Cardiac rehabilitation

1. Cardiac rehabilitation p. 470 - 491

2. Aims Regain full physical, psychological and social status Optimize long-term prognosis To promote and implement secondary prevention measures Exercise training, education sessions, psychosocial support and support/counselling for patient and family in acute phase, out-patient care and long-term follow-up.

3. Aims Decrease cardiac morbidity and relieve symptoms Risk modification and secondary prevention Decrease anxiety and increase knowledge and self- confidence Increase fitness and ability to do normal activities Reassurance, support and information Behavioural change Exercise programme

4. Phases of care Phase I in-hospital (3-5 days) Phase II post discharge (2-6 weeks) Phase III outpatient programme (6-12 weeks) Phase IV long-term maintenance in community

5. Cardiac rehabilitation For all cardiac patients who would benefit Interdisciplinary team of professionals involved in rehabilitation

6. Benefits of exerciseImproved exercise capacity Increased cardiovascular endurance is the main aim Endurance training = activity using large muscle groups, can be sustained for a prolonged period and is rhythmic and aerobic resulting in an increase in maximal oxygen uptake. Maximal oxygen uptake (VO2 max) is limited centrally by cardiac output and peripherally by the capacity of muscles to extract oxygen from the blood.

7. Improved exercise capacityCentral changes In healthy people = endurance training causes increase in CO as a result of increase in SV. Achieved by: Increased left ventricular mass and size Increased total blood volume Reduced peripheral resistance

8. Improved exercise capacityPeripheral changes Training-induced changes in muscles: Increased number and size of mitochondria Increased oxidative enzyme activity Increased capillarization Increased myoglobin

9. Improved exercise capacityIncrease in VO2 max In cardiac patients increase in VO2 max mostly because of peripheral changes – high intensity exercises needed for central changes – inappropriate. Repeated submaximal daily activities – less physiological stress (decreased heart rate, blood pressure and plasma catecholamine concentrations)

10. Risk factor modificationThe factors that contribute to disease, can influence progression and future events. Exercise in healthy people cause: • Raised metabolic rate • Increased synthesis of HDL • Improved insulin sensitivity • Decreased blood pressure Exercise reduces triggers in cardiac events: • Prevents thrombus formation • Improves endothelial function • Reduces potential for serious arrhythmias

11. Exercise prescription • Individuality • Progressive overload • Regression – “use it or lose it” • Specificity – FITT-principles

12. Exercise intensity Maximum or symptom-limited exercise ECG 60-75% of HRmax 10-20 beats below heart rate that elicits symptoms

13. Exercise intensity No ECG Age-adjusted prediction 40-65% of HRR

14. Exercise intensity • Borg 15-point scale or Borg CR10 scale • MET’s

15. Warm-up • Preparation for activity • 15 minute • Low impact, dynamic movements of large muscle groups • Take all major joints through normal ROM • Will delay onset of ischaemia by allowing enough time for coronary blood to flow in response to greater myocardial workload • Lessen risk of arrhythmias • Heart rate 20 bpm lower than lower end of prescribed training heart rate after warm-up ( 3 or 10-11 on Borg)

16. Aerobic exercises • Continious or interval approach • Interval approach – total volume of work done more, stimulus for physiological change is greater • Circuit training – station 30s to 2 minutes • Individualisation – duration of station, intensity, period of rest and overall duration (increase duration before intensity)

17. Aerobic exercises Exercise in lying not advised because: • Older patients have difficulty with transfers • Increase in venous return – increases pre-load and myocardial load – increased risk of arrhythmias and angina • Orthostatic hypotensive episodes

18. Resistance training Not previously used in cardiac patients: • increased blood pressure • increased myocardial workload • reduced ejection fraction and increased incidence in arrythmias, BUT also • increased diastolic pressure with better myocardial perfusion • 10-15 repititions to moderate fatigue, 8-10 exercises

19. Cool down 10 minutes of movements of diminishing intensity and passive stretches of major muscles because: • increased risk of hypotension • in older patients heart rate takes longer to reach pre- exercise rates • raised sympathetic activity after exercise – arrhythmias Patient observation for 30 minutes after exercises

20. Programme implementationIn-hospital Acute MI, coronary bypass surgery, unstable heart failure • First 24-48 hours - breathing exercises simple arm and leg ROM exercises limited self-care activities • Over the next 2-3 days - sit out of bed take short walks shower and dress

21. Programme implementationIn-hospital and post-discharge • By discharge patients should know signs and symptoms of excessive exertion and rate level of exertion • Home exercise programme for first 6 weeks, mostly walking • Contact and telephonic follow-ups with rehabilitation services FITT: • F + Time = 5-10 minutes, 2-3x daily and later 5-20 minutes, 1-2x daily • I = RPE < 11

22. Programme implementationOutpatient exercise programme • Patient should be seen by physician or cardiologist before exercising • Patient safety during exercising very important • Assessment of heart rate and blood pressure at rest and during exercising, RPE etc.

23. Risk factors for exercise Patients should not exercise if not feeling well, symptomatic or unstable on arrival or with the following: Fever, acute systemic illness Unresolved/unstable angina Blood pressure systolic > 200 mmHg and diastolic > 110 mmHg Unexplained drop in blood pressure Symptomatic hypotension Tachycardia Arrhythmias Breathlessness, lethargy, palpitations, dizziness Unstable heart failure, weight gain > 2 kg in 2 days Unstable/uncontrolled diabetes

24. Programme management • All staff competent, appropriate skills and training, regularly updated • Appropriate emergency equipment, checked regularly, policy for handling emergency situations, appropriate venue • Patient education important - aims and exercise goals safety use of equipment

25. Programme management Patients and families should know the following: • Signs and symptoms of exertion • Importance of warm-up and cool-down • Caution with isometric activities • Issue e.g. excessive heat/cold, dehydration • Avoid exercising after heavy meal, if ill an when tired • Remain for 30 min after exercise for observation • Excessive use of arm/upper body work results in higher systolic and diastolic blood pressure than the same work by legs

26. FITT-principles F: 1-2x per week rehabilitation class 2x per week home-based exercises walking the other days I: aerobic exercises, 40-65% HRR or 60-75% HRmax resistance training, 10-15 repetitions to moderate fatigue, 8-10 exercises, 2-3 times per week

27. FITT-principles T: Aerobic, interval approach T: 5-10 min, progress to 20-30 minutes warm-up 15-20 minutes cool down > 10 minutes

28. Long-term community based exercise programme • Patient must be able to manage himself regarding exercises • Community-based instructor