Cardiac Rehabilitation

Presented by-
Dr. Jheelam Biswas
Resident, Phase A
Palliative Medicine, BSMMU
What is cardiac rehabilitation
The term cardiac rehabilitation refers to
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 processes, thereby reducing
morbidity and mortality.
Core components

Source: British Association for Cardiovascular Prevention and

Outcomes: 1996 AHCPR Guidelines
 Smoking cessation
 Lipid management
 Weight control
 Blood pressure control
 Improved exercise tolerance
 Symptom control
 Return to work
 Psychological well-being/ stress management
Members of a cardiac rehab team
Cardiologist
SpecialistNurse
Physiotherapist
Dietitian
Psychologist
Exercise specialist
Occupational therapist
Indications
Post-MI
Post-CABG
Angina
PCI, PTCA
Valve replacement or repair
Heart transplant
Compensated CHF

(Source: Medcare, American Heart Association)

Phases of cardiac rehabilitation
Acute Phase (Phase I)
Convalescent Phase (Phase II)
Training Phase (Phase III)
Maintenance Phase (Phase IV)
 Phase I
Acute phase
Definition
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.
Objectives
Early mobilization and adequate discharge
planning.
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.
Mobilization- Post MI
The classic Wenger cardiac rehabilitation
program was to get individuals from bed rest to
climbing 2 flights of stairs in 14 days.

Under current practices, clinicians have

modified the classic program of cardiac
rehabilitation in of 3–5 days .
Steps of mobilization
Day 1-2 : bed rest, bed mobility, sitting on the
bed, breathing exercises
Day 3: short distance ambulation and bathroom
privileges with monitoring
Day 4-5: home exercise program, climbing
stairs, and increasing duration of ambulation.
Intensity: Post MI HR 20bpm and SBP
20mmhg from base line, RPE <13 in a 6-20
Borg scale (old scale)
Mobilization – Post PTCA
◦ May ambulate at comfortable pace following
surgery
◦ Avoid aerobic training for 2 weeks post-op
◦ Exercise prescription to be based on post-op
ETT results
◦ Often progress faster than MI patients
Patient and family education
Cardio-protective therapies
Anti-platelet therapy
Lipid-lowering therapies
Beta-blockers (Post myocardial infarction)
ACE inhibitors/ARBs
Calcium channel blockers
 Anticoagulants if necessary
Diuretics if necessary (e.g. heart failure)

( Source: British Association for Cardiovascular

Prevention and Rehabilitation)
Risk factors management
Initially-
 Lipid management
 Hypertension management
 Diabetes management

Advice about-
 Smoking / Tobacco cessation
 Lifestyle modification
 Stress management
 Lipid management
Goal:LDL<100 mg/dl (<70 mg/dl is desirable),
HDL >40 mg/dl, TC >200 mg/dl, TG <150 mg/dl

Intervention: If LDL > 100 mg/dl, advice

nutritional counseling and weight reduction and
Statins are prescribed.
If HDL < 40 mg/dl, advice exercise, smoking
cessation.
Hypertension management
Goal: Optimal BP is < 120/80 mmHg

Intervention: If BP >130/80 mmHg advice

about lifestyle modification before discharge .
Add drug therapy for patients with diabetes,
heart failure, or renal failure.
If BP > 140/90 mmHg advice lifestyle
modification and initiate drug therapy.
Diabetes management
Goal: Near normal fasting plasma glucose(< 7
mmol/l) and near normal HbA1 C (<7)

Intervention: Appropriate hypoglycemic

therapy e.g. diet modification, oral
hypoglycemic agents and/or insulin
Psychosocial management
Survival kit before discharge
Clear information about medication
Clear advice on managing chest pain and
reassurance
Advice and information on ‘what and when
they can do’ (work, travel, exercise etc)
 Phase II
Convalescent Phase
Definition
This phase encompasses the immediate post
discharge period, which is typically a period of
four to six weeks.
Objectives
It focuses on health education and resumption
of physical activity, however the structure of this
phase may vary dramatically from centre to
centre.

Itmay take the format of - telephone follow up,

home visits, or individual or group education
sessions.
Assessment before phase II rehabilitation

 Vitals(HR, BP, RR and rhythm, RPE, O2 sats, pulses)

 Dyspnea
 Auscultation of lungs
 Edema
 Surgical sites
 Heart rhythm via ECG if monitored
 Pain
 Posture
 Strength
 Medications and effects
Exercise guidelines
Frequency: 3 times /wk,
Duration: 30-60 minutes (5-10 min of warm-up
and cool down)
Mode: walking and/or cycle/arm ergometer and
strength training
Intensity: Submaximal, or determined by ETT
data upto a level of 70% maximum HR or MET
level 5 or RPE 7 in modified Borg scale.
Exercise guidelines (cont..)
• Strength training
begin at 3 weeks cardiac rehab, 5 weeks post
MI, 8 wks post CABG
Begin with bands and light weights (1-3 lbs)
Progress to moderate loads, 12-15 reps
Risk factor management
Itincludes the risk factors addressed as in the
phase I.
Lipid, hypertension and diabetes management
must be continued as in phase 1.
Active initiation of smoking cessation, and
weight reduction.
Psycho-Social Rehabilitation
Common psychological reactions: low mood,
tearfulness, sleep disturbance, irritability,
anxiety, acute awareness of minor somatic
sensations or pains, poor concentration and
memory.

Proper counseling must be done. Seek

professional help if needed.
 Phase III
Training Phase
Definition
This phase is sometimes erroneously referred to
as the ‘Exercise’ phase. The duration of Phase 3
may vary from six to 12 weeks.

Itincorporates exercise training in combination

with ongoing education and psychosocial and
vocational interventions.
Objectives
Functional goals – Exercise training under
supervision
Psychosocial goals – Return to work, return to
hobbies and lifestyle, anxiety/depression
management
Secondary preventive targets
Components
Assessments before phase III rehab
Clinical risk stratification is suitable for low to
moderate risk patients undergoing low to
moderate intensity exercise.

 Low level ETT and ECHO are recommended

for high risk patients and/or high intensity
exercise.
Assessments (cont…)
Vitals: PR, RR, BP, SpO2, ECG findings
 Respiratory, cardiovascular, CNS system
examination
Weight
Waist circumference
 Lipids
Blood Glucose/HbA1C
Risk stratification before exercise
Ischemic risk-
 Postoperative angina
 LVEF (EF <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 ectopic with exercise
 Myocardial ischemia with exercise
Risk stratification before exercise
Arrhythmic risk-
 Acute infarction within 6 weeks
 Active ischemia by angina or exercise testing
 Significant left ventricular dysfunction (LVEF
<30%)
 History of sustained VT
 History of sustained life-threatening SVT
 Initial therapy of a patient with a rate adaptive
cardiac pacemaker
Exercise prescription
The Modified Borg RPE (rate of perceived
exertion) scale and % HRmax (220- age of the
person) are considered during prescription of
exercise.

In low risk patients, a program to achieve 85%

of the maximum HR is safe. But in the patients
with risk of angina or arrhythmia, achievement
of HRmax as low as 60% is safe.
 Rate of Perceived Exertion (RPE)*

Sing – Talk –Gasp Test Maximal

10 very, very hard

9
Gasp: breathing heavily 8
7 very hard
6

5 hard
Talk: enough breath to carry a conversation 4 somewhat hard
3 moderate

2 easy
1 very easy
Sing: Enough breath to sing 0.5 very, very easy
0 nothing at all

*Modified Scale adapted by Borg

Heart Failure
 Criteriafor exercise-
Medically stable
Exercise capacity >3 METS
 Exercise training-
Prolonged Warm up and cool down
Low intensities (40-60%)
Increase duration as tolerated
Maintain HR below 115 bpm
Monitor RPE: fairly light
Avoid isometrics
May include light resistance
 Exercise Modalities in Heart Failure
(2013 Candian Heart failure management guideline)

Discharged with
Heart Failure NYHA I-III NYHA IV
Flexibility Exercises Recommended Recommended Recommended
Aerobic Exercises
• Suggested modality •Selected population only • Walk •Selected population only
•Supervision by an expert • Treadmill •Supervision by an expert
team needed • Ergocycle team needed
• Swimming

• Intensity Continuous training:

Moderate intensity:
• RPE scale 3-5,or
• 65-855 HRmax, or
• 50-75% peak VO2
Moderate intensity aerobic interval may be incorporated in
selected patients
• Intervals of 15-30 seconds with a RPE scale of 3-5
• Rest intervals of 15-30 seconds

• Frequency • Starting with 2-3 days/week

• Goal: 5 days/week
• Selected population only • Starting with 10-15 minutes •Selected population only
• Supervision by an expert • Goal: 30 minutes •Supervision by an expert
team needed team needed

Isometric/Resistance
Exercises

• Intensity • 10-20 repetitions of 5-10 pounds free weights

• Frequency • 2-3 days/week
STOP Exercise

◦ Persistent dyspnea
◦ Dizziness/confusion
◦ Onset of angina
◦ Leg claudication
◦ Excessive fatigue, pallor, cold sweat
◦ Ataxia, incoordination
◦ Bone/joint pain
◦ Nausea/vomiting
◦ Systolic BP>200 mmHg, Diastolic BP >110 mmHg
◦ Significant changes in ECG
Contraindications of exercise training
 Unstable angina
 Resting systolic BP (SBP) > 200 mm Hg or resting
Diastolic BP (DBP) > 110 mm Hg . Orthostatic BP drop
of >20 mm Hg with symptoms.
 Critical aortic stenosis
 Uncompensated CHF.
 3rd degree atrioventricular (AV) block wihout pacemaker.
 Active pericaditis or myocarditis.
 Recent embolism
 Thrombophlebitis
 Resting ST-segment depression or elevation (> 2mm)..
 Metabolic conditions, such as uncontrolled DM, acute
thyroiditis, hypokalemia, hyperkalemia or hypovolemia
Lifestyle modification
Patients must be regularly monitored for DM,
HTN control in very visit, and change in drug
therapy and exercise as needed. Blood lipids
must be monitored 2 months after initiation of
drug therapy.

Diet modification, smoking cessation and

weight reduction, stress management must be
addressed.
 Nutritional Counseling
 Recommended diet low in fat (especially saturated
fat), and high in complex carbohydrates .

 Diet should consist of 50-60% calories from

carbohydrates, up to 30% from fat (with saturated
fat forming 10% or less), and 10-15% from
protein.

 Individualized plans should be formulated,

depending on the presence of other risk factors.
Weight management
Goal: BMI 21-25 kg/m2 , waist < 35 inches in
men and < 31 inches in women.

Intervention: Advice a reduction in total caloric

intake, and increase in energy expenditure
through a combined program of diet, and
exercise.
Initially reduction of weight 10% from baseline
is indicated. If successful, then further reduction
can be advised.
Smoking/ Tobacco cessation
Goal: Complete cessation

Intervention: Provide individual education and

counseling. Encourage patient to quit in every
visit.
Provide nicotine replacement and
pharmacological therapy as appropriate.
Return to Work
Although improvement in functional capacity
and the associated reduction in cardio-
respiratory symptoms may enhance a cardiac
patient’s ability to return to work.

The time to return to work, after an MI can vary

greatly from about two weeks, to upwards of six
weeks.
 Phase III
Maintenance Phase
Definition
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

program and continue exercise and other
lifestyle modifications indefinitely.
Objectives
Maintenance of achieved functional status
Return to work
 Return to hobbies and lifestyle modifications
Secondary preventive targets
Exercise
The exercises need to be integrated into the
patient’s lifestyle and interests to assure
compliance.

The ongoing exercises should be performed at

the target HR for at least 30 minutes, three times
a week, if at a moderate level. If at a low level,
exercises need to be performed five times a
week.
Secondary prevention
The secondary prevention measures also need to
be integrated into the patient’s lifestyle.

Thecontinued control and monitoring of DM,

HTN, lipids must be ensured.
Patient and family
responsibilities
 Self care and self management in emergency
situations
 Family must help the patients to adhere to their
long term managements.

 Patients are often encouraged to join-

 local heart support groups
 community exercise and activity groups
community dietetic and weight management
services
 smoking cessation services.
Special conditions
Stable angina
 Full-level ETT should be done in order to
determine the maximum HR, and angina
threshold.

 The program of rehabilitation can begin at phase

III (training).

 The primary goal of rehabilitation in this group

of patients is aimed at increasing work capacity
and education in primary/secondary prevention
strategies.
Post-CABG
Cardiac rehabilitation after CABG has two
stages:
 Immediate postoperative period
 Later maintenance stage.

• In-hospital period lasts 5–7 days.

• At-home program is usually conducted as an
outpatient procedure, and intensity of exercise is
determined according to risk stratification.
Valvular Heart Disease
In valvular heart disease, the major problem is
often deconditioning along with CHF.
In patients receiving surgical correction of the
valvular disease, a post-CABG-type program is
used.
In uncorrected valvular heart disease with heart
failure, the program resembles the program for
CHF.
Cardiomyopathy
Dynamic exercise is preferred with a target HR
10 bpm. Isometric exercise should be avoided
where possible, and limited to 2-minute
intervals when performed.

Unstable angina, decompensated CHF, and

unstable arrhythmias are contraindications to
cardiac rehabilitation.
Pacemakers
Should know setting for HR limit
Use RPE
ST segment changes may be common
Avoid aerobic or strengthening exercises
initially after implant
Cardiac Transplant
HR alone is not an appropriate measure of
exercise intensity (heart is denervated).
◦ Use RPE, METS, dyspnea scale, BP

Use longer periods of warm-up and cool-down

because the physiological responses to exercise
and recovery take longer
Benefits
Reduces cardiovascular and total mortality
Improves myocardial perfusion
May reduce progression of atherosclerosis when
combined with aggressive diet
Improves exercise tolerance without significant
CV complications
 Improves skeletal muscle strength and
endurance in clinically stable patients
Promotes favorable exercise habits
Decreases angina and CHF symptoms
Thank You…