Post on 15-Jan-2016
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Cardiac Rehabilitation Cardiac Rehabilitation
ObjectivesObjectives
To gain an understanding of:
Aims and benefits of cardiac rehabilitation Cardiac rehabilitation pathway Assessment Risk stratification Exercise session Monitoring Safety Transfer to Phase IV
Principle of Cardiac RehabilitationPrinciple of Cardiac Rehabilitation
Enable the patient to regain full physical, psychological and social status
Promote secondary prevention to optimise long term prognosis
Comprehensive cardiac rehabilitation
Patient groupsPatient groups
Acute cardiac event Awaiting or post revascularisation Stable angina Stable heart failure Post valve surgery Post heart transplantation Post ICD insertion
Benefits of Cardiac RehabilitationBenefits of Cardiac Rehabilitation
↓ angina ↓ blood pressure ↓ anxiety and
depression ↓ hospital
admissions
↑ lipid profile ↑ functional capacity ↑ compliance with
lifestyle modification ↑ confidence ↑ return to work ↑ return to leisure
activities↓ mortality by 31% (Taylor et al,2004)
Cardiac Rehabilitation TeamCardiac Rehabilitation Team
Multi-professional Overall coordinator Interdisciplinary working Multi tasking / skill extension
Rehabilitation services should be available from people trained in:
Cardiology Exercise Lifestyle intervention Psychological treatments SIGN 2002
Phases of CRPhases of CR
Phase I In-patient stay
Phase II Post discharge at home(2 – 6 weeks)
Phase III Out-patient careHospital or communityDelivered by health care services
(6 -12 weeks)
Phase IV Long term maintenanceDelivered by leisure services
Pre Phase 1Pre Phase 1
Pre operative sessions for patients/spouse. Invited along to local CR site. Provide with information regarding surgery, hospital
stay, and planned follow up. Very well received and demonstrating positive
outcomes.
Phase IPhase I
Education about cardiac event / condition
Risk factor modification Symptom management Counselling & support Early mobilisation Referral to and contact
details for Phases II and III
Under care of GP• assessment of cardiac risk• assessment of physical, psychological and
social needs for cardiac rehabilitation• provision of lifestyle advice and psychological
interventions• Community nurse involvement
Often a neglected phase – patients can feel isolated
Phase IIPhase II
Phase IIPhase II
Delivered by:
Home visitTelephone contactTelephone help lineHeart manual
Problems at this stageProblems at this stage
Symptoms Medication titration Conflicting advice Inequity of cover throughout Grampian
Phase IIIPhase III
Timeframe 2 – 6 weeks post event
Venue hospital / community
Duration 8 weeks
twice week
Assessment at Phase IIIAssessment at Phase III
• Current clinical / cardiac status• Investigations / results• Risk stratification• Medication• Psychological status• Functional capacity assessment• Calculation of THR• Physical limitations• Personal goals• Habitual activity
Functional capacity testsFunctional capacity tests
Sub maximal Bruce / Modified Bruce Protocol Shuttle Walk test 6 minute walk test Cycle ergometer Chester step test
Risk StratificationRisk Stratification
Risk Stratification: The process of determining the level of risk of a
patient having a further cardiac event whilst exercising
Criteria used: cardiac history current cardiac status
Risk Stratification CriteriaRisk Stratification Criteria
Risks associated with exercise:
Extensive myocardial damage Poor LV pumping capacity Residual ischaemia Ventricular arrhythmias
Criteria checklist and AACVPR Stratification to risk stratify
Risk stratification determinesRisk stratification determines
Exercise prescription • Exercise intensity
Level of monitoring & supervision
Contraindications to Phase III exercise component
Contraindications to Phase III exercise component
unresolved unstable angina resting BP 200 / 110mmhg significant unexplained drop in blood
pressure during exercise resting tachycardia > 100 bpm uncontrolled atrial or ventricular arrhythmias unstable heart failure unstable / uncontrolled diabetes fever (febrile illness)
Screening and InductionScreening and Induction
Checklist prior to each session: Changes in symptoms/ medication Heart rate and BP measurements Home activity Problems / concernsInduction should include an explanation of: the aims of the programme the exercises and equipment to be used and any exercise
adaptations pulse monitoring/safe target heart rate ranges the use of ratings of perceived exertion (RPE) reporting abnormal symptoms
Conditioning ComponentConditioning Component
FITT principle
Both circuit or gym designs used
Monitoring
Progression
Safety
Home programmeHome programme
To support the phase III exercise sessions
Walking
Activities similar to those performed under supervision
Home exercise record
Education ComponentEducation Component
Heart disease, investigations and procedures
Risk factors for CHDEffects and benefits of exerciseHealthy eatingMedicationRelaxation / stress management
Psychological ComponentPsychological Component
Screening:Quality of life tools Anxiety and depression
Intervention:Motivational InterviewingCognitive Behavioural TherapyCounsellingRelaxation / Stress management
Health BeliefsHealth Beliefs
Health beliefs are central to a person’s management of their CHD.
They are formed from a variety of sources and influence perception of their illness and how to cope with it.
What are Health Beliefs?What are Health Beliefs?
When people have a diagnosis, illness or injury they generate beliefs in these 5 areas to help them to understand and respond to their health event:
Identity Cause Consequence Time line Cure / control
Leventhal el al., (1997)
IdentityIdentity
Diagnostic label Symptoms Type of people who have the same condition
Typical beliefs may include:‘I only had a heart attack.’‘It’s only men that get heart problems.’‘I’m like my Dad, he had problems with
his heart and veins.’
CauseCause
The patients perception as to why they have CHD may include:• Family history• Stress• Smoking• Bad luck
Accurate identification of risk factors are crucial Research shows misconceptions about causes of
CHD.
ConsequencesConsequences
This is the patient’s perception of the longer term impact and implications of their CHD on their lifestyle, family and friends.
Beliefs may include:• ‘My heart is weak and damaged, I’ll never be the
same again.’• ‘If I manage my risk factors, I can reduce the
chances that I have if I have another heart attack.’
TimelineTimeline
The length of time patients expect their illness to last will have an effect on their other health beliefs and how much that may do to modify their lifestyle positively.
• Beliefs that may be held could include:‘I have only had a heart attack, once I have finished my
rehabilitation I will be fine.’ ‘CHD is for life, I must change my lifestyle to manage my
condition.’
Cure / ControlCure / Control
Patients who believe that their condition is manageable/controllable are more likely to make a better physical and recovery:• ‘If I give up smoking and take up exercise I can reduce my
chances of problems in the future.’
Patients who wrongly perceive that their condition is cured or uncontrollable may not address their risk factors:• ‘I have had a bypass operation and now I am cured.’• It runs in the family, it was bound to happen, that’s life!’
Implications for Long TermImplications for Long Term
Beliefs are strongly held
Consider patient’s beliefs & experiences Can promote a good recovery and facilitate effective
management of patient’s recovery. Can also hinder recovery and prevent an individual
adjusting and managing condition.
Transfer to Phase IVTransfer to Phase IV
Ensure medically and psychologically stable Criteria required for transfer from Phase III to IVEnsure individual can:
• exercise independently and safely• self-monitor effectively • recognise warning signs and symptoms• identify goals for lifestyle change & risk factor reduction• identify psychological goals• demonstrate knowledge of their cardiac condition• demonstrate compliance to home-based activities
Fast track protocols
Long term management plan Long term management plan
Risk factor monitoring & management Local exercise opportunities / resources Details of medical follow up Long-term exercise advice Support services for behaviour change
maintenance Local support group information Phase III CR team contact details
SummarySummary
Principle and benefits
Phases
MDT Team
Exercise component of Phase III
Psychological component
Discharge and Transfer to phase IV
Risk Stratification