Cardiac Rehabilitation

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Cardiac Rehabilitation is the process of
restoring psychological, physical, and social
functions in people with manifestations of
coronary artery disease

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 Indications

MI and CABG
• LVD

• CCF
• Heart Transplantations
• Exercise induced ischemia
• Dysrhythmias
• Pace makers
• Coronary Angioplasty
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 Phases
Phase I – Inpatient Phase ( Till Discharge)

Phase II – Early Out Patient, Clinic or Home Based

Commence with in 3 weeks of Discharge
Last up to 3 months

Phase III – Late Out Patient, Community Based or

Home Based

Phase IV- Community based Maintenance Phase

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 Phase I

(In patient Phase)

Acute
Mobilization

Counter Deconditioning and Prepare patient for ADL

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 Acute Phase

Physical therapy goals

Surgical treatment
Preoperative pulmonary education
Mucus Clearance; Post Pulmonary Complications

Non-surgical treatment
Mucus Clearance
Ventilation

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 End Criteria

• No excess mucus retention and no atelectasis

No Pulmonary Problems
• Patient is hemodynamically and treatment stable
• No severe rhythm disorders or conduction
abnormalities.

Non-surgical treatment

• Patient
is hemodynamically stable
• Enzyme levels decreasing
• No severe rhythm disorders or conduction
abnormalities.
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 Contraindications for entry to
mobilization phase
• Unstable Angina
• Resting BP > 200 / 100 mm Hg
• Orthostatic BP
• Moderate to severe aortic stenosis
• Uncontrolled Dysrhythmias
• Tachycardia
• Systemic illness
•DVT
•Resting ST displacement
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 Mobilization phase

Physical therapy goals

• ADL
• Prepared for Phase II or
Independent

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 Surgery

• Nature of operation
• History-taking
•Time on respirator • Assessment
• clinical information

• Medication
Analysis

Combination of preoperative and postoperative

higher risk

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 Treatment plan

Improve ventilation Improve mucus removal

- maximum inspiration effective coughing and

-chronic obstructive blowing
pulmonary disease pressed- forced expiration
lip breathing techniques
Advice manual compression
Patient
Maximum inspiration five
time per hour
Nurse
- change position in bed
- mobilization
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 End Criteria

ADL activities
Moderate Aerobic capacity > 3 METs

Evaluation method
History
Risk Factor Check List

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 Phase II

• Progressively Improves Functional capacity

• Lower Cardio Vascular risk factors
• Prepare the for a return to his / her vocation

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Minimum information Required

• Medical diagnosis

• Relevant cardiac information, as decided by the

physician, including details of
- hemodynamic stability

- the location and extent of the infarction

- exercise testing results including ECG findings

(e.g., the presence of ischemia)

- heart rhythm disorders or conduction

abnormalities.
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• Co-morbid conditions

• Risk factors

• Medicine use

• The cardiologist’s estimate of exercise capacity

(i.e., low, medium or high) and prognosis

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 Data required
• Individual aerobic capacity goals and reasons for any
aerobic capacity limitations, such as fear or a dysfunctional
way of coping with heart disease

• Therapist’s diagnosis

If necessary:

• Information about work rehabilitation and prognosis

• Information on the patient’s family.

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Specific goals for physical therapy
• Learning to find one’s own physical limits
• Learning to deal with physical limitations
• Finding the optimum aerobic capacity level
• Diagnosis: evaluating aerobic capacity level and
correlating symptoms with objective disorders

• Reducing fear of movement

• Developing and attaining a physically active lifestyle

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An exercise program may consist of exercises that focus
on improving health or exercises that focus on improving
performance, or both

In cardiac rehabilitation, the patient’s physical functioning is

of central concern, not his or her sporting abilities

The treatment used in cardiac rehabilitation is not all given

at the same level. The therapeutic approach can vary from
professional sports training to learning the most efficient
way to tie shoelaces

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Symptoms of overloading during exercise
• angina pectoris
• left ventricular systolic dysfunctions
- shortness of breath
-excessive exhaustion for the level of physical activity

• rhythm disorders

- faster than expected heart rate for the level of physical

activity
- irregular heart rate, alterations in normal rhythm
• abnormally high or low blood pressure
• fainting
• dizziness
• orthosympathetic responses (e.g., sweating or pallor)
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 Guidelines for determining level of
risk

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 Low

• normal left ventricular function

• No complex arrhythmias

• no complications during the clinical phase

• hemodynamic stability while resting and during aerobic

capacity exercises

• no symptoms

• functional capacity greater than 7 MET’s

• absence of depression
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 Medium

• Moderate limitation of left ventricular function (i.e., ejection

fraction = 35–49%)

• Symptoms, including angina pectoris, occur during or after

exercising at a medium aerobic capacity level (i.e., 5–6.9
MET’s).

All patients who do not fit into the low-risk or high-risk

categories are classified as medium risk

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 High
• poor left ventricular function (i.e., ejection fraction < 35%)

• status after successful resuscitation

• complex ventricular arrhythmias

• myocardial infarction or heart operation with complications

• hemodynamic instability during aerobic capacity exercises

• symptoms, including angina pectoris, occur during or after

light aerobic capacity Exercises (< 5 MET’s)

• functional capacity less than 5 MET’s

ACSM Guideline

• clinically
14/10/07 significant depression
Cardiac Rehab
Functional class I
- sitting up in bed with assistance
-carrying out activities associated with personal hygiene
- sitting with assistance
- sitting in a chair for 15–30 minutes two or three times a

Functional class II
- sitting up in bed without assistance
- standing without assistance
- carrying out activities associated with personal hygiene
while sitting in the bathroom
- walking within the bedroom and to the bathroom, with or
without assistance.

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Functional class III
- sitting and standing without assistance
- carrying out activities associated with personal hygiene
while sitting or standing in the bathroom
- walking short distances (15–30 m) in the hallway with
assistance approximately three times a day.

Functional class IV
- carrying out activities associated with personal hygiene
and bathing;
- walking short distances (45–60 m) with minimal assistance
three or four times
a day

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Functional class V
- walking in the hallway without assistance for a distance of
75–150 m three or four times a day

Functional class VI
- walking without assistance 3–6 times a day

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 Patient education plan

Information

Instruction

Education

Guidance

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 The six steps in patient education

Being open
Understanding
Wanting
Being able
Doing
Keeping on doing
van der Burgt en Verhulst

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 Dyspnea scale

Level Description

+1 Mild, noticed by the patient but not

others
+2 Mild, minor problems, noticed by
observers
+3 Moderate problems, it is possible to
continue activity
+4 Serious problems, patient must stop
activity ACSM
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 Effects of aerobic training on the
cardio respiratory system

• Lowers heart rate

• Increases heart pump output volume

• Increases heart minute volume during maximum-

intensity exercise

• Increases blood volume and hemoglobin level

• Increases artery-vein oxygen differential

• Lowers blood pressure

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 Continues…

• Increases VO2-max

• Increases anaerobic threshold

• Increases maximum respiratory minute volume

• Increases ventilation

• Increases lung diffusion capacity

• Increases lung volume and capacity

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 Exercise Prescription

Frequency

Phase I Phase II Phase III

2-3 Times / Day 1 – 2 times/ Day 3-5 Times / Week

Healthy Adults
3 – 5 Times/ week

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 Intensity

Phase I Phase II Phase III

RHR + 20 RHR + 20 RPE 13 60- 85% 0f HR max

Healthy Adult
60 to 85% of RHR

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 Calculating Target Heart Rate

THR = Specific Percentage of HR Max

THR = RHR + Specific percentage of HRR

THR = HR at Specified VO2

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 Determining exercise intensity

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 Duration

Phase I Phase II
MI 5 -20 min MI 20 - 60 min
CABG 10-20min CABG 20 – 60 min

Phase III
30- 60 min

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 Final evaluation criteria

•The patient has achieved the specified goals

• The patient has partially achieved the specified goals and it

is expected that the patient will achieve all the goals by
himself or herself and be self-sufficient in performing
activities

• The patient has not met the specified goals but it is thought
that the patient’s maximum capacity has already been
reached. (The patient is sent back to the rehabilitation
team.)

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