Transcript Chapter 7 Slides

Exercise Management
CABG and PTCA
Chapter 07
Exercise Management – CABG and PTCA
CABG – Coronary Artery Bypass Graft Surgery
PTCA – Percutaneous Transluminal Coronary Angioplasty,
aka. Percutaneous Coronary Intervention
Coronary Artery
Occlusion
• Pathophysiology
• Coronary
Atherosclerosis
• Significant Plaque
Occlusion >75 %
• Progression of
disease requires
revascularization
Exercise Management – CABG and PTCA
• Purpose of Revascularization
• ↑Myocardial blood flow and O2
delivery beyond an obstructive
arterial lesion
• ↓ or eliminate myocardial ischemia,
including ST-segment changes,
angina, ventricular arrhythmias, or
combinations thereof
• ↓ cardiovascular mortality and
morbidity
• Movie Demonstration
PTCA (PCI)
Exercise Management – CABG and PTCA
• Indications for CABG (follows cardiac cath.)
• Relief of angina when pharmacologic therapy is
ineffective
• When PTCA is contraindicated
• Prolong life in patient with multiple artery, or
main artery disease, in patient with ventricular
dysfunction due to vascular disease
• Preserve LV function, especially following an MI
that has already compromised LV function
Exercise Management – CABG and PTCA
• CABG are performed on patients who have
multiple vessel disease and poor ventricular
function, and poor LV ejection fraction.
• Complications include infarction following surgery
and (saphenous) grafts tend to remain open 90% at
1 year, 80% at 5 years, and 60% at 11 years post
surgery.
• Mammary grafts have 93%, 10 yr patency (remain
open)
• The greatest incidence of graft occlusion occurs
between 5-8 years post surgery
• Total relief of angina is typically 70% at 5 years,
approx. 50% are asymptomatic at 10 years
Exercise Management – CABG and PTCA
• Indications and Concerns for PTCA
• Originally the choice for single vessel disease
• Now used to treat multiple vessel disease,
impaired LV function, and to open an acute
occlusion during an MI
• If PTCA fails then CABG is used during surgery
• PTCA is less invasive and requires a shorter
hospital stay
• Arterial injury, thrombosis, and restenosis are
the major complications of PTCA
• PTCA stints can now be coated with Sirolimus
to help prevent restenosis.
Exercise Management – CABG and PTCA
• Indications and Concerns for PTCA (PCI)
• Risks and Complications:
• Low risk symptomatic patients may not benefit
any more from PCI than with conservative
treatments
• PCI may involve:
• Bleeding at the catheter insertion site
• Blood clot or damage to the blood vessel at the
insertion site
• Blood clot within the vessel treated with PCI
• Infection at the catheter insertion site
• Cardiac dysrhythmias /arrhythmias
• MI
• Rupture of Coronary Artery
Exercise Management – CABG and PTCA
• Benefits of PTCA (PCI)
• Increases myocardial blood flow, thus:
• Correct ischemic complications reflected in exercise
ECG response (T wave inversion and ST-depression)
• Reduce angina on exertion
• Increase PWC (physical work capacity)
• Improve Oxygen supply and demand (MVO2) and
improve contractility and hemodynamic function
• May improve post-exercise chronotropic impairment,
and reduce the risk of hypotensive response
(reducing likelihood of pre-syncope)
Exercise Management – CABG and PTCA
• Effects of Exercise Training
•
•
•
•
Many results are similar to those with post MI
↑ Max Vo2 (mean 20%)
↓ myocardial demand (↓ Submax HR and SBP for given workload)
↑ glucose metabolism, ↓ insulin resistance, and
other typical changes in blood lipid profiles.
• In patients with stable CAD, PTCA (PCI) who
undertook a 12 month training program resulted
in a higher (event-free) survival rate. Each 1
MET increase in exercise appears to confer 817% reduction in mortality.
Exercise Management – CABG and PTCA
• Management and Medications
• Attempt to slow, halt, or reverse the progression
of atherosclerosis through medication and
health behavior management (diet, exercise,
stress management), while maintaining the
integrity of the vasculature addressed during
surgery.
• Poor prognosis includes: 1) recurrent angina, 2)
pre-syncope, syncope, and 3) threatening forms
of ventricular ectopy (multiform PVC, couplets,
V-tach )
• Repeat PTCA is the usual treatment for
restenosis.
Exercise Management – CABG and PTCA
• Recommendations for Exercise Testing
• Exercise testing may begin earlier than for post MI
patients (CABG = 3-5 weeks, PTCA 2-5 weeks)
• Cycle and Treadmill Tests commonly used with CABG
due to incision pain in the sternum area
• Retest procedures should follow for any patients who
are symptomatic within 5 years, and all patients after
five years.
• The combination of perfusion and exercise testing can
detect ischemia and restenosis.
Exercise Management – CABG and PTCA
• Recommendations for Exercise Testing
• Supine cycle ergometry and echocardiography may be
used to dectect wall function abnormalities and provide
prognostic information for risk assessment if clinical
restenosis.
• ST-segment changes, CP, or both present in the followup exercise test (2-5 weeks) may be indicative or
restenosis .
Exercise Management – CABG and PTCA
Recommendations for Programming (see chart p. 63)
• Significant increases in functional capacity and ADL will
occur in the weeks following CABG and PTCA ( improved
myocardial supply)
• CABG and PTCA patients can typically begin exercise
programming sooner and at a more accelerated rate than
post MI patients.
• ROM exercises are indicated for CABG patients and
contraindicated with excessive sternal movements.
• Individuals with > 4 MET capacity and who complete 12
week programs have less mortality risk
Exercise Management – CABG and PTCA
Recommendations for Programming (see chart p. 63)
• CABG and PTCA may begin inpatient exercise
rehabilitation sooner than post MI and;
• Progress at a more accelerated rate, and
• Devote more attention to upper extremity ROM
• CABG focused ROM - 1) Shoulder ROM exercises; 2) Hip ROM
exercises; Ankle ROM exercises.
Exercise Management – CABG and PTCA
End of Presentation