Cardiac rehabilitation pradeep

Cardiac Rehabilitation of adults with scenario and article reference

1. By; Pradeep.M M.Sc. Nursing II year Cardiac Rehabilitation Medical Surgical Nursing

2. Introduction ; Up until the 1950s, strict bed rest was thought to be the best medicine after a heart attack. Following discharge moderately stressful activity such as climbing stairs was discouraged for a year or more. "The patient is to be guarded by day and night nursing and helped in every way to avoid voluntary movement or effort." -Thomas Lewis

3. Definition ; Cardiac rehabilitation has been defined as the sum of activities required to ensure cardiac patients the best possible physical, mental and social conditions so that they may, by their own efforts, resume and maintain as normal a place as possible in the community. Cardiac rehabilitation has also been described as the combined and coordinated use of medical, psychosocial, educational, vocational and physical measures to facilitate return to an active and satisfying lifestyle. Coordinated, multifaceted interventions designed to optimize a cardiac patient’s physical, psychological, and social functioning, in addition to stabilizing, slowing or even reversing the progression of the underlying atherosclerotic process, thereby reducing morbidity and mortality .

4. Goals of Cardiac Rehabilitation ; Reduction of Cardiac risk factors Exercise & activity guidelines Patient education To improve functional capacity To alleviate or lessen activity-related symptoms To reduce disability To identify and modify coronary risk factors .

5. Indications ; Active myocardial infarction Coronary Artery Bypass Surgery (CABS) Percutaneous Transluminal Coronary Angioplasty (PTCA) Valvular replacement Pacemaker implantation

6. Phases of Cardiac Rehabilitation ; Phase I : Inpatient Phase II : Immediate Outpatient Phase III : Intermediate Outpatient Phase IV : Maintenance Phase of Indefinite Length

7. Phase I; Objectives ; Conditioning from acute event/ post-CABG To make patient functionally independent To adjust with discharge from the hospital Psychological counselling Nutritional counselling Secondary prevention targeting

8. Phase I ; Phase I relates to the period of hospitalization following an acute cardiac event. The duration of this phase may vary depending on the initial diagnosis, the severity of the event and individual institutions, usually one week acute event/post-operative. During this phase, early mobilization and adequate discharge planning. Individuals typically undergo a risk factor assessment and risk stratification Receiving information regarding their diagnosis, risk factors, medications and work/ social issues. Involvement and support of the partner and family is facilitated and encouraged .

9. Phase II; Objectives ; Functional goals - Exercise training under supervision/ at home Psychosocial goals Anxiety/depression management Secondary preventive targets

10. Phase II; Phase II: This phase encompasses the immediate post discharge period, which is typically a period of four to six weeks. It focuses on health education and resumption of physical activity, however the structure of this phase may vary dramatically from centre to centre. It may take the format of telephone follow up, home visits, or individual or group education sessions. Either way, some form of contact is maintained with the patient, facilitating ongoing education and exchange of information .

11. Phase III; Objectives ; Functional goals - Exercise training under supervision Psychosocial goals - Return to work Return to hobbies and lifestyle Anxiety/depression management Secondary preventive targets .

12. Phase III : This phase is sometimes erroneously referred to as the ‘Exercise’ phase. It incorporates Exercise training in combination with ongoing education and psychosocial and vocational interventions. The duration of Phase 3 may vary from six to 12 weeks, with patients required to attend a CR unit two to three times weekly for structured exercise and other lifestyle interventions .

13. Phase IV; Objectives ; Functional goals - Exercise training Psychosocial goals – Return to work Return to hobbies and lifestyle Anxiety/depression management Secondary preventive targets

14. Phase IV: This phase constitutes the components of long-term maintenance of lifestyle changes and professional monitoring of clinical status. It is when patients leave the structured Phase 3 programme and continue exercise and other lifestyle modifications indefinitely. This may be facilitated in the CR unit itself or in a local leisure centre. Alternatively, individuals may prefer to exercise independently and Phase 4 may involve helping them set a safe and realistic maintenance programme .

15. Benefits of Cardiac Rehabilitation ; Reduces cardiovascular and total mortality Does not increase non-fatal re-infarction rate Improves myocardial perfusion May reduce progression of atherosclerosis when combined with aggressive diet No consistent effects on hemodynamic, LV function or visible collaterals No consistent effects on cardiac arrhythmias Improves exercise tolerance without significant CV complications Improves skeletal muscle strength and endurance in clinically stable patients Promotes favourable exercise habits Decreases angina and CHF symptoms

16. Outcomes in Cardiac Rehabilitation ; Smoking cessation Lipid management Weight control Blood pressure control Improved exercise tolerance Symptom control Return to work Psychological well-being/stress management Physical activity Improves glucose metabolism Reduces body fat Lowers blood pressure Improves musculoskeletal strength Controls body weight Reduces symptoms of depression

17. Assessment before exercise training ; Clinical risk stratification is suitable for low to moderate risk patients undergoing low to moderate intensity exercise. Exercise testing and echocardiography are recommended for high risk patients and/or high intensity exercise Functional exercise capacity should be evaluated before and on completion of exercise testing .

18. Contra-indications exercise training ; Absolute Acute myocardial infarction (within two days) Unstable angina Uncontrolled cardiac arrhythmias causing symptoms or homodynamic compromise Symptomatic severe aortic stenosis Uncontrolled symptomatic heart failure Acute pulmonary embolus or pulmonary infarction Acute myocarditis or pericarditis Active endocarditis Acute aortic dissection Acute noncardiac disorder that may affect exercise performance or be aggravated by exercise Inability to obtain consent

19. Contra-indications exercise training ; Left main coronary stenosis or its equivalent Moderate stenotic valvular heart disease Electrolyte abnormalities Severe hypertension (systolic 200 mmHg and/or diastolic 110 mmHg) Tachy -arrhythmias or brady -arrhythmias, including atrial fibrillation with uncontrolled ventricular rate Hypertrophic cardio myopathy and other forms of outflow tract obstruction Mental or physical impairment leading to inability to cooperate High-degree atrio -ventricular block

20. Measurements during Cardiac Rehabilitation ; Exercise capacity Blood Pressure Weight Waist circumference Lipids Glucose/HbA1C Telemetry monitoring occurs during exercise sessions Nutritional survey tool

21. Exercise guidelines for Cardiac Patient; General In-patient Guidelines ; Frequency Early mobilization: 3-4 times/day (days 1-3) Later mobilization: 2 times/day (beginning on day 4) Progression: Initially increase duration up to 10-15 min, then increase intensity. By hospital discharge, the patient should: Demonstrate a knowledge of inappropriate exercises Have a safe, progressive plan of exercise formulated for them to take home Selected moderate to high risk patients should be encouraged to participate in outpatient cardiac rehabilitation programs &/or Manage their discharge rehabilitation plan and report any cardiovascular symptoms promptly (should they occur).

22. General Out-patient Guidelines ; Goals are to: Develop and help the patient to establish and implement a safe and effective home exercise program and recreational lifestyle, Provide patient and family education and therapies to maximize secondary prevention. In general, patients should engage in multiple activities to promote total conditioning including aerobic and resistance exercises. Principles of prescription are those for healthy adults but adjusted to take into account the patients clinical status .

23. Independent Exercise Guidelines ; Appropriate hemodynamic response to exercise Appropriate ECG response Adequate management of risk factor intervention strategy and safe exercise participation Demonstrated knowledge of disease process, abnormal signs and symptoms, medication use and side effects .

24. Sharing the Story of the Cardiac Rehab Patient Experience; Ellis , Jordan M. MA; Freeman, John Taylor MA; Midgette , Emily P. BA; Sanghvi , Anup P.; Sarathy , Brinda ; Johnson, Colin G.; Greenway, Stacey B. MA; Whited , Matthew C. PhD Author Information Journal of Cardiopulmonary Rehabilitation and Prevention:  July 2019 - Volume 39 - Issue 4 Purpose:  To provide a prototypical patient narrative of the cardiac rehabilitation (CR) experience for providers and prospective patients using narrative analysis.

25. Cont…. Methods:  Qualitative interviews with 17 CR patients from a previous study regarding their experiences, reasons, and motivations related to engagement in CR were analyzed using narrative inquiry. Interviews were previously analyzed and coded for recurring themes, and these themes were implemented in an exploratory narrative inquiry to craft a CR patient “story.” A hypothetical composite character representing the varied experiences of CR patients interviewed was developed, and a patient story was constructed that reflected on an initial cardiac event, time during rehabilitation, difficult experiences, social interactions, and personal values and accomplishments. Results:  The CR patient narrative is presented for use in CR recruitment and programming materials, and in provider education. Conclusion:  The narrative analysis comprehensively provides patients with an amalgam of patient experiences and can be used by providers to gain an understanding of CR patient experiences. Further research is needed to determine whether use of the resulting narrative analysis within the referral process and/or programming could increase participation and engagement.

26. Journal Article related to Cardiac Rehabilitation ; Muscular Strength and Cardiovascular Disease; An updated state-of-the-art narrative review Carbone , Salvatore PhD; Kirkman , Danielle L. PhD; Garten , Ryan S. PhD; Rodriguez- Miguelez , Paula PhD; Artero , Enrique G. PhD; Lee, Duck- chul PhD; Lavie , Carl J. MD Journal of Cardiopulmonary Rehabilitation and Prevention:  September 2020 - Volume 40 - Issue 5 - p 302-309 This review discusses the associations of muscular strength ( MusS ) with cardiovascular disease (CVD), CVD-related death, and all-cause mortality, as well as CVD risk factors, such as metabolic syndrome, diabetes, obesity, and hypertension. We then briefly review the role of resistance exercise training in modulating CVD risk factors and incident CVD.

27. Cont…. MusS is a strong modifiable risk factor for several CVDs, but also CVD-related mortality and all-cause mortality. Except for the risk of HTN, where the evidence is conflicting, MusS seems to exert protective effects on several CV and metabolic conditions ( ie , MetS , T2DM, and obesity). Importantly, such effects seem to be, for the most part, independent of the amount of LM, CRF, and physical activity. The studies discussed herein, however, cannot prove whether dynapenia is a mediator or perhaps only a marker of overall worse nutritional status able to identify those with frailty and  sarcopenia  among others, which, in turn, confer a greater risk for cardiometabolic diseases. In other words, is this relationship causal or merely association? Further study is clearly warranted to determine whether therapeutics, including targeting nutrition and RT, aimed at increasing MusS , with and without changes in LM, can, in fact, affect major clinical outcomes, and whether this can be implemented to improve cardiac rehabilitation outcomes in patients with established CVD, especially CHD and HF.

28. Summary

29. By; Pradeep.M M.Sc. Nursing II year