Section 7: Cardiac Rehabilitation Phases l-lll

Question 1

What is the primary goal of Cardiac rehabilitation

Answer 1

• Enable the patient to regain full physical, psychological and social status and to promote secondary prevention in order to optimise long-term prognosis

Question 2

What are the 10 improvements of Cardiac rehabilitation alongside improved survival?

Answer 2

1) Reduced hospital admission
2) Reduced angina
3) Improved lipid profiles
4) Improved blood pressure
5) Improved functional capacity
6) Improved compliance with lifestyle modifications
7) Reduced anxiety and depression
8) Improved confidence and well-being
9) Improved return to work and leisure activities
10) Education for family and friends

Question 3

What 10 groups can participate in Cardiac rehabilitation and who are the primary participants?

Answer 3

1) Acute cardiac event - MI
2) Had or awaiting revascularisation - CABG/PCI
3) Stable angina
4) Heart failure
5) Valve surgery
6) Heart transplant
7) Heart transplant
8) Cardioverter defibrillator (ICD implant)
9) Congenital heart disease
10) Ventricular assist device implant

Myocardial infarction and Revascularisation patients are prioritised

Question 4

Outline the 4 basic phases of Cardiac rehabilitation

Answer 4

Phase l - Inpatient stage due to a change (revascularisation), new or worsening in the condition
Phase ll - Following discharge from hospital back to GP
Phase lll - Structured rehab program beginning at 2 weeks following the event usually
Phase lV - Long term maintenance of physical activtiy

Question 5

What typically occurs during Phase l and what is the overarching aim?

Answer 5

1) Diagnosis and treatment
2) Management of chest pain
3) Psychological and emotional support
4) Risk factor modification and lifestyle change
5) Prescribed medication
6) Mobilisation and progression of physical activity
7) Feeling and relationships
8) Work
9) Driving, insurance and airline travel
10) Local Phase ll and lll resources
Overarching aim: To assess the patients physical, pscyhological and social needs

Question 6

What is the average stay of a hospital stay after a cardiac event and how long might the stay be in uncomplicated cases? What would be the typical criteria for discharge?

Answer 6

• Average stay of 5 days
• 2-4 days in uncomplicated cases
  Clinically stable and able to carry out self-care such as washing/dressing and able to walk short distances

Question 7

What is typically included in Phase ll and how long does it last?

Answer 7

2-6 weeks typically
Includes:
- Assessment of cardiac risk
- Assessment of physical, psychological and social needs
- Provision of lifestyle advice and psychological intervention
- Provision of resuscitation training to family members

Question 8

What are the 4 typical approaches used in Phase ll rehab?

Answer 8

1) Telephone call with health professionals
2) Visits by cardiac specialist nurse
3) visits by community staff nurses or district nurses
4) Heart manual, Angioplasty plan, Angina plan and revascularisation plan (can be used on its own for low-risk individuals particularly if resources are low)

Question 9

What is the recommendation for Phase lll rehab?

Answer 9

• Begins 2-6 weeks following event

- Twice a week for 6-12 weeks

Question 10

What are the 9 factors undertaken in Phase lll assesment?

Answer 10

1) Current clinical status (heart rate, BP, BMI, Risk factor profile
2) Cardiac status - revascularisation details, cardiac history, size of infarct
3) Current medication
4) Results of investigations - ECG ETT, Echocardiogram, Angiogram
5) Psychological status
6) Risk stratification (Determines exercise intensity)
7) Functional capacity assessment
8) Physical limitation those of cardiac or orthopaedic origin
9) Calculation of individual training heart rates

Question 11

What tests are used to assess functional capacity and why?

Answer 11

• ECG ETTs - used less often due to movement towards primary angioplasty following diagnosis
• Submaximal tests - Shuttle walk tests, 6 minute walk tests, Cycle ergometer, Chester step test
• Assess current status and improvements in functional capacity

Question 12

What 3 factors are influenced by a patients risk stratification?

Answer 12

1) Exercise intensity
2) Level of supervision
3) Level of monitoring

Question 13

What factors should a patient by asked about before participating in a session?

Answer 13

• Changes in medication
• Symptoms
• Home exercise activity
• Problems and concerns

Question 14

What 9 factors are absoltue contraindications to Phase lll rehab?

Answer 14

1) Fever or systemic illness
2) Unstable angina
3) >180 mmHg systolic and >110 mmHg diastolic
4) Unexplained drop in blood pressure during exercise
5) >100 bpm HR
6) Uncontrolled atrial or ventricular arrhythmia
7) Unstable/Uncontrolled diabetes
8) Symptomatic hypotension
9) New or recurrent symptoms of breathlessness, palpitation, dizziness or lethargy

Question 15

What is the FITT principle for Phase lll

Answer 15

F: 2-3 times per week (other days undertake walking and stuff
I: 40-70% HRR, 11-14 RPE Borg Scale, 2-4 CR10 scale
T: 20-30 minutes conditioning
T: Aerobic endurance training

Question 16

What is the ultimate goal of Phae lll?

Answer 16

Achieve 20 minutes of cotinous aerobic endurance activity

Question 17

What are the subjective and objective measure of intensity used during Phase lll?

Answer 17

Subjective:
1) Observation
2) Signs and symptoms of overexertion (dyspnea)
3) Loss of coordinated movement
4) RPE
Objective:
1) Blood pressure
2) Heart rate
3) MET level achieved

Question 18

Outline 7 safety considerations of cardiac rehabilitation?

Answer 18

1) Staff to patient ratio: Usually 5:1
2) Room size: Large for good ventilation and freedom to move
3) Temperature (18-22C) and Humidity (65%)
4) 15 minutes post-exercise obsevation
5) EAP should be available
6) Drinking water available throughout
7) Defibrillator on site and excess to a telephone in case of emergency

Question 19

What is a typical home program and how is compliance achieved?

Answer 19

• 30 minutes of walking RPE 2-4 or 11-14 to achieve recommended 3 times a week
• Compliance can be achieved using a exercise log

Question 20

What are the 7 key education topics used in Phase lll?

Answer 20

1) Heart disease procedures and relevant investigations
2) Risk factors for CHD
3) Effects and benefits of exercise
4) Diet
5) Medication
6) Relaxation
7) Stress management

Question 21

Outline the significance of Psychological aspects of rehab

Answer 21

• 34% reduction in cardiac mortality when psychological intervention was utilised in conjunction with PT
• Depression associated with 3-4 fold increase
• Psychological distress has 4 fold increase in hospital cost

Question 22

What are the typical psychological assessments used?

Answer 22

• Hospital anxiety and depression scale (HADS)
• SF 36
• Dartmouth Coop
• MacNew

Question 23

What are 6 typical tools used to address patients’ psychological issues?

Answer 23

1) Cognitive behavioural techniques
2) Individual Counselling
3) Motivational interviewing
4) Relaxation
5) Stress management
6) Referral to clinical psychologist or other trained professional

Question 24

What is the 8 criteria required for discharge from Phase lll

Answer 24

1) Exercise independently, safely and effectively
2) Monitor own intensity
3) Recognise warning signs/symptoms and take action (GTN)
4) Identify specific goals for long term maintenance
5) Identify goal relating to psychological interventions
6) Demonstrate knowledge of their condition
7) Demonstrate compliance with home-based activity
8) Typically a functional capacity of 5 METs (not essential though)

Question 25

What are the issues considered in a patients long term management plan with the cardiac rehab team?

Answer 25

• Who will monitor risk factors
• Details of medical follow up
• Details of venues for Phase lV
• Advice on long term exercise
• Details on services available for information and support
• Plan for potential relapse
• Local support group information
• Contact details for cardiac rehab team
• Importance of social support