CARDIAC REHABILITATION

DEFINATION

o The term cardiac rehabilitation refers to 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 processes, thereby reducing morbidity and mortality.

(AMERICAN HEART ASSOCIATION 2018)

 Cardiac rehabilitation (CR) is a multi-factorial and comprehensive intervention in secondary
prevention, designed to limit the physiological and psychological effects of cardiovascular disease,
manage symptoms, and reduce the risk of future cardiovascular events. CR is shown to reduce
mortality, hospital readmissions, costs and to improve exercise capacity, quality of life and
psychological well-being and is recommended in international guidelines for patients with a ST-
elevation acute myocardial infarction, a non ST-elevation myocardial infarction and stable coronary
artery disease.
( EUROPEAN SOCIETY OF CARDIOLOGY,2017)
 Cardiac rehabilitation is a comprehensive exercise, education, and behavior modification program
designed to improve the physical and emotional condition of patients with heart disease.
Prescribed to control symptoms, improve exercise tolerance, and improve overall quality of life.
The primary goal of cardiac rehabilitation is to enable the participant to achieve his/her optimal
physical, psychological, social and vocational functioning through exercise training and lifestyle
change.
(AMERICAN ASSOCIATION OF CARDIOVASCULAR AND PULMONARY REHABILITATION (AACVPR)
2007)
who should included in Cardiac Rehabilitation ?

Post MI
Post CABG
Congestive Heart Failure
Post PTCA
Heart Transplant
Pacemaker
Diagnosed with CAD
Any other Cardiac surgery
COMPONANTS OF CARDIAC REHABILITATION
MEMBERS OF CARDIAC REHABILITATION

PHARMACIST

PSYCHOLOGIS NURS
T
E

PATIEN
T&
SOCIAL FAMILY DIETICIAN
WORKER

PHYSIOTHERAPI CARDIOLOGIST
ST
 Goals

Cardiac rehabilitation meets the emotional, educational and physical needs of patient and their family in
acute hospital phase, though outpatient care and long term follow up in community.

Decrease cardiac morbidity and relieve symptoms

Promote risk modification and secondary prevention
Decrease anxiety and increase knowledge and self confidence
Increase fitness and the ability to resume normal activities
Elements of Exercise Prescription in CR

Rule out contraindications for exercise

Risk stratification and monitoring
Type, Intensity, Duration, Frequency,
Progression, Precaution
Warm up - Cool down
Stop with Signs & Symptoms of cardiovascular insufficiency or angina
Proper : Time, Place, Equipment, Clothes, Shoes
 Risk Stratification (AACVPR, 2005)
Low Risk
Uncomplicated MI , CABG, angioplasty, or
atherectomy
Functional capacity ≥6 METs 3 or more weeks
after clinical event
No resting or exercise-induced myocardial
ischemia manifested as angina and/or ST
segment displacement
No resting or exercise-induced complex
arrhythmias
No significant left ventricular dysfunction
(EF ≥ 50%)
Moderate Risk
Functional capacity <5-6 METs 3 or more weeks
after clinical event
Mild to moderately depressed left ventricular
function (EF 31- 49%)
Failure to comply with exercise prescription
Exercise-induced ST-segment depression of
1-2mm or reversible ischemic defects
(echocardiography or nuclear radiography)
High Risk
Severely depressed LV function (EF ≤ 30%)
Complex ventricular arrhythmias at rest or
appearing or increasing with exercise
Decrease in systolic blood pressure of >15mm Hg
during exercise or failure to rise consistent with
exercise workloads
MI complicated by CHF, cardiogenic shock, and/
or complex-ventricular arrhythmias
Patients with severe CAD and marked (>2mm)
exercise-induced ST-segment depression
 New York Heart Association (NYHA) Functional Classification

NYHA Class Symptoms

Cardiac disease, but no symptoms and no limitation in ordinary physical activity, e.g. no shortness of breath when
I
walking, climbing stairs etc.

II Mild symptoms (mild shortness of breath and/or angina) and slight limitation during ordinary activity.

Marked limitation in activity due to symptoms, even during less-than-ordinary activity, e.g. walking short distances
III (20–100 m).
Comfortable only at rest.

IV Severe limitations. Experiences symptoms even while at rest. Mostly bedbound patients.
Phases of Cardiac Rehabilitation

PHASE I: Acute care phase / In Patient Period (average 3-5)

PHASE II: Convalescent phase / Immediate post-discharge (2-6 weeks)

Phase III: Exercise training Phase / Supervised outpatient programme (6-12 weeks)

Phase IV: Maintenance phase

PHASE I: Acute care phase / In Patient Period (average
3-5 days)

Inpatient cardiac rehab uses a team approach based on activity progression, patient education, and
hemodynamic and ECG monitoring, together with medical and pharmacological management.

The role of the physical therapist is to monitor activity tolerance, prepare for discharge, educate the
patient to recognize adverse symptoms with activity, support risk factor modification techniques,
provide emotional support and collaborate with other team members.

GOAL IS EARLY MOBILISATION

Vital sign monitoring occurs before and after and if possible during activity.

Intensity of the activity

Borg RPE Scale - fairly light range
(OR)
1-2 METs
(OR)
↑ HR = 10-20 bpm (with or without Beta Blocker)

Duration
Intermittent training
Bouts lasting 3-5 min
Rest Periods 1-2 min (Always shorter than exercise bout)
Total duration = up to 20 min
Frequency
Early Period (1-2 days) = 3-4 times/day
Late Period (from day 3 onwards) = 2 times/day
 Inpatient Cardiac Rehabilitation Program

CCU – ESSENTIAL BEDREST

level 1 (1-1.5 METs)

Evaluation and patient education

Arms supported for meals and ADLs

Bed exercises and dangle with feet supported (If CPK have peaked and patient has no complications)

Education
Introduction to inpatient cardiac rehab and role of physical therapy
Monitored progression of activity . .
Home exercise/activity guidelines/outpatient cardiac rehab
 SITTING-LIMITED ROOM AMBULATION

Level 2 (1.5-2 METs)

Sitting 15-30 min, 2-4 times/day

Leg exercises

Commode privileges

Reclining upright chair

Limited ADL

Limited supervised room ambulation for small uncomplicated MI

Education
Identification of CAD risk factors
Concept of "healing interval" and need to pace activities
 ROOM-LIMITED HALL AMBULATION

3 Level (2-2.5 METs)

• Room or hall ambulation up to 5 min as tolerated 3-4 times/day

• Standing leg exercises optional
• Sit on side of bed or in bathroom to wash (per discretion nurse/PT)
• Bathroom privileges
• Independent or assisted ambulation in room or hall as advised by PT

Education
• Size of infarct and how it relates to the need for gradual resumption of activities
• Impact of exercise on reducing the patient's risk factors
• Teach use of Borg's Scale for Rating of Perceived Exertion and appropriate parameters with activity
 PROGRESSIVE HALL AMBULATION

Level 4 (2.5-3 METs)

• Hall ambulation 5-7 min as tolerated 3-4 times/day

• Standing trunk exercises optional
• Independent or assisted ambulation in hall as advised by PT

Education
• Teach pulse taking and appropriate parameters with activity
• Reinforce benefits of outpatient cardiac rehabilitation
 PROGRESSIVE HALL AMBULATION

Level 5 ( 3-4 METs)

• Hall ambulation 8- 10 min as tolerated

• Arm exercises optional
• Standing shower
• Independent hall ambulation as advised by PT

Education
Written home exercise/activity guidelines reviewed
Patient given written information on outpatient cardiac rehab
 STAIR CLIMBING

Level 6 (4-5 METs)

• Progressive hall ambulation as tolerated .

• Full flight of stairs (or as required at home) up and down one step at a time

Education
• Answer patient's questions
• Check for understanding of activity guidelines
PATIENT OUTCOME

• No systolic drop in BP > 1 0 mm Hg or increase > 30 mm Hg

• No HR increase > 12 if beta blocked, or no HR increase > 20 if not beta blocked
• No complaints of dizziness, lightheadedness or angina
• Perceived exertion < 13/20
AT TIME OF DISCHARGE

At the time of discharge a patient should understand about symptom recognition and appropriate activity
guidelines.

It is crucial that the patient be aware of and recognize, cardiac symptoms and understand the action to take if
they occur.

During first 4-6 weeks of post MI healing phase, physical activity involves a gradual increase in ambulation time,
with a goal of 20 to 30 minutes of ambulation 1 to 2 times per day at 4 to 6 weeks post MI.
 PHASE II: Convalescent phase / Immediate post-discharge (2-6
weeks)

Patients commonly undergo a symptom-limited maximal stress test (ETT) at 4 to 6 weeks post-MI.

Based on the results of the tests, either positive (+) for ischemia or negative (-) for ischemia, an supervised
exercise prescription is prescribed.

Symptom limited exercise testing before exercise prescription

Low to Moderate intensity exercises

Supervised / Regular monitoring

Goals

Provide patient and family education

Enhance CV function, physical work capacity, strength endurance and flexibility
Prepare patient to return to work
Improve QOL
Risk stratification
Prepare patient for long term exercise
Exercise Program

Warm up
Aerobic work out
 Intensity- HR +20 /30 or at RPE of 11-13
 Duration -10- 30 mins
 Frequency -3-5 times per week
Cool down
 Recommended ECG monitoring

lowest risk
Monitored-6 to 18 sessions
Up to 30 days post-event

Moderate risk
Monitored-12 to 24 sessions
up to 60 - 90 days post-event

Highest risk
monitored -18 to 24 sessions
for 90 days or more post-event
 PHASE III : Exercise training Phase / Supervised outpatient
programme (6-12 weeks)

This phase concentrates in maintaining and improving both CV and

muscular endurance
Increase in exercise capacity
Ensure continuity of exercise program with transition into home
environment
Relieve anxiety and depression
Modify and control risk factors
Goals

Appropriate patient monitoring and supervision

Return patient to pre-morbid vocational &/or recreational activities

Promote total conditioning including aerobic and resistance exercises

Who can participate ?

Patients completing phase 2

Patients with CAD risk factors

Healthy individuals interested in maintaining physical fitness

Principles of Exercise Prescription

Exercise test before participation

An individualized exercise prescription for aerobic and resistance training should

be obtained that is based on evaluation findings, risk stratification

Exercise prescription should specify duration, intensity, frequency and modalities

Include warm up, cool down and flexibility exercise

Principles of Exercise Prescription

According to FITT principle, exercise prescription will be prescribed

Frequency
Moderate intensity aerobic exercise - 5 day/week
(OR)
vigorous intensity aerobic exercise - 3 day/week
 Type
The aerobic exercise portion of the session should include rhythmic, large-muscle-
group activities.

The different types of exercise equipment may include:

• Arm ergometer
• Combination upper/lower extremity ergometer
• Upright and recumbent cycle ergometer
• Rower
• Stair climber
• Treadmill for walking
 Time (Duration)

• Warm-Up Exercises (10-15 mins)

- Low Intensity (≤ 40% HRR), ROM exercises, Stretching

• Conditioning / Aerobic / Circuit Training Exercises (20-60 mins)

- The goal for the duration of the aerobic conditioning phase is generally 20-60
minutes per session. After a cardiac event, many patients begin with 5-10 minute
sessions with a gradual progression in aerobic exercise time of 1-5 minutes per
session or an increase in time per session of 10% to 20% per week.

• Cool-Down Exercises (5-10 mins)

- Stretching, Low intensity exercise, shavasana
 Intensity

HRmax = 220-Age

According to Karvonan’s Formula:

Target HR (THR) = [(HRmax - HRrest) × 60-80% intensity] + HRrest
(OR)
Target VO₂max = VO₂max × 60-80% intensity
(OR)
Target MET = [(VO₂max)/3.5 ml/kg/min] × 60-80% intensity
(OR)
RPE = 12-15 (somewhat hard to hard )
 Phase IV : Maintenance Phase (6month & more)

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 programme and continue exercise and other lifestyle
modifications indefinitely.

This may be facilitated in the CR unit itself or in a local leisure center.

Alternatively, individuals may prefer to exercise independently and Phase 4 may involve helping them set a safe
and realistic maintenance programme.
Goals

Maintenance of achieved functional status

Return to work – Return to hobbies and lifestyle modifications

Secondary preventive targets

Prescription of Exercises

Depends on patients functional status and prognosis

Intensity
60 - 80% of VO2 max

70 - 85% of HRR
RPE 12 - 15 (somewhat hard to hard)
MET

Type
Aerobic training and resisted exercises
Duration
Desired 30 - 60 min continuous workout
Intermittent workout
Exercises bouts of 15 - 20 min
Frequency
One session/day
3 - 4 days/week
Progression to Maintenance phase

Guidelines to progress to unsupervised or minimally supervised program

Functional capacity  8 METS
Appropriate hemodynamic response to exercise
Appropriate ECG response
Adequate management of risk factor intervention strategy and safe exercise participation
Demonstrated knowledge of disease process, abnormal signs and symptoms, medication
use and side effects
Resistance Training
General Principles

Contraindications similar to aerobic programs

Generally require moderate to good LV function and exercise capacity > 5 METs without Sign &
Symptoms

Not recommended for high risk patients

After 2 - 3 weeks post MI and 4 - 6 weeks post surgery

Normally begin resistance program 2-3 weeks after initiating aerobic program
Exercises Prescription

Intensity
Initially start with 1 set of 10-15 reps
Can engage in other forms like springs, Theraband
Moderate fatigue
Check rate pressure product (RPP)

RPE: 11-14
Exercises Prescription

Duration
15 - 20 min per session

Progression
1 - 2 Kg/ week for upper limb
3 - 5 Kg / week for lower limb
Safety precautions
Movements should be rhythmical, Performed at moderate-to-slow controlled speed, With a
normal breathing pattern while lifting

Do repetitions rather than single maximal lifts

Do unilateral rather than bilateral movements when possible

Avoid overhead lifting Rest as needed, do not rush the circuit

Avoid exertion

Adequate rest periods

Special Considerations
 Hypertension
Aerobic exercise training leads to reductions in resting BP of 5 to 7 mm Hg in individuals with hypertension.
Exercise training also lowers BP at fixed submaximal exercise workloads.

Frequency: Aerobic exercise on most, preferably all days of the week;

Resistance exercise 2–3 d/week

Intensity: Moderate-intensity aerobic exercise (i.e., 40% to <60% HRR) supplemented by resistance
training at 60% to 80% 1-RM

Time: 30–60 min/day of continuous or intermittent aerobic exercise. If intermittent, use a minimum of 10-minute
bouts accumulated to total 30–60 min/day of exercise. Resistance training should consist of at least one set of
8-12 repetitions.

Type: Aerobic activities such as walking, jogging, cycling, and swimming. Resistance training programs should
consist of 8 to 10 different exercises targeting the major muscle groups.
 Patients with a Sternotomy

For 5 to 8 weeks after cardiothoracic surgery, lifting with the upper extremities should be restricted to 5-8
pounds (2.27–3.63 kg).

Range of motion (ROM) exercises and lifting 1-3 pounds (0.45–1.36 kg) with the arms is permissible if there is
no evidence of sternal instability, as detected by movement in the sternum, pain, cracking, or popping.

Patients should be advised to limit ROM within the onset of feelings of pulling on the incision or mild pain.
 Recent Pacemaker/Implantable Cardioverter
Defibrillator Implantation

Pacemakers may improve functional capacity as a result of an improved HR response to exercise.

The upper HR limit of dual-sensor rate responsive and pacemakers should be set 10% below the ischemic
threshold (i.e., the 10% safety margin).

When an ICD is present, exercise training intensity should be maintained at least 10 beats/min below the
programmed HR threshold for defibrillation.

To minimize the risk of lead dislocation, for 3 weeks after implantation, all pacemaker patients should avoid
activities that require raising the hands above the level of the shoulders.
 Cardiac Transplantation

Exercise prescription for these patients does not include use of a THR. For these patients, the clinician and
cardiac rehabilitation professional should consider

A. an extended warm-up and cool-down if limited by muscular deconditioning;

B. using RPE to monitor exercise intensity; and

C. incorporation of stretching and ROM exercises. However, at 1 year after surgery, approximately one third of
patients exhibit a partially normalized HR response to exercise and may be given a THR based on results from a
graded exercise test (GXT)