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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.

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Cardiac Rehabilitation

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    1. Cardiac Rehabilitation دکترامیر هوشنگ واحدی متخصص طب فیزیکی و توانبخشی

    2. 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.

    3. 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.

    4. 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.

    5. 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.

    6. 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.

    7. 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

    8. 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)

    9. 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.

    10. 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).

    11. Cardiac rehabilitation: • Exercise: Monitoring Non monitoring

    12. 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.

    13. 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.

    14. Risk stratification • Acute event. • Clinical stability. • Residual ventricular function. • Functional capacity. • Myocardial ischemia & arrythmias.

    15. Risk stratification • Low • Intermediate • high

    16. Low risk patients • Uncomplicated in acute phase. • EF>=50% • No detectable residual ischemia. • No complex arrythmias. • Functional capacity>6 METs.

    17. Intermediate risk patients • 31< EF >49%. • Exercise ST segment depression below 2 mm. • No sustained ventricular arrythmias.

    18. 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.

    19. 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.

    20. 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.

    21. RECOMMENDATION FOR MONITORING • Lowest risk for exercise prescription • Moderate risk for exercise prescription • Highest risk for exercise prescription

    22. 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.

    23. 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.

    24. 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.

    25. 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

    26. Four step of cardiac rehab. • Phase 1: Inpatient rehabilitation • Phase 2: outpatient rehabilitation • Phase 3: Supervised rehabilitation • Phase 4: Maintenance

    27. 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.

    28. 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.

    29. Component of CR P1 • The rehabilitation specialist →risk factor for CAD and reduce them. • The physical therapists→early mobilization • The registered dietitation→dietery change

    30. 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.

    31. 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.

    32. 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

    33. 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.

    34. 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.

    35. 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

    36. Exercise program design • Warm-up period • Conditioning period • Cool-down period

    37. Warm-up period • Static stretching • Dynamic R.O.M • Low level dynamic aerobic activity (25-40% of pt's F.C)

    38. 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)

    39. In conditioning period cosider: • Frequency • Intensity • Mode • Duration • Rate of progression.

    40. 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.

    41. 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.

    42. Intensity • Can be determined by: • Work load, MET’s & exercise intensity • Heart rate and & exercise intensity • RPE & exercise intensity • Oncet of symptom & exercise intensity

    43. 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.

    44. 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

    45. Borg Scale for Rating Perceived Exertion RPE OF 12-16 = 60-85%H.R Responce (somewath hard to hard)

    46. 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.

    47. 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)

    48. Rate of progression • Must be determined by; • Current level of fitness • Prior activity history • Health status • Age • sex • Personality • Goal of rehabilitation