Cardiac rehabilitation

Jargons
• VO2Max
• FITT
• RPE
• METs
• CO
• SV
• EF
• HRR
• HRmax
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Cardiac Rehab defined:
• A progressive program
with a goal of helping
patients restore and
maintain optimal health
while helping to reduce
the risk of future heart
problems.
 REHABILITASI
JANTUNG
Menurut World Health Organisation
Adalah sejumlah kegiatan yang dibutuhkan untuk
menjamin pasien penyakit jantung pada suatu kondisi
fisik, mental, sosial yang terbaik sehingga mereka dapat
dengan usaha mereka sendiri memperoleh kembali
kehidupan seoptimal mungkin dimasyarakat dan
menjalani hidup secara aktif.
Rehabilitasi Jantung konsep mobilisasi
dini.

Keuntungan Mobilisasi dini

• memulihkan kondisi fisik pasien,

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• mencegah tirah baring lama,
• menurunkan angka kesakitan dan
kematian
• meningkatkan kualitas hidup
 TUJUAN REHABILITASI JANTUNG

● Memulihkan kondisi fisik pasien agar sesegera

mungkin kembali kepada kehidupan yang aktif
dan produktif
● Meningkatkan kualitas hidup
Medical
Psychological
Social
Health Ser vice
Medical Goals :
- Meningkatkan fungsi jantung
- Mengurangi resiko kematian mendadak
dan infark berulang
- Meningkatkan kapasitas kerja
- Mencegah progresivitas yang mendasari
proses atheroskeloris.
- Menurunkan mortalitas dan morbiditas
Psychological goals :
- Mengembalikan percaya diri
- Mengurangi anxietas and depressi
- Meningkatkan managemen stres
- Mengembalikan fungsi seksual yang baik
Social Goals
- Bekerja kembali
- Dapat melakukan aktifitas
kehidupan sehari hari secara mandiri
Health Ser vice Goals :
- Mengurangi biaya medis
- Mobilisasi dini dan segera pasien bisa
pulang
- Mengurangi pemakaian obat-obatan
- Mengurangi kemungkinan dirawat
kembali
 Phases of care
Phase I in-hospital
assessment and mobilization, education on risk factors and a
discharge plan

Phase II post discharge

exercise, risk factor reduction, reduce morbidity/mortality,
improve function and quality of life and build confidence

Phase III outpatient programme

(Phase IV long-term maintenance in community)


REHABILITASI JANTUNG
PRE-OPERASI
➢ Edukasi
➢ ROM Exercise
➢ Chest physical therapy
➢ Latihan bagaimana
melakukan transfer dan
ambulasi yang akan
dilakukan setelah operasi
jantung stabil
TAHAPAN PROGRAM
PASCA-OPERASI
Fase I : Fase perawatan RS
( Inpatient )
Fase II : Fase setelah pulang RS
( outpatient )
Fase III : Fase pemeliharaan
( Maintenance )
 FASE – I
INPATIENT
o Mencegah tirah baring lama
o Mobilisasi dini
o Mampu melakukan aktivitas 3-4 Mets
1. Exercise :
● Bad exercise
● Chest physical teraphy
● Terapi inhalasi
● Mobilisasi dini-ambulasi (latihan
jalan)
Self care
● 2. Konseling
● Edukasi
● motivasi melakukan exercise
● perencanaan home program
 Hari 1 :

• Dalam kodisi stabil aktivitas dimulai di

• atas tempat tidur
• kemudian dilanjutkan untuk duduk dikursi
• samping tempat tidur
• Latihan lingkup gerak sendi dan pernafasan
• Activitas 1 –22:mets
Hari

• Latihan berjalan disekitar bed perawatan

• Latihan Lingkup gerak sendi anggota gerak
• Chest Therapy
• Activitas 1 – 3 Mets
 Hari ke 3 :
• Latihan jalan diruang rawat 100 – 200 m,
frekuensi 3 kali sehari
• Monitoring denjut jantung
• Aktivitas 1 – 4 mets

Hari ke 4 :
• Latihan jalan 200 – 300 m
• Latihan lgs dan pernafasan dada
• Aktivitas 2 – 4 mets

Hari ke 5 :
• Latihan stretching
• Latihan jalan ditingkatkan
• Aktivitas 3 – 4 mets
• Edukasi terhadap aktivitas
dirumah
• Six minute walk test
 FASE – II
OUTPATIENT

● Dimulai sesegera mungkin 1 mg seteleh pulang

RS
● Memperbaiki kapasitas fungsional dan
endurance
● Menghilangkan cemas dan depresi
● Perubahan gaya hidup
● Mampu melakukan aktivitas 6 Mets
● Selama 4-8Latihan
minggu: (Susan Garrison, 2001)
•Senam / stretching & erobic
•Jalan kaki / jogging
•Terapi relaksasi
• Melakukan tes uji jalan 6 menit
• Latihan erobik 3 – 4 kali seminggu selama 4 – 8 mg
• Target latihan pasien mampu jalan 3000 m/30 mnt
 • Akhir fase II melakukan treadmill tes untuk evaluasi

FASE – III
MAINTANCE

• Melanjutkan latihan fase II, dilakukan out

door
• Meningkatkan endurance & performernce
• meningkatkan kualitas hidup
• Mampu melakukan aktivitas 6-8 Mets
Latihan :
• Lamanya 3-6 bulan
•Senam / stretching & erobic
•Latihan beban
•Jalan kaki / jogging
•Terapi relaksasi
•Edukasi / konseling
 •Akhir fase III dilakukan treadmill test

Cardiac rehabilitation

For all cardiac Interdisciplinary

patients who would
benefit team of
MD professionals
SpKFR, SpJP
ExPT ACLS, ACSM

ADA,involved in
RN ACLS, Cv experience
RD Cv experience
Others Healt edu., OT, Pharmacist, etc
 rehabilitation

Facility
Typical Class
• At least 4:1 patient/staff ratio
• Hook up, 10 min. warm-up, 45 minutes cardiovascular
training, 10 minutes cool down
• Education classes
 Benefits of exercise
Improved exercise
capacity
•Increased cardiovascular endurance is the main aim
•Endurance training = activity using large muscle
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groups, can be sustained for a prolonged period and is
rhythmic and aerobic resulting in an increase in
maximal oxygen uptake.
•Maximal oxygen uptake (VO2 max) is limited centrally
by cardiac output and peripherally by the capacity of
muscles to extract oxygen from the blood.
VO2 max adalah kapasitas maksimum tubuh untuk
menyalurkan dan menggunakan oksigen saat olahraga
 Improved exercise
capacity
Central changes
In healthy people = endurance training causes increase in
CO as a result of increase in SV. Achieved by:

•Increased left ventricular mass and size

•Increased total blood volume
•Reduced peripheral resistance
 Improved exercise
capacity
Peripheral changes
Training-induced changes in muscles:

•Increased number and size of mitochondria

•Increased oxidative enzyme activity
•Increased capillarization
•Increased myoglobin
 Improved exercise
capacity
Increase in VO2 max
In cardiac patients increase in VO2 max mostly because of
peripheral changes – high intensity exercises needed for
central changes – inappropriate.

Repeated submaximal daily activities – less physiological

stress (decreased heart rate, blood pressure and plasma
catecholamine concentrations)
 Risk factor modification
The factors that contribute to disease, can influence
progression
and future events.
Exercise in healthy people Exercise reduces triggers in
cause: cardiac events:

• Raised metabolic rate • Prevents thrombus formation

• Increased synthesis of HDL • Improves endothelial
• Improved insulin sensitivity function
• Decreased blood pressure • Reduces potential for serious
arrhythmias
 Exercise prescription
• Individuality

• Progressive overload

• Regression – “use it or lose it”

• Specificity – FITT-principles
 FITT-principles
F: 1-2x per week rehabilitation class
2x per week home-based exercises
walking the other days

I: aerobic exercises, 40-65% HRR or 60-75% HRmax

resistance training, 10-15 repetitions to moderate fatigue,
8-10 exercises, 2-3 times per week
 FITT-principles
T: Aerobic, interval approach

T: 5-10 min, progress to 20-30 minutes

warm-up 15-20 minutes
cool down > 10 minutes
 Exercise intensity
Maximum or symptom-limited exercise ECG

10-20 beats below

60-75% of HRmax heart rate
that elicits symptoms
 Exercise intensity
No ECG

Age-adjusted 40-65% of HRR

prediction
• HRmax
Highest number of heart beats per minute (bpm) an
individual can achieve in an all-out effort. It is unique to the
individual due to age, heredity, and fitness level.

• HRR
Difference between resting heart rate (HRrest) and
maximum heart rate (HRmax).

HRR = HRmax - HRrest

Karvonen formula:
Exercise HR = % of target intensity (HRmax – HRrest) +
HRrest
 Exercise intensity

•Borg 15-point scale or Borg CR10 scale

•MET’s
(metabolic equivalents)
Functional capacity excellent (>10 METS), good (7 METs to 10 METS),
moderate (4 METs to 6 METS), poor (<4 METS).
Perioperative cardiac and long-term risks are increased in patients unable to
perform 4 METs of work during daily activities.
 Warm-up
•Preparation for activity
•15 minute
•Low impact, dynamic movements of large muscle groups
•Take all major joints through normal ROM
•Will delay onset of ischaemia by allowing enough time
for coronary blood to flow in response to greater
myocardial workload
•Lessen risk of arrhythmias
•Heart rate 20 bpm lower than lower end of prescribed
training heart rate after warm-up ( 3 or 10-11 on Borg)
 Aerobic exercises
•Continuous or interval approach

•Interval approach – total volume of work done more,

stimulus for physiological change is greater

•Individualisation – duration of station, intensity, period

of rest and overall duration (increase duration before
intensity)
 Aerobic exercises
Exercise in lying not advised because:

•Older patients have difficulty with transfers

•Increase in venous return – increases pre-load and
myocardial load – increased risk of arrhythmias and
angina
•Orthostatic hypotensive episodes
 Resistance training
Not previously used in cardiac patients:

•increased blood pressure

•increased myocardial workload
•reduced ejection fraction and increased incidence in
arrythmias, BUT also
•increased diastolic pressure with better myocardial
perfusion
•10-15 repititions to moderate fatigue, 8-10 exercises
 Cool down
10 minutes of movements of diminishing intensity and
passive stretches of major muscles because:

•increased risk of hypotension

•in older patients heart rate takes longer to reach pre-
exercise rates
•raised sympathetic activity after exercise – arrhythmias

Patient observation for 30 minutes after exercises

 Programme implementation
In-hospital
Acute MI, coronary bypass surgery, unstable heart failure

•First 24-48 hours - breathing exercises

simple arm and leg ROM exercises
limited self-care activities

•Over the next 2-3 days - sit out of bed

take short walks
shower and dress
 Programme implementation
In-hospital and post-discharge
•By discharge patients should know signs and symptoms of
excessive exertion and rate level of exertion
•Home exercise programme for first 6 weeks, mostly walking
•Contact and telephonic follow-ups with rehabilitation
services

FITT:
•F + Time = 5-10 minutes, 2-3x daily and later
5-20 minutes, 1-2x daily
•I = RPE < 11
 Programme implementation
Outpatient exercise programme

•Patient should be seen by physician or cardiologist

before exercising
•Patient safety during exercising very important
•Assessment of heart rate and blood pressure at rest and
during exercising, RPE etc.
 Risk factors for exercise
Patients should not exercise if not feeling well, symptomatic or
unstable on arrival or with the following:

• Fever, acute systemic illness • Symptomatic hypotension

• Unresolved/unstable angina
• Blood pressure systolic >
200 mmHg and diastolic >
110 mmHg
• Unexplained drop in blood
pressure
• Tachycardia
• Arrhythmias
• Breathlessness, lethargy,
palpitations, dizziness
• Unstable heart failure, weight
gain > 2 kg in 2 days
• Unstable/uncontrolled
diabetes
 Programme management
•All staff competent, appropriate skills and training,
regularly updated

•Appropriate emergency equipment, checked regularly,

policy for handling emergency situations, appropriate
venue

•Patient education important - aims and exercise goals

safety
use of equipment
 Programme management
Patients and families should know the following:

•Signs and symptoms of exertion

•Importance of warm-up and cool-down
•Caution with isometric activities
•Issue e.g. excessive heat/cold, dehydration
•Avoid exercising after heavy meal, if ill an when tired
•Remain for 30 min after exercise for observation
•Excessive use of arm/upper body work results in higher
systolic and diastolic blood pressure than the same work
by legs
 Long-term community based exercise
programme

•Patient must be able to manage himself regarding

exercises

•Community-based instructor
Exercise Training and Heart Failure
Recommendations - Rehabilitation and Exercise in HF
Exercise Training in Patients with Heart Failure

We recommend that all patients with stable New Strong Recommendation

York Heart Association class I-III symptoms be Moderate Quality
considered for enrolment in a supervised Evidence
tailored exercise training program, in order to
improve exercise tolerance and quality of life .

Values and Preferences:

This recommendation places a high value on improvements in non-morbid
outcomes and recognizes that not all patients will be able to participate in a
structured exercise training program due to patient preferences or availability of
resources.

Heart Failure Guidelines

Recommendations - Rehabilitation and Exercise in HF
Exercise Training in Patients with Heart Failure

We recommend that an assessment of clinical Strong Recommendation

status by a clinician experienced in the Low Quality Evidence
management of heart failure patients be
completed prior to considering an exercise
training program.

Values and Preferences:

This recommendation places a high value on clinician’s assessment of both the clinical
stability of a patient and their appropriateness to start exercise, recognizing that most
patients will be eligible to participate.

Heart Failure Guidelines

 Practical Tip
Rehabilitation and Exercise in HF
Exercise Training in Patients with Heart Failure

Adherence to an Exercise Program

1. Frequent reinforcement, including letters, phone calls and home visits, may
enhance adherence to exercise.

2. Identifying and addressing patient-specific barriers may aid in the uptake of

exercise for patients.

3. Once a home-based program is initiated, more frequent follow-up visits and

occasional supervised “refresher” sessions to answer questions, review concerns
or modify the training program may give patients the guidance needed to ensure
that home-based cardiac rehabilitation is successful.

Heart Failure Guidelines

 Recommendations -
Rehabilitation and Exercise in HF
Cardiac Rehabilitation Programs for Patients with Recently Decompensated or
Advanced Heart Failure

We recommend that gradual mobilization and/or Strong Recommendation

small muscle group strength/flexibility Low Quality Evidence
exercises be considered as soon as possible
either alone or in combination for patients with
New York Heart Association class IV symptoms
or recently decompensated heart failure. This
should be considered only in consultation with
an experienced heart failure team.

Values and Preferences:

This recommendation places high value on initiating mobilization and therapy early (even
if only limited exercises are prescribed) in order to prevent further decline of muscle
function, improve function during day to day activities and provide a baseline from which
to add further exercise modalities.

Heart Failure Guidelines

 Practical Tip
Rehabilitation and Exercise in HF
Cardiac Rehabilitation Programs for Patients with Recently Decompensated or
Advanced Heart Failure

1. Selected patients may benefit from limited exercise therapy, such as lower-
extremity or inspiratory muscle strengthening, directed towards alleviating
symptom of muscle fatigue.

Heart Failure Guidelines

 Practical Tip
Rehabilitation and Exercise in HF
Cardiac Rehabilitation in Heart Failure with Preserved Ejection Fraction

1. Until data specific for patients with heart failure and preserved ejection
fraction are available, exercise programs using a similar approach to patients
with impaired systolic function may be considered in patients with heart failure
and preserved ejection fraction.

Heart Failure Guidelines

 Practical Tip
Rehabilitation and Exercise in HF
Cardiac Rehabilitation in Patients with Cardiac Resynchronization Therapy and
Implantable Cardioverter Defibrillators

1. Exercise training is safe and not associated with an increased risk of ICD
therapy. The maximal target HR should be at least 20 beats below the ICD
intervention heart rate to avoid inappropriate ICD shocks.

Heart Failure Guidelines

 Practical Tip
Rehabilitation and Exercise in HF
Exercise in Frail Senior with Heart Failure

1. Frail seniors with heart failure should be offered multi-component (endurance

and resistance, balance) tailored exercise programs appropriate for their
comorbidities.

Heart Failure Guidelines

Recommendations - Rehabilitation and Exercise in HF
Exercise Prescription and Exercise Modalities in Heart Failure

We recommend moderate-intensity continuous Strong Recommendation

aerobic exercise training (e.g. brisk walking, Moderate Quality
jogging, and cycling) at rate of Modified Borg Evidence
Rating Perceived Exertion (RPE) scale 3-5, 65-
85% maximum heart rate, or 50-75% of peak
VO2 in patients with heart failure.

Values and Preferences:

This recommendation places a high value on using commonly available measurements to
assist in developing the exercise prescription. The priority is safety, hence, if a patient has a
history of ICD discharges, exercise should be avoided if a short loss of consciousness is
dangerous, i.e. swimming and activities associated with an increased risk of falling.

Heart Failure Guidelines

 Practical Tip
Rehabilitation and Exercise in HF
Exercise Prescription and Exercise Modalities in HF

Strength Training
1. For strength training, the use of light (5-10 lbs) free weights for 10-20 repetitions 2
to 3 times per week may improve muscle tone and strength.

Heart Failure Guidelines

 Practical Tip
Rehabilitation and Exercise in HF
Exercise Prescription and Exercise Modalities in HF

Interval Training
1. Interval training sessions should use 15-30s exercise intervals (RPE 3-5) with rest
intervals of equal duration and may last 15-30 seconds.

Heart Failure Guidelines

 Practical Tips
Rehabilitation and Exercise in HF
Exercise Prescription and Exercise Modalities in HF

Aerobic Exercise Training Intensity

1. The Modified Borg RPE scale and % HRmax are easier to use in practice
than equations based on heart rate reserve (HRR) or measurement of peak
VO2.

Heart Failure Guidelines

 Rate of Perceived Exertion (RPE)*
Sing – Talk –Gasp Test
Maximal

10 very, very
hard
Gasp: breathing
9
heavily
8
7 very
hard
6
Talk: enough breath to carry a conversation
5
hard
4 somewhat
Sing: Enough breath to sing hard
3
moderate
*Modified Scale adapted by Borg
2
easy
Heart Failure Guidelines
 Table: Exercise Modalities According to Clinical Scenario

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 (see text) • Ergocycle team needed (see text)
• 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 (see text) team needed (see text)
Isometric/Resistance
Exercises

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

• Frequency • 2-3 days/week