Cardiac rehabilitation

Cardiac rehabilitation program for the patient related to cardiac surgeries, MI, Angina pectoris, and any other cardiac condition.

1. BY DR. PRASHANT KAUSHIK MPT SPORTS ASSISTANT PROFESSOR KINPMS CARDIAC REHABILITATION

2. INTRODUCTION FEATURES OF CARDIAC REHABILITATION COMPONENTS OF CR INDICATIONS CONTRAINDICATION CR TEAM MEMBERS EXERCISE PHYSIOLOGY INPATIENT REHABILITATION PROGRAM BENEFITS OF CR PROGRAM CONTENTS

3. It is the process of restoring patient with heart disease to optimal functional status keeping in mind the physiological, psychological, vocational requirements. The goal is to maintain good cardiovascular function, and is to maintain good quality of life. The benefit of good rehabilitation program is that the 3 years survival rate is 95% with those in a program while it is 64% in nonparticipation. INTRODUCTION

4. It involves the active participation of patients and family members. It is a sequence of medical and rehabilitation protocols which merge with each other. It is personalized based on patient’s age and habits. The patient has to be rehabilitated back to his original activity, as much as possible. FEATURES OF CR

5. Medical management of diabetes and hypertension. A dietician prescribes a customized diet; usually a low protein and high fiber diet. Patient education, cessation of smoking, medication to reduce cholesterol and blood thinners. Psychological components: Any patient who has undergone a major surgery would naturally need counseling by a psychologist regarding issues like quality of life after surgery. Avoiding risk factors like stress and obesity. COMPONENTS OF CR

6. Coronary artery disease is one of the leading causes of death worldwide; survivors of myocardial infarction and patients with angina pectoris need a good rehabilitation program. Patients who undergo surgeries on the valves. Patients needing percutaneous transluminal coronary angioplasty(PTCA). Patients with milder form of MI. Patients who undergo coronary active bypass grafting(CABG). INDICATIONS

7. Severe MI. Unstable angina. Cardiac arrhythmias. Systolic pressure >220mmHg and diastolic pressure >110mmHg. Impaired cognition. Possible lack of compliance therapy. CONTRAINDICATION

8. Cardiac rehabilitation specialist. Physical therapist. Cardiothoracic surgeon. Cardiologist. Cardiac rehabilitation nurses. Psychologist. Dietician. Family members. CR TEAM MEMBERS

9. To understand the exercise physiology one must know a few terms: - Total oxygen consumption(VO2 ). Aerobic capacity. Cardiac output = heart rate/stroke volume. EXERCISE PHYSIOLOGY

10. The rehabilitation program for patient after a cardiac event like surgery divided into three phases: - 1. Phases one ( Inpatient phase) 2. Phases two ( Immediate out patient period) 3. Phase three ( Intermediate and maintenance periods) INPATIENT REHABILITATION PROGRAM

11. Day of surgery: - In ICU the patient would be connected to lines and monitors and ventilatory support. He would not be fully consious because of the effects of anaesthesia . The therapist visits three to four times during day and gives relaxed diaphragmatic breathing and gentle toe and ankle movements. Day 1: - As the patient is weaned off the ventilator, the therapist gives assisted coughing in sitting and active exercises to the upper limb within the pain free range, in addition to the therapy given above. It must be remembered that the operated site over the sterum can be painful. It can be repeated three to four times a day depending on patient’s cooperation. PHASES ONE (IN PATIENT PERIOD)

12. Day 2: - Patient’s intravenous lines are removed . Repetition of the same exercises as previous day. Day 3: - Patient shifted out of ICU and to ward if he is declared stable by the attending physician. The previous exercise are repeated and the patient is made to walk around the bed under supervision. Sitting in chair with back support is encouraged. Day 4: - Shoulder movements are performed within the pain free range. Walking distance is increased within the ward under the supervision of physiotherapist. Day 5 and Day 6: - Stair climbing up to five steps is started under the supervision of physiotherapist. Day 7: - The patient is asked to cover the longer distance, with increase in stride length and cadence.

13. Day 8: - Patient is counseled in the cardiac rehabilitation department by a team comprising of a psychologist, physiotherapist, dietician, cardiologist, and a cardiothoracic surgeon. Day 9 and Day 10: - Home exercise program is taught and patient is discharged after suture removal. Ideally by now the patient should achieved a metabolic equivalent between two and three for progression to the second phase of rehabilitation.

14. This is an outpatient program which means that the patient has to be brought to the department following his discharge until 3 months, thrice a week. Activities or exercises of intensity (3-4 METs) are given for 30 to 45 minutes checking vital signs periodically. A gradual warm up session for 5-10 minutes is given, followed by static cycling, treadmill walking, and group therapy for up to half an hour. Early ambulation is initiated starting in the room and then corridors of the hospital, starting 1mph and gradually increasing up to 2.5 mph as tolerated. PHASE 2 (IMMEDIATE OUT PATIENT)

15. A cool down program for 5 minutes is also given at the end of this session, by which stage the patient is expected to attain 5 METs. ROM exercise can be gradually increased in intensity with mild resistance or low weight.

16. A detailed home exercise program is taught which is followed by the patient at home. The rehabilitation program should monitor risk factor in post myocardial infarction (MI) patients like hypertension, increased serum cholesterol levels, obesity, and coronary atherosclerosis. Other habits like smoking and excessive drinking should be avoided. Graded exercise stress test are given to diagnose, prognosticate , and asses how the patient respond to increased physical stress. PHASE 3 (INTEMIDATE AND MAINTAINCE PERIODS)

17. Improvement in exercise limits. Reduction in symptoms of angina pectoris in patient, of heart failure in patients with left ventricular systolic dysfunction and improvement in clinical measures of myocardial ischemia. Improvement in blood lipid levels. Improvement in psychosocial well being and stress reduction. Reduction in mortality. BENEFITS OF CR