Cardiac Rehabilitation

Dr .Mohamed Gad Allah

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

Definition

• Phase I refers 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 institution

• Usually one week acute event /post-operative

• The classic Wenger cardiac rehabilitation program was to get
individuals from bed rest to climbing 2 flight stairs in 14 days

• Under current practices, clinicians have modified the classic program

of cardiac rehabilitation in of 3-5 days.
Cardio-protective therapies
• Anti-platelet therapy
• Lipid-lowering therapies
• Beta-blockers (post myocardial infarction)
• ACE inhibitors /ARBs (angiotensin receptors blockers)
• Calcium channel blockers
• Anticoagulant 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 ˃40mg/dl, TC
˂200mg/dl ,TG˂ 150 mg/dl

Intervention: If LDL ˃ 100mg/dl advice nutritional counselling, weight

reduction and statins are prescribed
IF HDL˂ 40mg/dl advice exercises and smoking cessation.
Hypertension management
• Goals : 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

• Goals : near normal fasting plasma glucose (˂7 mmol/l) and near
normal HbA1c (˂7 )

• Intervention : appropriate hypoglycemic therapy e.g diet

modification, oral hypoglycemic agents and/or insulin
Survival kit before discharge

• Clear information about medications

• Clear advice on managing chest pain and reassurance

• Advice and information on what and when they can do (work ,travel,
exercise etc. )
Respiratory pressure meter
Introduction to Cardiac rehabilitation
• What does cardiac rehab involve?
• Cardiac rehabilitation does not change your past, but it can help you to
improve your future.
• Cardiac rehabilitation is medically supervised programed designed
to improve your cardiovascular health if you have experienced heart
attack, heart failure, angioplasty or heart surgery.
Cardiac rehab has three equally important
parts:
• Exercise counseling and training: Exercise gets your heart pumping
and your entire cardiovascular system working. You’ll learn how to
get your body moving in ways that promote heart health.
• Education for heart-healthy living: A key element of cardiac rehab is
educating yourself: How can you manage your risk factors? Quit
smoking? Make heart-healthy nutrition choices?
• Counseling to reduce stress: Stress hurts your heart. This part of
cardiac rehab helps you identify and tackle everyday sources of stress
Cardiac rehab is a team effort
• You don’t need to face heart disease alone. Cardiac rehab is a team
effort.
• You’ll partner with physicians , nurses, pharmacists – plus family and
friends – to take charge of the choices, lifestyle and habits that affect
your heart.
 Cardiac rehabilitation team
The Doctor of Physical therapy(Exercise physiologist) and cardiologist who refers
the patients and give specialty medical care for your heart.

Nurses. Rehab nurse or occupational therapist

Nutritionist. Psychologist, social worker or other mental health

Phases of cardiac rehabilitation
• Acute phase(phase I)
• Convalescent phase(phase II)
• Training phase(phase III)
• Maintenance phase(phase IV)
 Phase I

Immediate inpatient phase

Length of hospital stay is commonly 3-5 days for uncomplicated MI (no

post-MI angina, malignant arrhythmias, or heart failure)
Role of physiotherapy in post operative cardiac patients

General Aims
• to relieve postoperative pain
• to remove secretions
• to relieve dyspnea and decrease the work of breathing
• to improve pulmonary functions
• to improve exercise tolerance and delay time of fatigue .
 Methods of Rehabilitation

• Traditional techniques • Devices

1- Air way clearance 1- incentive spirometer
maneuvers 2- inspiratory muscle trainer
2- Breathing exercises 3- positive end expiratory pressure
(diaphragmatic breathing
exercise)
3- Active ROM exercises for
upper and lower limb
4- Walking in corridor
5- Ascending and descending
stairs
 P.T intervention in days

• Immediate postoperative (IPO)

after weaning of mechanical ventilation
Air way clearance techniques will be beneficial in form of vibrating patient’s rib cage
and teaching patient how to cough .

1st post operative day

air way clearance maneuvers from prone position
Cough with the head of bed reclined 45⁰ for maximum 10 min
diaphragmatic breathing exercises from 3- 4 series 20 repetitions
assisted active exercises of ankles and wrists 3 series of 10 rep .
 2nd post operative day
• Airway clearance maneuvers in prone and semi-lateral position

• Cough assist in a sitting position for 10 min

• Diaphragmatic breathing exercises 3-4 series of 20 repetitions in

sitting position

• Active assisted exercises of upper and lower limb ( flexion –

extension of elbow and elevation of the arms 2 series for 10

repetitions for each exercise and the same for the knee .
 3rd post operative day

• The same steps of 2nd day PO

• Then do active free exercises of elbow and knee 2 series 10
repetitions with respiration
• Walking in place for 5 min

4th post operative day

During this phase :

the patient is in the medical ward
Like 2nd PO + walking for 10 min
 5th post operative day

• Airway clearance maneuver when necessary

• Assist cough 10 min
• Respiratory exercises
• walking in the hospital corridor for 10 min
• Walking up and down 1 flight of stairs .
Devices could be used postoperative

Incentive spirometer
(I.S)

Inspiratory muscle
trainer (IMT)

Positive end expiratory

pressure (PEEP)
IMT (inspiratory muscles training)
Consists of :
 mouthpiece
 Valve
 Load calibrated springs
 Outer sleeve
- It is adjusted according to the
PI max (sustained maximal
inspiratory pressure )
- It creates negative pressure
inside chest during inspiration
 The Respirex 2 incentive
The threshold inspiratory spirometer with a DHD
muscle trainer inspiratory muscle trainer inserted
in-line
High intensity 60% of PI max low intensity 15% of PI max

For optimal results of IMT

Training will be 3 times /10 weeks
Duration : 5-30 min or 30 deep breath
Inspiration is maximal and forced
Expiration is slow and long
 Benefits
• Improve the inspiratory muscle strength ( diaphragmatic thickness and
FRC(functional residual capacity)
• sustained maximal inspiratory pressure
• Ejection Fraction
• Blood supply to resting and exercising limbs
• Forced vital capacity
• Peak VO2
• 6 min walk distance test
• Improves dyspnea
• Increase resistance to fatigue and improve exercise tolerance
1-Goals of phase I (Exercise/ activity goals and outcomes.)

1-Initiate early return to independence in activities of daily living; typically

after 24 hours or until the patient is stable for 24 hours monitor activity
tolerance.

• Return to the activities of ADL.

• Counteract deleterious effects of bed rest: reduce risk of thrombi, maintain muscle
tone, reduce orthostatic hypotension, maintain joint mobility.

• To decrease anxiety and depression.

• To determine the effects of prescribed medications during activities.

cont. Goals of phase I (Exercise/ activity goals and outcomes.)

2-To initiate patient and family education

• To outline the course of cardiac rehabilitation and plan for resumption

of life at home.

• To modify risk factor of atherosclerosis as dietary changes, stop

smoking and stress management.

• Help allay anxiety and depression.

• Provide medical surveillance.

 2-Exercise/activity guidelines.

• a. Program components: ADLs, selected arm and leg exercises, early

supervised ambulation.

• b. Initial activities: low intensity (2-3 METs) progressing to 3-5 METs by

discharge; RPE in fairly light range; HR increase of 10-20 bpm above
resting, depending on medications.

• c. Short exercise sessions, two to three times a day; gradually duration is

lengthened and frequency is decreased.
 2-Exercise/activity guidelines.

• d. Postsurgical patients.

(1) Typically are progressed more rapidly than post-MI.

(2) Greater emphasis is placed on upper extremity ROM.

(3) Lifting activities are restricted, generally for 6 weeks.

3. Patient and family education goals.

• a. Improve understanding of cardiac disease, support risk factor

modification.
• b. Teach self-monitoring procedures, warning signs of exertional
intolerance; e.g., persistent dyspnea, anginal pain, dizziness.
• c. Teach concepts of energy costs, fatigue monitoring, general activity
guidelines, activity pacing, energy conservation techniques; home
exercise program (HEP).
• d. Teach cardiopulmonary resuscitation (CPR) .
• e. Provide emotional support.
4. Home exercise program (HEP) .
a. Low-risk patients may be safe candidates for unsupervised exercise at
home.
(1) Gradual increase in ambulation time: goal of 20-30 minutes, one to
two times per day at 4-6 weeks post-MI.
(2) Upper and lower extremity mobility exercises.
b. Elderly, home bound patients with multiple medical problems may
benefit from a home cardiac rehabilitation program.
c. Patients should be skilled in self-monitoring procedures.
d. Family training in CPR and AED (automated external defibrillator);
emergency lifeline for some patients.
 The deconditioning effects of prolonged bed rest :

• Decrease in the physical work capacity.

• Decrease in the strength of body musculature.
• Decrease in Lung volumes and capacities.
• Orthostatic hypotension
• Decreased in the circulating blood volume
• Decrease in the concentration of serum protein
• Negative nitrogen and calcium balance.
 Clinical Indications and
Contraindications for Inpatient and
Outpatient Cardiac Rehabilitation
Indications

• Medically stable post myocardial infarction (MI)

• Stable angina
• Coronary artery bypass graft surgery (CABG)
• Percutaneous transluminal coronary angioplasty (PTCA) or
other trans catheter procedure
• Compensated congestive heart failure (CHF)
• Cardiomyopathy
• Heart or other organ transplantation
• Other cardiac surgery including valvular and pacemaker
insertion (including implantable cardioverter defibrillator
[ICD])
Indications
Peripheral arterial disease (PAD)

• High-risk cardiovascular disease (CVD) ineligible for surgical intervention

• Sudden cardiac death syndrome

• End-stage renal disease

• At risk for coronary artery disease (CAD), with diagnoses of diabetes mellitus,
dyslipidemia, hypertension, obesity, or other diseases and conditions

• Other patients who may benefit from structured exercise and/or patient education,
based on physician referral and consensus of the rehabilitation team
Contraindications for entry inpatient and outpatient
exercise program:
Exercise prescription depends on the patients individual status and level
of recovery.
• Unstable angina
• Resting systolic BP (SBP) >200 mm Hg or resting diastolic BP (DBP)
>110 mm Hg that should be evaluated on a case-by-case basis
• Orthostatic BP drop of >20 mm Hg with symptoms
• Critical aortic stenosis (i.e ., peak SBP gradient of >50 mm Hg with an
aortic valve orifice area of <0.75 cm2 in an average size adult)
• Acute systemic illness or fever
• Uncontrolled atrial or ventricular dysrhythmias
• Uncontrolled sinus tachycardia (> 120 bpm)
Cont.
• Uncompensated congestive heart failure (CHF)
• Third-degree atrioventricular (AV) heart block without pacemaker
• Active pericarditis or myocarditis
• Recent embolism
• Thrombophlebitis
• Resting ST segment depression or elevation (>2 mm)
• Uncontrolled diabetes
• Severe orthopedic problems that would prohibit exercise
Other metabolic conditions, such as acute thyroiditis, hypokalemia,
hyperkalemia, or hypovolemia
 Criteria for termination of inpatient exercise programs:
So these patients will need further diagnosis evaluation and change in
the exercise prescription.
1. Excessive fatigue.
2. Failure of the monitoring equipment
3. Peripheral circulatory insufficiency as pallor, cyanosis , significant
exertional dyspnea, ataxia, confusion , nausea and headedness .
4. Inappropriate bradycardia (drop of the heart rate more than 10 b/m
with increase or no change in the exercise intensity)
5. Hypertensive response to exercise
S.B.P raises about 50 mmHg from resting , more than that is
hypertensive response, also less than indicates shock. The D.B.P raises
very little about 15 mmHg from resting, more than that up to 20 mmHg
is considerate critical.
 Cont,,
6-Exercises induced hypotension (drop of S.B.P more than 20 mmHg)

7-Exercises induced angina.

8-Exercise induced left bundle branch block

9-Exercise induced 2nd or 3rd degree of A-v block.

10-S.T Segment displacement about 3 mm horizontal or down sloping from rest.

11-Ventricular tachycardia.

-Three or more consecutive premature ventricular contractions

-Multifocal premature ventricular contractions

N.B:
1. In patients with normal cardiovascular system , the HR will be
abnormally high at rest and during low intensity exercises, but will be
appropriate at higher work.

2. Exercise has better effects on lipoproteins than diet.

3. Exercise helps to open collaterals.

Principles of training :

• The exercises in phase 1 should be low intensity , gradually increasing

the metabolic cost, safe and of dynamic nature.

• Activities are described in METs or metabolic equivalent.

• METs: measures energy requirements for basal homeostasis when the

subject is in the resting position ( a wake or sitting position ) METs=
3.5:4 ml or O2/kg /minute.

• Most inpatient programs begin with activities 2-3 METs and progress
to 5- METs before discharge.
Specific exercise progressions within program :
1-Passive to active Resistive ex.

2-Distal to intermediate to proximal joint exercises.

3-From extremities to trunk.

4-From supine to sitting then standing.

5-Progressive increase in the ambulation distance then stair climbing (down ) and
then progression to stair up.

6-Initially, the patents does the ex for short duration and high frequency ( Several
times) per day until the patient's condition improves and vice versa will occur
For the post surgical patients :

• Ambulation begins from the first day for post surgical patients.

• Activity progression is faster and the patient works at slightly higher

intensity.

• Emphasis is placed on the upper extremity R.O.M to counteract

shoulder and chest pain.
Exercise prescription in METS
Step number METs Activity Activity
description for description for
ischemic patient surgical patient
Step 1 1-1.5 ARM for all Up in chair two
extremities from times assistant
supine walk in the room
Step 2 1-1.5 Repeat Repeat assistant
walk in the room
and corridor
Step 3 1-2 Repeat with mild Repeat with
resistance increase distance
Step 4 1.5-2 ARM for all Repeat
extermities from
sitting and
breathing ex
Step 5 1.5.2 Repeat with mild ARM for all
reistance and exremitis from
walking up to 50 standing with 1-2
feet pound wt &
laterial binding
and trunk twist
Cont,,
Step 6 1.5-2 ARM for all Repeat 5
extermitts from
standing with 1-2
pound wr&
walking more
than 100 feet
Step 7 1.5-2.5 Repeat 6 & Repeat 6 &
walking more walking down
than 200 feet two flight
Step 8 2-2.5 Repeat 7 & Repeat 7 &
walking more walking down
than 300 feet two flight
Step 9 2.5-3 Repeat 8 & slight Up one flight and
knee bind and walking down
walking down one flight
one flight
Step 10 3-3.5 Repeat 9 & Repeat 9
walking down
two flight
Step 11 3.5 Repeat 10 & Repeat 10
waking down one
flight & up one
flight
Monitoring exercise responses In phase I :
1)The heart rate:
• It is simply easily measurable index of the myocardial oxygen
consumption and myocardial work.
• There is a linear relationship between H.R and the intensity of
workload.
• In certain cases, we can’t depend on H.R as monitoring for ex
response because in these cases, it is affected by certain drugs as anti-
hyperextension drugs, B- Blockers, as these drugs cause slow resting
H.R which rise very little during exercise.
• We take H.R before during and immediately after the exercise as it
will drop rapidly as recovery progresses.
• The activity of phase I are of low intensity so H.R will rise very little
to be equal H.R standing resting HR+ 10 or 20 beat / min
Cont,,

So according to this equation the exercise should be terminated if:

a)The H.R during ex .exceeds this value.

b)If the H.R decreases or fails to increase as the exercise insanity

increases.

• N.B: Anxious patients have a small anticipatory rise of H.R before ex

but this should level off once the ex. Begins.
2) Blood pressure :
• It is index of myocardial O2 consumption , taken before , during and
immediately after ex within the first 15 second . Rate pressure product
= H.R.X.S. B.P.
• A linear increase in S.B.P is expected with increase in the work
intensity, but The D.B.P changes very little form rest to the maximum
work load
• Abnormal blood pressure response to exercise
• 1)Hypertensive blood pressure (as mentioned before )
• 2)Failure of S.B.P to be rise as the intensity of work increases.
• 3)Progressive fall of S.B.P about 15 or 20 mmHg that may indicate
shock.
Rate pressure product allows you to calculate the internal workload or hemodynamic response.

Hemodynamic Response RPP

High more than 30000
High Intermediate 25000 - 29999
Intermediate 20000 - 24999
Low Intermediate 15000 - 19999
Low 10000 - 14999
• 3)ECG:
• Ventricular dysrhythmias are closely correlated to coronary artery
disease and sudden death.
• It includes:
• 1)Premature ventricular contraction (PVCS)
• 2)Ventricular tachycardia
• 3)Ventricular fibrillation.
• Loss serious dysrhythmias include.
• Premature atrial contraction
• Paroxysmal atrial tachycardia
• Atrial fibrillation
• Atrial flutter
• S-T segment changes:
• The magnitude (Amount) and the type of deviation (elevation or depression) will
depend on:
• a-The severity of the underlying coronary artery disease.
• b-The level of exertion.
• c-Some patients have S-T segment flat at rest but as the exertion increases, S-T
segment becomes depressed. But the other have depression at rest and post
recovery period.
• d-The deviation is measured by drawing line from one PQ junction to the next PQ
junction – this is called base line or isoelectric line and the point at which S-T
segment changes its slope called j point, the deviation is measured by the distance
from the baseline to (J) point.
• e-The depression can be down sloping, Horizontal, up sloping. the down sloping
depression is more serious than the horizontal.
 4)Signs and symptoms of exertional intolerance :

1. Excessive fatigue

2. Persistence dyspnea .

3. Severe leg claudication

4. Ataxia

5. Anginal pain

6. Dizziness or confusion

7. Pallor or clod sweating

The responses that may be delayed as long as several hours include.

• Prolonged fatigue.

• Insomnia

• Sudden weight gain due to fluid retention.

If the patient exhibits the symptoms of exertional intolerance :

(The session should be terminated)

• Reduce the intensity of ex in the next session.

• Report this information to the physician in medical report .

5) Rating of perceived exertion ( R.P.E)or (Borg scale):
• - It is subjective method to quantify the effort during ex.
• - It is used as the patients comprehension improves so he can monitor
himself during ex.
• - Both local symptoms (as muscle aches, cramps, pain or fatigue) and
central symptoms (feeling of being tired, breathlessness) contributes
to the over all feeling of work performance.
• - It is closely correlated to H.R and VO2 max ( aerobic capacity)
• -It is Commonly used when the patient under the effect of mediations
that decrease H.R.
 Borg RPE Scale Borg CR10 Scale

Scoring Level of Exertion Scoring Level of Exertion

6 No Exertion 0 No Exertion

7 Extremely Light 0.5 Very very Slight

8 1 Very Slight

9 Very Light 2 Slight

10 3 Moderate

11 Light 4 Somewhat Severe

12 5 Severe

13 Somewhat Hard 6

14 7 Very Severe

15 Hard (Heavy) 8

16 9 Very very Severe

17 Very Hard 10 Maximal

18

19 Extremely Hard

20 Maximal Exertion
Supervision of exercise program:

• It is important to make sure that the patients does the ex. Correctly as
any alteration in how the exercise is done will change the predicted
metabolic value of the activity, and can produce undesired
cardiovascular response. The dynamic nature of the activity and
rhythmic breathing should be stressed to avoid breathing holding,
isometric exercise and Valsalva maneuver.
Valsalva maneuver:

• It means holding of breathing then forced exhalation with nose, mouth

and glottis closed.

• It can lead to:

a)increase in the intrathoracic and intra-abdominal pressure.

b)Impairs the venous return and decreases C.O.P the patients with
ischemic left ventricle cannot tolerate those changes and will be
susceptible for dysrhythmias and angina.
The benefits of warm up :

• For gradual circulatory adjustment

• To decrease the incidence of arrhythmia.

• To modify the muscle temperature to prepare the muscle for more

vigorous ex.

• To minimize oxygen deficit and lactic acid accumulation.

• The walking (conditioning stimulus )
• a)Warm up by doing the previous ex. then walk at slow pace for
minutes

• b)Check your warm up pulse rate, then walk at faster pace for minutes
at your prescribed H.R (within the limits of target heart rate)

• c)Check your pulse and cool down by walking at slow pace for
minutes.
• Cool down benefits:
• By doing the previous Ex. Or walking at slow pace.

1-To maintain the systemic blood flow at a level that doesn’t increase the myocardial O2
demand.

2-Also adequate circulation to enhance removal of lactic acid so hastens recovery.

3-Enhancing venous return by the massaging effect of contracting and relaxing muscle on
the veins.

4-The ventricle filling increased and stroke volume is augmented in accordance with frank .
Starling law.
Sternal precautions
5 Ways to Maintain Sternal Precautions

• Sternal precautions mean that patient must limit the amount of force and motion
around shoulders and arms. This prevents sternal incision from separating and
keeps the risk of infection at a minimum and lasting from four to six weeks.
1-Patient use legs to stand up from a chair. Many people push with their arms
when rising from a seated position. Doing so may disrupt healing of sternal
incision. When rising from a chair patient use legs.

Technique: Simply slide heels back so the feet were positioned well under
the knees, and place hands on thighs. Lean forward with the nose over the
toes, and rise up, taking care not to push or pull with arms.
2-Roll shoulders to stretch. There's nothing like that first stretch in the
morning when place both arms overhead. But if patient do this after
open heart surgery, patient may be breaking the rules of sternal
precautions. Instead of reaching overhead to stretch, try rolling
shoulder blades forward and back with arms by side. This helps to
prevent excessive separation of breastbone and chest incision.
Roll shoulders to stretch
3-Ask patient to use a pillow to splint sternal bone when
coughing. Coughing can be painful after open heart surgery, and
coughing forcefully can place stress and strain through the sternum.

• Technique: Place a pillow over chest and hug it tightly if patient feel
the need to cough or sneeze after open heart surgery
4-Patient will ask for help when lifting items. Lifting heavy items is a
no-no after open heart surgery. If patient under sternal precautions,
make sure to ask for help when lifting items. Don't worry--there will be
a time when patient was able to lift things again, but patient must wait
until his physical therapist allows him to do so.
5-Patient will use the leg roll technique when getting out of bed. When
rising from bed, many people use their arms and hands to pull
themselves up. If patient was maintaining sternal precautions, he must
not do this.