Cardiac rehabilitation

Ahmad Osailan

What is cardiac rehabilitation

• is a sum of coordinated interventions required to ensure best physical, psychological and social wellbeing, so that patient with chronic or acute post CVD, by their own effort can resume optimal functioning in society through improved health behaviour to slow or reverse the progression of the disease

Mission of Cardiac Rehab

To restore and maintain an individual’s optimal physiological, psychological, social

wellbeing.

Target Groups

Coronary heart disease (CHD)– Exertional angina .– ACS (unstable angina or NSTEMI or STEMI)

following medical/surgical management.– Revascularisation– Stable heart failure and cardiomyopathy

Those at high risk of developing CVD: totalCVD risk > 20% over 10 years or diabetes mellitus.

What are the outcomes

• mortality and morbidity• hospital readmission• risk factors • physical activity and functional capacity• psychological problems

Components of CR.

• Lifestyle:– Diet and weight management– Smoking cessation– Physical activity and exercise– Secondary prevention– Education

• Psychosocial care• Long-term management strategy

Physical Activity

• Assess and risk stratify• Develop individual exercise plan• Teach FITT principle• Regain/develop physical fitness• Regain confidence in physical activity• Develop long-term activity plan• Self monitoring

Secondary Prevention

• Cholesterol management

• BP management

• Blood sugar management

• Cardio-protective drug therapy

Education

• CHD as a disease

• Treatment including medication

• Recovery process

• CHD risk factors

• Symptom management

• Living with CHD

Psychosocial Care

• Reduce fear and anxiety

• Assist with adjustment

• Promote positive attitude

• Facilitate behaviour change

• Identify need for further support

Phases of cardiac rehab

• Phase 1 inpatient phase • Phase 2 immediate post discharge phase • Phase 3 exercise training phase • Phase 4 maintenance phase

Inpatient phase

Pre-operation

• Clinical assessment: focusing on RHR, RBP, RR and O2 saturation

• Functional activities • Risk factors assessment:

Post- operation

• Education : focusing on :

- Precautions and movements to be avoided

- Importance of practising breathing Exercises

- The stages of rehab after OP and the activities allowed after OP

Phase 1

• Main aim: is to start changes in behavioural life style as soon as possible.

• Education of Risk factors and correction of

misconceptions • Addressing psychological issues.

• Gradual increase of activity and mobilization

Phase 1

• Contraindications for mobilization:- High SBP and DBP (hypertension) 185- Uncontrolled arrhythmias, (Afib)- Uncontrolled DM >250 mmol- O2 saturation < 85%- sever tachypnea RR > 40- Sever Hypotension SBP<85

Phase 2

• Aim: to promote self willingness to toward healthier life style.

• Following with patient via phone • Patient should receive a booklet for self

education.

Recommendations for exercises @ home

• Performing simple household activities • Encourage walking more than using the car• Walking duration should be gradual, the min is

10 min 3x per day• Encourage use of stairs.• Avoid stress

Phase 3Outpatient phase

• Aim: to introduce the supervised tailored exercise sessions to patients.

• Full clinical assessment including exercise capacity assessment via:

• 6MWT or ISWT

ISWT

6 MWT

• Course length• Different prediction equations • More simple than ISWT but less efficient

Exercise sessions

• According to BACR and SIGN guidelines:Frequency: 2-3/wkIntensity: at the beginning 60-65% of HRR and

progression occurs gradually (old population Vs young population)

Type:Mixture of Aerobic cardiovascular Exercise and

some light resistance training exercises Duration: 60 min per session

Types of Exercises

• 10-15 min of warming up with ended by stretching.

• 20-30 min of conditioning exercises aerobic Exe (biking, treadmill, rowing, stepping....etc) and resistance exercise.

• 10- 15 min of cooling down and relaxation techniques.

Exercise session

• Exercises can be performed in a group or individualized.

• If in a group: intensity will be set from Low –moderate

• If individualised: Vary upon exercise capacity during assessment.

Things to consider during sessions • Patients must feel slight breathlessness but not

speechless!

• Intensity of Exercise must be increased gradually

• Heart rate must be monitored all the time during the session ( Polar HR, or Telemetry unit)

• Any signs of Sever SOB noticed, Exe intensity must be decreased

• Never stand still.

Phase 4

• Aim: maintain the positive changes of healthy life style.

• But before advancement to phase 4 from phase 3 graduation criteria must be met:

- Improvement in functional capacity - Ability to recognize symptoms of HA- Reports self exercises and daily activities

Who can Refer a Patient?

Site-specific Policy:

Cardiologist

Primary Care Physician

Internist

Types of monitors during Exercise

Effects of Exercise on Risk factors

• Blood Pressure Taylor et al (2006)

• LDL (bad cholesterol) Joliffe et al (2001)

• HDL (good cholesterol) • Insulin Sensitivity• Glucose (sugar) Metabolism • Body Fat• Anxiety and Depression

Are exercises safe for cardiac patients?

Absolute risk vs. relative risk

• The chances of having MI in a healthy person during vigorous exe is 5 times normal.

• BUT: 56 more in less active person

Why it is safe to exercise cardiac patients

• ARCH inter MED: the risk of developing cardiac arrest during exercise is 1.3 in a million patient hours.

• Risks during exercise testing is higher 1.2 deaths /10000 test (2006)

Risk Factors

• Tobacco– Smoking and Chew– 50% decreased risk of CHD 1 year after cessation

• Hypertension– 90% middle-aged Americans will develop HTN– 35 million office visits/yr for HTN

Risk Factors

• Hyperlipidemia– 105,000,000 people with a tot chol > 200– 10% reduction in Total Cholestrol = 30% reduction in

incidence of CAD

• Physical Inactivity– $76 billion– > 60% of Americans don’t get sufficient exercise

Risk Factors

• Obesity– More than 50% women and 60% men are overweight or

obese– Nearly 300,000 American adults die of causes related to

obesity

• Diabetes– 58% reduction by lifestyle intervention– 75% of people w/DM die of CAD or vascular disease

Exercise Research

Direct relation between inactivity and cardiovascular mortality. Inactivity is an independent risk factor for of CAD.

Exercise capacity is a more powerful predictor of mortality among men than other established risk factors for CAD.

Physical fitness has been clearly associated with improvements in lipid profiles.

Evidence for cardiac rehab

• Joliffe et al (2001): Meta analysis shoed that exercise based CR reduce all cause mortality by 28% and cardiac mortality by 31%.

• Taylor et al (2006) Meta analysis shoed reduction in mortality by 28%. 50% of reduction attributed to risk factors.

Cost of Cardiac Rehabilitation

• The average cost per patient in 2006-7 was £413

• Single day in a CCU costs £1,400

• Angioplasty (does not reduce mortality) costs £3,000

• Bypass surgery costs £8,000.

Cardiac Rehabilitation Saves Lives!

• No treatment in cardiac disease has stronger scientific evidence or a significantly greater impact on survival.

• The scientific evidence has been reviewed by many scientific and expert bodies over the last 30 years. Every review has come to the same conclusion that cardiac rehabilitation is an essential treatment.

• CR is only form of chronic disease management with an evidence base.