Transcript Exercise Management

Exercise Management
Atrial Fibrillation
Chapter 9
Exercise Management
Pathophysiology
• Chronic atrial fibrillation is characterized by
chaotic, rapid, and irregular atrial depolarizations. It
is one of the most common arrhythmias
encountered clinically, and it occurs more
frequently with advancing age.
• It most likely occurs by multiple reentrant circuits
within the atria.
•The irregular ventricular response can impair
hemodynamic function
Exercise Management
• Complications of Atrial Fibrillation include:
– increased risk of thromboembolic events
– rapid ventricular rates
– incomplete ventricular filling, causing reduced
cardiac output
–decreased exercise capacity and fatigue.
Exercise Management
Effects on the Exercise Response
• rapid, irregular ventricular response
• heart rate is higher (including maximal heart rate)
at any level of exercise to compensate for the
diminished stroke volume and cardiac output in
Atrial Fibrillation (AF).
• exercise tolerance is reduced (20%) in AF relative
to normal sinus patients.
• because of the variability in the diastolic filling
period, the determination of systolic blood pressure
can be difficult to assess and is poorly
reproducible.
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Effects of Exercise Training
• Patients with AF would not be expected to
have a training response particularly different
from individuals in normal sinus rhythm.
•The major concern in terms of exercise
training is the underlying heart disease,
particularly valvular disease, chronic heart
failure, and coronary artery disease.
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Management and Medications
• 24hr ambulatory monitoring / INR monitoring if on
anticoagulant
•pharmacologic intervention to maintain sinus
rhythm
•involves converting the individual to normal sinus
rhythm, or undergoing radiofrequency ablation
•when AF is chronic, strategies to control the
ventricular rate response and reduce the incidence
of stroke. There is always the risk of thrombus
/embolus formation.
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Recommendations for Exercise Testing
(see Table 9.1, p.75, slide follows)
• Maximal exercise testing can be safely used to
determine functional capabilities of the patient
• The reduction in exercise capacity associated
with AF is a direct function of the underlying heart
disease.
• Because underlying heart disease is common,
small incremental exercise test protocols should be
used.
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Recommendations for Exercise Testing
• Contraindications to exercise testing related to
underlying conditions such as stability of chronic
heart failure, valvular disease, or complex
ventricular arrhythmias should take precedence
over AF itself.
• Otherwise AF patients may be safely taken to
fatigue or shortness of breath endpoints
• Age predicted maximal heart rate targets are
particularly useless in AF because of the rapid
and highly variable ventricular response.
See also medications and precautions, p.75.
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Recommendations for Exercise Programming
There are two major factors to consider in
exercise programming:
1) concomitant or underlying heart disease
2) inherent unreliability of the pulse rate in
prescribing exercise intensity.
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Recommendations for Exercise Programming
(see Table 9.2, p. 76, next slide)
•Because AF is frequently accompanied by ischemic heart
disease, chronic heart failure, or valvular heart disease,
exercise programming considerations for these conditions
should take precedence over AF.
•Because of the chronically irregular ventricular rate,
exercise intensity should be prescribed based on METs and
perceived exertion levels.
•Because AF can be intermittent (i.e., the client may be in AF one
day and in normal sinus rhythm the next); this will effect heart rate
response to exercise, and exercise tolerance.
•Ascertain rhythm on a daily basis
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End of Presentation