Cardiac Rehabilitation

Introduction

Cardiovascular disease (CVD) is one of the leading causes of death worldwide and the leading cause of death in the United States.

Cardiac rehabilitation is a complex interprofessional intervention tailored for individual patients with various cardiovascular conditions such as:

• Heart Attack
• Coronary artery disease (CAD),
• Heart failure
• Myocardial infarctions
• Patients who have undergone cardiovascular interventions such as coronary angioplasty or coronary artery bypass grafting [1].

Cardiac rehabilitation program

Cardiac rehabilitation programs aim to limit the psychological and physical stress of CVD, reduce the risk of death secondary to CVD, and improve cardiovascular function to help patients achieve the highest possible quality of life. Achieving these goals is a result of improving Overall cardiac function and volume halt or reverse progression of atherosclerotic disease and increase patient confidence through gradual regulation[1]

CR is the process of encouraging cardiac patients to work with a multidisciplinary team of health professionals to support, achieve, and maintain optimal physical and psychosocial health. Involvement of partners, other family members and caregivers is also important”[2]

They require a team approach that includes multidisciplinary teams that include:

• • Cardiologist/physician and coordinator lead cardiac rehabilitation
  • Clinical Nurse Specialist
  • Physiotherapist
  • Clinical nutritionist/Dietitian
  • Occupational Therapist
  • Pharmacist
  • Psychologist
  • Smoking cessation counselor/nurse
  • Social worker
  • Vocational counselor
  • Clerical Administration[3]

All cardiac rehabilitation personnel must possess appropriate training qualification skills and competencies to practice within their scope of practice and to recognize and respect the expertise of all other disciplines involved in providing comprehensive cardiac rehabilitation. this Cardiac rehabilitation teams should actively engage and effectively engage GPs and Nurse Practitioners in the sports and leisure industry, where Phase IV community pharmacists and other relevant agencies are undertaken to create a long-term approach to CVD management. [4]

Description

[5]

Indication

Cardiac rehabilitation services should be offered to all cardiac patients who benefit from:[6]

• Recent myocardial infarction
• Acute coronary artery syndrome
• Chronic stable angina
• Congestive heart failure
• After coronary artery bypass surgery
• After percutaneous coronary intervention
• Valvular surgery[1]
• Cardiac transplantation

Initiate CR as soon as possible in the intensive care unit (only when the patient is stable). The intensity of rehabilitation depends on the patient’s condition and complications from the acute phase of the disease [7]. Randomized controlled trials and systematic analyzes have shown that early Exercise improved physical function (54 m increase in walking distance on the 6-minute walk test) when patients were discharged from the hospital after cardiac surgery [8]. Another prospective randomized clinical trial improved postoperative functional capacity (6-minute walk test) shortened duration Mechanical ventilation reduces dependence on oxygen therapy and reduces length of hospital stay in patients undergoing elective coronary artery bypass graft surgery [9].

Goals of Cardiac Rehabilitation

A comprehensive cardiac rehabilitation program should contain specific core components.

These components should optimize cardiovascular risk reduction, reduce disability, encourage positive and healthy lifestyle changes, and help maintain these healthy habits after rehabilitation is complete. A cardiac rehabilitation program should focus on:

• Patient Assessment Nutritional Counseling
• Weight management
• Blood pressure management
• Lipid management
• Diabetes management
• Tobacco cessation
• Psychosocial management
• Physical activity counseling
• Exercise training[1]

Individual Risk Assessment

CR can be tailored to meet individual needs, so patients should be fully assessed and evaluated for CV risk factors at the beginning of the program. This should be accompanied by continuous assessment and reassessment program. [4]

Risk factors should be assessed using validated measures that take into account other comorbidities [2][3][10].

Risk factors Non-modifiable Modifiable Age Alcohol intake Excessive gender Dyslipidemia Personal history of heart disease Hypertension Family history of cardiovascular disease Obesity Diabetes (unless pre-diabetic) Smoking Lack of exercise Anxiety/depression Hostility Stress

Other factors to consider

• Family Support
• Social History
• Occupation

Cardiac Rehabilitation Participation

All heart patients who need it should participate in a cardiac rehabilitation program. Age is not and should not be a barrier to participation in cardiac rehabilitation [4]. However, consideration of patient safety leads to the following specific inclusion/exclusion criteria Apply to participate in the exercise portion of Phase III. [11]

Included to exclude post-MI unstable angina coronary artery bypass surgery ECG ischemic changes resting systolic blood pressure >200 mmHg or resting diastolic blood pressure >110 mmHg stable angina orthostatic blood pressure >10 mmHg symptomatic stable heart failure (NYHA I-III) Severe aortic stenosis (peak pressure gradient >50 mmHg, aortic valve orifice <0.75 cm2) cardiomyopathy acute systemic disease or fever heart transplantation uncontrolled atrial or ventricular arrhythmias implantable cardioversion Defibrillator uncontrolled sinus tachycardia (>120bpm) valve Repair/replacement Uncompensated CHF Pacemaker installation (with one or more other inclusion criteria) Acute systemic disease Peripheral arterial disease Third-degree AV block Acute pericarditis/myocarditis after pacemaker-free cerebrovascular disease at risk for coronary artery disease Diagnosis of diabetes Dyslipidemia Hypertension Recent embolism Thrombophlebitis Uncontrolled diabetes Severe orthopedic problems Other metabolic problems such as acute thyroiditis Hypokalemia Hypovolemia

Phases of Cardiac Rehabilitation

Cardiac rehabilitation consists of three phases.

Phase I: Clinical phase

This phase begins in the inpatient setting shortly after completion of the cardiovascular event or intervention. It begins by assessing the patient’s physical ability and motivation to tolerate rehabilitation. Therapists and nurses can start by instructing patients on non-strenuous exercise Bedside or bedside focuses on a range of motion and limits hospital access to indications. The rehabilitation team can also focus on activities of daily living (ADLs) and educate patients about avoiding excessive stress. Encourage the patient to remain relatively rested until completion Treat comorbidities or postoperative complications. The rehabilitation team assesses the patient’s needs, such as assistive device patient and family education, and discharge planning.

Phase II: Outpatient cardiac rehab

Once the patient is stable and cleared by cardiology, outpatient cardiac rehabilitation can begin. Phase two usually lasts three to six weeks, but some may last as long as twelve weeks. Initial assessment of the patient with a focus on identifying limitations in physical function limitations Participation secondary to comorbidities and activity limitations. A more rigorous patient-centred treatment program was designed, consisting of three modes: an informative/advice customized training program and a relaxation program. Treatment phases designed to promote independence and lifestyle Changes to prepare patients to return to life at home.

Phase III: After cardiac rehabilitation. maintain

This stage involves more independence and self-monitoring. The third phase focuses on adding flexibility strengthening and aerobic conditioning.

Goal: To promote long-term maintenance of lifestyle changes, monitoring of risk factor changes and secondary prevention. [12]

Options:

• Educational sessions
• Support groups
• Telephone follow up
• Review in clinics
• Outreach programmes
• Exercise program led by a qualified Phase 4 fitness trainer
• Links to GPs and primary care teams
• Ongoing partner/spouse/family involvement[4]

A randomized controlled study demonstrated positive outcomes of an Internet-based telehome cardiac rehabilitation program [13]

Note that there is also a preoperative phase where the patient begins cardiovascular rehabilitation. A few studies have shown that patients tolerate the postoperative route better [1].

Cardiac Rehabilitation Course Sample Format

1. Check in (vitals assessed)
2. Warm Up (15 mins)
3. Main class (30 mins)
4. Cool down (10 mins)
5. Monitor and reassess vital signs and check

[14]

Warm-Up

Purpose: To increase the pulse rate in a gradual and safe manner to prepare the body for exercise

Effects:

• redistributes blood to active tissues
• Increases muscle temperature and speed of muscle action and relaxation
• prepares the mind
• Preparing muscles for ROM involved in the conditioning period

Pulse raising activities (5 minutes) should be included, e.g.) walking in place for low level cycling, followed by stretching of major muscle groups (5 minutes), followed by more pulse raising activities.

NOTE: Try to keep your feet moving at all times to maintain your heart rate and body temperature and to avoid pooling of water.

Main Class

For group rehab circuit training seems to be the most popular. Depending on CV status and functional capacity, patients may be treated with an intermittent or continuous circuit approach.

Individual stations are set up and participants spend a fixed amount of time (30 seconds to 2 minutes) at each aerobic station before moving on to the next station, which may be rest or active in the form of resistance training targeting specific muscle groups recover.

Resistance training as prescribed by ACSM 2006 – 10-15 repetitions of 8-10 exercises to moderate fatigue. [15][16]

Personalization of the CV component can be achieved by varying; the duration spent at each CV station the intensity (increased resistance speed or ROM) the rest periods the total duration of the session [17]

Cool Down

10 minutes at the end

Goal: Return the body to a resting state

Exercises of decreasing intensity and passive stretching of major muscle groups should be combined.

Necessary because of;

• Increased risk of hypotension
• Older hearts take longer to return to resting state
• Increased sympathetic activity during exercise increases the risk of cardiac arrhythmias immediately after exercise. [17]

Health and Safety

A French study reviewing the safety of cardiac rehabilitation found a cardiac arrest rate of 1.3 per million patient hours of exercise[1]

Patients should not exercise if they arrive generally unwell or are clinically unstable;

• Fever/acute systemic illness
• Unresolved/unstable angina
• Resting systolic blood pressure >200mmHg and diastolic blood pressure >110mmHg
• Significant drop in BP
• Symptomatic hypotension
• Rest/uncontrolled tachycardia (>100bpm)
• Uncontrolled atrial or ventricular arrhythmias
• New/recurring symptoms of dyspnea, lethargy, palpitations, dizziness
• Unstable heart failure
• Unstable/uncontrolled diabetes[18][4]

Need to consider the following;

• Clearly display local written policies for emergencies
• Quickly contact emergency teams in hospital or by ambulance
• Regular inspection and maintenance of all equipment
• Provide drinking water and glucose supplements as needed
• Emergency exits to and from venues Toilets and changing areas Check lighting surfaces and room spaces to ensure they are appropriate
• Sufficient space for patient passage and safe placement of equipment
• Adequate temperature and ventilation
• Patient Medication and Related Effects

Assessment and Outcome Measures

It is essential to;

• Develop and evaluate the effectiveness of exercise programs
• Provide objective feedback to patients
• facilitate evidence-based practice

Metrics can be used as baseline metrics and exit outcome metrics. These may include;

• HR and BP @ rest and during exercise
• RPE
• Bodyweight
• BMI
• Waist circumference

Measures of functional capacity;

• 6MWT
• shuttle walk test
• chester step test

Exercise Testing and Risk Stratification

A patient undergoing a stress test. Electrodes are attached to the patient’s chest and to the EKG machine. An EKG records the electrical activity of the heart. A blood pressure cuff is used to record a patient’s blood pressure while walking on a treadmill. [19]

Both the EACPR ACCPVR CACR ESC and the AHA recommend exercise testing as part of the initial evaluation of a patient for cardiac rehabilitation. The exercise test allows for the following;

• Diagnosis – identification of patients with congenital heart disease and severity of disease
• Prognosis – identifying low-intermediate-risk and high-risk patients
• Evaluation – to determine the effectiveness of selected interventions
• Measures of functional capacity—used as the basis for recommending ADL re-ADL and formal exercise prescription
• Measurement of Acute Exercise Response – BP HR Ventilator Response and Detection of Exercise-Induced Arrhythmias
• Provide suitable training objectives HR [16]

Exercise ECG using an incremental protocol is most commonly used, and symptom-limited testing is often performed before entering a phase III program. Usually using the Bruce protocol

Criteria for terminating a test[16]:

Horizontal or descending ST-segment depression >2 mm – indicates a significant drop in ischemic systolic pressure >20 mmHG – indicates poor LV fxn or severe coronary artery disease severe arrhythmias – ventricular tachycardia in patients with fatigue and/or excessive dyspnea at low workload – Difference fxnl volume or more serious problems such as heart failure

Negative Test Positive Test Normal Hemodynamic Response Significant ECG Change Completion of a workload equivalent to Phase II of the Bruce Protocol (7 MET) Inappropriate HR/BP Response to Incremental Workload.

Note: The patient’s HR BP and 12-lead ECG must be continuously evaluated while testing is in progress. Once the test is terminated, recovery monitoring must continue for at least 6 seconds or until the ECG returns to its pre-test state. [16]

Risk Stratification[11]

Definition: “Assessment of a patient to assess the degree of risk for future exercise-related cardiac events” [2]

Low risk (all features listed must be present to maintain minimum risk) Intermediate risk (any one or combination of these findings) High risk (any one or combination) Uncomplicated MI CABG angioplasty Functional capacity <5-6 METs Severely suppresses the LV functFunct. volume >6 METs mild – moderate Depressed left ventricular dysfunction (EF 31-49%) Complex arrhythmias @ rest or during exercise) No rest/exercise-induced complex arrhythmias Exercise/recovery Decreased systolic blood pressure during mild to moderate ischemic exercise >15mmHg/blood pressure failed to continue to rise with exercise load No signal. Low pressure Dysfunction (EF >50%) Exercise-induced ST-segment depression 1-2 mm or reversible ischemic effects MI Complicated CHF/cardiogenic shock/complex ventricular arrhythmia Normal hemodynamic response during exercise During high-intensity exercise Angina or related symptoms (>7 METs) severe CAD and significant (>2mm) exercise-induced ST-segment depression No CHF Cardiac arrest survivor No angina/other sign Complicated MI or revascularization procedure No clinical depression Presence of clinical depression

Risk stratification is important because it affects required staffing and population mix. This must also be considered when determining the level of monitoring a patient needs and setting their target training heart rate.

Requirements for cardiac rehabilitation

Facilities and Equipment

The minimum facilities required to provide cardiac rehabilitation services are:

• Separate office space and facilities for cardiac rehabilitation staff
• Education rooms have in-seat TVs and DVD players, and a selection of information brochures and DVDs are available. The size of the education room will depend on the number of participants (patient, spouse and staff) in the education session and the resources given.
• It is recommended that the exercise warm-up area and the exercise room total about 300m2
• Exercise room should be air-conditioned
• In addition, patients should be able to obtain
  • Toilet
  • Shower and changing room
  • Available drinking water[4]

Fitness room equipment may include[4]

Central Monitor and Telemetry Treadmill Versa Climber Chair Music System with First Aid Cart Portable Suction Defibrillator and Oxygen Dual Cycle Ergometer Hand Crank Rowing Machine Blood Glucose Meter Automatic Blood Pressure Recorder such as Dinamap Bike Ergometer Multigym Weight System and / or dumbbells bell stethoscope tape measure

Staffing Levels

ACPICR 2009 – The minimum staff to patient ratio should be 1:5, but this will vary according to the risk stratification of the class. For higher risk patients, the staff ratio is increased eg) 1:3

SIGN 2002 Guidelines: Staff should be trained in basic life support and be able to use defibrillators as needed for low to intermediate risk patients [2]

Future Research

In a systematic review of 19 randomized clinical trials of complex electronic coaches, it was found that

• E-coaching was found to be an effective method for delivering treatment tailored to clinical status of physical ability and psychosocial wellbeing (detailed protocol not well described).
• Determining which aspects of e-coaching are most beneficial requires further development.
• Basic e-tutoring was not found to be effective. [1]

According to an analysis of Indian data from the Global Cardiac Rehabilitation (CR) Audit and Survey conducted by the International Committee on Cardiovascular Prevention and Rehabilitation (ICCPR) (April 2020), the need for CR is highest in India. Research shows lack of patient referral and Financial resources are an obstacle to planning. Healthcare provider training and government financial support can make CR delivery better in India [20].

Resources

• BACPR
• SIGN Guidelines
• Cardiac Rehabilitation: Getting More Patients on the Path to Recovery American Heart Association May 2017.
• Cardiac Rehabilitation Podcast BMJ Talk Medicine 2015