Cardiac Rehabilitation

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Cardiac Rehabilitation

• Presented By
• Dr. Ramesh Tharwani
• Consultant Cardiologist Choithram Hospital

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• Integrated Treatment to regain physical
  function, promoting emotional adjustment,
  secondary prevention of cardiac events and lead
  active life.

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Target Patient Groups

• Following Myocardial Infarct
• Post PTCA/CABG
• Chronic Stable Angina
• Congestive Heart Failure
• Pacemaker/Valve surgery

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Coronary artery bypass surgery
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Coronary Intervention
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Long Term Mortality Benefits
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GOALS

• Daily Activities ?Active lifestyle
• Emotional/Psychological adjustment
• Diet/Exercise
• Sexual Activity
• Risk Factor Reduction
• Smoking cessation

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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 NAUGHTONS
• gt 5-7 METS
• gt 80-85 THR

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• ERGOMETER Knee/Lower limb problems, Neuro/Ortho
  Limitation
• ECHO LV functions, RWMA
• STRESS THALLIUM Viable Myocardium
• Useful in patients with abnormal ECGs like
  LBBB, WPW
• VO2 Max with Stress Test to differentiate between
  Cardiac and Pulmonary dyspnoea.

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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

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Initial Phase contd..

• Sexual Activities 3-5 METS, 2 flight stair Test
• Return to Work/ Recreational Activities
• gt 3-5 METS Self Care/Daily activities
• gt 5-7 METS Sedentary Work (Table Work)
• gt 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

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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
• gtUnstable Angina
• gtResting BP more than 200 mm/ 100 mm Hg
• gtPostural BP drop to more than 20 mm Hg
• gtAortic Stenosis
• gtAcute illness or fever
• gtUncontrolled Atrial or Ventricular Arrhythmias
• gtUncontrolled CHF
• gtRecent ST Displacement(More than 3 mm Hg)
• gtMusculo-Skeletal Disorders

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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

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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

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Benefits of Cardiac Rehabilitationin old age
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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

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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

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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

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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.

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Thank you all