REHABILITATION MEDICINE

Cardiac Rehabilitation

INTRODUCTION Heart Failure

Comprehensive and Multidisciplinary approach focusing on: Table 2 Heart Failure Types
Systolic Dysfunction Diastolic Dysfunction
• Health education
• Impaired contractility • Impaired filling/relaxation
• Cardiac risk reduction • Etiology: Ischemic heart disease, • Etiology: HPN with LV
• Exercise protocols chronic HPN, dilated hypertrophy, restrictive and
• Stress management cardiomyopathy, and myocarditis hypertrophic cardiomyopathies,
• Thin/weak heart muscle fibrosis, amyloidosis, sarcoidosis,
• Low ejection fraction constrictive pericarditis,
• S3 gallop hemochromatosis, valvular
disease, and aging
• Stiff/thick heart muscle
• Normal ejection fraction
• S4 gallop

New York Heart Association (NYHA) Heart Failure Classification

• Class I
o No limitation of physical activity
o Ordinary physical activity does not cause symptoms
• Class II
o Slight limitation of physical activity
o Comfortable at rest
o Ordinary physical activity causes symptoms
• Class III
o Marked limitation of physical activity
o Comfortable at rest, but less than ordinary activity
causes symptoms
• Class IV
o Severe limitation and discomfort with any physical
activity
o Symptoms present even at rest

Pathophysiology
• The inability of the heart to provide sufficient output
to meet the demands of the body
• A variety of disorders can lead to low output or high
CARDIOVASCULAR CONDITIONS output failure
Coronary Artery Disease o Pulmonary and systemic venous congestion
• Manifested by: o Increased sympathetic nervous system activity
o Angina ▪ ADH secretion from the brain
o Dyspnea during exertion o Cardiac dilation and hypertrophy
• Caused by: o Neurohormonal responses worsens heart failure
o Flow limiting lesion or plaque due to atherosclerosis o Sodium and water retention
o Block due to a diffuse inflammatory process
▪ Increased preload
o Block due to an abnormal growth within the coronary
artery
▪ Increased afterload

Table 1 Established Risk Factors for Coronary Artery Disease Identified by the
Framingham Heart Study
Modifiable Risk Factors Nonmodifiable Risk Factors
Hyperlipidemia Age
Smoking Sex
Diabetes Family and/or personal history of
Hypertension coronary heart disease
Physical inactivity
Overweight/obesity
Diet high in carbohydrate and fat

Page 1 of 7
 REHABILITATION MEDICINE
Cardiac Rehabilitation

Table 3 Medications and Side Effects CARDIAC REHABILITATION

Possible S/E, Interactions, &
Medication Type Purpose
Special Instructions • Gold Standard of Care for cardiac patients
ACE Inhibitors To lower blood Dizziness, cough, low blood • Has 4 phases (according to Doc’s PPT)
and ARBs pressure and allow pressure. Kidneys and potassium
blood to flow more levels should be monitored with
o Phase I – In-patient program
easily from the heart blood tests. o Phase II-IV – Outpatient program
Antiarrhythmics To control irregular Depends on the class of drugs.
heartbeat Channel blockers can cause General Phases in Cardiac Rehabilitation
headaches, ankle swelling.
Amiodarone can increase
Phase I - Inpatient Program
sensitivity to sunlight and affect • Begins soon after a cardiac event - CCU/CTW/Gen Med
eyesight. It may be important to
monitor thyroid function and
• End when the patient is ready to go home
avoid grapefruit. • Low-level exercise and education for the patient and family.
Antiplatelet To thin the blood Stomach pain, headache,
Medications and help prevent dizziness, and breathing Acute period
and dissolve clots in difficulties. Side effects more
arteries and stents severe in patients with asthma and • Low intensity activities (1-2 METS)
allergies. Take with food. • Passive ROM (1.5 METS)
Aspirin To prevent and Stomach upset, headaches, and • Range of motion exercises
dissolve clots in the drowsiness. An allergic reaction
arteries could cause breathing difficulties. o Upper limb (1.5 METS)
Other severe side effects include o Lower Limb (2.0 METS)
blood in the stool or coughing • Avoid the following:
blood. Take with food to reduce
risk of upset stomach. o Isometrics (increases Heart rate)
Beta-Blockers To lower blood Dizziness, fatigue, dry mouth slow o Raising legs above the heart (increase preload)
pressure and heart heart rate, weight gain, cold o Valsalva Maneuvers (promotes arrhythmia)
rate hands and feet. May reduce side
effects if taken with food.
Clot Busters To restore blood Bleeding, abnormal heartbeat, Table 4 Example Protocol often used for Phase I
(Thrombolytics) flow during a heart new clotting.
attack or stroke and
to break up blood
clots in the legs
(deep vein
thrombosis)

Coumadin To prevent blood Bleeding, vomiting or coughing

(anticoagulant) clots from forming in blood, blood in stool, headaches,
the arteries and and dizziness. Do not take with
heart aspirin unless directed by doctor.

Digoxin To improve your Side effects are more common if

heart's ability to too much is taken and may include
pump blood and nausea, vomiting, diarrhea, Subacute period
helps to slow down stomach pain, loss of appetite,
an irregular unusual tiredness, and slow • Transfer to ward
heartbeat heartbeat. Take on an empty • Activities or exercises within the 3 to 4 METS range
stomach, high-fiber foods can
decrease its absorption.
• ROM with intensity gradually increase by speed or duration.
o Weights may be included (1 to 2 lbs.)
Smoking To make it easier to See "SecondsCount Guide to • Early ambulation on flat surfaces starting at 1 mph to
Cessation stop smoking Medications That Help you Quit
Medication Smoking"
increase by 0.5 mph as tolerated until 2.5 mph
o 1 mph (slow stroll) is around 1.5 to 2 METS
Statins To lower your Muscle pain, liver damage, o 2mph (regular slow walk ) is around 2- 3 METS
cholesterol level and memory loss, nausea, gas,
reduce the risk of diarrhea, constipation, rash
o Wheelchair propelling is around 2 -3 METs
heart attacks and • Activities of daily living should be patterned after the
strokes number of METS being tolerated and closely monitored
Diuretics (Water To lower blood Frequent urination, dehydration, Phase II - Outpatient Hospital-based
Pills) pressure blurred vision, fatigue, rash, loss of
appetite. Monitor blood pressure • ≥2 weeks after discharge (1 day, 1 week to 8 weeks)
and kidney function. • Dietitians, social workers, pharmacists, clinicians & others
Vasodilators To widen the blood Headaches, nausea, and dizziness • Emphasizes monitored exercise
vessels to increase (especially older people). Do not
the flow of blood drink grapefruit juice. May interact • Education and lifestyle management.
and lower blood negatively with cold medicine • Phase that starts as soon as the patient is discharged
pressure
• Closely monitored with ECG for dysrhythmias
• Intensive risk factor modification

Page 2 of 7
 REHABILITATION MEDICINE
Cardiac Rehabilitation

Phase III - Community-based or Clinic or Polyclinic
• Ongoing exercise & education - health facilities
• Maintenance program
• ECG Monitoring done ONLY if patient have signs and
symptoms that warrant monitoring
• Monitor if:
o With low ejection fraction
o Abnormal blood pressure response to exercise
o History of arrhythmias
o ECG ST segment depression during low level of exercise
• Endurance training
• Risk factor monitoring is continued
Phase IV - Community-based
• Without supervision - community center
• Patients continue to apply what they have learned
• Home-based exercises
• Continue risk factor modification
• Constant follow up to maintain newly acquired risk behavior
modification
• Monitoring of weight, lipid control, blood pressure,
glycemic control
Exercise Physiology in Cardiac Rehabilitation
• Total Oxygen Consumption (VO2)
o Oxygen consumption of the whole body
o Represents work of the peripheral skeletal muscle
• Aerobic capacity (VO2 Max)
o Measure the work capacity of an individual
o As individual increases the workload or exercise, the
VO2 increases in a linear fashion until it reaches a
plateau despite further increases in the workload
• Myocardial oxygen consumption: (MVO2)
o Actual oxygen consumption of the heart
o Measured directly with cardiac catheterization
o Not practical
o Estimated using rate pressure product, calculated as (HR
X Systolic Blood Pressure )/100
o Rate pressure product- refers to work of the heart
o Cardiac Output= Heart rate (HR) X stroke volume
• Metabolic Equivalent (MET)
o Amount of energy used by an individual at REST
o Equivalent to basal metabolic rate (1 kcal/min or 3.5 ml
O2/kg/min)
Who can avail of cardiac rehabilitation?
• Patients who have had:
o Myocardial infarction
o Coronary artery bypass (CABG) or angioplasty
o Heart failure and arrhythmia
o Dilated cardiomyopathy
o Non ischemic heart diseases
o Concomitant pulmonary disease
o Pacemaker
o Heart valve repair or replacement
o Aneurysm or organ transplantation
Absolute Contraindications for Entry Into Inpatient And
Outpatient Exercise Testing
• Unstable angina
• Resting systolic blood pressure of greater than 200 mmHg
or resting diastolic pressure of 110 mmHg or greater
• A significant drop of 20 mmHg in resting systolic blood
pressure from the patient’s average level that cannot be
explained by medication
• Moderate to severe aortic stenosis
• Uncontrolled atrial or ventricular arrhythmias
• Acute systemic illness or fever
• Uncontrolled tachycardia (>100 Beats per min)
• Symptomatic congestive heart failure
• Third degree heart block without pacemaker
• Active pericarditis or myocarditis
• Recent embolism
• Thrombophlebitis
• Resting ST wave displacement (> 3 mm as seen on ECG
• Uncontrolled diabetes
• Orthopedic problems that would prohibit exercise

Main Goals of Cardiac Rehabilitation

• Improve exercise tolerance
• Decrease symptoms
• Improve blood lipid levels
• Cessation of Smoking
• Stress reduction and management
• Improve psychological well being
• Reduction of overall risk of mortality and morbidity
• Safety

Page 3 of 7
 REHABILITATION MEDICINE
Cardiac Rehabilitation

ACTIVITY CLASSIFICATION

Exercise Testing Protocols

EXERCISE TESTING
• An objective tool for assessment
• Help define future interventions
• Endpoints for testing can be:
o Submaximal-rate at 70% of maximal heart rate
▪ Can also be measured using the Borg scale
▪ Usually used for high risk patients
o Symptom limited end points
▪ Usually used for lower risk patients
▪ Terminated if such symptoms appear
• Amputee (lower limb) use upper limb ergometers
• Treadmill testing provides physiologic stress
• Cycle ergometers use less space and less costly than
treadmill
• Balke-Ware protocol
o Increase metabolic demands by 1 METs per stage
o Used for high risk patients with functional capacity of
less than 7 METs
• Bruce Protocol
o Metabolic demands of > 2 METs per stage
o Appropriate for low to intermediate risk patients with
functional capacity greater than 7 METs

Page 4 of 7
 REHABILITATION MEDICINE
Cardiac Rehabilitation
• Naughton treadmill protocol
o Low intensity exercise protocol that has incremental
increases in workload
o Longer exercise duration than Bruce Protocol
Exercise Prescription
• Exercises should specify what type of exercise in terms of
intensity, duration, and frequency
• Type of exercise
o Exercises for cardiovascular conditioning should be
isotonic, rhythmic, and aerobic
o Large muscles are used
o No isometrics
o Aerobic activity should be included
o Warm up and cool downs should be incorporated
o Resistance exercises may also be added
▪ Resistance exercises are proven to be safe and
effective method to improve strength and
cardiovascular endurance in low risk patients
▪ Surgical and myocardial infarction patients should
wait 3 to 6 weeks before beginning resistance
training
• Exercise intensity
o Exercise intensity is usually prescribed as some
percentage of the maximum capacity obtained on
exercise testing (e.g., O2 consumption, heart rate,
workload, or degree of exertion
o For reconditioned cardiac patient, exercise even at 40 to
50 % of Max VO2 may result in improvement.
o Intensity is based on the target heart rate
▪ 70 to 80% of clearance heart rate
▪ Clearance heart rate is the clinical maximum HR
attained on stress test
→ Target HR is the following:
(a) Beginning range=Clearance HR X 0.7
(b) End range=Clearance HR X 0.85
▪ For cardiac patient, 70% of Maximum HR attained
on exercise stress test
▪ For healthy patient 70 to 85% of predicted age
adjusted Maximum HR
→ Average Maximum = 220 – age
• Borg Scale
• Conversational exercise level:
o Patient should be able to talk while exercising (talk test).
o Conversational level is of adequate intensity to induce a
training effect but allows the exerciser to talk without
becoming excessively out of breath while exercising
• Duration and Frequency of exercises
o Duration is dependent on level of fitness and the
intensity of exercise
o Usual duration when 70% of max HR is 20 to 30 mins at
conditioning level
o Poorly conditioned individual , daily exercise as low as 3
to 5 minutes can bring about improvement.
o Higher intensities of exercise, duration may be reduced
to 10 to 15 minutes
• Format of exercise session
o Warm up phase before training
▪ Warm up phase is usually at a lower intensity level of
exercise and gradually increasing to the prescribed
intensity
o Cool down phase after training
▪ Gradual reduction in exercise intensity tallow
gradual redistribution of blood from extremities to
other tissues to avoid sudden reduction in venous
return
▪ Avoids sudden physiologic hypotension
Page 5 of 7
 REHABILITATION MEDICINE
Cardiac Rehabilitation

CARDIAC REHABILITATION OF SPECIAL GROUPS Stroke

Heart transplant • Acute MI and acute stroke
• Consider: • CABG and acute stroke
o Transplanted heart still denervated, hence loss of vagal • Complications include:
inhibition to the SA node o Hypertension
o Physiologic response is different o Angina
o High resting heart rate o Myocardial infarction
o Lower peak exercise heart rate o CHF
o Post exercise recovery rates show a slow return to o Rhythm disturbance
resting level • Treadmill ambulation if tolerated
o Lower work capacity, cardiac output, systolic BP and • Stationary bicycle/ergometer modified for involved leg
total O2 consumption is lower at maximum effort o Portable leg ergometers that allow for seating in a
o Pre transplantation, rehabilitation strength training may wheelchair or armchair
enhance preoperative and post operative recovery • Arm ergometers modified for involved hand or use one
o Atherosclerosis may be accelerated following transplant handed arm ergometers
• Heart rate guidelines are not used • Telemetry monitoring
o Intensity of exercises is based on: • Hemiplegic ambulation compared to Normal ambulation
o BORG RPE scale 11 to 14 o Speed : 40% to 45 % slower
o Percentage of Max Oxygen consumption or maximum o Energy cost is at 50% to 65 % or higher
workload performed on stress test
o Anaerobic threshold Elderly population
o Duration frequency and types of exercises follow other • Consider other morbidities such as:
types of cardiac problem o Frailty
o During exercise testing, ischemia is not present as o Pulmonary conditions
angina, o Arthritis
▪ ECG changes and other symptoms should be o Depression
followed o Cognitive impairments
o Diabetes
Coronary Artery Disease With Other Comorbidities • Evaluate also the parameters associated with the above
Amputee conditions
• May be due to diabetes, atherosclerotic disease causing • Severely deconditioned patients may not be able to do
limb loss treadmill test: use the 6 Minute walk test
• Level of amputation: higher the level , the higher the oxygen
consumption Table 6 6-Minute Walk Test (Normal Range of Scores)
• Pharmacologic stress testing using dipyridamole of patients Distance covered by Distance covered by
Age
unable to perform any exercise stress test Women in meters Men in meters
• Upper limb ergometer stress test-determine safety and 60 – 64 498 – 603 558 – 673
ability of mobility 65 – 79 457 – 580 512 – 640
• Telemetry monitoring during ambulation in all periods 70 – 74 439 – 571 498 – 622
Table 5 Energy Cost of Ambulation for the Amputee 75 – 79 398 – 535 430 – 585
% Increase 80 – 84 352 – 454 407 – 553
Amputation METS
in Energy 85 – 90 311 – 466 347 – 521
No prosthesis with crutches 50% 4.5
Unilateral BK with prosthesis 9 – 28% 3.3 – 3.8 Dysrhythmias, pacemakers
Unilateral AK with prosthesis 40 – 65% 4.2 – 5.0 • Rarely are participants in Cardiac Rehab
Bilateral BK with prosthesis 41 – 100% 4.2 – 6.0 • Majority are Non-life threatening
BK plus AK with prosthesis 75% 5.3 • Implantable cardioconvertor – Defibrillator patients may
Bilateral AK with prosthesis 280% 11.4 need longer ECG monitoring
Unilateral hip disarticulation with
• Exercise testing to help guide the adjustment of pacemakers
82% 5.5
prosthesis
Hemipelvectomy with prosthesis 125% 6.75

Page 6 of 7
 REHABILITATION MEDICINE
Cardiac Rehabilitation

Heart Failure
• Low intensity exercises are advocated for compensated HF
• Continuous Aerobic training using treadmill or cycle
ergometers
• Low intensity exercises of around neck 40% VO2 Max is
effective
• Initial duration of 15 minutes of aerobic activity is usually
adopted as a baseline for deconditioned patients

References:
• Cardiac Rehabilitation PPT (Canvas)
• DeLisa’s Physical Medicine and Rehabilitation, Principles and Practice, 5th ed.

@titsayy

Page 7 of 7