Cardiac RehabilitationShort review

DR. MAHENDRACARDIOLOGY,JIPMER

Cardiac rehabilitation is the coordinated sum of interventions required to ensure the best physical, psychological and social

conditions so that patients with chronic or post-acute cardiovascular disease may, by their own efforts, preserve or resume optimal functioning in society and, through improved

health behaviors, slow or reverse progression of disease.

Aims of cardiac rehabilitation• Maximize physical, psychological and social functioning to enable people with

cardiac disease to lead fulfilling lives with confidence.• Introduce and encourage behaviors that may minimize the risk of further cardiac

events and conditions. • Facilitate and shorten the period of recovery after an acute cardiac event.• Promote strategies for achieving mutually agreed goals of ongoing prevention.• Develop and maintain skills for long-term• behavior change and self-management.• Promote appropriate use of health and community services, including

concordance with prescribed medications and professional advice.

It included-• Medical evaluation and risk stratification• Exercise• Education• Psychological and social support.

Eligible patients

• myocardial infarction (ST elevation MI, non-ST elevation MI)• revascularization procedures• stable or unstable angina• controlled heart failure• other vascular or heart disease.

Benefits• Reduces cardiovascular and total mortality.• Does not increase non-fatal reinfarction rate.• Improves myocardial perfusion.• May reduce progression of atherosclerosis when combined with aggressive diet.• No consistent effects on hemodynamics, LV function or visible collaterals. • No consistent effects on cardiac arrhythmias• Improves exercise tolerance without significant CV complications• Improves skeletal muscle strength and endurance in clinically stable patients• Promotes favorable exercise habits• Decreases angina and CHF symptoms

EXERCISE GUIDELINES FOR

CARDIAC PATIENTS

Epidemiological studies of exercise and mortality

• Regular exercise is associated with lower mortality from both cardiovascular disease and all causes.• Risk of coronary artery disease was less than half in the most active compared to

the most sedentary individuals (>20 vs. <2 MET. hours/week respectively) • No clear consensus on the health benefits of vigorous and prolonged exercise

compared to more moderate physical activity. • Exercise energy expenditure of greater than 2000 kcal/week (~8360kJ/week)

provides no additional health benefit. • Most evidence is for aerobic exercise, but recent observational studies suggests

resistance training also has favorable effects on cardiovascular risk.

• regular exercise associated with a significant 28% reduction in all-cause mortality and a possible but nonsignificant 24% reduction in recurrent myocardial infarction.

• Risks of exercise-• Vigorous exercise may trigger myocardial infarction or sudden death but regular

exercise protects against this.• the risk of myocardial infarction is on average six times higher during and for one

hour after vigorous exercise. • risk is higher in persons with impaired left ventricular function, severe coronary

artery disease with inducible myocardial ischemia, recent myocardial infarction and in individuals with significant ventricular arrhythmia.

Exercise in specific cardiac conditions

• Angioplasty and stenting-• Although regular exercise is likely to reduce long term risk, no studies reliably assess whether

exercise training influences outcomes following PTCA. • There is also limited information on the safety of exercise early after coronary angioplasty

and stenting.• Coronary artery bypass grafting and other cardiac surgery-• Cardiac rehabilitation with exercise may more rapidly improve functional capacity following

coronary artery bypass surgery, particularly in patients with physical deconditioning. • Exercise is normally limited during the early weeks until there is adequate healing of the

sternotomy and surgical incisions, but low level activities, eg- walking, can usually begin 48 hours following surgery with gradual progression.

• In the long term, regular exercise is likely to reduce cardiovascular risk.

• Arrhythmias-• The effects of exercise training in persons with arrhythmias is uncertain.• The presence of exercise induced high grade ventricular ectopy is usually a contraindication to

vigorous exercise.

• For persons with benign arrhythmias, exercise training is not contraindicated.• Pacemakers• should not restrict physical activity.• For many patients with pacemakers heart rate is not a reliable guide to exercise intensity.• indicators such as perceived exertion need to be used to guide appropriate levels of exercise.

• Older people• much less likely to be referred for cardiac rehabilitation than younger groups.• both male and female older persons with established coronary disease, can

improve exercise capacity with training comparable to younger groups.

Exercise prescription

• An individual approach is needed because of the wide range of age, fitness level, disease severity, risk factor profile and medications.

• five major components to consider when prescribing exercise• frequency • duration • type of exercise• intensity, warm-up • cool-down. The intensity and duration of exercise sessions should start at a low level and gradually increase.

• Frequency-• Most exercise prescriptions are modified from a 3 session per week model.• Patients with low (< 5 METS) functional capacity are encouraged to take part in several, brief (<

10 minutes) exercise sessions each day.• Patients with higher functional capacities will benefit from fewer, longer sessions. • Patient’s program may start out with several short sessions each day and gradually increase into

three-to-five, 30 – 45 minute sessions per week as functional capacity improves.

• Duration-• duration can be adapted from a baseline value of 30 minutes per session.

• Type of exercise• To achieve the best aerobic training effect, prolonged continuous low to moderate intensity. • exercise (40 – 75% VO2max), using large muscle groups is indicated like walking, running, cycling

and swimming. . • Exercise intensity-• low-to-moderate intensity exercise is beneficial and increased benefit may be achieved with

more intense exercise

NUTRITION MANAGEMENT• Nutritional assessment• Evaluation of food and nutrient intake• Evaluation of physical activity levels and exercise tolerance• Identification of diet-related diseases or conditions that contribute to CVD• Evaluation of smoking habits• Evaluation of current medication use• Measurement of height• Measurement of body weight and waist circumference • Measurement of blood pressure• Measurement of blood lipid levels.

Nutrition education• aim of nutrition education in cardiac rehabilitation is to facilitate the adoption of more healthy

food-related behaviors.• The ‘stages of change model’ is promoted by the Heart Foundation for the management of

patients with dyslipidemia. • change is cyclical, individuals who intentionally change behavior do so through a series of

stages. These stages have been termed: • 1 pre-contemplation• 2 contemplation • 3 preparation• 4 action • 5 maintenance • 6 relapse.

cardioprotective dietary pattern

Benefits of smoking cessation• reduce the risk of a recurrent myocardial infarct or death by half if they stop smoking. • beneficial to stop smoking at any age. • major and immediate health benefits for smokers of all ages• Within one day of quitting, the chance of a heart attack decreases.• excess risk of heart disease is reduced by half after one year’s abstinence. The risk of a major

coronary event reduces to the level of a never smoker within five years.

MANAGING PSYCHOSOCIAL ISSUES• Up to one in four patients will experience a disabling level of anxiety or depression following

a myocardial infarction.• A patient's illness perception may determine the degree of anxiety and depression

experienced and may delay or substantially reduce social and leisure activities.• Depression is associated with a five-fold increase in mortality at six months and a three-fold

increase in one year cardiac mortality.• Major depression following a coronary event runs a long term course with the majority of

those affected remaining depressed at one year.• Most patients will return to work or primary activity following myocardial infarction. The

return to work is associated with an improvement in emotional well being.• Marital status, emotional and social support and social networks are likely to have a

protective effect and reduce risk of future fatal and non-fatal coronary heart disease and total mortality.

• Anxiety and depression• 15-30% of post-myocardial infarction patients and 14-18% of post CABG patients experience moderate

to severe levels of anxiety and depression • Depression and anxiety increased overall number of primary care visits, rehospitalisation or recurrent

cardiac event.• associated with a five fold increase in mortality at six months and over three fold increase in one year

cardiac mortality.

• Sexuality• oxygen requirements during sexual activity are moderate . • Heart rate levels during intercourse are similar to those found in everyday life • sexual activity for those with coronary heart disease is associated with low risk of cardiac

complication

Potential impact of medications on sexual functioning

• PHASES OF CARDIAC REHABILITATION• Phase I - Inpatient rehabilitation• Phase II - Outpatient rehabilitation• Phase III - Long-term maintenance

Objectives of Phase I Cardiac Rehab 

• Conditioning from acute event/ post-CABG• To make patient functionally independent• To adjust with discharge from the hospital• Psychological counselling• Nutritional counselling• Secondary prevention targeting.

Phase II• Phase II: This phase encompasse Immediate post discharge period, which is

typically a period of four to six weeks. • It focuses on

• health education • resumption of physical activity, however the structure of this phase may vary dramatically

from centre to centre. • It may take the format of

• telephone follow up, • home visits, or • individual or group education sessions.

• Either way, some form of contact is maintained with the patient, facilitating ongoing education and exchange of information.

Objectives of Phase II Cardiac Rehab 

• Functional goals– Exercise training under supervision/ at home• Psychosocial goals

– Anxiety/depression management• Secondary preventive targets

Phase III• Phase III: This phase constitutes the components of long-term maintenance of

lifestyle changes and professional monitoring of clinical status. • It is when patients leave the structured Phase 3 program and continue exercise

and other lifestyle modifications indefinitely. • This may be facilitated in the CR unit itself or in a local leisure centre.• Alternatively, individuals may prefer to exercise independently and • Phase 4 may involve helping them set a safe and realistic maintenance program.

Measurements

• Exercise capacity• Quality of life • BP• Weight• Waist circumference• Lipids• Glucose/HbA1C• Telemetry monitoring occurs during exercise sessions• Nutritional survey tool

Outcomes in Cardiac Rehabilitation

1. Smoking cessation2. Lipid management3. Weight control4. Blood pressure control5. Improved exercise tolerance6. Symptom control7. Return to work8. Psychological well-being/stress management

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