Cardiac Rehabilitation

Eve ScarleSenior Physiotherapist and

Lecturer in Exercise and Health Sciences

Aims of the session

1. Explanation of coronary heart disease and cardiac rehabilitation

2. Rationale for the use of physical activity in cardiac rehabilitation

3. Exercise prescription for Phase IV cardiac rehabilitation

4. Professional development opportunities in CR.

Group Task Plan a short exercise regime you may use for a 50

year old patient who has suffered a heart attack 4 months ago. Consider the; Frequency Intensity Duration Progression Type of exercise that you would prescribe for this

patient Are there any types of activity you think should be avoided?

Cardiovascular Disease (CVD)

CVD accounts for one of two of all deaths in UK accounting for approximately 238,000 deaths in 2002

Leading cause of premature death in both men and women.

CHD most common form of CVD and is responsible for 60% of all deaths from CVD.

Our Healthier Nation target – CHD and Stroke - reduce death rate in

people under 75 years by two fifths

CARDIOVASCULAR DISEASE

(CVD)

CORONARY HEART DISEASE (CHD)

STROKE

PERIPHERAL VASCULAR

DISEASE

Coronary Heart Disease (CHD)

♥ Refers to the deposition of fatty substances in the lumen of the coronary arteries

♥ This can start as early as the teenage years

♥ Only when the artery is ~ 70% occluded do symptoms start to appear

♥ Symptoms may appear as angina or a myocardial infarction (MI)

♥ Angina occurs when demand for oxygen does not meet the supply as the coronary arteries are narrowed

Coronary Atherosclerotic Plaque

Atherosclerosis is the build up of fatty and fibrous material (atheroma) on the inside surfaces of arteries

Atherosclerosis

Atherosclerosis

Angina A symptom of CHD Occurs during ischaemia when supply of

oxygen does not meet the demand for oxygen

When do you think individuals may get angina symptoms?

What will the symptoms be?

Stable Angina

Exertion

Stress

Extreme temperatures

After a heavy meal

Chest pain /tightness/discomfort

Burning/dull sensation

Pain/heavy feeling in left arm or both

Discomfort in throat, jaw or abdomen

Short of breath on exertion

Myocardial Infarction (Heart Attack)

♥ Occurs when a fatty plaque becomes unstable and ruptures

♥ This causes a blood clot to form stopping blood getting any further

♥ This leads to areas of myocardial ischaemia which if it persist can lead to tissue damage

♥ Needs prompt management to limit damage and reduce complications

Coronary Artery Bypass Graft

♥ Where narrowing occurs in multiple areas

♥ Veins and arteries are harvested from elsewhere in the body and used to bypass the narrowing

♥ This involves open heart surgery, being on the bypass machine and a prolonged recovery period

Coronary Angioplasty

♥ Procedure done under local anaesthetic

♥ Catheter passed from the groin up to the aorta

♥ Then pass into the narrowed area and inflate a small balloon to squash plaque into the artery wall

♥ Small cylindrical stents can be left in place to hold the artery open

Aims of Cardiac Rehabilitation

‘To promote physical, psychological and emotional recovery, enabling patients to

achieve and maintain better health, with a reduced risk of death from continuing heart

disease.’

(Effective Health Care, 1998)

History of Cardiac Rehabilitation

♥ Cardiac rehab first started in the 1960s when the benefits of active mobilisation were recognised (Kavanagh et al, 1973).

♥ Disease processes in CHD may be slowed or even reversed by the instigation of lifestyle modification (Ornish et al, 1990 and 1998; Berlardinelli et al, 2001).

♥ National Service Framework for CHD (DoH, 2000) sets national standards for CHD management

What exactly is Cardiac Rehabilitation?

What is it? Combination of exercise, education

and counselling

How long does it last? Varies across the country

Where does it occur? Hospital and community-based

What exactly is Cardiac Rehabilitation?

Who is it delivered by?

Delivered by a ,multi-disciplinary team which can consists of:-

Counsellor Nurse Occupational therapist Physiotherapist Psychologist Exercise physiologist Phase IV instructor

Phases of CR

Phase I In Hospital

Phase II Immediate post discharge period

Phase III Out-patient programme

Phase IV Ongoing maintenance phase

Phase I

♥ Acute phase in hospital ♥ A member of the cardiac team provides

specific information on:- heart disease management of chest pain how to handle serious cardiac symptoms gradual increase in PA use of medication risk factor modification and lifestyle changes feelings and relationships driving, insurance and airline travel.

Phase II

♥ Patient at home under care of GP, lasts 2 - 6 weeks.

♥ Often neglected phase of rehab.♥ Ideal time to reinforce important

messages and behaviour change.♥ Telephone advice service♥ Home visiting

Phase III♥ Consists of exercise, health education,

risk factor modification, relaxation and stress management, and occupational counselling.

♥ Can take place in hospital or community ♥ Exercise and education for up to 12

weeks.♥ Exercise aim is to educate individuals

on safe and effective ways to make exercise a part of their lives

Phase IV

♥ Community-based CR♥ Little community provision for this group

and previous structured sessions make it difficult for patients to exercise independently.

♥ British Association of Cardiac Rehabilitation (BACR) developed protocol for CHD patients to move from Phase III to Phase IV.

Phase IV

♥ Aims of Phase IV:- provide regular supervised CV training

sessions establish individualised ex. prescription for

independent activity. review participants progress over time (or

regression) and amend prescription accordingly.

offer general advice and support in lifestyle changes

encourage independence , self help and self motivation.

Phase IV♥ Class format could take the following:-

integration of individuals with CHD into mainstream classes

specialist phase IV classes one to one training

♥ What are the disadvantages/advantages of these different sessions? Write down your ideas

  Advantages Disadvantages

Mainstream Class 

*Get back to normal life*Integration 

*Not geared up to heart patients*? correct exercise

Phase IV Class 

*Social support*Regular exercise groups*Specifically for heart patients

*Reinforce message that something is wrong with you*Does the exercise have progressions

One-to-one training 

*Individual advice*Easy to progress exercise

*No social support for other patients

Classroom Task

Exercise Prescription for Phase IV

Inclusion criteria (BACR, 2003): Post Myocardial infarction Post coronary artery bypass graft (CABG) Post angioplasty (with or without pre cardiac

event) Post transplant Post valve replacement Stable angina Permanent pacemaker Implanted defibrillator

Also partners/spouses encouraged to attend.

Phase IV Exercise Prescription

Frequency At least 3 times a week

Intensity 60-80% of max HR

13-15/3-5 RPE Time 20-60 mins

Type Aerobic endurance training

Session components – Warm-up

♥ Content♥ Pulse raising and mobility♥ Preparatory stretching.

♥ Rationale♥ Gradual, progressive w/up extends ischaemic and

angina threshold. Too strenuous can lead to arrhythmias and a reduced ejection fraction.

♥ Duration♥ 15 mins. minimum.

♥ Intensity♥ HR to within 20 bpm of training HR or RPE no higher

than 10-11 on 6-20 scale.

Interval Training Approach Effective in early stages of recovery

and those who are deconditioned Allows a greater total duration of

exercise per session Allows easy management of a group

of individuals of differing abilities

Ultimate AimTo achieve continuous

cardiovascular work for 20- 60 minutes

Active Recovery Low intensity activity e.g. walking at a

slower speed Alternative activity e.g. muscular

strength work (with feet moving)

Can fit with different activities e.g. circuit programme, gym, walking, home programme

BACK LUNGE

BIKESIDE STEPS

HAMSTRING CURLS

SQUATS

AR STATION5 EXERCISES

LEVEL 1

LEVEL 2

Session components –Cool down

Content Recovery period, slow walking, gentle movements, large

muscle groups, stretching. Rationale

Older adults take longer to return to pre-exercise states due to aging and baroreceptor changes.

Increased risk of arrhythmias with increased intensity and lack of cool down

Duration 10 mins.

Intensity Reduced, aim to return to pre-exercise state

Session components – MSE Content

Floor based has to be done out of main circuit Could Integrate standing MSE as active recovery in the

aerobic section. Rationale

Increases strength and endurance of specific muscle groups

Duration Dependent on location within class

Intensity Low resistance high repetitions, 1 x10-15 reps 8-10 exercises

Professional development opportunities in CR

British Association for CardiacBritish Association for CardiacRehabilitation (BACR) Rehabilitation (BACR)

♥ BACR - founded in 1993, national organisation for professional involved in CR.

♥ Phase IV Exercise Instructor Training Module

Evidence of Benefit of CR

♥ Improved survival (25-31% reduction) (1,2)

♥ Improved functional capacity and VO2MAX (3)

♥ Reduced angina (4)

♥ Improved lipid profiles♥ Lowers BP (5)

♥ Reduced anxiety and depression (6)

♥ Increased confidence and well being (7)

♥ Improved return to work and leisure (8)

♥ Effect of improved health education in family and friends

♥ Improved compliance with lifestyle modification

Rationale for the use of PA in CR

Jolliffe et al., 2001; Enhanced coronary blood flow Increased angina threshold Improved peripheral muscle

metabolism efficiency Improved quality of life.

Review of lecture

1. What is cardiac rehabilitation?2. Evidence base for exercise

component in cardiac rehabilitation

3. Exercise prescription for Phase IV4. Professional development

opportunities in CR.

Group Task

♥ Look back to your original ideas for exercise prescription

♥ Is there anything you would change now you know more about the recommendations?

♥ Dot down your ideas in your groups

References1. O’Connor, G. Buring, J. & Yusuf, S. (1989) An Overview of Randomised Trials of

Rehabilitation with Exercise after Myocardial Infarction, Circulation, 80, pp. 234-44.

2. Jolliffe, J. Rees, K. Taylor, R. Thompson, D. Oldridge, N. & Ebrahim, S. (2000) Exercise-Based Rehabilitation for Coronary Heart Disease (Cochrane Review). In: The Cochrane Library, Issue 2, Chichester: John Wilet and Sons Ltd.

3. Laughlin. M, Oltman. C, Bowles. D. (1998) Exercise Training-induced Adaptations in the Coronary Circulation, Medicine and Science in Sport and Exercise, 30, pp 352-60.

4. Stahle, A. Mattsson, E. Rydent, L. Unden, A. & Nordlandert, R. (1999) Improved Physical Fitness and Quality of Life following Training of Elderly Patients after Acute Coronary Events, European Heart Journal, 20, pp 1475-1484.

5. Ades, P. Waldmann, M. & Gillespie, C. (1995) A Controlled Trial of Exercise Training in Older Coronary Patients, Journal of Gerontology, 50A (1), M7-11.

6. Dugmore, L. Tipson, R. Phillips, M. Flint, E. Strentford, N. Bone, M. and Littler, W. (1999) Changes in Cardiorespiratory Fitness, Psychological Well-Being, Quality of Life, and Vocational Status following a 12-month Cardiac Exercise Rehabilitation Programme, Heart, 51, pp. 359-66.

References

7. Westin, L. Carlsson, B. Israelsson, B. Willenheiner, R. Cline, C. & McNeil, T. (1997) Quality of Life in Patients with Ischaemic Heart Disease: A Prospective Controlled Study, Journal of Internal Medicine, 242, pp. 239-247.

8. Petrie, K. Weinman, J. Sharpe, N. & Buckley, J. (1996) Role of Patient’s View of their Illness in Predicting Return to Work and Functional Capacity after Myocardial Infarction: Longitudinal Study, British Medical Journal, 312, pp. 1191-94.

9. Department of Health (1999) Saving Lives: Our Healthier Nation, London: The Stationery Office.

10. Department of Health (2000) The National Service Framework for Coronary Heart Disease, London: HMSO.

11. Law, M. Morris, J. (1998) By how much does Fruit and Vegetable Consumption reduce the Risk of CHD?, European Journal of Clinical Nutrition, 52, pp. 549-556.

12. Marckmann, P. and Gronbaek, M. (1999) Fish Consumption and Coronary Heart Disease Mortality. A Systematic Review of Prospective Cohort Studies, European Journal of Clinical Nutrition, 53 (8), pp. 585-590.