Cardiac RehabilitationContents Introduction- Definition Epidemiology- in Indian context Indications Contraindications Risk factor stratification Diet & nutrition Psychological & behavioral support Barriers & challenges in CR lo lo oO Oo lO.- Phases of CR & evidences lo oO oO lo lo _ References Dr Str PoncaIntroduction G The first person to introduce exercise systematically into the therapy of cardiovascular disease was M. Oertel in 1875. He successfully treated a patient who was overweight and was short of breath with an increasing number of steps in a hilly terrain. Later he used an arm ergometer for this purpose, The World Health Organization’s current definition addresses the cardiovascular status of the patient before, during, and after the event: “The rehabilitation of cardiac patients is the sum of activities required to influence favourably the underlying cause of the disease, as well as the best possible physical, mental and social conditions, so that they may by their own efforts, preserve or resume when lost, as normal a place as possible in the society. Rehabilitation cannot be regarded as an isolated form of therapy but must be integrated within fhe entire treqtment eeeAccording to AHA scientific statement; CR is the coordinated, multifaceted interventions designed to optimize a cardiac patient’s physical, psychological and social functioning in addition to stabilizing, slowing or even reversing the progression of the underlying atherosclerotic process thereby reducing morbidity and mortality.Heart disease- Indian context 3 Cardiovascular diseases have become the leading cause of mortality in India. a Incomparison with the people of European ancestry, CVD affects Indians at least a decade earlier & in their most productive midlife years, e.g., 23% of CVD deaths before the age of 70 years, In India, this number is 52% <1 The age standardized CVD death rate of 272/1,00,000 in India is higher than the global average of 235 /1,00,000 population. ‘ShrIndications for CR in clinica guidelines 1 Myocardial infarction tO Percutaneous coronary intervention 1 Coronary bypass grafting [O Chronic stable angina CO Heart failure CO Peripheral arterial disease AMERICAN COLLEGE of CARDIOLOGYContraindications Unstable angina Critical aortic stenosis Active paricarditis or mycarditis Resting SBP >200 mmhg or DBP >110 mmhg Uncontrolled CHF 3° AV block Resting ST-segment depression >2 mmBenefits- 1996 AHCPR report40-60 ca/min Patients with cardiac disease but without resulting limitations of physical activity. Ordi- ‘nary physical activity does not cause undue fatigue, palpitation, dyspnea, or anginal pain. 65 METS 30-40 calmin Patients with cardiac disease resuiting insight limitation of physical activity. They are comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea, or anginal pain 20-30cal/min Patients with cardiac disease resulting in marked limitation of physical activity. They are ‘comfortable at rest. Less than ordinary physical activity causes fatigue, palpitation, dys- ‘ea, or anginal pain. 3OMETS 1.0-20.cal/min Patients with cardiac disease resulting in inability to carry on any physical activity with- ‘Out discomfort. Symptoms of cardiac insufficiency or of the anginal syndrome may be [Present even at rest. f any physical activity is undertaken, discomfor is increased. Dr Shruti PoncaAUS US Aibidil 0 27 17 5 27 17 10 ee 17 12 4.0 2.5) 14 5.4 34 16 6.7 42 18 8.0 5.0 Dr Str Ponca 0 =0 Other points: |B Assessment related to cardiac risk factors Reversible risks Irreversible risks Sedentary lifestyle Cigarette smoking Hypertension Low HDL cholesterol (<0.9 mmol/L [35 mg/dL) Hypercholesterolemia (25.20 mmoV/L [200 mg/dL) High lipoprotein A Abdominal obesity Hypertriglyceridemia (2.8 mmol/L (250 mg/dL]) Hyperinsulinemia Diabetes mellitus De Shr Age Male gender Family history of premature CAD (before age 55 in a parent or sibling) Past history of CAD Past history of occlusive peripheral vascular disease Past history of cerebrovascular diseaseMET Value of Physical Activities Light Intensity Exercises: MET <3 Sleeping 0.9 Watching television 1.0 Writing, deskwork, typing 15 Walking1.7mph(2.7km/h) 2.3 level ground, strolling very slow Walking, 2.5mph(4km/h) 2.9Moderate Intensity Activities: MET 3-6 + Stationary bicycling,SO watts, 3.0 very light effort Walking,3.0mph(4.8km/h) 33 Calisthenics, home ex,, light or 3.5 moderate effort Walking 3.4mph(5.5km/h) 3.6 Bicycling <10mph(16km/h) 40 Bicycling, stationary, 100watts, 5.5 light effort Vigorous Intensity Activities: MET >6 + Jogging general 7.0 + Calisthenics (push ups, pull ups 8.0 sit ups, jumping) + Running, jogging in place 8.0 + Rope jumping 10.0‘Secondary <— prevention — ‘Angina, Ml, CHF, PAD, Primary stroke, sudden death prevention ee Dr Str Pancha Core components of cardiac rehabilitation Primordial Prevention UnhealthyTake (closer look! AT CRY Se XNPhases of CR CO Phase |: In hospital 1 Phase II: Convalescence following discharge CO Phase Ill: Supervised out patient program tO Phase IV: Unsupervised maintenance program Dr Str Pancha‘Acute MI Post CABG Angioplasty Valve repair Congestive Heart failureHospital-associated deconditioning Hospital admission Post Recovery S ° ZB 8 s S a Rehabilitation | No rehabilitation Time ‘Am J Phys Med Rehab, 2008, 88(1):66-77BP Pee oe Be Crem prescription of exercises in phase I of cardiac rehabilitation Intensity TPE below 13 (scale 6-20) Post AMI: HR below 120 bpm or resting HR +20 bpm (Arbitrary lower limit) Post-surgery: resting HR + 30 bpm (Arbitrary upper limit) Up to tolerance if non-symptomatic Duration Intermittent sessions lasting from 3 to 5 min Resting periods out of As the patient wishes Lasting from 1 to 2: min Shorter than the time of the exercise sessions Total duration of 20 min in hall tivities Early mobilization: 3 to 4 times per day (Ist to 3rd days) Subsequent mobilization: twice per day (As from the 4th day) Progression Initially increase the duration by up to 10 to 15 min of exercise time and * then increase the intensity sn Px 3y, upPatient & family education 10 Risk factors control -Smoking cessation -Control of HTN & DM Lifestyle modification - Dietary changes - Regular exercise a Behavior modification -Stress management -Creation of hobbiesEvidences Bocas Eos Effects ofan 100 patients Both group ey roup 1(n=50) Individualized were oe rt Eurodat anreeved) a heart group 2(n=50) Routine CR functional (ants) Twice a day up capacity but to discharge ICR did better ee than RCR Phase I of cardiac rehabilitation: A new challenge for evidence based physiotherapy; Rafael Michel de Macedo et al., World journal of cardiology(2011)© Convalescent phase is designed to allow scar over infarction to mature C It focus on health education& resumption of physical activity . CO Psychological goals- anxiety/depression Mx.Gradual increase in ambulation time Goal: 20-30 minx1-2times/day at 4-6wks. ‘c Pt’s day will be a combination of rest & & low level activity including ambulation & LE -UE mobilityEvidences © Phase ll intensive monitored cardiac rehabilitation for coronary artery disease & coronary risk factors-a six session protocol; Barbara Johnston Fletcher et al, (2015); American Journal of cardiology. 31 patients underwent for a progressive 6-level exercise protocol with careful supervision & assessment of HR, rhythm, BP & RPE. Duration after the cardiac event ranged from 12days to 8 years; activities individually prescribed according to percentages of maximal MET level achieved on ETT. Exercise session incorporated calisthenics , treadmill training, bicycling & arm ergometry with progressive increase in work load. Bi six sessions; each session was of 1 hour 1 The results suggest benefits of proper exercise instruction, successful achievement of 50-75% exercise target HR, & there were no critical cardiac events.Phase III Ee Es — Ee Ee CO Goals: -Provision of flexible, individualized exercise program Dr Str PanchaO Program started after symptomatic ETT. oO Warm up(5-10min) & cool down(10-15min) is compulsory oO FITT would be... Negative ETT Positive ETT Frequency 3 sessions/wk; 3 sessions/wk; 6-8 week 6-8 week Intensity 65% -80% HRmax 65yrs); Intervention group received Rehab program including exercise therapy, diet & weekly counseling; control group received usual outpatient care . Bn intervention group BMI, waist size significantly decreased; peak VO2 & anaerobic threshold were maintained & serum total cholesterol levels significantly decreased; where as in control group no change in BMI, waist size, peak VO2 decreased & serum cholesterol levels unchanged. Home-based v/s centre-based cardiac rehabilitation: abridged Cochrane systemic review & meta-analysis; S A Buckingham et al, BMJ (2016) The Cochrane Central Register of controlled trials, MEDLINE, EMBASE, PsycINFO & CINHAL were searched; 17 studies with 2172 patients were included @ Conclusion: Home-based & centre-based CR provide ilar benefits in terms of clinical & health related Qol.Objectives: Maintenance of achieved functional status cc Return to work: hobbies & lifestyle modification | Secondary prevention Dr Str Panchac If the patient stops exercising, the benefits gained from phase III can be lost in a few weeks. co FITT : 3 sessions/wk(moderate level)/5 sessions/wk (low level) At THR level Continuous for at least 30 min -45 minEvidences Impact of community-based CR on clinical parameters of pts with cardiovascular diseases; Ong KY, et al, Asean Heart J.(2016) A retrospective cohort study, 94 pts who had completed a hospital based CR program & continued community-based CR compared with pts who received regular care(157); primary outcome measure was LDLlevels. @ pts in intervention group had significant lowering of LDL, while in control group LDL increased . The intervention group had greater improvement in triglycerides, total cholesterol, fasting blood glucose & BP .Low Palate eCar ly raat >7 METs AS 250% Uncomplicated MI, CABG, PTCA, no CHF Dla Tord cs Assymptomatic Pane! Nil Normal with DU ar tes aerice Pt) Ueto Tey Risk factors stratification AACYVPR Guidelines <5 METs <40% CA survivor, cardiogenic shock post MI or CABG, CHF, post procedure Ischemia ‘Signs, symptoms <5 METs ‘Complex ventricular arrhythmias, rest or exerci: Abnormal with exercise Clinically significantSmoking cesession Recommendations for smoking intervention strategies It is recommended to identify smokers and provide repeated advice on stopping with offers to help, by the use of follow-up support, nicotine replacement therapies, varenicline, and bupropion individually or in combination It is recommended to stop all smoking of tobacco or herbal products, as this is strongly and independently causal of CVD O It is recommended to avoid passive smokingSee Diet Modification According to European society of cardiology Saturated fatty acids to account for <10% of total energy intake, through replacement by polyunsaturated fatty acids Transunsaturated fatty acids as little as possible, preferably no intake from processed food, and <1% of total energy intake from natural origin <5 g of salt per day 30-45 g of fiber per day, preferably from wholegrain products >200 g of fruit per day (2—3 servings) >200 g of vegetables per day (2-3 servings) Fish 1-2 times per week, one of which to be oily fish 30 g unsalted nuts per day Consumption of alcoholic beverages should be limited to 2 glasses per day (20 g/d of alcohol) for men and 1 glass per day (10 g/d of alcohol) for women Sugar-sweetened soft drinks and alcoholic beverages consumption must eeuPsychological support & Behavioral modification © All the individuals taking part in cardiac rehabilitation should undergo a valid assessment of anxiety, depression, quality of life and other relevant psychological factors using an appropriate assessment tool. - stress management at home - stress management at work - creation of hobbies - time out - conflict resolution skills PSYCHOLOGICAL CARE: - Assist with adjustment - Promote positive attitude - Facilitate behaviour change - Identify need for further supportBarriers & Challenges to CR Low referral & low attendance rates major challenges Lack of physician recommendation Lack of insurance Lower education Psychological barriers i.e, depression, social deprivation & lower socio-economic status, dependent spouse at home, lack of transportation, lack of motivation.