Objectives

Introduction to Cardiac Rehabilitation

Definition
Goals of Cardiac Rehabilitation
Benefits of the Program
Indications/Contraindications
Assessment -Pre-enrollment workup
Program Structure- Phase I- Phase IV
Implementation of the Program
Assessment of Outcome
 DEFINITION
Cardiac Rehabilitation has been defined
as:

Coordinated, multifaceted interventions

designed to optimize a cardiac patient’s
physical, psychological, and social functioning
so that they may, by their own efforts, resume
and maintain as normal a place as possible in
the community
GOALS OF CARDIAC REHAB
Curtail the pathophysiologic and
psychosocial effects of heart disease
Limit the risk for reinfarction or sudden
death
Relieve cardiac symptoms
Retard or reverse atherosclerosis by
instituting programs for exercise training,
education, counseling, and risk factor
alteration
Reintegrate heart disease patients into
successful functional status in their
families and in society
BENEFITS OF REHAB PROGRAM
Offset deleterious pyschologic and
physiologic effects of bed rest during
hospitalization

Enable patients to return to activities of

daily living within the limits imposed
by their disease

Reduces cardiovascular and

total mortality

Improves myocardial perfusion

INDICATIONS
Acute myocardial infarction
Coronary artery bypass
grafting
Angioplasty with or without
stenting
Valve replacement or
repair Heart
transplantation Surgery
involving the great
vessels
Congestive heart failure
CONTRAINDICATIONS
Unstable Angina
Uncontrolled Arrhythmias or A-V
Block Resting Systolic Blood
Pressure >200
mm hg Resting Diastolic
Blood Pressure >100 mm hg
Recent embolism
Moderate to severe Aortic Stenosis
Acute Systemic illness or fever
Orthopedic problems that
would prohibit exercise
Poorly controlled hypertension
Patients unwilling to exercise 8
CORE COMPONENTS
Patient Assessment
Nutritional Counseling
Weight Management
Blood Pressure Management
Lipid Management
Diabetes Management
Tobacco Cessation
Psychosocial Management
Exercise Training
Physical Activity Counseling 9
 REDUCTION IN RISK
FACTORS

Blood lipids
 Significant reductions of total cholesterol,
LDL-cholesterol, and triglycerides,
 an increase in HDL-cholesterol with
training

10
 Hypertension control

 Regular exercise helps keep arteries

elastic (flexible)
 This ensures good blood flow and normal
blood pressure
 Consistent long term exercise can reslut in
atleast 10 to 20mmhg decrease in both resting
and exercise blood pressure of hypertension

11
 Glucose intolerance

 Lower serum insulin level after training

because of increase in insulin sensitivity at
the cellular level
 Decreased serum triglycerides and body
fat levels

12
CARDIAC REHABILITATION
PROGRAM
PHASE I
Duration: 5 to 7 days.

Components:
– Medical evaluation

– Reassurance and education

– Correction of cardiac misconception

– Risk factor assessment

– Early individualized Mobilization

– Discharge planning
 Goals
Assessment of hemodynamic responses to
self-care and progressive ambulation
activities

Determination of the effectiveness of the

patient’s medications in controlling
abnormal responses to activity

Establishment of clinical data that

contribute to the patient’s prognosis and
thus to optimal medical management

Early behavior modification and risk

factor reduction along with family
Day Protocol
1 Coronary care unit
2 (Stabilization)
3
4 Self-care evaluation
5 Monitored ambulation
6
7 Low-level exercise test
8 Discharge
Step 1- PROM, active ankle exercise, self-feeding,
orientation to program

Step 2- same exercise, legs dangling at the side of bed

Step 3- AAROM, sitting in chair, bedside commode,

more detailed explanation of the program, light
recreation, Assissted ADL,Walking

Step 4- minimal resistance, increase sitting time, patient

education, light activities, independet ADL,walking
Step 5- moderate resistance, unlimited sitting, sitting for
meals, seated ADL , continued patient education

Step 6- increase resistance, walking to bathroom, Stairs,

standing ADL, group meetings
Step 7- increase exercise program, review energy-
conservation and pacing techniques.

Step 8- increase exercise with light weight and increase

walking distance, increase craft activities, discuss home
exercise program
Phase II
 Happy to be back HOME……

• Is the immediate post-discharge phase.

• Duration : 8th day to 6 weeks

• Components:

– Addresses health education

– Exercise

– Stress management
 Goals
• Increase exercise capacity and endurance in a
safe and progressive manner
• Teach the patient to apply techniques of self-
monitoring to home activities
• Relieve anxiety and depression

• Increase patient’s knowledge

 Exercise program
• Frequency: 3-5 times/week

• Intensity: RHR+20 bpm ; RPE<11;

METs=4
• Time: 5-30 minutes; interspersed with
rest periods and progress to about
30 minutes
• Type: sitting/standing functional
activities; ROM exercises; walking
Phase III
The patient has stabilized and requires
ECG monitoring only if signs and
symptoms necessitate.

Duration : 6 weeks to 12 weeks

Begins with symptom limited ETT

Result of this test are used to determine

a target HR for exercise training
 Goals
• Improve and maintain physical fitness

• Provide professional supervision for exercise

• Continue with educational and

behavioral program
 Types of Training
• Steady State Training:

– Is a sustained activity, where workload and

HR are maintained at a constant sub-
maximal intensity.
– Jogging, walking, stepping and cycling.
• Interval Training:

– The exercise is followed by a rest interval.

– Is perceived to be less demanding than

continuous
– High-intensity work can be achieved as
there is appropriate spacing of work- relief
intervals.
• Circuit Training:

– Employs a series of exercise activities. At

the end of the last activity, the individual
starts from the beginning and again moves
through the series.
– Improves strength and endurance by
stressing both the aerobic and anaerobic
systems.
 Warm-up period
– To increase in muscle temperature

– Increase need for oxygen

– Dilation of previously constricted capillaries

with increase in circulation.
– Decreases susceptibility of the musculoskeletal
system to injury by increasing flexibility.
 Exercise Program

• Frequency: 3-4 times/week

• Intensity: 60-70% maximal HR; 12- 13 RPE; 40-

60% of VO2 max
• Time: 20-60 minutes; inclusive of warm up and
cool down
• Type: aerobic/endurance training
 Cool-down period:
– Prevent pooling of the blood in the
extremities by continuing to use muscles to
maintain venous return.
– Enhance recovery period with the oxidation
of metabolic waste and replacement of the
energy stores
Phase IV
 Goals
• Continued improvement and
maintenance of fitness.
• Unsupervised exercise
program
• Self exercise

• Long term behavioral

modifications
 Exercise Program
• Frequency: one session/day;
3-4 days/week
• Intensity: 60-80% of VO2 ; 70-85% of HRR;
RPE 12-15
• Time: desired 30-60 minutes continuous workout

• Type: dancing, hill walking, resistance exercise.