pulmonary rehab 2

Question 1

define cardiac rehab

Answer 1

The coordinated sum of activities required to influence favourably the underlying cause of cardiovascular disease, as well as to provide the best possible physical, mental and social conditions, so that the patients may, by their own efforts, preserve or resume optimal functioning in their community and through improved health behaviour, slow or reverse progression of disease”.

Question 2

4 phase: phase 1

Answer 2

Phase 1 (2-5 days): This phase relates to the period of hospitalisation following an acute cardiac event.During this phase, individuals typically undergo a risk assessment and risk stratification as well as receiving information regarding their diagnosis, risk factors, medications and work/social issues. Involvement of the partner and family is facilitated and encouraged. This phase also includes early mobilisation and adequate discharge planning.

Question 3

phase 2

Answer 3

period of four to six weeks. It focuses on health education and resumption of physical activity. It may take the format of telephone follow up, home visits or individual or group education sessions.

Week one post discharge: Aim to walk for five minutes each day. If you find that this is very easy, you can do two five minute walks in the one day before increasing your walking time.
Week Two: Aim to walk for 10 minutes non-stop each day, as it becomes easier, you may increase the time by a minute or two.
Week Three: Aim to walk for 15-20 minutes non-stop each day.
Week Four: Aim to walk for 20-25 minutes non-stop each day.
Week Five: Aim to walk for 25-30 minutes non-stop each day.
Week Six: Aim to walk for 30-40 minutes non-stop each day.

Question 4

phase 3

Answer 4

Incorporates exercise training in combination with on-going education and psychosocial and vocational interventions. The duration of phase 3 may vary from six to eight weeks, with patients required to attend a CR unit two to three times weekly for structured exercise and other lifestyle interventions.

Question 5

phase 4

Answer 5

This phase constitutes the components of long-term maintenance of lifestyle changes.It is when patients leave the structured Phase 3 programme and continue exercise and other lifestyle modifications indefinitely. Patients may join a Phase 4 class or may prefer to exercise independently
Need to have a plan before the end of the programme
Need to think of barriers to exercise
Need to start before the end of the programme

Action and coping planning is a very effective method for promoting behaviour change
What are you going to do?
When are you going to do it? 
Where are you going to do it?
What are you going to do if…….

Question 6

inclusion criteria

Answer 6

Medically stable post MI
Coronary artery by-pass surgery (CABG)
Percutaneous Coronary Intervention (PCI)
Stable angina
Stable Heart Failure (NYHA class I - III)
Cardiomyopathy
Cardiac Transplantation
Implantable Cardioverter Defibrillator (ICD)
Valve Repair/Replacement
Insertion of Cardiac Pacemakers (with one or more other inclusion criteria)
Peripheral Arterial Disease
At risk of coronary artery disease with diagnosis of diabetes, dyslipidaemia, hypertension etc.

Question 7

exclusion criteria

Answer 7

Unstable angina
Ischaemic changes on resting ECG
Resting systolic blood pressure ≥200mmHg or resting diastolic≥110mmHg [should be evaluated on a case by case basis ]
Orthostatic blood pressure drop >10mmHg with symptoms
Critical aortic valve stenosis (peak pressure gradient >50mmHg)
Uncontrolled sinus tachycardia (>120bpm)
Uncompensated CHF
Acute systemic illness
3rd - degree atrioventricular (A-V) block (without pacemaker)
Active pericarditis or myocarditis
Recent embolism
Thromophlebitis
Uncontrolled diabetes (resting blood glucose >400mg/dL)
Severe orthopaedic problems that would prohibit exercise
Other metabolic problems, such as acute thyroiditis, hypo-hyperkalaemia, hypovolaemia etc.

Question 8

referrals

Answer 8

Patients can be referred to cardiac rehabilitation by: 
Cardiologist/Physician
 Cardiothoracic Surgeon 
Cardiac team (Registrar, SHO, Intern) 
Cardiac Rehabilitation Coordinator 
 G.P. 
Coronary Care Unit (CCU) nurses 
Members of Multidisciplinary Team

Question 9

assessment

Answer 9

Individual risk assessment: age, gender, family history, diabetes, excessive alcohol intake, dyslipidaemia, hypertension, obesity, physical inactivity, psychosocial factors (anxiety and depression), stress, personality issues.
Family support, social support, occupation.

Type A and type D personality have been implicated in the pathogenesis of cardiovascular disease. The type A person may respond to stress with hostility or aggression, feel a sense of time pressure, and be competitive and ambitious (Kent & Shapiro, 2009). Recent evidence suggests that the risk of coronary heart problems is linked to the Type A characteristics of hostility and anger (Chida & Steptoe, 2009). Type D, (the distressed personality), describes patients who experience increased negative emotions and tend to inhibit the expression of these emotions in social interactions. Type D has been associated with increased depression and fatigue (Kent & Shapiro, 2009).

Question 10

medications

Answer 10

betablockers Postural HTN
Attentuated HR response
Take 20-30bpm off target HR

ACE inhibitor
Increase exercise capacity with heart failure
Postural HTN

angiotensin receptor blockers
Postural HTN

angiotensin receptor blockers
Care with eqpt

antiplatelet
Breathing difficulties

diuretics
Dehydration
Postural HTN
Compliance with attending 
class (frequent mituration)

lipid lowering drugs
Possible aching in legs

Question 11

Outcome meausures

Answer 11

Outcome measures:
Physical activity; International Physical Activity Questionnaire (IPAQ) (Craig et al. 2003)
Anxiety and depression: -Hospital Anxiety and Depression Scale (HADS) (Sever et al. 2020)
Alcohol – Alcohol Use Disorders Test (https://patient.info/doctor/alcohol-use-disorders-identification-test-audit )
Stress: Perceived stress scale

Question 12

CI to Exercise testing

Answer 12

Acute myocardial infarction within 2 to 3 days
Unstable angina not previously stabilized by medical therapy (SOBOE/fatigue/weak/unpredictable)
Uncontrolled cardiac arrhythmias causing symptoms or hemodynamic compromise
Symptomatic severe aortic stenosis
Uncontrolled symptomatic heart failure
Acute pulmonary embolus or pulmonary infarction
Severe pulmonary hypertension
Acute myocarditis or pericarditis or endocarditis
Acute aortic dissection
High-grade AV blocks
Severe hypertension (SBP greater than 200 mm Hg, DBP greater than 110 mm Hg, or both)
Inability to exercise given extreme obesity or other physical/mental impairment

Question 13

chester step test

Answer 13

A multistage, sub-maximal test which requires the subject to step on to and off a low step at special rate.
Every two minutes the heart rate and exertion level (RPE) are checked and recorded and the stepping rate is then increased slightly.
The test continues in this progressive manner until the subject reaches 80%HRMax and/or reports a moderately vigorous level of exertion (RPE=14).
(220-age) x 0.8) = 80% HRMax
Whilst aerobic capacity may be predicted from only 2 exercise heart rates (i.e. completing only 2 Levels), the accuracy of the test will be improved if the subject completes a minimum of 3 Levels.

Question 14

exercise prescription

Answer 14

Exercise intensity and 40-70% HRR for cardiac patients has been proposed

Maximum heart rate – resting heart rate= heart rate reserve

John
Max on exercise test: 112
Resting heart rate: 53
Heart rate reserve: 112-53 = 59
40%: 23.6+53= 76.6
70%: 41.3 +53+ 94.3
Can start with 8 minutes cardiovascular work and build up from here.

Question 15

exercise class layout 
safety during class

Answer 15

warm up 10-15 mins
cool down 
10 mins 
Depends on risk assessment
Telemetry
Polar watches
Staff with basic life support training and ability to use a defibrillator are required for group exercise of low to moderate risk patients. 
Basic life support training should be regularly updated based on local protocols. 
Immediate access to on site staff (hospital emergency team) with advanced cardiac life support (ACLS) training is required for high risk patients
Staff ratio
BACR 1:6
ACPICR 1:5

Question 16

monitoring according to ACCPVR

low risk

Answer 16

Patients at lowest risk for exercise participation:

• Direct staff supervision of exercise should occur for a minimum of 6-18 exercise sessions, beginning with continuous ECG monitoring and decreasing to intermittent ECG monitoring as appropriate (e.g. 6-12 sessions).
• For a patient to remain at lowest risk, his or her ECG and hemodynamic findings should remain normal, there should be no development of abnormal signs and symptoms either within or away from the exercise program, and progression of the exercise regimen should be appropriate

Question 17

medium risk

ACCPVR

Answer 17

Patients at lowest risk for exercise participation:

• Direct staff supervision of exercise should occur for a minimum of 6-18 exercise sessions, beginning with continuous ECG monitoring and decreasing to intermittent ECG monitoring as appropriate (e.g. 6-12 sessions).
• For a patient to remain at lowest risk, his or her ECG and hemodynamic findings should remain normal, there should be no development of abnormal signs and symptoms either within or away from the exercise program, and progression of the exercise regimen should be appropriate

Question 18

moderate risk

Answer 18

Direct staff supervision of exercise should occur for a minimum of 12-24 exercise sessions beginning with continuous ECG monitoring and decreasing to intermittent ECG monitoring as appropriate (e.g.12-18 sessions).
For a patient to move to the lowest-risk category, ECG and hemodynamic findings during exercise should be normal, there should be no development of abnormal signs and symptoms either within or away from the exercise program, and progression of the exercise regimen should be appropriate.
Abnormal ECG or hemodynamic findings during exercise, the development of abnormal signs and symptoms either within or away from the exercise program, or the need to severely decrease exercise levels may result in the patient remaining in the moderate-risk category or even moving to the high-risk category

Question 19

highest risk ACCPVR

Answer 19

Patients at highest risk for exercise participation
Direct staff supervision of exercise should occur for a minimum of 18-36 exercise sessions, beginning with continuous ECG monitoring and decreasing to intermittent ECG monitoring as appropriate ( e.g.18, 24, or 30 sessions).
For a patient to move to the moderate-risk category, ECG and hemodynamic findings during exercise should be normal, there should be no development of abnormal signs and signs either within or away from the exercise program, and progression of the exercise regimen should be appropriate.
Abnormal ECG or hemodynamic findings during exercise, the development of abnormal signs and symptoms either within or away from the exercise program, or significant limitations in the patient’s ability to participate in the exercise regimen may result in discontinuation of the exercise program until appropriate evaluation and intervention where necessary, can take place

Question 20

screening before class

Answer 20

Symptomatic hypotension (Hypotension is generally defined as SBP <90 and or DBP <60. Symptoms: Dizziness/nausea/lightheadedness/syncope/blurred vision/nausea/fatigue/general weakness)
Symptomatic hypertension (BP systolic >180mmHg or BP diastolic >100mmHg)
Tachycardic at rest (>100 bpm)
Unstable arrhythmias (A fib = most common one picked up at cardiac rehab, ventricular fib=no pulse)
Unstable heart failure (2kg weight gain over 2 days compounded with symptom change)
Unstable diabetes
Febrile illness
Unstable angina (SOBOE/fatigue/weakness/not feeling well/unpredictable)

Question 21

self monitoring

Answer 21

How they feel when exercising at the right intensity
Knowing when to stop
Knowing when they’re working at the right intensity

Question 22

educational component

Answer 22

Cardiac anatomy and physiology related to the cardiac event
Recognition of cardiac pain and symptom management
Risk factor identification and management
Benefits of physical activity
Energy conservation/graded return to activities of daily living 
Cardio protective healthy eating
Prescribed cardiac medication and importance of compliance with same
Resumption of sexual activity
Benefits and entitlements

Question 23

MDT

Answer 23

Cardiologist/Physician and co-coordinator to lead cardiac rehabilitation (as per Department of Health, 1999)
Clinical Nurse Specialist
Clinical nutritionist/Dietician
Occupational Therapist
Pharmacist
Physiotherapist
Psychologist
Smoking cessation counsellor/nurse
Social worker
Vocational counsellor
Clerical Administrator

Question 24

evidence for cardiac rehab

Answer 24

Reduced depression

Improved quality of life

Improved exercise capacity (functional capacity)

Reduced hospitalisations

Servey and Stephens 2016

Dropout rates up to 56% and 82% in high- and middle income countries, respectively. Turk-Adawi and Grace 2015

Question 25

health behaviour change and education

Answer 25

To facilitate effective behaviour change, cardiovascular prevention and rehabilitation services should ensure:
The use of health behaviour change interventions and key behavior change techniques underpinned by an up-to-date psychological evidence-base.
The provision of or access to, training in communication skills for all staff which may include motivational interviewing techniques and relapse prevention strategies.
The provision of information and education to support fully informed choice from a menu of evidence based locally available programme components. Offering choice may improve uptake and adherence to cardiovascular prevention and rehabilitation.
They address any cardiac or other misconceptions (including any about cardiovascular prevention and rehabilitation) and illness perceptions that lead to increased disability and distress.
Support for patients (and significant supporting others) including goal-setting and pacing skills, and exploring problem-solving skills in order to improve long-term self-management.
Regular follow up to assess feedback and advise on further goal setting.
Where possible, the patient identifies someone best placed to support him/her (e.g. a partner, relative, close friend). The accompanying person should be encouraged to actively participate in CPRP activities whenever possible, to maximise patient recovery and health behaviour change whilst also addressing their own health behaviours

Education should be delivered not only to increase knowledge but importantly to restore confidence and foster a greater sense of perceived personal control. As far as possible, education should be delivered in a discursive rather than a didactic fashion. It is not enough to simply deliver information in designated education sessions; health behaviour change needs to be achieved simultaneously and fully integrated into the whole service.
Attention should be paid to establishing existing levels of knowledge and to assessing learning needs (of individuals and groups), and subsequently tailoring information to suit assessed needs.
Patients (and significant supporting others) should be encouraged to play an active role in the educative process, sharing information in order to maximise uptake of knowledge.
Education should be culturally sensitive and achieve two key aims: - To increase knowledge and understanding of risk factor reduction - To utilise evidence-based health behaviour change theory in its delivery. Incorporation of both aspects of education increases the probability of successful long-term maintenance of change.
The educational component should be delivered using high quality and varied teaching methods which take account of different learning styles and uses the best available resources to enable individuals to learn about their condition and management. Information should be presented in different formats using plain language and clear design, and tailored to the learning needs identified during initial assessment

Question 26

lifestyle and risk factor management

Answer 26

Physical activity and exercise training
Appropriately qualified and competent individual
Baseline assessment
Risk stratification and exercise prescription
Patients should receive individual guidance and advice on ADLs together with a tailored activity and exercise plan with the collective aim to increase physical fitness as well as overall daily energy expenditure and decrease sedentary behaviour.

Healthy eating and body composition

Appropriately skilled individual
Baseline assessment
The focus of advice should be on making healthy dietary choices to reduce total cardiovascular risk and improve body composition
Personalised dietary advice
Appropriate referral, e.g. patients with complex comorbidities

tobacco cessation and relapse prevention
Tobacco cessation and relapse prevention
Appropriately qualified and competent individual
Tobacco use assessed
At the first assessment, medical advice to quit should be reinforced and a quit plan discussed which proposes the use of pharmacological support and follow up counselling within the prevention and rehabilitation service.
Patient preference is a priority regarding the choice of aids to use in tobacco cessation
Relapse prevention

Question 27

psychosocial health

Answer 27

People taking part in cardiovascular prevention and rehabilitation may have many different emotional issues, and a comprehensive, holistic assessment is crucial to achieving the desired outcomes. Every patient should be screened for psychological, psychosocial and sexual health and wellbeing as ineffective management can lead to poor health outcomes

Attention should be paid to social support, as social isolation or lack of perceived social support is associated with increased cardiac mortality. Whereas appropriate social support is helpful, overprotection may adversely affect quality of life.

Question 28

medical risk managment

Answer 28

Assessment should include:

• Measurement of blood pressure, lipids, glucose, heart rate and rhythm with the aim of helping the individual reach targets defined by national guidelines
• Current medication use (dose and adherence).
• Patients’ beliefs about medication as this affects adherence to drug regimens.
• A discussion regarding sexual activity / function (pending patient’s willingness to discuss).
• Implantable device settings where applicable.

Question 29

long term strategies

Answer 29

By the end of the CRP the patient should have:
Undergone assessment and reassessment as identified in Standards 3 and 5
participated in a tailored programme that encompasses the Core Components
Identified their long-term management goals.