2. Objectives
• To understand the process of assessment
& exercise prescription, patients for
Cardiac Rehabilitation Program.
• To define risk of progression &
stratification
• To understand the exercise prescription
process for Cardiac Rehabilitation
Program.
3. Introduction
In 1772,william heberden described a patient with
angina who “ set himself a task of sawing wood for
half an hour every day, and was nearly cured.
Before 1930 immobilization and extended bedrest
were encouraged for up to 6 weeks after CV event,
leading to significant deconditioning.
In 1940 things slowly began to change ,Levine
introduced up to chair therapy.
In 1950 short daily walk in the ward was introduced.
2019 era exercise and cardiac rehabilitation is class 1
indication indeed.
4. What is Cardiac
Rehabilitation
Cardiac rehabilitation mean physician supervised
program, that furnishes physician prescribed :
• Exercise
• Cardiac risk factors modification
• Psychosocial assessment
• Outcome assessment
Multidisciplinary & multifactorial Intervention
( including education and cardio-protective
therapies to control symptoms and overall quality
of life)
7. Definitions
• Physical activity, defined as any bodily movement.
• Exercise, defined as physical activity
performed to stress primarily the oxygen
transport system ( Aerobic exercise), muscular
skeletal system ( Resistance exercise )
• Exercise training, defined as exercise
performed repetitively to increase the maximal
capacity of the oxygen transport ( Aerobic
exercise training/ resistance exercise training) .
8. Exercise Training
Exercise training in patients with CV disease increases
exercise capacity ,reduces cardiac ischemia, delays the onset
of or elimination of angina, and improves endothelial
function, thus reduces CAD and related mortality .
Despite these benefits , inexpensive and generally safe is
being rarely prescribed especially amongst women and
older patients.
The reasons for this underutilization are not defined but
probably include health professionals underestimation of
the benefits of exercise, lack of awareness and training
among many healthcare workers and last not the least lack
of large randomized clinical trials.
9. Assessment &
Risk Stratification
Clinical examination :
– The site & size infarct & operation details
– Current cardiac status
– Any complications
– Current medication
– Progress since Discharge
– Current exercises level – including the recent results
– Any symptoms, exercise chest pain, shortness of breath,
dizziness
– Relevant past medical history
– Risk factor for Coronary Heart Disease.
– Weight/ BMI
– Psychological status/ mood
– Orthopedic limitations
10. Assessment &
Risk Stratification
Risk Stratification
Process of assessing the risk of patients
having a further event depend upon.
The main risk factors :
•Extensive cardiac damage
•Residual ischaemia
•Ventricular arrhythmias on exercise
11. Assessment &
Risk Stratification
Risk Stratification
1. History of :
- more than one previous infarct
- An anterior rather than inferior infarct
- ↑ cardiac enzyme levels at the time of infarct
- complications ie: LV failure/ Cardiogenic Shock
2. Symptoms severe exertional breathlessness &
orthopnea.
3. Finding of large heart/ Pulmonary venous congestion & low
Ejection Fraction.
4. A low capacity on the exercise. Test with significant ECG
changes/ poor HR/BP response.
5. Current angina
12. Assessment &
Risk Stratification
Uncomplicated MI.CABG,
Angioplasty
FC equal or greater than
6METs
3 or more weeks after event
FC less than 5-6 Mets 3 or
more weeks after event
Mild – moderately depressed
LVF (EF 31to 49%)
Severely depressed LVF
(≤30%). Complex ventricular
arrhythmias at rest/
appearing/ increasing
with exercise
No resting/ exercise induced
myocardial ischemia
manifested as angina & or ST
segment displacement.
Failure to comply with
Exercise Prescription
↓ SBP of › 15mmHg during
exercise or failure to rise.
MI complicated by CHF,
cardiogenic shock .
No resting/ exercise induced
complex arrhythmias
No significant LV dysfunction
(EF = / ↑ than 50%)
Exercise induced ST-segment
depression of 1-2mm/
reversible
ischemic defects (echo/
nuclear radio)
Patients with severe CAD &
marked (›2mm) exercise
induced ST segment
depression. Survivor of
cardiac arrest
Low Risk Moderate Risk High Risk
13. Phases of exercise
Cardiac Rehabilitation
Phase 1
Inpatient ( last few days
before discharge)
Exercise may involve simple
ward ambulation
mild activities of daily living ,
Referral to phase 2
enrollment.
Phase 11
Outpatient/ hospital based
or home based
Comprehensive secondary prevention
model
Individual treatment plan
Exercise prescription Education
classes.
Risk modification, smoking,
hypertension, diabetes, obesity, lipid
and nutrition counseling.
Psychosocial counseling
Phase 111
Maintenance Cardiac monitoring no longer
needed.
Independent continuation of risk
factors modification and
exercise, with periodic physician
evaluation.
14.
15. Exercise
Recommendation
Aerobics
• Large muscle
activities
(arm/leg ergometry
Increase aerobic
capacity
• Decreased BP & HR
response to sub max
exercise
40-85 VO2max/ HRR
• Intensity to be kept
below ischemic
threshold
• 3-7 days a week
• 20-60 mins continuous
exercises• 5-10 mins
warm up/down
4-6 months
Strength
• Circuit training
Increase ability to
perform leisure,
occupational & daily
living activities
• Increased muscular
strength
40-50% maximal
voluntary contraction
(avoid vasalva)
• 2-3 days/ week
• 1-3 sets, 10-15
repetitions• Resistance
should begradually
increased over time (1-2 lbs)
4-6 months
Flexibility
• Upper & lower body
ROM
Decreased risk of
injury
• Improved ROM in
post sternotomy
2-3 days/ week 4-6 months
Modes Goals Intensity Time to goal
16. Exercise Prescription
FITT Principles
F
FREQUENCY
2 – 3 TIMES WEEKLY / >3 TIMES WEEKLY ( Total 36 visits )
(2 REHABILITATION CLASSES & 1 HOME CIRCUIT)
OTHER DAYS WALK/ LEISURE ACTIVITIES
I
INTENSITY
70% - 85% OF PREDETERMINED PEAK HEART RATE
12 – 13 RPE (BORG SCALE)
60% - 75 % OF VO2 max ( Prescription is standard for most exercise training programs )
T
TIME / DURATION
20 – 30 MINUTES per session
(not inclusive of warm/up or cool down ) 5 min
T
TYPE/ MODE
AEROBIC, ENDURANCE TRAINING
Resistance exercise 30 to 50% RM 12-15 repetitions, 1 set 2-3 times weekly
17. Heart Rate
Karvonen Formula
THR = ((HRmax − HRrest) × % intensity) + HR rest
Example for someone with a HRmax of 180 and a HRrest of 70:
50% Intensity: ((180 − 70) × 0.50) + 70 = 125 bpm
85% Intensit
Predicted maximal HR
e.g. if patient is 40 years of age and is required to work at 60% - 75% of MHR
220 – Age =
220 – 40 = 180 (MHR)
180 x 60% = 108
180 x 75% = 135
Therefore the THR is (108 -135)
Note: Remember that Beta Blockers reduces the heart rate @ rest & during
exercise. Please take off 20- 30 BPMy: ((180 − 70) × 0.85) + 70 = 163 bpm
18. Indications of exercise &
Cardiac Rehabilitation
1) Myocardial infarction in past 12 months. ( Class 1 )
2) Coronary artery bypass grafting ( Covered by US center medicated services 2006)
3) Post Percutaneous coronary intervention.
4) Heart Valve repair or replacement.
5) Chronic stable angina.
6) Compensated heart Failure with FC11 -1V, symptoms,
EF <35% and stable on medications or no planned
procedure in past 6 weeks. ( Class 11a, added in 2014)
7) Heart/ heart lung transplant
8) Peripheral arterial Disease ( added in 2017 )
19. Base line
Exercise Test.
Objective:
- Assess the patient response to
exercise
- Enable risk stratification for
future events
- Determine medical & rehab management
Info from the result:
- Duration & rate of work achieved
- HR & BP response via exercise
- HR, BP & exercise level at peak/
changes
- Medication during test
- RPE (rate perceive exertion )
20. Base line Exercise
Test
CAD patients should undergo
symptom limited exercise testing on
their usual medications , before
referral ,to establish a baseline
maximal heart rate ,and to exclude
important ischemia , symptoms or
arrhythmias because that would alter
the therapeutic approach.
21. Exercise
Prescription & Proscription
Prescription, Virtually all patients
with known CAD,& PAD if stable
should engage in regular physical
activity. The simplest approach for
clinicians prescribing exercise is to
refer patients to an established
cardiac rehabilitation program.
3 times a week for at least 30 min.
Prescription , Historically exercise
training was prohibited in patients
with HF, with the feeling that it
will compromised LV function.
Different meta analysis conclude
that exercise training improves
exercise tolerance in HF, is safe,
and may reduce mortality.
Proscription, There are few exercise
proscription for CAD patients like during
first week of acute MI, unstable angina ,
exercise induced arrhythmias, ist week of
cardiac surgary, wound infection &
thrombophlebitis. PAD with resting symptoms
Proscription
Advanced HF NYHA class 111 &
1V should refrain from exercise
training until their symptoms
permit exercise.
Coronary artery disease Heart Failure
22. Contraindications
of exercise & CR
Unstable or unresolved angina.
• Fever and acute systemic illness.
• Patient in severe pain.
• Resting blood pressure: SBP>
180mmHg, DBP> 100mmHg
• Significantly unexplained drop
in blood pressure.
• Tachycardia > 100bpm.
• New or recurrent symptoms of
breathlessness, palpitation,&
dizziness.
• Significant lethargy Your Heart… Our Passion
23. Exercise Termination
Criteria
Any angina symptoms
or feeling too breathless to continue
• Feeling dizzy or faint
• Leg pain limiting
further exercise
• Exceeds level of
perceived exertion >
15 (Borg Scale)
• Increased Heart Rate
> 85% as of THR
Your Heart …Our Passion
24. 10 Rules Of Exercise
1. Choose a form of exercise that suits patients
2. Always build up gradually
3. If patients have a break for whatever reason, build up
gradually again
4. Always warm up & cool down
5. Do not allow patients to exercise if they are ill
6. Stop exercise if patients c/o of pain/ feel dizzy/
uncomfortable/ palpitation/ irregular
7. Patients should be able to talk & exercise @ the same time
8. Do not exercise patients immediately after a meal
9. Make sure patients wear suitable clothing & good footwear
10. If in doubt consult your colleague.
25. General
Considerations
Content must be simple & adaptable
• Adopt educational approach
• Monitor type A behavior
• Ensure that goals are
agreed upon rather than
imposed & readily achievable
• Exercise prescription
must reflect individual
differences, patients will differ
greatly in most other
Respects.
Your Heart …….our Passion
26. Clinical
Characteristics
1) Patient population ( Post PCI, Acute MI,CABG )
2) What about heart failure ( Yes Stable HF included )
3) How many training sessions are schedule for each
patient .( 9 -36 sessions)
4) What is the graduation rate ( 75% phase 11 CR )
5) What is the functional capacity goal at the end of
rehabilitation program ?
6) Are baseline stress test performed before the exercise
prescription is written. ( No ,depend upon physician choice
7) Who is writing exercise prescription for CR Patients.
( certified clinical exercise physiologist )
27. Aerobic Exercise
Prescription
1) How often is aerobic exercise performed each week
for each patient?. ( 3 days per week)
2) How is intensity for aerobic training prescribed
3) How is intensity prescribed in absence of baseline
exercise test. ( 11 -14 RPE )
4) How long does each aerobic training last. ( 40 min )
5) What types of training modes are used for aerobic
exercise. ( Treadmill , ergometer)
6) Which type of training is used for aerobic exercise
( Continuous, interval )
7) How are patients progressed throughout their
program. ( combination of intensity & duration)
28. Resistance Exercise
Prescription
1) How many strength training session are performed
each week? ( 1-3 days per week)
2) How is training intensity determined ( Trial & error
RPE )
3) On average , How many sets are performed for each
strength exercise? ( one )
4) On average ,how many strength exercises are
performed each session? ( 6-12 )
5) Which type of resistance training is used ? ( Free
weights, elastic bands, resistance machines, body
weight. )
29. Conclusion
In Clinically stable CAD patients ,who respond to
treatment ,the benefits of physical activity far
outweight the risk .
Indeed regular exercise appears similarly effective
in secondary prevention as many drug interventions
without significant side effects.
Both aerobic and resistance training are safe for
people with stable CAD, as long as they are
assessed properly with suitable exercise
prescription.
30. References
• British Heart Foundation (2002) British Heart
Foundation CHD Statistics
British Heart Foundation
• Campble, N.C , Grimshaw, J.M , Ritchie, L.D and Rawles
,JN ( 1996)
`Outpatient` Cardiac Rehabilitation ; are the potential
benefits being
realised?’ Journal of the Royale College of Physicians,30,
pp.514-19
• Ewart , C.K , Taylor , C.B, Reese, L.B and de busk , R.F
(1983) ` Effects of
Early post-myocardial infraction exercise testing on self-
perception and
subsequent Physical Activity’ American journal
Cardiology ,51, pp.1076-80
