Cardiac Rehab and Early Mobility

Question 1

cardiac rehab AHA definition

Answer 1

supervised program to help patients recover from

• MI
• heart surgery such as bypass, ventricular assist device (VAD), valve repair
• minimally invasive procedures such as angioplasty, stenting, valve replacement, pacemaker or implantable cardioverter defibrillator (ICD)
• risk factors such as CAD or angina
• heart failure (HF)

Question 2

core components of cardiac rehab

Answer 2

optimize CV risk reduction
foster healthy behaviors and compliance with these behaviors
reduce disability
promote an active lifestyle

Question 3

general principles/goals of cardiac rehab

Answer 3

decrease length of hospital stay to 3-5 days
early mobilization
assessment
prepare for readiness for discharge home
recommendations for home care
referral to outpatient cardiac rehab program

Question 4

initial assessment

-review chart and note the following…

Answer 4

past medical history
S/S
employment
risk factor assessment and plan for intervention or teaching
-stress management, psychological concerns
medications

Question 5

what cardiac rehab can’t do

Answer 5

reverse atherosclerotic process
decrease myocardial ischemia
have much effect on ejection fraction
reverse effects of lung disease such as COPD

Question 6

indications for cardiac rehab

-begins after initial acute phase when patient is relatively medically stable as evidenced by…

Answer 6

stable angina (no pain for at least 8 hours)
control of dangerous dysrhythmias
control of myocardial insufficiency
labs trending toward normal
compensated HF (when the heart compensates by increasing rate of contraction)
s/p cardiac surgery

Question 7

cardiac rehab contraindications

Answer 7

unstable angina
dnagerous arrhythmias
decompensated HF (when the heart cannot compensate even on medications)
embolism
metabolic instability
critical labs such as high blood sugars in the 400 range, hyperkalemia (K+ above 5.8)

Question 8

precautions to activity

Answer 8

low EF
-20% or less
presence of other medical conditions: diabetes, obesity, renal failure, stroke
active infection
abnormal labs
high oxygen requirements
shortness of breath at rest
sternal precautions

Question 9

medical vs surgical activity guidelines

Answer 9

medical
-post-MI: HR < 120 beats/min or 20 beats above resting allowed with activity
surgical
-post-surgery: 30 beats above resting is allowed
-surgical patients may have sternal precautions

Question 10

why different guidelines for medical vs. surgical activity

Answer 10

surgical

-can go higher because the problem is “fixed”

Question 11

importance of activity

Answer 11

prevents complications of bed rest
improve cardiac and pulmonary function
prevent secondary chest infection
prepare for home discharge through self-care

Question 12

traditional sternal precautions

Answer 12

no lifting more than 10 pounds
no shoulder flexion greater than 90 degrees
keep hands in visual field
no driving
no pushing or leaning
no pulling self up on a trapeze bar while in the hospital
6-8 weeks following medial sternotomy

Question 13

safety in the clinic

Answer 13

selection of appropriate patients
proper monitoring
all professional exercise personnel must be able to do basic life support including defibrillators
emergency procedures must be specified
warm up and cool down are required

Question 14

guiding metrics for exercise

Answer 14

VO2 peak
-closely related to cardiac output and functional capacity of the heart
VO2 peak increases most effectively with exercise of large muscle groups in a rhythmic pattern such as walking or bicycling
HRR and VO2R have a linear relationship
maximal HR empirically is 208-0.7xage

Question 15

use of betablockers precludes use of…

Answer 15

HRR

target is 50% HRR at cardiac phase II, 60-80% of HRR by phase IV

Question 16

cardiac rehab: includes a _____

Answer 16

monitored recovery

Question 17

monitored recovery

-what does it include

Answer 17

gives the patient a safe, monitored environment for exercise
auscultate heart and lung sounds
measure the patient’s vitals: blood pressure, HR< EKG, O2 saturation (low O2 stresses the heart)
check patient’s subjective symptoms - e.g. fatigue, exertion
speed of HR return to resting levels

Question 18

phases of cardiac rehab

Answer 18

I
-inpatient
II
-outpatient ECG monitored
III
-outpatient --> optional ECG monitoring
IV
-community-based

Question 19

phase I cardiac rehab

• settings
• patient may begin if…

Answer 19

settings
-cardiac unit, surgical ICU, medical ICU, telemetry unit, transplant unit
MD approval/order
no chest discomfort (8 hours)
no new signs of decompensated HF
no abnormal ECG changes such as ST segment depression

Question 20

phase I

• goals
• activity
• start with bouts of _____

Answer 20

normal CV response to changes in position and activites of daily living
reach 3-4 MET activity level by discharge
activity - slow progression of activity intensity (increase by 1 MET/day)
start with bouts of 3-5 minutes of activity

Question 21

phase I

• what can the PT do
• what should the PT avoid

Answer 21

active assistive range of motion for DVT prevention
change position e.g. “dangling” legs over edge of bed, watching for BP changes
-stop if systolic BP drop is >20 mmHg
avoid isometrics
avoid valsalva maneuver
keep activites at 2 METs to start
avoid head down position (pass out)

Question 22

Phase I education

Answer 22

risk factor modification
stress management
dietary modifications
smoking cessation
safe sexual activity
cardiac medications
what to do in case of symptoms

Question 23

phase II

• time frame
• _____ performed prior to rehab
• ECG monitoring done how often?
• goals
• patient education on…

Answer 23

supervised outpatient program x 6-8 weeks
exercise test performed prior to rehab
-tested on dosage of medication they will be on during exercise
ECG monitoring every session
goals - increase exercise capacity to 5 METs
-beta blockers decrease HR response to exercise
patient education on HR, exercise, Sx, pacing skills

Question 24

phase II education

Answer 24

self-monitoring during an exercise period
identify the intensity of their workload
ability to work at the appropriate HR and RPE when exercising away from all of the monitoring equipment of the outpatient facility

Question 25

psychosocial aspects of phase II

Answer 25

opportunity to reassure the patient that they can still have a high QOL

• relief of fear and anxiety
• confidence to increase functional activities

Question 26

phase II outpatient

• evaluation
• interventions
• goals

Answer 26

eval
-symptom-limited exercise test
–HR, rhythm, ST segment changes, hemodynamics, signs, symptoms, RPE, exercise capacity
-level of supervision assessment
interventions
-individual exercise program (aerobic and resistance)
goals
-increased aerobic capacity, strength, flexibility
-reduced symptoms, improved risk factor profile, improved QOL

Question 27

for high risk patient, at what %1RM do you start them with resistance training

Answer 27

40%

Question 28

AACVPR rules for starting resistance training

• MI
• CABG
• %1RM

Answer 28

minimum of 5 weeks post MI, including 3 weeks of participation in cardiac rehab
minimum 8 weeks post CABG, including 3 weeks of participation in cardiac rehab
resistance training at > 50% of 1RM
theraband, light weight (1-3#) may be initiated sooner if indicated

Question 29

phase III outpatient

• function capacity goals
• what is expected

Answer 29

> 8 METs
training effects expected
no cardiac Sx
ECG monitoring happens occasionally or when increasing activity parameters
patients learn self-monitoring of HR and Sx
few insurance companies reimburse for phase III and beyond

Question 30

cardiac rehab phase IV

Answer 30

unsupervised program

community-based

Question 31

expected outcomes 1 month after surgery

Answer 31

light housework
dining out
shopping
stain climbing
putting a golf ball

Question 32

expected outcomes 1-3 months after

Answer 32

bicycling
gardening
dancing
chipping a golf ball

Question 33

other effects of exercise training

Answer 33

lower BP
HDL +5-15%, helps remove LDL from blood
helps control body weight along with appropriate diet
reduction in Sx of depression (as effective as antidepressant medication in mild to moderate cases)

Question 34

why early mobilization?

Answer 34

if patient mobilizes after critical illness, there is a chance of a bad outcome
if a patient does not mobilize after critical illness, then they are sure to have a bad outcome

Question 35

effects of deconditioning

Answer 35

muscle breakdown
atrophy
-occurs in ubiquitin-proteasome pathway
system inflammation
-results in weakness beyond normal atrophy