Measures of Energy Expenditure Kilocalorie (KCal)

Maximal oxygen consumption (V02max) • Used to quantify energy expended.

o Max amount of 02 consumed per minute • Amount of heat to raise 1kg of water 1 degree
when an individual reached maximum celsius.
effort.
• Can be expressed on oxygen equivalents.
o Usually expressed relative to body weight
(mL/kg per min). • (5 Kcal = 1L O2)

o Dependent on: • An average person doing daily task expends 1,800 -

3,000 Kcal.
▪ Transport of 02
▪ The 02 — Binding Capacity
METabolic Equivalents (MET)
▪ Cardiac Function
• Oxygen consumed per kg body weight per min (mL/
▪ 02 Extraction Capabilities kg per min).
▪ Muscular Oxidative Potential • 1 MET: Provides a measure of the energy
expenditure to run bodily functions while the
o Measured by Fick's Equation individual is at rest.
o (Normal: 4-5 mL) • 1 MET = 3.5 mL/kg per minute.
• < 3 METs: Light Intensity
• 3-6 METs: Moderate Intensity
• 6 METs: Vigorous

Myocardial Oxygen Supply and Demand

• Measure of O2 used by the heart.
• Determined by:
o HR
o Systemic BP
o Myocardial Contractility
Measures of Energy Expenditure
o Afterload
• Computed from the amount of oxygen consumed at
rest or while performing any given activity. • Balance b/w myocardial O2 supply & demand
(MVo2) should be maintained.
• Units include:
• MVO2 = RPP = Pulse rate x Systolic BP
o Kcal
• Cardiac muscles extract 70 - 75% of O2 from blood
o L/02 during rest.
o mL of 02 per kg of body weight per minute • Main source of supply during exercise is from
(METs). INCREASED CORONARY BLOOD FLOW (CBF)
• Main Drainage: Coronary Sinus
• Main Supply of the Heart: Coronary Artery

 Normal Response to Aerobic Exercise • Dependent on:

• HR → Workload o Sufficient Intensity
• Chronotropic Incompetence - Failure of the H o Duration
• BP → Workload o Frequency
• RR • Recruitment of slow twitch fibers (Type 1).
• Skin color and temperature
• Level of Cognition Components Aerobic Exercise Training
• Perceived Exertion • Intensity:
o How hard an exercise is.
Abnormal Responses o THR, MET, Intensity (watt).
• (+) S/sx -> STOP activity o Usual Target: 80 - 85% of HR max of ETT.
• Look for: o Secondary Prevention: ~60%
o Facial Expression
o Skin Color • Duration:
o Tone of Voice o How long a given bout of exercise is.
o Thought Processing o Usual requires 20 to 30 minute sessions.
o 5 - 10 mins warm-up and cool down.
Indications of Inadequate Cardiac Output
• Altered Mental Status • Frequency:
• Peripheral Vasoconstriction o How often exercise is performed over a
fixed time period.
• Lightheadedness
o Moderate-intensity: — 3x times per week.
• Angina (Levine's Sign)
o Low-intensity: 5x per week.
• Decreased BP

• Specificity:
Aerobic Exercise Training (Conditioning)
o The activity to be done in exercise.
• Rhythmical activity that uses large muscle groups &
challenges the cardiorespiratory system. o Activity-specific.
• Augmentation of the energy utilization of muscle by o Individualized.
means of an exercise program.
o ↑ oxidative enzymes in muscles
Benefits of Aerobic Exercise Training
o ↑ mitochondrial density & size
• Aerobic Capacity:
o ↑ capillary supply to muscles
o Maximum capacity increases with training.
o Resting Vo2 is stable as is the Vo2 at a given
workload.
o Specific to the trained muscles.

 • Cardiac Output: Deconditioning ("Immobility Syndrome")

o ↑ Max CO; resting CO is stable. • Occurs with Prolonged Bed rRest
o ↑ Resting SV; ↓ resting heart rate. • Decrease in:
• VO2 Maximum
• Heart Rate: • Cardiovascular Function
o Lower at rest and at any given workload. • Muscle Mass & Strength
o HR max is unchanged. • Total blood, plasma, and heart volume
• Exercise Tolerance
• Stroke Volume: • Orthostatic Tolerance
o ↑ SV at rest and at all levels of exercise. • Bone Mineral Density
o ↓ RPP for a given level of exertion.
Adaptation
• Myocardial Oxygen Capacity: • Significant changes in the cardiovascular system &
the muscles after exercise training are measurable in
o Maximum MVO2 does not usually change; 10 - 12 weeks.
less at a given workload.
• Performance improves in the same amount of work
o ↓ Angina after exercise at Lower Physiological Cost.
o ↑ MVO2 (pharmacologic treatments or • Dependent on training stimulus threshold (↓ initial
revascularization procedures). level of fitness, ↓ intensity needed to elicit
significant changes).

• Peripheral Resistance:
o ↓ PVR by reducing "afterload" through Interventions and Rehabilitation based on Cardiac
lowering arterial and arteriolar tone. Pathology

o ↓ RPP and ↓ Mv02 at a given workload and Cardiac Dysfunctions

at rest. • Patient with Cardiac Disease
o Myocardial Infarction
• Minute Ventilation: o Coronary Bypass Surgery
o ↓ minute ventilation for a given activity. o Chronic Stable Angina Pectoris
o large reduction in dyspnea. • Failure of:
o Oxygen supply of the heart
• Tidal Volume: o Contractility of the ventricles
o ↑ TV on exertion → ↓ RR and ↓ dyspnea. o Impulse initiation or conduction

 Hypertension Two Major Categories of Medical Interventions:

• Lifestyle modification and antihypertensive • Revascularization Procedures
medication.
• Pharmacological Interventions
• Roles of PT:
o Weight Loss (target BMI: 18.5-24.9 kg/m2).
Percutaneous Transluminal Coronary Angioplasty
o Dietary Approaches to Stop Hypertension (PTCA)
(DASH) Diet.
• Balloon and collapsed stent on the tip of a catheter,
o Reducing Sodium Intake (no more than 100 inserted into the radial or femoral → aorta →
meq/day). coronary arteries → site of lesion.
o Increasing Physical Activity. • Balloon is inflated → stent expands → plaque
compressed against the interior artery walls →
o Moderating Alcohol Consumption. increase luminal area.
• Balloon is deflated and stent holds the lumen open.
• Pharmacologic Interventions:
o Beta-adrenergic Blockers
o Alpha-adrenergic Blockers
o Angiotensin-converting Enzyme (ACE)
Inhibitors
o Diuretics
o Vasodilators
o Calcium Channel Blockers
Coronary Artery Bypass Graft (CABG)
• Use of donor vessel to bypass the lesion (narrowed
• PT Interventions: lumen) and establish an alternate improved blood
o Aerobic + Resistance Training decreases: supply.

o SBP: 4-6 mmHg

o DBP: 3 mmHg • Donor Vessel:

o Recommended Parameters: o Radial Artery of the Non-dominant Upper

Extremity (UE).
o Frequency: 3 - 4x per week for 12 weeks.
o Saphenous Vein.
o Intensity: Moderate
o Internal Mammary Artery.
o Duration: 40 mins.

• Attachments:
Acute Coronary Syndrome
o Proximal: Aorta
Goals of medical management:
o Distal: Beyond the the Occluded Artery
• Keep the patient hemodynamically stable. (except IMA).
• Optimize the wound healing of the myocardium. • On-Pump vs Odd-Pump

 • Recommendations:
• Surgical Incision/Approach: o Lifting, pushing, pulling objects > 10 lb
o Full Sternal Cut o Performing shoulder and or flex > 90 when
upper extremity is weighted.
o Partial Sternal Cut
o Encouraging shoulder AROM in pain-free
o Intercostal Approach range.
• Donor Graft Incision o Avoiding scapular retraction past neutral.
o Avoiding trunk flex and rotation with supine
PT Implications: to sit transfers.

• Recovery Time: CABG > PTCA o Minimizing or avoiding upper extremity use
with sit to stand.
• Post-op CABG positioning → ulnar nerve palsy.
o Applying sternal counter pressure (splinting)
• Soft tissue impairments associated with the incision with cough.
→ maintain appropriate tissue extensibility and
ROM. o Limiting driving.

• Sternal Wound: Pharmacologic Management of ACS

o Scapular retraction and functional shoulder • Goal: Re-establish the balance of myocardial supply
movements. and demand.

o PNF IJE patterns > Cardinal plane ROM.

o Few repetitions with increased frequency to • Anti-ischemic Drugs:
prevent soreness. o Beta-blockers: ↓ HR and contractility → ↓
• Early ambulation and mobility. energy demand.
o CCBs: ↓ BP → ↓ myocardial workload; ↓
coronary artery spasm → ↑ myocardial
• Sternal Precautions blood supply.
o Prevent Dehiscence o Nitrates: Potent vasodilators → ↓ preload,
↓ afterload → ↓ myocardial workload;
o RF: DM, Pendulous Breast Obesity, COPD coronary artery vasodilation.

• After-load Reducers: Normalize BP and ↓

myocardial workload.
o ACE inhibitors
o ARBs

Enhanced Extracorporeal Counter Pulsation

 Heart Failure Heart Transplant Patients

• Impaired cardiac pump function, resulting in • Problems Post-op:
inadequate systemic perfusion and an inability to
meet the body's metabolic demands. o Calf Cramps dt / Cyclosporine
o Decreased LE Strength

• Goals of Pharmacology: o Fracture / Osteoporosis

o To increase the contractility or pumping o Atherosclerosis in the coronary arteries of

ability of the heart to relieve congestion. the donor heart.

o To decrease the workload on the heart by • HR alone provides a limited measure of exercise
reducing either the total volume of fluid in intensity.
the system (the preload) or the vascular • BP and perceived exertion should be included in the
resistance (the afterload). routine data collection.
• Positive Inotropes: Digoxin
• Reduce Preload: Diuretics COUGH CPR
• Reduces Afterload: ARBs and ACEi • During a sudden arrhythmia (abnormal heart rhythm),
a conscious, responsive person may be able to cough
forcefully and repetitively to maintain enough blood
• Surgical Options: flow to the brain to remain conscious for a few
seconds until the arrhythmia is treated.
o Heart Transplant
• Not recommended
o LVADs
o Myoplasty
Cardiac Rehabilitation
o Biventricular Pacing
• The coordinated sum of interventions required to
ensure the best physical, psychological, and social
Valvular Heart Disease conditions.

• I: Stenosis/regurgitation of aortic/mitral valves • comprehensive exercise, education, and lifestyle

modification program designed to enable
• Tx: Valve replacement participants to achieve optimal physical,
psychological, social, and vocational functioning.
• Mechanical vs Biological valves (cadavers /
porcine / bovine).
• Roles of PT:
• Post-op Care: o Assess the Physical Needs
o Similar to CABG. o Devise Exercise Program
o Frequent neurologic examination. o Supervise the Exercise Sessions

• Goal of Interventions:
o Exercise Capacity
o Exercise Efficiency
o Exercise Intolerance
o Self-management and QOL

 • Phases of Cardiac Rehabilitation: PHASE 2: Training/Outpatient

o l: Acute Phase • After symptom limited ETT
o lb: Inpatient Rehabilitation Phase • THR:
o II: Training Phase • Low Risk: 85% of the Max HR on an ETT.
o III: Maintenance Phase • High Risk: 65-75% of Max HR.
• Supplemental O2 pm (>90% Sp02)
Phase 1: Acute Inpatient • 3 sessions per week for 8-12 weeks
• Education about cardiopulmonary risk factor • Stretching session → warm-up → training exercise
modification. → cool-down period.
• Cardiac monitors.
• Post MI: No increase in HR of <20bpm; SBP of PHASE 3: Maintenance Phase
<20mmHg from baseline.
• Most Important.
• Exercise response of decrease 10 mmHg = STOP
Exercise. • PURPOSE:

• Target: 4 METs • Patients receive continuing support with the aim of

maintaining their behaviors, medication, and
assuring the behavioral relapse doesn't occur.
PHASE 1B: Inpatient Rehab • Demonstrated to significantly reduce deaths and
recurrent events.
• Those patients who require either acute or subacute
rehabilitation treatment before discharge home. • Moderate exercise at the target intensity learned in
their rehabilitation program for at least 30 minutes
• For patients with: three times a week.
o Advanced Age
o Substantial Comorbidities Monitoring
o Other Disability • Hemodynamic Response
• Longer Recovery Period / Hospital Care • Vital signs before, during, and after an activity
or exercise.

PHASE 1: Upon Discharge • Talk Test

• Establish activity guidelines for the first 4 to 6 Borg's Rate of Perceived Modi ed Borg's Test (10
weeks post MI while myocardium is healing. Exer on (RPE) (15 pts) pts) (NEW)
• GOAL: To increase ambulation time to 20-30 min at (OLD)
a comfortable pace 1-2x per day at the end of 4th-6th 7 — very very light 0— Nothing
week post MI. 9 — very light 0.5 — very very weak
• Home Exercise Program: 11 — fairly light 1 — very weak
13— somewhat hard 2 —weak
o Ambulation 15 — hard 3 — moderate
o Upper and Lower Extremity Mobility 17 — very hard 4 — somewhat strong
19 — very. very hard 5— strong
• Home Instructions: 7 — very strong
o Try to change position every 1 - 2 hours. 10 — very very strong

o Verbally outline daily schedule.

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 Signs and Symptoms of Excessive Effort Exclusion

• Persistent Dyspnea • Apparently fit and healthy individual
• Dizziness or Confusion • The following are serious conditions requiring
attention before exercise is commenced:
• Pain
Hypertension or Hypotension
• Excessive Fatigue
Severe Aortic Stenosis
• Pallor
Uncontrolled Arrhythmias
• Cold Sweats
Uncontrolled Congestive Heart Failure
• Ataxia
Uncontrolled Diabetes or Metabolic
• Pulmonary Rales Disturbance
• Delayed Responses High Grade Atrioventricular Block without
• Prolonged Fatigue Pacemaker

• Insomnia Current Pericarditis or Myocarditis

• Sudden Weight Gain Owing to Fluid Retention Recent Pulmonary or Other Embolism
Recent Stroke or Transient Ischemic Attack

Prescription for Exercise Training Recent Major Surgery

• Eligibility for and exclusions from exercise training. Terminal Illness or Severe Disabling
Concurrent Illness
• The intensity of exercise training.
Acute Febrile or Systemic Illness
• The determination of training heart rate and rate of
perceived exertion. Physical or Psychological Disability Preventing
Participation
• The frequency, number and duration of exercise
classes. Physician or Patient Refusal

• Individual/group cardiac rehabilitation, including

exercise, should be offered to ALL patients with
cardiovascular disease.

Eligibility
• Individual/group cardiac rehabilitation, including
exercise, should be offered to ALL patients with
cardiovascular disease.

 Determinant of Exercise Program • Duration

• Intensity o Dependent on total work performed,
exercise intensity and frequency fitness
o Overload Principle level.
o Maximum Heart Rate o The greater the intensity of the exercise, the
▪ Need to be determined to provide shorter the duration and vice versa.
basis for intensity of aerobic ▪ Strength - ↑ load, ↓ duration
exercise.
▪ Endurance - ↑ duration, ↓ load
1. May be determined using a stress test.
o 20 - 30 minutes session at 60 - 70% is
2. HR max = 220 — age (less accurate) generally optimal.
3. HR max = 220 — age — 11 (for UE exercise) o Deconditioned: Brief rests every 5 minutes.
o Low to moderate intensity exercise training o 10 - 15 minutes exercise periods if high
is recommended for all cardiac rehabilitation intensity.
programs.
▪ 45 minutes, increased risk of
o Exercise training at low to moderate has musculoskeletal complications.
effect similar to those of moderate to high
intensity exercise training
o Exercise Heart Rate or Target Heart Rate ACSM Guidelines
▪ Percentage of Maximum Heart Rate • Poor Functional: 5 - 10 mins 1 - 2x a week.
• THR = MHR x % fitness • Beginners: 10 - 20 mins every other day in 8
level weeks.
▪ Karvonen's Formula (heart rate • Average: 20 - 45mins 3 - 5x a week.
reserve)
• Athletes: 30 - 60 mins 5x daily.
• THR = RHR + % fitness
level (MHR - RHR)
o GOAL: To achieve 50-85% of v02 Max • Frequency
(60-90% of MHR) o Optimal frequency is 3 - 5 times a week.
▪ Poor Functional Capacity: 40 - o Greater frequency for lower intensity
50% of Vo2 Max exercise.
▪ Beginners: 50 - 60% of Vo2 Max o Increased risk of musculoskeletal
▪ Average: 60 - 70% of Vo2 Max complications if frequency goes beyond the
optimal range.
▪ Athletes: 70 - 86% of Vo2 Max

• Mode
Involves large muscle groups.
Rhythmic, aerobic in nature.
Walking, treadmill, stair climbers, cycle
ergometers (UE & LE).

Progression Interval Training

▪ Initial Conditioning Phase • Have rest intervals.
o Patient is re-evaluated often. • Rest Relief - Passive recovery.
• Work Relief - Active Recovery.
▪ Improvement Phase o Continuous exercise but at a lowered
intensity.
o Progression should be closely monitored and
progressed when appropriate. • The longer the work interval. more stress is given to
the aerobic system.
o Consider duration before intensity.
• 1:1 or 1:5 work-recovery ratio is appropriate to
o Maybe done after 1 - 3 weeks. stress the aerobic system.
• Less demanding.
Aerobic Exercise Program • Improves strength and power in healthy individuals.
Submaximal, rhythmic, repetitive, and dynamic exercise
of large muscle groups is emphasized.
Circuit Training
• 4 methods:
• Series of activities.
o Continuous Training
• At the end of the last activity, the individual starts
o Interval Training from the beginning and moves again through the
o Circuit Training series repeating it several times.

o Circuit Interval • Can improve strength and endurance.

Continuous Training Circuit Interval Training

• Submaximal intensity. • Effective because of combined aerobic and

anaerobic production of ATP.
• Stress is primarily on slow twitch fibers.
• There is a delay in the need of glycolysis and
• 20 - 60 minutes duration without exhausting the production of lactic acid due to relief intervals.
oxygen transport system.
• Overload is done by increasing the duration.
• Recommended for healthy individuals to improve
endurance.

 Resistance Training Cool Down

• Indications for resistance exercise training for • PURPOSE:
outpatients:
o Prevent pooling of blood in the
o 30-50% RM. 2-3x weekly, 12-15 reps. extremities.
• Considerations for patients following o Prevent fainting by increasing venous
revascularization: return to heart and brain.
o PTCA o Enhanced recovery by oxidation of
metabolic wastes and replenishment of
▪ Aerobic exercise 2 weeks after energy stores.
to allow inflammatory process
to subdue. o Prevent myocardial ischemia,
arrhythmias, and other heart
o CABG complications.
▪ Patients more deconditioned. • Calisthenics, Passive stretching.
▪ Pain at operative site. • 5 - 10 minutes.
▪ Split Sternum: Takes 6 weeks
for solid bone healing.
GENERAL GUIDELINES:
1. Establish THR and MHR.
• Sternal Precautions
2. Warm up gradually for 5 - 10 mins.
o Split incision site.
3. Increase pace of activity to maintain MHR for
o Avoid extreme bilateral shoulder 20 - 30 minutes.
retraction, extension, and external
rotation. 4. Cool down for 5 - 10 mins.
o No lifting > 5 lbs. 5. Use appropriate equipment such as correct
footwear.
o Overhead activities can be done
unilaterally. 6. Avoid running, jogging, or aerobic dancing on
hard surface e.g. asphalt and concrete.
o Avoid pushing, pulling, lifting heavy
objects until 4-6 weeks post-surgery. 7. Increase repetitions or times by no more than
10% per week.
8. Monitor patient's response before, during, and
after treatment.

 Precau ons for CHF Pa ents Played Video:

Class I Resul ng limita ons of physical ac vity • Basic Life Support Module 1
MAX MET's = 6.5 MET's • Basic Life Support for Healthcare Professionals
Class II Slight limita on of physical ac vity • Philippine Heart association
MAX MET's = 4.5 MET's
• Council on Cardiopulmonary Resuscitation
Class Ill Marked limita on of physical ac vity
MAX MET's = 3.0 MET's
Class IV Inability to carry on physical ac vity
without discomfort
MAX MET's = 1.5 MET's

Educa on for Pa ents with Heart Disease

Topics Content
Ac vity • Planned exercise sessions, leisure
Guidelines me and rests.
Self • Pulse Rate and RPE, also Dyspnea
Monitoring Scale.
• Awareness of other symptoms or
signs that may suggest exercise
intolerance (light-headedness,
mental confusion, dyspnea, and
inability to carry on a brief
conversa on).
Symptom • Recognize cardiac symptoms and to
Recogni on know how to respond.
& Response • (Angina, weight gain > 2lbs, LE
edema, PND).
Nutri on • Fat intake.
• Salt and uid intake.
Medica ons • Desired ac on, SE, dosage, ming.
• Allowed OTC drugs.
Lifestyle • Return to work.
Issues
Sexual • Resume if energy level throughout
Ac vity the day is sa sfying for them, and
they can walk outdoors and climb
stairs comfortably.
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