Cardiac Rehabilitation

From Anvita Health Wiki

Contents 1 Introduction 2 Indications 3 Clinical-significance 4 Procedure 5 Complications 6 More General Terms 7 Additional Terms 8 References

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
• coronary angioplasty
• 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

Clinical-significance

• Benefits:

• decreased mortality
• peripheral training effects
• myocardial training effects?
• risk factor modification

• weight loss
• 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 [2,3]
  

• 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

• cardiology
• rehabilitation

Additional Terms

• exercise tolerance testing (ETT)
• myocardial perfusion & viability scintigraphy

References

1. Genova, A, UCLA Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 12-15, 2001
2. 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: &dopt=Abstract
3. 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: [1]
4. 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: [2]
5. National Guideline Clearinghouse Cardiac rehabilitation. (New Zealand) ngc-guideline: [3]
   - Cardiac rehabilitation. A national clinical guideline. ngc-guideline: [4]

cardiac rehabilitation