Cardiac Rehabilitation of adults with scenario and article reference

1. By;
Pradeep.M
M.Sc. Nursing II
year
Cardiac Rehabilitation
Medical Surgical Nursing

2. Introduction;
 Up until the 1950s, strict bed rest
was thought to be the best medicine
after a heart attack. Following discharge
moderately stressful activity such as
climbing stairs was discouraged for a
year or more.
 "The patient is to be guarded by day
and night nursing and helped in every
way to avoid voluntary movement or
effort."

3. Definition;
 Cardiac rehabilitation has been defined as the sum of
activities required to ensure cardiac patients the best
possible physical, mental and social conditions so that
they may, by their own efforts, resume and maintain
as normal a place as possible in the community.
 Cardiac rehabilitation has also been described as the
combined and coordinated use of medical,
psychosocial, educational, vocational and physical
measures to facilitate return to an active and satisfying
lifestyle.
 Coordinated, multifaceted interventions designed to
optimize a cardiac patient’s physical, psychological,
and social functioning, in addition to stabilizing,
slowing or even reversing the progression of the

4. Goals of Cardiac
Rehabilitation;
 Reduction of Cardiac risk factors
 Exercise & activity guidelines
 Patient education
 To improve functional capacity
 To alleviate or lessen activity-related
symptoms
 To reduce disability
 To identify and modify coronary risk factors.

5. Indications;
 Active myocardial infarction
 Coronary Artery Bypass Surgery
(CABS)
 Percutaneous Transluminal Coronary
 Angioplasty (PTCA)
 Valvular replacement
 Pacemaker implantation

6. Phases of Cardiac
Rehabilitation;
 Phase I : Inpatient
 Phase II : Immediate Outpatient
 Phase III : Intermediate Outpatient
 Phase IV : Maintenance Phase of
Indefinite Length

7. Phase I;
Objectives;
 Conditioning from acute event/
post-CABG
 To make patient functionally
independent
 To adjust with discharge from the
hospital
 Psychological counselling
 Nutritional counselling

8. Phase I;
 Phase I relates to the period of hospitalization following
an acute cardiac event. The duration of this phase may
vary depending on the initial diagnosis, the severity of
the event and individual institutions, usually one week
acute event/post-operative.
 During this phase, early mobilization and adequate
discharge planning.
 Individuals typically undergo a risk factor assessment
and risk stratification
 Receiving information regarding their diagnosis, risk
factors, medications and work/ social issues.
 Involvement and support of the partner and family is
facilitated and encouraged.

9. Phase II;
Objectives;
 Functional goals - Exercise training under
supervision/ at home
 Psychosocial goals
 Anxiety/depression management
 Secondary preventive targets

10. Phase II;
 Phase II: This phase encompasses the immediate
post discharge period, which is typically a period
of four to six weeks.
 It focuses on health education and resumption of
physical activity, however the structure of this
phase may vary dramatically from centre to centre.
 It may take the format of telephone follow up,
home visits, or individual or group education
sessions.
 Either way, some form of contact is maintained
with the patient, facilitating ongoing education and
exchange of information.

11. Phase III;
Objectives;
 Functional goals - Exercise training
under supervision
 Psychosocial goals -
 Return to work Return to hobbies and
lifestyle
 Anxiety/depression management
 Secondary preventive targets.

12. Phase III:
 This phase is sometimes erroneously
referred to as the ‘Exercise’ phase.
 It incorporates
 Exercise training in combination with
ongoing education and psychosocial and
vocational interventions.
 The duration of Phase 3 may vary from six
to 12 weeks, with patients required to
attend a CR unit two to three times weekly
for structured exercise and other lifestyle
interventions.

13. Phase IV;
Objectives;
 Functional goals - Exercise training
 Psychosocial goals –
 Return to work
 Return to hobbies and lifestyle
 Anxiety/depression management
 Secondary preventive targets

14. Phase IV:
 This phase constitutes the components of long-
term maintenance of lifestyle changes and
professional monitoring of clinical status.
 It is when patients leave the structured Phase 3
programme and continue exercise and other
lifestyle modifications indefinitely.
 This may be facilitated in the CR unit itself or in a
local leisure centre.
 Alternatively, individuals may prefer to exercise
independently and
 Phase 4 may involve helping them set a safe and
realistic maintenance programme.

15. Benefits of Cardiac
Rehabilitation;
 Reduces cardiovascular and total mortality
 Does not increase non-fatal re-infarction rate
 Improves myocardial perfusion
 May reduce progression of atherosclerosis when
combined with aggressive diet
 No consistent effects on hemodynamic, LV function or
visible collaterals
 No consistent effects on cardiac arrhythmias
 Improves exercise tolerance without significant CV
complications
 Improves skeletal muscle strength and endurance in
clinically stable patients
 Promotes favourable exercise habits
 Decreases angina and CHF symptoms

16. Outcomes in Cardiac
Rehabilitation;
 Smoking cessation
 Lipid management
 Weight control
 Blood pressure control
 Improved exercise
tolerance
 Symptom control
 Return to work
 Psychological well-
being/stress
management
 Physical activity
 Improves glucose
metabolism
 Reduces body fat
 Lowers blood pressure
 Improves
musculoskeletal strength
 Controls body weight
 Reduces symptoms of
depression

17. Assessment before exercise
training;
 Clinical risk stratification is suitable for low
to moderate risk patients undergoing low
to moderate intensity exercise.
 Exercise testing and echocardiography
are recommended for high risk patients
and/or high intensity exercise
 Functional exercise capacity should be
evaluated before and on completion of
exercise testing.

18. Contra-indications exercise
training;
 Absolute Acute myocardial infarction (within two days)
 Unstable angina
 Uncontrolled cardiac arrhythmias causing symptoms or
homodynamic compromise
 Symptomatic severe aortic stenosis
 Uncontrolled symptomatic heart failure
 Acute pulmonary embolus or pulmonary infarction
 Acute myocarditis or pericarditis
 Active endocarditis
 Acute aortic dissection
 Acute noncardiac disorder that may affect exercise
performance or be aggravated by exercise
 Inability to obtain consent

19. Contra-indications exercise
training;
 Left main coronary stenosis or its equivalent
 Moderate stenotic valvular heart disease
 Electrolyte abnormalities
 Severe hypertension (systolic 200 mmHg and/or
diastolic 110 mmHg)
 Tachy-arrhythmias or brady-arrhythmias, including
atrial fibrillation with uncontrolled ventricular rate
 Hypertrophic cardio myopathy and other forms of
outflow tract obstruction
 Mental or physical impairment leading to inability to
cooperate
 High-degree atrio-ventricular block

20. Measurements during Cardiac
Rehabilitation;
 Exercise capacity
 Blood Pressure
 Weight
 Waist circumference
 Lipids
 Glucose/HbA1C
 Telemetry monitoring occurs during exercise
sessions
 Nutritional survey tool

21. Exercise guidelines for Cardiac
Patient;
General In-patient Guidelines;
 Frequency
Early mobilization: 3-4 times/day (days 1-3)
Later mobilization: 2 times/day (beginning on day 4)
 Progression: Initially increase duration up to 10-15 min,
then increase intensity.
 By hospital discharge, the patient should: Demonstrate a
knowledge of inappropriate exercises
 Have a safe, progressive plan of exercise formulated for
them to take home
 Selected moderate to high risk patients should be
encouraged to participate in outpatient cardiac
rehabilitation programs &/or
 Manage their discharge rehabilitation plan and report any
cardiovascular symptoms promptly (should they occur).

22. General Out-patient
Guidelines;
 Goals are to: Develop and help the patient to
establish and implement a safe and effective
home exercise program and recreational lifestyle,
 Provide patient and family education and
therapies to maximize secondary prevention.
 In general, patients should engage in multiple
activities to promote total conditioning including
aerobic and resistance exercises.
 Principles of prescription are those for healthy
adults but adjusted to take into account the
patients clinical status.

23. Independent Exercise
Guidelines;
 Appropriate hemodynamic response to
exercise
 Appropriate ECG response
 Adequate management of risk factor
intervention strategy and safe exercise
participation
 Demonstrated knowledge of disease
process, abnormal signs and symptoms,
medication use and side effects.

24. Sharing the Story of the Cardiac
Rehab Patient Experience;
 Ellis, Jordan M. MA; Freeman, John Taylor MA;
Midgette, Emily P. BA; Sanghvi, Anup P.; Sarathy,
Brinda; Johnson, Colin G.; Greenway, Stacey B.
MA; Whited, Matthew C. PhD
 Author InformationJournal of Cardiopulmonary
Rehabilitation and Prevention: July 2019 - Volume
39 - Issue 4
Purpose:
 To provide a prototypical patient narrative of
the cardiac rehabilitation (CR) experience for
providers and prospective patients using narrative
analysis.

25. Cont….
Methods:
 Qualitative interviews with 17 CR patients from a previous study
regarding their experiences, reasons, and motivations related to
engagement in CR were analyzed using narrative inquiry.
Interviews were previously analyzed and coded for recurring
themes, and these themes were implemented in an exploratory
narrative inquiry to craft a CR patient “story.” A hypothetical
composite character representing the varied experiences of CR
patients interviewed was developed, and a patient story was
constructed that reflected on an initial cardiac event, time during
rehabilitation, difficult experiences, social interactions, and
personal values and accomplishments.
Results:
 The CR patient narrative is presented for use in CR recruitment
and programming materials, and in provider education.
Conclusion:
 The narrative analysis comprehensively provides patients with an
amalgam of patient experiences and can be used by providers to
gain an understanding of CR patient experiences. Further
research is needed to determine whether use of the
resulting narrative analysis within the referral process and/or

26. Journal Article related to Cardiac
Rehabilitation;
Muscular Strength and Cardiovascular Disease; An
updated state-of-the-art narrative review
 Carbone, Salvatore PhD; Kirkman, Danielle L. PhD;
Garten, Ryan S. PhD; Rodriguez-Miguelez, Paula
PhD; Artero, Enrique G. PhD; Lee, Duck-chul PhD;
Lavie, Carl J. MD
 Journal of Cardiopulmonary Rehabilitation and
Prevention: September 2020 - Volume 40 - Issue 5 -
p 302-309
 This review discusses the associations of muscular
strength (MusS) with cardiovascular disease (CVD),
CVD-related death, and all-cause mortality, as well
as CVD risk factors, such as metabolic syndrome,
diabetes, obesity, and hypertension. We then briefly

27. Cont….
 MusS is a strong modifiable risk factor for several CVDs,
but also CVD-related mortality and all-cause mortality.
Except for the risk of HTN, where the evidence is
conflicting, MusS seems to exert protective effects on
several CV and metabolic conditions (ie, MetS, T2DM, and
obesity). Importantly, such effects seem to be, for the most
part, independent of the amount of LM, CRF, and physical
activity. The studies discussed herein, however, cannot
prove whether dynapenia is a mediator or perhaps only a
marker of overall worse nutritional status able to identify
those with frailty and sarcopenia among others, which, in
turn, confer a greater risk for cardiometabolic diseases. In
other words, is this relationship causal or merely
association? Further study is clearly warranted to
determine whether therapeutics, including targeting
nutrition and RT, aimed at increasing MusS, with and
without changes in LM, can, in fact, affect major clinical

28. Summary

29. By;
Pradeep.M
M.Sc. Nursing II
year