You are on page 1of 5

SUPPLEMENT TO JAPI DECEMBER 2011 VOL.

59 51
C
oronary heart disease (CHD) is a major cause of mortality
and morbidity in India. The reported prevalence of CHD in
Indian adults has risen 4-fold over the last 40 years (to a present
level of around 10%), and even in rural areas the prevalence
has doubled over the past 30 years (to a present level of around
4%).
1
Within the spectrum of CHD, myocardial infarction (MI)
is the leading cause of death. For those who survive an MI, the
prevention of subsequent coronary events and the maintenance
of physical functioning are the major challenges.
2
Secondary
prevention is an essential part of the contemporary care of the
patient with CHD. Cardiac rehabilitation/secondary prevention
programs are recognized as integral to the comprehensive care
of patients with CHD and as such are recommended as useful
and efective (Class I) by the American Heart Association and
the American College of Cardiology in the treatment of patients
with CHD.
3
What is Cardiac Rehabilitation?
The term cardiac rehabilitation refers to coordinated,
multifaceted interventions designed to optimize a cardiac
patients physical, psychological, and social functioning,
in addition to stabilizing, slowing, or even reversing the
progression of the underlying atherosclerotic processes, thereby
reducing morbidity and mortality.
4,5
In essence, cardiac rehabilitation services are comprehensive
programs involving education, exercise, risk factor modifcation
and counselling, designed to limit the physiological and
psychological efects of heart disease, reduce the risk of death
or recurrence of the cardiac event, and enhance the psychosocial
and vocational state of patients.
6
Inpatient Cardiac Rehabilitation after MI
After an MI, the goal is to mobilize the patient as soon as
he is clinically stable. A patient is considered stable if there is
no new or recurrent chest pain in the past eight hours; creatine
kinase and/ or troponin levels are not rising; no new signs of
uncompensated heart failure and no new signifcant, abnormal
rhythm or ECG changes in the past eight hours.
Once the patient is stable, he should be made to sit at the edge
of the bed during the frst day, and then gradually mobilized
throughout the hospital stay. During mobilization the goal
should be to keep the heart rate below120 beats/min, or if the
patient has a high resting heart rate, then the goal should be to
keep the heart rate within 20 beats above resting heart rate. The
patient should be made to walk within the room at frst, and
then in the corridors for about 2-5 minutes, three to four times
a day. Progression of activity depends on the initial assessment
as well as the daily assessment of the patient and may vary
from a rapid increase in activity tolerance in the low-risk
Cardiac Rehabilitation after Myocardial Infarction
Aashish S Contractor
*
*
Head of Department: Preventive Cardiology & Cardiac Rehabilitation,
Asian Heart Institute, Bandra-Kurla Complex, Bandra (E),
Mumbai-400051
Table 1: Patient Mobilization Guidelines for Inpatient
cardiac rehabilitation
Frequency: Early mobilization: 2 to 4 times per day.
Exercise intensity:
Post-MI: Maintain heart rate (HR) less than 120 beats/min or HR at
rest + 20 beats/min
Rate of perceived exertion (RPE) < 13 on a 6-20 Borg scale
Exercise Type: Walking
Duration: Intermitent bouts lasting 2 to 5 minutes
Abstract
Cardiac rehabilitation / secondary prevention programs are recognized as integral to the comprehensive care of
patients with coronary heart disease (CHD), and as such are recommended as useful and effective (Class I) by
the American Heart Association and the American College of Cardiology in the treatment of patients with CHD.
The term cardiac rehabilitation refers to coordinated, multifaceted interventions designed to optimize a cardiac
patients physical, psychological, and social functioning, in addition to stabilizing, slowing, or even reversing the
progression of the underlying atherosclerotic processes, thereby reducing morbidity and mortality.
Cardiac rehabilitation, aims at returning the patient back to normal functioning in a safe and effective manner
and to enhance the psychosocial and vocational state of the patient.
The program involves education, exercise, risk factor modification and counselling.
A meta-analysis based on a review of 48 randomized trials that compared outcomes of exercise-based rehabilitation
with usual medical care, showed a reduction of 20% in total mortality and 26% in cardiac mortality rates, with
exercise-based rehabilitation compared with usual medical care.
Risk stratification helps identify patients who are at increased risk for exercise-related cardiovascular events
and who may require more intensive cardiac monitoring in addition to the medical supervision provided for
all cardiac rehabilitation program participants. During exercise, the patients ECG is continuously monitored
through telemetry, which serves to optimize the exercise prescription and enhance safety. The safety of cardiac
rehabilitation exercise programs is well established, and the occurrence of major cardiovascular events during
supervised exercise is extremely low.
As hospital stays decrease, cardiac rehabilitation is assuming an increasingly important role in secondary
prevention. In contrast with its growing importance internationally, there are very few cardiac rehabilitation
centers in India at the present moment.
52 SUPPLEMENT TO JAPI DECEMBER 2011 VOL. 59
Table 2: Comprehensive Risk Reduction Guidelines for Patients with CHD. (Adapted from Ref 18,19)
Lipid management
Evaluation: Obtain fasting measures of total cholesterol, HDL, LDL, and triglycerides.
Repeat lipid profles at 4-6 weeks after hospitalization and at 2 months after initiation of, or change in lipid-
lowering medications
Goal: Primary goal: LDL < 100 mg/dl; further reduction of LDL < 70 mg/dl is reasonable
Secondary goals: HDL > 40 mg/dl, total cholesterol < 200 mg/dl, triglycerides < 150 mg/dl
Intervention: In patients with LDL > 100 mg/dl, provide nutritional counselling and weight management; consider adding drug
therapy. Statins are the drug of choice, unless contraindicated.
In patients with HDL < 40 mg/dl, emphasize exercise, smoking cessation, and consider targeted drug therapy.
Hypertension management
Evaluation: Measurement of resting BP on two or more visits.
Assess current treatment and compliance.
Goal: Optimal BP is < 120/80 mmHg
Intervention: For patients with systolic BP >130 mmHg or diastolic BP > 85 mmHg initiate lifestyle modifcation (including
exercise, weight management, moderate sodium restriction, alcohol moderation and smoking cessation). Add drug
therapy for patients with diabetes, heart failure, or renal failure.
For patients with systolic BP > 140 mmHg or diastolic BP> 90 mmHg initiate lifestyle modifcation and drug
therapy.
Diabetes management:
Evaluation: Obtain fasting plasma glucose measurements in all patients and HbA
1
C in diabetic patients to monitor therapy.
Goal: Near normal fasting plasma glucose(< 100 mg/dl)and near normal HbA
1
C (<7)
Intervention: Appropriate hypoglycemic therapy (including weight control, exercise, and if needed oral hypoglycemic agents
and/or insulin).
Monitor glucose levels before and / or after exercise sessions. Instruct patient regarding identifcation and
treatment of post exercise hypoglycaemia. Exercise with caution if blood glucose > 300 mg/dl (evaluate for urine
ketones as well), after consulting with a physician.
Smoking / Tobacco:
Evaluation Document smoking and / or tobacco consumption habits in detail, including amount and duration.
Assess the readiness to change on the part of the patient.
Goal: Complete cessation.
Intervention: Provide individual education and counselling. Encourage patient to quit at each and every visit.
Provide nicotine replacement and pharmacological therapy as appropriate.
Weight management
Evaluation: Measure weight, height, and waist circumference. Calculate body mass index (BMI).
Goal: BMI 21-25 kg/m
2
, waist < 35 inches in men and < 31 inches in women.
Intervention: For patients who do not meet the goal criteria, advice a reduction in total caloric intake, and increase in energy
expenditure through a combined program of diet, and exercise.
The initial goal of weight loss therapy should be to reduce body weight by approximately 10% from baseline. With
success, further weight loss can be atempted , if indicated.
Psychosocial management
Evaluation Identify patients with clinically signifcant depression, anxiety, anger, and substance abuse.
Goal: To minimize the patients psychosocial distress.
Intervention: Stress management and individual or group education to help the patient adjust to his/her disease.
When needed, refer the patient to appropriate mental health specialists for further treatment.
patient (uncomplicated MI or a patient without left ventricular
dysfunction) to a slower progression in higher risk or more
debilitated patients, such as those with heart failure.
7
The goals of inpatient rehabilitation are to assist the patient in
becoming ambulatory; to prepare the patient and family to cope
with the psychological and emotional stress that accompanies a
coronary event; and to educate the patient about coronary risk
factor modifcation. The guidelines for patient mobilization for
inpatient cardiac rehabilitation are enlisted in Table 1.
Outpatient Cardiac Rehabilitation
The outpatient program can be begun once the patient has left
hospital and has clearance from his/her physician. Depending
on the patients clinical condition, and the severity of the MI, the
outpatient program, is typically begun two to four weeks after
the event. Cardiac rehabilitation programs were frst developed
in the 1960s, once the benefts of ambulation during prolonged
hospitalization for coronary events had been recognized.
Concern about the safety of unsupervised exercise after discharge
led to the development of highly structured rehabilitation
programs that were supervised by physicians and included
electrocardiographic monitoring. The focus of these programs
was almost exclusively on exercise.
8
A meta-analysis based on
a review of 48 randomized trials that compared outcomes of
exercise-based rehabilitation with usual medical care, showed a
reduction of 20% in total mortality and 26% in cardiac mortality
rates, with exercise-based rehabilitation compared with usual
medical care.
5
Over time, cardiac rehabilitation programs
have evolved, to comprehensive cardiovascular risk reduction
programs, with exercise being an integral component of the
program, but not the only component.
Since, hospital stays for MI has dramatically decreased over
time, thereby reducing the opportunity for in-hospital risk factor
interventions, outpatient cardiac rehabilitation programs have
gradually broadened their scope to become an important avenue
for secondary prevention.
2

SUPPLEMENT TO JAPI DECEMBER 2011 VOL. 59 53
Components of Cardiac Rehabilitation
A comprehensive cardiac rehabilitation program should aim
to identify each patients risk factors, establish risk reduction
goals and then help the patient achieve these goals through
lifestyle modifcation, supervised exercise, and medications.
Table 2 lists the major risk factors, their evaluation, goal values,
and suggested intervention. For maximum efcacy the program
staf should coordinate their eforts with the patients personal
physician.
Physical Activity / Exercise
Physical activity can be defined as bodily movement
produced by skeletal muscle that requires energy expenditure
and promotes health benefits. Exercise can be defined as
planned, structured, and repetitive bodily movement done
to improve or maintain one or more components of physical
ftness.
9
Over the years research has shown that an increase
in leisure time physical activity, as well as structured exercise
training, play an important role in reducing CHD mortality.
Exercise Prescription
A comprehensive exercise prescription for the cardiac patient
includes activities performed in formal supervised programs,
as well as everyday physical activities. The exercise program
should prescribe the appropriate mode, frequency, intensity, and
duration of exercise, which should be tailored to the individuals
cardiovascular and general medical status. However, there are
Table 3: Contraindications for Exercise in Outpatient
Cardiac Rehabilitation. ( From Ref 10)
1. Unstable angina
2. Resting systolic BP (SBP) > 200 mm Hg or resting Diastolic BP
(DBP) > 110 mm Hg that should be evaluated on a case-by-case
basis.
3. Orthostatic BP drop of >20 mm Hg with symptoms.
4. Critical aortic stenosis (i.e., peak SBP gradient of > 50 mm Hg
with an aortic valve orifce area of <0.75 cm
2
in an average-size
adult.
5. Acute systemic illness or fever
6. Uncontrolled atrial or ventricular dysrhythmias
7. Uncontrolled sinus tachycardia (> 120 beats per min).
8. Uncompensated CHF.
9. Third-degree atrioventricular (AV) block wihout pacemaker.
10. Active pericaditis or myocarditis.
11. Recent embolism
12. Thrombophlebitis
13. Resting ST-segment depression or elevation (> 2mm).
14. Uncontrolled diabetes mellitus.
15. Severe orthopedic conditions that would prohibit exercise.
16. Other metabolic conditions, such as acute thyroiditis,
hypokalemia, hyperkalemia or hypovolemia
Table 4: Summary of Aerobic Exercise and Resistance
Training Recommendations for Patients with CHD
Frequency:
Aerobic: Structured exercise 3-5 days per week (lifestyle physical
activity daily)
Resistance: 2-3 days per week
Intensity:
Aerobic: 60-85% of HRmax (Predicted HRmax = 220 age of person).
Resistance: Moderate (avoid breath holding and excessive straining)
Time (duration):
Aerobic: 20- 60 minutes
Resistance: 10-15 repetitions; 3 sets of 8-10 diferent exercises for both
upper and lower body
Type of exercise:
Aerobic: Walking, running, cycling, swimming, etc.
Resistance: Hand weights, elastic bands, machine weights.
Special Considerations:
Monitor for abnormal signs and symptoms, i.e., chest pain or
pressure, dizziness, and dysrhythmias.
High-intensity exercise may precipitate cardiovascular complications
in post-MI patients.
Patients with stable angina should always carry nitroglycerin and be
educated in its use.
Heart rate guidelines may not be applicable to patients taking drugs,
which slow down the heart rate, e.g. beta-blockers.
Lift weights through a full range of motion and avoiding breath-
holding
Table 5: Comparison of Efects of Aerobic Endurance
Training with Strength Training on Health and Fitness
Variables. (From Ref 11)
Variable
Aerobic
Exercise
Resistance
Exercise
Indicates values increase; , values decrease; 0, values remain
unchanged; 1 arrow, small efect; 2 arrows, moderate efect; 3 arrows,
large efect; HDL, high-density lipoprotein cholesterol; and LDL, low-
density lipoprotein cholesterol.
Body composition
Bone mineral density
Percent body fat
Lean body mass 0
Muscle strength 0
Glucose metabolism
Insulin response to glucose challenge
Basal insulin levels
Insulin sensitivity
Plasma lipids and lipoproteins
HDL cholesterol 0 0
LDL cholesterol 0 0
Triglycerides 0
Cardiovascular dynamics
Resting heart rate 0
Stroke volume, resting and maximal 0
Cardiac output, rest 0 0
Cardiac output, maximal 0
SBP at rest 0 0
DBP at rest 0 0
VO
2
max 0
Submaximal and maximal endurance time
Submaximal exercise rate-pressure product
Basal metabolic rate 0
Health-related quality of life 0 0
54 SUPPLEMENT TO JAPI DECEMBER 2011 VOL. 59
some patients for whom exercise is contraindicated, as listed
in Table 3.
A summary of the exercise prescription is given in Table 4.
After two to four weeks of participation in a traditional aerobic
exercise program, low-to-moderate risk patients should initiate
resistance training. Prescribed and supervised resistance training
(RT) enhances muscular strength and endurance, functional
capacity and independence, and quality of life while reducing
disability in persons with CHD.
11
Both endurance and strength training can elicit substantial
increases in physical ftness. Table 5 summarizes many of these
benefts and atempts to weigh them according to the current
literature. Endurance training induces greater improvements in
aerobic capacity and associated cardiopulmonary and metabolic
variables and more effectively modifies CHD risk factors.
Resistance training enhances muscular strength, endurance, and
muscle mass to a greater extent.
11
Nutrition Counselling
It is necessary to assess the dietary habits of the patient
to obtain an estimate of total caloric intake, as well as daily
consumption of saturated fat, cholesterol, sodium, and other
nutrients. Patients should be recommended a diet low in fat
(especially saturated fat), and high in complex carbohydrates.
3

As a general guideline, the diet should consist of 50-60%
calories from carbohydrates, up to 30% from fat (with
saturated fat forming 10% or less), and 10-15% from protein.
Individualized plans should be formulated, depending on the
presence of risk factors, such as diabetes, hypertension, and
hypercholesterolemia.
Psycho-Social Rehabilitation
After an MI, some of the common psychological reactions
that patients may experience are: low mood, tearfulness, sleep
disturbance, irritability, anxiety, acute awareness of minor
somatic sensations or pains, poor concentration and memory.
It should be explained to the patient that these symptoms are
normal, that they are universal, and are part of the natural course
of recovery following any potentially life threatening event.
12
Psychological factors are strong risk factors for CHD and
adversely afect recovery after major CHD events. Although
most of the atention has been directed at depression, other
adverse psychological characteristics, including anxiety and
hostility, may also be signifcant CHD risk factors. Studies
have demonstrated reductions of between 40% and 70% in the
prevalence of depression, anxiety, and hostility after cardiac
rehabilitation.
13
Studies have also shown that depressed patients
with CHD who atended a formal cardiac rehabilitation program,
had nearly a 70% reduction in mortality risk. It has been found
that only small improvements in exercise capacity may produce
profound improvements in depression and depression-related
mortality.
13,14,15
Safety
Use of a risk stratification schema, to evaluate patients
on entry into cardiac rehabilitation programs is essential to
optimize patient management and minimize potential risk.
The relative safety of medically supervised, physician directed,
cardiac rehabilitation exercise programs is well established. The
occurrence of major cardiovascular events during supervised
exercise ranges from 1/50,000 to 1/120,000 patient-hours of
exercise, with only 2 fatalities reported per 1.5 million patient-
hours of exercise.
16
Risk stratifcation helps identify patients who are at increased
risk for exercise-related cardiovascular events and who may
require more intensive cardiac monitoring in addition to the
medical supervision provided for all cardiac rehabilitation
program participants.
4
Return to Work
Although improvement in functional capacity and the
associated reduction in cardio-respiratory symptoms may
enhance a cardiac patients ability to return to work, factors
unrelated to physical ftness appear to have a greater infuence
on whether a patient returns to work after a cardiac event. These
include socioeconomic and worksite-related issues and previous
employment status. The educational and vocational counselling
components of cardiac rehabilitation programs should further
improve the ability of a patient to return to work.
4
Therefore, the
time to return to work, after an MI can vary greatly from about
two weeks, to upwards of six weeks.
Patient Participation in Cardiac Rehabilitation
International guidelines and experts recommend the use
of cardiac rehabilitation after MI. As hospital stays decrease,
cardiac rehabilitation is assuming an increasingly important
role in secondary prevention.
17
In contrast with its growing
importance, there is litle contemporary information on the use
of cardiac rehabilitation after MI, in India and essentially no
published data on the same.
References
1. Reddy K S. India Wakes Up to the Threat of Cardiovascular
Diseases. Journal of American College of Cardiology 2007;50:13702.
2. Ades P A. Cardiac rehabilitation and secondary prevention
of coronary heart disease. New England Journal of Medicine
2001;345:892902.
3. Balady G J, Williams M A, Ades P A, Bitner V, Comoss P, Foody J M,
Franklin B, Sanderson B, Southard D. Core Components of Cardiac
Rehabilitation/Secondary Prevention Programs: 2007 Update: A
Scientifc Statement From the American Heart Association, Exercise,
Cardiac Rehabilitation, and Prevention Commitee, the Council
on Clinical Cardiology; the Councils on Cardiovascular Nursing,
Epidemiology and Prevention, and Nutrition, Physical Activity,
and Metabolism; and the American. Association of Cardiovascular
and Pulmonary Rehabilitation. Circulation 2007;115:2675-2682.
4. Leon A S, Stewart K J, Thompson P D, Williams M A, Lauer M S,
Franklin B A, Costa F, Balady G J, Berra K A. Cardiac Rehabilitation
and Secondary Prevention of Coronary Heart Disease: An American
Heart Association Scientifc Statement From the Council on Clinical
Cardiology (Subcommitee on Exercise, Cardiac Rehabilitation, and
Prevention) and the Council on Nutrition, Physical Activity, and
Metabolism (Subcommitee on Physical Activity), in Collaboration
With the American Association of Cardiovascular and Pulmonary
Rehabilitation. Circulation 2005;111;369-376
5. Taylor RS, Brown A, Ebrahim S, Jollife J, Noorani H, Rees K,
Skidmore B, Stone JA, Thompson DR, Oldridge N. Exercise-based
rehabilitation for patients with coronary heart disease: systematic
review and meta-analysis of randomized trials. American Journal
of Medicine 2004;116:682 697.
6. Wenger NK, Froelicher ES, Smith LK, Ades PA, Berra K, Blumenthal
JA, Certo CM, Datilo AM, Davis D, DeBusk RF, Drozda JP Jr,
Fletcher BJ, Franklin BA, Gaston H, Greenland P, McBride PE,
McGregor CG, Oldridge NB, Piscatella JC, Rogers FJ. Clinical
Practice Guidelines No. 17: Cardiac Rehabilitation as Secondary
Prevention. Rockville, Md: US Department of Health and Human
Services, Public Health Service, Agency for Health Care Policy and
Research, National Heart, Lung and Blood Institute; 1995. AHCPR
Publication 96-0672.
7. American Association of Cardiovascular and Pulmonary
SUPPLEMENT TO JAPI DECEMBER 2011 VOL. 59 55
Rehabilitation. Guidelines for Cardiac Rehabilitation and Secondary
Prevention Programs. 4th edition. Champaign, Ill: Human Kinetics;
2004. Chapter 4, Cardiac Rehabilitation in the Inpatient and
Transitional Setings; 31-51.
8. Pashkow FJ. Issues in Contemporary Cardiac Rehabilitation: A
Historical Perspective. Journal of American College of Cardiology
1993;21:822-34.
9. Leon AS. Physical Activity and Cardiovascular Health: A National
Consensus, Champaign, IL: 3-4: Human Kinetics: 1997
10. American College of Sports Medicine (ACSM). ACSMs Guidelines
for Exercise Testing and Prescription; 8
th
Edition. Lippincott
Williams & Willikans; 2009. Chapter 9, Exercise Prescription for
Patients with Cardiac Disease; p. 207-224.
11. Williams M A, Haskell W L, Ades P A, Amsterdam E A, Bitner
V, Franklin B A, Gulanick M, Laing S T, Stewart K J,. Resistance
Exercise in Individuals With and Without Cardiovascular
Disease: 2007 Update: A Scientifc Statement From the American
Heart Association Council on Clinical Cardiology and Council
on Nutrition, Physical Activity, and Metabolism. Circulation
2007;116;572-584.
12. Thompson D R, Lewin R LP; British Heart Foundation Rehabilitation
Research Unit, Department of Health Studies, University of York,
UK. Coronary Disease Management of the Post-Myocardial
Infarction Patient: Rehabilitation and Cardiac Neurosis. Heart
2000;84:101105.
13. Milani R V, Lavie C J. Impact of cardiac rehabilitation on
depression and its associated mortality. American Journal of Medicine
2007;120:799-806.
14. Lavie C J, Thomas R J, Squires R W, Allison T G, Milani R V. Exercise
Training and Cardiac Rehabilitation in Primary and Secondary
Prevention of Coronary Heart Disease. Mayo Clinic Proc 2009;84:373-
383.
15. Lichtman J H, Bigger JT Jr, Blumenthal J A, et al. Depression
and coronary heart disease: recommendations for screening,
referral, and treatment: a science advisory from the American
Heart Association Prevention Committee of the Council on
Cardiovascular Nursing, Council on Clinical Cardiology, Council
on Epidemiology and Prevention, and Interdisciplinary Council on
Quality of Care and Outcomes Research. Circulation 2008;118:1768-
1775.
16. Franklin B A, Bonzheim K, Gordon S, Timmis G C. Safety of
medically supervised cardiac rehabilitation exercise therapy: a
16-year follow-up. Chest 1998;114:902906.
17. Brandi J W, Jacobsen S J, Weston S A, Killian J M, Meverden R A,
Allison T G, Reeder G S, Roger V L. Cardiac Rehabilitation After
Myocardial Infarction in the Community. Journal of American College
of Cardiology 2004;44:98896.
18. AHA / AACVPR scientifc statement. Core components of cardiac
rehabilitation / secondary prevention programs. Circulation
2000;102:1069-1073.
19. Smith S C, Allen J, Blair S N, Bonow R O, Brass L M, Fonarow G
C, Grundy S M, Hiratka L, Jones D, Krumholz H M, Mosca L,
Pasternak R C, Pearson T, Pfefer M A, Taubert K A. AHA/ACC
Guidelines for Secondary Prevention for Patients With Coronary
and Other Atherosclerotic Vascular Disease: 2006 Update: Endorsed
by the National Heart, Lung, and Blood Institute. Circulation
2006;113;2363-2372.