CARDIAC REHABILITATION​

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Definition- Cardiac Rehabilitation refers to coordinated, multifaceted interventions designed to optimize a patients physical, psychological and social functioning, in addition to stabilizing, slowing and even reversing the progression of underlying atherosclerotic processes, thereby reducing morbidity and mortality.
(according to American heart association 2018)

Cardiac rehab is multidisciplinary and may include the physician, nurses, physical and occupational therapists, exercise physiologist, nutritionist, and social service caseworker

 

Indications:

• Post CABG

• Post PTCA

• Post Myocardial infarction

• Congestive heart failure

• Pacemaker

• Coronary artery disease

• Heart transplant

• Any other cardiac surgery

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Contraindications:

• Unstable angina

• Symptomatic and uncompensated heart failure

• Uncontrolled arrhythmias

• Moderate to severe aortic stenosis

• Uncontrolled diabetes

• Resting blood pressure > 200/100

• Uncontrolled resting tachycardia

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GOALS

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• Decrease cardiac morbidity and relieve symptoms

• Promote risk modification and secondary prevention

• Decrease anxiety and increase knowledge and self confidence

• Increase fitness and ability to resume normal activities.

• Increase aerobic capacity

• Strength, power and endurance should be improved

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Exercise Prescription for Cardiac Patients:

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The AACVPR established guidelines to check for contraindicated conditions. Once these conditions are corrected and appropriate begin the exercise program. Exercise prescription depends upon frequency, intensity, and duration of training, mode(type) of activity, patient risk status, and initial level of fitness. Of these factors intensity of activity is difficult to determine. Too high intensity is related to increased rate of cardiac events. Intensity may be prescribed by:

Borg RPE scale,

Karvonen’s formula: - Target Heart Rate = [(max HR − resting HR) × %Intensity] + resting HR.

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Risk stratification criteria by AACVPR

• High Risk

  • Left ventricular ejection fraction < 40%

  • Survivor of cardiac arrest 

  • Complex ventricular arrythmias at rest or with exercise 

  • MI or cardiac surgery complicated by cardiogenic shock, CHF, and/or complex ventricular arrythmias

  • Decreasing systolic blood pressure during exercise or failure to rise consistent with exercise workloads

• Low Risk

  • Left ventricular ejection fraction > 50%

  • No resting or exercise-induced myocardial ischemia.

  • Uncomplicated MI, CABG, angioplasty, or atherectomy.

  • Functional capacity >6METS 3 or more weeks

• Moderate Risk

  • Functional capacity <5-6 METS

  • Mild to moderately depressed LV function

  • Failure to comply with exercise prescription

 

PHASES

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1. Inpatient Phase (average 3-5 weeks)           

2. Immediate Post Discharge Phase (2-6 weeks)

3. Supervised Outpatient Phase(6-12weeks)     

4. Maintenance Phase                                 

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INPATIENT PHASE: 3-5 weeks

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It is usually 3 to 5 days. Role of physical therapist is to monitor activity tolerance, prepare for discharge, educate the patient to recognize adverse symptoms with activity etc. 

The immediate inpatient phase has 6 levels:

Level 1 
1-1.5 METs
Arms supported for meals and ADLs.
Interventions - Bed exercises like ankle pumps, Deep breathing exercises, limited personal care.

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Level 2 
1.5- 2 METs
Interventions - Leg exercises- ATMs, knee extension, marching in place

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Level 3
2-2.5 METs
Interventions - Standing leg exercises, Independent or assisted ambulation
 
Level 4 
2-2.5 METs
Interventions - Hall ambulation, standing trunk exercises, Independent or assisted ambulation in hall

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Level 5

3-4 METs
Interventions - Hall ambulation, Arm exercises, Standing shower.

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Level 6 
4-5 METs
Interventions - Full flight of stairs, Progressive hall ambulation
 

Warm-up: 15-20 mins

Frequency: 3-4 times/day

Intensity of activity is low level and PRE should be “fairly light” of Borg scale or 1-2 METs. 

Duration - Myocardial Infarction: 5-15 min

              Coronary Artery Bypass Graft: 5-15min

Type of activities- ROM, walk cycle, stairs/steps 

Cool down: 5-10 mins

 

Home Exercise Program

• Patients needs to understand recognition of symptoms and appropriate activity guidelines.

• Goal of 20-30 minutes of ambulation one to two times/day at 4-6 weeks.

• Patients are encouraged to walk comfortably, dress appropriately and try to exercise in ambient temperature

• HEP includes combination of rest and low-level activity including ambulation of UE & LE.

• Patient is encouraged to change positions every 1-2 hrs.

 

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IMMEDIATE POST DISCHARGE PHASE: 2-6 weeks

Warm up: 15-20 mins
Frequency: - 1-2 /day, 5days/week
Duration: - MI:15-45 min
                      CABG: 15 -45 min
Intensity: - RHR: +20/BPM
                     RPE: 12-13 
Type: Walk, cycle, stairs, weight training
Cool down: 15 mins

Strength Training

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Resistance training may begin with the use of elastic bands and light hand weights(1-3lb) and progress to load that allows 12-15 repetitions.

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1. Guidelines for resistance training include

2. Exercising large muscle groups

3. Exhalation with exertion

4. Avoiding sustained tight grip

5. Focusing on RPE 11-13

6. Slow controlled movements

7. Stop exercise with any warning signs.

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SUPERVISED OUT PATIENT PHASE: 2-6 weeks

Warm up: 10-15 min
Frequency: 3-5days/week
Duration: 30-60 Mins
Intensity: 40/50-85% OF HRRmax (VO2 max)
Type: walk, cycling, jogging, swimming, wt. training.
Cool down: 15 mins
                 

MAINTENANCE PHASE: 2-6 weeks

Warm up: 10-15 mins
Frequency: 3-5 days/week
Intensity: 50-85% HRRmax
            65-90% HRRmax
            RPE- 12-16
Duration: 30-60 mins
Type: Walk, cycling, jogging, wt. Training, swimming, lifestyle activity.

Cool down:15mins.

 

Additional intervention for patients with congestive heart failure:
 

• Ventilatory muscle training:

  • Diaphragmatic breathing

  • Pursed lip breathing

  • Improve strength with help of inspiratory muscle trainer, acapella etc

• Activity pacing and energy conservation techniques:

  • Frequent rest intervals

  • Easy and difficult tasks with rest intervals

  • Adjust environment to make tasks easier and sit when feasible while doing strenuous activity.

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Refrences
Physical Rehabilitation 6th editionSusan B. O'Sullivan
Cardiac rehabilitation by Nanette K. Wenger et al.