- Jayatheeswaran. Vijayakumar-  

Patient Rehabilitation Post-MI

INTRODUCTION

Atherosclerosis

Definition of CR

Coordinated, multifaceted interventions designed to optimize a cardiac patient’s physical, psychological, and social functioning, in addition to stabilizing, slowing or even reversing the progression of the underlying atherosclerotic process, thereby reducing morbidity and mortality 

AHA Scientific Statement, Circ 2005;111:369-76

The History of Cardiac Rehabilitation (US)1912 Herrick J.B. Association of American Physicians Modern Concept of coronary thrombosis and myocardial infarction (MI)

1912 – 1950 Lewis TAbsolute bed rest 6-8 wks. with total nursing care to prevent further

ischemic, LV aneurysm, ventricular rupture, arrhythmia, recurrent MI, sudden cardiac death

1951 Levine SA & Lown BEncourage pt. to sit 1-2 hours from D1 of MI to avoid deconditioning

1951-1960s Practices varies Bed rest 1day – 4 weeks

Hospitalization 2-6 weeks

1964 WHO: Rehabilitation of Patients with Cardiovascular Diseases. (Technical report Series No 270) Geneva

1971 Wenger NK, Gilbert C., Skoropa M.Cardiac conditioning after myocardial infarction. An early intervention program. J. Card. Rehabil2:17, 1971

Benefits of CR

Limit the adverse physiologic effects of cardiac illness

Limit the adverse psychological effects of cardiac illness

Reduce the risk of sudden death or reinfarction

Control cardiac symptoms

Stabilize or reduce atherosclerosis

Improve functional capacity

Enhance psycho-social and vocational status

Phases of Cardiac Rehabilitation

Phase I : Inpatient

Phase II: Outpatient EKG monitored

Phase III: Outpatient with decreasing monitoring

Phase IV: Community based, independent exercise

Inpatient Cardiac Rehabilitation Principles

Goals:1) Normal cardiovascular response to changes in position

and ADLs (Activities of Daily Living)2) Reach 3-4 MET activity level by discharge

Activity: 1)Slow progression of activity intensity (increase by 1 MET/day)

Initiating Inpatient Cardiac Rehab

Post-MI, Post-surgery, Post-stent (no MI), CHF, heart transplant

Patient may begin if: No chest discomfort (8 hours) No new signs of decompensated heart failure No abnormal EKG changes (8 hours)

Cardiac Rehab Phase II

Supervised outpatient program 6-8 wks.

Exercise test performed prior to rehab

EKG monitoring every session

Goals - increase exercise capacity to 5 METS

Patient education on HR, exercise, symptoms

Phase III Outcomes

Functional capacity goals > 8 METS or 2x energy requirements of work

Training effects expected

No cardiac symptoms

EKG monitoring happens occasionally, or when increasing activity parameters

Patients learn self-monitoring of HR and symptoms

Cardiac Rehab Phase IV

Unsupervised program

Community Based

Exercise Training Program

Exercise training is defined as a sub-category of physical activity in which planned, structured, and repetitive bodily movements are performed to maintain or improve one or more attributes of physical fitness and thus it is a structured intervention over a defined period of time.

The Benefits of Exercise Primary Prevention

Brisk walking, 30mins/day, 5 times/week

30% ↓vascular events in 3.5 years follow-up1

3 hours of brisk walking/week = 1.5 hours of vigorous exercise per week2

Resistance exercise and weight training were also beneficial3

1. Manson JE, Greenland P, LaCroix AZ, et al: Walking compared with vigorous exercise for the prevention of cardiovascular events in women N Eng. J. Med 347;716, 2002

2. Manson JE, Hu FB, Rich Edward JW , et al: a prospective study of walking as compared with vigorous exercise in the prevention of coronary artery disease in women. N Eng. J. Med 341:650, 1999

3. Tanasescu M, Leitzmann MF, Rimm EB, et al: Exercise type and intensity in relation to coronary heart disease in men. JAMA 288:1994, 2002

The Benefits of Exercise Secondary Prevention

Physical activity with 1000kcal/wks. 20-30% ↓ all cause mortality1

For patients without revascularization Exercise training improves SBP, angina symptoms and exercise

tolerance2

For patients with revascularization Improvement in exercise tolerance ↓29% cardiac events ↓re-admissions (18.6 vs 46%)3

1. Lee I-M, Skerett PJ: Physical activity and all-cause mortality—What is the dose response relation? Med. Sci Sports exerc33(6Suppl):S459,2001

2. Hambrecht R. Wolf A, Gielen S, et al: Effects of exercise on coronary endothelial function in patients with coronary artery disease. Am J Cadriol 90:124, 2002

3. Belardinelli R, Paolini I, Cianci G, et al: Exercise training intervention after coronary angioplasty: The ETICA trial. J Am Coll Cardiol 37:1891, 2001

Indication

Absolute Contraindication to Exercise

Absolute Acute myocardial infarction (within two days)

Unstable angina

Uncontrolled cardiac arrhythmias causing symptoms or homodynamic compromise

Symptomatic severe aortic stenosis

Uncontrolled symptomatic heart failure

Acute pulmonary embolus or pulmonary infarction

Acute myocarditis or pericarditis Active endocarditis

Acute aortic dissection

Acute non-cardiac disorder that may affect exercise performance or be aggravated by exercise

Inability to obtain consent

Exercise standards for testing and training: a statement for healthcare professionals from the American Heart Association. Circulation 2001; 104:1694

Relative Contraindication to Exercise

Left main coronary stenosis or its equivalent

Moderate stenotic valvular heart disease

Electrolyte abnormalities

Severe hypertension (systolic 200 mmHg and/or diastolic 110 mmHg)

Tachyarrhythmias or Bradyarrhythmias, including atrial fibrillation with uncontrolled ventricular rate

Hypertrophic cardiomyopathy and other forms of outflow tract obstruction

Mental or physical impairment leading to inability to cooperate

High-degree atrioventricular block

Exercise standards for testing and training: a statement for healthcare professionals from the American Heart Association. Circulation 2001; 104:1694;

Safety of Exercise

Exercise without medical advice: Sudden Cardiac Arrest: 1 per 60,000 pt. hours1

Supervised Programs: Cardiac events: 8.9 per 1,000,000 pt. hours Myocardial Infarction: 3.4 per 1,000,000 pt. hours Mortality: 1.3 per 1,000,000 pt. hours 2

1. Fletcher GF, Balady GJ, Amsterdam EA, et al: Exercise standards for testing and training: A statement for healthcarecare professionals from the American Heart Association. Circulation 104:1694, 2001

2. Ades PA: Cardiac rehabilitation and secondary prevention of coronary heart disease. N Eng J Med 345:892, 2001

General Inpatient Prescription Guidelines

Frequency Early mobilization:

3-4 times/day (days 1-3) Later mobilization:

2 times/day (beginning on day 4)

Progression: Initially increase duration up to 10-15 min, then increase intensity.

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General Inpatient Prescription Guidelines

1)Selected moderate to high risk patients should be encouraged to participate in outpatient cardiac rehabilitation programs

&/or

2) Manage their discharge rehabilitation plan and report any cardiovascular symptoms promptly (should they occur).

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Risk stratification

1. Cardiology assessment, management & stabilization of patient:

Unstable angina SBP ≥ 180mmHg or DBP ≥ 100mmHg Symptomatic orthostatic BP drop > 20mmHg Critical aortic stenosis Acute systemic illness or fever Uncontrolled arrhythmia Uncompensated CHF 3rd degree AV Block (complete heart block) Acute pericarditis & myocarditis Recent embolism Thrombophlebitis Resting ST displacement ≥ 2mm Uncontrolled DM Electrolyte disturbance Hypovolemia

2. Initial assessment - Treadmill exercise stress test - (Functional Capacity Assessment)

Principles of Exercise Prescription

3. Tips on Exercise Prescription

4. Regular clinical follow-up for exercise progress and symptoms reassessment:

A) To assess the cardiovascular status

B) Chest pain, dizziness, palpitation, dyspnea, appetite, resting BP & P.

C) To assess the progress of exercise tolerance

D) Advancing the prescription according to The improvement in fitness To increase in steps of 5 – 10% of max. heart rate To maintain ~ 85% of max. heart rate during the whole exercise session

Exercise Stress Test After MI

Conclusion

Thank You