cardiac rehabilitation
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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[11]
- acute coronary syndrome[17]
- PCI, coronary angioplasty, coronary stent placement
- coronary artery bypass graft (CABG)
- valve repair/replacement[13]
- angina
- cardiomyopathy
- cardiac transplant
- myocardial infarction
- 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[5]
- heart failure[18]
- frail elderly benefit the most from intensive physical cardiac rehabilitation after hospitalization for acute heart failure[18]
- abnormal exercise stress test that does not meet criteria for a positive test[5]
Clinical significance
Benefits:
- decreased mortality
- improves functional capacity[17]
- peripheral training effects
- myocardial training effects?
- improved emotional & behavioral outcomes[5]
- reduction in cognitive impairment (improved cognitive function)*[5]
- decrease in symptoms of depression*[5]
- improves medication adherence[17]
- improves risk factors
- weight reduction
- improved lipid profile
- decreased blood pressure
- improved glucose utilization
* benefits of home-based cardiac rehabilitation
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
- 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
- goals
- phase 3: long-term outpatient
- less intensely supervised
- maximum of 10 patients/therapist
- phase 4: home/community gym
- home-based cardiac rehabilitation as effective but not more effective than hospital/medical center-based rehabilitation[2][3][5][8]
- home-based cardiac rehabilitation is a reasonable option for patients with cardiovascular disease at low-to-moderate risk[12]
- 12-week program with personalized, one-on-one training from a physical therapist
- continued elements of program at home out to 6 months[14]
- improvements in balance, walking ability, & strength, followed by gains in 6-minute walk & measures of physical functioning, frailty, & quality of life[14]*
- benefits more pronounced in patients LV diastolic dysfunction (HFpEF)[14]
- death & rehospitalizations unaffected[14]
- 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
- 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
- target heart rate:
- 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
- outflow tract obstruction
- exacerbation of congestive heart failure
- uncontrolled diabetes
More general terms
More specific terms
References
- ↑ Genova, A, UCLA Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 12-15, 2001
- ↑ 2.0 2.1 Oerkild B et al Home-based cardiac rehabilitation is as effective as centre- based cardiac rehabilitation among elderly with coronary heart disease: results from a randomised clinical trial. Age Ageing. 2011 Jan;40(1):78-85. Epub 2010 Sep 15. PMID: https://www.ncbi.nlm.nih.gov/pubmed/20846961
- ↑ 3.0 3.1 Clark AM et al A meta-analysis of randomized control trials of home-based secondary prevention programs for coronary artery disease. Eur J Cardiovasc Prev Rehabil. 2010 Jun;17(3):261-70 PMID: https://www.ncbi.nlm.nih.gov/pubmed/20560165
- ↑ Dalal HM, Zawada A, Jolly K, et al Home-based versus centre-based cardiac rehabilitation: Cochrane systematic review and meta-analysis. BMJ. 2010 Jan 19; 340:b5631 PMID: https://www.ncbi.nlm.nih.gov/pubmed/20085991
- ↑ 5.0 5.1 5.2 5.3 5.4 5.5 5.6 Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013
Geriatric Review Syllabus, 9th edition (GRS9) Medinal-Walpole A, Pacala JT, Porter JF (eds) American Geriatrics Society, 2016
Geriatric Review Syllabus, 11th edition (GRS11) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2022 - ↑ Ferrara N, Corbi G, Bosimini E et al Cardiac rehabilitation in the elderly: patient selection and outcomes. Am J Geriatr Cardiol. 2006 Jan-Feb;15(1):22-7. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/16415643
- ↑ Suaya JA, Stason WB, Ades PA et al Cardiac rehabilitation and survival in older coronary patients. J Am Coll Cardiol. 2009 Jun 30;54(1):25-33. PMID: https://www.ncbi.nlm.nih.gov/pubmed/19555836
- ↑ 8.0 8.1 Taylor RS, Dalal H, Jolly K Home-based versus centre-based cardiac rehabilitation. Cochrane Database Syst Rev. 2015 Aug 18;(8):CD007130. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/26282071
- ↑ Menezes AR, Lavie CJ, Forman DE et al Cardiac rehabilitation in the elderly. Prog Cardiovasc Dis. 2014 Sep-Oct;57(2):152-9. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/25216614
- ↑ Lawler PR, Filion KB, Eisenberg MJ. Efficacy of exercise-based cardiac rehabilitation post- myocardial infarction: a systematic review and meta-analysis of randomized controlled trials. Am Heart J. 2011 Oct;162(4):571-584.e2. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21982647
- ↑ 11.0 11.1 Fang J, Ayala C, Luncheon C, Ritchey M, Loustalot F. Use of Outpatient Cardiac Rehabilitation Among Heart Attack Survivors - 20 States and the District of Columbia, 2013 and Four States, 2015. MMWR Morb Mortal Wkly Rep 2017;66:869-873 https://www.cdc.gov/mmwr/volumes/66/wr/mm6633a1.htm
- ↑ 12.0 12.1 Thomas RJ, Beatty AL, Beckie TM et al Home-Based Cardiac Rehabilitation. A Scientific Statement From the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Heart Association, and the American College of Cardiology. Circulation, May 2019 PMID: https://www.ncbi.nlm.nih.gov/pubmed/31082266 https://www.ahajournals.org/doi/pdf/10.1161/CIR.0000000000000663
- ↑ 13.0 13.1 Patel DK, Duncan MS, Shah AS et al Association of Cardiac Rehabilitation With Decreased Hospitalization and Mortality Risk After Cardiac Valve Surgery. JAMA Cardiol. Published online October 23, 2019. PMID: https://www.ncbi.nlm.nih.gov/pubmed/31642866 https://jamanetwork.com/journals/jamacardiology/article-abstract/2753611
- ↑ 14.0 14.1 14.2 14.3 14.4 Stiles S Novel Rehab Program Fights Frailty, Boosts Capacity in Advanced HF. Medscape - May 16, 2021. https://www.medscape.com/viewarticle/951244
- ↑ O'Neill D, Forman DE. Never too old for cardiac rehabilitation. Clin Geriatr Med. 2019;35(4):407-421 PMID: https://www.ncbi.nlm.nih.gov/pubmed/31543175 PMCID: PMC7241425 Free PMC article https://www.geriatric.theclinics.com/article/S0749-0690(19)30049-7/fulltext
- ↑ Schopfer DW, Forman DE. Cardiac rehabilitation in older adults. Can J Cardiol. 2016;32(9):1088-1091 PMID: https://www.ncbi.nlm.nih.gov/pubmed/27297002 https://www.onlinecjc.ca/article/S0828-282X(16)00226-9/fulltext
- ↑ 17.0 17.1 17.2 17.3 Medical Knowledge Self Assessment Program (MKSAP) 19 American College of Physicians, Philadelphia 2022
- ↑ 18.0 18.1 18.2 Kitzman DW, Whellan DJ, Duncan P et al Physical Rehabilitation for Older Patients Hospitalized for Heart Failure. N Engl J Med. 2021 Jul 15;385(3):203-216 PMID: https://www.ncbi.nlm.nih.gov/pubmed/33999544 PMCID: PMC8353658 Free PMC article https://www.nejm.org/doi/10.1056/NEJMoa2026141
Pandey A, Kitzman DW, Nelson MB et al. Frailty and effects of a multidomain physical rehabilitation intervention among older patients hospitalized for acute heart failure: A secondary analysis of a randomized clinical trial. JAMA Cardiol 2023 Jan 4; [e-pub]. PMID: https://www.ncbi.nlm.nih.gov/pubmed/36598761 PMCID: PMC9857661 (available on 2024-01-04) https://jamanetwork.com/journals/jamacardiology/fullarticle/2799721