EXPH 3180- Exercise Prescription for Individuals with Cardiovascular Disease

Cardiac Rehabilitation

used to deliver exercise and other lifestyle interventions to individuals with cardiovascular disease (or expected disease)  

Cardiovascular diseases to consider

-coronary artery disease

-ischemia or infarction

-heart failure

-revascularization

-pacemaker/ICD

-heart transplant

-peripheral arterial disease

Ischemia

signifies risk for heart attack/potential blockage, but no damage done

Infarction

already had a heart attack/have damage to heart

Heart Failure 

-heart injury = increased risk for heart failure 

-age 

Coronary Artery

supplies heart muscle with blood

Coronary artery with plaque buildup

disrupts bloodflow to heart muscle

Systolic Heart Failure

enlarged chambers of the heart

-cant generate enough force to eject blood 

(decreased cardiac output) 

How can systolic heart failure be treated?

increase contractility of the heart

-can be done with medications or a pacemaker

Diastolic heart failure

thick ventricles, smaller chambers

-doesn’t fill well, but squeezes/ejects well

-hiigh afterload 

Diastolic heart failure treatment

more difficul to treat (there is no intervention to enlarge the chambers)

-most need transplant 

Hemorrhagic Stroke

brain bleed, causes brain swelling

Ischemic Stroke

inadequate nutrient delivery to the brain

Revascularization: Bypass Graft

open heart surgery

-add a vessel from the aorts to the coronary artery, bypassing the blockage 

-low restenosis rate 

Revascularization: Balloon + Stent

guidewire places a balloon to widen the artery

-not for multi-vessel disease

-quicker recovery

-potentially shorter-term

Pacemaker/ICD

peak heart rate is set, which impacts exercise capability 

-self-paces or automatically defibrillates heart upon abnormal rhythm 

Heart Transplant 

no nervous system innervation with transplanted organ (SNS + PSNS are unable to regulate) 

Guidelines for inpatient cardiac rehab programs should focus on:

-current clinical status assessment

-mobilization

-identification and provision of information regarding modifiable risk factors and self-care

-discharge planning wiht a home PA and ADL

-referral to outpatient CR

Inpatient Cardiac rehab clinical assessments

diagnosis, current medical status, comorbidities, CVD risk factors, personalized goals, and readiness for PA (risk stratification) and learning 

What does supervised daily ambulation include

-assessment and documentation of vital signs

-intermittent sitting or standing within 12-24 hours of MI may prevent exercise performance decrements

-No defined optimal dose- progress from self-care activities, ROM, and postural changes to limited supervised walking

Inpatient Rehab- Education

modifiable risk factors, lifestyle changes, and self-care should occur once the individual’s physical ability and psychological willingness to learn is assessed

What should we assess in the process of educating on cardiac rehab programs

-assess knowledge of disease and treatment

-determine preferred learning style

-communicate in lay terms 

-expand knowledge with use of technology, visual aids, and family involvement 

inpatient cardiac rehab: upon discharge

-create comprehensive plan of care and education materials 

-psychosocial and socioeconomic issues, such as access to care, risk of depression, social isolation, and health care disparities

-safe, progressive plan of exercise

!CAUTION!

until evaluated with an exercise test or entry into a clinically supervised outpatient program, the upper limit of HR or RPE noted during exercise should not exceed those levels observed during inpatient programming

Inpatient Prescription- frequency

2-4 sessions for the first 3 days of the hospital stay

Inpatient Prescription- intensity

seated/standing resting HR +20 BPM

Inpatient Prescription- time

intermittent walking bouts of 3-5 minutes as tolerated, progressively increasing duration until 2:1 exercise/ rest ratio is achieved 

Inpatient Prescription- type

walking

-if facilities has safe accomodations for treadmill/cycle

Why would flexibility training be useful in inpatient populations

to aid chest wall recovery

Outpatient cardiac rehabilitation - upon first meeting/physician referral

-record medical and surgical history including most recent cardiovascular event, comorbidities, and other pertinent medical history

-physical examination with an emphasis on the cardiopulmonary and musculoskeletal systems 

Outpatient Rehab Preexercise assessment

-HR, BP, weight

-symptoms or evidence of change in clinical status not necessarily related to activity (ex: dyspnea at rest, light-headedness or dizziness, palpations or irregular pulse, chest discomfort) 

-symptoms or evidence of exercise intolerance

-change in medications and adherence to prescribed medication regimen 

-ECG and HR surveillance for accurate rhythm detection 

Outpatient Prescription- aerobic frequency

at leadt 3 days/week, preferably 5 days/week

Outpatient Prescription- resistance frequency

2-3 nonconsecutive days/week

Outpatient Prescription- aerobic intensity

use 40-80% of exercise capacity using HRR, VO2R, or VO2peak

Outpatient Prescription- aerobic time

20-60min

Outpatient Prescription- resistance intensity

preform 10-15 repetitions of each exercise without significant fatigue (RPE 11-13 on scale of 20 or 40-60% 1RM) 

Outpatient Prescription- resistance time

1-3 sets, 8-10 different exercises focused on the major muscle groups 

Outpatient Prescription- aerobic type

arm ergometer, combination of upper and lower extremity ergometry, upright and recumbent cycle ergometer, recumbent stepper, rower, elliptical, stair climber, treadmill

Outpatient Prescription- resistance type

equipment that is safe and comfortable for the individual to use 

Outpatient: Exercise Training Considerations

-for those with very limited exercise capacities, daily bouts <10 minutes may be a good starting point 

-if ischemic threshold has been determined, exercise intensity should be prescribed at a HR of 10 BPM below the HR at which the event occurred

RPE Method - light exercise intensity

<12 (<3 on a CR10 scale) OR <40% HRR

RPE Method - somewhat hard exercise intensity

12-13 (4-6 on CR10 scale) OR 40-59% of HRR

RPE Method- hard exersice intensity

14-16 (7-8 on CR10 scale) OR 60-80% HRR

B Blocker

may have attenuated HR Response to exercise and an increased or decreased maximal exercise capacity 

Diuretic Therapy

elevated risk for volume depletion, hypoalemia, or orthostatic HTN (particularly after exercise) 

Continuous EKG monitoring - known stable CVD and low risk for complications

begin with continuous EKG monitoring and decrease to intermittent or no monitoring after 6-12 sessions or sooner as deemed appropriate by medical team 

Continuous EKG monitoring - known CVD at moderate to high risk for cardiac complications

begin with continuous EKG monitorig and decrease to intermittent or no monitoring after 12 sessions as deemed appropriate by the medical team