CARDIAC

REHABILITATION

Presented by:
Yoga Yudhistira
Yos Akbar Irmansyah

Supervised By:
dr. Astri Kurniati Martiana, SpJP
 WHAT IS CARDIAC REHABILITATION

 The term cardiac rehabilitation refersto

coordinated, multifaceted interventions
designed optimize a cardiac patient’s
to physical, psychological, and social
functioning, in addition to
slowing, or even
stabilizing,
reversing the progression
of the underlying atherosclerotic processes,
thereby reducing morbidity and mortality.
 CORE COMPONENTS

Source: British Association for Cardiovascular Prevention and

 OUTCOMES: 1996
AHCPR GUIDELINES
 Smoking cessation
 Lipid management
 Weight control
 Blood pressure control
 Improved exercise tolerance
 Symptom control
 Return to work
 Psychological well-being/ stress
management
 MEMBERS OF A
CARDIAC REHAB TEAM
 Cardiologist
 Specialist Nurse
 Physiotherapist
 Dietitian
 Psychologist
 Exercise specialist
 Occupational therapist
 INDICATIONS

 Post-MI
 Post-CABG
 Angina
 PCI, PTCA
 Valve replacement or repair
 Heart transplant
 Compensated CHF

(Source: Medcare, American

Heart Association)
 Acute Phase (Phase I)
 Convalescent Phase (Phase II)
 Training Phase (Phase III)
 Maintenance Phase (Phase IV)
 DEFINITION

 Phase I relates to the period of

hospitalization following an acute cardiac
event.

 The duration of this phase may

depending on the initial diagnosis, the
vary
severity of the event and individual
institutions, one week acute
usually
event/post-operative.
 OBJECTIVES

 Early mobilization and adequate

discharge planning.
 Risk factor assessment and
risk stratification
 Receiving information regarding their
diagnosis, risk factors, medications and
work/ social issues.
 Involvement and support of the partner and
family.
 MOBILIZATION- POST MI

 The classic Wenger cardiac rehabilitation

program was to get individuals from bed
rest to climbing 2 flights of stairs in 14 days.

 Under current practices, clinicians have

modified the classic program of cardiac
rehabilitation in of 3–5 days .
 STEPS OF MOBILIZATION

 Day 1-2 : bed rest, bed mobility, sitting on

the bed, breathing exercises
 Day 3: short distance ambulation and
bathroom privileges with monitoring
 Day 4-5: home exercise program, climbing
stairs, and increasing duration of
ambulation.
 Intensity: Post MI HR 20bpm and SBP
20mmhg from base line, RPE <13 in a 6-20
Borg scale (old scale)
 MOBILIZATION – POST PTCA

◦ May ambulate at comfortable pace

following surgery
◦ Avoid aerobic training for 2 weeks
post-op
◦ Exercise prescription to be based on post-
op ETT results
◦ Often progress faster than MI patients
PATIENT AND FAMILY EDUCATION
 CARDIO-PROTECTIVE THERAPIES

 Anti-platelet therapy
 Lipid-lowering therapies
 Beta-blockers (Post myocardial infarction)
 ACE inhibitors/ARBs
 Calcium channel blockers
 Anticoagulants if necessary
 Diuretics if necessary (e.g. heart failure)

( Source: British Association for Cardiovascular

Prevention and Rehabilitation)
 RISK FACTORS MANAGEMENT

Initially-
 Lipid management
 Hypertension management
 Diabetes management

Advice about-
 Smoking / Tobacco cessation
 Lifestyle modification
 Stress management
 LIPID MANAGEMENT

 Goal: LDL<100 mg/dl (<70 mg/dl is

desirable), HDL >40 mg/dl, TC >200 mg/dl,
TG <150 mg/dl

 Intervention: If LDL > 100 mg/dl, advice

nutritional counseling and weight reduction
and Statins are prescribed.
If HDL < 40 mg/dl, advice exercise, smoking
cessation.
 HYPERTENSION MANAGEMENT

 Goal: Optimal BP is < 120/80 mmHg

 Intervention: If BP >130/80 mmHg advice

about lifestyle modification before
discharge . Add drug therapy for patients
with diabetes, heart failure, or renal failure.
If BP > 140/90 mmHg advice lifestyle
modification and initiate drug therapy.
 DIABETES MANAGEMENT

 Goal: Near normal fasting plasma

glucose(< 7 mmol/l) and near normal HbA1
C (<7)

 Intervention: Appropriate hypoglycemic

therapy e.g. diet modification, oral
hypoglycemic agents and/or insulin
PSYCHOSOCIAL MANAGEMENT
 SURVIVAL KIT BEFORE DISCHARGE

 Clear information about medication

 Clear advice on managing chest pain and
reassurance
 Advice and information on ‘what and
when they can do’ (work, travel, exercise
etc)
 PHASE II
CONVALESCENT
PHASE
DEFINITION

 Thisphase encompasses the immediate

post discharge period, which is typically a
period of four to six weeks.
 OBJECTIVES

 It focuses on health education and

resumption of physical activity, however the
structure of this phase may vary
dramatically from centre to centre.

 It
may take the format of - telephone follow
up, home visits, or individual or group
education sessions.
ASSESSMENT BEFORE PHASE II
REHABILITATION

 Vitals (HR, BP, RR and rhythm, RPE, O2 sats,

pulses)
 Dyspnea
 Auscultation of lungs
 Edema
 Surgical sites
 Heart rhythm via ECG if monitored
 Pain
 Posture
 Strength
 Medications and effects
 Frequency: 3 times /wk,
 Duration: 30-60 minutes (5-10 min of warm- up and
cool down)
 Mode: walking and/or cycle/arm ergometer and
strength training
 Intensity: Submaximal, or determined by ETT data
upto a level of 70% maximum HR or MET level 5
or RPE 7 in modified Borg scale.
 EXERCISE GUIDELINES (CONT..)

• Strength training
begin at 3 weeks cardiac rehab, 5 weeks
post MI, 8 wks post CABG
Begin with bands and light weights
(1-3 lbs)
 Progress to moderate loads, 12-15 reps
 RISK FACTOR MANAGEMENT

 It includes the risk factors addressed as in

the phase I.
 Lipid, hypertension and diabetes
management must be continued as in
phase 1.
 Active initiation of smoking cessation, and
weight reduction.
 PSYCHO-SOCIAL REHABILITATION

 Common psychological reactions: low

mood, sleep
tearfulness, disturbance, acute
irritability,somatic
minor anxiety,sensations
awarenessor ofpains,
poor concentration and memory.

 Proper counseling must be done.Seek

professional help if needed.
DEFINITION

 This phase is sometimes erroneously

referred to as the ‘Exercise’ phase. The
duration of Phase 3 may vary from six to 12
weeks.

 It incorporates exercise training in

combination ongoing education and
with
psychosocial and vocational interventions.
 OBJECTIVES

 Functional goals – Exercise training under

supervision
 Psychosocial goals – Return to work, return
to hobbies and lifestyle, anxiety/depression
management
 Secondary preventive targets
COMPONENTS
• Clinical risk stratification is suitable for low
to moderate risk patients undergoing low to
moderate intensity exercise.
• Low level ETT and ECHO are recommended for high
risk patients and/or high intensity exercise.
• Vitals: PR, RR, BP, SpO2, ECG findings
• Respiratory, cardiovascular, examination
CNS system
• Weight
• Waist circumference
• Lipids
• Blood Glucose/HbA1C
Ischemic Risk
 Postoperative angina
 LVEF (EF <35%)
 NYHA grade III or IV CHF
 Ventricular tachycardia of fibrillation in the
postoperative period
 SBP drop of 10 points or more with
exercise
 Excessive ventricular ectopic with exercise
 Myocardial ischemia with exercise
Arrhythmic Risk
 Acute infarction within 6 weeks
 Active ischemia by angina or exercise
testing
 Significant left ventricular dysfunction
(LVEF
<30%)
 History of sustained VT
 History of sustained life-threatening SVT
 Initial therapy of a patient with a rate
adaptive cardiac pacemaker
 The Modified Borg RPE (rate of perceived
exertion) scale and % HRmax (220- age of the
person) are considered during prescription of
exercise.

 In low risk patients, a program to achieve 85%

of the maximum HR is safe. But in the
patients with risk of angina or arrhythmia,
achievement of HRmax as low as 60% is safe.
 Sing – Talk –Gasp Maximal
Test
10 very, very hard
9
Gasp: breathing heavily 8
7 very hard
6

5 hard
Talk: enough breath to carry a conversation 4 somewhat hard
3 moderate

2 easy
1 very
Sing: Enough breath to sing 0.5 easy
0 very, very
easy
*Modified Scale adapted by Borg
nothing
at all
 HEART FAILURE

 Criteria for exercise-

 Medically stable
 Exercise capacity >3 METS
 Exercise training-
 Prolonged Warm up and cool down
 Low intensities (40-60%)
 Increase duration as tolerated
 Maintain HR below 115 bpm
 Monitor RPE: fairly light
 Avoid isometrics
 May include light resistance
 EXERCISE MODALITIES IN
HEART FAILURE
(2013 C A N D I A N H E A R T F A I L U R E MANAGEMENT G U I D E L I N E )
Discharged with
Heart Failure NYHA I-III NYHA IV
Flexibility Exercises Recommended Recommended Recommended
Aerobic Exercises
• Suggested modality • Selected population only • Walk • Selected population only
• Supervision by an expert • Treadmill • Supervision by an expert
team needed • Ergocycle team needed
• Swimming

• Intensity Continuous training:

Moderate intensity:
• RPE scale 3-5,or
• 65-855 HRmax, or
• 50-75% peak VO2
Moderate intensity aerobic interval may be incorporated in
selected patients
• Intervals of 15-30 seconds with a RPE scale of 3-5
• Rest intervals of 15-30 seconds

• Frequency • Starting with 2-3 days/week

• Goal: 5 days/week
• Selected population only • Starting with 10-15 minutes • Selected population only
• Supervision by an expert • Goal: 30 minutes • Supervision by an expert
team needed team needed

Isometric/Resistance
Exercises

• Intensity • 10-20 repetitions of 5-10 pounds free weights

• Frequency • 2-3 days/week
 STOP EXERCISE

◦ Persistent dyspnea
◦ Dizziness/confusion
◦ Onset of angina
◦ Leg claudication
◦ Excessive fatigue, pallor, cold sweat
◦ Ataxia, incoordination
◦ Bone/joint pain
◦ Nausea/vomiting
◦ Systolic BP>200 mmHg, Diastolic BP >110
mmHg
◦ Significant changes in ECG
 Unstable angina
 Resting systolic BP (SBP) > 200 mm Hg or resting Diastolic BP (DBP)
> 110 mm Hg . Orthostatic BP drop of >20 mm Hg with symptoms.
 Critical aortic stenosis
 Uncompensated CHF.
 3rd degree atrioventricular (AV) block wihout pacemaker.
 Active pericaditis or myocarditis.
 Recent embolism
 Thrombophlebitis
 Resting ST-segment depression or elevation (> 2mm)..
 Metabolic conditions, such as uncontrolled DM,
 Patients must be regularly monitored for DM, HTN
control in very visit, and change in drug therapy
and exercise as needed. Blood lipids must be
monitored 2 months after initiation of drug
therapy.

 Diet modification, smoking cessation and weight

reduction, stress management must be
addressed.
 Recommended diet low in fat (especially saturated
fat), and high in complex carbohydrates.

 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 other risk factors.
 WEIGHT MANAGEMENT

 Goal: BMI 21-25 kg/m2 , waist < 35 inches in men and < 31 inches in
women.
 Intervention: Advice a reduction in total caloric intake, and increase in
energy expenditure through a combined program of diet, and exercise.
 Initially reduction of weight 10% from baseline is indicated. If successful,
then further reduction can be advised.
 Goal: Complete cessation
 Intervention: Provide individual education and counseling.
Encourage patient to quit in every visit.
 Provide nicotine replacement and pharmacological
therapy as appropriate.
 Although improvement in functional capacity and
the associated reduction in cardio-respiratory
symptoms may enhance a cardiac patient’s ability
to return to work.
 The time to return to work, after an MI can vary
greatly from about two weeks, to upwards of six
weeks.
 This phase constitutes the components of long-
term maintenance of lifestyle changes and
professional monitoring of clinical status.

 It is when patients leave the structured Phase 3

program and continue exercise and other lifestyle
modifications indefinitely.
 Maintenance of achieved functional status
 Return to work
 Return to hobbies and lifestyle modifications
 Secondary preventive targets
 The exercises need to be integrated into the patient’s lifestyle
and interests to assure compliance.
 The ongoing exercises should be performed at the target HR
for at least 30 minutes, three times a week, if at a moderate
level. If at a low level, exercises need to be performed five
times a week.
 The secondary prevention measures also need to be
integrated into the patient’s lifestyle.
 The continued control and monitoring of DM, HTN, lipids
must be ensured.
 Self care and self management in
emergency situations
 Family must help the patients to adhere to their long term
managements.
 Patients are often encouraged to join-local heart support
groups
 Communty exercise and activity groups community dietetic
and weight managent services.
 Smoking cessation services
 SPECIAL
CONDITIONS
 Full-level ETT should be done in order to determine the
maximum HR, and angina threshold.
 The program of rehabilitation can begin at phase III
(training).
 The primary goal of rehabilitation in this group of patients
is aimed at increasing work capacity and education in
primary/secondary prevention strategies.
Cardiac rehabilitation after CABG has two stages:
 Immediate postoperative period
 Later maintenance stage.

• In-hospital period lasts 5–7 days.

• At-home program is usually conducted as an outpatient
procedure, and intensity of exercise is determined
according to risk stratification.
 In valvular heart disease, the major problem is
often deconditioning along with CHF.
 In patients receiving surgical correction of the
valvular disease, a post-CABG-type program is
used.
 In uncorrected valvular heart disease with heart
failure, the program resembles the program for
CHF.
 Dynamic exercise is preferred with a target
HR 10 bpm. Isometric exercise should be
avoided where possible, and limited to 2-
minute intervals when performed.

 Unstable angina, decompensated CHF,

and unstable arrhythmias are
contraindications to cardiac rehabilitation.
 PACEMAKERS

 Should know setting for HR limit

 Use RPE
 ST segment changes may be common
 Avoid aerobic or strengthening exercises
initially after implant
 CARDIAC TRANSPLANT

 HR alone is not an appropriate measure of

exercise intensity (heart is denervated).
◦ Use RPE, METS, dyspnea scale, BP

 Use longer periods of warm-up and cool-

down because the physiological responses
to exercise and recovery take longer
 BENEFITS

 Reduces cardiovascular and total mortality

 Improves myocardial perfusion
 May reduce progression of
atherosclerosis when combined with
aggressive diet
 Improves exercise tolerance
without significant CV complications
 Improves skeletal muscle strength
and endurance in clinically stable patients
 Promotes favorable exercise habits
 Decreases angina and CHF symptoms