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Cardiac Rehabilitation, and secondary prevention

Cardiac rehabilitation can be defined as the effort toward cardiovascular risk factor reduction designed to lessen the chance of a subsequent event, to slow, and perhaps stop the progression of cardiovascular disease process. Multifactorial and multidisciplinary approach is imperative to meet such challenges. Long term comprehensive cardiac care program involves a close follow up, risk factor modification, patient education, and psychological guidance

Indication of Cardiac Rehabilitation

Cardiac rehabilitation programs are indicated for patients recovering from recent MI, following coronary bypass, valve surgery or coronary angioplasty, cardiac transplantation, patients with stable angina or patient with compensated chronic heart failure. traditionally, cardiac rehabilitation has been provided to some what lower risk patient who could exercise without getting into trouble. However the rapid evolution in the management of IHD has now changed the demographics of the patients who can be a candidate for rehabilitation training.

Contraindication of Cardiac Rehabilitation

cardiac rehabilitation services are contraindicated in patients with severe residual angina, uncompensated heart failure, uncontrolled arrhythmias, poor left ventricular out flow tract, and unstable concomitant medical problems

Phase I of Cardiac Rehabilitation


Phase I of CRP begins when the patient is admitted to the hospital and ends on discharge .The goals of exercise in this phase are to avoid the deleterious effect of bed rest by making a gradual transition from passive rang of motion to active range of motion with low intensity, short duration exercise and ambulation

Phase II of Cardiac Rehabilitation


The patient, who has completed hospitalization, has to undergo through a pre discharge exercise tolerance test to determine his functional capacity, before he can begin phase II of CRP, where the physician and cardiac rehabilitation staff members formulate the level of exercise to meet an individual patient's needs, based on the result of exercise test. An exercise training usually are scheduled at a rehabilitation facility with a constant medical supervision including exercise electrocardiograms .In addition to exercise, counseling, and education about stress management, smoking cessation, nutrition, and weight loss also incorporated in this phase which may last three to six months

The main goals of phase II CRP are to improve functional capacity, progress toward full resumption of habitual and occupational activities and to promote positive life style changes .Exercise training in phase II is generally administered three to four times per week. Duration range from as low as 10 to 15 minutes per session, and gradually increasing up to 30 to 60 minutes per session as the level of fitness improve. Programs may offer a single mode of training or a circuit mode of training in which the patient spends a prescribed amount of time at one exercise station before moving into the next (e.g. treadmill, cycle ergo meter
,arm ergo meter, weight.)

Cardiovascular response to work during training session is monitored by number of factors, including heart rate, blood pressure, rhythm disturbance, rate of perceived exertion and sign of exertional intolerance

After performing another stress or cardiopulmonary exercise test, Phase III CRP (maintenance phase) is usually initiated for individual who participated in phase I and phase II (typically 6 to 12 weeks after discharge) .This phase is designed to continue for patient's life time, aiming for maintaing patient function, promoting life long commitment to physical fitness and physical health management. In this phase, individuals are expected to progress from supervision to self regulation of their programs and the activities consist of the type of exercise that the patient enjoys such as walking bicycling or jogging. Regular medical follow up and periodic graded exercise test are required every 3 to 6 months or annually

Both normal persons and patients with cardiovascular disease usually show an improvement in exercise tolerance with physical training. This improvement is a result of increased ability to use oxygen to deliver energy for physical work. Physical training also increase the amount of oxygen consumed at maximal effort, possibly because of increased availability of oxygen provided by the circulation, increased uptake by the skeletal muscles or both. Desirable changes in homodynamic, hormonal, metabolic, neurological and respiratory functions are also associated increased exercise tolerance

Regular aerobic exercise is effective in preventing and treating IHD as it improve cardiovascular efficiency and, in combination with other measures such as medication use, diet changes, and smoking cessation, may stop the progression or reverse the process of atherosclerosis. Exercise increases cardiovascular functional capacity with no effects on left ventricular function, and it decease myocardial oxygen demand at a given sub maximal load to be more efficient in responding to higher workload with less effort

Physical training results in decreased oxygen demand of the heart for a given level of total body oxygen consumption. This is manifested as a decrease in the product of HR multiplied by systolic arterial BP (an index of myocardial oxygen consumption) for a given level of exercise (Mc henry, et al "1990"). Reduced oxygen demand and myocardial work are reflected in lowered heart rate and blood pressure at rest and general reduction in sympathetic tone. This is in addition to, increasing collateral arteries formation and reducing the rate of progression of coronary artery atherosclerosis (Howard, et al "2001").

Influence of Cardiac Rehabilitation and Exercise training on Coronary Risk Factors

Most controlled exercise training studies showed only modest weight loss (2 to 3 Kg) in the exercise group. However when diet is added to the exercise program, the average weight loss is 8.5 kg. Most of which is body fat, whereas a diet only program results in lesser weight loss (5.1 kg over the same study period), and those undergoing neither diet nor exercise programming increased weight by an average of 1.7 kg (Blair, "1993").

Weight loss may be also promoted by prolonged elevated post exercise oxygen consumption, as it has been reported that in obese post coronary patients, this effect was large enough to produce substantial reduction of body fat without specific dieting (Mertens, et al "1998").

Body adaptation during exercise leading to fat reduction

1- Increased epinephrine-stimulated hydrolysis from subcutaneous fat, 2- Increased the capacity of the trained muscle to oxidize fat. 3- Increased hydrolysis of triglycerides within the trained muscle. 4- Increased hydrolysis of circulating triglycerides through Lipoprotein lipase activity. 5- Decreased insulin concentration, which is considered as an inhibitory factor to lipid mobilization. 6- Increased maximum oxygen consumption and greater

energy expenditure during and after exercise periods

Effect of exercise on Hypertension


regular aerobic exercise has been found to lower blood pressure in hypertensive patients (Gerald, "2001"). In mildly hypertension men, short term physical activity decreased blood pressure for 8 to 12 hours after exercise, and average blood pressure was lower on exercise days than on non exercise days (Pescatello,"1991"). In hypertensive black men, moderate physical activity for 16 to 32 weeks resulted in a decrease in diastolic blood pressure, which was sustained after reduction in hypertensive medication (Kokkinos,"1995"). Aerobic exercise also decrease systolic and diastolic pressure in hypertensive and normotensive individuals, and in those who are overweight or of normal weight (Whelton, et al" 2002").

Exercise and Diabetes Mellitus


Aerobic exercise training improves glucose tolerance, insulin resistance, and has a protective role in preventing the development of alteration of glucose metabolism associated with diabetes. Hevener,"2000" reported that in diabetic patients with insulin resistance, sex weeks of exercise training was shown to increase the whole body maximal insulin-stimulated glucose disposal 2.7 folds, which could be attributed to increase in insulin stimulated phosphatidyl inositol kinase activity that leads to 30% increase in the glucose disposal rate, this in addition to enhancing the ability of insulin to stimulate glucose uptake in skeletal muscles.

Principles of exercise prescription

Benzer, "2001", reported that exercise test is the primary mean used to evaluate the safety of participating in an exercise program and to formulate the exercise prescription. Because of the wise scatter of maximal heart rate when plotted against age, it is much better to determine person's actual maximal heart rate by testing to assign a target heart rate for training rather than giving a predicted value. Exercise test can also be to advance patients safely to a higher level of performance; also the improvement in exercise capacity demonstrated by an exercise test can be effective incentive and can encourage risk factor modification.

The exercise should be individualized according to the result of exercise test. The heart rate at anaerobic, or ventilatory threshold (AT) measured by cardiopulmonary exercise test is usually used as the heart rate for intensity recommendation, however, one must be sure that heart rate at (AT) is safe and that the patient does not exhibit symptoms of angina or moderate dyspnea at that level

Exercise Prescription

Mode

Intensity

Frequency

Duration

Relative intensity refers to the relative percentage of maximal aerobic power that is maintained during exercise and is expressed as percentage of maximal heart rate or percentage of VO2 max (Roy, et al "1999").

Each subject was participated in exercise training program for 12 weeks, three times per week. The program was designed in the form of circuit interval training mode, where the patient was riding bicycle for 1520 minutes, running on treadmill, climbing the stair master for the same periods as in bicycling. Each individual training intensity was calculated as target heat rate (THR) based on his maximum, and resting heart rate obtained from the exercise test, and according to karvonen formula

THR = HR rest + (HR max - HR rest) TF Where HR rest = resting heart rate in bpm HR max = maximum HR attained during CPET in bpm. TF = training fraction, it was 60 to 65% in mild training intensity, 65% to 75% in moderate training intensity, and 75% To 85% in severe training intensity

Subject During Performance of Exercise Training on Treadmill

Subject During Performance of Exercise Training on Bicycle Ergometer

Subject During Performance of Exercise Training on Stair Master