CARDIAC REHABILITATION - Website Staff UIstaff.ui.ac.id/system/files/users/deddy...Cardiac rehabilitation is the sum of activities required to influence favourably the underlying cause

CARDIAC REHABILITATION

Angela B.M.TulaarDeddy Tedjasukmana

Definition

Cardiac rehabilitation is the sum of activities required to influence favourably the underlying cause of the disease, as well as the best possible physical, mental and sosial condition, so that they may by their own efforts preserve or resume as normal a place as possible in the community. ( WHO 1993 )

Candidates for Cardiac Rehabilitation:- Post MCI- Chronic stable angina- CHF - Cardiac arrhytmias- Post CABG- Post PTCA- Post cardiac valve surgery- Post cardiac transplantation

Cardiac Rehabilitation Involves: - Medical evaluation - Exercise prescription - Modification of risk factors - Education - Counselling - Vocational programs

Goals of cardiac rehabilitation General goals:

- to optimize the patient’s physiologic, psychosocial, and vocational function; - to reduce the morbidity and mortality of

cardiac disease Educational program:

- lifestyle modification such as low-cholesterol diet, stress-reduction, and smoking

cessation to reduce the risk factor for heart disease;- reconditioning exercises to improve safety

and tolerance of daily activities (vocational, recreational, and sexual activity)

Cardiac rehabilitation team: Physicians (Cardiologist; Physiatrist=

Physical Medicine & Rehabilitation Specialist)

Nurses Physical therapists Occupational therapists Exercise physiologists Nutritionist Psychologists Social worker Vocational counsellors

Coronary heart disease (CHD) Risk factors Modifiable CHD risk factors :

hypertension, cigarette smoking, obesity, habitually sedentary lifestye, hypercholesterolemia, high level LLD, low level HDL, hypertriglyceridemia, hyperinsulinemia, DM

Coronary heart disease (CHD) Risk factors

Unmodifiable CHD risk factors: Advanced age, Gender,

Family history of premature CHD, Past history of CHD, cardiac event, Abnormal ECG, Past history of occlusive peripheral vascular disease or CVD

Cardiac Evaluation A. History : - Chief complaint - Past history - Medication history - Functional and occupational history - Personal history - Social history - Family history

Cardiac EvaluationB. Physical Examination : General Vital signs Cardiovascular:

Inspection Palpation Auscultation :

Heart sounds Heart murmur Pericardial rub

Pulmonary Neurologic and musculoskeletal

Cardiac EvaluationC. Diagnostic tests Chest radiograph Cardiac tests :

ECG echocardiography

Laboratory tests blood tests Cardiac stress tests

Cardiac rehabilitation Consists of four (4) distinct

phases Each phase of cardiac

rehabilitation has specific goals with educational or lifestyle modification component

Phase I : In-patient cardiac rehabilitation

In-patient acute phase(generally lasting from 3-6 days)

Started as soon as the patients condition has stabilized

Goals : prevent the sequelae of immobilization

and assist the patient in tolerating self-care activities and household ambulation

Phase I : In-patient cardiac rehabilitation Goals: prepare the patient ( and family ) for a

healthy lifestyle reduce psychologic and emotional

disorders that accompany the cardiac diagnosis

facilitate adjustment to the acute event and to the hospital environment

motivate the patient to make a long-term commitment to the cardiac rehabilitation program

Phase I program : Education and risk-modification

program : Hyperlipidemia control Hypertension control Smoking cessation DM control Stress management

Exercise Exercise program

Low-metabolic demand exercise and activities.

5-10 minute (progressed up to 20-30 minutes), 2-4 times daily,

Activity < 4 METS (1 MET = VO2rest = 3,5 ml 0f O2 consump.)

Not raise HR above 20 bpm

Selected exercises & ADL1,5 METs: sitting at ease, talking, eating, calculating1,7 METs: standing2,0 METs: writing/typing in sitting position2,4 METs: washing face, hands & brushing hair2,9 METs: bicycling slowly, no resistance 5 mph, 3 METs: using bedside commode3,5 METs: Shaving, warm shower3,6 METs: bowel movement using toilet4,2 METs: Hot shower standing4,7 METs: bowel movement using bedpan

Exercise program Passive or active assistive ROM exercise

– active exercise in supine, sitting, upright position

Ankle pumping exercise Exercise parameter : pulse, BP, ECG,

activity- induce symptoms Exercise testing

At the end of phase I or prior to starting phase II

Stop Exercise if Signs and symptoms :

angina, light-headedness, nausea, dyspnea, fatigue, pallor, cyanosis, ataxia, hypoxia, altered mental status, peripheral circulatory insufisiency, bradicardia (drop in HR of more 10 bpm), activity-induce BP changes, SBP > 220 mmHg, DBP >110 mmHg, activity-induced ECG change

Contraindications to exercise Absolute:

1. unstable angina2. heart failure (acute, uncompensated)3. uncontrolled arrhythmias4. 2nd or 3rd degree AV block5. resting ST-segment displacement >3mm6. resting BP >200/110 mmHg7. inappropriate asymptomatic postural or

exertional BP responses

Contraindications to exercise Absolute:

8. severe aortic stenosis (>50 mmHg gradient)9. active pericarditis or myocarditis10. recent embolism11. acute or chronic thrombophlebitis12. idiopathic hypertrophic subaortic stenosis13. dissecting aneurysm14. acute systemic illness or fever (>100º F)

Contraindications to exercise Relative:

1. resting BP >180/100 mmHg2. hypotension3. inappropriate rise in BP during exercise4. sinus tachycardia at rest (>120 bpm)5. resting ST-segment depression >2 mm6. moderate aortic stenosis7. ventricular aneurysm

Contraindications to exercise Relative:

8. compensated heart failure9. pericarditis associated with CABG, excessive incisional drainage after CABG,

new ECG changes suggestive of infarction10. poorly controlled DM11. symptomatic anemia12. significant emotional stress/ psychological

disorder/ neuromuscular or orthopedic problems that would prohibit exercise

Phase II : Outpatient Conducted in an outpatient setting or towards

the end of hospitalization if the patient is discharged from the hospital phase II start within 1 - 2 weeks and last 8 to 12 weeks

By end of phase II, patient should be able to perform the daily self-administered exercise program safely, have adequate knowledge of his or her disease and symptoms to persue vocational , recreational, and sexual activities safely

The goal : To enhance cardiovascular function and physical

work capacity (strength,endurance,flexibility) To detect ECG changes during exercise To teach the patient proper techniques of

exercise and provide him/her with guidelines for long-term exercise

To establish healthy lifestyle in patient and family To enhance the patient’s psychologic function

and prepare him or her for return to work and resumption of normal familial and social roles

Phase II program : Education and risk-modification

program Exercise :

The patient is given individualized prescription of intensity,duration, frequency, mode activity

Physical reconditioning, begin with dynamic-rhytmic or aerobic exercise at a level of 5 METs (sexual activity)

Exercise involving upper and lower limb

Phase II program : Exercise :

Equipment : treadmills, bicycle ergometers, arm ergometers, wall pulleys, steps, rowing machines

Exercise session lasting 1 hour (including warming-up and cooling-down), 3 times a week

Exercise goal : target HR for at least 20-30 min for training adaptation

Intensity is increased on a weekly basis, progressing to 8 mets before starting phase III

Phase II program :Return to work program Patient are prepared to return to their

original job 7 Mets without any abnormal

responses, generally patients should be able to return to most jobs except heavy industrial work (bicycling fast = 6,9 METs)

Deep breathing to reduce stress Lie down or sit straight up in a chair Rest your hands on your stomach Slowly count to four and inhale through your

nose.  Feel your stomach rise and hold the breath for a second.

Slowly count to four while you exhale through your mouth.  Purse your lips together, like you’re going to whistle, so you don’t exhale too quickly.  Your stomach will slowly fall.

Repeat 5 – 10 times.

Phase III : Maintenance Phase III usually last from 3 - 6

month and generally includes clinical supervision and intermittent ECG

Exercise in outpatient setting, then progress to a community or home setting

Phase III Goals: similar to phase II designed to provide a smooth transition

from structured, closely supervised to individually suited program

Program include : - Education and risk modification - Exercise : aerobic exercise,

resistance training, aquatic exercise program (water temp. 26-33° C)

Phase IV : Long term cardiac rehabilitation

Education and risk-modification program

Exercise (at least 3 times per week for 30-60 min, target HR 80% max HR, progress gradual until 85%) Aerobic exercise Resistance training Aquatic exercisewater exercise

Phase IV : Long term cardiac rehabilitation

Goal : to continue in improving and maintaining fitness and a healthy lifestyle