Cardiac rehabilitation (CR) is a multidisciplinary program that helps patients restore health and reduce future heart risks after a cardiac event. CR includes exercise training, risk factor modification, and psychosocial support. The goals are to influence the underlying heart disease, optimize physical and mental health, and help patients resume normal activities. CR is delivered in phases from the hospital through long-term maintenance. Exercise training in CR increases cardiovascular fitness and muscle adaptations, lowering heart rate and blood pressure during activity. Arterial blood gases are analyzed to assess respiratory function and acid-base status, and guide safe exercise progression in CR.

1. CARDIAC
REHABILITATION
Reza Nejat, M.D.,
Anesthesiologist, FCCM,
ex-Assistant Professor, SBMU
Bazarganan Hospital

2. Cardiac Rehab
 Cardiac Rehabilitation (CR) is an
interdisciplinary team approach
to patients with functional
limitations secondary to heart
disease.

3. Cardiac Rehab
 WHO definition of Cardiac Rehab:
 the activities required to influence:
 the underlying cause of the disease,
 the best possible physical, mental, and social
conditions:
 so that the patient may, by their own efforts,
preserve or resume, as normal a place as
possible in the society.
 Rehabilitation:
 cannot be regarded as an isolated form of
therapy,
 must be integrated within the entire
treatment.

4. Cardiac Rehab
 Cardiac Rehab:
 A progressive program with a goal of
helping patients to restore and
maintain optimal health while
helping to reduce the risk of future
heart problems.

5. Cardiac Rehab
 Early mobilization:
 helps to decrease the effects of bed
rest,
 enables the patients to return to their
activities of daily living (ADL), within
the limits of the disease,
 identifies patients at risk of
cardiovascular and physical
impairments,
 prepares the patient and the support
system at home to optimize recovery

6. Cardiac Rehab
CR staffing:
 Medical Director- MD
 Available for consult
 Assist in program development
 Approve all policies/procedures
 Be involved in therapeutic aspects of
program
 Coordinator- RN, Phys, RD, MBA
 Administrative duties
 Direct patient care

7. Cardiac Rehab
 Cardiac Rehab phases:
 phase-1: in the hospitalized period of
the patient following an acute MI, (3-
5 days)
 phase-2: the immediate post
discharge period, (2-6 weeks)
 phase-3: the stage of a structured
exercise program, (6-12 weeks)
 phase-4: the maintenance phase

8. Cardiac Rehab
 CR core components:
1. Baseline patient assessment,
2. Nutritional counseling,
3. Risk factor modification,
4. Psychosocial interventions,
5. Physical activity counseling,
6. Exercise training.

9. Cardiac Rehab
• What CR does
• cardiac morbidity and relieve
symptoms
• Modifying risk factors and
secondary prevention
• Anxiety and increase knowledge
• Increase fitness and restores
normal activities

10. Cardiac Rehab
• The benefit of CR:
1) Increased cardiovascular endurance
2) Endurance training = activity using
large muscle groups,
3) Increase in maximal oxygen uptake
4) Maximal oxygen uptake (VO2 max)
is limited:
I. Centrally by cardiac output
II. peripherally by the capacity of
muscles to extract oxygen from the
blood

11. Cardiac Rehab
 In healthy people:
endurance training:
increase in CO due to increase in SV
increase in SV:
1) LV mass and size
2) Increased total blood volume
3) Reduced peripheral resistance

12. Cardiac Rehab
 What happens to the muscles in CR:
A. Increased number and size of
mitochondria
B. Increased oxidative enzyme activity
C. Increased capillarization
D. Increased myoglobin

13. Cardiac Rehab
 In patients with IHD:
increase inVO2 max should be mostly
achieved by:
peripheral changes
Note: high intensity exercises needed for
central changes – inappropriate.

14. Cardiac Rehab
 In patients with IHD:
Repeated submaximal daily activities with
less physiological stress:
1) Decreased heart rate,
2) Decreased blood pressure and
3) Decreased plasma catecholamine
concentrations

15. Cardiac Rehab
How you might describe your exertion Borg RPE
Examples
(for most adults <65 years old)
None 6 Reading a book, watching television
Very, very light 7 to 8 Tying shoes
Very light 9 to 10
Chores like folding clothes that seem to take
little effort
Fairly light 11 to 12
Walking through the grocery store or other
activities that require some effort but not
enough to speed up your breathing
Somewhat hard 13 to 14
Brisk walking or other activities that require
moderate effort and speed your heart rate and
breathing but don’t make you out of breath
Hard 15 to 16
Bicycling, swimming, or other activities that
take vigorous effort and get the heart pounding
and make breathing very fast
Very hard 17 to 18 The highest level of activity you can sustain
Very, very hard 19 to 20
A finishing kick in a race or other burst of
activity that you can’t maintain for long

16. Cardiac Rehab
 A high correlation
exists between a
person's perceived
exertion rating
times 10 and the
actual heart rate
during physical
activity

17. Cardiac Rehab
 A MET, the resting metabolic
rate:
 the amount of oxygen
consumed at rest like sitting
quietly in a chair,
 approximately 3.5 ml 02/kg/min
 1.2 kcal/min for a 70-kg person

18. Cardiac Rehab
In early stages of acute heart
diseases like MI, post-CABG, Acute
HF:
First 24-48 hours:
1. Breathing maneuvers
2. Simple arm and leg exercises
3. Limited self-care activities
Over the next 2-3 days:
1. RBR,
2. Take short walks
3. Take shower and dressing with help

19. Cardiac Rehab
 CR programming:
 Warm up
 Aerobic exercises
 Resistive exercises
 Cooling down

20. Cardiac Rehab
 Be careful! stop training in case of:
1) Fever, acute systemic illness
2) Unresolved/unstable angina
3) Blood pressure systolic > 200 mmHg
and diastolic > 110 mmHg
4) Unexplained drop in blood pressure

21. Cardiac Rehab
 Be careful! stop training in case of:
1) Symptomatic hypotension
2) Tachycardia
3) Arrhythmias
4) Breathlessness, lethargy, palpitations,
dizziness
5) Unstable heart failure, weight gain > 2 kg
in 2 days
6) Unstable/uncontrolled diabetes

22. ABG in Cardiac Rehab
 Accurate and timely
interpretation of ABG and an
acid–base disorder can be
lifesaving,
 The establishment of a correct
diagnosis may be challenging

23. ABG in Cardiac Rehab
 Assessment of ABG
1. careful clinical evaluation
2. determine the primary acid–base disorder
3. consider the metabolic component
4. consider the possibility of a mixed metabolic
acid–base disturbance
5. note the serum osmolal gap in any patient with
an unexplained high anion-gap acidosis
6. evaluate the respiratory component
7. determine the cause of the identified processes

24. ABG in Cardiac Rehab
 Assessment of ABG
1. careful clinical evaluation
2. determine the primary acid–base disorder
3. consider the metabolic component
4. consider the possibility of a mixed metabolic
acid–base disturbance
5. note the serum osmolal gap in any patient with
an unexplained high anion-gap acidosis
6. evaluate the respiratory component
7. determine the cause of the identified processes

25. ABG in Cardiac Rehab
 Respiratory insufficiency:
 Low FiO2
 Hypoventilation
 PaCO2= VCO2/VA, VCO2
 V/Q mismatch
 Shunt
 (PAO2-PaO2)/20
 Diffusion
 DLCO

26. ABG in Cardiac Rehab
 𝑷𝑷𝒂𝒂 𝑶𝑶𝟐𝟐 < 𝟓𝟓𝟓𝟓 𝒎𝒎𝒎𝒎𝒎𝒎𝒎𝒎
 Memory defect, impaired judgement
 𝑷𝑷𝒂𝒂 𝑶𝑶𝟐𝟐 < 𝟒𝟒𝟒𝟒 𝒎𝒎𝒎𝒎𝒎𝒎𝒎𝒎
 Tissue damage
 𝑷𝑷𝒂𝒂 𝑶𝑶𝟐𝟐 < 𝟑𝟑𝟑𝟑 𝒎𝒎𝒎𝒎𝒎𝒎𝒎𝒎
 Unconsciousness
 𝑷𝑷𝒂𝒂 𝑶𝑶𝟐𝟐 < 𝟐𝟐𝟐𝟐 𝒎𝒎𝒎𝒎𝒎𝒎𝒎𝒎
 Death

27. ABG in Cardiac Rehab
Clinical features of
Hypoxemia Hypercapnia
Cyanosis Flapping tremor of hands
Tachypnea Tachypnea
Tachycardia→arrhythmia→bradycardia Tachycardia
Peripheral vasoconstriction Peripheral vasodilation
warm hands/ headache
Restlessness→confusion→coma drowsiness→hallucination→coma
Sweating

28. ABG in Cardiac Rehab
 In normal subjects:
 𝑷𝑷𝒂𝒂 𝑶𝑶𝟐𝟐 = 𝑭𝑭𝒊𝒊 𝑶𝑶𝟐𝟐 × 𝟓𝟓
 PaO2/FiO2
 Normal 100/0.21=500
 200< PaO2/FiO2<300 MILD ARDS
 100< PaO2/FiO2<200 MODERATE ARDS
 PaO2/FiO2<100 SEVERE ARDS
 (on PEEP=5cmH2O)

29. ABG in Cardiac Rehab
 SpO2/FiO2=235
 PaO2/FiO2=200
Moderate ARDS:
PaO2/FiO2<200
 SpO2/FiO2=315
 PaO2/FiO2=300
Mild ARDS:
PaO2/FiO2<300

30. ABG in Cardiac Rehab
 Assessment of ABG
1. careful clinical evaluation
2. determine the primary acid–base disorder
3. consider the metabolic component
4. consider the possibility of a mixed metabolic
acid–base disturbance
5. note the serum osmolal gap in any patient with
an unexplained high anion-gap acidosis
6. evaluate the respiratory component
7. determine the cause of the identified processes

31. ABG in Cardiac Rehab
 Acidosis
 the hydrogen-ion concentration ↑
 Alkalosis
 the hydrogen-ion concentration ↓

32. ABG in Cardiac Rehab
 the plasma concentration of hydrogen
ions normally
 very low 40 nmol/L
 the pH
 the negative logarithm of the hydrogen-ion
concentration,
 is generally used in clinical medicine to
indicate acid–base status.
 “acidemia”
 Plasma pH is abnormally low (acidic)
 “alkalemia”
 Plasma pH is abnormally high (alkaline)

33. ABG in Cardiac Rehab
 the Henderson–Hasselbalch equation
 pH = pK + log10 ([HCO3−] / [0.03 × (PaCO2)])
 HCO3− = proton acceptor = BASE (KIDNEY)
 CO2 = proton donor = ACID (LUNG)
 pH = pK + log10 ([BASE] / [ACID])
 pH = pK + log10 ([kidney] / [lung])

34. ABG in Cardiac Rehab
 pH = pK + log10 ([kidney] / [lung])
 ACIDOSIS:
 Respiratory
 Metabolic
 ALKALOSIS:
 Respiratory
 Metabolic

35. ABG in Cardiac Rehab
 Met Acidosis:
 low pH (<7.35) and low bicarb (<22 meq/l)
 Met Alkalosis:
 high pH (>7.45) and high bicarb (>26 meq/l)
 Resp Acidosis:
 low pH and high PCO2 (>42mmHg)
 Resp Alkalosis:
 high pH and low PCO2 (<38mmHg)

36. ABG INTERPRETATION

37. ABG INTERPRETATION
 Metabolic acidosis
 pH <7.38 and [HCO3−] <22 mmol/liter
 Secondary (respiratory) response:
 PaCO2 = 1.5 × [HCO3−] + 8±2 mm Hg
or
 PaCO2 = [HCO3−] + 15 mm Hg
 Complete secondary adaptive response
within 12–24 hr

38. ABG INTERPRETATION
 Metabolic alkalosis
 pH >7.42 and [HCO3−] >26 mmol/liter
 Secondary (respiratory) response:
 Paco2 = 0.7 × ([HCO3−] − 24) + 40±2 mm Hg
or
 Paco2 = [HCO3−] + 15 mm Hg
or
 Paco2 = 0.7 × [HCO3−] + 20 mm Hg
 Complete secondary adaptive response within
24–36 hr

39. ABG INTERPRETATION
 Respiratory acidosis
 pH <7.38 and Paco2 >42 mm Hg
 Secondary (metabolic) response
 Acute: [HCO3−] is increased by 1mmol/liter for
each Paco2 increase of 10 mm Hg above 40 mm
Hg
 Chronic: generally [HCO3−] is increased by 4–5
mmol/liter for each Paco2 increase of 10 mm Hg
above 40 mm Hg
 Complete secondary adaptive response within
2–5 days

40. ABG INTERPRETATION
 Respiratory alkalosis
 pH >7.42 and Paco2 <38 mm Hg
 Secondary (metabolic) response
 Acute: [HCO3−] is decreased by 2 mmol/liter for
each Paco2 decrease of 10 mm Hg below 40 mm
Hg
 Chronic: [HCO3−] is decreased by 4–5 mmol/liter
for each Paco2 decrease of 10 mm Hg below 40
mm Hg
 Complete secondary adaptive response within
2–5 days

41. ABG INTERPRETATION
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