Exercise Prescription for Cardiac Patients

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Exercise Prescription for Cardiac Patients

• Prof. Warren Payne

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Benefits of Exercise for Cardiac Patients

• Offset deleterious pyschologic and physiologic
  effects of bed rest during hospitalization
• Provide additional medical surveillance of
  patients

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Benefits of Exercise for Cardiac Patients

• Enable patients to return to activities of daily
  living within the limits imposed by their disease
• Prepare the patient and the support system at
  home to optimize recovery followed by hospital
  discharge

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Traditional Classification of Programs

• Phase I Inpatient
• Phase II Up to 12 weeks of supervised exercise
  and/or education following discharge
• Phase III Variable length program, intermittent
  or no ECG monitoring
• Phase IV No ECG monitoring and limited
  supervision

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Contemporary Approaches

• Background
• Changes in risk stratification
• New data on exercise safety
• Financial pressures
• Changes to traditional approach to cardiac
  rehabilitation

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Contemporary Approaches

• Movement towards individualized
• program according to patient recreational and
  occupational needs,
• length of program,
• degree of ECG monitoring,
• level of clinical monitoring.

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Inpatient Programs

• Most patients will benefit from some form of
  inpatient intervention including risk factor
  assessment, activity counseling and patient and
  family education.
• Follow a risk stratification approach taking into
  account contraindications to exercise (eg.
  Unstable angina, resting SBP gt 200 mmHg or
  resting DBP gt 110, acute illness or fever,
  uncontrolled PVCs)

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Inpatient Programs

• First 48 Hours
• Logically restrict activities to ADLs, arm and
  leg mobilization and postural change.

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Inpatient Programs

• Structured, formalized, in-hospital exercise
  programs after acute MI appear to offer little
  additional physioligic or behavioral benefits
  over routine medical care.
• Use of formal exercise 3-5 days post MI may
  assist in quantifying exercise tolerance

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Activity Classification Guide for Inpatient
Activities

• Class I
• Sit up in bed with assistance
• Does own self care activities
• Sit in chair 15-30 min, 2-3 times/day
• Class II
• Sit in bed without assistance
• Walks in room and to bathroom

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Activity Classification Guide for Inpatient
Activities

• Class III
• Sits and stands independently
• Walks in halls with assistance short distances
  (15-30 meters) as tolerated, up to 3 times/day
• Class IV
• Does own self care and bathes
• Walks in halls (50-70 meters) with minimal
  assistance, 3-4 times/ day

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Activity Classification Guide for Inpatient
Activities

• Class V
• Walks in halls independently (80-150 meters) 3-4
  times/day
• Class VI
• Independent ambulation on unit 3-6 times/day.

(ACSM Guidelines 2000 pp. 168)
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General Inpatient Prescription Guidelines

• Intensity
• RPE lt 13
• Post MI
• HR lt 120 bpm or HRrest 20 bpm
• Postsurgery
• HRrest 30 bpm
• To tolerance if asymptomatic

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General Inpatient Prescription Guidelines

• Duration
• Intermittent bouts lasting 3-5 min
• Rest Periods
• At patients discretion, lasting 1-2 min, shorter
  than exercise bout
• Total duration of up to 20 min

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General Inpatient Prescription Guidelines

• Frequency
• Early mobilization
• 3-4 times/day (days 1-3)
• Later mobilization
• 2 times/day (beginning on day 4)
• Progression
• Initially increase duration up to 10-15 min, then
  increase intensity.

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General Inpatient Prescription Guidelines

• By hospital discharge, the patient should
• Demonstrate a knowledge of inappropriate
  exercises
• Have a safe, progressive plan of exercise
  formulated for them to take home

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General Inpatient Prescription Guidelines

• Selected moderate to high risk patients should be
  encouraged to participate in outpatient cardiac
  rehabilitation programs /or
• Manage their discharge rehabilitation plan and
  report any cardiovascular symptoms promptly
  (should they occur).

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Outpatient Programs

• Goals are to
• Provide appropriate patient monitoring and
  supervision to detect a deterioration in clinical
  status and to provide timely feedback to the
  referring physician to enhance effective medical
  feedback,

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Outpatient Programs

• Goals are to
• Contingent upon patient clinical status, return
  patient to pre-morbid vocational /or
  recreational activities, modify or find
  alternative activities,

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Outpatient Programs

• Goals are to
• Develop and help the patient to establish and
  implement a safe and effective home exercise
  program and recreational lifestyle,
• Provide patient and family education and
  therapies to maximize secondary prevention.

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Outpatient Programs

• In general, patients should engage in multiple
  activities to promote total conditioning
  including aerobic and resistance exercises.
• Principles of prescription are those for healthy
  adults but adjusted to take into account the
  patients clinical status.

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Intensity

• Above training threshold but below that which
  induces abnormal clinical signs and symptoms
• For deconditioned cardiac patients 40-50 of VO2
  Reserve (VO2R).
• Normally approximated by the HRR method of
  Karvonen (also can be applied to MET reserve)

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Intensity

• Use of RPE. Particularly useful when GXT has not
  been performed or medications change.
• Normally 11-13 (fairly light to somewhat hard)
  for Phase II.
• Later (Phase III or IV) may use 12-15
  (Approximately 60-80 VO2R

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Intensity

• RPE can be used with beta-blockers BUT
• Should remember that significant and serious ST
  segment and/or arrhythmias can still occur at low
  intensities and RPEs

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Intensity

• Some patients need to know when abnormalities
  occur to enable exercise below anginal or
  ischemic threshold
• Use of HR monitor with alarms
• Peak exercise HR 10 bpm below appropriate
  threshold.
• Need to allow for medication effects on exercise
  tolerance and HR.

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Intensity

• Signs and symptoms below which an upper limit for
  exercise should be set
• Onset of angina or other symptoms of CV
  insufficiency
• Plateau or decrease in SBP, SBP gt 240 or DBP gt
  110 mmHg.
• ? 1mm ST-segment depression
• Increasing frequency of ventricular arrhythmias
• Other significant ECG changes
• Other signs or symptoms of intolerance to exercise

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Duration

• Desire to have 20-60 min of continuous or
  intermittent activity
• Inversely proportional to intensity
• May be able to accumulate in short (10-15 min)
  bouts.

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Rate of Progression

• Depends upon patient functional capacity and
  prognosis
• Generally, progress over 3-6 months to 1000
  kcal/week
• Follow principles of initial, conditioning and
  maintenance phase
• Generally progress every 1-3 weeks with goal of
  achieving 20-30 min of continuous exercise.

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Rate of Progression

• Patients requiring intermittent program (eg.
  Peripheral vascular disease, low functional
  capacity) should progress according to symptoms
  and clinical status

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Guidelines for Progression to Independent
Exercise with Minimal or No Supervision

• 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

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Exercise Prescription Without a Preliminary
Exercise Test

• Programs should be conservative, close medical
  surveillance and a period of ECG monitoring is
  recommended.
• Close observation for exercise intolerance and
  blood pressure monitored regularly.

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Exercise Prescription Without a Preliminary
Exercise Test

• Initial intensities determined according to
  length of time from acute cardiac event and
  associated complications, duration since
  discharge and patient information (ADLs current
  home program, associated signs and symptoms)
• Use of Duke Activity Status Index

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Exercise Prescription Without a Preliminary
Exercise Test

• Initial intensities Normally 2-3 METs (eg.
  100-300 kgm.min-1 on bicycle ergometer or 1.5 to
  5 km.hr -1
• THR approx. 20 beats/min above standing resting
  HR.
• Gradual increase using RPE
• ??? Use of ECG telemetry

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Resistance Training

• Contraindications similar to aerobic programs
  (unstable angina, uncontrolled PVCs etc.)
• Generally require moderate to good LV function
  and exercise capacity gt 5 METs without angina or
  ST-segment depression

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Resistance Training

• Previously required abstinence from resistance
  training for several months post MI.
• Now many patients can start by carrying up to 13
  kg by 3 weeks post MI.
• Generally use approx. 50 1RM or use of other
  modes such as bands, hand weights etc. in Phase
  II.

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Resistance Training

• Should not begin until 2-3 weeks post MI.
• After 4-6 weeks post MI, may start bar bells
  and/or weight machines
• Note surgical patients need to adjust program to
  accommodate sternotomy
• Normally begin resistance program 2-3 weeks after
  initiating aerobic program.

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Resistance Training

• Advocate 1 set of 8-10 different exercises that
  focus on large muscle groups, 2-3 days/week.
  Will result in significant improvements
• Additional sets/reps do not seem to result in
  substantial improvements.

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Resistance Training

• Initially start with 1 set of 10-15 reps to
  moderate fatigue using 8-10 different exercises
• Increase 1-2 kg/week for arms and 3-5 kg/week for
  legs.
• Check rate, pressure product. Shouldnt exceed
  that for endurance exercise
• RPE 11-14.
• Avoid Valsalva