Cardiac Patients

Pathophysiology

Exercise Low risk characteristics

Exercise Low risk characteristics

• no complex ventricular dysrhythmias during exercise testing and recovery

• no angina or other symptoms

• Normal HR and BP during exercise and recovery

• Functional capacity >or equal to 7 METS

Non-exercise low risk charateristics

• resting EF > or equal to 50%

• Uncomplicated MI or angioplasty or CABG procedure

• No complex ventricular dysrhythmias at rest

• Absence of congestive heart failure

• absence of s/s of post event/ procedure myocardial ischemia

• absence of clinical depression

need all characteristcs

Exercise moderate risk classification

• angina or other significant symptoms only at high levels of exertion of > or equal 7 METS

• mild to moderate silent ischemia during exercise testing and recovery (ST segment depression <2 mm from baseline)

• Functional capacity <5 METS

• any one of these

Non-exercise Testing Moderate risk factors classification

Resting EF 40-49%

Exercise Highest Risk classification

• presence of complex ventricular dysrhythmia during exercise testing or recovery

• presence of angina or other significant symptoms at low levels of exertion <5 METs or during recovery

• High level of silent ischemia during exercise testing and recovery (ST segment depression >2 mm from baseline)

• abnormal HR and/ or BP responses during exercise recovery

any combo or one

Non-Exercise Testing High Risk Classification

• resting EF <40%

• History of cardiac arrest or sudden death

• complex dysrhythmias at rest

• complicated myocardial infarction or revacdularization

• presence of congestive heart failure

• presence of s/s of post event/ producer MI

• presence of clinical depression

Phase 1: inpatient lasts

2-4 days

• directly after event and in patients room

Phase 2 outpatient m duration

up to 36 sessions/ 12 weeks

• depending on AACVPR stratification

Phase 2 outpatient supervision and works on

• part supervised and part home base

• self monitoring strongly emphasized

Guideline for inpatient CR program should focus on:

• current clinical status assessment (s/s, EKG)

• mobilization

• identification and provision of info regarding modifiable risk factors/ self care

• discharge planning with a home PA and ADL and referral to outpatient

Patients in Phase 1 will work individually with an

exercise physiologist

The EP should be able to obtain

• HR

• BP

• Heart Sounds

• Lung sounds

What is the main focus in Phase 1 inpatient

flexibility and cardiorespiratory

Before beginning any type of PA what should be done

• base line assessment s

• risk stratified immediately to help guide initiation and progress of PA

AACVPR Parameters for Inpatient Cardiac Rehab Daily Ambulation

• no new or recurrent chest pain in previous 8 hours

• stable or falling creating kinase and troponin values

• no indication of decompensated Heart failure

• normal cardia rhythm and stable EKG for 8 hours

Signs of heart failure

resting SOB, bibasilar rales (lung sounds)

Adverse response to inpatient exercise leading to exercise discontinuation

• DBP > or equal to 110

• decrease SBP >10 during exercise increasing workload

• significant ventricular or atria arrhythmias w or w/out s/s

• 2 or 3 degree heart block

• s/s of exercise intolerance

S/s of exercise intolerance consist of

• Angina

• Marked Dyspnea

• ECG changes suggestive of ischemia

Phase 1 frequency

2-4 session / day for first 3 days

Phase 1 intensity for those with a MI

RHR +20 RPE <5

Phase 1 intensity for those recovering surgery

RHR+30 RPE <5

Phase 1 type/mode

walking, treadmill, cycle ergometer

Phase 1 time

-intermittent bouts of walking

• 3-5 min between

• rest can be a slower walk or rest

• attempt to have 2:1 exercise to rest ration

Phase 1 progression

progress to 10-15 min of continuous walking

Before leaving Phase 1 an individual should:

-strongly encouraged to participate in an outpatient program

• be counseled on how to identify abnormal s/s leading to medical evaulation

• be five a safe and progressive exercise prescription (until outpatient)

At phase 1 hospital discharge patient should have

-specific instruction regarding strenuous work

• these are permissible and should be avoiding

At the time of physical referral or program entry, the following assessment should be performed

• medical and surgical history

• physical exam

• review of cardiovascular tests and prodcedures

• current medication

• CVD risk factors

what should the medical and surgical history include

• most recent cardiovascular event

• cormobidities

• other pertinent medical history

What should the physical exam have an emphasis on

cardiopulmonary and musculoskeletal system

goals for outpatient cardiac rehab

• Develop and assist patient to implement a safe and effective formal exercise and lifestyle physical activity program

• Provide supervision and monitoring to detect change in clinical status

• Provide ongoing surveillance to patient's health care providers in order to enhance medical management

• Return patient to vocational and recreation activities or modify based on status

• Provide patient and partner/family education to optimize secondary prevention (risk factor modification) through aggressive lifestyle management and judicious use of cardioprotective medications

Components of outpatient cardiac rehab

• CV risk factor assessment and counseling on aggressive lifestyle management

• Education and support to make healthy lifestyle changes to reduce risk of secondary cardiac event

• Development and implementation of safe and effective personalized exercise plan

• Monitoring with goal of improving blood pressure, lipids/cholesterol, and diabetes mellitus

• Psychological/stress assessment and counseling

• Communication with each patient's physician and other health care providers regarding progress and relevant medical management issues

• Return to appropriate vocational and recreational activities

Phase 2 begins

1-2 weeks after patient is discharged

Duration of phase 2

2-12 weeks

What is the duration of phase 2 determined by

• risk stratification

• need for monitoring

• progression toward outcomes

What is happening during phase 2

• ECG monitoring

• self monitoring taught and enforced

• education with emphasis on risk factor reduction

How long does phase 3 last

often 3-4 weeks

Transition into phase 3 varies case by case from

often when vital signs remain relatively stable with increase workloads

Phase 3 entails

• more independent and group exercise

• patients are still supervised, but vitals are no longer strictly monitored

• further incorporate strength training and stretching

Before, during, and after exercise, the clinician should assess the following

• vitals (HR, BP, SPO2)

• body weight

• sign and symptoms or evidence of clinical status not necessarily related to exercise

• symptoms and evidence of exercise intolerance

• changes to medications

• ECG and HR monitoring via telemetry

What are s/s and or evidence in clinical status not necessarily related to exercise

• Dyspnea at rest

• light headedness

• irregular heart rate

• chest discomfort

ECK monitoring for patients with known stable CVD and low risk for complications

• may begins with continuous ECG monitoring

• decrease to intermittent or no ECG monitoring after 6-12 session or sooner is deemed appropriate

ECK monitoring for patients with know CVF and at moderate to high risk for cardiac complication

• begin with continuous ECG monitoring

• decrease to intermittent or no ECG monitoring after 12 sessions and as deemed appropriate

When considering removing or reducing ECG monitoring, the patient should understand

individual exercise level that is safe

Phase 2 Aerobic exercise frequency

at least 3 days a week preferably > or equal to 5 days/ week

Phase 2 Aerobic exercise intensity if GXT was performed

40-80% of HRR or VO2

• can be steady state or interval training

Phase 2 Aerobic exercise if no VO2 peak test was performed

+20-30 bpm of RHR for a standing or sitting exercise

• or RPE of 4-7

LOOK OVER INTERVAL TRAINING SLIDE

Phase 2 Aerobic exercise time

20-60 minutes

Phase 2 Aerobic exercise type

• arm ergometer

• treadmill

• elliptical

• stair climber

• cycle ergometer

Phase 2 Aerobic exercise progression if exercise test was performed

maintain (0%) to 20%

Phase 2 Aerobic exercise progression if no exercise test was performed

can increase up to 30 bpm above resting HR

Progression for cardiac individuals should

occur at a slower, more gradual progression

Criterial for participation (GETP)

• all risk classifications may participate in resistance training

• must occur with supervision

Contraindications for resistance training

• congestive heart failure

• uncontrolled dysrhythmias

• uncontrolled hypertension

• unstable symptoms

Criteria for cardiac rehab patient structured RT if they have undergone a percutaneous coronary intervention

• initiate RT prescription 2-3 weeks post intervention and

• 2 weeks of supervises aerobic training

Criteria for cardiac rehab patient structured RT if they have suffered a MI or undergone a CABG

• initiate RT 5 weeks post MI or CABG and

• after 4 weeks of supervised aerobic training

ROM and very light resistance may be

started immediately if tolerated

Phase 2 resistance training frequency

2-3 d/ week

Phase 2 resistance training intensity

40-60% of estimated 1-RM

Phase 2 resistance training reps and sets

10-15 reps, 1-3 sets, (8-10 exercises)

CABG patients intensity in phase 2 for RT

often limited to 10 lbs from 8-12 weeks but high variability

Phase 2 resistance training type

elastic bands, light hand weight, machines, tubing

Phase 2 resistance training progression

10-20%

• and the 2x2 rule

2 by 2 rule

when a patient is able to comfortably complete one to two reps over the desired of reps on two consecutive training sessions

If patients functional capacity has been measure by an exercise test and an ischemic threshold was identified as

angina and/ or > or equal 1 mm ischemic ST segment depression on exercise test

Exercise intensity must be keep

below ischemic threshold

Upper limit is

10 bpm below ischemic threshold

Classic angina pectoris that is induced with exercise training and relieved with rest or nitro is

sufficient evidence for the presence of myocardial ischemia

If peak Hr is unknown, what method is used

RPE method should be used to guide exercise intensity

<3 on modified Borg scale is

light, <40% of HRR

4-6 on modified Borg Scale is

somewhat hard, or 40-59% of HRR

7-8 on modified Borg Scale is

is hard or 60-80% of HRR

If their is updated medications

a new stress test may be needed

It is recommended that an exercise test be performed any time that symptoms or clinical changes occur

• change in their level of chest pain or dyspnea

• possibly for those with an ischemic etiology who have not undergone a coronary revascularization procedure

• those who have been incompletely revacularize

• those who have rhythm disturbances and desire to exercise to a higher intensity level

However, another exercise test may not be medically necessary in patients who

• have undergone complete coronary revascularization

• who are asymptomatic

• when it is logistically impractical

Systolic heart failure

thin, weak heart muscle

Diastolic heart failure

thick, stiff heart muscle

Types of Heart failure

HFpEF HFrEF

HFpEF means

heart failure with preserved ejection fraction

• above 40%

HFrEF means

heart failure with reduced ejection fraction

• below 40%

What can indicate heart failure

exerting dyspnea and fatigue

What is exercise training a valuable adjunct in the therapeutic approach to the care of patients with stable chronic HR and is recommended by the ACC and AHA

• improve QOL

• VO2 peak

• hospitalization

• autonomic NS function

VO2 testing with heart failure patients, exercise tolerance is reduced

~ 30-40%

What exercise protocol should be used for chronic heart failure

-exercise protocol that starts at a lower work rate and imposes smaller increases in work rate per stage

• Modified Naughton is common

What can be used to help guide when to refer a patient to an advanced HF specialist or when to further evaluate for advanced therapies

VO2 peak and the slope relationship between minute ventilation and carbon dioxide production (related to prognosis)

Chronic heart failure frequency for aerobic training

3-5 days/week

Chronic heart failure frequency for resistance training

1-2 nonconsecutive days

Chronic heart failure intensity for aerobic training if HR data is available

40-50% HRR

Chronic heart failure intensity for aerobic training if HR isn't available

RPE 2-4

Chronic heart failure intensity for resistance training upper body

40%

Chronic heart failure intensity for resistance training lower body

50%

Chronic heart failure time for aerobic training

start at 30 mins

Chronic heart failure time for resistance training

2 sets, 10-15 reps

Chronic heart failure type for aerobic training

treadmill, walking, cycle

Chronic heart failure type for resistance training

machines

Chronic heart failure progression for aerobic training

30-40%

Chronic heart failure progression for resistance training

can progress up to 70% of Estimate 1RM

HF patient consideration for increasing, what should increase before others

duration and frequency should be increase before intensity

HF after patients have adjusted to and are tolerating aerobic training takes how long

at least 4 weeks

HF after patients have adjusted to and are tolerating aerobic training what can be added

• resistance traininging (at least after 4 weeks)