CPR 3.2

Cardiac Rehabilitation (Part 1)

Patients for Cardiac Rehabilitation

- Hypertensive
- Angina Pectoris
- Post-MI
- Cardiomyopathy
- Coronary Bypass Graft
- Coronary Angioplasty
- Coronary Atherectomy
- Pacemaker Implant
- Valvular Replacement
- Cardiac Transplant
- Elderlies
- Arryhtmias, CAD, Non-ischemic Heart disease, Pulmonary disease, PVD
- Healthy individuals who are at risk for CVD

Goals of Cardiac Rehab

- Increase functional capacity
- Reduce pathophysiologic effects of heart disease or reverse pathological diseases leading to CVD
- Manage cardiac sx effectively
- Retard or reverse atherosclerosis
- Reduce mortality & morbidity
- Improve lipid profile
- Ameliorate high BP
- Counter obesity
- Control adult-onset diabetes
- Alleviate depression
- Improve QOL

FITT Principle

Frequency, Intensity, Time/Duration, Type/Mode, Progression

Components of Exercise Training

- Warm-up: 5-10 mins
- Conditioning: 20-60 mins
- Cool down: 5-10 mins

What happens if pt immediately engages in endurance properly without performing warm-up?

Sudden rise/inc of HR
- not good as it is difficult to control already --> poses more risks

What happens when warm-up is done prior to endurance proper?

HR or VS will gradually inc intensity up until gray area is reached

Acute: focus on lower limit of gray area, aim for middle as progression
Chronic: focus on upper limit of gray area
In-pt: focus on white area below gray area

TYPE/MODE: FLEXIBILITY EXERCISES

> General body stretching
- (+) tightness, spasm
- dependent on age, condition
> ROM

TYPE/MODE: CALISTHENICS

> Gross motor movements
> Generalized big/large movements of the body
- provides general flexibility & general CV endurance
> Rhythmical
- incorporate muscle so pts can follow rhythm

Cardiopulmonary Exercises - Group A

> Endurance activities (minimal skill and fitness)
> Adults (sedentary)
> Walking leisurely, cycling, aqua-aerobics, slow dancing (Zumba)

Cardiopulmonary Exercises - Group B

> Vigorous intensity endurance activities requiring minimal skill (advanced)
> Physically active adults
> Jogging, running, aerobics, fast dancing (more diff Zumba, ballroom)

Cardiopulmonary Exercises - Group C

> Endurance activities requiring skill (advanced)
> Adults with acquired skill (under training)
> Swimming, skating

Cardiopulmonary Exercises - Group D

> Recreational sports (advanced)
> Adults with regular exercise (if athletes, engage them to actual compet)
> Basketball, soccer, hiking

Determinants of Intensity/Parameters/Methods

> HR Method
> Oxygen Consumption

Heart Rate Method

> Monitor pulse
> Compute THR using Karvonen's Formula
> [rHR + intensity % (HRmax - rHR)]
> HRR = HRmax - rHR
> Training SBP = %(SBPmax - SBPrest) + SBPrest
*Some pts HR is inaccurate (pts taking betablockers), use training SBP

O2 Consumption Method

> Determine VO2max
- requires gas analysis, pts wear O2 masks
> 60-70% of VO2max
> Equivalent to HRmax
> 60-70% VO2max = HRmax

Maximum HR

> age dependent
> HRmax = 220 - age
> 60-80%(HRmax): normal indivs
>

Heart Rate Reserve

> HRR = HRmax - HRrest
- HRrest (baseline HR): while pt is NOT doing exercise
> 40-60%(HRR): cardiac pts
> 60-80%(HRR): normal indivs

Target Heart Rate

> Normal: 60-80% (HRR) + HRrest
> Athletes: 80-95% (HRR) + HRrest
> Cardiac pts: 40-60% (HRR) + HRrest

Metabolic Equivalent

> Amt of O2 consumed by the body to perform physical activity at a given time
> 1 MET = 3.5 ml of O2 / kg of BW / min
> Cardiac pt = 50-60%

MET of Lying Quietly

1.0

MET of sitting at ease

1.2-1.6

MET of sitting, writing

1.9-2.2

MET of standing at ease

1.4-2.0

MET of walking at 1 mph

2.3

MET of light housework

1.7-3.0

MET of heavy housework

3.0-6.0

Rate of Perceived Exertion

> acute: 11-13 (60-70%)
> progress: 14-16 (70-90%)
> athletes: 17-20 (90-100%)

FREQUENCY - In patient

> daily (usually BID)
> daily intervention but shorter duration
> 2x/day (20-30 mins, AM & PM)
> pt c advanced conditions (severely impaired CV endurance)

FREQUENCY - out patient

3-5x/week

FREQUENCY - > 5 METS

3-5x/week

FREQUENCY - < 5 METS

Multiple daily sessions (usually bid)

Progression

> Duration inc first before intensity

Progress intensity if

- HR is lower than THR
- RPE is lower
- Sx of ischemia do not appear

Phases of Cardiac Rehab

I - acute, in pt care
II - home-based recuperation
III - out pt program
IV - indep self care

Phase 1 - duration

upon admission until discharge (7-14 days)

Phase 1 - goals

> offset deleterious physiologic & psychological effects of bed rest
> provide medical surveillance/monitoring
> evaluate and prepare pts to safely return to ADLs within the limits imposed by their conditions
> prep the pt and support system at home or in a transitional setting
> facilitate physician referral and pt entry into an outpt cardiac rehab program

Phase 1 - indications for modified program

> pt presents c clinical sx
> need to lower intensity
> indicated but c caution (relative contraindication)
> large infarction (stable after 2-3 days )
> resting tachycardia (> 100 bpm) or inappropriate hR inc c self-care ADLs
> BP failing to rise or dec c self care ADLs (expected response is for BP to inc)
> ECG revealing >6-8 PVC/min or progressive heart block c self care ADLs
> angina or undure fatigue c self-care ADLs
> need for prolonged bed rest (> 4 days)
> complicated MI

Complicated MI (McNeer Criteria)

> poor ventricular function
> significant ischemia c low-level activity
> cardiogenic shock
> ventricular tachycardia and/or fibrillation
> 2nd or 3rd AV block
> persistent sinus tachycardia (HR > 100 bpm at rest)
> persistent systolic hypotension (

Phase 1 - Contraindications for program

> severe pump failure
> high risk subset:
- recurrent malignant arryhtmias
- angina at rest
- 2nd-3rd degree block
- persistent hypotension (

Phase 1 - General Exercise Guidelines

> low intensity exercises (2-3 METs) --> 5 METs by discharge
> RPE: fairly light
> HR inc of 10-20 bpm above HRrest
> short exercise sessions c freq of 2-3x daily
> exercise tolerance test

Defining factor for Phase 1 discharge

5 METs

Exercise tolerance test

determines max capacity of pt and prescribed amt of exercise intensity