Rehabilitation for Patients with Cardiovascular Disease

1
Rehabilitation for Patients with Cardiovascular
Disease

• MR ??? ??
• MA ??? ??

2
Book Reading

• ACSM's Resource Manual for Guidelines for
  Exercises Testing and Prescription
• Chapter 35 Exercise Prescription in Patients with
  Cardiovascular Disease
• Braddom
• Chapter 34 Cardiac Rehabilitation
• DeLisa
• Chapter 83 Cardiac Rehabilitation

3
Background

• 18 65 years old healthy adults need
• Moderate-intensity activity at least 30 minutes
  on 5 days per week
• 
  Or
• Vigorous-intensity aerobic activity at
  least 20 minutes on 3 days per week
• Resistance training involving the major muscle
  groups at least 2 days per week
• Exercise is also recommended for the elderly or
  people with illness!

4
Canadian Family Physician, http//www.cfpc.ca/cfp/
2002/jan/vol48-jan-cme-1.asp
? DeLisa Table 83-7
5
Cardiac Rehabilitation

• Introduction of Cardiac Rehabilitation
• Disease-Specific Effects on Physiologic Responses
  and Fitness
• Scientific and Physiologic Rationale for Exercise
  Therapy in Patients with Heart Disease
• Morbidity, Mortality, and Safety of Cardiac
  Rehabilitation
• Exercise Prescription and Programming

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Definition

• Cardiac rehabilitation is an interdisciplinary
  team approach to patients with functional
  limitations secondary to heart disease

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Goals

• Restore patients to their optimal medical,
  physical, psycological, social, emotional,
  sexual, vocational, and economic status
  compatible with the severity of their heart
  disease
• Prevention of heart disease
• Primaryscreen healthy people to identify and
  treat risk factors
• Secondaryto improve heart disease risk factors
  and limit further morbidity and mortality

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Cardiac Rehabilitation

• Introduction of Cardiac Rehabilitation
• Disease-Specific Effects on Physiologic Responses
  and Fitness
• Scientific and Physiologic Rationale for Exercise
  Therapy in Patients with Heart Disease
• Morbidity, Mortality, and Safety of Cardiac
  Rehabilitation
• Exercise Prescription and Programming

9
Cardiovascular Response during Exercise

• Heart Rate
• Normal
• Achieving HR within 2 standards deviations of an
  age-predicted maximum value
• Decreasing HR to baseline fairly quickly during
  recovery

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Cardiovascular Response during Exercise

• Heart Rate
• Abnormal
• Chronotropic Incompetence Failure to achieve 85
  predicted maximum HR
• (without medication
  effect) ? Predict CAD and associated with
  increased risk of Mortality/Morbidity
• Abnormal HR recovery Walking decrease in HR lt
  12 bpm / 1 minute Supine   decrease in HR lt 22
  bpm / 2 minutes ? Predict future cardiac
  mortality

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Cardiovascular Response during Exercise

• Blood Pressure
• Normal
• DBP Constant or slightly decrease
• SBP Increase progressively about 812 mmHg/MET,
  with a plateau at peak exercise
• Abnormal
• In patients with CAD, SBP during exercise may
  respond normally or may disproportionately
  increase or inappropriately decrease

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Cardiovascular Response during Exercise

• Blood Pressure
• Abnormal
• Exertional hypertension SBP gt 250 mmHg or
• DBP gt
  115 mmHg
• Exertional hypotension
• Compare to resting BP, SBP decrease ? 10mmHg
  
• ? Exertional systolic hypertension/hypotension
  would increase cardiac event risk
• Increase DBP ? 10mmHg
• ? Often a marker for future hypertension

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Cardiovascular Response during Exercise

• Cardiac Output and Oxygen uptake
• NormalPeak VO2 3045 ml/kg/min
• CAD patientPeak VO2 reduction ? 20
• Due to ?Cardiac Output
• Cardiac Output Heart Rate x Strove volume
• Heart RateChronotropic incompetence
• Strove VolumeLeft ventricular dysfunction
• ?With Exercise Training ? VO2?1530

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Oxygen Consumption

• 1 MET (Metabolic Equivalent)
• Oxygen consumption at resting
• Basal metabolic rate
• At rest, 70kg man O2 consumption
• 3.5ml oxygen/ minute/ Kg of BW

Relationship between oxygen consumption and
intensity of work being performed.
Braddom Figure 34-1
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Braddom Table 34-6 The metabolic equivalent
energy expenditure of varying intensity
activities
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Cardiac Rehabilitation

• Introduction of Cardiac Rehabilitation
• Disease-Specific Effects on Physiologic Responses
  and Fitness
• Scientific and Physiologic Rationale for Exercise
  Therapy in Patients with Heart Disease
• Morbidity, Mortality, and Safety of Cardiac
  Rehabilitation
• Exercise Prescription and Programming

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Ischemic cascade

• The temporal sequence of cellular, hemodynamic,
  electrocardiographic, and symptomatic expressions
  occurring during ischemia
• Imbalance between Myocardial oxygen supply and
  demand
• ?Ischemic event
• ?Abnormalities in Diastolic function
• ?Abnormalities in Systolic function
• ?EKG changes, such as ST-segment depression
• ?Patient may or may not experience Angina

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Ischemic cascade

• After the myocardial oxygen supply and demand
  imbalance is corrected at the cellular level, the
  process is reversed
• Angina resolves
• ?EKG changes
• ?Improvement in Systolic function
• ?Normalization of Diastolic function

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Ischemic cascade

• Patients with CAD studied during ischemia
• Hemodynamic abnormalitiesnearly all
• Radionuclide evidence of global or regional wall
  motion abnormalities80
• EKG50
• Symptomatic evidence of ischemia30
• Some patients, such as DM or undergone cardiac
  transplant, experience ST-segment depression
  without angina (i.e., silent angina), whereas
  others may experience angina without ST-segment
  depression.

Berger HJ, Reduto LA, Johnstone DE, et al. Global
and regional left ventricular response to cycle
exercise in coronary artery disease assessment
byquantitative radionuclide angiocardiography, Am
J Med. 1979 66 13-21
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Myocardial Oxygen Demand

• Increase myocardial oxygen demandincreasing HR,
  increasing left ventricular preload, and
  increasing myocardial contractility
• Myocardial oxygen consumption can be reliably
  estimated by
• RatePressure Product HR x Systolic BP
• (Double product)
• The normal maximal exercise response results in a
  ratepressure product of 25,000 or higher

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RatePressure Product
Just like a ß-blocker, regular exercise training
lowers HR and BP responses during submaximal
exercise and also creates a rightward shift in
the ratepressure product.

• ACSMs Figure 35-1. Regular exercise training
  attenuates myocardial O2 demand during exercise,
  as estimated by the ratepressure product.

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Myocardial Oxygen Supply

• Four factors affect myocardial O2 supply
• Coronary artery stenosis with endothelial
  dysfunction
• Microvascular dysfunction
• Abnormalities of the autonomic nervous system
• Abnormalities of coagulation and fibrinolytic
  systems
• ? Endothelial dysfunctionParadoxical
  vasoconstriction is observed in patients with CAD
  or chronic heart failure, maybe due to decreased
  production of nitric oxide

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lt1000 kcal per week experienced the greatest
amount of disease progression gt1400 kcal per week
showed improved cardiopulmonary fitness gt1500
kcal per week demonstrated the slowest rate of
disease progression gt2200 kcal per week showed
regression of CAD
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Cardiac Rehabilitation

• Introduction of Cardiac Rehabilitation
• Disease-Specific Effects on Physiologic Responses
  and Fitness
• Scientific and Physiologic Rationale for Exercise
  Therapy in Patients with Heart Disease
• Morbidity, Mortality, and Safety of Cardiac
  Rehabilitation
• Exercise Prescription and Programming

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Morbidity, Mortality, and Safety of Cardiac
Rehabilitation

• Total cardiovascular mortality are reduced in
  patients following myocardial infarction who
  participate in cardiac rehabilitation exercise
  training
• The 1995 Agency for Heath Care Policy and
  Research (AHCPR) Clinical Practice Guidelines for
  Cardiac Rehabilitation
• Cardiac rehabilitation reduced all-cause
  mortality by approximately 25
• Taylor RS, Brown A, Ebrahim S, et al.
  Exercise-based rehabilitation for patients with
  coronary heart disease systematic review and
  meta-analysis of randomized controlled trials. Am
  J Med. 2004116682692.

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Classification of Cardiac Rehabilitation

• Inpatient phase
• Minimize the de-conditioning time
• Education about risk factors and lifestyle
  modification
• Early outpatient phase
• Maintenance phase
• Follow-up phase
• Differing based on extent of supervision and
  monitoring, subject independence, and time from
  the event
• Improve exercise performance and modify cardiac
  risk factors

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Cardiac Test

• Rest/ Exercise cardiac test should be performed
  before prescription
• Cardiac TestingResting EKG, CXR, 2D-echo, Holter
  exam, Coronary angiography, Cardiac exercise
  stress test
• ?Cardiac exercise stress test is generally safe,
  and adverse outcomes are infrequent

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Cardiac Exercise Stress Test

• Modality
• Treadmill, Bicycle, Arm ergometers
• Dipyridamole, Adenosine
• End point
• Normal EST 85 age/gender predicted HRmax
• Symptom-limited maximum EST
• Low-level submaximal EST
• HR 120
• 70 HRmax
• Peak MET 5

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Contraindications to Exercise

• Unstable angina
• Resting ST depression gt 2mm
• Uncontrolled arrhythmias
• Critical aortic stenosis
• Uncompensated congestive heart failure
• Resting SBP gt 200mmHg or DBP gt110mmHg
• Fall in SBP gt 10mmHg with exercise
• Symptomatic orthostatic SBP drop 10-20 mmHg

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Comorbidities Impacting the Safety of Exercise
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Cardiac Rehabilitation

• Introduction of Cardiac Rehabilitation
• Disease-Specific Effects on Physiologic Responses
  and Fitness
• Scientific and Physiologic Rationale for Exercise
  Therapy in Patients with Heart Disease
• Morbidity, Mortality, and Safety of Cardiac
  Rehabilitation
• Exercise Prescription and Programming

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Exercise Pattern - Aerobic Training
Braddom Figure 34-5
Braddom Figure 34-4
Braddom Figure 34-6
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Exercise Pattern Resistance Exercise

• Moderate-intensity dynamic resistance exercise
  (defined as 5060 of one repetition maximum
  1RM) results in improved muscle strength and
  endurance
• A small reduction of 3 and 4 mm Hg for resting
  systolic blood pressure and diastolic blood
  pressure, respectively
• A commonly recommended resistance-training
  program involves performing one set of eight to
  10 regional exercises, performed 2 to 3 days per
  week
• Isometric exercises are not recommended because
  of a potential significant rise in systolic and
  diastolic blood pressure

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Exercise Pattern Resistance Exercise

• Time to Start Resistance Exercise
• Catheterization with or without PCI3 weeks later
• Recover from an uncomplicated MI5 weeks later
• CABG surgery or valve surgery involving a
  sternotomyavoid upper-limb resistance training
  until sternal healing has occurred), generally 6
  to 12 weeks after surgery

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Target Heart Rate

• HR Reserve Method (Karvonen Method)
• HRR HRmax HRrest
• HRmax 220 age
• Target HR ( HRmax HRrest ) x HRrest
• ? HRmax 200, HRrest 80
• ? HR reserve 200 80 120
• ? If 80 HRR
• ? Target HR 80 120 x 80 176

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ACSMs Table 35-4 Summary of Unique Exercise
Prescription Issues among Patients with
Cardiovascular Disease
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ACSMs Table 35-4 Summary of Unique Exercise
Prescription Issues among Patients with
Cardiovascular Disease
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Coronary Artery Disease

• Intensity40/50-85 of HRR
• To affect mortality, frequency, duration, and
  intensity of training should sum to yield a
  weekly energy expenditure1500 kcal/ week
• Total energy expenditure is more important than
  duration or type of activity

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Braddom Box 34-1 Risk Factors for Coronary Artery
Disease
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ACSMs Table 35-3 Summary of Effects of
Cardiorespiratory Exercise Training on Selected
Cardiovascular Risk Factors
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Angina

• Exercise, lifestyle behavior changes, and medical
  compliance
• 40/50-85 of HRR
• Patients with evidence of exercise-induced
  ischemia (i.e., angina, ECG changes), the upper
  HR for exercise training should be set 10 or more
  beats below the HR or RPP
• Goal for patients with angina
• To perform routine daily activities at a lower
  RPP, thus reducing the amount of angina/ fatigue
  they experience
• To increase the amount of work, home activity, or
  exercise they can perform at a given RPP

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Angina

• Patients need to recognize and understand their
  symptoms first
• Patients regularly experience angina at
  relatively low workloads (e.g., 2 METs) to take
  one sublingual nitroglycerin about 15 minutes
  before starting their warm-up.
• ?Exercise in a pain-free manner and at slightly
  higher workloads
• A longer warm-up (10 min) to minimize or avoid
  ischemia

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Myocardial Infarction

• Start at the lower end of their training
  intensity (4060 of HR reserve method)
• Three nonconsecutive days of cardiac
  rehabilitation per week, with each exercise
  session consisting of a 5- to 10-minute warm-up
  and cool-down period
• Progressively increase exercise intensity and
  duration up to 85 of HR reserve method and 20 to
  60 minutes
• Encouraged to adopt an active life style,
  including exercise and daily activities, so that
  they expend gt1500 kcal each week

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Revascularization (Coronary Artery Bypass Graft
and Percutaneous Coronary Intervention)

• Signs of ischemia during exercise are often
  eliminated after revascularization
• Patients undergoing PCI
• Recommendations for exercise programming for
  patients after PCI are generally the same as for
  other patients with CAD
• Because patients undergoing PCI frequently do not
  experience myocardial damage or extensive
  surgery, they can sometimes begin cardiac
  rehabilitation, return to work, and resume ADLs
  much sooner
• Cardiac rehabilitation can begin within 48 hours
  after PCI

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Revascularization (Coronary Artery Bypass Graft
and Percutaneous Coronary Intervention)

• Patients undergoing CABG surgery
• Begin rehabilitation as early as 2 weeks after
  surgery, with the initial focus on aerobic-type
  exercises
• All upper-body exercise should be limited to ROM
  and light repetitive activities until 4 to 8
  weeks after surgery
• Following the initial wound healing, patients
  should be able to exercise up to 85 of HR
  reserve method, 3 to 4 days per week, for 20 to
  60 minutes
• After the sternum is healed at 6 to 12 weeks,
  patients can then begin a resistance-training
  program similar to other patients with
  cardiovascular disease

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Valve Dysfunction/Repair/Replacement

• Heart valve abnormalities
• ? Increase the work the heart due to reducing
  effective cardiac output
• ? Myocardial hypertrophy
• ? Mild diastolic dysfunction or a decrease in
  ventricular distensibility
• Exercise will not improve or change the function
  of the valves, but it will help to improve the
  efficiency of oxygen extraction by the skeletal
  muscles and improve the work capacity of the
  individual

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Valve Dysfunction/Repair/Replacement

• The majority of valve abnormalities can be
  corrected with surgical procedures.
• Patients follow the same guidelines as CABG
  patients following surgery
• Patients on warfarin for mechanical valves or
  atrial fibrillation should avoid contact sports

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Heart Failure

• Exercise intolerancePeak exercise capacity
  reduced 30 to 40 in patients with heart failure
  
• Several mechanisms to explain the exercise
  intolerance
• A reduction in peak cardiac output (40)
• Chronotropic incompetence
• Reduced stroke volume
• The ability to increase blood flow to the more
  metabolically active skeletal muscles during
  exercise is attenuated
• Abnormalities in the skeletal muscle, such as a
  reduction in myosin heavy chain I isoforms,
  reduced activity of the enzymes associated
  aerobic metabolism, and a reduction in fiber size

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Heart Failure

• Moderate exercise is generally safe and results
  in improvements in many aspects
• Exercise training increases ejection fraction and
  decreases LV end-diastolic volume
• Patients with decompensated heart failure should
  not be involved in an exercise program
• More opportunity for rest, then progressively
  increase to 30 minutes or more.
• The upper end of exercise intensity at 60 of HR
  reserve method, based on patient's condition
• ECG monitoring or not

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Cardiac Transplant

• Cardiac transplant recipients continue to
  experience exercise intolerance after
  transplantation
• This exercise intolerance is believed to be
  primarily attributable to the absence of efferent
  sympathetic innervation of the myocardium,
  affecting heart rate and contractility responses,
  residual skeletal muscle abnormalities developed
  before transplantation because of heart failure,
  and decreased skeletal muscle strength

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Cardiac Transplant

• After transplantation, many differences
• Elevated resting HR (often gt90 bpm)
• Elevated systolic and diastolic BPs at rest ?
• Attenuated increase in HR during submaximal work
• Lower peak HR and peak stroke volume
• Greater increase in plasma norepinephrine during
  exercise
• Delayed slowing of HR in recovery ?
• ? Elevated systolic and diastolic BPs at rest,
  partly attributable to increased plasma
  norepinephrine and the immunosuppressive
  medications (i.e., cyclosporine and prednisone)
• ? Delayed HR in recovery is thought to be
  attributable to increased levels of plasma
  norepinephrine, exerting its positive
  chronotropic effect in the absence of vagal
  efferent innervation

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Cardiac Transplant

• In the first year after surgery, it is best to
  simply disregard all HR-based methods because of
  the abnormal HR control in these patients
• Cardiac transplant patients undergo exercise
  training
• Exercise capacity increases by about 15 to 40
• Resting HR is unchanged or decreases slightly
• Peak HR increases
• Little change in peak stroke volume or cardiac
  dimensions
• Quality of life is favorably altered
• A progressive resistance training program started
  6 to 12 weeks after transplant surgery and
  performed twice per week

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DeLisa Table 83-2 Borg Scales for Rating
Perceived Exertion
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Pacemakers, Implantable Cardiac Defibrillators,
and Arrhythmias

• In general, the exercise training prescription is
  unaltered for patients with these devices.
• Exercise intensity in patients with an ICD should
  be set at least 10 beats below the programmed
  firing threshold
• Avoid activities that stretch the arms. After 8
  wk, nonballistic activities may be resumed, and
  ballistic activities may be resumed after 12 wk.

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Summary

• The inclusion of exercise in the treatment of
  these patients is beneficial because of its
  favorable effects on risk factors, symptoms,
  functional capacity, physiology, and quality of
  life.
• All patients with cardiovascular disease should
  be encouraged to participate in exercise because
  of its real or likely positive impact on
  mortality and morbidity.

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Thanks for your attention!