Cardiac Rehabilitation

Presented By:

Dr. Ramesh Tharwani

Consultant Cardiologist Choithram Hospital

“Integrated Treatment to regain physical function, promoting emotional

adjustment, secondary prevention of cardiac events and lead active life.”

Target Patient Groups

• Following Myocardial Infarct

• Post PTCA/CABG

• Chronic Stable Angina

• Congestive Heart Failure

• Pacemaker/Valve surgery

Coronary artery bypass surgery

Coronary Intervention

Long Term Mortality Benefits

GOALS

• Daily Activities Active lifestyle

• Emotional/Psychological adjustment

• Diet/Exercise

• Sexual Activity

• Risk Factor Reduction

• Smoking cessation

Assessment• SYMPTOMS : Chest Pain, SOB, Palpitations

• EXAMINATION : CHF, Wound, Concurrent Illness, Musculo-Skeletal disease, Emotional Status(Anxiety/Depression)

• DIAGNOSTIC STUDIES : Lipid Profile, Hb A1C, PFT

• ECG before exercise/Telemetry

• STRESS TEST : Sub maximal modified NAUGHTON’S

> 5-7 METS

> 80-85% THR

• ERGOMETER : Knee/Lower limb problems, Neuro/Ortho Limitation

• ECHO : LV functions, RWMA

• STRESS THALLIUM : Viable Myocardium

Useful in patients with abnormal ECG’s like LBBB, WPW

• VO2 Max with Stress Test to differentiate between Cardiac and Pulmonary dyspnoea.

Initial Phase

• Risk Factor Reduction : Optimal Medical Management Avoid Increase/Decrease BP, No Angina on daily activities

• Smoking Cessation : Psycho Counseling + Drugs (Buprobion HCL, Nicotine Patch)

• Diet Advice : Low Cholesterol, Less than 30% calories from fats

• Decrease Emotional Stress : Relaxation Techniques, YOGA

Initial Phase contd..

• Sexual Activities : 3-5 METS, 2 flight stair Test• Return to Work/ Recreational Activities :

> 3-5 METS Self Care/Daily activities> 5-7 METS Sedentary Work (Table Work)> More than 7 METS Normal Vocational activities (Back To Work). Avoid Heavy physical work.

• Playing Tennis 4-7 METS• Golf 2-5 METS • Volley ball 3-4 METS

Exercise Training (Rehabilitation)

• Walking for 15-30 mins /3-5 times a week• Patient can still talk while walking (Brisk Walk for

initial 2 weeks)• Contra indication to exercise training

>Unstable Angina>Resting BP more than 200 mm/ 100 mm Hg>Postural BP drop to more than 20 mm Hg>Aortic Stenosis>Acute illness or fever>Uncontrolled Atrial or Ventricular Arrhythmias>Uncontrolled CHF>Recent ST Displacement(More than 3 mm Hg)>Musculo-Skeletal Disorders

Exercise Prescription

• Aerobic Exercise preferred than resistive or weight training

• Walking/Cycling• Intensity/Frequency/Duration will depend on

tolerance• THR (220- Age in years) try to achieve 80-85%

THR• 66% MET of level of completed TMT or 25

watts less than completed stage on cycle Ergometer

• Borg scale target 11-15

Exercise Prescription contd.• Exercise session

Warm Up (2-5 mins) Stimulus (conditioning 20-30 mins) Cool Down (5-10 mins, slow speed, prevents low BP and joint pains)

• Graded Exercise with telemetry in high risk population recommended.

• 1-3 months Target 7-8 METS followed by self directed maintenance

Benefits of Cardiac Rehabilitationin old age

Benefits of Exercise Training work capacity fatigue

Heart rate during Exercise

RPP

symptoms of CHF

Atherogenicity by maintaining body weight HDL

TG platelet aggregation

• Improve blood glucose level

• Improves coronary blood flow and myocardial perfusion

Benefits of Exercise Training contd.

• Endurance Training VO2 max 10-40%, BP, HR

BMD

• Positive changes in body composition body weight (1-3 kg), % fat (1-3%)

• Positive metabolic changes insulin sensitivity, cholesterol

• Resistance Training strength 150%

Conclusions

• Cardiac rehab is feasible and safe in an octagenarian patient population

• Exercise training yields clinically significant functional and metabolic improvements for both men and women– 33% in exercise time– 20% in functional capacity (est. METs)– 9% in HDL cholesterol

Potential Treatment complications

• MACE ( Massive Adverse Cardiac Events)

1 per 300,000 hours of exercise

• SCD ( Sudden Cardiac Death )

1 per 800,000 person hours of exercise

• Proper Selection of cases/ avoiding Contra indications to exercise training can minimize the risk.

Thank you all