Cardiovascular Disease Flashcards
What are the 10 indications for inpatient and outpatient cardiac rehabilitation?
1) Medically stable post myocaridal infarction
2) Stable angina
3) CABG surgery
4) Percutaneous coronary angioplasty
5) Stable heart failure caused by either systolic or diastolic dysfunction
6) Heart transplant
7) Valve disease/surgery
8) Peripheral arterial disease
9) At risk for CAD: Diabetes, Hypertension, Dyslipidaemia, or Obesity
10) Individual’s who may benefit for structured exercise or individual educations based on physician referral and consensus of rehab team
What are the 17 contraindications for inpatient and outpatient based cardiac rehabilitation?
1) Unstable angina
2) Uncontrolled hypertension (resting SBP >180 mmHg, Diastolic >110 mmHg)
3) Orthostatic blood pressure drop of >20 mmHg with symptoms)
4) Significant aortic stenosis (<1.0 cm2)
5) Uncontrolled atrial or ventricular arrhythmia
6) Uncontrolled sinus tachycardia (<120 bpm at rest)
7) Uncompensated heart failure
8) Third degree atrioventricular block without pace maker
9) Active pericarditis or myocarditis
10) Recent embolism (pulmonary or system)
11) acute thrombophlebitis
12) Aortic dissection
13) Acute systemic illness or fever
14) Uncontrolled diabetes mellitus
15) Severe orthopaedic conditions that would prohibit exercise
16) Metabolic conditions such as acute thyroiditis, hypokalaemia, hyperkalaemia, hypovolemia (until treated)
17) Severe psychological disorder
What does the AACVPR state inpatient CR should focus on?
1) Clinical assessment via chart view and individual interview
2) Physical ambulation and mobilization
3) Education regarding modifiable risk factors and self-care
4) Referral to outpatient CR
What are the 5 adverse responses to inpatient exercise that should lead to exercise discontinuation?
1) Diastolic blood pressure >110
2) Decrease in systolic blood pressure >10 mmHg with increasing workload
3) Significant ventricular or atrial arrhythmias with or without associated signs and symptoms
4) Second- or third-degree heart block
5) Signs/Symptoms of exercise intolerance including angina and marked dyspnea with ECG changes suggestive of ischemia
What are the 8 strategies that influence referral and enrolment to CR?
1) Automatic inpatient CR referral system
2) Inpatient liaison
3) Combination of automatic CR and liaison
4) Limit out of pocket expense
5) Inclusion of home-based CR option
6) Flexible hours of operation (weekends)
7) Early outpatient appointment established before hospital discharge
8) Insure CR referral is assessed, reported, and acted on in a systematic quality improvement programme
What are the 5 goals for outpatient cardiac rehabilitation?
1) Develop and assist the individual to implement a safe and effective formal exercise and lifestyle physical activity program
2) Provide supervision and monitoring to detect change in clinical status
3) Provide ongoing surveillance to individual healthcare provider to enhance medical management
4) Return the individual to vocational and recreational activity or modify activity based on clinical status
5) Provide individual and family education to optimise secondary prevention (e.g risk factor modification) through aggressive lifestyle management and use of cardioprotective medication
What assessments should be performed at time of CR program entry
1) Medical and surgical history (most recent CV event, comorbidities, and relevant medical history)
2) Review of recent cardiovascular tests and procedures including 12-lead ECG, angiogram, echocardiogram, stress test, Interventions (PCI, CABG, Valve, Pacemaker)
3) CVD risk factors
4) Current medications including dose, route of administration, and frequency
5) Physical examination with a emphasis on cardiopulmonary and musculoskeletal function
What are the 7 components of CR?
1) Education to reduce risk CV risk factors
2) Education to reduce risk of second CV event
3) Develop/Implement personalised exercise plan
4) Monitoring with goal of improving blood pressure, lipid/cholesterol, and T2DM
5) Psychological assessment and counselling
6) Communication with individual’s clinical team regarding progress and relevant medical management issues
7) Return to appropriate vocational and recreational activities
What are the 6 factors should be routinely assessed before, during, and after each CR session?
1) HR
2) BP
3) Bodyweight
4) Symptoms indicating clinical status change (dyspnea at rest, light-headedness/dizziness, palpitations, irregular pulse, chest discomfort, sudden weight gain)
5) Symptoms of exercise intolerance
6) Change in medications and adherence to the prescribed medication regimen
Outline the FIIT principle aerobic exercise in outpatient CR
F: 3-5 days/week
I: 40-80% of HRR, VO2R, or VO2peak (with exercise test), HR rest +20-30 bpm, or RPE 12-16 on 6-20 scale.
T: 20-60 minutes
T: Rhythmic large muscle groups with focus on caloric expenditure for maintenance of a healthy bodyweight
Outline the FIIT principles for resistance exercise in outpatient CR
F: 2-3 non-consecutive days
I: 10-15 repetitions without significant fatigue - RPE 11-13 (light-somewhat hard) or 40-60% 1RM
T: 1-3 sets, 8-10 exercises focused on major muscle groups
T: Safe and comfortable equipment
Outline the FIIT principles for flexibility exercise in outpatient CR
F: 2-3 with daily best
I: To the point of feeling tightness/Discomfort
T: 10-30s hold for static strength, 4 or more repetitions for each exercise
T: Static, Dynamic, PNF focus on major limb joints and lower back
What are the exercise considerations relating to safety in outpatient CR
Clinical status, risk stratification, exercise capacity, adverse event/ischemic/angina threshold, musculoskeletal limitations, and cognitive/psychological impairment
Give example of adverse events that may occur during a exercise test and how would this information be used in a patients exercise prescription?
- > 1mm ST-segment depression, compromised hemodynamic response, angina .
- The exercise intensity should be prescribed at an HR of 10 bpm below the HR at which the event occurred.
What are the corresponding RPE values for individual’s in outpatient CR that are used for those without peak HR?
<12: light (<40% HRR)
12-13: somewhat hard (40-59% HRR)
14-16: hard (60-80% HRR)
The presence of angina pectoris that is relieved with GTN is evidence of what?
Myocardial ischemia
What’s a important note regarding the conditioning portion of the programme?
Conditioning should be varied with multiple upper and lower extremity exercises, and varied aerobic equipment
How should the warm-up be conducted?
5-10 minutes of very-light to light aerobic activities with dynamic/static stretching
When and why might HIIT training be incorporated in CR?
No universal guidelines currently but may be beneficial for this population - HIIT may be shifted to community sessions after 12-18 session of early CR
What medication considerations are needed in patients undergoing CR and how might this effect the prescription provided?
Beta-blocker: Attenuated heart rate response to exercise with increase or decrease in exercise capacity.
1) Monitor for signs and symptoms, 2) Note HR/RPE used in previous session 3) Prescribe new RPE/HR at workload achieved previously 4) Ensure it is taken at usual time
Diuretic therapy: Increased risk of orthostatic hypotension, hypokalaemia, and hypovolemia with exercise.
1) Monitor symptoms of dizziness, 2) Monitor symptoms of arrhythmias 3) Education on proper hydration
What are 3 factors to consider when setting goals for patients in CR?
1) Premorbid activity level
2) Vocational and avocational goals
3) Personal health and fitness goals
