Cardiac Rehabilitation

Cardiac Rehabilitation Matthew N. Bartels, MD, MPH Department of Rehabilitation Medicine Montefiore Medical Center Albert Einstein College of Medicine

Learn the basic terminology of exercise physiology Learn basic principles of Cardiac Rehabilitation (CR) Learn needed testing to allow for cardiac rehabilitation Learn the conditions that are treated as an outpatient Learn the application of cardiac rehabilitation services in the acute and inpatient rehabilitation settings Learning Objectives

Identify common neurological, musculoskeletal and orthopedic limitations seen with Cardiac Rehabilitation. Learn appropriate adaptations to allow for completion of a cardiac rehabilitation program in patients with Learn simple adaptations for safe exercise with co-morbidities. Learning Objectives

Aerobic Capacity Cardiac Output Heart Rate Stroke Volume Myocardial Oxygen Consumption Basic Terms

Typically described in terms of metabolic equivalents 1 MET = 3.5 mL O2/Kg weight/min Use of standardized MET tables can help assess independence AND GOALS Help to establish disability and support needs Assessment of Demands of Cardiac Activities

Functional versus diagnostic exercise tests Diagnostic testing for cardiac risk assessment and evaluation of cardiac risk Functional testing to determine: Exercise capacity Safety Maximum heart rate Can be estimated by 220-age Baseline functional stress testing to obtain individualized maximum heart rate Role of Exercise Tolerance Testing

Numerous protocols Balke-Ware, Naughton, Bruce, others Can be done with ramped/staged Cycle Ergometry Basic principles Staged levels Done in controlled setting Treadmill most common Evaluate for heart rate and safety guidelines Functional ETT Protocols

Goal is to provoke a positive response for plan of further interventions. Pharmacologic Stress Dobutamine/adenosine/persantine tests Alternate diagnostic criteria Echocardiography Nuclear Imaging MRI, and others Often done off or on limited meds to provoke events/ischemia Often of limited use for exercise prescription with no clear heart rate targets or not done with actual exercise (phamacologic) Diagnostic ETT Testing

Benefits: Can assess cardiac risk Help diagnose issues to be treated However: Often not useful for setting heart rate guidelines Can’t assess functional response to exercise Unless done on medications, can’t asses status for cardiac therapy program Does not allow for evaluation of recovery from exercise and post exercise risks Pros/Cons of Diagnostic ETT for Cardiac Rehab

Baseline cardiogram Assessment of ischemia for those with coronary disease (CAD) Arrhythmia risk assessment Consideration of Peripheral Vascular Disease (PVD) Can seriously limit progress in a conditioning program Management of Heart Failure (HF) Other diagnostic studies for CR

Question 1: • All patients who start a program of cardiac rehabilitation should have consideration of all of the following tests except: • A. Electrocardiogram • B. Cardiac stress test • C. Non invasive flow studies of the legs • D. Echocardiogram • E. Chest computed tomography Scan

Basic principles to follow in most individuals Intensity 85% Max HR is a target in normal individuals 60% Max HR is a target in diseased individuals Duration 20-30 minutes of aerobic exercise Frequency 3 to 5 times/week Specificity Should be task specific (i.e. do walking to improve walking, stairs to improve stair climbing) Principles of Aerobic Training

Increased Aerobic Capacity Cardiac Output Stroke Volume Decreased Heart Rate Myocardial Oxygen Consumption Effects of Aerobic Training

Angina decreases Reversal of lesions Blood pressure decreases Exercise tolerance increases Decreased depression/anxiety Resting heart rate decreases Improved quality of life Benefits of Aerobic Training

Question 2: • For patients with coronary disease, aerobic training does all of the following except: • A. lower blood pressure • B. increase peripheral resistance • C. lower cholesterol • D. improve exercise tolerance • E. decrease resting heart rate

Classical program designed by Wenger Historically important, as a radical new approach in the 1970’s, no longer used 14 day in hospital program after acute infarction Current in hospital programs shorter - 3-5 days Overall program divided into four phases Acute - I Convalescent - II Training - III Maintenance - IV Classical Rehabilitation Post MI

Wenger Classical Program of Cardiac Rehabilitation • Phase I – Acute phase - 14 days in hospital form bed to about 4-5 MET’s activity • Phase II – Convalescent phase - 5-6 weeks (to allowe infarct healing to prevent myocardial rupture) • Phase III – Training phase - program for 3 times a week for 12 weeks, total of 36 sessions • Phase IV – Maintenance phase – patient to be on a self directed exercise program.

Since revascularization and better acute heart attack care, convalescence is usually no longer needed. So now 3 phase approach in most cases Overall program divided into three phases Phase 1: Acute - 2-3 days in hospital, up to 4-5 METs – (one to two flights of stairs) Phase 2: Training - classical outpatient 36 sessions of cardiac rehab over 12 weeks Phase 3: Maintenance – Home and/or center based maintenance exercise program Current Cardiac Rehab Schema

Begins in coronary care unit (Coronary Care Unit) Early Mobilization CCU to 2 flights of stairs in 2-3 days Telemetry monitoring at each stage of increased activity, can avoid telemetry if stable at a given level of activity Begin patient education at this time This is a “teachable moment” Ends at discharge from hospital Low level stress test prior to discharge Phase 1: Acute

Patients now often have procedures post MI Ischemia is “fixed” => can be more vigorous Multiple co-morbidities may exist => PVD, etc. Survivors of major events with severe debility Long ICU stays Critical illness complications Severe CHF/low EF Phase 1 may be prolonged in these settings New concept of prolonged institutional phase 1 rehabilitation: Phase 1B Rehabilitation Newer Views on Acute Cardiac Rehabilitation (Phase 1)

Continued Inpatient hospitalization for rehab Can be in an Acute (hospital) or subacute (rehabilitation facility) setting Usually in patients with advanced needs Pateints with complicated courses, advanced age, multiple co-morbidities, stroke, etc. Goals Safe independent function at home Achieve 4-5 MET safe exercise tolerance Preparation for Phase 2 rehab program Phase 1B Cardiac Rehabilitation

Comorbidity Stroke – either preceding or from the cardiac event Amputation/Vascular Disease Advanced Age Severe Deconditioning Prolonged ICU Stay and Recovery Inability to Progress to Ambulation Infection or other complications Medical Indications for Phase 1B Cardiac Rehabilitation

Complex Patient Populations Post Transplantation Complex Cardiac Surgical Patients Severe Heart Failure, decompensation Start Phase 1B when on Stable Regimen Severe Cardiac Arrhythmias Only after adequate control is achieved After automatic internal cardiac defibrillator (AICD) or medical management Medical Indications for Phase 1B Cardiac Rehabilitation

Standard Prescription Rules Apply Diagnosis – include cardiac and other issues Precautions – Heart rate, Blood pressure, and other parameters Goals – Intensity and duration of exercises Exercises Aerobic Conditioning Strengthening of Upper and Lower Extremities Stretching Program Monitoring Guidelines – need for telemetry, pulse oximetry, other issues Prescription Writing forPhase 1B Cardiac Rehabilitation

Improve Function Improve Fitness Improve Exercise response Improve Self-Image Return to Normal Activities Decrease Morbidity Prevent Complications Education about cardiac disease and risk factor modification Lifestyle modification to start Goals for Phase 1BCardiac Rehabilitation

Can Safely Establish a Phase 1B Program in Existing Rehabilitation Facilities Coordinate in a Multidisciplinary Approach Basic Principles of Rehabilitation Apply Must have Close Monitoring and Tightly Written Exercise Prescriptions Rehabilitation Approach can Treat Multiple Comorbidities in Comprehensive Way Allows treatment of patients with both cardiac and physical disabilities. Overview of Phase 1B Programs

Maintain early mobilization Gradually increase endurance Maximum heart rate as previously determined by low level ETT (can be 6 minute walk test, stair climb test, shuttle walk test) In Classic Program (phase II) a six week program to allow for scar formation Now only after cardiac surgery with a sternotomy (allows for healing) Exercise 3-5 times per week at 4-5 METs maximum 20-30 minute sessions at target HR set by d/c ETT 5 minute warm up/cool down sessions End of Phase 1 and 1B: Discharge

Classical Program (phase III) 6 weeks post MI, full level ETT performed Screen out arrhythmias, ischemia Set target heart rate With revascularization, start as soon as possible Monitoring with each increase in level Patient self monitoring taught Borg Scale Heart rate Education is critical her Lifestyle modification Disease specific teaching (Diabetes, hypertension) Medication education Phase 2: Training

Usual program as outpatient 3 sessions a week minimum Minimum 6-8 weeks in duration, can be longer Up to 4 hours per session Cross training (use treadmill, cycle, stair climber) Always start with a 5 minute warm up/cool down 20-30 minutes on each piece of apparatus Include a strengthening program low weight (<50% one repetition maximum) high repetition (3 sets of ten with a few minutes between sets) Phase 2: Training

Most important phase Benefits of training can be lost in a few weeks of being sedentary Regular exercise necessary Minimum of 2 to 3 times a week At least 30 minutes of exercise per session excluding warm up and cool down Alternate with strengthening sessions Role for maintenance/wellness program Phase 3: Maintenance

Tobacco cessation – this is critical!!! BP - <140/90 mmHg or <130/80 in DM or renal disease Lipid control: LDL-C <100 mg/Dl for TG >200, non HDL-C <130 mg/Dl. These targets are being modified so need to keep up with recent guidelines Physical activity 30+ minutes for at least 5 days a week Stress relief: Relaxation techniques Secondary prevention goals in CR

Weight management: BMI 18.5 to 24.9 and waist <40 in men and <35 in women DM: HgbA1c <7% Depression/anxiety: Evaluate for depression/anxiety If present => treat Exercise capacity: Assess with ETT if possible Develop individual training program Encourage healthy lifestyle and lifestyle choices Secondary Prevention Goals in CR

Medications: Assess current medications Assure beta blockade Assure antiplatelet agent Assure cholesterol lowering agent Assess BP control medications Assess medication adherence and knowledge Assess ability to manage diabetes Self monitoring Dietary and insulin management Secondary Prevention Goals in CR

Be more aggressive after revascularization Patients now with smaller initial MI Shorter recovery Revascularized at presentation CR needs to be available to all post MI patients, only offered to about 10-20% of patients Need to refer patients CR more effective than any single medication intervention in lowering morbidity and mortality Limitations of access and referral need to be addressed. Practical Issues

Question 3: • A primary goal of Secondary Prevention in cardiac rehabilitation includes: • A. Financial counseling • B. Weight management • C. Arthritis management • D. Breathing control • E. Postural control

Ideally a physician supervised program with trained physical therapists, nurses, exercise physiologists providing care Consider cardiac rehabilitation in: Post Myocardial Infarction Post bypass surgery, Post Valve surgery Stable Angina Heart failure Post transplant Stable arrhythmias Basic Needs for Outpatient Services

Medical supervision – Can be internist, rehabilitation physician, cardiologist Trained staff – Exercise physiologists, nurse, physical therapists Training available with the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) Mixed strength/endurance/flexibility training Education components must be present Nutritional counseling, medication management Smoking cessation Support groups Maintenance support Elements in an Outpatient Program

Secondary Prevention

If exercise was a medication, it would be the highest selling pharmaceutical of all time However, since exercise is work, it is grossly underutilized for almost every condition for which it would be appropriate Basic Observations on Exercise

Angina Pectoris Begin once medical management optional Includes training and maintenance phases Exercise at just below anginal threshold (heart rate) Cardiac arrhythmias Use limits set by ETT, continuous telemetry Proceed normally in patients with AICD Avoid AICD firing rate with stress testing and exercise program (keep heart rate at least 10 beats per minute below AICD ventricular tachycardia firing rate with exertion) Rehabilitation in Special Situations

Immediate post operative period Mobilize starting POD #1 Progressive mobilization POD 2-5 Discharge planning and exercise prescription Consider a symptom limited ETT 3 to 4 weeks post surgery, should exercise at 4-5 METs until rehab starts For sternotomy patients, no upper limb exercise over 10 pounds until sternum healed (bone healing time) Phase 2 as in Post MI patients Maintenance Phase is essential to prevent recurrence Three types of programs Low, moderate, high intensity Rehabilitation After Bypass Surgery

Patients with ejection fraction < 30% Multiple medical problems High risk of sudden death Deconditioned Depressed Low endurance Fatigue Still can have marked benefits with cardiac rehabilitation. Cardiomyopathy and Heart Failure: Physiology

Altered physiology in Heart Failure Lack of normal response to exercise Possible decrease in ejection fraction with increased afterload, possible decrease in stroke volume and blood pressure Cardiac output may not increase sufficiently to generate a dynamic exercise response Can have prolonged fatigue post exertion May be more prone to arrhythmias Cardiomyopathy and HF: Physiology

Unlike Classic rehabilitation, little effect on the heart muscle, does not usually increase stroke volume Most improvements are peripheral changes that allow for better exercise tolerance Increased peripheral oxygen extraction Improved oxygen carrying capacity Better release of oxygen by red blood cells Lower heart rate at submaximal exercise Lower systemic vascular resistance Increased maximum workload Can improve New York Heart Association functional level by one level Heart Failure: Benefits of Rehabilitation

Question 4: • For patients with Heart Failure, the chance of sudden death is less than patients with angina or ischemic heart disease. • A. True • B. False

Prolonged warm ups and cool downs Improves safety, allows for accommodation to exercise, prevents rapid blood pressure changes Dynamic exercise preferred over isometrics Prevents increased afterload Target heart rate 10 bpm below any significant endpoint Start and advance under close supervision Continuous telemetry for severe left ventricular dysfunction Heart Failure: Rehabilitation Program Specifics

Graded exercise tolerance test for all patients before starting exercise program is suggested Rule out arrhythmias, angina, or atypical exercise response Establish safe guidelines for heart rate, blood pressure and level of exercise. Contraindications to cardiac rehabilitation in HF Unstable angina Decompensated HF Unstable arrhythmias Rehabilitation in Heart Failure

Treat patients with valve disease as those patients in heart failure In presence of anticoagulation use low impact exercises Critical Aortic Stenosis (AS) is the only contraindicated condition. Severe AS is allowed, but needs exercise test to assure safety. After valve replacement surgery Program is similar to post bypass surgery patient Training can increase work capacity by up to 60%, rate pressure product by up to 15% Rehabilitation in Valvular Heart Disease

Most common comorbidities are in “vasculopaths” and come with aging Orthopedic limitations are extremely common Lower limb arthritis and back pain Vascular disease travels in common - so CAD often seen with stroke and PVD Scope of Issue of Dual Disability in Cardiac Rehabilitation

Spinal cord injury: Primary cause of death is now cardiac disease. There is an accelerated rate of development of CAD (more and earlier than normal controls). Exercise can case improvements But peak exercise levels are not equal to normal Cardiac Disease in Patients with Primary Disability

Cardiac Rehabilitation