Transcript Cardiac rehabilitation

p. 470 - 491
•Regain full physical, psychological and social status
•Optimize long-term prognosis
•To promote and implement secondary prevention
measures
Exercise training, education sessions, psychosocial
support and support/counselling for patient and family
in acute phase, out-patient care and long-term followup.
•Decrease cardiac morbidity and relieve symptoms
•Risk modification and secondary prevention
•Decrease anxiety and increase knowledge and self-
confidence
•Increase fitness and ability to do normal activities
•Reassurance, support and information
•Behavioural change
•Exercise programme
Phase I
in-hospital (3-5 days)
Phase II
post discharge (2-6 weeks)
Phase III
outpatient programme (6-12 weeks)
Phase IV
long-term maintenance in community
For all cardiac
patients who
would benefit
Interdisciplinary team of
professionals involved in
rehabilitation
•Increased cardiovascular endurance is the main aim
•Endurance training = activity using large muscle
groups, can be sustained for a prolonged period and is
rhythmic and aerobic resulting in an increase in
maximal oxygen uptake.
•Maximal oxygen uptake (VO2 max) is limited centrally
by cardiac output and peripherally by the capacity of
muscles to extract oxygen from the blood.
In healthy people = endurance training causes increase
in CO as a result of increase in SV. Achieved by:
•Increased left ventricular mass and size
•Increased total blood volume
•Reduced peripheral resistance
Training-induced changes in muscles:
•Increased number and size of mitochondria
•Increased oxidative enzyme activity
•Increased capillarization
•Increased myoglobin
In cardiac patients increase in VO2 max mostly
because of peripheral changes – high intensity
exercises needed for central changes – inappropriate.
Repeated submaximal daily activities – less
physiological stress (decreased heart rate, blood
pressure and plasma catecholamine concentrations)
Risk factor modification
The factors that contribute to disease, can influence progression
and future events.
Exercise in healthy people
cause:
Exercise reduces triggers in
cardiac events:
 Raised metabolic rate
 Prevents thrombus
 Increased synthesis of
formation
 Improves endothelial
function
 Reduces potential for
serious arrhythmias
HDL
 Improved insulin
sensitivity
 Decreased blood pressure
Exercise prescription
 Individuality
 Progressive overload
 Regression – “use it or lose it”
 Specificity – FITT-principles
Exercise intensity
Maximum or symptom-limited exercise ECG
60-75% of HRmax
10-20 beats below heart rate
that elicits symptoms
Exercise intensity
No ECG
Age-adjusted prediction
40-65% of HRR
Exercise intensity
Borg 15-point scale or Borg CR10 scale
MET’s
Warm-up
Preparation for activity
15 minute
Low impact, dynamic movements of large muscle groups
Take all major joints through normal ROM
Will delay onset of ischaemia by allowing enough time
for coronary blood to flow in response to greater
myocardial workload
Lessen risk of arrhythmias
Heart rate 20 bpm lower than lower end of prescribed
training heart rate after warm-up ( 3 or 10-11 on Borg)
Aerobic exercises
Continious or interval approach
Interval approach – total volume of work done more,
stimulus for physiological change is greater
Circuit training – station 30s to 2 minutes
Individualisation – duration of station, intensity, period
of rest and overall duration (increase duration before
intensity)
Aerobic exercises
Exercise in lying not advised because:
Older patients have difficulty with transfers
Increase in venous return – increases pre-load and
myocardial load – increased risk of arrhythmias and
angina
Orthostatic hypotensive episodes
Resistance training
Not previously used in cardiac patients:
increased blood pressure
increased myocardial workload
reduced ejection fraction and increased incidence in
arrythmias, BUT also
increased diastolic pressure with better myocardial
perfusion
10-15 repititions to moderate fatigue, 8-10 exercises
Cool down
10 minutes of movements of diminishing intensity and
passive stretches of major muscles because:
increased risk of hypotension
in older patients heart rate takes longer to reach pre-
exercise rates
raised sympathetic activity after exercise – arrhythmias
Patient observation for 30 minutes after exercises
Programme implementation
In-hospital
Acute MI, coronary bypass surgery, unstable heart failure
First 24-48 hours - breathing exercises
simple arm and leg ROM exercises
limited self-care activities
Over the next 2-3 days -
sit out of bed
take short walks
shower and dress
Programme implementation
In-hospital and post-discharge
By discharge patients should know signs and symptoms of
excessive exertion and rate level of exertion
Home exercise programme for first 6 weeks, mostly walking
Contact and telephonic follow-ups with rehabilitation
services
FITT:
F + Time = 5-10 minutes, 2-3x daily and later
5-20 minutes, 1-2x daily
I = RPE < 11
Programme implementation
Outpatient exercise programme
Patient should be seen by physician or cardiologist
before exercising
Patient safety during exercising very important
Assessment of heart rate and blood pressure at rest and
during exercising, RPE etc.
Risk factors for exercise
Patients should not exercise if not feeling well, symptomatic or
unstable on arrival or with the following:
 Fever, acute systemic
 Symptomatic hypotension
illness
 Unresolved/unstable
angina
 Blood pressure systolic >
200 mmHg and diastolic >
110 mmHg
 Unexplained drop in blood
pressure
 Tachycardia
 Arrhythmias
 Breathlessness, lethargy,
palpitations, dizziness
 Unstable heart failure,
weight gain > 2 kg in 2 days
 Unstable/uncontrolled
diabetes
Programme management
All staff competent, appropriate skills and training,
regularly updated
Appropriate emergency equipment, checked regularly,
policy for handling emergency situations, appropriate
venue
Patient education important - aims and exercise goals
safety
use of equipment
Programme management
Patients and families should know the following:
Signs and symptoms of exertion
Importance of warm-up and cool-down
Caution with isometric activities
Issue e.g. excessive heat/cold, dehydration
Avoid exercising after heavy meal, if ill an when tired
Remain for 30 min after exercise for observation
Excessive use of arm/upper body work results in higher
systolic and diastolic blood pressure than the same work
by legs
FITT-principles
F:
1-2x per week rehabilitation class
2x per week home-based exercises
walking the other days
I:
aerobic exercises, 40-65% HRR or 60-75% HRmax
resistance training, 10-15 repetitions to moderate
fatigue, 8-10 exercises, 2-3 times per week
FITT-principles
T:
Aerobic, interval approach
T:
5-10 min, progress to 20-30 minutes
warm-up 15-20 minutes
cool down > 10 minutes
Long-term community based exercise
programme
Patient must be able to manage himself regarding
exercises
Community-based instructor