Lecture 14: HF/CAD/DM Cardiac Rehab pt. 2 Flashcards
describe phase 2 cardiac rehab
outpatient setting
starts as soon as possible after hospital dc
36 sessions (3x/wk x 12 wks)- Medicare pays this much
led largely by exercise physiologists
Vitals taken before, during, and after activity with adjustments made based on exercise response
factors that help determine frequency of monitoring and degree of direct supervision in CR exercise program
prior clinical course (complicated vs uncomplicated)
GXT results
degree of LV impairment
initial assessment
risk stratification
exercise components in phase 2 CR should consist of
combo of aerobic, resistance, and flexibility
specificity for CR
training should mirror pts regular functional tasks
changes will occur in specific mm groups or aerobic tasks that are challenged
mode of exercise for CR phase 2
should engage mm used for regular functional tasks
variety of exercise equipment to accomplish task
take pt preferences into account if able
intensity for phase 2 cardiac rehab
too intense = hazard
not intense enough = ineffective
aerobic training effects occur at 70-85% HR max, but as little as 40-60% HR max in elderly or more compromised pts
use HR max and RPE to monitor
type of activities for CR phase 2
warm up (5-10 min) = allows mm to stretch to max length used in peak exercise
steady state exercise
cool down (5-15 min) = allows slowed return to rest since abrupt end can reduce blood return to heart
interval training can be used for pts who are not yet able to tolerate long duration aerobic activities
combination of BLE and BUE exercise will produce a higher VO2 max consumption
duration of phase 2 cardiac rehab per session
goal = 45 min continuous steady state
can start with shorter period and progress per individualized pt needs
frequency phase 2 CR
typical schedule = 3x/week
more impaired pts should start with low intensity, short duration, high frequency exercise program if possible
resistance training guidelines for phase 2 CR
initiated after aerobic
goal = 30-50% 1RM, 8-10 reps, 2-3x/wk to major mm groups
can increase weights by 5-10 lbs when 12-15 reps are comfortable
train large mm before small
exhale with exertion to avoid valsalva
take individual pt needs into consideration to determine focus on mm power vs endurance
describe phase 3 CR
maintenance stage
focus on lifelong exercise involvement
progressive independence and self monitoring of symptoms and health
larger exercise groups with less individualized supervision (i.e. YMCA, senior centers, private gyms)
benefits of CR
47% lower mortality risk
31% lower risk of repeat MI if 36 sessions attended
decreased hospital readmission
higher QOL
lower cost to healthcare system
barriers to cardiac rehab
pts who would benefit but are not being referred (greatest predictor of participation is strength of MD recommendation)
geographic location; 30% less likely to participate if living outside of large city
long wait times; every day a pt waits to enroll, they are 1% less likely to ever do so
finances; pts who make >$75k are 2x as likely to participate
safety precautions in CR
avoid exercise 1-2 hours post meal
avoid isometrics and breath holds
add warm up and cool down periods to lower risk of adverse event
take shorter showers and not extreme temps to maintain normal blood flow/distribution
staff should be trained on how to respond to emergency
CR programs in high altitude ares or environments of extreme temps should adjust properly
CVD prevention methods
healthy lifestyle reduces risk of MI by 81-94%; pharm treatment alone is only 20-30% reduction
most effective treatment = combo of pharm management and lifestyle choices
key changes = diet, physical activity, weight management, smoking cessation, and stress management
nutrition recommendations for prevention and management of CVD
adherence to mediterranean diet
increased intake fruits/vegetables
limit processed foods
balance macronutrient absorption
reduce sodium and sugar intake
regular monitoring and education
components of the mediterranean diet
lots of fruits/vegetables (antioxidants to reduce systemic inflammation)
whole grains
healthy fats from EVOO, nuts, seeds
legumes (plant based protein and fiber)
fish/seafood (omega 3 to lower cholesterol)
moderate consumption of eggs, poultry, and dairy
infrequent consumption of red meat and sugar
herbs and spices in place of salt
red wine in moderation
recommended sodium intake per day to prevent HTN
<2000mg
benefits of mediterranean diet
reduced risk of CVD and CVA
lower indidence of type 2DM
better weight management/reduced obesity rate
enhanced cognitive function and reduced risk of neurodegenerative diseases
overall longevity and improved QOL
pharm management of type 1 DM
needs insulin replaced
made with human and animal products
meds have various characteristics and can be a combo of short acting and long acting properties
pharm management for type 2 DM
effective only for type 2
different mechanism to lower blood sugar than type I
- slow rate pf glucose released by liver
- stimulate insulin secretion by beta cells of pancreas
- blocks glucose reabsorption in kidneys
- enhance insulin sensitivity in peripheral tissues
- artificial replacement of insulin
how does metformin (glucophage) work and what are the side effects
- slows rate of glucose released by liver
- enhances insulin sensitivity in peripheral tissues
first drug of choice in type 2 DM with Hgb A1c >7%
very low risk of hypoglycemia when used alone (doesn’t affect insulin secretion in pancreas)
side effects = GI distress and increased lactic acidosis with exercise
types of insulin stimulators
GLP-1 agonists
DPP-4 inhibitors
Sulfonylureas
how do GLP-1 agonists work
mimic a GO hormone released with digestion that stimulates pancreas to produce/release insulin
successful in weight reduction
how do DPP-4 inhibitors work
prevent breakdown of GLP-1 allowing it to act on the pancreas to produce/release insulin
how do sulfonylureas work
directly stimulate pancreas to release insulin
higher risk of hypoglycemia compared to others
what is thiazolidinediones (TZDs)
insulin sensitizer
enhances insulin sensitivity in adipose, muscle, and liver tissue
insulin is utilized at the cell membrane to make cells more receptive to blood glucose
higher risk of side effects; no prescribed as much anymore
how is glucose lowered with the kidneys (what drugs)
SGLT-2 inhibitors
block glucose absorption in kidneys, allowing a higher excretion of glucose in urine
side effects = hypotension, UTI, yeast infections
impact of exercise on DM
sustained PA reduces insulin secretion
decreased insulin secretion is compensated for by heightened sensitivity of peripheral tissues to insulin, causing more rapid glucose uptake by mm
help decrease BS and HgbA1c
resistance training = more effective at improving glycemic control when targeting major mm groups with high intensity strength training (3 sets of 8-10 reps at weight that incudes near fatigue 3x/wk)
rehab managent of type 1 DM
avoid exercise induced hypoglycemia (can occur during, immediately after, or up to 24 hours post exercise)
avoid exercise during peak effect of insulin- reduces risk of hypoglycemia
aim for blood sugar of 120-160 prior to exercise
avoid exercise of limb used for insulin injection for 60-90 min or until after peak effect has been reached
ensure adequate hydration
tips to avoid exercise induced hypoglycemia
eat a meal 60% carbs 1-3 hours prior to exercise
check BS 60 and 30 min prior to exercise to assess trend
- if BS <70 = eat more cards, no exercise until BS 100-120
- if BS >250 = may need insulin, no exercise until BS 100-120
> 250 mL fluid intake 20 min prior to exercise
monitor BS every 30 min during long duration exercise
insert short bouts of intense anaerobic exercise throughout aerobic exercise to blunt hypoglycemic effects
monitor BS for 24 hours and adjust insulin dosing if needed
eat slow acting carbs to protect against late onset hypoglycemia
rehab management of type 2 DM
during low-mod intensity exercise = mm have increased glucose uptake for energy production and reduces hyperglycemia
combined aerobic and resistance training has more benefit on HgbA1c than either in isolation
weight loss benefits all risk factors of DM2
greatest CVD risk reduction achieved with >4 hours/wk of mod intensity exercise
> 7 hours/wk mod intensity exercise is more successful in achieving and maintaining weight loss
