Cardiac Rehabilitation Flashcards
What are the rates of recurrence for heart attacks?
More than 1/3 of hospital admissions for heart attacks are repeat events
What does heart disease include?
- Acute coronary syndrome (significant episode of angina or a heart attack)
- Chronic heart failure
- Other diagnoses e.g. atrial fibrilation
- Post-op patients e.g. CABG
What is the prognosis for chronic heart failure?
No cure, progressive
What is the pathophysiology behind CHD?
- Formation of artherosclerotic plaque in coronary artery
- Reduces lumen size & blood flow to myocardium
- Limits flow of oxygen & nutrients to myocardium (ischaemia)
- Complete lack of oxygen resulting in myocardial cell death = MI (heart attack)
What are the medical/surgical interventions for CHD?
- Coronary angioplasty (balloon)
- Coronary stenting
- Coronary artery bypass grafting (CABG)
- Conservative e.g. medication, lifestyle modification
What are the non-modifiable risk factors for CVD?
- Age
- Male/female post-menopause
- Genetic predisposition
- Ethnicity
What are the modifiable risk factors for CVD?
- High cholesterol
- Hypertension
- Diabetes
- Overweight
- Smoker
- Physically inactive
- Depression/psychosocial issues
- Poor nutrition
What is cardiac rehab?
- Coordinated system of care
- Helps people with CVD return to an active life
- Prevents recurrence of cardiac events or new CV conditions
- Collaboration between health professionals
- Typically short-term, but commonly becoming a more long-term program (continuum)
What is the broad aim of cardiac rehab?
Maximise physical, psychological & social functioning (QOL) to enable people to lead fulfilling lives with confidence
What are the specific aims of cardiac rehab?
- Facilitate/shorten period of recovery
- Promote strategies for achieving ongoing prevention goals
- Develop/maintain skills for long-term behaviour change & self-management
- Promote appropriate use of health services/medications
What are the core components of cardiac rehab?
- Referral & access to services
- Assessment & ST monitoring
- Recovery & LT maintenance
- Lifestyle modification & medication adherence
- Evaluation & quality improvement
What are the 4 traditional phases of cardiac rehab?
- Inpatient education, mobilisation (3-5 days)
- Supervised, outpatient group exercise & education (2-6 weeks)
- Maintenance program (6-12 weeks)
- Community-based, independent
What patients are eligible for cardiac rehab?
- MI
- Re-vascularisation procedures
- Stable angina
- Controlled heart failure
- Valve device, replacement & repair
- Permanent pacemaker (PPM) & implantable defibrillator insertion (ICD)
- Heart transplant & ventricular assist device (VAD)
- Atrial fibrillation
- High risk of future event
- Other vascular/heart diseases
What does the multidisciplinary team for cardiac rehab include?
- Coordinator (nurse/allied health)
- Cardiologist/GP
- Nurse
- Physio
- EP
- Dietitian
- Social worker
- OT
- Psychologist
- Indigenous health worker
What is the evidence for cardiac rehab?
- Sundararajan et al 2004: 35% benefit in 5 year survival associated with cardiac rehav
- Taylor et al 2004: Decreased all-cause mortality, cholesterol & SBP
- Anderson et all 2016: Decreased cardiac mortality, hospital admissions over 1 year, increased QOL
What are some of the problems with traditional CR?
- Poor uptake (10-30%)
- Those in greatest need least likely to attend
- Inflexible model - requires transport etc & tends to be exercise-focused
What are some of the contemporary solutions to CR?
- Case-management model
- Often individualised
- Telephone support & follow-up
- More flexible
- Engagement of physicians
- Focus equally on risk factors
- Longer follow-up than traditional CR
- Home-based CR just as effective as centre-based
What did systematic reviews by Jolliffe (2000), Clark (2005) and Clark (2007) find?
Programs with and without structured exercise that are either brief or long reduced death & events to a similar degree
What were the findings of the Coach program?
- Phone coaching to risk factor targets
- Significant decrease in multiple risk factors
What were the findings of the Choice program?
- Patient engagement & choice in risk factor modification & phone support
- Significant decrease in multiple risk factors
What were the findings of the Scrip program?
- Nurse case management & phone
- Decreased TC & BP, increased CV meds
What were the findings of the Multifit program?
- Nurse case management, phone, counselling & exercise
- Decreased TC, fewer smokers, increased CV meds
What was involved in the Text Me program?
- Text messaged based prevention program
- Significant decrease in multiple risk factors
What are the goals of phase 1 of CR?
- Maintain functional capacity
- Develop patient confidence
- Minimise anxiety & depression
- Maximise early discharge
- Risk factor ID & lifestyle modifications
- Stabilise patient
- Control pain & arrhythmias
- Limit myocardial damage
What are the considerations/CIs of phase 1 of CR?
- Febrile
- Sinus tachycardia (>120bpm @ rest)
- Anaemia
- Wound infection
- Unstable sternum
- Complicated MI
What are the considerations for a sternotomy patient?
- UL exercises: Minimise adhesions, muscle shortening & atrophy, stiffness, prevents guarding
- 6/12 for sternum to fully unit
- Sternal PCs 8-12/52
- Pain control
What are the aims of phase 2 of CR?
Increase CV fitness, confidence to exercise & provide secondary prevention (education)
What assessments are used in CR?
- Chest & sternum
- Mobility & exercise tolerance (ISWT, 6MWT)
- Medical history
- Medications
- Investigations
- Psychosocial (QOL, depression)
- Goal setting
- Risk factors
What tests are used to assess risk factors?
- Cholesterol: Blood test
- Blood pressure
- Heart rate: Pulse, SpO2
- Weight: BMI, waist, WHR
- Nutrition: Diet assessment
- Smoking history
- Exercise/PA
- Diabetes (Y/N)
What is involved in exercise testing?
- 6 minute walk test
- Shuttle walk test
- Monitor SOB (Borg scale), HR, signs & symptoms
- Goal is 30 mins moderate intensity PA on most weekdays
What are the absolute CIs of exercise testing?
- Progressive worsening of exercise tolerance/dyspnoea over previous 3-5 days
- Significant ischaemia & low exercise intensities
- Uncontrolled diabetes
- Acute systemic illness/fever
- Recent embolism (<4 weeks)
- Thromboplebitis
- Active pericarditis or myocarditis
- Severe aortic stenosis
- Regurgitate valvular HD requiring surgery
- MI within previous 3 weeks
- New onset AF
- Resting HR > 120bpm
What are the relative CIs of exercise testing?
- 2kg increase in body mass over past 1-3 days
- Concurrent continuous/intermittent dobutamine therapy
- Decrease in systolic BP with exercise
- NYHA functional class IV
- Complex ventricular arrhythmia
- Supine resting HR >100bpm
- Pre-existing co-morbidities
- Moderate aortic stenosis
- BP> 180/10
- SpO2<88% on room air
What exercise training is included in CR?
- CV (walking, cycling, stairs)
- Resistance
- Functional (daily PA)
- Reduce sedentary behaviour
- Independence aiming to change lifestyle
What does general education in CR include?
- Basic anatomy/physiology of heart
- Symptom monitoring & warning signs
- Recovery/healing process
- Risk factors for heart disease
- Importance of long-term behaviour change
- Resumption of normal daily activities
- Mood/depression/social issues
- Medications
- Action plan
How is CHF managed?
- Non-pharmacological strategies (PA programs etc)
- Best practice pharmacotherapy
- Surgical procedures & supportive devices
- Post-discharge CHF Mx programs
- Palliative care
What are the CFH considerations?
- Clinical condition fluctuates
- Hospital readmissions are common
- Closely monitor symtoms
- Self-management is fundamental
What are the general issues with CHF?
- Monitor HR, SOB, BP, signs/symptoms, wound site
- May need oxygen
- Generalised weakness, oedema
- Consider co-morbidities
- Aim to improve ADLs
- General PA
What is involved in the follow-up & ongoing care for CHD?
- Telephone
- Internet
- Lifelong change
- GP contact
- 6-12 months & ongoing
- Transition to community
What are the 4 classes of CHF?
I: No limitation of PA
II: Slight limitation of PA, comfortable at rest
III: Marked limitation of PA
IV: Unable to carry on any PA without discomfort, symptoms at rest
