Cardiac Rehabilitation

Imtiyaz Ali
Lecturer, UTAR
Objectives
 Define Cardiac rehabilitation
 List benefits of exercise training
 List Benefits of cardiac rehab
 Discuss indications, contra-indications &
termination criteria for cardiac rehab
 Know risk stratification for exercises during
assessment
 Discuss about general principles of exercise in
cardiac rehab
 Explain each phase of cardiac rehab in detail
Definition
 combined and co-ordinated use of medical,
psychosocial, educational, vocational and
physical measures to facilitate return to an
active and satisfying lifestyle
 It is a multidisciplinary program for education
and exercise established to assist individuals
with heart diseases in achieving optimal
physical, psychological and functional status
within limits of their disease
Definition
 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 underlying atherosclerotic
process, thereby reducing
morbidity and mortality

AHA Scientific Statement, Circ 2005;111:369-76

Specialized Team
 Doctors
 Nurses
 Physiotherapists
 Dietician/nutritionist
 Exercise physiologist
 Psychologist
 Vocational counselor
 Occupational therapist
 Social worker
Benefits of Exercise Training
 Decreases in blood pressure
 Decrease serum triglycerides
 Increases in high-density lipoprotein cholesterol
 Improvements in insulin sensitivity
 Glucose homeostasis
 Loss in body weight
 Reduce the risk of type 2 diabetes mellitus
Benefits of Exercise Training
 Increased physical fitness
 Reduced angina
 Reduced HR variability
 Improved thrombolysis
 Psychological well being
 Quality of life
 Return to work
 Improved survival
Effect of Training on Exercise Capacity

Central changes
 Increased VO2 max
 Increased cardiac output
 Increased stroke volume
 Decreased heart rate
Effect of Training on Exercise Capacity
Peripheral Changes
 Increase in the number of mitochondria
 Increase in oxidative enzyme activity
 Increase capillarization
 Increase myoglobin
 Increase VO2 max (due to peripheral
adaptation)
Benefits of Cardiac Rehabilitation
 Reduces cardiovascular and total mortality
 Improves myocardial perfusion
 May reduce progression of atherosclerosis when
combined with aggressive diet
 Decreases angina and CHF symptoms
 No consistent effects on cardiac arrhythmias
 Improves exercise tolerance without significant
CV complications
 No consistent effects on hemodynamics, LV
function or visible collaterals
1996 AHCPR Report
Indications for Cardiac Rehabilitation

 Coronary artery disease (particularly with modifiable

coronary risk factors or poor exercise tolerance (6 METs or
inadequate to meet domestic or occupational needs)
 Myocardial infarction
 Coronary artery bypass surgery
 Cardiac transplantation
 Congestive heart failure
 Percutaneous transluminal coronary angioplasty
 Valvular surgery
Absolute Contraindication to Exercise
 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/pericarditis/endocarditis
 Acute aortic dissection
 Acute non-cardiac disorder that may affect exercise performance or be
aggravated by exercise
 Inability to obtain consent

Exercise standards for testing and training: a statement for healthcare professionals from
the American Heart Association. Circulation 2001; 104:1694
Relative Contraindication to Exercise
 Left main coronary stenosis or its equivalent
 Moderate stenotic valvular heart disease
 Electrolyte abnormalities
 Severe hypertension (systolic 200 mmHg and/or diastolic 110 mmHg)
 Controlled Tachyarrhythmias or bradyarrhythmias
 Hypertrophic cardiomyopathy and other forms of outflow tract
obstruction
 Mental or physical impairment leading to inability to cooperate
 High-degree AV block

Exercise standards for testing and training: a statement for healthcare professionals from the
American Heart Association. Circulation 2001; 104:1694;
Criteria to Terminate Exercise
 Fatigue
 Light-headedness, confusion, ataxia, cyanosis, dyspnea,
nausea, or peripheral circulatory insufficiency
 Onset of angina with exercise
 Onset of 2nd or 3rd degree heart A-V block
 Exercise hypotension (>20 mm Hg drop in systolic BP)
 Excessive blood pressure risk: systolic >220 or diastolic >110
mm Hg
 Inappropriate bradycardia ( <10 beats/min) with no increase
in workload
 ST displacement >3 mm from rest
 Ventricular tachycardia
 Exercise-induced left bundle branch block
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
Risk Stratification for Exercise
Low risk
 No significant LV dysfunction (EF > 50%)
 No resting or exercise induced complex
dysrthymias
 Uncomplicated MI, CABG, angioplasty,
atherectomy, stent
 Asymptomatic including absence of angina with
exertion or recovery
 Functional capacity > or = 7.0 METS
 Absence of clinical depression
Risk Stratification for Exercise
Moderate risk
 Moderately impaired LV function ( EF = 40– 49% )
 Signs / symptoms including angina at moderate
levels of exercise ( 5 -6.9 METS) or in recovery
Risk Stratification for Exercise
Highest risk
 Decreased LV function (EF< 40%)
 Survivor of cardiac arrest or sudden death
 Complex ventricular dysrhythmia at rest or with exercise
 MI or cardiac surgery complicated by cardiogenic shock,
CHF, and/or signs or symptoms of pos procedure ischemia
 Abnormal hemodynamics with exercise
 Signs/symptoms including angina pectoris at low levels of
exercise ( < 5.0 METS)
 Clinically significant depression
 Functional capacity < 5.0 METS
Risk Stratification for Exercise
◦ Class A
◦ Class B
◦ Class C
◦ Class D

 Guidelines published by the American Heart Association use four categories

of risk according to clinical characteristics
Risk Stratification for Exercise
 Class A: apparently healthy and no clinical evidence
of increased cardiovascular risk of exercise
 Class B: established CHD that is clinically stable,
Overall low risk of cardiovascular complications of
vigorous exercise

 Guidelines published by the American Heart Association use four

categories of risk according to clinical characteristics
Risk Stratification for Exercise
 Class C: moderate or high risk of cardiac
complications (multiple myocardial infarctions or
cardiac arrest, Exercise capacity of < 6 METs, or
significant ischemia on the exercise test
 Class D: unstable disease for whom exercise is
contraindicated

 Guidelines published by the American Heart Association use four

categories of risk according to clinical characteristics
Recommended for ECG monitoring
Lowest risk
 Monitored-6 to 18 sessions
 Up to 30 days post-event
Moderate risk
 Monitored-12 to 24 sessions
 Up to 60 - 90 days post-event
Highest risk
 Monitored -18 to 24 sessions
 For 90 days or more post-event
General Principles of Exercise
 Frequency
 3-5 days/week
 Time: 15-20 min excluding 10 min warm up and
10 min cool down
 Type:
◦ Aerobic training
◦ Resistance training
General Principles of Exercise
Intensity
 VO2 max
 Maximum heart rate: 10-20 beats less than HRmax
 HR which produces symptoms
 Karvonen’s formula: 60% - 75% RHR + (HRmax-RHR)
◦ 206.9 - (0.67 x(age) = HRmax
 HRR
 RPE
 METS
 Talk test
VO2max Tests
 2.4km Run Test
 Astrand Treadmill test - VO2max test running on a
treadmill
 Astrand 6 minute Cycle test - Vo2 max test on a
static bike
 Balke Incremental treadmill protocol test-
VO2max test on a treadmill
 Bruce Incremental treadmill protocol test-
VO2max test on a treadmill
 VO2max from a one mile jog
 VO2max Queens college Step Test
Heart rate
 220-age (Inaccurate)
 206.9 - (0.67 x(age) = HRmax
 Low range - 50 percent
 High range - 70 percent
 Beta-blockers- should use another option for
monitoring their intensity
Heart Rate which produces symptoms
 High intensity- 75% to 85%
 Moderate exercise- 65% to 75%
 Low intensity- 50% to 65%
Rate of Perceived Exertion
Talk Test
 Subjective
 Too easy- sing several phrases of a song without
breathing hard
 Good intensity- light conversation
 Working too hard- speech starts to break, slow,
or cause discomfort
METs
 One MET= 3.5 ml/kg/min
 Very light- <3.2
 Light- 3-5
 Moderate- 5-7
 Hard- 7-10
 Very hard- >10.3
 Max- 12
Elements of Exercise Prescription
 Rule out contraindications for exercise
 Risk stratification and monitoring
 Type, Intensity, Duration, Frequency
 Progression, Precaution
 Warm up - Cool down
 Proper : Time, Place, Equipment, Clothes
Phases of cardiac rehabilitation
 Phase I: 7-14 days in patient phase
 Phase II: 2-12 weeks convalescence phase
 Phase III: 4-6 months cardiac rehab supervised
phase
 Phase IV: >6 months maintenance phase
Objectives of phase I
 To assist - ambulatory
 To prepare patient, family and significant others
- healthy life-style, decreasing further risk
 To reduce psychological and emotional
disorders
 To facilitate adjustments – hospital environment
 To identify, modify CAD risk factors
 Create positive attitude- motivate
Conduct of the program
Rehab for CABG, PTCA, valve surgery, stable
angina, CAD:
 HRrest + 30 bpm

Post MI:
 HR < 120 bpm or
 HRrest + 20 bpm
Phase I
STEP 1
 Active range of exercises to all extremities
 Surgical patients - Up in chair 2 times daily,
ambulation with assistance in room
 MET level: 1.0 to 1.5
Phase I
Exercises:
 Shoulder flexion
 Shoulder abduction
 Shoulder horizontal abduction
 Hip/knee flexion and extension
 Hip abduction
 Ankle pumps
Phase I
Step 2:
 Breathing and relaxation techniques
 Gait: standing pregait activities (dips, weight
shifting)
 Up in chair 30 to 60 min
 MET level:1.0 to 1.5
 Exercises- Wand exercises as per level 1
◦ Shoulder circling
◦ Trunk rotation
◦ Hip/knee flexion and extension
◦ Knee extension
Phase I
Step 3
 Gait: short walks in the room as tolerated
 Gait: walk in room ad libitum
 MET level:1.5 to 2.0
 Exercises- Wand exercises
◦ Head circles
◦ Arm circles
◦ Trunk rotations
◦ Trunk lateral flexion
◦ Dips
◦ Toe raise
Phase I
Step 4
 Exercises - Wand exercises: progress to wrist
weights ( begin at 1 pound), when patient has
full range of motion at the shoulder, elbow
flexion/extension
 Gait: walk in room ad libitum
 Stationary cycle: 5 min at min resistance
 MET level: 1.5 to 2.0
Phase I
Step 5
 Exercise and walking as per level 4
 Stationary cycle: 10 min at min resistance
 Cool down stretches for quadriceps and heel
cords
 MET level: 1.5 to 2.0
Phase I
Step 6
 Exercise and walking as per level 4
 Stationary cycle: 15 min at min resistance
 Cool down stretches as per level 5 plus
hamstring stretch
 MET level: 2.0 to 2.5
Phase I
Step 7
 Exercise and walking as per level 6
 Stationary cycle: 20 min at mild resistance (RPE
11-13)
 Include 2-3 min slower warm-up and cool down
 Cool down stretches as per level 6
 MET level: 2.5 to 3.0
Phase I
Step 8
 Repeat step 7
 Walk not more than 300 feet
 Surgical patients- continue step 7
 Walk down two flight of stairs (up in elevator)
 MET level: 1.5 to 2.5
Phase I
Step 9
 Repeat step 8
 Add knee bend and trunk bend
 Walk to tolerance and go upstairs one flight
 Surgical patients- up one flight, down one flight
 MET level: 2.0 to 2.5
Phase I
Step 10
 Repeat step 9
 Down two flight of stairs
 Surgical patients- repeat step 9
 MET level: 2.0 to 2.5
Phase I
Step 11
 Repeat step 10
 Down one flight of stairs and up with assistance
 MET level: 2.5 to 3.0
 Medical patients with congestive cardiac
failure or other complications take longer to
mobilize
Wegners mobilization program for
uncomplicated MI
 Step 1 PROM, active ankle movt and feeding
 Step 2 repeat 1 and high sitting
 Step 3 active assisted ROM and sitting on a chair
 Step 4 minimal sitting time, inclined sitting time,
light craft activities
 Step 5 moderate resistance and sitting for ADLs,
patient education
 Step 6 increase resistances, walking to bathroom,
standing ADLs
 Step 7 standing warm up exercises, walking 100
feet at comfortable pace
Wegners mobilization program for
uncomplicated MI
 Step 8 increase active standing exercise, increase
ambulation, stair go down come up with lift
 Step 9 increase exercise program
 Step 10 increase walking duration, start discussing
home program
 Step 11 increase duration
 Step 12 walking down 2 flight stairs
 Step 13 same activities
 Step 14 up and down one flight of steps
Phase II
 Phase II of cardiac rehabilitation is a supervised
out-patient program of individually prescribed
exercise with continuous or intermittent ECG
monitoring
 It may be operated as a hospital-based or free
standing physician directed facility
Objectives
 Enhance cardiovascular function, physical work
capacity, strength, endurance, and flexibility
 Detect arrhythmias and other ECG changes during
exercise
 Educate patients on proper technique of exercise
 Work with patient, family, and significant others to
establish healthy lifestyle
 Enhance the psychological function of patients
 Prepare patients for a return to work and resumption of
normal family and social roles
 Provide patients with guidelines for a longterm exercise
Phase II
Exercise Prescription
 Intensity:
◦ (Above training threshold)
 Heart rate
◦ Mild to Moderate
◦ 40% – 60% of HR Max
◦ (Age predicted or from exercise testing)
 RPE
◦ 11 -13 (Light to somewhat hard)
Phase II
 Duration:
◦ 15 – 30 min
◦ Intermittent
◦ Slow progression
 Frequency
◦ One session / day
◦ Three to Four Days / week
Phase III
 It is compose of safe incremental progression of
activity and health education involving risk
factor modification and providing
psychological support through counselling and
stress management program
Objectives
 To improve and maintain physical fitness
 To monitor heart rate, blood pressures ECG, signs
and symptoms that are potential contraindications
for exercise
 To provide professional supervision for exercise
 Provide smooth transition- less monitored,
supervised exercise program
 Continue with educational and behavioural
program
 Provide the foundation for safe and effective
home-based program
Objectives
 To promote the importance of a lifetime
commitment to physical exercise and healthy
lifestyle
 To introduce new exercise activities
 To teach skill for self monitoring and self
awareness
 To prevent the recurrence and complication of
CHD
Phase III
Exercise Prescription
 Intensity
◦ Above training threshold but below that which
induces abnormal clinical signs and symptoms
◦ For deconditioned cardiac patients: 40-50% of VO2
Reserve (VO2R)
 Particularly useful when
◦ GXT has not been performed
◦ Medications affect the HR response (especially beta-
blockers)
Phase III
 RPE
◦ 12-15 (somewhat hard to hard )
◦ (Approximately 60 - 80% VO2 Reserve and 60 – 85%
HRmax)

 Karvonen formula
◦ THR = % HRR + HR rest
◦ THR – Target heart rate (training zone)
◦ HRR – Heart rate reserve (HR max- HR rest)
 Heart rate: Training zone
◦ THR = 60% – 85% HR max
Phase IV
 Maintenance of endurance and strength
 Minimal or unsupervised exercise program
 Self exercise and sports programs
 Long tem behavioural modifications
Guidelines to progress to unsupervised
or minimally supervised program
 Functional capacity ≥ 8 METS or twice
occupational level
 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
Phase IV
Exercise Prescription
 Intensity
◦ 60 - 80% of VO2 reserve
◦ 70 - 85% of HRR
◦ RPE 12 - 15 (somewhat hard to hard)
 Duration
◦ Desired 30 - 60 min continuous workout
◦ Intermittent workout
 Exercise bouts of 15 - 20 min
 Frequency
◦ One session/day
◦ 3 - 4 days/week