Cardiac Rehabilitation. دکترامیر هوشنگ واحدی متخصص طب فیزیکی و توانبخشی. Background. CVD are the leading cause of mortality and morbidity in the industrialized world, accounting for almost 50% of all deaths annually.
Cardiac Rehabilitation دکترامیر هوشنگ واحدی متخصص طب فیزیکی و توانبخشی
Background • CVD are the leading cause of mortality and morbidity in the industrialized world, accounting for almost 50% of all deaths annually. • CR aims to reverse limitations experienced by patients who have suffered the adverse pathophysiologic and psychological consequences of cardiac events. • CR has been provided to somewhat lower-risk patients who could exercise without getting into trouble.
History • In 1912→Herrick first described a MI.→Bed rest for 2 months . • In the 1930s, patients with MI→observe 6w of bedrest. • In the 1940s, and by the early 1950s→ Chair therapy & 3-5 minutes of daily walking , (beginning at 4 weeks). • Clinicians gradually recognized → early ambulation. →safety of unsupervised exercise ?→ development of structured, physician-supervised rehabilitation programs, which included clinical supervision, &ECG monitoring.
History • In the 1950s, Hellerstein presented his methodology for the comprehensive rehabilitation of patients recovering from an acute cardiac event. • He advocated a multidisciplinary approach to the rehabilitation program. • His approach was adopted by ‘CR programs’ throughout the world. • Despite multiple advances, Hellerstein's original ideas have not been improved upon significantly. • However, due to changing patient demographics, many more patients now have the opportunity to receive the benefits offered by CR. • Multifactorial intervention, including aggressive risk factor modification, has become an integral part of present day CR.
Goals of cardiac rehab • Greater physical activity. • Improved risk profile. • Improved quality of life. • Better social functioning. • Less hospital admission. • Improved survival. • Reduced recurrent events.
Indication of cardiac rehab • Patient with MI. • Post CABG Patients. • Post PTCA Patients. • Stable angina patients. • HF (stable patient in class II &III of NYHA) • Post valvular surgery patients. • Post heart transplantation.
NYHA-New York Heart Association classification: • Class 1: Heart disease without symptoms • Class 2: Heart disease with symptoms during ordinary activity • Class 3: Heart disease with symptoms during less than ordinary activity • Class 4: Heart disease with symptoms at rest
PRESENT PROBLEMS WITH CARDIAC REHABILITATION • The major present problem with exercise-based cardiac rehabilitation is its underutilization. • (25 to 30 percent of men and 11 to 20 percent of women)
INSURANCE COVERAGE • Starting March 22, 2006 • *1. Have had an acute AMI within the preceding 12 months • * 2. Have undergone CAGB • *3. Have stable angina pectoris • 4. Have undergone a cardiac valve repair or replacement • 5. Have undergone PTCA • 6. Have received a heart or heart-lung transplant • 7. HF??? • Routine coverage is for a total of 36 exercise sessions.
Contraindication of CR • UA. • Uncontrolled atrial or ventricular arrhythmia. • Uncontrolled HF. • Moderate to severe AS. • Resent thrombophelebitis or PE. • Non cardiac reasons(orthopedic or other disease).
Cardiac rehabilitation: • Exercise: Monitoring Non monitoring
Criteria for ECG monitoring during exercise • 1-Severely depressed LV function (EF<30%). • 2-Resting complex ventricular arrythmia. • 3-Ventricular arrythmias appearing or increasing with exercise. • 4-Survivors of sudden cardiac death. • 5-Decrease in systolic blood pressure with exercise.
Criteria for ECG monitoring during exercise • 6-Survivors of MI complicated by CHF, cardiogenic shock, serious ventricular arrythmias or some combination of three. • 7-Severe CAD and marked exercise-induced ischemia(ST segment depression greater than or equal 2mm). • 8-Initially to self-monitor HR because of physical or intellectual impairment.
Risk stratification • Acute event. • Clinical stability. • Residual ventricular function. • Functional capacity. • Myocardial ischemia & arrythmias.
Risk stratification • Low • Intermediate • high
Low risk patients • Uncomplicated in acute phase. • EF>=50% • No detectable residual ischemia. • No complex arrythmias. • Functional capacity>6 METs.
Intermediate risk patients • 31< EF >49%. • Exercise ST segment depression below 2 mm. • No sustained ventricular arrythmias.
High risk patients • Survivors sudden cardiac death. • Complications during acute phase. • EF<30%. • Myocardial ischemia with ST segment depression greater than 2 mm. • Complex ventricular arrythmia at rest. • Decrease in SBP>15mmHg during exercise.
Readiness for cardiac rehab.: • To begin rehab. • No new or reccurent chest pain in past 8 hours. • Ck or troponin levels are not rising. • No new sign of uncompensated HF (dyspnea at rest & basilar rals.) • No new significant abnormal rhythm or ECG changes in past 8 hours.
Progression of rehab. • Adequate HR increase. • Adequate SBP rise to within 10-40 mmHg from rest. • No new rhythm or ST change on telemetry rhythm strip. • No cardiac symptoms such as palpitation, dyspnea, excessive fatigue or CP.
RECOMMENDATION FOR MONITORING • Lowest risk for exercise prescription • Moderate risk for exercise prescription • Highest risk for exercise prescription
Lowest risk for exercise prescription • Direct staff suppervision for 6-18 exercise session or 30 days post event or procedure,beginning with continuous EKG monitoring and decreasing to intermittent EKG monitoring (at 6-12 session) • For a patient to remain at Lowest risk normal ECG & hemodynamic, no sign or symptoms and progression of exercise should be normal.
Moderate risk for exercise prescription • Direct staff suppervision for 12-24 exercise session or 60 days post event or procedure,beginning with continuous EKG monitoring and decreasing to intermittent EKG monitoring (at12-18 sessions) • For a to patient move to lowest risk normal EKG & hemodynamic,no sign or symptoms and progression of exercise should be normal. • Abnormal EKG & hemodynamic during exercise, abnormal sign & symptom within or away from exercise & need to severely ↓ exercise level → remain in moderate risk or move to ↑ risk category.
Highest risk for exercise prescription • Direct staff suppervision for 18-36 exercise session or 90 days post event or procedure,beginning with continuous EKG monitoring and decreasing to intermittent EKG monitoring (at18-24 sessions) • For a patient move to moderate risk category: normal EKG & hemodynamic,no sign or symptoms within or away from exercise, and progression of exercise should be appropriate.
ET before starting cardiac rehab. • ET is useful, especially those after recent MI, but not all patients, undergo such testing. • Patients who did not undergo exercise testing before the program can exercise at a heart rate 20 beats faster than their resting value. • • their resting HR plus a specified additional percent of rest. • month 1→ rest HR+20 to 30 percent rest HR; • month 2→ rest HR+20 to 40 percent rest HR • month 3→ rest HR+20 to 50 percent rest HR
Four step of cardiac rehab. • Phase 1: Inpatient rehabilitation • Phase 2: outpatient rehabilitation • Phase 3: Supervised rehabilitation • Phase 4: Maintenance
Phase 1 • Inpatient rehabilitation, usually lasting for the duration of hospitalization. It emphasizes a gradual, progressive approach to exercise and an education program that helps the patient understand the disease process, the rehabilitation process, and initial preventive efforts to slow the progression of disease.
Phase 1 goals; • Clear the patient for any skeletal, muscle, and orthopedic problems. • Clear the patient for any pulmonary problems that would limit activity • Return the patient home and workplace→safe activity (without reinjuring their hearts) • Decrease the patient pain & fear of living. • Increase the patient,s physical work capacity. • Help the patient to modify their coronary risk factor. • Give objective information back to all member of CR team.
Component of CR P1 • The rehabilitation specialist →risk factor for CAD and reduce them. • The physical therapists→early mobilization • The registered dietitation→dietery change
Phase 1 exercise • Include ROM activity, walking, exercise to stretch muscle and stair climbing. • This is done to: enhance recovery, decrease deconditioning associated with bed rest(muscle atrophy, blood clot formation...)& improve confidence for long term lifestyle change. • The exercises are individualized for patient depending on medical condition.
General guidelines for exercise priscription(for recommendation) • Week 1:walk 3-5 min. Continuously 3-4 times daily. • Week 2:walk 6-10 min. Continuously 3 times daily. • Week 3:walk 11-15 min. Continuously 2 times daily.
Plan exercise into one day • Dont exceed a 20 min. Continuously without your doctor,s okey. • May add a few extra walks if you can tolerate it, avoid doing too much; avoid fatigue. • Rest 20 min.before & after walking. • Walk at a pace that feels fairly easy( should be able to talk) • Wait at least 1 h. after a meal before you go walking
Walking often with assistant→target heart rate <20 beat above the resting heart rate. • At discharge the patient should undrestand what activities are safeand which activities should be avoided for the next several weeks.
Phase 1.5 (post discharge phase) • Begin after the patient returns home from the hospital. • Team member check the patient’s medical status. • This phase of recovery include low-level exercise & physical activity • Risk reduction strategies are emphasized again. • After 2-6 weeks of recovery at home the patient is ready to start CR phase 2.
Phase 2 • Multifaceted outpatient rehabilitation, lasting 2-3 mo. • Emphasizes safe physical activity to improve conditioning with continued behavior modification aimed at smoking cessation, weight loss, healthy eating, and other factors to reduce disease risk. • Initiate an exercise prescription
Exercise program design • Warm-up period • Conditioning period • Cool-down period
Warm-up period • Static stretching • Dynamic R.O.M • Low level dynamic aerobic activity (25-40% of pt's F.C)
Conditioning period(focus on following activity) • To increase caloric expenditure(weight management) • To improve overall F.C • To delay the onset of symptoms • To maintain current fnnctional ability • To improve muscle tone or strenght • To obtimize job or avocational abilities. • To obtimize recreational activities performance. • To obtimize activities of A.D.L(activity of daily living)
In conditioning period cosider: • Frequency • Intensity • Mode • Duration • Rate of progression.
Frequency affected by: • Overall goal of CR program. • Functional ability of the patient • The type and intensity of activity • The patient interests. • Level of personal commitment &recent activity history.
Averrage rehab. Program frequency: • Begin with 3 time per week at least 3to6 months and after this time the program can be extended to 4-5 time per week.
Intensity • Can be determined by: • Work load, MET’s & exercise intensity • Heart rate and & exercise intensity • RPE & exercise intensity • Oncet of symptom & exercise intensity
Work load, MET’s & exercise intensity • ACSM recommended VO2 Reserve as a method to prescribe exercise intensity. • Gaskell et. al (2004) demonstrated %HRR is better related to %VO2max than to VO2R in 630 initially sedentary individuals (ages 17 to 65 years). • Gaskell concludes %VO2max is the better measure for prescribing exercise intensity.
Heart rate and & exercise intensity • The Karvonen Formula: • 220 - Age= Predicted MHR- RHR(average of 3 mornings)= HRR • HRRx.50( )+ RHR= Minimum Training Threshold • HRRx .85 ( )+ RHR= Maximum Training Threshold ========================================= • Target heart rate: • 50( )%-85( )% MHR is Target HR
Borg Scale for Rating Perceived Exertion RPE OF 12-16 = 60-85%H.R Responce (somewath hard to hard)
Oncet of symptom & exercise intensity • Oncet of symptom should be an absolute determinat of the upper limit of exercise intensity; • Drop in SBP/Exaggerated BP response/>2mm ↓ST segment/↑Chest pain/Fatigue/Shortness of breath/ Wheezing/Leg cramps/Intermittent claudication/ CNS symptom/Arrythmia/ Patient request to stop.
Mode • Depend on the; • Specific goal • Needs • Ability of the patient. • P.F.C of cycle ergometry=85% P.F.C of treadmill • P.F.C of arm ergometry=60% of cycle ergometry • (P.F.C= peak functional capacity)
Rate of progression • Must be determined by; • Current level of fitness • Prior activity history • Health status • Age • sex • Personality • Goal of rehabilitation