Cardiac

Rehabilitation

Presented by-
Dr. Jheelam Biswas
Budharapu
Resident, Phase A Rahul

52 group
Palliative Medicine, BSMMU
What is cardiac rehabilitation
 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.
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)
Phases of cardiac
rehabilitation
 Acute Phase (Phase I)
 Convalescent Phase (Phase II)
 Training Phase (Phase III)
 Maintenance Phase (Phase IV)
 Phase I
Acute phase
Definition
 Phase I relates to the period of
hospitalization following an acute cardiac
event.

 The duration of this phase may vary

depending on the initial diagnosis, the
severity of the event and individual
institutions, usually one week acute
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
 This phase 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
Exercise guidelines
 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, tearfulness, sleep disturbance,
irritability, anxiety, acute awareness of
minor somatic sensations or pains, poor
concentration and memory.

 Proper counseling must be done. Seek

professional help if needed.
 Phase III
Training Phase
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 with ongoing education and
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
Assessments before phase III
rehab
 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.
Assessments (cont…)
 Vitals: PR, RR, BP, SpO2, ECG findings
 Respiratory, cardiovascular, CNS system
examination
 Weight
 Waist circumference
 Lipids
 Blood Glucose/HbA1C
Risk stratification before exercise
 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
Risk stratification before 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
Exercise prescription
 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.
 Rate of Perceived Exertion (RPE)*
Sing – Talk –Gasp Test Maximal

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 easy
Sing: Enough breath to sing 0.5 very, very easy
0 nothing at all

*Modified Scale adapted by Borg

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 Candian Heart failure management guideline)

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
Contraindications of exercise
training
 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)..
Lifestyle modification
 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.
Nutritional Counseling
 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.
Smoking/ Tobacco cessation
 Goal: Complete cessation

 Intervention: Provide individual education

and counseling. Encourage patient to quit
in every visit.
Provide nicotine replacement and
pharmacological therapy as appropriate.
Return to Work
 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.
 Phase III
Maintenance Phase
Definition
 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.
Objectives
 Maintenance of achieved functional status
 Return to work
 Return to hobbies and lifestyle
modifications
 Secondary preventive targets
Exercise
 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.
Secondary prevention
 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.
Patient and family
responsibilities
 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
 community exercise and activity groups
community dietetic and weight
management services
 smoking cessation services.
Special conditions
Stable angina
 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.
Post-CABG
 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.
Valvular Heart Disease
 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.
Cardiomyopathy
 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
Thank You…