Cardiac rehabilitation

What does cardiac rehab involve? Cardiac rehabilitation doesn't change your past, but it can help you improve your heart's future. Cardiac rehab is a medically supervised program designed to improve your cardiovascular health if you have experienced heart attack, heart failure, angioplasty or heart surgery.

1. CARDIAC
REHABILITATION
Dr.Arjun Patel
Assistant Professor

2. Definition
Cardiac rehabilitation is a multidisciplinary
program of education and exercise
established to assist individuals with heart
disease to achieve optimal physical,
psychological and functional status within
the limits of their heart disease.

3. It is established through
Education to patient and family members
By reducing the risk factors
By reducing the psychological problems
due to impairment.
Vocational counseling

4. Cardiac rehabilitation team
Team
Team of
doctors
Family
doctor, heart
specialist and
surgeon
Physical
therapist
Nurses
Occupational
therapist
Dietitian
Family
members
Vocational
counselor
Social
worker
psychologist

5. Goals of cardiac rehabilitation
Educationto the patient and family members in
the recognition, prevention and treatment of
cardiovascular diseases.
To limit the adverse effects of illness
To prevent harmful secondary effects.
(circulatory and respiratory complications)
Stratificationof risk factor for a further cardiac
event through proper assessment.
Modificationsof risk factor as far as possible.
To improve cardiovascular fitness after illness

6. To identify psychological response to illness
and additional supportive measures to make a
successful rehabilitation
To accomplish all the goals to inter disciplinary
efforts directed at discovering each patients
optimal diet and activity etc..
To create a positive attitude that will motivate
the patient to make a long term commitment.

7. 5 mark question/ do write in
assessment of cardiac rehab
(CABG,PTCA, MI)
RISK STRATIFICTION
CRITERIA FOR CARDIAC
PATIENTS BY THE
AMERICAN COLLEGE OF
PHYSICIANS

8. Low Risk
Uncomplicated MI or CABG
Functional capacity ≥ 8 METs 3 weeks after
clinical event
No ischemia, left ventricular dysfunction or
complex arrhythmias
Asymptomatic at rest with exercise capacity
adequate for most vocational and recreational
activities

9. Moderate Risk
Functional capacity < 8 METs 3 weeks after
clinical event
Shock or CHF during recent MI (< 6months)
Failure to comply with exercise prescription
Inability to self monitor heart rate
Exercise induced ST segment depression< 2mm

10. High Risk Ef=EDV-ESV/EDV= SV/EDV%
Severely depressed LV dysfunction (EF< 30%) (n value
is 55 to 70%)
Resting complex ventricular arrhythmias
PVC (premature ventricular contraction) appearing or
increasing with exercise
Excertional hypotension (≥ 15 mm Hg decrease in
systolic pressure during exercise)
Recent MI (<6months) complicated by serious
ventricular arrhythmias
Exercise induced ST segment depression > 2mm
Survivor of cardiac arrest.

11. Role of PT
To prevent deconditioningeffects of disease
To improve cardio vascular endurance and
training
To improve musculoskeletalproblems
Plan and formulate home programs and
instructions based on individual needs and
demands.

12. Assessmentof patients regularly and report to
CR team
Therapist should be skillful in exercise
physiology, pathology, exercise training
techniques, arrhythmia recognition, cardio
pulmonary equipment knowledge, equipment
monitoring and advance life support
(defibrillators).

13. Cardiac rehab after….
Coronary artery bypass graft (CABG) surgery
Interventional procedures such as balloon angioplasty,
PTCA, atherectomy, rotoblation or stent placement
Angina
Heart attack (myocardial infarction)
Heart failure
Heamodynamic disorders, such as syncope
Peripheral artery disease
Other heart or vascular disorders
Valve repair or replacement
Aortic aneurysm repair or replacement
Heart transplant

14. Phases of recovery
Phase 1: inpatient rehabilitation (1week)
Phase 2: convalescent phase (2
nd
week to
8 to 12 weeks)
Phase 3: 4-6 months (supervised)
Phase 4: more than 6 months
(unsupervised)

15. A MET or metabolic equivalent is the
amount of energy used by the body to
perform a physical activity or daily task. At
rest, the average person has an oxygen
consumption of 1 MET (or 3.5 ml/kg-min).
MET values increase as more activity is
performed.

16. Phase 1

17. After 24 hours of event, CPK stabilized and other
factors.
Essential bed rest level 1day 1
1 -1.5 METs
Bed rest
Education about disease.
Arm supported for meals and ADL
Foot exercises
Breathing exercises
Coughing / huffing.

18. Sitting level 2day 2
1.5 to 2 METs
Breathing exercises
Sitting 15 –30 minutes / 2 to 4 times per day
Reliving of orthostatic hypotension
Limited room ambulation
Few steps (highly supervised with assistance)
Leg exercises
Education regarding exercises being performed.

19. Limited hall ambulation level 3 day 3
Breathing exercises, foot exercises.
METs 2 to 2.5
Ambulation for 5 minutes
Standing leg exercises
Bathroom activities.

20. Progressive hall ambulation level 4 
day 4
2.5 to 3 METs
Ambulation 5 to 7 minutes. 3 to 4 times/
day
Trunk exercises.

21. Progressive hall ambulation level 5 
day 4
3 to 4 Mets
8-10 minutes. 3 to 4 times/ day

22. Stair climbing level 6 day 5
Usually ETT is performed before stair
climbing
One step at one time
Trunk exercises

23. Termination criteria for exercises
SBP > 200 mm Hg
DBP > 100 mm Hg
Heart rate is more than 12 if B blockers are used
Heart rate is more than 20 if B blockers are not
used
Orthostatic hypotension (more than 20 mm Hg
drop in systolic BP
C/o angina
Fatigue
Confusion, dyspnea, nausea, cramps

24. Phase 2

25. Home exercise program:
Before giving the home exercise program.
Train the patient to monitor himself
Written form of activity guidelines
20 to 30 minutes of walking daily which should be
gradually increase
No afternoon sleep
Proper diet, low cholesterol
If Any discomfort during exercise, report to doctor
Visit the consultant at regular intervals.

26. Phase 2 To Phase 4

27. Aerobic training program
Intensity of exercise:
70 to 75% of max HR (220-age= max HR)
Karvonen Formula: Target Heart Rate =
((max HR − resting HR) ×%Intensity) +
resting HR example

28. For example, for a 25 yr old who has a resting heart rate
of 65, wanting to know his training heart rate for the
intensity level 60% -70%.
His Minimum Training Heart Rate:
220 -25 (Age) = 195
195 -65 (Rest. HR) = 130
130 x .60 (Min. Intensity) + 65 (Rest. HR) = 143
Beats/Minute
His Maximum Training Heart Rate:
220 -25 (Age) = 195
195 -65 (Rest. HR) = 130
130 x .70 (Max. Intensity) + 65 (Rest. HR) = 156
Beats/Minute
His training heart rate zone will be 143-156 beats per
minute

29. Duration:
30 to 40 minutes-exercise phase
5 to 10 minutes warm up (dynamic
stretches)
5 to 10 minutes cool down (static
stretches)
Frequency:
3 to 4 times/ week

30. Bruce protocol treadmill
stress test
The Bruce Test is commonly used treadmill
exercise stress test. It was developed as a
clinical test to evaluate patients with suspected
coronary heart disease, though it can also be
used to estimate cardiovascular fitness
aim: to evaluate cardiac function and fitness.

31. equipment required: treadmill, stopwatch, a 12-
lead electrocardiograph (ECG) machine and
leads, sticking tape, clips
procedure: Exercise is performed on a
treadmill. If required, the leads of the ECG are
placed on the chest wall. The treadmill is started
at 2.74 km/hr (1.7 mph) and at a gradient (or
incline) of 10%. At three minute intervals the
incline of the treadmill increases by 2%, and the
speed increases as shown in the table below.

32. Stage Duration
(min)
% slopeMPH METs
1 3 10 1.7 4.7
2 3 12 2.5 7.0
3 3 14 3.4 10.1
4 3 16 4.2 12.9
5 3 18 5.0 15.0

33. results: The test score is the time taken on the
test, in minutes. This can also be converted to
an estimated VO2max score using the calculator
below and the following formulas, where the
value "T" is the total time completed (expressed
in minutes and fractions of a minute e.g. 9
minutes 15 seconds = 9.25 minutes).
Women: VO2max (ml/kg/min) = 2.94 x T + 3.74
Men: VO2max (ml/kg/min) = 2.94 x T + 7.65

34. Avoid or use less isometrics
Use leg exercises more than arm
exercises
Initially 2 extremities then 4 extremities like
jogging swimming
Recent studies suggest that strength
training is important during cardiac
rehabilitation

35. Indication for aerobic exercises
4 to 6 month after CABG (or) MI
1 to 2 weeks after PTCA
Completion of phase 2
DBP< 105 mm hg
Peak exercise capacity > 5 METs
No CHF

36. Contraindications or termination
criteria for exercises
SBP > 200 mm Hg
DBP > 100 mm Hg
Heart rate is more than 12 if B blockers are used
Heart rate is more than 20 if B blockers are not used
Orthostatic hypotension (more than 20 mm Hg drop in
systolic BP
C/o angina
Fatigue
Confusion, dyspnea, nausea, cramps
Sever aortic stenosis
3 rd degree av block

37. Ventricular and atrial arrhythmias
Ventricular tachycardia
Recent embolism
Thrombophlebitis
Resting ST depression > 3mm
CCF
Acute illness

38. Effects of exercise training and
education
Increase cardio vascular fitness
Increase a-vo2 differences
Increase coronary collaterals
Increase myocardial perfusion
Increase functional status
Increase knowledge and prevention of disease
Decrease chances of secondary complications
Early ability to do activities

39. Precautions after PTCA/ CABG
No strict guidelines for PTCA
Post revascularization ETT results are imp
Low intensity aerobic training
Few repetitions throughout the day
rest periods importance
Avoid lifting, pushing, pulling objects for 4
to 6 weeks
Avoid sternal discomfort.
Avoid sexual relations for 3 to 6 weeks

40. Home exercises program
Rest, leisure activity
30 mins walking gradually increase the
frequency.
Sternal protection is important
Add all UE, trunk and LL activities
Begin aerobic and strength training after 6
week.

41. Guideline for strength training
Avoid holding your breath.
Be sure to warm up and cool down to prevent injury and
soreness.
Complete a smooth, controlled, and full range of motion
with each activity.
Balance your exercise between complementary muscle
groups:
Biceps and triceps
Quadriceps and hamstrings
Chest and upper back
Always include exercises that strengthen your trunk (lower
back and abdomen).

42. Avoid gripping the weight handles tightly to prevent
an excessive blood pressure response to lifting.
Typically, weight training is done after aerobic
exercise and/or on alternate days.
Begin with exercises for major muscle groups: work
large muscles, such as chest and back, before
smaller muscles, such as biceps and triceps.
Delayed onset of muscular soreness may occur, so
progress slowly and allow for recovery time.
Do not do strength training every day, because your
muscle groups need at least one day to recover.

43. 5 mark question
Effects of exercises on heart
patients/ cardio protective
effects of exercises.