Cardiac Rehabilitation 132

Heart Diease-

Types of Heart Disease

There are generally four types of cardiac disease that will commonly be
encountered by the practicing physiatrist.
1. Because of protocols and improvement in acute management, cardiac
rehabilitation of the post-MI patient is now usually handled in an acute
3- to 5-day hospital stay, followed by outpatient rehabilitation.
2. Post-surgical patients, including those who have had CABG, valve
replacement, cardiac defect repairs, and devices implanted (automatic
internal cardiac defibrillators, etc.), usually will have a smooth and
uncomplicated course. Advances in surgery have also made CABG less
invasive for many (minimally invasive CABG, off-pump CABG, and
robotic surgery are just a few new techniques), but have also expanded
the populations to whom these interventions are being offered. This can
increase the risk of complications postoperatively in more debilitated
patients, and the presence of comorbidities and the possibility of a long,
debilitating postoperative course is increased, leading to the need for
more intensive rehabilitation interventions.
3. Unlike in the past, the patient with severe CHF or severe arrhythmias is
now being referred for cardiac rehabilitation. With appropriate precau-
tions and monitoring, rehabilitation can be very successful in these pop-
ulations.
4. Finally, the population of transplant patients has their own unique phys-
iology and issues, which make the services of rehabilitation especially
helpful in that population.
All of these different populations will be discussed separately in later
portions of this chapter.
 Table 1
Coronary Artery Disease Risk Factors
Reversible risks Irreversible risks
• Sedentary lifestyle • Age
• Cigarette smoking • Male gender
• Hypertension • Family history of premature CAD
• Low HDL cholesterol (before age 55 in a parent or
(<0.9 mmol/L [35 mg/dL]) sibling)
• Hypercholesterolemia • Past history of CAD
(>5.20 mmol/L [200 mg/dL]) • Past history of occlusive
• High lipoprotein A peripheral vascular disease
• Abdominal obesity • Past history of cerebrovascular
• Hypertriglyceridemia disease
(>2.8 mmol/L [250 mg/dL])
• Hyperinsulinemia
• Diabetes mellitus
CAD, coronary artery disease; HDL, high-density lipoprotein.

MAJOR SIGN AND SYMTOMS OF MI-

Pain, discomfort- stabbing like pain, chest tightness, burning in the chest radiate to
neck, jaw, arms
Pain assessment scale.
Shortness of breath – NYHA score
Dizziness or syncope
Oerthopnea or Paraoxysmal nocturnal dyspnea
Ankle odema
Palpitation or Tachycardia
Intermittent claudication
Heart murmur- Systolic murmur if papillary muscle involve
Unusual fatique or shortness of breath with usual activities.

Classic Post-MI Cardiac Rehabilitation Program

Risk-Factor Modification

Diabetes
Close control of blood sugars has been shown to decrease the risk of
cardiac disease through the slowing of the development of atherosclerosis
and secondary conditions, such as nephrogenic hypertension. Exercise
training can also help to improve diabetic control. The exact benefits of
exercise training in combination with good glucose control are still being
elucidated.
Cardiac Rehabilitation 134
Hypertension
Control of hypertension has been shown to be beneficial in individuals
with normal cardiograms. Reduction of dietary salt and increased exercise
to improve conditioning in combination with pharmacological
management can significantly improve blood pressure.

Hypercholesterolemia
Lowering cholesterol levels and increasing high-density lipoprotein is
associated with decreased risk of cardiac disease. Patients can decrease
their lipids by adhering to a low-cholesterol, low-fat diet along with
weight reduction, even without the addition of exercise. The American
Heart Association recommends that the total amount of calories from fat in
the diet should not exceed 30%.
Obesity
The multiple metabolic syndrome of obesity, diabetes, hypertension,
and hyperlipidemia is associated with increased morbidity and mortality,
and the obesity is at the center of the syndrome. Weight loss can decrease
blood pressure, improve lipid profile, and improve diabetic control, as
well as improve the ability to perform exercise. Attention to proper weight
needs to be part of any cardiac rehabilitation program.

Cigarette Smoking
Cigarette smoking is one of the greatest single modifiable risk factors
for cardiac disease. Smoking cessation is associated with a 30% decrease
in 10-year mortality in individuals with angiographically demonstrated
CAD or MI. Smoking accelerates atherosclerosis, contributes to
hypertension, and is associated with a sedentary lifestyle. Smokers tend to
be less com- pliant in cardiac rehabilitation programs, and exercise is not
associated with decreased cigarette use. However, cardiac rehabilitation
coupled with coun- seling for smoking cessation can lead to a decrease in
smoking. Although smoking cessation programs are not a primary
rehabilitation function, awareness of available resources and appropriate
referrals for patients should be available for all smokers with cardiac or
other disease.
Table 2
The Distributions of Infarcts by Anatomy
Area of infarct Associated syndrome
Left anterior • Anterior wall and septum †Papillary muscle necrosis
descending †Left heart failure
†Left ventricular aneurysm
†Anterior wall thrombus
†Conduction block
†Sudden death
Left circumflex • Apex and lateral wall †Apical thrombus
†Left heart failure
Left main • Anterior and lateral wall †Massive congestive heart
coronary artery apex failure
†Left ventricular aneurysm
†Anterior wall thrombus
†Conduction block
†Sudden death
Right coronary • Inferior wall and right †Sinus node arrest
artery ventrical †Bradycardia
†Right ventricular failure
†Peripheral edema

Cardiac Rehabilitation of the Post-MI Patient

Acute Phase (Phase I)

The rehabilitation of the post-MI patient (conservative management or

minimal invasive surgery) follows the principles of the classic model of
cardiac rehabilitation as first described by Wenger et al. Cardiac
rehabilitation is traditionally divided into four stages or phases. Phase I is
the acute phase, immediately following the MI up to discharge. Phase I
rehabilitation is characterized by breathing exercise and early
mobilization.

Aims of physiotherapy :
1. To teach and encourage relaxation.

2. To prevent accumulation of secretion in the lungs.

 Cardiac Rehabilitation 136
3. To prevent pressure sores.

4. To prevent deep vein thrombosis.

5. To explain the purpose of an active rehabilitation

programme.

 Relaxation: lying or half-lying, conscious relaxation 10

min approx. Modified physiological relaxation may be
131

indicated. If the patient can learn to relax, the heart rate

is reduced and this aids recovery by easing the load on
the heart.

 Breathing exercise- Deep breathing,Thoracic

expansion,Assisted breathing, Incentive spirometer

 Bronchial hygiene- ACBT, FET, PEP devices, Postural

Drainage, passive chest PT, Suctioning.
 Early mobilization--Mobilization started in phase I until the
myocardial scar has matured. The innovation in Dr. Wenger’s
model of cardiac rehabilitation was early mobilization. The
classic Wenger cardiac rehabilitation program is outlined in
table-

Table 5
Wenger Protocol
Step Activity
1 Passive range of motion (ROM); ankle pumps; introduction to the program;
self-feeding.
2 As above; also dangle at side of bed.
3 Active-assisted ROM; sitting upright in a chair, light recreation, and use of
bedside commode.
4 Increased sitting time; light activities with minimal resistance; patient educa-
tion.
5 Light activities with moderate resistance; unlimited sitting; seated activities of
daily living (ADL).
6 Increased resistance; walking to bathroom; standing ADL; up to 1-hour group
meetings.
7 Walking up to 100 feet; standing warm-up exercises.
8 Increased walking; walk down stairs (not up); continued education.
9 Increased exercise program, review energy conservation, and pacing techniques.
10 Increase exercises with light weights and ambulation; begin education on home
exercise program.
11 Increased duration of activities.
12 Walk down two flights of stairs; continue to increase resistance in exercises.
13 Continue activities, education, and home exercise program teaching.
14 Walk up and down two flights of stairs; complete instruction in home exercise
program and in energy conservation and pacing techniques.
Adapted from Bartels MN. Cardiac rehabilitation. In: Physical Medicine and
Rehabilitation: The Complete Approach. Grabois M, ed. Chicago: Blackwell Science,
2000.

The goal of the original program was to get individuals from bed rest to
climbing 2 flights of stairs in 14 days. Under current prac- tices, clinicians
have modified the classic program of cardiac rehabilitation to allow stays
of 3–5 days after MI. The 14 steps of the classic program are
 Cardiac Rehabilitation 138
now condensed. Patients are encouraged to be sitting out of bed and in a
chair by days 1–2 (steps 1–5), with short distance ambulation and
bathroom privileges by days 2–3 (steps 6–9). By days 4–5, the patient
learns the home exercise program, climbs stairs, and increases duration of
ambulation (steps 10–13). Prior to discharge, the patient has a low-level
ETT for risk stratifi- cation and completes learning the home program
(step 14). Education is started at this time. Cardiac monitoring should be
performed under the supervision of a trained physical or occupational
therapist or nurse during phase I. The post-MI HR rise should be kept to
within 20 bpm of baseline, and the SBP rise within 20 mmHg of baseline.
Any decrease of SBP of 10 mmHg or more should stop exercise. The
intensity target for the phase I program is activities up to 4 METs, which is
within the range of most daily activities.

Progression:

1)Increase no. of repetitions.

2.Increase the length of time for each exercise.

3.Increase speed.

4.Add weights.

5.Alter range.
Table 3
Sample Metabolic Equivalent (MET) Levels
Energy costs Energy costs
of activities of daily living MET of avocational activities METs
s
Sitting at rest 1 Backpacking (45 pounds) 6–11
Dressing 2–3 Baseball (competitive) 5–6
Eating 1–2 Baseball (noncompetitive) 4–5
Hygene (sitting) 1–2 Basketball (competitive) 7–12
Hygene (standing) 2–3 Basketball (noncompetitive) 3–9
Sexual intercourse 3–5 Card playing 1–2
Showering 4–5 Cycling, 5 mph 2–3
Tub bathing 2–3 Cycling, 8 mph 4–5
Walking, 1 mph 1–2 Cycling, 10 mph 5–6
Walking, 2 mph 2–3 Cycling, 12 mph 7–8
Walking, 3 mph 3–3.5 Cycling, 13 mph 8–9
Walking, 3.5 mph 3.5–4 Karate 8–12
Walking, 4 mph 5–6 Running 12 minutes/mile 8–9
Climbing up stairs 4–7 Running 11 minutes/mile 9–10
Bed-making 2–6 Running 9 minutes/mile 10–11
Carrying 18 pounds upstairs 7–8 Skiing crosscountry, 3 mph 6–7
Carrying suitcase 6–7 Skiing crosscountry, 5 mph 9–10
Housework (general) 3–4 Skiing downhill 5–9
Mowing lawn (push power mower) 3–5 Skiing water 5–7
Ironing 2–4 Swimming (backstroke) 7–8
Snow shoveling 6–7 Swimming (breaststroke) 8–9
Swimming (crawl) 9–10
Television 1–2
Tennis (singles) 4–9
Cardiac Rehabilitation 140

Table 3 (Continued)
Sample Metabolic Equivalent (MET) Levels
Energy costs
of vocational activities METs

Assembly line work 3–5

Carpentry (light) 4–5
Carry 20–44 pounds 4–5
Carry 45–64 pounds 5–6
Carry 65–85 pounds 7–8
Chopping wood 7–8
Desk work 1.5–2
Digging ditches 7–8
Handyman 5–6
Janitorial (light) 2–3
Lift 100 pounds 7–10
Painting 4–5
Sawing hardwood 6–8
Sawing softwood 5–6
Sawing (power) 3–4
Shoveling 10 pounds, 10 per minute 6–7
Shoveling 14 pounds, 10 per minute 7–9
Shoveling 16 pounds, 10 per minute 9–12
Tools (heavy) 5–6
Typing 1.5–2
Wood splitting 6–7

Adapted from Dafoe, WA. Table of Energy

Requirements for Activities of Daily Living, Household
Tasks, Recreational Activities, and Vocational Activities.
In: Pashkow FJ, Dafoe WA, eds. Clinical Cardiac
Rehabilitation: A Cardiologist’s Guide. Baltimore, MD:
Wiiliams and Wilkins; 1993: 359–376.
Table 6
Borg Scale
Perceived Modified Perceived
Borg exertion Borg scale exertion
scale
0.0 Nothing at all
0.5 Very, very weak
1.0 Very weak
1.5
2.0 Weak (light)
6 2.5
7 Very, very light 3.0 Moderate
8 3.5
9 Very light 4.0 Somewhat strong
10 4.5
11 Fairly light 5.0 Strong (heavy effort)
12 5.5
13 Somewhat hard 6.0
14 6.5
15 Hard 7.0 Very strong
16 7.5
17 Very hard 8.0
18 8.5
19 Very, very hard 9.0 Very, very strong
20 9.5
10.0 Maximal
Cardiac Rehabilitation 142

Table 7
Patients at High Risk During Cardiac Rehabilitation
Ischemic risk
• Postoperative angina
• LVEF <35%
• NYHA grade III or IV CHF
• Ventricular tachycardia of fibrillation in the postoperative period
• SBP drop of 10 points or more with exercise
• Excessive ventricular ectopy with exercise
• Incapable of self-monitoring
• Myocardial ischemia with exercise
Arrhythmic risk
• Acute infarction within 6 weeks
• Active ischemia by angina or exercise testing
• Significant left ventricular dysfunction (LVEF <30%)
• History of sustained ventricular tachycardia
• History of sustained life-threatening supraventricular arrhythmia
• History of sudden death, not yet stabilized on medical therapy
• Initial therapy of patients with automatic implantable cardioverter defibrillator
• Initial therapy of a patient with a rate adaptive cardiac pacemaker
LVEF, left ventricular ejection fraction; NYHA, New York Heart Association; CHF,
congestive heart failure; SBP, systolic blood pressure.

Key References and Suggested Additional Reading

American Association for Cardiovascular and Pulmonary Rehabilitation.
Guidelines for Cardiac Rehabilitation and Secondary Prevention Programs,
4th ed. Champaign, IL: Human Kinetics, 2004.
American College of Chest Physicians. Cardiac rehabilitation services. Ann
Intern Med 1988; 109:671–673.
American College of Sports Medicine. ACSM’s Guidelines for Exercise Test-
ing and Prescription, 6th ed. Philadelphia: Lippincott, Williams and
Wilkins, 2000.
April EW. Anatomy. Philadelphia: John Wiley and Sons, 1984, pp. 143–161.
Bartels MN. Cardiopulmonary assessment. In: Grabois M, ed, Physical
Medicine and Rehabilitation: The Complete Approach. Chicago: Blackwell
Science, 2000:351–372.
Bartels MN. Cardiac rehabilitation. In: Grabois M, ed, Physical Medicine and
Rehabilitation: The Complete Approach. Chicago: Blackwell Science,
2000.
Berne RB, Levy MN. Cardiovascular Physiology. St Louis: CV Mosby,
1986:1435–1456.
Billingham ME. Graft coronary disease: the lesions and the patients. Trans-
plant Proc 1989; 21:3665–3666.
Borg G. Psychopathological bases of perceived exertion. Med Sci Sports
Exerc 1982; 14:377–381.
Braunwald E, Sonnenblick EH, Ross J. Normal and abnormal circulatory
function. In: Braunwald E, ed. Heart Disease. Philadelphia: W. B. Saun-
ders, 1992, pp. 351–392.
Bresike JF, Levy RI, Kelsey SF, et al. Effects of therapy with cholstyramine on
progression of coronary arteriosclerosis: results of the NHLBI Type II
Coronary intervention study. Circulation 1984; 69:313–324.
Brown G, Albers JJ, Fisher LD, et al. Regression of coronary artery disease as
a result of intensive lipid lowering therapy in men with high levels of
apolipoprotein B. N Engl J Med 1990; 323:1289–1298.
Cannistra LB, Balady GJ, O’Malley CJ, et al. Comparison of the clinical pro-
file and outcome of women and men in cardiac rehabilitation. Am J of
Cardiol 1992; 69:1274–1279.
Cannom DS, Rider AK, Stinson EB, et al. Electrophysiologic studies in the
denervated transplanted human heart. Amer. J. Cardiol 1975; 36:859.
Chandrasheckhar Y, Anand IS. Exercise as a coronary protective factor. Am
Heart J 1991; 122:1723–1739.
Christopherson LK. Cardiac transplantation: a psychological perspective.
Circulation 1987; 75:57–62.
Dafoe, WA. Table of energy requirements for activities of daily living, house-
hold tasks, recreational activities, and vocational activities. In: Pashkow FJ,
Dafoe WA, eds. Clinical Cardiac Rehabilitation: A Cardiologist’s Guide.
Baltimore, MD: Lippincott, Williams and Wilkins; 1993: 359–376.
DeBusk RF, Haskell WL, Miller NH. Medically directed at-home rehabilita-
tion soon after clinically uncomplicated acute myocardial infarction: a new
model for patient care. Am J Cardiol 1985; 55:251–257.
De Marneffe M, Jacobs P, Haardt R, Englert M. Variations of normal sinus
node function in relation to age: role of autonomic influence. Eur Heart J
1986; 7:662.
Dubach P, Froelicher VF. Cardiac rehabilitation for heart failure patients.
Cardiology. 1989; 76:368–373.
Dubach P, Froelicher V, Klein J, et al. Use of the exercise test to predict prog-
nosis after coronary artery bypass grafting. Am J Cardiol 1989; 63:530.
Fletcher BJ, Lloyd A, Fletcher GF. Outpatient rehabilitative training in
patients with cardiovascular disease: emphasis on training method. Heart
Lung 1988; 17:199–205.
Fletcher GF, Blair SN, Blumenthal J, et al. Statement on exercise. Benefits and
recommendations for physical activity programs for all Americans. A state-
ment for health professionals by the Committee on Exercise and Cardiac
Rehabilitation of the Council on Clinical Cardiology. American Heart
Association. Circulation 1992; 86:76–84.
Cardiac Rehabilitation 144
Frick MH, Elo O, Haapa K, et al. Helsinki Heart Study: Primary prevention
trial with Gemfibrizol in middle aged men with dyslipidemia. N Engl J
Med 1987; 317:1237–345.
Froelicher VF. Exercise testing and training: clinical applications. J Am Coll
Cardiol 1983; 1:114–125.
Gordon T, Kannel WB, McGee D. Death and coronary attacks in men after
giving up cigarette smoking: a report from the Framingham study. Lancet
1974; 2:1375.
Graves EJ. 1992 Summary: National Hospital Discharge Survey. Advance data
from vital and health statistics; no. 249. Hyattsville, MD: National Center
for Health Statistics, 1994.
Guyton AC. Textbook of Medical Physiology, 7th ed. Philadelphia: W. B.
Saunders, 1986.
Hausdorf G, Banner NR, Mitchell A, et al. Diastolic function after cardiac and
heart lung transplantation. Br Heart J 1989; 62:123–132.
Heck CF, Shumway SJ, Kaye MP. The registry of the international society for
heart transplantation: sixth official report 1989. J Heart Transplant 1989; 8:
271–276.
Humphry R, Bartels MN. Exercise, cardiovascular disease and chronic heart
failure: a focused review. Arch Phy Med Rehabil 2001; 82(Suppl 1): S76–
S81.
Ignarro LJ. Endothelium derived nitric oxide: actions and properties. FASEB J
1989; 3:31–36.
Juneau M, Geneau S, Marchand C, Brosseau R. Cardiac rehabilitation after
coronary bypass surgery. (review). Cardiovasc Clin 1991; 21:25–42.
Juneau M, Rogers F, Desantos V, et al. Effectiveness of self monitored, home
based, moderate intensity exercise training in sedentary midddle aged men
and women. Am J Cardiol 1987; 60:66–70.
Kannel WB, Plehn JF, Cupples LA. Cardiac failure and sudden death in the
Framingham Study. Am Heart J 1988; 115: 869–75.
Kavanaugh T. Exercise training in patients after heart transplantation. Herz
1991; 16:243–250.
Kavanaugh T, Yacoub MH, Campbell R, Mertens D. Marathon running after
cardiac transplantation: a case history. J Cardiac Rehab 1986; 6:16–20.
Kavanaugh T, Yacoub M, Mertens DJ, Kennedy J, Campbell RB, Sawyer P.
Cardiorespiratory responses to exercise training after orthotopic cardiac
transplantation. Circulation 1988; 77:162–171.
Krone RJ. The role of risk stratification in the early management of myocar-
dial infarction. Ann Intern Med 1992; 116:223–237.
Krone RJ, Gillespie JA, Weld FM, Miller JP, Moss AJ. Low level exercise
testing after myocardial infarction: usefulness in enhancing clinical risk
stratification. Circulation 1985; 71:80–89.