Cardiac Rehabilitation

INTRODUCTION
Definition by WHO –Sum of activities required to influence
favourably the underlying cause of the disease as well as the
best possible mental physical ,mental and social condition so
that they may be by there own effort preserve or resume when
lost as normal place as possible in the community .
According to AHA –Cardiac rehabilitation refer to
coordinated multifactorial intervention designed to optimize a
cardiac patient physical psychological and social function in
addition to stabilizing slowing or even reversing progression
of underlying process and thus reducing the mortality and
morbidity .
HISTORY OF CARDAIC REHABLITATION
In the 1930s, patients with myocardial infarction (MI) were
advised to observe 6 weeks of bedrest. Chair therapy was
introduced in the 1940s, and by the early 1950s, 3-5 minutes
of daily walking was advocated, beginning at 4 weeks
Clinicians gradually began to recognize that early
ambulation avoided many of the complications of bed rest,
including pulmonary embolism (PE), and that it did not
increase the risk. However, concerns about the safety of
unsupervised exercise remained strong; this led to the
development of structured, physician-supervised
rehabilitation programs, which included clinical supervision,
as well as electrocardiographic monitoring.
Hellerstein presented his methodology for
the comprehensive rehabilitation of patients recovering from
an acute cardiac event.9 he advocated a multidisciplinary
approach to the rehabilitation program.
 PHASES OF CARDIAC REHABILITATION
CARDIAC REHABILITATION SERVICES ARE DIVIDED INTO 3
PHASES, AS FOLLOWS:

PHASE 1 - INITIATED WHILE THE PATIENT IS STILL IN THE

HOSPITAL

PHASE 2 - A SUPERVISED AMBULATORY OUTPATIENT PROGRAM

SPANNING 3-6 MONTHS

PHASE 3 - A LIFETIME MAINTENANCE PHASE IN WHICH PHYSICAL

FITNESS AND ADDITIONAL RISK-FACTOR REDUCTION ARE
EMPHASIZED
Phase 1: in-hospital phase
This program begins while patients are still in the hospital
Activities done during this phase include
Breathing exercises
Passive and active movements
Activities with MET value 1.5 and graudally progress to 3.5
before discharge.
Low-risk patients should be encouraged to sit in a bedside
chair and to begin performing self-care activities
On transfer to the step-down unit, patients should, at the beginning, try
to sit up, stand, and walk in their room. Subsequently, they should start
to walk in the hallway at least twice daily either for certain specific
distances or as tolerated without being unduly pushed or held back.
Standing heart rate and blood pressure should be obtained followed by
5 minutes of warm-up or stretching. Walking, often with assistance, is
resumed, with a target heart rate of less than 20 beats above the resting
heart rate and an RPE of less than 14.
Starting with 5-10 minutes of walking each day, exercise time gradually
can be increased to up to 30 minutes daily.
 Phase 2 Supervised phaser

In this phase all the activities are supervised according to

karvonen formula low intensity exercises are performed
Maximum heart rate-220-age
(MHR-heart rate at rest)*exercise intensity +HRrest
Low intensity exercise-less than 40% of MHR
Moderate intensity exercise-40-60% ofMHR
High intensity exercise-more than 60% of MHR
Low intensity exercise done during this phas
Like free cycling jog treadmill.
Phase 3: maintenance phase
Phase 3 of cardiac rehabilitation is a maintenance program designed to
continue for the patient's lifetime. The exercise sessions usually are scheduled
3 times a week.
Activities consist of the type of exercises the patient enjoys, such as walking,
bicycling, or jogging
ECG monitoring usually is not necessary.
The main goal of phase 3 is to promote habits that lead to a healthy and
satisfying lifestyle.
Phase 3 programs do not usually require medical supervision.
Moderate intensity exercise are incorporated and also exercise with weight .
 RISK FACTORS
STRATIFICATION

PATEINTS IDENTIFICATION FOR INCLUSION IN

CARDAIC REHABLITATION.

THREE RISK STRATIFICATION ARE THERE

ACCORDING TO WHICH PATEINT IS IDENTIFIED
AS .
LOW RISK
MODERATE RISK
HIGH RISK
 LOW RISK PATIENT
MEN LESS THEN 40 YEARS.
WOMEN LESS THAN 5O YEARS.
MET MORE THAN 7.
LVEF MORE OR EQUAL TO 50%.
NO HISTORY OF CARDAIC INVOLVEMENT

MODERATE RISK PATEINT

MALES MORE THAN EQUAL TO 40.
FEMALES MORE THAN OR EQUAL TO 50
MET 5 TO 7
PRESENCE OF ONE OR MORE RISK FACTORS
NO DECREASE OF BLOOD PRESSURE WITH EXERCISE
LVEF 35-45
HIGH RISK PATIENT
AGE MORE THAN 40 IN MALES
AGE MORE THAN 50 IN FEMALES
HISTORY OF CARDIAC DISEASE.
MET LESS THAN 5.
LVEF LESS THAN 35
ST SEGMENT CHANGES MORE THAN 2MM.
  Patient Selection
 Lower-risk patients following an acute cardiac event
 Patients who have undergone coronary bypass surgery
 Patients with chronic, stable angina pectoris
 Patients who have undergone heart transplantation
 Patients who have had percutaneous coronary angioplasty
 Patients who have not had prior events but who are at risk because of a remarkably unfavorable risk
factor profile
 Patients with stable heart failure
 Patients who have undergone noncoronary cardiac surgery
 Patients with previously stable heart disease who have become seriously deconditioned by
intercurrent, comorbid illnesses
 The short-term goals of cardiac rehabilitation include the restoration of the physical, psychological,
and social condition, while the long-term goals involve the promotion of heart-healthy behaviors that
enable the individual to return to productive and/or joyful vocational and avocational activities.
 The cardiac rehabilitation programs benefit women and men equally.10 Elderly patients also can derive
significant benefit from rehabilitation programs.
 Cardiac rehabilitation services are contraindicated in patients with the following
conditions:
 Severe residual angina
 Uncompensated heart failure
 Uncontrolled arrhythmias
 Severe ischemia, LV dysfunction, or arrhythmia during exercise testing
 Poorly controlled hypertension
 Hypertensive or any hypotensive systolic blood pressure response to exercise
 Unstable concomitant medical problems (eg, poorly controlled or "brittle" diabetes,
diabetes prone to hypoglycemia, ongoing febrile illness, active transplant rejection)
 In such patients, every effort should be made to correct these abnormalities through
optimization of medical therapy, revascularization by angioplasty or bypass surgery, or
electrophysiologic testing and subsequent antiarrhythmic drug or device therapy.
Patients should then undergo retesting for exercise prescription.
 Exercise testing
 Two forms of exercise tests are performed in patients following an acute cardiac event:
submaximal exercise testing and symptom-limited exercise testing. Furthermore, CPX also
may be performed, particularly in patients with cardiomyopathy or CHF, to determine
objectively the patient's exercise capacity.
 Submaximal exercise testing
 In this strategy, the patients exercise enough to achieve 70% of maximum predicted heart
rate for their age (ie, 70% of 220 minus age in years).
 This test is commonly performed prior to discharge and is followed by maximal exercise
testing 6-8 weeks later (when patients aim to achieve 90% of maximum predicted heart
rate).
 Symptom-limited exercise testing
 The patients exercise soon after a cardiac event.

 A representative schedule might begin exercise at intervals, such as 7-21 days following
uncomplicated acute myocardial infarction (MI), 3-10 days following angioplasty, or 14-28
days after bypass surgery.
Physiology of exercise in cardiac events
Normally there exit balance between nitrous oxide which is
a vasodilator which is produce by activity of nitrous
synthase and reactive oxygen

This balance get disturbed in

patient with CAD
 
This led to endothelial destruction

Exercises in cardiac rehabilitation phase

Correction in Decrease in
nitrous deactivation of Increase
nitrous synthase endothelial
synthase
activity by reactive Control
relaxation
oxygen
group
Reversal of
endothelial
dysfunction
Reduction in mortality and
morbidity
 Exercise prescription and surveillance

 Phase 2 of a cardiac rehabilitation program is initiated based on the result of the exercise testing, and the exercise prescription is
individualized. Three main components of an exercise training program are as follows:
 Frequency - The minimum frequency for exercising to improve cardiovascular fitness is 3 times weekly.
 Time - Patients usually need to allow 30-60 minutes for each session, which includes a warm-up of at least 10 minutes
 Intensity - The intensity prescribed is in relation to one's target heart rate. Aerobic conditioning is emphasized in the first few weeks
of exercise. Strength training is introduced later. The Borg scale of Rate of Perceived Exertion (RPE) is used. Patients usually should
exercise at an RPE of 13-15.
 Borg scale of perceived exertion

 6
 7 - Very, very light
8
 9 - Very light
 10
 11 - Light
 12
 13 - Somewhat hard
 14
 15 - Hard
 16
 17 - Very hard
 18
 19 - Very, very hard
 20 - Exhaustion