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CARDIAC

REHABILITATIONBetty Matteson, BA. MS

Program Director

Paula Miller, MD

Medical Director

UNC Cardiac Rehabilitation

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13.7 million patients in the US have CHD(50% MI / 50% angina)

Men Prevalence Women

7% - ages 40-49 5%

13% - ages 50-59 8%16% - ages 60-69 11%

22% - Ages 70-79 14%

Rehabilitating the Heart

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MI described first in 1912 by HerrickGenerally confined to bed for 2 months.

1930s: Mallory et al described evolution of

MI over 6 weeks from the initial event andending up with a scarresulted in strict bed

rest for 6-8 weeks.

(Return to normalcy rare)

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Background

Mortality was 30-40%

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Cardiac RehabilitationInfancy 96 sInitially thought inappropriate for:

Elderly patients

CHF patients

Patients with angina

Patients with arrhythmias

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1940s: Beginning to question theprolonged bed restchair therapy

Newman & Co-workersearly ambulation

3-5 minutes of walking 2 x daily during the4thweek

Brummer (1956) Early ambulation within 14

days of the event. 1961 Cain et al reported on graded activityprogram

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Background

Available MedicationsMorphine

NitroglycerinDigitalis

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Late 1960s: 3 weeks hospitalization wasclinically routine in the US

1970searly mobilization (UK)

Boyle, Hutter, Bloch, Abraham and Assoconfirmed no significant difference in theoccurrence of angina, re-infarction,heartfailure or death; Bloch demonstratedgreater disability in those who had notperformed early mobilization.

h l

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Cardiac RehabilitationInfancy: 1980-1990s

Expanded populations:Post CABG

Post PCICHF

AnginaValvular Heart Disease

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CARDIAC REHABILITATION

Comprehensive long-term services involving:

1.Medical evaluation;2. Prescribed exercise;

3. Cardiac risk factor modification;4. Education, counseling and behavioral

interventions

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Physical Activity and Coronary Disease

Several studies have shown a strong inverse

relationship between habitual exercise andfitness and the risk of CAD

Harvard study2000 kcal/wk29% reduction(equivalent and additive to other life stylemeasures)

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Benefits of ExercisePrevention of age related endothelial dysfunction

due to preservation or restoration of nitric acid

Reduction in hemostatic factors

Decrease in C-reactive protein

Attenuation of age-related reductions in arterial

compliance and restoration is previously sedentaryindividuals

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Benefits of Exercise (cont)

Restoration of ischemic pre-conditioning

Reversal of age-related decline in maximum

oxygen uptake (MET)Improved physical fitness, physical work capacity

and endurance

Enhanced flexibility

Bone mass & Bone density

Improved self image and self confidence

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Increase in leisure activities

Increase in sexual interest andfunction

Improved sleep status

Enhanced optimism

IMPROVED Quality of Life

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Low risk:

8 METs - 3 weeks after cardiac event

No symptoms

Intermediate Risk

< 8 METs 3 weeks after cardiac event

Angina with moderate or intense exerciseHistory of CHF

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High Risk

1. < 5 METs 3 weeks after cardiac event2. Exercise induced hypotension

3. Ischemia induced at low levels of

exercise4. Persistence of ischemia after exercise

5. Sustained arrhythmia

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Costs:1. Cost effectiveness: $4950 per year of lifesaved (compared favorable to othermeasures except smoking cessation)

2. Cost utility/quality-adjusted life years:$3293

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Compared with other treatmentsMore cost effective than:

1. Single vessel by-pass

2. CABG surgery3. Cholesterol lowering drugsSimilar to:

1. Beta blocker therapyLess cost effective than:

1. Smoking cessation

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Cardiac has become an intrinsic part of thecare of the patient with CVD

Demand will increase with;

1) Shorter hospital stays

2) Aging population3) Advanced cardiac interventions

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ELVD TrialEvaluated efficacy of exercise in patients with

first MI and EF 38%) with nochange in volumes (no dilatation)

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BENEFITS1. Improvement in CHF symptoms and VO2

(RELATED TO LEFT VENTRICULAR FUNCTION)2. Improved functional capacity after MI

(20%)

3. Significant reduction in MORTALITY

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GOALS

1. Improvement in Functional Capacity

2. Ability to perform self care and ADLs

3. Functional Independence

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POSITIVE FINDINGS

Documented in the LiteratureImprovement in exercise tolerance

Improvement in symptomsImprovement in lipid levels

Cessation of smoking

Improvement in well beingReduction in stress

Reduction in Mortality

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WHY DONT MORE PEOPLE GO?

It is estimated that approximately

1/3 of all patients eligible for CardiacRehabilitation ever make it to aprogramand women are even

less likely to get there!!!!

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WHY DONT MORE PEOPLE GO?

Lack of access

Reimbursement issues

Lack of MD referral

Reluctance to alter life styles

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Covered Diagnoses

1. Stable Angina

2. Post MI

3. Post CABG

4. Post Stent placement

5. Post valve surgery

6. Post transplant

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PHASES

Phase I: In-hospital

Phase 2: First three months

(36 sessions)

Phase 3: 3-12 Months

Phase 4: Maintenance

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PHASE 1

Early assessment

MobilizationRisk Factor Management

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PHASE 1

1. Heart Rate increase of 5-20 beats above rest

2. BP rise 10-40 mmHG above rest3. No new rhythm changes

4. No cardiac symptoms

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METABOLIC EQUIVALENTS

Toileting 1-2 METS

Bathing 2-3 METS

Walking varies with speed

Upper Body 2-3.1 METS

Leg Calisthenics 2.5-4.5 METS

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METABOLIC EQUIVALENTS

Stair Climbing down 2.5 METSup 4.0 METS

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PHASE 1

Day 1: 1-2 METS bed rest/OOB

Day 2: 2-3 METS sitting/walking

Day 3-5: 2-4 METS

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PHASE 2

Generally, first 36 sessions (12 weeks)Multidisciplinary approach

Individualized for each patient

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PHASE 2

1. Exercise Prescription (based onETT/Six minute walk test)

2. Dietary Evaluation

3. PFTs & Body Fat EvaluationEvaluation

4. Psychological Evaluation

5. Flexibilty and Grip Strength

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PHASE 2

Patient is evaluated at 1, 2 and 3months for progress in the exercise,dietary and psychological categories

and problems are identified andaddressed.

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PHASE 2

Exercise is limited until patient

graduates to the PHASE 3program. Generally start with awalking program and progress

to more strenuous as tolerated.

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PHASE 2

At the end of the 36 sessions, the patientperforms a repeat ETT and if he/she

attains a MET level of at least 7, he/she

is graduated into the PHASE 3.

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PHASE 3

Continues with exercise and medicalmonitoring but now allowed to doaerobics and more vigorous exercise

(basketball, raquetball, etc). Weighttraining, resistance training and spinclasses are available.

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PHASE 4

Maintenance:

No longer requires medical supervisionbut if chooses to stay in the program, it

is provided.

All exercises acceptable but regimenapproved by exercise physiologist.

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WHAT DOES IT MEAN WHEN YOU SEND A PATIENTTO THE CARDIAC REHABILITATION PROGRAM

A referral form must be filledout or a RX written forreferral to the program and

outlining any restrictions.

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EXERCISE PRESCRIPTION

220 AGE = E

(E ) (.60)=A

(E) (.80) = B

Range is HR between A and B


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70 year old individual220-70 = 150

(150)(.60) = 90

(150) (.80) = 120

Target Range = 90 120Based only on age

Tends to give a little lower range


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Peak HR from ETT-Rest HR= E

(E) ( .60) = A(E) (.80) = B

Lower rate = A + Rest HR

Higher Rate = B + Rest HR

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70 year old individualPeak HR = 150, Rest HR = 60

150 60 = 90

(90)(.60)= 54(90)(.80) = 72

54 + 60 = 114

72 = 60 = 132HR Range = 114 132Takes in to consideration the patients baseline fitness.

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RATINGS OF PERCEIVED EXERTION

RPE

BORG:

6-20 LINEAR WITH WORD ANCHORS THAT

DESCRIBE THE INTENSITY (Perceived Exertion of 12-16 correlates to HR response of 60-85%)

0-10 EXPONENTIAL DESIGN WITH WORDANCHORS (Perceived Exertion of3-6 corresponds toHR response of 60-85%).

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6 Nothing at all 0 Nothing at all

7 Very, very light .5 Very, very light

9 - Very light 1 Very light

11 Light 2 Light

12 3 Moderate

13 Somewhat hard 4 Somewhat hard

15

Hard 7 Very hard17 Very hard 10 Very, very hard

19 Very, very hard

BORG SCALES

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FIVE KEY FACTORS1. Frequency

2. Intensity3. Mode

4. Duration

5. Rate of Progression

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MODE

Any activity that uses a large muscle group ina rhythmical and repetitive fashion at theappropriate intensity and duration results in

an improved Functional Capacity.

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Resistance TrainingDecreased reps, increase weight

MUSCLE STRENGTH

Increased reps, decrease weight

TONING

2 sets/activity 2-3 sessions/week

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PROGRESSIONLevel of Fitness

Prior Activity History

Health Status

AgePersonal Preferences

Goals

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CALORIC EXPENDITURE1-2 #/WEEK

(faster loss results in loss of lean body mass anddehydration)

3500-700 kcal/week

500-1000 kcal/day

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Calculation of Caloric Expenditure1 MET = 1kcal/kg per hour of activity

e.g.120 kg patient exercising for 30 minutes at 5 METS (FC = 10 METS)

Kcal/session = (5 METS) x (120 kg) x 90.5 hr) = 300

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EXERCISE ANDREHABILITATION

A VITAL PART OF WELLNESSAND HEALING

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