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EXMD4742 > WK4 - Ex Prescription for CVD and HF > Flashcards

WK4 - Ex Prescription for CVD and HF Flashcards

1
Q

What are the Ex goals in CR?

A

Increase…
* aerobic capacity
* muscular strength/endurance
* BP and HR response to Ex
* ADLs

Decrease…
* CVD risks
* falls and injury risk

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2
Q

What does FITT-VP stand for?

A

Frequency
Intensity
Time
Type
Volume
Progression

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3
Q

What are the recommended frequencies for aerobic, RT and PA exercise?

A

> 3x/wk - aerobic
At least 2x - HIIT

2-3x/wk - 48h rest - RT

MVPA most days - PA

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4
Q

What is the recommended intensity for cardiac disease patients?

A

Mod-high (55-90% HRmax) - aerobic

mod-high (50-80% 1RM) - RT

MVPA, use RPE/BORG scale - PA

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5
Q

What is the recommended Ex time for CVD patients?

A

> 30mins - aerobic
* for severely deconditioned 5-10min bouts with rest, repeat 2-3 times

> 20mins (>1s concentric, >3s eccentric + 60s rest) - RT

150-300min MIPA or 75-150mins VIPA - PA

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6
Q

What is the recommended type of Ex for CVD patients?

A

Variety of aerobic Ex

Whole body, multi-joint - RT

Variety of mode: domestic, occupation, transportation, leisure - PA

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7
Q

What is the recommended volume of Ex for CVD patients?

A

min. 150mins of mod-high intensity, with target of >210min/wk for cardiometabolic benefit - aerobic

total session volume 15-36R, 3S of 8-15R - RT

> 150min MVPA, 7500 steps/day - PA

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8
Q

What is the recommended progression for CVD patients?

A

start slow, progress gradually to 30mins. Increase 5-10% every 1-2wks - aerobic

progress one of FITT-VP - RT

start slowly, progress gradually to 30mins - PA

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9
Q

What are some considerations for Ex programs in CVD patients?

A
  • incl. supervised Ex sessions and home-based Ex sessions
  • aerobic + RT in same session is okay
  • for HF pateints, start 2-3x/wk for aerobic
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10
Q

What are some intensity considerations?

A

Low risk - incl. stable HFrEF
*MIPA to Ax Ex response - progress to VIPA or HIIT
* complete longer training periods at MIPA (until able to train 30mins total) before progressing to mod-vig or HIIT

High risk - HFrEF
* start aerobic and RT at LIPA and progress to mod
* forther other cardiac mod-high risk strat. patients, start aerobic and RT at lower range of MIPA and progress to upper MIPA

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11
Q

When to set an upper-limit of Ex Intensity?

A

Onset of angina or other Sx of cardiac insuffiency

  • > 1mm ST depression
  • SBP >250 or DBP >115
  • decrease SBP >10 during Ex
  • increase frequency of ventricular dyshythmias
  • Sig. ECG disturbances
  • Sx of Ex intolerance
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12
Q

How to prescribe walking speed?

A

RPE recorded during 6MWT - useful for walking intensity
* RPE<11: prescribe walking training at 100% 6MWT avg walking speed
* RPE 12-14: 90% 6MWT avg speed
* RPE >14: 80% of 6MWT speed

Calculation for avg. speed (in km/hr) = (6MWT distance (m) * 10) divided by 1000

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13
Q

What are the max. HR equations for measuring intensity?

A

W/o beta-blockage

(Tanaka et al) = 208-(0.7*age)
* men/women >40y

(Nes et al) = 211-(0.64*age)
* men/women 19-89y

With beta-blockage
(Brawner et al)=164-(0.7*age)
* men + women

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14
Q

What are the challenges for using % max. HR?

A
  • maximal Ex testing not routinely performed
  • maximal effort not achieved during test (peripheral fatigue)
  • prediction equations for HRmax less accurate - meds
  • specific equations for beta-blocker meds can still be inaccurate - if not on max. dose (still titrating up) / HR modulating effect of meds may differ
  • meds affect HR diff across day
  • not practical for short intervals - insufficient time for HR rise/HR lag
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15
Q

What are the challenges/limitations of measuring intensity with RPE?

A
  • highly subjective
  • underestimate Ex intensity
  • difficult/confusing for patients - requires education
  • clinician may need to validate with observer RPE (initially)
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16
Q

Ideally, what resistance % should RT be at of 1RM?

A

50-80%.

Alternatively, use 5-7 on OMNI scale

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17
Q

What is the recommended time for CVD patients?

A

Aerobic - at least 30mins/session at mod-high intensity. Should precede with WU at light (3-15mins) followed by CD at light (3-10mins)

RT - at least 20mins/session, >4s/rep (>1:3s for concentric/eccentric phases

PA - 150-300mins/wk

For Ct severely deconditioned/have Sx at low workloads. Start aerobic 5-10mins in duration (with breaks if required) and repeat 2-3x during session

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18
Q

Why are WU’s important?

A

50-75% Ex workload

reduces risk of adverse events during Ex (e.g. ST depression, arrhythmia, transient LV dysfunction)

  • gradual transition from resting to increased physiological demand in Ex = increased skeletal muscle perfusion and thermoregulation

Prolonged aerobic WU 10-15min, considered for…
* stable angina (extend time to angina threshold)
* chronic HF (due to delayed CV response)
*V VVI or metabolic sensing pacemakers (improve SA node sensing)

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19
Q

Why are CD’s important?

A

50% workload
* reduces risk of adverse events (e.g. post-Ex hypotension, dizziness, arrhythmias, catecholamine surges)
* failure to CD = decreased venous return and reduced coronary blood flow while HR and myocardial O2 consumption high

  • allow HR + BP return to resting values / reduces venous blood pooling in active muscles

Prolonged CD coonsidered for…
* stable angina, esp. if taken GTN
* chronic HF - delayed CV response, altered vasodilation and lactic acid removal
* all pacemaker Ct (prevent sudden drop in HR)
* Ct on diuretics or multiple BP meds

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20
Q

List some types of Ex and any important considerations.

A

Aerobic - large muscle group - walking, cycling, elliptical, swimming, stair climb etc

RT - body weight, free/machine weights, therabands

PA - domestic, occupational, transportation, leisure

Considerations:
* surgical Ct with median sternotomy, UB movements prescribed with KMIT paradigm
* for new implanted devices (PPM, ICD), avoid elevating arm >90deg for 4wks and restrict UB RT for 6wks
* begin with L/UB Ex easily learned (e.g. treadmill) for deconditioned Ct, then progress (e.g. rowing)

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21
Q

What is the recommended volume for CVD patients?

A

aerobic - >150mins/wk at M/VIPA. Increased metabolic benefit >210mins/wk
aim >500-1000 MET-min/wk for most Ct’s BUT >180-420 MET-min/wk for HF Cts

RT - 15-36R per muscle group/session based on 8-15R/S and 1-3S/Ex

PA - 150-300mins/wk at mod-vig PA; >7500 steps/day

Considerations (RT), initial prescriptions can consider lower volumes to allow Ct familiarisation prior to progressing towards higher volumes.

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22
Q

How to calculate MET-min?

A

Volume (MET-min/WK)=intensity(METs)time(mins)frequency

Avg. METs for…
MIPA - 3-5.9
VIPA - 6-8.7
Near Max. - >8.8

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23
Q

Define progression and overload.

A

Rate of increasing volume/Ex
-> least defined/appreciated/most challenging part of Ex prescription.
*CRF strong, independent predictor of future CV events/mortality

Overload: Ex dose above/beyond accustomed amount of Ex for given individual - essential concept for progression

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24
Q

How to progress aerobic Ex?

A

Applied to any Ex component: FITT
* start slowly, progress slowly
* increase duration to 30mins, before increasing intensity
* MIPA performed 30mins, progress frequency. Low risk Ct’s encouraged to Ex at M/VIPA
* increase intensity/duraton 5-10% every 1-2wks
* Ex type can be progressed. e.g. from non weight-bearing or combination U/LB = increasing energy expenditure.

25
How to progress RT?
Overload applied by increasing session frequency, amount of R and no. reps/set, no. of sets/Ex or decreasing rest between sets * add RT once aerobic Ex sufficient. Aerobic SUP to RT for improvements in CRF, cardiac remodelling, endothelial function, CVD risk * volume of RT progressed before other variables * complete 8-10reps at M/VIPA then increase no. of sets *deconditioned Ct's, can commence with single muscle Ex and progress to whole body
26
What are some special considerations for CVD patients?
* ECG monitoring * median sternotomy * anginal threshold * HF * atrial fibrillation * meds * devices - PPM/ICD * HEART online - program guidelines by Dx/procedure
27
What is the purpose of 3 lead ECG monitoring?
ECG telemetry monitoring in CR not shown to reduce adverse events/prevents sudden death Useful... * document Ct's Ex response * identify rhythm abnormalities if HR is irregular on palpation * linking Sx with arrhythmais Long-term = detrimental to confidence in unmonitored environment Use risk stratification ofr duration of monitoring... * low risk - ECG monitoring upto 6sessions * mod-high risk - monitoring upto 12 sessions
28
What to consider for patients with median sternotomy?
W/o sternum instability from 4wks - UB ROM PA (Schwinn Airdyne)/ light bilat UB RT (KMIT) From 7/8wks - rowing machines/arm ergometry Usual care: delay CR for 4-6wks after surgery
29
Provide some evidence on Ex and median sternotomy.
SCAR trail (Ennis et al, 2022): Commening CR 2/52 post-surgery was as effective from 6/52post. SAFE-ARMS study (pengelly et al, 2022): Bilat UB RT performed on cam-based machines = no sternal micromotion exceeding 2mm or increase Ct rep pain.
30
KMIT considerations for patients with median sternotomy?
* healing rate varies * exclude load/time restrictions * use ergonomics/pain as guide * keep UB in "imaginary truncal tube when arms loaded" - decrease LAT pull on sternum
31
What is ischaemic threshold of a stable angina and how do we assess/monitor it?
Ischaemic threshold: workload/HR where there is... * presence of angina Sx with Ex, relieved with rest or nitroglycerin * >1mm ischaemic ST depression on Ex test Monitor: * sensing angina (chest, arm, back, shoulder, jaw) * activitives/intensity causes angina * how Sx resolved * severity of discomfort
32
What are some strategies for stable angina in Ex?
* prescribe workload/HR at 10bpm below identifiedischaemic threshold Reduce physiological demand - reduce workload, less volume of muscle (e.g. unilat leg ext vs cycling) - interval training - need workload for longer duration (esp. warm environments) * longer WU (increase time to ischaemia) * use prophylactic sublingual nitroglycerin (GTN) in GP consult 10min before Ex --> Ct seated (due to systemic vasodilation) --> BP monitoring before/after GTN
33
How does Ex affect the anginal threshold?
creates a new higher anginal threshold, where they can tolerate higher Ex intensity before Sx of angina begin.
34
What are the Ex considerations for HF?
* high risk/deconditioned w HFrEF - start w LIPA * extend WU due to delayed CV response * extend CD due to altered vasodilation, lactic acid removal * mild SOB okay (2-4/10 on BORG dyspnoea scale)
35
What are some Ex and Ax considerations for atrial fibrillation?
* AF compliant with meds --> anticoagulants control HR * AF - chronic/intermittent (paroxysmal) * unDx AF = no Ex until GP consult * monitor irregular/rapid ventricular rates * RHR controlled (<100bpm) * HR Ax manually - irregular ventricular responses = inaccurate HR w pulse oximetry/monitors * BP Ax difficult w irregular HR * age-predicted HRmax targets not valid * HR unreliable for prescribing Ex intenisity
36
What are some considerations for Ex and meds?
* always take meds as prescribed!! BETA-BLOCKERS = affect HR response to Ex & reduce tolerance - affected by med dose/time - use RPE/HR at recent workload for new HR target DIURETICS = > risk of volume depletion, orthostatic HTN, dehydration - BP w Ex and Rx, monitored w Sx of dizziness/light-headedness - extend CD - prevent post-ex HTN BB + DIURETICS = affect thermoregulation - for diabetics, monitor hypoglycaemia Sx (shakiness, weakness) - monitor heat intolerance
37
What are the effects of BB on Ex?
RHR decrease and w Ex RBP decrease and w Ex monitor for Sx of hypotension/bradycardia Avoid intensity monitoring on HR
38
What are the effects of nitrates on Ex ?
Increase RHR, increase/no change w Ex RBP decrease, decrease/no change w Ex Acute use = hypotension/reflex tachy common - cease Ex if occurs Monitor Sx of hypo, tachy and angina
39
What are the effects of Ca2+ channel blockers on Ex?
HR: no change at rest or w Ex (dihydropyridines) OR decrease at rest and Ex (verapamil + diltiazem) BP: decrease at rest + Ex Monoitor Sx of hypo, brady. dihydropyridines = greatest effect peripherally --> lower BP. Tachy may occur Verapamil and diltiazem depress SA&AV node conduction = peripheral vasodilation = affect HR and BP Avoid intensity monitoring on HR
40
What are the effects of digoxin?
HR decrease in patients with AF and maybe CHF BP no change at rest/w Ex Monitor for brady
41
What are the effects of diuretics on Ex?
HR no change at rest/Ex BP no change/decrease at rest/w Ex Monitor Sx of hypo and unexpected rapid weight change Over diuresis/fluid loss through vomitting/diarrhoea in presence of diuretics, may exacerbate hypo
42
How do ACE inhibitors and ARB affect Ex?
HR: n ochange at rest or w Ex BP: decrease at rest and Ex Monitor Sx of hypotension
43
What are the different types of PPM?
Rate responsive - increase/decrease HR to match PA Single-chambered - definitive rate control - for chronic AF or AV block Dual-chambered - re-establish normal AV synchrony Biventricular - re-establish RV and LV synchrony (patients with HF who have LBBB)
44
Explain the coding for PPM.
1st Letter = chamber paced (A=atria, V=ventricle, D=dual) 2nd = chamber sensed (A=atria, V=ventricle, D=dual, O=off) 3rd = pacemaker reponse to sensed event (I=inhibited, D=dual inhibited, O=off) 4th = rate reponse capabilities of pacemaker (R=rate responsive)
45
What does ventricular pacing, atrial pacing and dual pacing look like?
V pacing = no P wave, PPM spide before QRS, wide QRS complex A pacing = produce PPM spike before P wave, followed by normal QRS complex. P wave appear inverted/irregular. PR interval may vary, depending on lead location. D pacing = can include comination of A and/or V pacing
46
What are ICD's?
Implantable cardioverter defibrillator --> monitors heart rhythm and delivers electrical shock if life-threatening rhythms detected --> protect against cardiac death from V tachy and V fib and are safe for those performing regular Ex * used for high-rate ventricular tachy or ventricular fib, those at risk of SCD (previous CA, cardiomyopathy, HF) * first detection of irregular beat = antitachy pacing --> if unsuccessful = shock (cardioversion)
47
What Ax are required for PPM/ ICD?
* reason for device * triggers for dysrhythmias * type of pacemaker * indiivdual intervention threshold * sequence of therapy
48
What are some Ex cosniderations for PPM and ICD?
* use Ex testing to evaluate HR * 3-4wks after implant, prescribe LB, avoid rig UB PA * 4-6wks after, avoid elevating arm >90deg * for PA sensing devices, thoracic movement needed to increase HR * extend CD * for VVI/metabolic sensing PPM, extend WU * monitor HR, use HRreserve and RPE as guide for intensity * for ICD, ExHR 10-15bpm below programmed HR threshold for defib * choose modes where loss of consciousness = less harmful * water Ex supervised!
49
What is HIIT?
Alternating periods of high intensity (anaerobic) Ex with periods of lower intensity or no Ex HIIT is relative to the patient!
50
What is the difference between HIIT and SIT?
Similar: near-max. to max. interval training Difference: HIIT = target intensity 80-100% peak HR RPE15-17 SIT = target intensity >100% of VO2max RPE 19-20
51
Is HIIT safe?
Vig Ex acutely increases risk of SCD and MI in patients with heart disease Incidence of risk is greatest in least active * deconditioned Pt = ADLs can fall into category of vig intensity * safety concerns must be considered! * better to initially expose patients to VIPA in safe, monitored environment
52
What does research/evidence say about HIIT in cardiac patients?
* risk of CV event low after HIIT and MIPA in CV rehab setting * risk of adverse event during/within 24h post HIIT (~8%), somewhat higher compared to previously rep risk during MIPA *HIIT - relatively low rate of major adverse CV events for CAD/HF Pt in CR settings
53
What are the benefits of HIIT?
* time efficient * increase peak VO2 - each 10% increase in %HRpeak = 1ml/kg/min increase * HIIT SUP to MICT in improving CRF * sig. result for CR programs >6wks
54
Explain the relationship between peak VO2 and survival.
For every 1ml/kg/min increase in fitness during CR reduces CV events by 21% and all-cause mortality by 13%
55
Is HIIT similar to M/VIPA?
HIIT = 5.3ml/kg/min MICT = 4.5
56
Who is suitable for HIIT?
Low/mod risk patients with CAD/HF who are ASx and stable, w/o residual high-risk lesions/Ex induced arrhythmias Higher risk/less fit - start with lead-in period of MICT to Ax Ex response, improve Ex tolerance and minimise MSK injuries.
57
How is HIIT prescribed using RPE and HR range?
* 3-4mins intervals: start at RPE15 --> maintain workload to reach RPE 17-18 by end * at end, Pt should feel they "want to stop" but also could continue for another 30-60s * set realistic HR targets - Pt may only reach end of 1st interval, aim for halfway in subsequent intervals
58
What are some strategies for clinicians in prescribing HIIT in CR?
* goals/preferences! * use HIIT option in conjunction with other Ex modes * set realistic HR target/time to reach target * use variety of Ex to increase enjoyment/reduce joint discomfort * use music throughout intervals (fast vs slow) * progressive HIIT may be better tolerated
59
What are some considerations for HIIT progression in CV patients?
Low risk (incl. stable HFrEF) - higher volume HIIT protocols recommended (4x4min) for greater CV adaptation Workload intervals can be progressed in duration (1-2min to 3-4min) for Pt w reduced aerobic capacity/unable to complete full 4min workload

EXMD4742 (9 decks)

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