4.5 - Cardiac Rehab

Question 1

Describe the abnormal responses to exercise (indications to terminate)

Answer 1

Dizziness, lightheadedness
Angina
Claudication
Cyanosis, pallor
Marked Dyspnea
Excessive fatigue
Hypertensive BP response >200/110
Drop in SBP >10 mmHg
SBP not increasing with increasing workloads
Significant change in EKG rhythm

Question 2

Describe / review the indications to begin cardiac rehab

Answer 2

Medically stable post-MI
Stable angina
CABG
Stable heart failure
Heart transplantation
Valvular heart surgery
PAD, CAD

“Stable conditions”
“Post-surgical”

Question 3

Describe / review contraindications to begin cardiac rehab

Answer 3

Unstable angina
Uncontrolled HTN (>200 or >110)
Orthostatic hypotension
Aortic stenosis
Uncontrolled arrhythmias
Pericarditis / myocarditis
3rd deg AV black w/o pacemaker
Uncontrolled PE / DVT

“Any unstable conditions”

Question 4

Describe how to calculate RPP

Answer 4

RPP = HR x BP

Question 5

Describe a (+) vs (-) exercise tolerance test

Answer 5

(+) = signs of myocardial oxygen supply inadequate for demand
(-) = balanced oxygen supply and demand

Question 6

Describe the norms for the 6-minute walk test for “good long-term survival rate”

Answer 6

> 300m (~1000 ft)

Question 7

Review Borg’s RPE scale

Answer 7

Simple way to remember: multiples 6-20 scale by 10 to get ~HR at that intensity

Question 8

At what RPE does the majority of cardiac rehab take place?

Answer 8

12-15 (somewhat hard to hard)
4-6 (somewhat hard to hard) on 0-10 scale

Question 9

Summarize the three phases of cardiac rehab

Answer 9

Phase 1
- Inpatient, acute stay
- Goal: get back to ADLs

Phase 2:
- Outpatient phase
- Progressively increase tolerance to activity

Phase 3:
- Community program
- Self-regulated, maintenance / progression

Question 10

Describe the appropriate exercise intensity for phase I cardiac rehab

Answer 10

HRrest +20-30 bpm (HR<120 total)

Borg RPE <13/20

“Light exercise w/ minimal increase in HR”

Question 11

Describe the appropriate exercise intensity for phase 2 cardiac rehab

Answer 11

55-90% HRmax
Borg RPE 12-16 (light to somewhat hard)
5-9 METs

“Progressively increase tolerance to activity”

Question 12

Describe the appropriate RPP for phase II cardiac rehab

Answer 12

Keep activities <90% of ISCHEMIC RPP

Ischemic RPP - RPP at which ischemic symptoms are noted

Question 13

Describe phase III cardiac rehab

Answer 13

Community program

Self-regulated, maintenance / progression
x6-12 months

Question 14

Describe the Karvonen method for determining exercise intensity

Answer 14

(HRmax-HRrest) x %intensity + HRrest = Target HR

HRreserve = HRmax - HRrest

Question 15

Determine the appropriate target HR for a 55 yo male exercising at an intensity of 75% HRreserve

HRrest = 65 bpm

Answer 15

(165 - 65) x .75 + 65 = 140 bpm

Question 16

Describe the appropriate parameters for strength training during cardiac rehab

Answer 16

10-15 repetitions comfortably
40-60% 1RM
11-13 RPE

Large muscle groups
Exhalation w/ exertion (AVOID valsalva maneuver)

Question 17

Describe the sternal precautions

Answer 17

Post sternectomy

AVOID:
- UE lifting >10 lbs
- Pushing / pulling
- Scapular adduction (activates pec major)
- UE resistive exercises above 90 deg
- NO UE assistance w/ S2S
- Sternal “splinting” w/ cough, laugh, or sneeze

Question 18

What are the common classes of cardiac medications?

Answer 18

Beta-blockers
ACE inhibitors
Calcium channel blockers

Question 19

Beta-blockers

Describe how recognize this medications
MOA
Clinical considerations / Side effects

Answer 19

“-lols”
- metropolol, propranolol, etc.

MOA:
- Blocks beta-receptors in heart –> doesn’t allow for NE & E to bind receptors –> decreases sympathetic stimulation
- Decrease HR, decrease contractility

Clinical Considerations:
- Do NOT use HR as a measure for exercise intensity with these patients
- Meds decrease submaximal and maximal HR & BP response to exercise
- Patients fatigue more easily

Side Effects:
- Fatigue
- Orthostatic hypotension
- Dizziness
- (Bronchoconstriction)

Question 20

ACE Inhibitors

Describe how to identify
MOA
Clinical considerations / Side Effects

Answer 20

“-prils”
- Lisinopril, captopril, etc.

MOA:
- Blocks production of ACE (angiotension-converting enzyme) –> vasodilation
- Reduces BP

Side Effects:
- Orthostatic hypotension
- Cough (annoying, but not life-threatening)
- Dizziness, fatigue
- HYPERkalemia (due to inhibition of aldosterone –> decrease Na+ & K+ reabsorption)

Question 21

Calcium Channel Blockers

Common medications
MOA
Clinical Considerations / Side Effects

Answer 21

“pines” - amlodipine, nifedipine
verapamil, diltiazem

“Pine trees have lots of Ca++; have to take these trees to the ‘mil’.”

MOA:
- Block calcium entry into cardiac muscle tissue –> vasodilation & decreased vascular resistance
- Decreases BP, HR

Question 22

Nitrates (nitroglycerin)

MOA
Describe how to administer
Clinical Considerations / Side Effects

Answer 22

MOA:
- Releases nitric oxide - a potent vasodilator
- Vasodilation –> increases BF to cardiac tissue; decreases BP (peripheral resistance) to decrease cardiac workload

Administer:
- Patient bring their OWN medications
- Sublingual
- Repeat up to 3x every 5 min
- If no resolution of symptoms after 15 min –> emergent referral

Adverse Effects:
- Headache
- Orthostatic hypotension

Clinical Considerations:
- Have patient lie down when taking due to high risk of hypotension!

Question 23

Cardiac glycosides

Common medications
MOA

Answer 23

Digoxin, digitoxin, digitalis

MOA:
- Decrease HR –> increased filling time –> increased EDV –> improved myocardial contraction force
- Inhibits sympathetic NS; slows sodium-potassium pump
- “Fewer, but better beats!”

Side Effects:
- GI distress - n/v, diarrhea
- Cognitive functioning - drowsiness, confusion, fatigue
- Arrhythmias - PAC, PVC, a-tach, v-tach, AV blocks