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Cardiac Rehabilitation
and the High Risk Patient
Ma. Paz Mildred F. Luque, MD, FPCP, FPCC
HEART INSTITUTE
St. Luke's Medical Center
Quezon City ♥ Global City
High-risk patients

Severe LV dysfunction

Severe exercise-induced ischemia, ST-segment
depression of greater than 0.2 mV on an ECG,
multiple perfusion defects on exercise nuclear
stress testing, or multiple dyskinetic LV segments
on stress echocardiography

Complex ventricular arrhythmias or a history of
previous sudden cardiac arrest

Hypotensive response to exercise

Low functional capacity

Patient's inability to self-monitor his/her heart
rate
Components of a program

Medical evaluation

Prescribed exercise

Education

Counselling of patients with cardiac
disease
Short term goals

"Reconditioning" the patient sufficiently
enough to allow him/her to resume
customary activities

Limiting the physiologic and psychological
effects of heart disease

Decreasing the risk of sudden cardiac
arrest or reinfarction

Controlling the symptoms of cardiac
disease
Long term goals

Identification and treatment of risk factors

Stabilizing or reversing the atherosclerotic
process

Enhancing the psychological status of the
patients
Risk stratification

Assessment of the patient's functional
capacity

Educational and psychosocial status

Whether alternatives to traditional cardiac
rehabilitation can be used

Whether the patient is suffering from
myocardial ischemia, ventricular
dysfunction, or arrhythmias
Heart Failure
Limited exercise capacity

Low cardiac output

Reduced muscle blood flow

Skeletal muscle dysfunction

Deconditioning
Effects of exercise

Clinical

Enhanced peak VO2, possibly peak cardiac
output due to a higher workload achieved, and
leg blood flow during exercise

Improved muscle energetics

Improvement in symptoms
Effects of exercise

Pathophysiologic

Reduced sympathetic tone and increased
vagal tone at rest

Reduced neurohumoral activity with
decreased resting levels of angiotensin,
aldosterone, vasopressin and natriuretic
peptide

Improvement in endothelial function

Reduction in plasma levels of proinflammatory
cytokines
No ventilatory, hemodynamic,
autonomic, or clinical factor at baseline
predicts the outcome with exercise training
in patients with heart failure
Effects of exercise training

Hemodynamics


Functional capacity


Improves measures of left ventricular function
and hemodynamics
Improvement in maximal exercise tolerance
Patient outcome

Reduce heart failure related hospitalization

Improve health-related quality of life
HF Action Trial

2331 patients with left ventricular ejection
fraction ≤35 percent and NYHA class II to
IV HF

Randomly assigned to either a supervised
exercise training program or usual care
including education and recommendation
of regular exercise

Background medical therapy was
optimized

Median follow-up was 30 months
HF Action Trial

Modest but significant decrease in allcause mortality or all cause hospitalization
(after adjusting for baseline prognostic
variables) with the exercise training
program

Significant reduction in cardiovascular
mortality or HF hospitalizations

High level of safety during and after the
training sessions

Significant improvement in health status
Exercise recommendations

Patients with stable class II to class III HF
who do not have advanced arrhythmias,
and who do not have other limitations to
exercise

Exercise intensity of 70 percent of heart
rate reserve, three days per week for six to
eight weeks
Exercise guidelines

Longer warm-up period

Begin at 40 to 60 percent VO2max for
intervals of two to six minutes separated by
one to two minutes of rest

Gradually increase length of the exercise
interval by one to two minutes until the
patient tolerates 30 minutes of continuous
exercise
Self care

Actions aimed at maintaining physical
activity, avoidance of behaviors that can
worsen the condition and detection of the
early symptoms of deterioration

Linked to symptom control, functional
capacity, QOL, hospital admissions,
prognosis, reduced mortality

Precipitating factors in deterioration: nonadherence to diet or medication regimen,
inappropriate use of medications,
infections arrhythmia, ischemia
Cardiac Transplantation
Abnormal levels of
functional capacity

Marked deconditioning prior to transplant
due to heart failure

Surgical denervation

Corticosteroid therapy

Peripheral vasoconstriction
Pre-transplantatiion

For stable outpatients, exercise as an
adjunct to pharmacologic therapy during
the entire waiting period

Preferred timing of referral is during the
hospital stay for the transplant event

For patients on home inotropic therapy, a
monitored program in a cardiac
rehabilitation center
Pre-transplantation

For patients on inotropic support who are
being monitored hemodynamically, activity
will vary depending upon patient mobility

Limited data suggest that exercise training
may be beneficial in patients who receive a
left ventricular assist device (LVAD) as a
bridge to transplantation
Immediate post-op

Prior to removal of the chest tubes and
pacer wires, passive and active range of
motion plus incentive spirometry

Once out of bed in a chair, leg raising and
hip girdle exercises

Once the patient is able to stand,
ambulation is initiated

Prior to discharge, exercise on a stationary
bicycle ergometer and/or treadmill.

Predischarge cardiopulmonary exercise
test
Post-hospital prescription

Intensity

Duration

Frequency

Progression

Resistance exercise
Exercise guidelines

Exercise in 15 to 30 minute sessions three
to five times per week

Avoid repetitive lifting of greater than a few
pounds

Maintain RPE at 10 to 13
ICD
Baseline information

ICD detection threshold setting in beats per
minute

Whether the device is set for ventricular
tachycardia or ventricular fibrillation

Rapid onset setting

Sustained ventricular tachycardia settings

ICD mode of therapy

Beta-blockers
Exercise

Avoid contact sports

Swimming possible unless arrhythmia is
triggered by swimming; must be
accompanied at all times

Snorkeling not recommended

SCUBA diving should not be undertaken

Avoid exposure to strong magnetic or
electrical fields or a powerful radio source
Physical activity & exercise

Aerobic skilled flowing movement,
muscular endurance, flexibility

Progress slowly

Monitor intensity using heart rate or
perceived effort

Warm up and cool down

Avoid static exercise when you are holding
tight or resisting strongly and holding your
breath

Most exercise should be performed
standing
Physical activity & exercise

Most exercise should be performed
standing

Avoid excessive shoulder range movement
and or highly repetitous vigorous range
movements

Continuous physical activity of 30 minutes
or more most days of the week
Chronic Kidney Disease
Cardiovascular Disease

Leading cause of death regardless of CKD
stage

As renal function declines, all cause and
cardiovascular mortality increases
exponentially

40% of patients with established CVD have
concomitant CKD

Worse prognosis

Worse revascularization outcomes

Higher procedural complication rates
CVD risk factors and CKD

Traditional risk factors are rampant in the
CKD population

U-shaped mortality curve associated with
cholesterol and hypertension levels with an
increased risk of death for both extremes
of measurement

Qualitatively and quantitatively different
risk factor exposure

Burden of CKD-associated non-traditional
risk factors
Physical fitness and CKD

Limited physical function across amny
subjective and objective domains

Deficits in measures of cardiopulmonary
fitness (walking distance/time, treadmill,
cycle ergometry) and strength

Association between declining exercise
performance and creatinine over time,
independent of hemoglobin level
Beneficial effects

Physical fitness

Blood pressure

Psychosocial
function

Lipid parameters

Hemoglobin levels

Measures of
arterial stiffness

Quality of life

Cardiorespiratory
parameters

Renal functional
parameters
Barriers to participation

Socio-economic

Logistic

Patient-related

Biased referral
patterns
Special considerations


Hemoglobin

Direct relationship with exercise capacity

Treatment with erythropoesis-stimulating
agents (i.e., erythropoietin) improves exercise
capacity and VO2 peak
Strength training and resistance exercises

Intrinsic muscle changes contribute more to
poor performance than do limitation in oxygen
supply

1997 study showed strength training alone
can improve VO2 peak in CKD patients
Psychological stressors and
adjustments

Higher stress levels

Alteration in social and role responsibilities,
dependence and interdependence issues
and uncertainty about the future

Intensify as CKD progresses and need for
renal replacement therapy draws nearer

Cardiac rehabilitation provides an
opportunity to foster coping skills and help
patients adjust to these stressful changes
Dietary counseling

Maintenance of optimal nutrition

Prevent or minimize metabolic
derangements of CKD

Retard the progression of renal failure
Cardiac rehabilitation & CKD

Regular structured exercise

Dietary intervention

Psychosocial counselling

Life skills and coping skills retraining

Pharmacologic intervention
Elderly
Elderly

High risk of disability after coronary event or
hospitalization for heart failure

Complications of MI and myocardial
revascularization are more frequent at an
advanced age

Prolonged hospitalization leads to
deconditioning

Less referral to and participation in cardiac
rehabilitation
Physical activity

Improvements in gait, balance, overall
functional capacity and bone health

Increase quality of life
Physical activity

Cardiovascular fitness

At least 30 minutes of moderate intensity
exercise on most, if not all, days of the week

Exercise mode that does not impose excessive
orthopedic stress; and is accessible, convenient
enjoyable

Start low and individually progress according to
tolerance and preference

Measured peak heart rate preferable to agepredicted heart rate because of underlying CAD
Physical activity

Resistance training

Begin first 8 weeks with little resistance

One-set of 8-10 multi-jointed exercises that
include all major muscle groups

Set should include 15 repetitions at RPE of 1213

Number of repetitions increased before the
resistance
Physical activity

Flexibility

Improvement in ability to perform ADL, balance
and agility

Reduction in injury potential

For every major joint of the body, at least 2 to 3
times per week
Thank you
for your kind attention