Introduction of Cardiac Rehabilitation

Hu Dayi

People’s Hospital, Peking University

Disclaimer

• No financial disclaimers• No conflict of interest disclaimers

Outline

• Brief History of Cardiac Rehab• Current definition of cardiac rehab• Benefits of Cardiac Rehab• Detailed description of Phase 1 and Phase 2

of cardiac rehab• Exercise Testing• Life style modifications• Psychosocial Aspects of Cardiac Rehab• Diagnosis specific key point

Brief History of Cardiac Rehabilitation (CR)

Brief History of CR – 1700s

• Dr. William Herberden Sr. (1710 – 17 May 1801) \• British physician• Credited with the first description of Angina Pectoris• First physician to mention exercise in CVD• “I knew [a patient with angina pectoris] who set himself a task of

sawing wood for half an hour every day, and was nearly cured” - 1771

Brief History of CR – 1800s

• Max Joseph Oertel (March 20, 1835 - July 17, 1897) • German Physician• early advocate of the "terrain cure", a set of therapeutic

exercises that involved graduated hiking and climbing.• First physician accredited to prescribe physical exercise. • Careful Description of the effect of graded increasing exercise

on blood pressure, heart rate, and physical fitness – Oertel, M.J.: Therapie der Kreislaufstorugen. Leipzig; 1885

Brief History of CR – early 1900s

• James Bryan Herrick (1861 -1954)• Landmark article in JAMA in 1912 first coining the phrase

“Myocardial infarction”• 1918- First to encourage use of EKG for diagnosis of MI• Unfortunately, was very conservative, and recommended 6-8

week bed rest for his patients.• In 1930s, Mallory and White advocated even longer bed rest.

Brief History of CR – 1950s

• 1950s: Levine and Lowe openly challenged the necessity of long term bed rest after MI

• American Heart Association (AHA) 1953, Louis Katz – "physicians must be ready to discard old dogma

when they are proven false and accept new knowledge."

• Late 1950s, Turell and Hellerstein recommended a graded step program, a prototype to contemporary cardiac rehabilitation, based on established energy requirements

Brief History of CR – 1960s

• US President Dwight Eisenhower suffered MI in 1955

• Paul Dudley White prescribed hi graded exercise, including swimming, walking and golf

• By 1960, numerous studies have shown adverse effect of long bed rest post-MI

Brief History of CR – 1960s to present

• Inpatient cardiac rehabilitation was formalized by the efforts of Wenger, Zohman, Tobis and Bruce.

• The adopted programs instituted early supervised reconditioning during the acute post-MI phase while patient is still in CCU

• The results was very promising• By the end of the 1960s, Hellerstein, a well-

known Cleveland cardiologist, started the first outpatient cardiac rehab

Current State of Cardiac Rehabilitation

Official Definition of Cardiac Rehabilitation

“Cardiac rehabilitation services are comprehensive, long-term programs involving medical evaluation, prescribed exercise, cardiac risk factor modification, education, and counselling. These programs are designed to limit the physiologic and psychological effects of cardiac illness, reduce the risk for sudden death or re-infarction, control cardiac symptoms, stabilize or reverse the atherosclerotic process, and enhance the psychosocial and vocational status of selected patients”

- Cardiac Rehabilitation/Secondary Prevention Performance Measures Writing Committee

2007

Core components of Cardiac RehabCore components of Cardiac Rehab

• Patient assessmentPatient assessment• Nutritional counselingNutritional counseling• Lipid managementLipid management• Hypertension managementHypertension management• Smoking cessationSmoking cessation• Diabetes managementDiabetes management• Psychosocial managementPsychosocial management• General education (meds, procedures, condition)General education (meds, procedures, condition)• Physical activity counselingPhysical activity counseling• Exercise trainingExercise training

Disease Management Components

• Population Identification processesPopulation Identification processes• Evidence-based practice guidelines Evidence-based practice guidelines • Collaborative practice models Collaborative practice models • Patient self-management education Patient self-management education • Process and outcomes measurement, evaluation, Process and outcomes measurement, evaluation,

and management and management • Routine reporting/feedback loopRoutine reporting/feedback loop

Patient Selection

• Patients who are considered eligible for CR include those who have experienced 1 or more of the following conditions as a primary diagnosis sometime within the previous year: – MI/acute coronary syndrome– CABG– PCI – Stable angina– Heart valve surgical repair or replacement – Heart or heart/lung transplantation

Typical Cardiac Rehab Team

• Physicians• Nurses• Physical Therapists• Nutritionists• Psychosocial therapist• Pharmacists• Exercises Instructors• Social workers• Family members

Benefit of Cardiac RehabilitationBenefit of Cardiac Rehabilitation

Phases of Cardiac Rehabilitation

3 distinct phase of CR

– Phase 1 Inpatient CR (also known as Phase 1 CR): a program that delivers preventive and rehabilitative services to hospitalized patients following an index CVD event, such as an MI/acute coronary syndrome;

– Phase 2 Early outpatient CR (also known as Phase 2 CR): a program that delivers preventive and rehabilitative services to patients in the outpatient setting early after a CVD event, generally within the first 3 to 6 months after the event but continuing for as much as 1 year after the event;

– Phase 3 Long-term outpatient CR (also known as Phase 3 or Phase 4 CR): a program that provides longer term delivery of preventive and rehabilitative services for patients in the outpatient setting.

Phase 1 of CR

• Occurs while patient is still in hospital• Goals

– 1. Clear the patient for any skeletal, muscle or orthopedic problems - ROM, pectus excavatum, pectus carinatum, scoliosis, joint swelling, gross muscle weakness, etc.

– 2. Clear the patient for any pulmonary problems that would limit activity - i.e. - thoracic deformities, obstructive or restrictive pathologies, presence of adventitious sounds (crackles, wheezes, bronchophony, egophony, whispered pectoriloquy, stridor), etc.

– 3. Return the patient home and to the workplace with the patient having a clear understanding about what are the safe activities they can participate in without reinjuring their hearts.

– 4. Decrease the patient's pain and fear of living. – 5. Increase the patient's physical work capacity. – 6. Help the patient to modify their coronary risk factors through

education. – 7. Give objective information back to all members of the cardiac

rehab team.

Phase 2 of CR - Goals

• Happens a few days to 1-2 weeks post-discharge• Goals of Phase 2 CR

– Give the patient a safe, monitored environment for exercise. Monitoring consists of measuring the patient's blood pressure, HR, EKG, heart sounds, and lungs sounds. It is also important to monitor the patient's subjective symptoms - i.e. - fatigue, effort of difficulty of the exercise bout (Borg Scale), etc.

– Increase the patient's exercise work capacity. This is one of the main goals of Phase II and must be done in an orderly progressive fashion.

– Teach the patient to monitor himself/herself during an exercise period. It is very important that the patient have a very good understanding of how hard to exercise when they are not in your Phase II program. They need to be able to work at the appropriate heart rate and perceived exertion intensity when exercising away from all of the monitoring equipment of your out-patient facility.

– Relieve fear and anxiety. Phase II is an opportunity to reassure the patient that they can still have a high quality of life. If they exercise properly, following the counsel they have received during the educational sessions of Phase I and Phase II, they may have reason to feel good about their future.

– Patient Education. Patient education continues in Phase II as an extension of what was discussed in Phase I. Topics that can be discussed are : risk factor modification, stress management, dietary modifications to lower fat intake, smoking cessation, anatomy of the heart, sexual activity, cardiac medications, and what do you do when you feel symptoms ?

Phase 2 of CR – Mode of Exercises

Phase 2 of CR - Monitoring

• Monitoring – Before exercises– BP and HR– Review of patient’s symptoms– Stress test maybe required prior to starting

• Monitoring – During exercises– Review patient’s symptoms every 3-5 minutes– Telemetry for high risk patients

• Monitoring – After exercises– BP and HR– Review symptoms

Exercise Testing

Exercise Testing

• Types of Tests– Maximal vs Submaximal– Depends on age, risk factors and reason for test

• Modes of testing– Treadmills, bicycle ergometer or arm ergometer

• Measurement– Direct measurement of VO2, HR, BP, EKG, and

RPE

Exercise Testing - RPE

• Rate of Perceived Exertion

Exercise Testing - MET

• Metabolic Equivalent of Tasks (MET)– 3.5 ml O2·kg−1·min−1 or equivalently 1 kcal·kg−1· h−1 – One MET is defined as 1 kcal/kg/hour and is roughly

equivalent to the energy cost of sitting quietly

Exercise Testing - MET

Life Style Modification

Heart 2007; 93: 862-864

LifeStyle ModificationLifeStyle Modification

• LifestyleLifestyle– Regular activityRegular activity– Stop SmokingStop Smoking– Mediterranean DietMediterranean Diet– 7 gm of Omega-3 fatty acids/week7 gm of Omega-3 fatty acids/week– Healthy weightHealthy weight– Stress Management /Psychosocial modificationStress Management /Psychosocial modification– 14 “units” of alcohol per week14 “units” of alcohol per week– No beta-caroteneNo beta-carotene– No evidence for antioxidants and folic acidNo evidence for antioxidants and folic acid

Psychosocial Aspects of Cardiac Rehab

Psychological aspects of Cardiac Rehab

• Frightening, life threatening event (MI, major surgery)• A chronic illness, reduced life expectancy, symptoms• Altered identity - an invalid, walking time bomb• Fears for family and partner being left alone• Threat to employment and financial status• Medication side effects (lethargy, impotence)• Being treated differently by other people• Neurological impairement (esp. cardiac arrest pats.)• Making lifestyle changes, smoking, diet, activity

• Of all patient’s post-MI– 1/3 feels as good as before or better

• active coping style, optimistic personality, improved sex life, low anxiety, previous good mental health.

– 1/3 feels long-term psychological damage • anxious and/or depressed. Cardiac neurosis, poor

coping, high in misconceptions, poor recovery, poor motivation, younger age, no obvious risk factors, post MI angina

– 1/3 feels “OK, but not quite the same”• fear of activity, fear of excitement, fear of travel, reduce

work output or retire early, severely reduced or abandoned sex life, avoid arguments or convesations

Psychological aspects of Cardiac Rehab

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