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Cardiac rehabilitation. Ahmad Osailan. What is cardiac rehabilitation.

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Cardiac rehabilitation

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what is cardiac rehabilitation
What is cardiac rehabilitation
  • is a sum of coordinated interventions required to ensure best physical, psychological and social wellbeing, so that patient with chronic or acute post CVD, by their own effort can resume optimal functioning in society through improved health behaviour to slow or reverse the progression of the disease
mission of cardiac rehab
Mission of Cardiac Rehab

To restore and maintain an individual’s optimal physiological, psychological, social wellbeing.

target groups
Target Groups

Coronary heart disease (CHD)

Exertional angina .

ACS (unstable angina or NSTEMI or STEMI) following medical/surgical management.


Stable heart failure and cardiomyopathy

Those at high risk of developing CVD: total

CVD risk > 20% over 10 years or diabetes


what are the outcomes
What are the outcomes
  • mortality and morbidity
  • hospital readmission
  • risk factors
  • physical activity and functional capacity
  • psychological problems
components of cr
Components of CR.


Diet and weight management

Smoking cessation

Physical activity and exercise

Secondary prevention


Psychosocial care

Long-term management strategy

physical activity
Physical Activity

Assess and risk stratify

Develop individual exercise plan

Teach FITT principle

Regain/develop physical fitness

Regain confidence in physical activity

Develop long-term activity plan

Self monitoring

secondary prevention
Secondary Prevention

Cholesterol management

BP management

Blood sugar management

Cardio-protective drug therapy


CHD as a disease

Treatment including medication

Recovery process

CHD risk factors

Symptom management

Living with CHD

psychosocial care
Psychosocial Care

Reduce fear and anxiety

Assist with adjustment

Promote positive attitude

Facilitate behaviour change

Identify need for further support

phases of cardiac rehab
Phases of cardiac rehab
  • Phase 1 inpatient phase
  • Phase 2 immediate post discharge phase
  • Phase 3 exercise training phase
  • Phase 4 maintenance phase
inpatient phase
Inpatient phase


Post- operation

Education : focusing on :

Precautions and movements to be avoided

Importance of practising breathing Exercises

The stages of rehab after OP and the activities allowed after OP

  • Clinical assessment: focusing on RHR, RBP, RR and O2 saturation
  • Functional activities
  • Risk factors assessment:
phase 1
Phase 1
  • Main aim: is to start changes in behavioural life style as soon as possible.
  • Education of Risk factors and correction of misconceptions
  • Addressing psychological issues.
  • Gradual increase of activity and mobilization
phase 11
Phase 1
  • Contraindications for mobilization:
  • High SBP and DBP (hypertension) 185
  • Uncontrolled arrhythmias, (Afib)
  • Uncontrolled DM >250 mmol
  • O2 saturation < 85%
  • sever tachypnea RR > 40
  • Sever Hypotension SBP<85
phase 2
Phase 2
  • Aim: to promote self willingness to toward healthier life style.
  • Following with patient via phone
  • Patient should receive a booklet for self education.
recommendations for exercises @ home
Recommendations for exercises @ home
  • Performing simple household activities
  • Encourage walking more than using the car
  • Walking duration should be gradual, the min is 10 min 3x per day
  • Encourage use of stairs.
  • Avoid stress
phase 3 outpatient phase
Phase 3Outpatient phase
  • Aim: to introduce the supervised tailored exercise sessions to patients.
  • Full clinical assessment including exercise capacity assessment via:
  • 6MWT or ISWT
6 mwt
  • Course length
  • Different prediction equations
  • More simple than ISWT but less efficient
exercise sessions
Exercise sessions
  • According to BACR and SIGN guidelines:

Frequency: 2-3/wk

Intensity: at the beginning 60-65% of HRR and progression occurs gradually (old population Vs young population)


Mixture of Aerobic cardiovascular Exercise and some light resistance training exercises

Duration: 60 min per session

types of exercises
Types of Exercises
  • 10-15 min of warming up with ended by stretching.
  • 20-30 min of conditioning exercises aerobic Exe (biking, treadmill, rowing, stepping....etc) and resistance exercise.
  • 10- 15 min of cooling down and relaxation techniques.
exercise session
Exercise session
  • Exercises can be performed in a group or individualized.
  • If in a group: intensity will be set from Low –moderate
  • If individualised: Vary upon exercise capacity during assessment.
things to consider during sessions
Things to consider during sessions
  • Patients must feel slight breathlessness but not speechless!
  • Intensity of Exercise must be increased gradually
  • Heart rate must be monitored all the time during the session ( Polar HR, or Telemetry unit)
  • Any signs of Sever SOB noticed, Exe intensity must be decreased
  • Never stand still.
phase 4
Phase 4
  • Aim: maintain the positive changes of healthy life style.
  • But before advancement to phase 4 from phase 3 graduation criteria must be met:
  • Improvement in functional capacity
  • Ability to recognize symptoms of HA
  • Reports self exercises and daily activities
who can refer a patient
Who can Refer a Patient?

Site-specific Policy:

  • Cardiologist
  • Primary Care Physician
  • Internist
effects of exercise on risk factors
Effects of Exercise on Risk factors
  • Blood Pressure Taylor et al (2006)
  • LDL (bad cholesterol) Joliffe et al (2001)
  • HDL (good cholesterol)
  • Insulin Sensitivity
  • Glucose (sugar) Metabolism
  • Body Fat
  • Anxiety and Depression
absolute risk vs relative risk
Absolute risk vs. relative risk
  • The chances of having MI in a healthy person during vigorous exe is 5 times normal.
  • BUT: 56 more in less active person
why it is safe to exercise cardiac patients
Why it is safe to exercise cardiac patients
  • ARCH inter MED: the risk of developing cardiac arrest during exercise is 1.3 in a million patient hours.
  • Risks during exercise testing is higher 1.2 deaths /10000 test (2006)
risk factors
Risk Factors
  • Tobacco
    • Smoking and Chew
    • 50% decreased risk of CHD 1 year after cessation
  • Hypertension
    • 90% middle-aged Americans will develop HTN
    • 35 million office visits/yr for HTN
risk factors1
Risk Factors
  • Hyperlipidemia
    • 105,000,000 people with a tot chol> 200
    • 10% reduction in Total Cholestrol= 30% reduction in incidence of CAD
  • Physical Inactivity
    • $76 billion
    • > 60% of Americans don’t get sufficient exercise
risk factors2
Risk Factors
  • Obesity
    • More than 50% women and 60% men are overweight or obese
    • Nearly 300,000 American adults die of causes related to obesity
  • Diabetes
    • 58% reduction by lifestyle intervention
    • 75% of people w/DM die of CAD or vascular disease
exercise research
Exercise Research
  • Direct relation between inactivity and cardiovascular mortality. Inactivity is an independent risk factor for of CAD.
  • Exercise capacity is a more powerful predictor of mortality among men than other established risk factors for CAD.
  • Physical fitness has been clearly associated with improvements in lipid profiles.
evidence for cardiac rehab
Evidence for cardiac rehab
  • Joliffe et al (2001): Meta analysis shoed that exercise based CR reduce all cause mortality by 28% and cardiac mortality by 31%.
  • Taylor et al (2006) Meta analysis shoed reduction in mortality by 28%. 50% of reduction attributed to risk factors.
cost of cardiac rehabilitation
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.

cardiac rehabilitation saves lives
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.