Cardiac Rehab Flashcards
What does early mobilization show
- improved mortality rates
– Mediated through cardiopulmonary effect
– Reduced “complications” of hospitalization
– Quicker recovery
– Shorter stay
what is cardiac rehab?
A comprehensive program of progressive exercise & education designed to optimize a patient’s recovery from cardiovascular disease
Joint Statement by AHA, US Dept. of Health & Human
Services and Agency for Health Care Policy:
“comprehensive, long term program involving
medical evaluation, prescribed exercise,
cardiac risk factor modification, education &
counseling”
Which patients qualify for rehab based on the Medicare Guidelines?
– MI
– Heart failure
– Cardiac transplantation
– Angina
– CABG
– Valve replacement or repair
* Diagnoses that may qualify:
* CAD w/ angioplasty or stent
do all medicare patients who need CR get it?
no- only 11-30%
indications for cardiac rehab
- medically stable post MI
- stable angina
- coronary artery bypass graft surgery
- percutaneous transluminal coronary angioplasty
- stable heart failure caused by either systolic or diastolic dysfunction (cardiomyopathy)
- heart transplantation
- valvular heart disease/surgery
- PAD
- At risk for CAD with DM, dyslipidemia, HTN, or obesity
- other pts who may benefit
Benefits of cardiac rehab
- Improved exercise tolerance
- Improvement in symptoms
- Improved blood lipids/BP/ clotting
- Reduction in smoking
- Improved psychological well being
- Reduced mortality
what is included in cardiac rehab?
▪ Education: teach patient about HD, exercise, risk
factors, diet, medication, lifestyle changes.
▪ Risk Factors Reduction
▪ Exercise: structured and progressive
▪ Vocational/psychological counseling
Phase one of cardiac rehab
Phase I or acute phase:
– begins when patient enters ICU/CCU or step-down unit
Phase II of cardiac rehab
subacute /outpatient recovery phase:
– According to Medicare, phase II refers to outpatient
medically supervised programs that are typically initiated
1-3 weeks after D/C and provide ECG monitoring
Phase III of cardiac rehab
According to Medicare, refers to maintenance programs
without physician supervision and monitoring.
time frame and facility for Phase I CR
▪ Time Frame: 4 - 7 days
▪ Facility: hospital ICU or Step down unit
goals of phase I CR
– prevent secondary effects of bed rest
– identify risk factors
– initiate patient & family education
Phase I CR exercise
- Exercise intensity: 1-3 METS,
– HR 12-25 bpm above resting HR - Exercise duration: intermittent (5-15 min)
- Frequency: 7-day coverage
- Exercise mode: Bilateral UE & LE ROM
progressing to 1-2 lbs weights, ambulation, stairs,
bike, breathing ex
Phase I exercise testing
postpone or sub-maximal exercise test
What all is included in phase I Cardiac rehab
–Acutely ill patients seen bedside, or hallway
–Ensure medical clearance
–Day to day reassessment of function required.
–Patient education: coughing, deep breathing, sternal precautions,
etc…
–Basic exercise program in bed (AROM)
–Bedside dangle, standing at bed side
–Transfers
–Ambulation/ stairs
–D/C planning (to step down or subacute floor)
Transfer patient out of bed or to sitting at
side of bed
- Check vitals and EKG at rest in bed
- Explain what you are about to do to the patient
- Get organized first:
– Inform nursing
– Move catheter, IV, monitors and chest tube collection box
– Have walker/chair ready
– Review precautions
Transfer post open heart surgery patient out of bed or to sitting at side of bed
Log roll technique, hug pillow, sternal precautions
ACSM Guidelines for cardiac patients
- Frequency, Intensity, Time & Type (FITT)
– 2022 Intensity limitations for acute phase cardiac rehab: - PRE < 13 (on 6-20 Borg Scale)
- Post MI: HR < resting + 20
- Post surgery: HR < resting + 30
- Generally for cardiac patients, keep HR < 120 bpm
Contraindications
slide 125
Education in Phase I contraindications
– No lifting > 5-10 lbs… vs MIT,
– No forceful use of UE or Ab-duction (example: do not
use axillary crutches for patient s/p CABG)
Education in Phase I Rx
Exercise on their own or with help form family
– Elevate LE,
– Sit up QD,
– Ambulate BID/TID,
– Perform ankle pumps, SLR, UE ROM
Education in Phase I
- education on disease process
- Risk factors (diet, smoking, sedentary lifestyle)
- Role of exercise and activity guidelines (warm up,
monitor HR, get to target HR, etc) - Medication effects on exercise
- Teach cough technique & self monitoring
- What to do in case of emergency
- “Pep talk” on the importance of continuing exercise and
need to make “life style changes” slowly, over time
move in the tube
minimal sternal complications, providing evidence that modified sternal precautions are safe and can benefit patient
Phase II Cardiac Rehab
- Out-patients or people in skilled or rehab unit who require exercise supervision and monitoring to regain full
function. - Require further instruction in self- monitoring and HEP to
be independent with it. - Require further counseling/education to make life style changes
Phase III Cardiac Rehab
- Outpatients requiring less supervision and
monitoring.
– Once a week- 3 x/week
– Phase III: monitoring during exercise, Phase IV:
weekly/monthly EKG/vital sign checkups.
– Exercise specialist in charge of advancing
program and making changes in program as
symptoms/ex tolerance changes
Assessment
- Part of cardiac rehab which requires the most
skill/judgment:
– Perform complete eval, but focus on CV fx - What level of exercise will induce beneficial
changes, but be safe for the patient
– Need to get to some threshold for benefits
The CCU Medical Chart Review
- Admitting diagnosis, age and date of admission
- Pt’s signs & symptoms (progress notes)
- PMH/PSH- progress notes & surgery notes
- Labs- lab section
- Meds- physician orders
- Social Hx. (prog report pt. assessment)
Exercise Prescription
An exercise program given to the patient as a result
of an assessment that allows for safe progression in
exercise tolerance and maximizes benefits for an
individual patient.
– Exercise mode
– Duration
– Intensity
– Frequency
– Method of self assessment
What should exercise prescription be based on?
- Based on chart review, labs, tests, exercise testing,
pt. assessment & pt’s risk status
Exercise prescription mode of exercise
– aerobic
* walking
* A-ROM/low resistance-isotonic exercises
* ergometer/biking
* other forms of exercise
– strength training
* weights
* isometric exercise (not good 20 to BP changes)
exercise prescription intensity
based on HR and HRR
exercise prescription duration
progressive, rest as needed
Modified exercise testing skip this card is dumb
You don’t want to bring pt. to
max HR (or even to close) in first week after MI or CABG
exercise testing in clinic first week after cabg or mi
- Warm up with A-ROM or light resistance isotonic exercise.
- Monitor HR via pulse as pt. performs progressive aerobic
exercise.
– Walking down the hall, walking in place (if tubes/lines
don’t permit pt to ambulate), etc… - Stop and measure pulse every 2 minutes
– how long to return to baseline?
exercise testing in the clinic for acutely ill or patients recovering from recent surgery
– Use simple sub-maximal HR (HR after walking x
10, 20, 50 ft…), which does not cause symptoms as
lower end of target HR:
– Target HR zone will be 5 bpm above and below this
value
Review Borg Scale
Cardiopulmonary physical assessment
- General appearance
- Vital signs: BP :100-140/70-90, HR 60-100
- Auscultation of the heart: S1, S2, S3, S4 murmur
- Signs of peripheral edema: JVD, swelling
- Signs of hypoxia: cyanosis, clubbing
- Signs of CHF: crackles, SOB, orthopnea
Cardiopulmonary physical exam
- Examination of extremities
- ROM
- Strength
- Neuro exam (more in-depth neuro exam if indicated)
Epidemiology of Coronary heart disease
▪Most prevalent dx in US & industrialized nations
▪Accounts for ~ 50% of all deaths in US
▪Total # of deaths from CHD has declined over past
decade, but morbidity increased
Framingham Heart Study
showed that CHD starts
in 2nd decade & ID’d risk factors
Atherosis
accumulation of cholesterol in
macrophages
▪ once mature plaques (fibrous) form, difficult to
reverse
Sclerosis
inflammatory reaction in media with loss
of distensibility & compliance
Modifiable Risk Factors
▪ Smoking
▪ Hypertension
▪ most prevalent risk factor in US
▪ BP > than 140/90- increased risk 2º sheer stress on
arteries
▪ Elevated Cholesterol
▪ High LDL and /or total cholesterol, low HDL
▪ Physical Inactivity
▪ Obesity or overweight
▪ Diabetes (blood glucose)
non modifiable risk factors
- Family History -
– hypercholesterolemia
– familial hypertrophic cardiomyopathy - Previous History of Heart Disease
- Age -
– age > 65 y/o, but depends on other factors - Gender - males have 6 x risk of MI compared to females (< 55
y/o)
– But MI is 2nd leading cause of death in females < 45 y/o
– After menopause, risk for males & females is nearly equal
patients with chronic stable angina typically have what kind of lesions
concentric
patients with unstable angina typically have what type of lesions?
eccentric
sudden death
20-25 % pt’s w/ CHD die w/in 1 hr
what is angina
imbalance in O2 supply and demand
chronic stable angina
- no pain at rest
- predictable symptoms depending on level of
exertion - increased mortality
unstable angina
even greater mortality risk than with stable angina
unstable angina signs and symptoms
▪ Angina at rest
▪ Occurrence of angina at lower level of
activity then usual
▪ Deterioration of previously stable pattern- pain more
often, increased Nitro use
▪ Evidence of loss of myocardial reserve-
decreased distance walked, shorter time to fatigue
hospital management of patients with acute MI in first 24 hours
▪ Continuously monitored (death occurs in first 24 hr in 25% of
cases)
– EKG: calibrated 12 lead EKG at all times
– Cardiac enzymes every 12 hours
– Monitor physical activity (absolute minimal activity for
12 hours, minimize stress on the heart)
– Echo: check for mural thrombus
Procedures/Rx in First 24 Hours after mi
- Pain and/or anxiety should be Rx with analgesics
- Emergency preparations should be immediately available
(atropine, lidocaine, TC-pacing patch, defibrillator & epinephrine) - Thrombolytics, GP2a/3b or Heparin
– -break-up clot versus prevent further clot formation - Drug Rx: aspirin, -blockers (especially pts w/ ST-elevation),
nitrates, ACE-inhibitor - Calcium channel blockers contraindicated in first 24 hr
Immediate Surgical Intervention
- Failed percutaneous transcoronary angioplasty (PTCA) w/ CP
- Persistent or recurrent ischemia refractory to medical stability
but not candidate for catheter intervention - Cardiogenic shock & coronary artery disease not amenable to
PTCA - Mechanical abnormalities leading to severe pulm congestion or
hypotension - Papillary muscle rupture
Risk Stratification after MI- Level I
uncomplicated-low risk: pts with:
– small-moderate infarct
– no ischemia or LV failure, shock, serious arrhythmia,
conduction disturbances or serious illness by day 4
Risk Stratification after MI- Level 2
uncomplicated-mod risk: pts who:
– later (day 2-4) develop poor ventricular function, decreased
cardiac reserve or serious arrhythmia
Risk Stratification after MI- Level 3
pt with:
– one or more of characteristics listed in uncomplicated MI
Endocarditis/myocarditis:
▪ bacterial, viral or noninfectious inflammation of
endocardium or myocardium
Heart valve disease
▪ mitral valve prolapse: mitral valve incompetence.
▪ Rx with valve replacement, valvulotomy (incision of valve) and
commissurotomy (separation of leaflets)
▪ aortic valve insufficiency, regurgitation & stenosis:
▪ valve rupture (chordae tendinea)
drug induces cardiomyopathy
Often associated with chemotherapy
▪ Anthracyclines (most often- doxorubicin)
Prinzmental angina
coronary vasospasm
CHF is characterized by elevated pulmonary venous pressure - R vs L
▪ Right HF- primarily pulmonary congestion
▪ Left HF- primary systemic congestion
Prevalence of HF
▪ age 55-59 — 1%
▪ but increases to 10% by 80-89 years of age
Causes of HF
▪ MI or ischemia
▪ Arrhythmia
▪ Renal dysfunction
▪ Cardiomyopathy
▪ Heart valve disease
▪ Pericardial effusion/ myocarditis
▪ Pulmonary embolism (PE)
▪ SCI
▪ Congenital abnormalities
▪ Aging
HF facts and prognosis
slide 159
Stratifying patients with HF
slide 160
slide 161
dilated cardiomyopathy
ventricle enlarges, but wall thins
− Wall tension must increase
concentric hypertrophic cardiomyopathies
wall thickens
− May restrict filling
Restrictive cardiomyopathy
Decreased relaxation, Ex. cardiac tamponade
consequences of dilation
▪ Energetic disadvantage
▪ Stasis of blood
▪ Perfusion problems
▪elevated EDP limits perfusion in diastole
▪ Arrhythmia’s:
▪atrial fibrillation, heart block
Pulmonary edema in CHF
– This is often the earliest and primary finding, but may be subtle
– Fluid backs up into pulmonary venous system, leaking into alveoli
symptoms of pulmonary edema
- Dyspnea,
- Exercise intolerance,
- Orthopnea (inability to lie flat due to SOB),
- Atelectasis (local collapse of lung)
- Frothy blood-tinged sputum
- Non-productive cough
- Increased RR/tachypnea (normal = 12-18/20, but concern when RR >24 bpm)
- Paroxysm nocturnal dyspnea
how is pulmonary edema managed?
pharmacologically with beta blockers, diuretics, and
vasodilators
what might pulmonary edema progress to
left side and global heart failure
* Systemic venous HTN, ankle swelling, JVD
PT Clinical Practice Guidelines for Pts with HF
slide 167 key phrases
CHF Sxs
Dyspnea
* Tachycardia
* Paroxysm nocturnal
dyspnea
* Orthopnea
* Peripheral edema
* Weight gain
* Hepatomegaly
* Crackles
* Presence of S3 or S4
heart sound
* Sinus tachycardia
* Decreased exercise
tolerance
* JVD
what to do in event of heart failure
▪ Be prepared!
▪ Crash cart
▪ O2
▪ Nitroglycerine
▪ Know your CPR
▪ Good Clinical Judgment:
▪ Know went to listen to patient vs…. push patient to
participate.
▪ Advance patient as appropriate
Steps in Designing an Exercise Program
for a Patient with HF
– Establish baseline HR, EKG, BP, O2 sat.
– Set target HR (or max safely attainable HR) for
exercise or activity level
– Monitor patient during exercise
– Give adequate rest intervals
– Record HR, BP, EKG, SAO2 and note changes
– Adjust goals/expectations & target HR appropriately
anemia with HF
often associated with HF
▪paradoxically, may increase CO by decreasing blood viscosity
▪decreases O2 delivery to tissues & heart itself
renal failure with HF
▪an underlying cause of HF & hypervolemia
▪can be a result of HF secondary decrease CO
cardiac tamponade
fluid in pericardial space inhibits ventricular filling
long term management of HF
- Before D/C, all pts should receive exercise testing (stress treadmill is
gold standard, but often not realistic for in-patients)
– 4-7 days for submaximal test
– 10-14 days for symptom limited test - Indefinite Rx w/ ACE-inhibitors, beta-blockers, diuretics
- Education to attain ideal weight
- Education regarding reduction in blood chol. and LDL and elevation
in HDL - Smoking cessation
- Participation in formal cardiac rehab program
outcome measures for HF rehab
- gait speed
- 6 min walk test
- 3MWT, 5xSTS, TUG, sub and max treadmill/ergometer tests
what are pacemakers
electronic impulse generator that takes over as the
SA node
when is a pacemaker indicated
when hemodynamic effect of arrhythmia is either
dangerous or symptomatic
what can pacemakers help?
– Used to Rx A-Fib, heart block and ventricular dysrhythmias
– Post Sx when normal SA node function is suppressed or
conduction abnormality develops
are pacemakers unipolar or bipolar
can be either
power of pacemakers
lithium: 6 years
nuclear (12 years)
placement of pacemaker
- endocardial power source in L infraclavicular pocket
- tip in contact w/ R atrium
EKG with pacemaker
Vertical spike right before the P wave is indicative of a pacemaker
epicardial lead implantation
during Sx, electrodes are sewn into myocardial surface
and exit either below xiphoid (temporary) or go to power
source in a subxiphoid pocket
endocardial implantation
placed intravenously into the R atrium, but can also
perivenously (through the vessel)
materials for pacemaker
highly flexible multi strand wires
Functions of pacemakers
▪ Inhibit or trigger a depolarization:
▪ Hyperpolarize membranes
▪ Suppress tachycardia
▪ Demand: increase rate w/ increased endogenous atrial firing rate
(rate-modulation capability)
▪ Allows increase in HR with activity
Contraindications with pacemakers
- Electrical interference:
- Microwaves, diathermy, MRI, etc…
- E-stimulation: could be lethal!
- US over the power source
- L UE abduction/flex past 90° until healed
HF often leads to “dyschroynization” of the heart
- Associated with atrial fibrillation and other electrical abnormalities
- Right & left ventricles depolarizing and beating at different rates
and out of time: - Exacerbates HF
- Increases risk of “sudden cardiac death”
Cardiac resynchronization therapy
– Cardiac resynchronization therapy (CRT) has been shown to
decrease symptoms of HF & risk of SCD
* Improves LF function, ejection fraction and Ex tolerance
– May actually induce ventricular remodeling (toward normal)
– Benefits shown by numerous RCTs
– Now considered “class I indication for HF patients” with wide
QRS (key Dx sign), poor LV function and sinus dysrhythmia
How is CRT accomplished?
with a biventricular pacing system
– Often difficult to achieve a good balance between synchrony
and heart rate
* Dysrhythmias in HF tend to be tachyarrhythmia and it is difficult to
slow the pace with a pacemaker
* Therefore, “ablation therapy” sometimes has to be done along with
biventricular pacing
* Alternately anti-arrhythmic medications have to be used to slow the
intrinsic rate
cardiac defibrillators
implantable defibrillators to prevent “sudden cardiac death” in
patients with dysrhythmias
what do cardiac defibrillators do?
Deliver a shock via implanted electrodes either in apex of R
ventricle or outside heart
– Often ICD is also a pacemaker and delivers CRT
can you use e stim, ultrasound, etc with cardiac defibrilator?
no
Pacemakers/CRT/ICD all used with HF
Patients with MetX & Obesity
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