Exercise Management

1. Exercise Management CABG and PTCA Chapter 07

2. Pathophysiology Coronary Atherosclerosis Significant Plaque Occlusion >75 % Progression of disease requires revascularization Coronary Artery Occlusion Exercise Management – CABG and PTCA CABG – Coronary Artery Bypass Graft SurgeryPTCA – Percutaneous Transluminal Coronary Angioplasty, aka. Percutaneous Coronary Intervention

3. Exercise Management – CABG and PTCA PTCA (PCI) • Purpose of Revascularization • ↑Myocardial blood flow and O2 delivery beyond an obstructive arterial lesion • ↓ or eliminate myocardial ischemia, including ST-segment changes, angina, ventricular arrhythmias, or combinations thereof • ↓ cardiovascular mortality and morbidity • Movie Demonstration

4. Exercise Management – CABG and PTCA • Indications for CABG (follows cardiac cath.) • Relief of angina when pharmacologic therapy is ineffective • When PTCA is contraindicated • Prolong life in patient with multiple artery, or main artery disease, in patient with ventricular dysfunction due to vascular disease • Preserve LV function, especially following an MI that has already compromised LV function

5. Exercise Management – CABG and PTCA • CABG are performed on patients who have multiple vessel disease and poor ventricular function, and poor LV ejection fraction. • Complications include infarction following surgery and (saphenous) grafts tend to remain open 90% at 1 year, 80% at 5 years, and 60% at 11 years post surgery. • Mammary grafts have 93%, 10 yr patency (remain open) • The greatest incidence of graft occlusion occurs between 5-8 years post surgery • Total relief of angina is typically 70% at 5 years, approx. 50% are asymptomatic at 10 years

6. Exercise Management – CABG and PTCA • Indications and Concerns for PTCA • Originally the choice for single vessel disease • Now used to treat multiple vessel disease, impaired LV function, and to open an acute occlusion during an MI • If PTCA fails then CABG is used during surgery • PTCA is less invasive and requires a shorter hospital stay • Arterial injury, thrombosis, and restenosis are the major complications of PTCA • PTCA stints can now be coated with Sirolimus to help prevent restenosis.

7. Exercise Management – CABG and PTCA • Indications and Concerns for PTCA (PCI) • Risks and Complications: • Low risk symptomatic patients may not benefit any more from PCI than with conservative treatments • PCI may involve: • Bleeding at the catheter insertion site • Blood clot or damage to the blood vessel at the insertion site • Blood clot within the vessel treated with PCI • Infection at the catheter insertion site • Cardiac dysrhythmias /arrhythmias • MI • Rupture of Coronary Artery

8. Exercise Management – CABG and PTCA • Benefits of PTCA (PCI) • Increases myocardial blood flow, thus: • Correct ischemic complications reflected in exercise ECG response (T wave inversion and ST-depression) • Reduce angina on exertion • Increase PWC (physical work capacity) • Improve Oxygen supply and demand (MVO2) and improve contractility and hemodynamic function • May improve post-exercise chronotropic impairment, and reduce the risk of hypotensive response (reducing likelihood of pre-syncope)

9. Exercise Management – CABG and PTCA • Effects of Exercise Training • Many results are similar to those with post MI • ↑ Max Vo2(mean 20%) • ↓ myocardial demand (↓ Submax HR and SBP for given workload) • ↑ glucose metabolism, ↓ insulin resistance, and other typical changes in blood lipid profiles. • In patients with stable CAD, PTCA (PCI) who undertook a 12 month training program resulted in a higher (event-free) survival rate. Each 1 MET increase in exercise appears to confer 8-17% reduction in mortality.

10. Exercise Management – CABG and PTCA • Management and Medications • Attempt to slow, halt, or reverse the progression of atherosclerosis through medication and health behavior management (diet, exercise, stress management), while maintaining the integrity of the vasculature addressed during surgery. • Poor prognosis includes: 1) recurrent angina, 2) pre-syncope, syncope, and 3) threatening forms of ventricular ectopy (multiform PVC, couplets, V-tach ) • Repeat PTCA is the usual treatment for restenosis.

11. Exercise Management – CABG and PTCA • Recommendations for Exercise Testing • Exercise testing may begin earlier than for post MI patients (CABG = 3-5 weeks, PTCA 2-5 weeks) • Cycle and Treadmill Tests commonly used with CABG due to incision pain in the sternum area • Retest procedures should follow for any patients who are symptomatic within 5 years, and all patients after five years. • The combination of perfusion and exercise testing can detect ischemia and restenosis.

12. Exercise Management – CABG and PTCA • Recommendations for Exercise Testing • Supine cycle ergometry and echocardiography may be used to dectect wall function abnormalities and provide prognostic information for risk assessment if clinical restenosis. • ST-segment changes, CP, or both present in the follow-up exercise test (2-5 weeks) may be indicative or restenosis .

13. Exercise Management – CABG and PTCA Recommendations for Programming (see chart p. 63) • Significant increases in functional capacity and ADL will occur in the weeks following CABG and PTCA ( improved myocardial supply) • CABG and PTCA patients can typically begin exercise programming sooner and at a more accelerated rate than post MI patients. • ROM exercises are indicated for CABG patients and contraindicated with excessive sternal movements. • Individuals with > 4 MET capacity and who complete 12 week programs have less mortality risk

14. Exercise Management – CABG and PTCA Recommendations for Programming (see chart p. 63) • CABG and PTCA may begin inpatient exercise rehabilitation sooner than post MI and; • Progress at a more accelerated rate, and • Devote more attention to upper extremity ROM • CABG focused ROM - 1) Shoulder ROM exercises; 2) Hip ROM exercises; Ankle ROM exercises.

15. Exercise Management – CABG and PTCA End of Presentation