoms and clinical status HM734 Exercise Testing and Prescription: Cardiorespiratory

30. Guidelines for Progression to Independent Exercise with Minimal or No Supervision • Functional capacity  8 METS or twice occupational level • Appropriate hemodynamic response to exercise • Appropriate ECG response • Adequate management of risk factor intervention strategy and safe exercise participation • Demonstrated knowledge of disease process, abnormal signs and symptoms, medication use and side effects HM734 Exercise Testing and Prescription: Cardiorespiratory

31. Exercise Prescription Without a Preliminary Exercise Test • Programs should be conservative, close medical surveillance and a period of ECG monitoring is recommended. • Close observation for exercise intolerance and blood pressure monitored regularly. HM734 Exercise Testing and Prescription: Cardiorespiratory

32. Exercise Prescription Without a Preliminary Exercise Test • Initial intensities determined according to length of time from acute cardiac event and associated complications, duration since discharge and patient information (ADL’s current home program, associated signs and symptoms) • Use of Duke Activity Status Index HM734 Exercise Testing and Prescription: Cardiorespiratory

33. Exercise Prescription Without a Preliminary Exercise Test • Initial intensities: Normally 2-3 METs (eg. 100-300 kgm.min-1 on bicycle ergometer or 1.5 to 5 km.hr -1 • THR: approx. 20 beats/min above standing resting HR. • Gradual increase using RPE • ??? Use of ECG telemetry HM734 Exercise Testing and Prescription: Cardiorespiratory

34. Resistance Training • Contraindications similar to aerobic programs (unstable angina, uncontrolled PVC’s etc.) • Generally require moderate to good LV function and exercise capacity > 5 METs without angina or ST-segment depression HM734 Exercise Testing and Prescription: Cardiorespiratory

35. Resistance Training • Previously required abstinence from resistance training for several months post MI. • Now many patients can start by carrying up to 13 kg by 3 weeks post MI. • Generally use approx. 50% 1RM or use of other modes such as bands, hand weights etc. in Phase II. HM734 Exercise Testing and Prescription: Cardiorespiratory

36. Resistance Training • Should not begin until 2-3 weeks post MI. • After 4-6 weeks post MI, may start bar bells and/or weight machines • Note: surgical patients need to adjust program to accommodate sternotomy • Normally begin resistance program 2-3 weeks after initiating aerobic program. HM734 Exercise Testing and Prescription: Cardiorespiratory

37. Resistance Training • Advocate 1 set of 8-10 different exercises that focus on large muscle groups, 2-3 days/week. Will result in significant improvements • Additional sets/reps do not seem to result in substantial improvements. HM734 Exercise Testing and Prescription: Cardiorespiratory

38. Resistance Training • Initially start with 1 set of 10-15 reps to moderate fatigue using 8-10 different exercises • Increase 1-2 kg/week for arms and 3-5 kg/week for legs. • Check rate, pressure product. Shouldn’t exceed that for endurance exercise • RPE: 11-14. • Avoid Valsalva HM734 Exercise Testing and Prescription: Cardiorespiratory