Cardiac Rehabilitation and the High Risk Patient

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Cardiac Rehabilitationand the High Risk Patient

• Ma. Paz Mildred F. Luque, MD, FPCP, FPCC
• H E A R T I N S T I T U T E
• St. Luke's Medical Center
• Quezon City ? Global City

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High-risk patients

• Severe LV dysfunction
• Severe exercise-induced ischemia, ST-segment
  depression of greater than 0.2 mV on an ECG,
  multiple perfusion defects on exercise nuclear
  stress testing, or multiple dyskinetic LV
  segments on stress echocardiography
• Complex ventricular arrhythmias or a history of
  previous sudden cardiac arrest
• Hypotensive response to exercise
• Low functional capacity
• Patient's inability to self-monitor his/her heart
  rate

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Components of a program

• Medical evaluation
• Prescribed exercise
• Education
• Counselling of patients with cardiac disease

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Short term goals

• "Reconditioning" the patient sufficiently enough
  to allow him/her to resume customary activities
• Limiting the physiologic and psychological
  effects of heart disease
• Decreasing the risk of sudden cardiac arrest or
  reinfarction
• Controlling the symptoms of cardiac disease

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Long term goals

• Identification and treatment of risk factors
• Stabilizing or reversing the atherosclerotic
  process
• Enhancing the psychological status of the patients

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Risk stratification

• Assessment of the patient's functional capacity
• Educational and psychosocial status
• Whether alternatives to traditional cardiac
  rehabilitation can be used
• Whether the patient is suffering from myocardial
  ischemia, ventricular dysfunction, or arrhythmias

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Heart Failure
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Limited exercise capacity

• Low cardiac output
• Reduced muscle blood flow
• Skeletal muscle dysfunction
• Deconditioning

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Effects of exercise

• Clinical
• Enhanced peak VO2, possibly peak cardiac output
  due to a higher workload achieved, and leg blood
  flow during exercise
• Improved muscle energetics
• Improvement in symptoms

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Effects of exercise

• Pathophysiologic
• Reduced sympathetic tone and increased vagal tone
  at rest
• Reduced neurohumoral activity with decreased
  resting levels of angiotensin, aldosterone,
  vasopressin and natriuretic peptide
• Improvement in endothelial function
• Reduction in plasma levels of proinflammatory
  cytokines

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No ventilatory, hemodynamic,autonomic, or
clinical factor at baselinepredicts the outcome
with exercise trainingin patients with heart
failure
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Effects of exercise training

• Hemodynamics
• Improves measures of left ventricular function
  and hemodynamics
• Functional capacity
• Improvement in maximal exercise tolerance
• Patient outcome
• Reduce heart failure related hospitalization
• Improve health-related quality of life

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HF Action Trial

• 2331 patients with left ventricular ejection
  fraction 35 percent and NYHA class II to IV HF
• Randomly assigned to either a supervised exercise
  training program or usual care including
  education and recommendation of regular exercise
• Background medical therapy was optimized
• Median follow-up was 30 months

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HF Action Trial

• Modest but significant decrease in all-cause
  mortality or all cause hospitalization (after
  adjusting for baseline prognostic variables) with
  the exercise training program
• Significant reduction in cardiovascular mortality
  or HF hospitalizations
• High level of safety during and after the
  training sessions
• Significant improvement in health status

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Exercise recommendations

• Patients with stable class II to class III HF who
  do not have advanced arrhythmias, and who do not
  have other limitations to exercise
• Exercise intensity of 70 percent of heart rate
  reserve, three days per week for six to eight
  weeks

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Exercise guidelines

• Longer warm-up period
• Begin at 40 to 60 percent VO2max for intervals of
  two to six minutes separated by one to two
  minutes of rest
• Gradually increase length of the exercise
  interval by one to two minutes until the patient
  tolerates 30 minutes of continuous exercise

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Self care

• Actions aimed at maintaining physical activity,
  avoidance of behaviors that can worsen the
  condition and detection of the early symptoms of
  deterioration
• Linked to symptom control, functional capacity,
  QOL, hospital admissions, prognosis, reduced
  mortality
• Precipitating factors in deterioration
  non-adherence to diet or medication regimen,
  inappropriate use of medications, infections
  arrhythmia, ischemia

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Cardiac Transplantation
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Abnormal levels of functional capacity

• Marked deconditioning prior to transplant due to
  heart failure
• Surgical denervation
• Corticosteroid therapy
• Peripheral vasoconstriction

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Pre-transplantatiion

• For stable outpatients, exercise as an adjunct to
  pharmacologic therapy during the entire waiting
  period
• Preferred timing of referral is during the
  hospital stay for the transplant event
• For patients on home inotropic therapy, a
  monitored program in a cardiac rehabilitation
  center

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Pre-transplantation

• For patients on inotropic support who are being
  monitored hemodynamically, activity will vary
  depending upon patient mobility
• Limited data suggest that exercise training may
  be beneficial in patients who receive a left
  ventricular assist device (LVAD) as a bridge to
  transplantation

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Immediate post-op

• Prior to removal of the chest tubes and pacer
  wires, passive and active range of motion plus
  incentive spirometry
• Once out of bed in a chair, leg raising and hip
  girdle exercises
• Once the patient is able to stand, ambulation is
  initiated
• Prior to discharge, exercise on a stationary
  bicycle ergometer and/or treadmill.
• Predischarge cardiopulmonary exercise test

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Post-hospital prescription

• Intensity
• Duration
• Frequency
• Progression
• Resistance exercise

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Exercise guidelines

• Exercise in 15 to 30 minute sessions three to
  five times per week
• Avoid repetitive lifting of greater than a few
  pounds
• Maintain RPE at 10 to 13

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ICD
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Baseline information

• ICD detection threshold setting in beats per
  minute
• Whether the device is set for ventricular
  tachycardia or ventricular fibrillation
• Rapid onset setting
• Sustained ventricular tachycardia settings
• ICD mode of therapy
• Beta-blockers

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Exercise

• Avoid contact sports
• Swimming possible unless arrhythmia is triggered
  by swimming must be accompanied at all times
• Snorkeling not recommended
• SCUBA diving should not be undertaken
• Avoid exposure to strong magnetic or electrical
  fields or a powerful radio source

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Physical activity exercise

• Aerobic skilled flowing movement, muscular
  endurance, flexibility
• Progress slowly
• Monitor intensity using heart rate or perceived
  effort
• Warm up and cool down
• Avoid static exercise when you are holding tight
  or resisting strongly and holding your breath
• Most exercise should be performed standing

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Physical activity exercise

• Most exercise should be performed standing
• Avoid excessive shoulder range movement and or
  highly repetitous vigorous range movements
• Continuous physical activity of 30 minutes or
  more most days of the week

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Chronic Kidney Disease
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Cardiovascular Disease

• Leading cause of death regardless of CKD stage
• As renal function declines, all cause and
  cardiovascular mortality increases exponentially
• 40 of patients with established CVD have
  concomitant CKD
• Worse prognosis
• Worse revascularization outcomes
• Higher procedural complication rates

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CVD risk factors and CKD

• Traditional risk factors are rampant in the CKD
  population
• U-shaped mortality curve associated with
  cholesterol and hypertension levels with an
  increased risk of death for both extremes of
  measurement
• Qualitatively and quantitatively different risk
  factor exposure
• Burden of CKD-associated non-traditional risk
  factors

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Physical fitness and CKD

• Limited physical function across amny subjective
  and objective domains
• Deficits in measures of cardiopulmonary fitness
  (walking distance/time, treadmill, cycle
  ergometry) and strength
• Association between declining exercise
  performance and creatinine over time, independent
  of hemoglobin level

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Beneficial effects

• Physical fitness
• Psychosocial function
• Quality of life
• Cardiorespiratory parameters
• Renal functional parameters

• Blood pressure
• Lipid parameters
• Hemoglobin levels
• Measures of arterial stiffness

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Barriers to participation

• Socio-economic
• Logistic
• Patient-related

• Biased referral patterns

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Special considerations

• Hemoglobin
• Direct relationship with exercise capacity
• Treatment with erythropoesis-stimulating agents
  (i.e., erythropoietin) improves exercise capacity
  and VO2 peak
• Strength training and resistance exercises
• Intrinsic muscle changes contribute more to poor
  performance than do limitation in oxygen supply
• 1997 study showed strength training alone can
  improve VO2 peak in CKD patients

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Psychological stressors and adjustments

• Higher stress levels
• Alteration in social and role responsibilities,
  dependence and interdependence issues and
  uncertainty about the future
• Intensify as CKD progresses and need for renal
  replacement therapy draws nearer
• Cardiac rehabilitation provides an opportunity to
  foster coping skills and help patients adjust to
  these stressful changes

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Dietary counseling

• Maintenance of optimal nutrition
• Prevent or minimize metabolic derangements of CKD
• Retard the progression of renal failure

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Cardiac rehabilitation CKD

• Regular structured exercise
• Dietary intervention
• Psychosocial counselling
• Life skills and coping skills retraining
• Pharmacologic intervention

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Elderly
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Elderly

• High risk of disability after coronary event or
  hospitalization for heart failure
• Complications of MI and myocardial
  revascularization are more frequent at an
  advanced age
• Prolonged hospitalization leads to deconditioning
• Less referral to and participation in cardiac
  rehabilitation

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Physical activity

• Improvements in gait, balance, overall functional
  capacity and bone health
• Increase quality of life

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Physical activity

• Cardiovascular fitness
• At least 30 minutes of moderate intensity
  exercise on most, if not all, days of the week
• Exercise mode that does not impose excessive
  orthopedic stress and is accessible, convenient
  enjoyable
• Start low and individually progress according to
  tolerance and preference
• Measured peak heart rate preferable to
  age-predicted heart rate because of underlying CAD

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Physical activity

• Resistance training
• Begin first 8 weeks with little resistance
• One-set of 8-10 multi-jointed exercises that
  include all major muscle groups
• Set should include 15 repetitions at RPE of 12-13
• Number of repetitions increased before the
  resistance

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Physical activity

• Flexibility
• Improvement in ability to perform ADL, balance
  and agility
• Reduction in injury potential
• For every major joint of the body, at least 2 to
  3 times per week

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Thank you for your kind attention