EFFICACY OF POST OPERATIVE CARDIAC

REHABILITATION IN PATIENTS WITH

MYOCARDIAL INFARCTION
Submitted by:
VANGURU PARVATHI
(2019-2024)
Regd.no:1908345024

Guided by:
DR. FARHEEN GIGANI
MPT (ORTHOPAEDIC)
MODERN INSTITUTE OF PHYSICAL MEDICINE
&REHABILITATIONHYDERABAD-500012
(AFFILIATED TO KNRUHS)

1
 EFFICACY OF POST –OPERATIVE CARDIAC
REHABILITATION IN PATIENTS WITH
MYOCARDIAL INFARCTION

Submitted by:
VANGURU PARVATHI
(2019-2024)

Project Work Submitted as a Partial Fulfillment of

Graduation in Bachelors of Physiotherapy

MODERN INSTITUTE OF PHYSICAL MEDICINE

AND REHABILITATION
12-2-279/1, 1st Floor, Sugra Estate, Siddiamber Bazar,
HYDERABAD 500012

(AFFILIATED TO KNRUHS)

2
 CERTIFICATE

This is to certify that “EFFICACY OF POST-OPERATIVE

CARDIAC REHABILITATION IN PATIENTS WITH
MYOCARDIAL INFARCTION” is a bonafide project work by
VANGURU PARVATHI final year student of Modern Institute of
Physical Medicine and Rehabilitation (M.I.P.M.R), Hyderabad 2019-
2024 batch, towards the partial fulfilment of the (B.P.T), degree course
under K.N.R University of health sciences, Warangal.

DATE PLACE: HYDERABAD

PROJECT GUIDE: PRINCIPAL:

DR. FARHEEN GIGANI DR.G. ARUN BABU
MPT (ORTHOPAEDIC) MPT (NEUROSCIENCES)
MIPMR, HYDERABAD MIPMR, HYDERABAD

3
 CERTIFICATE

This is to certify that “EFFICACY OF POST-OPERATIVE

CARDIAC REHABILITATION IN PATIENTS WITH
MYOCARDIAL INFARCTION” is a bonafide project work by
VANGURU PARVATHI final year student of MODERN INSTITUTE
OF PHYSICAL MEDICINE AND REHABILITATION (M.I.P.M.R)
2019-2024 batch, towards the partial fulfilment of the (B.P.T), degree
course under K.N.R University of health sciences, Warangal.

Date: Place: Hyderabad

Internal Examiner External Examiner

4
 ACKNOWLEDGEMENT

It is my pleasure to present this project work on the topic “EFFICACY

OF POST-OPERATIVE CARDIAC REHABILITATION IN
PATIENTS WITH MYOCARDIAL INFARCTION” and take
opportunity to thank everyone who helped me in this task.
First, I would like to thank God and my parents who have the greatest
contribution in all my achievements.
My special thanks to respected Principal DR.G. ARUN BABU,
MPT (NEURO SCIENCES) for having faith in me and allowing me to
do this project.
I deeply indebted and thankful to my project guide DR. FARHEEN
GIGANI MPT (ORTHOPAEDIC) for her unflagging energy and
dedication.
She has tried in every conceivable way to get me to complete this project.
I also thankful the staff members of my college for the guidance and
encouragement.

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 CONTENTS

1. INTRODUCTION
2. DEFINITION
3. ANATOMY
4. PHYSIOLOGY
5. ETIOLOGY
6. PATHOPHYSIOLOGY
7. CLASSIFICATION
8. CLINICAL FEATURES
9. REVIEW OF LITERATURE
10. DIAGNOSIS
11. MANAGEMENT
12. METHODOLOGY
13. ASSESSMENT
14. CASE STUDY
15. CONCLUSION
16. BIBLIOGRAPHY

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INTRODUCTION

7
 INTRODUCTION

• Myocardial Infarction (MI), commonly known as "Heart attack".

• It occurs when blood flow decreases or stops in the coronary artery
of the heart, causing damage to the heart muscle. (Myocardium).
• The most common symptoms is chest pain or discomfort. It travel in
to the shoulder, arm, back, neck or jaw.
• Often it occurs in the Centre or left side of the chest and lasts for more
than few minutes, other symptoms include shortness of breath,
nausea, feeling faint, cold sweat or feeling tired
• The blockage is caused by a buildup of plaque in the arteries
(atherosclerosis) Plaque is made up of deposits, cholesterol, and other
substances, when plaque breaks (ruptures), a blood clot quickly
forms. The blood clot is the actual cause of the heart attack.
• If the blood and oxygen supply is cut off, muscle cells of the heart
begin to suffer damage and start to die. Irreversible damage begins
within 30 minutes of blockage.
• More than 3 million people each year are estimated to have an acute
ST- elevation myocardial infarction (STEMI), with more than 4
million having a non-ST-elevation myocardial
Infarction (NSTEMI).
• Most myocardial infections occur due to coronary artery disease. Risk
factors include high blood pressure, smoking, diabetes, lack of
exercise, obesity, high blood cholesterol, poor diet and excessive
8
 alcohol intake.
• MIs are less commonly caused by coronary artery spasms, which may
be \due to cocaine, significant emotional stress (commonly known as
takotsubo syndrome or broken heart syndrome) and extreme cold,
among others.
• Aspirin is an appropriate immediate treatment for a suspected MI.
• Nitroglycerin or opioids may be used to help with chest pain;
however, they do not improve move all outcome Supplemental
oxygen is recommended in those with low oxygen levels or shortness
of breath.
• Regular physical activity helps your heart and the rest of your body
get stronger and work better.
• Physical activity improves your energy level and lifts your spirits. It
also reduces your chances of future heart problems, including heart
attack.
• Counselling and education can help the patient quit smoking, eat
healthy food, lose weight, and lower your blood pressure and
cholesterol levels. Counseling may also help you learn to manage
stress and to feel better about your health.

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DEFINITION

10
 DEFINITION

• Myocardial infarction is defined as necrosis of a portion of a

myocardium.
• The death of the myocardium occurs as a result of hypoxia and
myocardial ischemia.

• The vessels affected are the right and left coronary arteries.

11
ETIOLOGY

12
 ETIOLOGY

• Coronary artery disease

• Smoking

• Hypertension

• Low density lipoprotein cholesterol

• Diabetes

• Obesity

• Physical inactivity

• Air pollution

• A positive family history of heart disease

13
EPIDEMIOLOGY

14
 EPIDEMIOLOGY

• Coronary disease is the commonest cause of death in England.

• 30% of males and 23% female deaths.

15
ANATOMY

16
 ANATOMY
The heart is a hollow conical muscular organ situated in the mediastinum
covered by pericardium.
It is divided in to four chambers:
• The right atrium
• The right ventricle
• The left atrium
• The left ventricle
The upper chambers are called atria and lower chambers called
ventricles
Atria and ventricles are separated from each other by
atrioventricular groove.
Both the atria are separated from each other by inter atrial groove.
Both the ventricles are separated from each other by inter ventricle
groove.
LOCATION
The heart is situated between the lungs, behind the sternum and
above diaphragm in middle mediastinum.
BORDERS OF THE HEART
The heart has 3 borders:
o Right border: it extends from superior vena cava to inferior
vena cava
o Left border: it extends from apex to left atrium.

17
 o Inferior border: it extends from inferior venacava to apex of
the heart.
The heart has five surfaces:
Base (posterior), diaphragmatic (inferior), stern costal (anterior),
and left and right pulmonary surfaces.
CHAMBERS OF THE HEART:
THE RIGHT ATRIUM.
• The right atrium is the right upper chamber of the heart.
• It receives deoxygenated blood from whole body.
• Sends to the right ventricle through atrioventricular valve or
tricuspid valve.
• The chamber receives deoxygenated blood from superior
venacava at upper end and inferior venacava at lower end
THE RIGHT VENTRICLE
• The right ventricle is the triangular chamber which receives
deoxygenated from the right atrium and pumps it to the lungs
through pulmonary arteries.
THE LEFT ATRIUM
• It forms most of the base of the heart.
• It receives blood from the lungs through four pulmonary veins.
• Blood passes from the left atrium into the left ventricle through
the mitral valve.
THE LEFT VENTRICLE
• The left ventricle is the thickest chamber of the heart and forms apex
of the heart
• Blood passes from the left ventricle through the aortic valve into the
18
 ascending aorta.
• From here blood flows into the coronary arteries, with branch from
the ascending aorta and carry blood to the heart wall.
• Branches of the hearts of the aorta and ascending aorta and
descending aorta carry blood throughout the blood.

ANATOMY OF HEART
VALVES OF THE HEART
• These are helps to maintain the flow of blood in unidirectional
• They are two pairs of valves in the heart, they are
o Semilunar valves.
o Atrioventricular valves
o Semilunar valves are aortic valve and pulmonary valve.
o Atrioventricular valves are tricuspid valve and mitral valve.

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VALVES OF HEART

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BLOOD SUPPLY OF THE HEART
• The heart is supplied by two coronary arteries.
• They are right coronary artery and left coronary artery.
• These are arising from the ascending aorta

BLOOD SUPPLY OF HEART

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VENOUS SUPPLY OF THE HEART
• The great cardiac vein
• Middle cardiac vein
• Anterior cardiac vein
• Thebesian vein

VENOIUS SUPPLY OF HEART

LYMPHATICS OF THE HEART

• Brachia cephalic lymph nodes
• Tracheobronchial lymph nodes
NERVE SUPPLY OF THE HEART
• Cardiac plexus
• Vagus nerve
The right atrium and ventricle receive deoxygenated blood from
22
systemic veins and pump it to the lungs, while the left atrium and
ventricle receive oxygenated blood from the lungs and pump it to the
systemic vessels which distribute it throughout the body.
• The left and right sides of the heart are separated by the interatrial
and interventricular septa which are continuous with each other.
Furthermore, the atria are separated from the ventricles by the
atrioventricular septa. Blood flows from the atria into the ventricles
through the atrioventricular orifices (right and left)–openings in the
atrioventricular septa. These openings are periodically shut and
open by the heart valves, depending on the phase of the heart cycle.
• Heart valves separate atria from ventricles, and ventricles from great
vessels. The valves incorporate two or three leaflets (cusps) around
the atrioventricular orifices and the roots of great vessels.
• The cusps are pushed open to allow blood flow in one direction, and
then closed to seal the orifices and prevent the backflow of blood.
Backward prolapse of the cusps is prevented by the chordae
tendineae–also known as the heart strings–fibrous cords that
connect the papillary muscles of the ventricular wall to the
atrioventricular valves.
• There are two sets of valves: atrioventricular and semilunar. The
atrioventricular valves prevent backflow from the ventricles to the
atria:
• The right atrioventricular/tricuspid valve is between the right atrium
and right ventricle. It has three cusps/leaflets:
anterior/anterosuperior, septal, and posterior/inferior.
• The left atrioventricular/bicuspid valve is also called the mitral
23
 valve since it only has two cusps and resembles a miter in shape. It
is between the left atrium and left ventricle and has two
cusps/leaflets: anterior/aortic and posterior/mural.
• Semilunar valves prevent backflow from the great vessels to the
ventricles.
• The pulmonary semilunar valve is between the right ventricle and
the opening of the pulmonary trunk. It has three semilunar
cusps/leaflets: anterior/non-adjacent, left/left adjacent, and
right/right adjacent.
• The aortic semilunar valve is between the left ventricle and the
opening of the aorta. It has three semilunar cusps/leaflets: left/left
coronary, right/right coronary, and posterior/non-coronary.
Blood flow through the heart
• The blood flow through the heart is quite logical. It happens with
the heart cycle, which consists of the periodical contraction and
relaxation of the atrial and ventricular myocardium (heart muscle
tissue). Systole is the period of contraction of the ventricular walls,
while the period of ventricular relaxation is known as diastole. Note
that whenever the atria contract, the ventricles are relaxed and vice
versa.
• The right atrium receives deoxygenated blood from the superior and
inferior venae cavae and coronary sinus
• The right atrium contracts pushing blood through the right
atrioventricular valve into the right ventricle. The right ventricle
then contracts passing the blood into the pulmonary trunk via the
pulmonary valve to reach the lungs
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 • In the lungs, the blood gets oxygenated then moves back into the
heart entering the left atrium through the pulmonary veins.
• The left atrium contracts and pushes the blood into the left ventricle
through the left atrioventricular valve.
• The left ventricle pushes oxygenated blood through the aortic
semilunar valve into the aorta, from which blood is distributed
throughout the body.

CORONARY CIRCULATION

• The heart must also be supplied with oxygenated blood. This is done
by the two coronary arteries: left and right.
• Heart muscles work constantly so the heart has a very high nutrient
need. The coronary arteries arise from the aortic sinuses at the
beginning of the ascending aorta, In this way, oxygenated blood
reaches every part of the heart Venous blood from the heart is
collected into the cardiac veins: middle, posterior, and small. They
are all tributaries to coronary sinus–a large vessel that delivers
deoxygenated blood from the myocardium to the right atrium.

GREAT VESSELES OF HEART

• The great vessels of the heart are the: aorta, pulmonary artery,
pulmonary vein, and superior and inferior vena cava. Because they
are large in size; the diameter of the ascending aorta is 2.1
25
 centimeters, and they all carry blood to and from the heart. The
aorta gives off branches which supply the entire body with
oxygenated blood.
• Major branches of the aorta include the brachiocephalic trunk, the
left common carotid artery and the left subclavian artery. The
superior vena cava receives blood from the upper half of the body
via the left and right brachiocephalic veins, and the inferior vena
cava from the lower half, through the common iliac veins.

26
PHYSIOLOGY

27
 PHYSIOLOGY

Cardiac cycle is defined as the succession of (sequence of) coordinated

Cardiac cycle:
• Events taking place in heart during each beat.
• Each heartbeat consists of two major periods, systole and diastole.
During systole, heart contracts and pumps the blood through arteries.
• During diastole, heart relaxes and blood is filled in the heart. All these
changes are repeated during every heartbeat, in a cyclic manner.
• Events of cardiac cycle are classified into two, atrial events and
ventricular events.
Divisions and duration f cardiac cycle
Duration of each cardiac cycle is about 0.8 second
Atrial events are divided into two divisions:
1. Atrial systole : 0.11 (0.1) second
2. Atrial diastole : 0.69 (0.7) second
Ventricular events are divided into two divisions:
1. Ventricular systole : 0.27 (0.3) second
2. Ventricular diastole : 0.53 (0.5) second
Ventricular systole is divided into two sub divisions and ventricular
diastole is divided into five sub divisions.

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Subdivisions of ventricular events
Ventricular systole (0.27 sec)

1. Isometric contraction 0.05 sec

2. Ejection period 0.22 sec

Ventricular diastole (0.53 sec)

1. Proto diastole 0.04 sec

2. Isometric relaxation 0.08 sec
3. Rapid filling 0.11 sec
4. Slow filling 0.19 sec
5. Last rapid filling (atrial systole) 0.11 sec

Among atrial events, atrial systole accures during the last phase of
ventricular diastole. Atrial diastole is not considered as a separate phase,
since it coincides with whole of ventricular systole and earlier part of
ventricular diastole.
Atrial systole
• Atrial systole is also known as last rapid filing phase or pre systole.
It is usually considered as the last phase of ventricular diastole. Its
duration is 0.11 second.
• During this period, only a small amount, i.e., 10% of blood is forced
from atria into ventricles.

29
• Atrial systole is not essential for maintenance of circulation.
• Many persons with atrial fibrillation survive for years, without
suffering from circulatory insufficiency.
• However, such persons feel difficult to cope up with physical stress
like exercise.
Atrial diastole
• After atrial systole, atrial diastole starts. Simultaneously,
ventricular systole also starts. Atrial diastole lasts for about 0.7
second (accurate duration is 0.69 second).
• This long atrial diastole is necessary, because this is the period
during which atrial filling takes place.
• Right atrium receives deoxygenated blood from all over the body
through superior and inferior venae cavae.
• Left atrium receives oxygenated blood from lungs through
pulmonary veins

Cardiac output
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Definitions and normal values
• Cardiac output is the amount of blood pumped from the each ventricle.
Usually, it refers to left ventricular output through aorta.
• Cardiac output is the most important factor in cardiovascular system
because the rate of blood flow through different parts of the body
depends upon cardiac output.
• Usually, cardiac output is expressed in three ways, stroke volume,
minute volume and cardiac index.
• In routine clinical practice, cardiac output refers to minute volume.
1. Stroke volume
• Stroke volume is the amount of blood pumped out by each ventricle
during each beat.
• It is the difference between end-diastolic volume and end-systolic
volume.
Stroke volume = end-diastolic volume – end-systolic volume.
Normal value: 70mL (60 to 80mL) when the heart rate is normal (72 per
minute)
2. Minute volume
Minute volume is the amount of blood pumped out by each ventricle in
1 minute. It is the product of stroke volume and heart rate:
Minute volume = stroke volume * heart rate
Normal value: 5L/ventricle/min.
3. cardiac index
• Cardiac index is the minute volume expressed in relation to square
meter of body surface area.
• It is defined as the amount of blood pumped out per
31
 ventricle/minute/square meter of the body surface area.
• Normal value: 2.8 ± 0.3 L/sq m of body surface area/ minute (body
surface area in an adult is 1.734 square meter and normal minute
volume of 5 L/min).

Ejection fraction
• Ejection fraction is the fraction of end-diastolic volume that is ejected
out by each ventricle.
• Normal ejection fraction is 60 to 65%.
Cardiac reserve
• Cardiac reserve is the maximum amount of blood that can be pumped
out by heart above the normal value.
• Cardiac reserve plays an important role in increasing the cardiac output
during the conditions like exercise. It is essential to withstand the stress
of exercise.

32
Values of cardiac reserve
Cardiac reserve is usually expressed in percentage.
1. Normal young healthy adult: 300 to 400%
2. Old aged person: 200 to 250%
3. Trained athletes: 500 to 600%
4. In cardiac diseases: minimum or nil.
Factors maintaining cardiac output
1. Venous return
2. Force of contraction
3. Heart rate

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PATHOPHYSIOLOGY

34
PATHOPHYSIOLOGY

35
CLASSIFICATION

36
 CLASSIFICATION

1. Type 1 Myocardial – infarction

It is spontaneous and is instigated through atheroma- thrombotic
CAD besides is related to atherosclerosis plaques wearing down
and- or split, cleft or partion in artery of myocardium.
2. Type 2 myocardial- infarction
It happens because of optional to ischemia which may be because of
augmented exigency of oxygen or declined oxygen distribution,
e.g., fixed myocardial atherosclerosis, myocardial embolism,
coronary artery dissection, respiratory failure, etc.
3. Type 3 myocardial -infarction
It is associated with abrupt cardiac death, as well as heart failure, is
frequently accompanied by signs of coronary ischemia escorted
through predictable fresh ECG ischemic alterations either ventricular
fibrillation either sign of fresh thrombus in myocardial artery
through angiography either or both at postmortem examination . In
this type, demise occurs earlier then serum sample is collected or
formerly the releases of myocardial injury markers inside systemic
circulation.
4. Type 4 myocardial - infarction
It is related to myocardial technical cardiac damage correlated with
cardiac revascularization procedure of PCI. In this Type 4a
myocardial - infarction related by percutaneous coronary
intervention. In type 4b be related by scaffold thrombosis or stent
related through percutaneous coronary intervention recognized
37
 through angiography or by postmortem examination whereas type 4c
myocardial - infarction occurs due to restenosis associated with PCI.
5. Type 5 myocardial -infarction
It is accompanied by CABG.

38
CLINICAL FEATURES

39
 CLINICAL FEATURES

➢ Angina
➢ cardiomyopathy
➢ Ischemic Cardiac arrest
➢ Sudden cardiac death
➢ Silent ischemia Chest pain
➢ Fatigue
➢ Palpitation’s
➢ Dizziness
➢ Abnormal heart rhythms
➢ Shortness of breath
➢ Swelling in hands and feet indigestion
➢ Alteration of skin color
➢ Clamminess and sweating
➢ Altered pulses
➢ Anxiety
➢ Irregular heart beat
➢ Hemoptysis
➢ Cardiac syncope
➢ Cerebral anoxia
➢ Nausea and vomiting
➢ Indigestion
➢ Constipation
➢ Pain radiating: The pain may radiate to the left arm, neck, jaw or
back.
40
REVIEW OF LITERATURE

41
 REVIEW OF LITERATURE

1. Vladislav Gladis, et al – 2022

Systematic r Systematic review of the eff view of the effect of exect
of exercise on the r cise on the reduction of eduction of myocardial
remodeling following a my emodeling following a myocardial infar
dial infarctioncompared to a sedentary approach- : Studies in which
exercise was introduced following a myocardial infarction have
demonstrated a reduction in cardiac remodeling and an improvement
in overall cardiac function. These findings suggest that an exercise
program following a myocardial infarction can benefit patients in
reducing negative complications such as cardiac wall thinning, infarct
expansion, and heart failure.
2. Margret Leosdottir, et al – 2022
Exercise-based cardiac rehabilitation after acute myocardial infarction
in Sweden - While EBCR delivery in Sweden is highly consistent
with European and national guidelines, there are several areas that
need to be improved. It is crucial to encourage centers to offer
evidence-based pre- and post-exercise assessments to secure the
safety and efficacy of exercise. Moreover, access to supervised
center-based exercise programs must be enhanced, but it is also
suggested that supervised home-based alternatives should be further
assessed to increase flexibility and variation. Resources in terms of
both direct and indirect costs require sufficient funding for the
implementation of an evidence-based EBCR program. Sufficient
physiotherapist staffing must be considered. The present survey
42
assessed the structure- and process-based metrics of EBCR, but it is
not possible to ascertain how these translate to goal attainment and
this must be studied in more detail. In a future study based on the
Perfect-CR study we plan to examine the association between CR
program standards and patient outcomes in order to identify
predictors of treatment goal fulfillment in EBCR. To enable the
benchmarking of results against other countries, the creation of a
common CR registry would be ideal.
3) ANDREAS MITSIS et al – 2022
Effectiveness of Early Mobilization in Prevention and Rehabilitation
of Functional Impairment after Myocardial Revascularization Surgery
- EM is effective in the prevention and rehabilitation of functional
parameters after CABG. Especially when combined with other
techniques, EM promoted an improvement in functional capacity,
respiratory muscle power, gas exchange and quality of life, and a
reduction in the incidence of atelectasis and pleural effusion.
4) Diah Ivana SAR Et Al -. (2022)
Cardiac Rehabilitation to Prevent Rehospitalization in Myocardial
Infarction Patients - Increasing cardiac ejection fraction, exercise
tolerance, and physical status are all possible cardiac rehabilitation
outcomes for patients recovering from a myocardial infarction. As a
result, it can help reduce the number of times patients need to be
readmitted to the hospital after suffering a myocardial infarction. In
addition to cardiologists and primary care physicians working closely
together, patients and their loved ones should also be encouraged
to pitch in
43
5) Evgenia Trevlaki, et al – 2022

The safety of exercise-based cardiac rehabilitation program in

patients after Myocardial Infarction- The present review has
demonstrated that that individualized and prescribed ex CR are
generally safe and recommended. The complications of these
programs appear to be of low risk and with no statistical importance.
The ex CR when combined with patient participation, proper
equipment and educated physicians present a very safe clinical
approach to cardiovascular patients.

6) Hall Dora O¨ gmundsdottir Michelsen, et al – 2020

Cardiac rehabilitation after acute myocardial infarction in Sweden –

Evaluation of program characteristics and adherence to European
guidelines - In the current study we have shown that the overall
quality of cardiac rehabilitation services provided in Sweden is high,
but we have detected several areas with potential for improvement.
To improve current practice Swedish cardiac rehabilitation
programs could benefit from appointing a medical director, having
structured teamwork including regular team meetings and
standardizing patient follow-up to include all cardiovascular risk
factors. Also, all centers are recommended perform a regular quality
control using registry data with the aim to improve work routines.
Future work to build on this study would be to drilldown on those
individual parts of cardiac rehabilitation programs that lead to
44
favorable patient outcomes, to guide allocation of limited resources
into the most efficient components of the cardiac rehabilitation
program. Analysis of the Perfect-CR study data, in conjunction with
SWEDEHEART and other national registry data, is currently being
conducted, the results of which may contribute to further improving
cardiac rehabilitation programs based on real-life data in order to
optimize patient outcomes following an AMI.

45
DIAGNOSIS

46
 DIAGNOSIS

• ECG: it shows ST segment elevation.

The higher the elevation and the more leads involved, the
larger the infarct & the greater the mortality.
• Coronary angiogram-diagnose coronary arteries, its location and
severity.
• Serum cardiac markers-creatinine phosphokinase
Lactic dehydrogenase.
Cardiac specific troponins
• Cardiac computerized tomography
• Exercise stress test.

47
MANAGEMENT

48
 MEDICAL MANAGEMENT

• Vasodilators-nitrates, isosorbide, dinitrat & mononitrate (These drugs

acts as blood vessel dilator)
• Beta – blockers (Decrease work load in heart)
Propranolol 20-40 mg
• Calcium channel blocker (they improve coronary blood flow)
Nifedipine
Verapamil
• Anticoagulant drugs
Heparin
• Opiate analgesic (for reduce pain)
Morphine sulphate
• Thrombolytic drugs
Streptokinase, urokinase.

49
 SURGICAL MANAGEMENT

• Coronary artery bypass grafting (CABG)

Coronary artery bypass surgery creates a new path for blood to flow
around a blocked or partial blocked artery in the heart. The surgery
involves taking a healthy blood vessel from other part of the body. The
vessel is connected below the blocked heart artery. The new pathway
improve blood flow to the heart.

50
 PHYSIOTHERAPY MANAGEMANT

The problems that arise after surgery:

• Pain
• Decreased air entry
• Retained secretions
• Decreased ROM
• Bronchospasm
• Hematoma
• Wound infection/delayed healing
AIMS OF THE PHYSIOTHERAPY MANAGEMENT
• To prevent complications.
• To maintain clear airway.
• To maintain good posture.
• To maintain range of motion of the upper limbs, neck, trunk &
lower limbs.
• To improve exercise tolerance
• To improve patient’s self-dependency.
• To improve lung volumes and capacities.

POST OPERATIVE TREATMENT PLAN

• Ensure that the patient has adequate analgesia.
• Assisting the deep breathing exercises in half lying, lying or
alternate side lying as necessary.
• Intermittent Positive pressure breathing (IPPB) given if necessary.
51
 • Unilateral active/assisted arm and leg exercises, active ankle
exercises.
• Increase mobility and progress to stair climbing.
TREATMENT PROCEDURE:
• The treatment procedure vary from patient to patient and surgeon
to surgeon.
• For some co-operative patients physiotherapy treatment is started
and for others will ask the patient to wait till 24hours.

TREATMENT PROTOCOL FOR POST OPERATIVE DAY TILL

THE DAY OF DISCHARGE OF PATIENT.

ON THE DAY OF OPERATION:

• No treatment is given.
POST OPERATIVE DAY 1:
• The therapist should check the patient condition and start
the first treatment in the ITU.
• If the patient condition is stable with a good blood pressure,
and a normal potassium then proceeding for postural
drainage.
• Mediastinal drain, then the treatment plan can followed.
• Arm and leg exercises are given in half lying, if vein graft is
present in leg then proper bandaging and care must be taken
and allow for the good movements, therapist should asses
for any neurological damage while carrying exercise.
• The chest should be auscultated before changing the position
52
 and starting chest therapy, exercises must be carried out in
such a way to relief strain in abdominal muscles by flexing
the hips and knees, breathing exercises must be praticised to
patient as per treatment plan.
• If patient is returning to the ward shortly
After physiotherapy, patient can be rolled to allow the
stretcher canvas to be inserted.
• Encouraging the patient for huffing and coughing techniques
with sternal support.
• Oxygen therapy should be continuous throughout the
treatment session only the oxygen mask is being removed
only for personal communication.
THE SECOND TREATMENT MUST BE GIVEN IN THE WARD.
• Patient case sheet and patient condition is checked in the
ward if suitable condition for the patient then the treatment
is proceed.
• The patient should be positioned in side lying with the help
of the bed rope, to practice his breathing exercises.
• The Physiotherapist should help the patient back to a sitting
position against pillows.

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THE THIRD TREATMENT USUALLY DONE FOR MOST OF
THE PATIENTS ACCORDING TO THE PLAN BUT IN SITTING
POSITION.

POST OPERATIVE DAY 2:

• Prior to the treatment any necessary analgesics is given to reduce
the pain.
• The patient will probably be sitting out in a chair and unless there
are severe chest problems, treatment can be carried out in the
chair, oxygen therapy will be probably discontinued by this
stage.
THE SECOND TREATMENT:
• The patient is allowed to have first walk with the help of
therapist.
• Most patients gains weight of one kg after operation but it
should be lost over the next one or two days.
• Up to 1 kg of weight gain can be seen, but more than 1kg of
weight gain can leads to feel of shortness of breath and has
swollen ankle, late inspiratory crackles.
POST OPERATIVE DAY 3:
• If all observations are remains stable then walking can be
increased. If vein grafts are taken, then we apply bandage and firm
stockings should be worn until good healing occurred. The chest is
treated according to the findings and the chest radiograph.

54
POST OPERATIVE DAY 4:
• If the patient can walk about 100 yards with no shortness of breath
then stair climbing begin.
• It is advisable to climb only 1 flight at first to ensure that there is
no adverse effects.

POST OPERATIVE DAY 5:

• Stair climbing and walking should be increased and the patient
advised to continue exercising on his own.
• Trunk exercises can be included.
POST OPERATIVE DAY 6 & 7:
• Follow first 5 days protocol
• A list of exercises which includes neck, shoulder girdle, arm and
trunk movements advised. The breathing exercises and coughing is
useful.
• The walking should be increased gradually each day until 1-2
miles a day is achieved by the time he attends for his 6 weeks post-
discharge appointment.
HOME PROGRAMME:
• Breathing exercises.
• Chest expansion exercises.
• Maintaining proper posture
• Stair climbing with breaks in between.
• Walking for long distances with small intervals in between.
• Exercise protocol: initially normal active exercises to be
performed. From day 4/5 small weights to be added for resistance.
55
 Repeat each exercise for 10 times and perform twice a day.
• Dumbbells, sand bags or available home resources can be used for
resistance exercise.
• Performing independently – activities of daily life.
• The patient will be advised that he should not drive for 6 weeks.
• Sexual relations should be avoided for 4 weeks after leaving
hospital.
• Whenever patients feel breathlessness that activity should be
paused immediately and relax for some time. Resume that activity
when patient feels normal.
• Advice patient to use western toilet.
• Do not do forceful coughing after brush.
• Diet maintaining (protein diet advised).
• Any reoccurrence of symptoms patient should visit the doctor
immediately.
FOLLOW-UP:
Patient should go for regular follow ups as suggested by the cardiologist
and physiotherapist. To check for the complications and exercise
tolerance of the patient.

Suggested improvisations in the exercise protocol should be followed by

the patient.

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METHODOLOGY

57
 METHODOLOGY
Type of surgery: CABG
A study was done on the postsurgical cardio rehabilitation patients to
know the efficacy of physiotherapy.
INCLUSION CRITERIA:
It includes
• The median age was 56 years
• No severe lung injury
• No neuromuscular impairment
• No cognitive impairment
• No renal impairment
• No emergency services
• Mechanical ventilation less than 24 hours
EXCLUSION CRITERIA:
It includes
• Patients with previous CABG
• Congenital heart disease
• Mechanical complications of acute MI
• Death or transfer of patients to other hospital
Duration:
• Treatment duration is 10 to 20 minutes at 2 hours interval for 2
weeks.
Day of operation
• The physiotherapist must note the position of drips, tubes and lines.

58
 Therapist must check recordings such as temperature, blood -
pressure, ECG, pulse rate, respiration rate, and time of
administration of analgesic drugs.
• If the patient does not require artificial ventilation and there are no
excessive pulmonary secretions, physiotherapy may be delayed
until the endo tracheal tube has been removed.
• The patient is helped to sit forwards from half-lying with the help of
therapist. With the incision supported.
• The patient is encouraged to take three deep breaths and try to one
or two huffs. Patient is then repositioned in half-lying with full
support for his head and trunk from pillows.

DAY – 1:
• Treatment is given three times during the day. Diaphragmatic and
bilateral basal breathing exercises are practiced with huffing and
then coughing when the patient can manage.
• Deep Breathing exercises

59
• Position sense training is incorporated because the shoulders,
head and neck should be aligned before breathing exercises are
performed and relaxation encouraged after coughing.

60
DAY-2:
• The physiotherapy will be the same as for day 1. A rope ladder
may be tied to the end of the bed to enable the patient to sit up
himself.
• Arm movements should be full range on the side of a lateral
thoracotomy.
• Where the incision has been a median sternotomy, the patient
may start bilateral movements.
• By the fourth treatment session the patient may be up to sit
beside his bed, and breathing exercises are given in this
position.

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 DAY-3:
• The patient will be clear of all drips, drains and lines and will
be back in the ward of the cardiothoracic unit.
• Breathing exercises and huffing should continue.
• General arm and trunk exercises will be included in at least one
session and the patient may be taken for a short walk (within the
ward) on another session.
• Posture correction and arm swinging should be incorporated
into the walking practice.

DAY- 4:
• The patient should be up and about independently and
allowed to go to the toilet on his own.
• The physiotherapist may assess chest expansion once at
least. Arm, trunk and leg activities performed.

DAYS (5-14):
• Activities until the day of discharge–usually 2 weeks
after the operation-must be guarded to the individual
patient.
• Around days 5-7 the patient should be able to walk
upstairs (about 8-10stairs) and an exercise program
should be developed and follow up the patient.

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ASSESSMENT

63
 ASSESSMENT

CARDIO RESPIRATORY ASSESSMENT

SUBJECTIVE ASSESSMENT
• Name
• Age
• Gender
• Occupation
• Address
• Date of surgery
CHIEF COMPLAINTS:
• Chest pain
• Cough with sputum
• Wheeze
• Dyspnea
HISTORY
• Present history
• Past history
• Medical history
• Surgical history
• Physiotherapy history
• Occupational history
• Socio-economic history
• Personal history
• Family history
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OBJECTIVE ASSESSMENT
Vital signs
• Temperature
• Heart rate
• Respiratory rate
• Pulse rate
• Blood pressure
• Spo2
• Hb
LEVEL OF CONSCIOUSNESS
• Eye opening response
• Verbal response
• Motor response

ON OBSERVATION
• Appearance of patient

65
• Head and face
• Facial expressions
• Edema and puffiness
• Eyes:
Pallor-anemic
Plethoric-increased Hb
Yellow -jaundice
• Nose -flarring
• Lips – cyanosis
Any pursed lip breathing
• Neck – bulk- usage of accessory muscles
▪ Position of trachea
▪ Jugular venous pressure
• Chest deformities pectus carinatum
Pectus excavatum
Kyphoscoliosis

66
 • Extremities- cyanosis
Clubbing of fingers and toes
Pedal edema
ON PALPATION
o Tracheal position
o Accessory muscles tenderness

ON AUSCULTATION
▪ Heart sounds
▪ Breath sounds

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CHEST EXCURSION

PERCUSSION
• With the middle finger over the intercostal spaces. Compare bilaterally
-Hyper resonant – air/hyperinflation/pneumothorax
-Dull – fluid/soft tissue/consolidation.
VOCAL FREMITUS
• Hand placement same as chest excursion. Compare bilaterally
Ask pt. to say ‘K’ or ‘99’
Note sound transmission under palm
Decrease transmission = air/emphysema
Increase transmission = consolidation, fluid
INVESTIGATIONS:
Complete blood picture
Chest x- ray
Arterial blood gas analysis

68
CASE STUDY

69
 CASE STUDY-1

SUBJECTIVE ASSESSMENT
• Name: Srinivas
• Age: 65 years
• Gender : Male
• Address : kalwakurthy
• Chief complaint: Chest pain and difficulty in breathing
HISTORY OF PAIN
• ONSET: Gradual recurred over a period of 10 days
• LOCATION: Left side of chest radiating down the left arm.
VAS SCALE: 5

Present history
• known case of diabetes-12yrs & ischaemic Heart disease 2yr
• Chest pain started 6hrs back
• Crushing in nature
• Retrosternal
70
 • Past history
• Diabetes :12 years
• HTN: positive
Personal history
• Chronic smoker
• 5-6 cigars/day since past 6 years
Medical history
• patient is taking anti diabetics
• Anti-hypertensive drugs
Present surgical history :
Surgery name : CABG
Type of incision used : Median sternotomy -vertical incision
Wound /scar : presented with padded cotton
Drains : Thoracic chest drains are placed after surgery
Past Surgical history
• No significant surgical history
Family history
• positive for IHD, HTN and DM
• 2 brothers died of MI
Socio economic history: Satisfactory
OBJECTIVE ASSESSMENT:
VITALS:
• Blood pressure :160/90mmHg in lying position
• Temperature:101 F
• Pulse rate: 115 b/m, regular, tachycardia

71
 • Respiratory rate :30/m
LEVEL OF CONSCIOUSNESS: GCS SCORE 10/15
ON OBSERVATION:
• Patient appearance: pale and anxious
• Body built– Mesomorphic
• Breathing pattern- Abdominothoracic
• Facial expression- patients looks tired
ON PALPATION
• Chest expansion: symmetrical
• Upper lobe: fair
• Lateral costal: fair
• Diaphragm: poor
ON PERCUSSION
• Dullness
• Pain at operative site
• Back aching
• Reduced chest expansion and secretion retention
• Unable to produce effective cough
ON AUSCULTATION:
• Crackle sound at the left and right lower lobes
• Coughing – unproductive cough
• Sputum – slightly thick and greenish +blood with minimal
amount

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INVESTIGATION:
• ECG
• Chest X-Ray
• 3D - echo
• Angiography
MANAGEMENT
Medical management:
• Beta blocker
Prophylactic i.v infusion
Inj. Atenolol (50 mg)
• Oral administration for few days Tab. Atenolol
• Morphine (2.5–5.0 mg i.v)
• Aspirin (162- 325 mg orally)
Surgical management
• Coronary artery bypass graft (CABG)
Physiotherapy management
Day -2
• Breathing exercises
• Bilateral arm movements
• Chest expansion exercises
• Huffing and coughing
Day – 3 to 14
• General arm and trunk exercises
• Posture correction
• Arm, trunk and leg movements along with Stair walking

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 CASE STUDY-2

SUBJECTIVE ASSESSMENT
• Name: Anitha
• Age: 60 years
• Gender: Female
• Occupation: House wife
• Address: Nagar Kurnool
Chief complaints:
• sudden chest pain with tightness
• fainting since 1 day
• shortness of breath since 2days
• sweating since 2 days
• decreased urinary output since 3 days
History of pain:
• onset: pain from 15 days
• location: left side of chest

VAS SCALE: 6

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 • Present history: patient came with the sudden chest pain and
restlessness
• Past history: patient has history of high blood pressure and
20%coronary blockage before 5 years.
• Personal history: patient has no any habits currently
• Medical history: patient taking antihypertensive since 5 years
• Past Surgical history: patient has history of hysterectomy before 3
years
• Present surgical history :
Surgery name : CABG
Type of incision used : Median sternotomy -vertical incision
Wound /scar : presented with padded cotton
Drains : Thoracic chest drains are placed after surgery
• Family history: no any family history
• Socioeconomic history: satisfactory
OBJECTIVE ASSESSMENT:
VITALS:
• Blood pressure: 160/90mmHg
• Temperature: 101F
• Pulse rate: 96bpm
• Respiratory rate: 24/min
• SPO2: 90%
LEVEL OF CONSCIOUSNESS: GCS SCORE 10/15

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ON OBSERVATION:
• Patient appearance: pale and anxious
• Body built– Mesomorphic
• Breathing pattern- Abdominothoracic
• Facial expression- patients looks tired
ON PALPATION
• Tenderness – absent
• Diaphragm - normal
• Chest expansion – asymmetric
ON PERCUSSION
• lung field: clear
• resonance: hyper resonance
• diaphragmatic excursion: normal
ON SAUSCULTATION
• breathing sound – vesicular
• adventitious sound – absent
• respiratory pattern – tachypnea
INVESTIGATION
• Electrocardiogram – ST segment elevation
• Coronary angiography
• Echocardiography – moderate MR and left ventricular dysfunction.
MANAGEMENT:
Medical managemesssssnt:
• Injection Streptokinase
A single dose of 1.5 million IU should be infused

76
 intravenously over one hour.
• Tablet Nitroglycerin
2.5 to 6.5 mg 3 to 4 times in a day
• Injection Morphine
Infused intravenously, the dose is in the range of 2.5 to 15
mg given slowly over 4 to 5 minutes.
• Aspirin Tablet
300 mg tablets 1 or 2 tablets taken every 4 to 6 hours.
Surgical management
• CABG
Physiotherapy management
Day -2
• Breathing exercises
• Bilateral arm movements
• Chest expansion exercises
• Huffing and coughing
Day – 3 to 14
• General arm and trunk exercises
• Posture correction
• Arm, trunk and leg movements
• Stair walking

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CONCLUSION

78
 CONCLUSION

• The study has been done as post-operative physiotherapy, in patients

with myocardial infarction who underwent Coronary Artery Bypass
Graft (CABG) surgery.
• Implementing cardiac rehabilitation for 14 days seems to be
effective in improving the functional exercise capacity (aerobic
capacity)
• By performing breathing exercises, arm and trunk exercises,
posture and gait training exercise and chest expansion exercises
produced more efficiency and improved patient’s health.

• Hence, Cardiac rehabilitation should be implemented more

frequently and health care providers should be aware of its
importance.

79
BIBLIOGRAPHY

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