Cardiac Rehabilitation Flashcards
Clinical indications for inpatient and outpatient cardiac rehabilitation
- medically stabile post MI
- stabile angina pectoris
- coronary artery bypass surgery
- percutaneous transluminal coronary angioplasty
- compensated heart failure
- cardiomyopathy
- heart transplant
- other cardiac surgery
- PAD
- high risk for coronary artery disease with diagnosis of diabetes melitus, dyslipidemia, hypertension or obesity
- end-stage renal disease
Clinical contraindications for inpatient and outpatient cardiac rehabilitation
- unstable angina
- resting systolic pressure > 200 mmHg or resting diastolic pressure > 110 mmHg
- orthostatic blood pressure drop of >20 with symptoms
- critical aortic stenosis
- acute systemic illness or fever
- uncontrolled atrial/ventricular arrhythmias
- third-degree atrial ventricular block without pacemaker
- active pericarditis or myocarditis
- recent embolism
- thrombophlebitis
- resting ST segment depression or elevation > 2mm
- uncompensated congestive heart failure
- orthopedic or metabolic conditions that would prohibit exercise
Inpatient cardiac rehabilitation (ICR) (phase 1)
- consists of patient and family education, self-care evaluation, continuous monitoring of vital signs, group discussions, and low-level exercise
- AROM, ambulation, and self-care
ICR phase 1 medical evaluation
May begin if
- no new recurrent chest pain in eight hours
- no new signs of uncompensated heart failure
- no new significant, abnormal heart rhythm or ECG changes in eight hours
- stable creatine kinase and troponin levels
ICR phase 1 monitoring and safety
- ask patient to report any chest discomfort, dyspnea, or faintness that occurs during activity
- discontinue exercise for any of the following adverse responses
- -heart rate > 130 beats/minute or >30 beats/minute above resting heart rate
- DBP >110
- decrease in SBP >10
- significant ventricular or atrial dysfunction
- 2nd or 3rd degree heart block
- s/s including angina, marked dyspnea, and ECG changes suggestive of ischemia
ICR phase 1 active exercise
- active upper and lower extremity exercises may begin 24 hours after bypass graft surgery and two days after infarction
- active exercise progress from sitting to standing (1-4 mets)
- upper extremity exercise should not stress the incisions of post surgical patients
ICR phase 1 aerobic exercise
Mode
- progressive, supervised level of walking (2-3 mets) to walking up and down steps or treadmill (3-4 mets)
Intensity
- RPE=13
- post infarction heart rate <120 OR <20 above beating heart rate
- post surgery <30 bpm above resting heart rate
Duration
- intermittent bouts of 3-5 minutes, progressing to 10-15 of continues activity
Frequency
- first three days: three to four times per day
Progression
- progress varies according to patient tolerance and risk stratification
- activity may be progressed provided
- -adequate increase in heart rate
- adequate rise in systolic blood pressure (10-40)
- no new dysrhythmias or ST changes on the ECG
- no cardiac symptoms are observed
Expected outcomes of inpatient cardiac rehave
- prevent the harmful physiological effects of bed rest during hospitalization
- walk 5-10 min continuously, or 1000 feet, four times daily
- walk up and down one flight of stairs independently
- know safe heart rate and RPE for exercise
- recognize abnormal signs and symptoms suggesting intolerance to activity
- promote a more rapid and safe return to activity
- prepare the patient and home support system to optimize recovery following discharge
Immediate outpatient (phase 2)
can begin immediately after hospitalization and last up to 12 weeks
Phase 2 medical evaluation
- heart rate and rhythm
- signs and symptoms
- ST segment changes
- exercise capacity
- risk stratification
- target heart rate for exercise
- initial level of work for exercise
- medical history
- cardiovascular disease risk profile
- BMI or waist hip ratio
- resting ECG and blood pressure
- auscultation of lung sounds
- palpation and inspection of extremities for arterial pulses, edema, and skin integrity
- exam of chest and leg wounds
- orthopedic and meuro status
phase 2 monitoring and safety
low risk patients- 6-12 sessions of ECG and BP monitoring and medical supervision
mod to high risk patients- continuous ECG and BP monitoring and medical supervision are recommended usually >12 sessions
discontinue if
- plateau or decrease in HR with increase in work
- SBP plateaus or falls with increase in work or > 250
- DBP > 115
- ST segment depression >1
- 2 or 3 degree heart block
- ventricular dysrhythmias
- angina or other symptoms of cardiovascular insufficiency
HR max
220-age
lower Target heartrate
HRmax x 55%
Upper target heart rate
HRmax x .90%
