cardiac rehabilitation

Introduction

Use of counseling, education, nutrition & exercise to develop & maintain a desirable level of physical, social & psychologic functioning after onset of cardiovascular illness.

Indications

• precipitating events
  • myocardial infarction
    • only 1/3 of survivors undergo cardiac rehabilitation after myocardial infarction
  • acute coronary syndrome
  • PCI, coronary angioplasty, coronary stent placement
  • coronary artery bypass graft (CABG)
  • valve repair/replacement
  • angina
  • cardiomyopathy
  • cardiac transplant
• contributing factors
  • hypertension
  • peripheral vascular disease
  • medically complex patients, taking multiple cardiac or other medications
  • patients with multiple cardiac risk factors
• stable coronary artery disease
  • including those with myocardial ischemia
• heart failure
  • frail elderly benefit the most from intensive physical cardiac rehabilitation after hospitalization for acute heart failure
• abnormal exercise stress test that does not meet criteria for a positive test

Clinical significance

Benefits:

• decreased mortality
• improves functional capacity
  • peripheral training effects
  • myocardial training effects?
• improves medication adherence
• improves risk factors
  • weight reduction
  • improved lipid profile
  • decreased blood pressure
  • improved glucose utilization

Procedure

Objectives:

• prevent adverse effects of prolonged bedrest
• identify/modify chronic risk factors
• facilitate return to lifestyle/work
• provide medical survellance during recovery
• facilitate psychological/social adaptation

Program Structure:

• phase 1: acute hospitalization
  • education goals
    • self assessment of response to exertion
    • symptom recognition
    • risk factors/modification
    • appropriate home exercise
• phase 2: immediate outpatient
  • goals
    • adequate fitness for daily life/occupation
    • normal hemodynamic response to exercise
    • normal or unchanged EKG at peak exercise
    • satisfactory understanding of:
      • cardiovascular disease
      • medications
      • risk factors
    • appropriate execution of exercise
    • recognition of adverse symptoms of exercise
• phase 3: long-term outpatient
  • less intensely supervised
  • maximum of 10 patients/therapist
• phase 4: home/community gym
• home-based cardiac rehabilitation as effective as hospital/medical center-based rehabilitation
• home-based cardiac rehabilitation is a reasonable option for patients with cardiovascular disease at low-to-moderate risk
• 12-week program with personalized, one-on-one training from a physical therapist
  • continued elements of program at home out to 6 months
  • improvements in balance, walking ability, & strength, followed by gains in 6-minute walk & measures of physical functioning, frailty, & quality of life*
  • benefits more pronounced in patients LV diastolic dysfunction (HFpEF)
  • death & rehospitalizations unaffected

Risk stratification:

• low risk
  • uncomplicated clinical course in hospital
  • no evidence of myocardial infarction
  • functional capacity > 7 METS on ETT*
  • normal left ventricular function (LVEF > 50%)
  • no significant ventricular ectopy
• intermediate risk
  • ST segment depression 2 mm flat or downsloping
  • reversible defects on myocardial perfusion study
  • moderate to good left ventricular function (LVEF > 35-40%)
  • changing pattern or new onset of angina
• high risk
  • prior myocardial infarction, involving 35% or more of left ventricle
  • LVEF < 35% at rest
  • fall in systolic blood pressure during exercise, or failure to rise > 10 mm Hg
  • functional capacity < 5 METS, with
    • hypotensive blood pressure response, or
    • >= 1 mm ST segment depression
  • ST segment depression 2 mm or more at peak heart rate of 135/min or less
  • high-grade ventricular ectopy
  • congestive heart failure while in hospital

* ETT: exercise tolerance testing

Exercise prescription:

• intensity of exercise
  • target heart rate:
    • resting heart rate + 10-20 bpm
    • Karvonen formula: rest* + (desired % of rest) x max rest: resting heart rate; max maximum heart rate
  • keep heart rate below ischemic threshold
  • beta blockade
• mode
  • treadmill walking
  • exercise cycling
  • resistance training ( avoid after CABG)
• frequency: generally 3 times/week
• duration:
  • goal: 20-30 minutes of aerobic exercise 3 times/week
  • high risk: start with 7-10 minute session
• levels of monitoring
  • high risk: blood pressure monitoring
  • high risk: telemetry, phase 2
• special precautions
  • avoid upper extremity resistance exercise after CABG
  • appropriate warm up & cool down

Complications

Red Flags:

• outflow tract obstruction
  • aortic stenosis
  • hypertrophic obstructive cardiomyopathy
• exacerbation of congestive heart failure
• uncontrolled diabetes

More general terms

• rehabilitation

More specific terms

• cardiopulmonary rehabilitation