Cardiac Patients

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Exercise Low risk characteristics

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Pathophysiology

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1

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

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2

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

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3

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

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4

Non-exercise Testing Moderate risk factors classification

Resting EF 40-49%

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5

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

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6

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

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7

Phase 1: inpatient lasts

2-4 days

  • directly after event and in patients room

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8

Phase 2 outpatient m duration

up to 36 sessions/ 12 weeks

  • depending on AACVPR stratification

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9

Phase 2 outpatient supervision and works on

  • part supervised and part home base

  • self monitoring strongly emphasized

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10

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

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11

Patients in Phase 1 will work individually with an

exercise physiologist

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12

The EP should be able to obtain

  • HR

  • BP

  • Heart Sounds

  • Lung sounds

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13

What is the main focus in Phase 1 inpatient

flexibility and cardiorespiratory

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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

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15

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

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16

Signs of heart failure

resting SOB, bibasilar rales (lung sounds)

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17

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

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18

S/s of exercise intolerance consist of

  • Angina

  • Marked Dyspnea

  • ECG changes suggestive of ischemia

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19

Phase 1 frequency

2-4 session / day for first 3 days

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20

Phase 1 intensity for those with a MI

RHR +20 RPE <5

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21

Phase 1 intensity for those recovering surgery

RHR+30 RPE <5

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22

Phase 1 type/mode

walking, treadmill, cycle ergometer

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23

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

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24

Phase 1 progression

progress to 10-15 min of continuous walking

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25

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)

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26

At phase 1 hospital discharge patient should have

-specific instruction regarding strenuous work

  • these are permissible and should be avoiding

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27

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

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28

what should the medical and surgical history include

  • most recent cardiovascular event

  • cormobidities

  • other pertinent medical history

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29

What should the physical exam have an emphasis on

cardiopulmonary and musculoskeletal system

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30

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

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31

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

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32

Phase 2 begins

1-2 weeks after patient is discharged

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33

Duration of phase 2

2-12 weeks

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34

What is the duration of phase 2 determined by

  • risk stratification

  • need for monitoring

  • progression toward outcomes

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35

What is happening during phase 2

  • ECG monitoring

  • self monitoring taught and enforced

  • education with emphasis on risk factor reduction

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36

How long does phase 3 last

often 3-4 weeks

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37

Transition into phase 3 varies case by case from

often when vital signs remain relatively stable with increase workloads

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38

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

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39

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

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40

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

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41

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

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42

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

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43

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

individual exercise level that is safe

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44

Phase 2 Aerobic exercise frequency

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

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45

Phase 2 Aerobic exercise intensity if GXT was performed

40-80% of HRR or VO2

  • can be steady state or interval training

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46

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

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47

LOOK OVER INTERVAL TRAINING SLIDE

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48

Phase 2 Aerobic exercise time

20-60 minutes

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49

Phase 2 Aerobic exercise type

  • arm ergometer

  • treadmill

  • elliptical

  • stair climber

  • cycle ergometer

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50

Phase 2 Aerobic exercise progression if exercise test was performed

maintain (0%) to 20%

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51

Phase 2 Aerobic exercise progression if no exercise test was performed

can increase up to 30 bpm above resting HR

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52

Progression for cardiac individuals should

occur at a slower, more gradual progression

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53

Criterial for participation (GETP)

  • all risk classifications may participate in resistance training

  • must occur with supervision

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54

Contraindications for resistance training

  • congestive heart failure

  • uncontrolled dysrhythmias

  • uncontrolled hypertension

  • unstable symptoms

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55

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

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56

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

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57

ROM and very light resistance may be

started immediately if tolerated

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58

Phase 2 resistance training frequency

2-3 d/ week

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59

Phase 2 resistance training intensity

40-60% of estimated 1-RM

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60

Phase 2 resistance training reps and sets

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

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61

CABG patients intensity in phase 2 for RT

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

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62

Phase 2 resistance training type

elastic bands, light hand weight, machines, tubing

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63

Phase 2 resistance training progression

10-20%

  • and the 2x2 rule

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64

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

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65

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

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66

Exercise intensity must be keep

below ischemic threshold

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67

Upper limit is

10 bpm below ischemic threshold

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68

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

sufficient evidence for the presence of myocardial ischemia

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69

If peak Hr is unknown, what method is used

RPE method should be used to guide exercise intensity

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70

<3 on modified Borg scale is

light, <40% of HRR

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71

4-6 on modified Borg Scale is

somewhat hard, or 40-59% of HRR

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72

7-8 on modified Borg Scale is

is hard or 60-80% of HRR

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73

If their is updated medications

a new stress test may be needed

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74

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

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75

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

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76

Systolic heart failure

thin, weak heart muscle

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77

Diastolic heart failure

thick, stiff heart muscle

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78

Types of Heart failure

HFpEF HFrEF

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79

HFpEF means

heart failure with preserved ejection fraction

  • above 40%

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80

HFrEF means

heart failure with reduced ejection fraction

  • below 40%

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81

What can indicate heart failure

exerting dyspnea and fatigue

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82

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

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83

VO2 testing with heart failure patients, exercise tolerance is reduced

~ 30-40%

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84

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

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85

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)

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86

Chronic heart failure frequency for aerobic training

3-5 days/week

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87

Chronic heart failure frequency for resistance training

1-2 nonconsecutive days

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88

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

40-50% HRR

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89

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

RPE 2-4

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90

Chronic heart failure intensity for resistance training upper body

40%

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91

Chronic heart failure intensity for resistance training lower body

50%

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92

Chronic heart failure time for aerobic training

start at 30 mins

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93

Chronic heart failure time for resistance training

2 sets, 10-15 reps

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94

Chronic heart failure type for aerobic training

treadmill, walking, cycle

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95

Chronic heart failure type for resistance training

machines

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96

Chronic heart failure progression for aerobic training

30-40%

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97

Chronic heart failure progression for resistance training

can progress up to 70% of Estimate 1RM

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98

HF patient consideration for increasing, what should increase before others

duration and frequency should be increase before intensity

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99

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

at least 4 weeks

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100

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

  • resistance traininging (at least after 4 weeks)

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