Cardiac Rehab Flashcards
A cardiac rehabilitation (CR) program in the outpatient setting is a multidisciplinary program
- of exercise, education, & lifestyle modification
What are the 2 problems with primary prevention of CVD
- Compliance
- Lack of payment for services by medical insurance companies
What are the criteria for metabolic syndrome
- Low levels of HDL cholesterol: <50 for women & <40 for men
- Elevated blood sugar levels: ≥126
- High blood pressure: consistently 130/85 or higher
- Excess weight in abdomen: ≥40 in for men and ≥35 in for women
- Hypertriglyceridemia: >150
Risk factors affected by primary prevention
-Reduction of total cholesterol to high-density lipoprotein (HDL) ratio
- Reduction in low-density lipoprotein (LDL) cholesterol
- Improvement in aerobic capacity and exercise tolerance
- Reduction in body mass index (BMI)
- Reduction in resting blood pressure in prehypertensive and hypertensive individuals
- Improved glucose tolerance and insulin sensitivity
- Improved feeling of wellbeing and improved stress tolerance
ABCDE primary prevention strategies for ASCVD (atherosclerotic cardiovascular disease)
- Assess risk
- Antiplatelet therapy
- Blood pressure
- Cholesterol
- Cigarette smoking
- Diabetes
- Diet & weight
- Exercise
- Economic and social factors
ASCVD risk enhancers
- Family Hx of premature ASCVD
- Primary hypercholesterolemia
- Chronic kidney disease
- Metabolic syndrome
- Conditions specific to women
- Chronic inflammatory conditions
- Ethnicity
- Persistently elevated triglycerides (≥175)
Which smoking cessation methods are FDA approved
- Patch
- Gum
- Lozenge
- Nasal spray
- Oral inhaler
- Bupropion
- Varenicline
Risk enhancers for diabetes
- Long duration (≥10 yrs DM II & ≥20 yrs DM I)
- Albuminuria ≥30
- eGFr <60
- Retinopathy
- Neuropathy
- ABI <0.9
Describe normal, elevated, stage I, and stage II blood pressures
- Normal: <120/80
- Elevated: 120-129/<80
- Stage I hypertension: 130-139/80-89
- Stage II hypertension: ≥140/90
Non-pharmacological interventions for hypertension
- Weight loss
- Healthy diet
- Reduced intake of dietary sodium
- Enhanced intake of dietary potassium
- Physical activity: aerobic, dynamic resistance, isometric resistance
- Moderation in alcohol intake: reduce to ≤2 drinks/wk for men and ≤1 drink/wk for women
Components of a CVD rehabilitation program
- Education in the recognition, prevention, & treatment of CVD
- Reduction of risk factors
- Dealing with psychologic & behavioral factors influencing recovery
- Progressive physical activity
- Vocational/return to leisure activities counseling
- ADL and functional training
What are the phases of cardiac rehabilitation
- Phase I: acute or in-hospital phase
- Phase II: early outpatient/intensive monitoring
- phase III: training & maintenance phase
- Phase IV: reserved for high risk pts in a disease prevention program
Describe the acute/in-hospital phase
- Early mobilization
- Poor candidates: uncontrolled HTN, healthy pts, unstable heart issues
A modified CR program is indicated for patients who are designated as complicated for one or more of these reasons:
- Large infarction clinically, although stable after 2-3 days
- Resting tachycardia (100 bpm) or inappropriate HR increase with self-care activities
- BP failing to rise or decreasing with self-care activities
Complications with acute MI per McNeer Criteria for modifying CR program
- Poor ventricular function
- Significant ischemia with low-level activity
- Cardiogenic shock
- Ventricular tachycardia and/or fibrillation
- Atrial flutter or fibrillation
- Second- or third-degree atrioventricular (AV) block
- Persistent sinus tachycardia (HR >100 at rest)
- Persistent systolic hypotension (systolic BP <90 mm Hg at rest)
- Pulmonary edema
How long do you follow sternal precautions and when can pts start lifting
- Restricted immediately after surgery for 6-12 weeks
- Pts should be empowered to resume load bearing ADLs at their own pace immediately after surgery
Relative contraindications to continuing exercise in phase I CR program
- Unusual HR increase: >50 bpm increase with low level activity
- BP indicative of HTN: >210/>110
- Drop in systolic BP >10 with low level exercise
- Sx with activity: angina, excessive dyspnea/fatigue, mental confusion or dizziness, severe leg claudication
- Signs of pallor, cold sweat, ataxia
- Changing lung sounds with activity
- ECG abnomalities
Conditions that may be addressed with CR program
- Myocardial infarction
- Heart failure
- Angioplasty and/or stent
- Heart transplant
- Stable angina
- CABG
- Valve replacement
- Comorbid conditions
- Poor ejection fraction
- Cardiomyopathy
- Serious arrhythmias
When would insurance not cover cardiac rehab
- Cardiac rehab in the wake of procedures to implant a pacemaker or implantable cardioverter defibrillator (ICD)
- Coverage after HF is limited to pts with a “compromised ejection fraction” which affects about half of the population with HF
Secondary prevention of CVD in outpatient setting
- Should consist of aerobic exercise training, resistance training, & flexibility exercise
- Specificity of exercise
What is the commonly accepted range of training HR
- 70-85% of maximal heart rate
- 50-85% of maximal oxygen consumption
Components of exercise prescription for aerobic training
- Intensity: commonly using HR, RPE, and/or signs and symptoms
- Mode of exercise
- Continuous aerobic training: warm-up, peak interval phase, and cool-down
- High intensity interval training: alternating bouts of moderate & vigorous intensity exercise
- 4 versus 2 extremity exercise: combined produces higher max oxygen consumption
- Duration individualized
- Circuit training: keeps the HR elevated
Exercise duration for aerobic train is individualized and based on several factors
- Length of disability
- Reduced activity as a result of the acute event
- Premorbid activity level & neuromuscular capability
Patients can progress based on tolerance of the activity in several ways
- Increasing the duration of exercise
- Increasing the intensity of exercise
- Changing the mode of exercise
What are the 5 social determinants of health
- Education access and quality
- Health care access and quality
- Neighborhood and built environment
- Social and community context
- Economic stability
Considerations for nutritional care for management of CVD risk factors
- Specific lipid abnormality
- Cultural background
- Lifestyle/preferences
- Any pertinent comorbidities: diabetes, renal disease
____________ is a significant risk factor for coronary artery disease, heart failure, and arterial fibrillation
- Obesity
Major ASCVD events
- Recent acute coronary syndrome (within last 12 mo)
- Hx of MI
- Hx of ischemic stroke
- Symptomatic peripheral arterial disease
High risk conditions for future ASCVD events
- Age ≥65
- Heterozygous familial hypercholesterolemia
- Hx of prior coronary artery bypass surgery or PCI outside of the major ASCVD events
- Diabetes
- HTN
- Chronic kidney disease
- Current smoking
- Persistently elevated LDL despite max tolerated statin therapy & ezetimibe
- Hx of congestive heart failure
Strategies to motivate lifestyle changes in secondary prevention/management of risk factors
- Education
- Strong leadership & a team approach
- Enthusiasm
- Development of a good relationship b/w therapist & patient
- Reinforcing self-management & self-monitoring techniques (RPE, HR limits)
_____________________ assesses effectiveness in providing patient care & the subsequent improvement in quality of care
- Outcome evaluation
Follow-up assessment should be performed and discussed with the patient at least ________ times per month during the subacute and intensive rehabilitation phases.
- 2 times per week
Criteria for discharge
- Anticipated goals and desired outcomes have been achieved.
- Patient declines to continue intervention.
- Patient is unable to progress toward goals because of medical or psychosocial complications.
- Patient fails to make reasonable progress toward goals because of nonadherence to the home program.
- Patient fails to attend scheduled appointments.
- Patient lacks willingness or ability to participate.
Safety precautions in the CR setting include
- Avoiding exercise within 1-2 hours after meals
- Avoiding isometrics and breath holding with exercise
- Adding warmup & extended cool-down periods of 15 minutes or more with strenuous exercise
- Seeing showers brief & not at a hot or cold temperature (keep legs active)
