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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
Q

How to progress RT?

A

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
Q

What are some special considerations for CVD patients?

A
  • ECG monitoring
  • median sternotomy
  • anginal threshold
  • HF
  • atrial fibrillation
  • meds
  • devices - PPM/ICD
  • HEART online - program guidelines by Dx/procedure
27
Q

What is the purpose of 3 lead ECG monitoring?

A

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
Q

What to consider for patients with median sternotomy?

A

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
Q

Provide some evidence on Ex and median sternotomy.

A

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
Q

KMIT considerations for patients with median sternotomy?

A
  • 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
Q

What is ischaemic threshold of a stable angina and how do we assess/monitor it?

A

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
Q

What are some strategies for stable angina in Ex?

A
  • 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
Q

How does Ex affect the anginal threshold?

A

creates a new higher anginal threshold, where they can tolerate higher Ex intensity before Sx of angina begin.

34
Q

What are the Ex considerations for HF?

A
  • 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
Q

What are some Ex and Ax considerations for atrial fibrillation?

A
  • 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
Q

What are some considerations for Ex and meds?

A
  • 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
Q

What are the effects of BB on Ex?

A

RHR decrease and w Ex

RBP decrease and w Ex

monitor for Sx of hypotension/bradycardia

Avoid intensity monitoring on HR

38
Q

What are the effects of nitrates on Ex ?

A

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
Q

What are the effects of Ca2+ channel blockers on Ex?

A

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
Q

What are the effects of digoxin?

A

HR decrease in patients with AF and maybe CHF

BP no change at rest/w Ex

Monitor for brady

41
Q

What are the effects of diuretics on Ex?

A

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
Q

How do ACE inhibitors and ARB affect Ex?

A

HR: n ochange at rest or w Ex
BP: decrease at rest and Ex

Monitor Sx of hypotension

43
Q

What are the different types of PPM?

A

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
Q

Explain the coding for PPM.

A

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
Q

What does ventricular pacing, atrial pacing and dual pacing look like?

A

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
Q

What are ICD’s?

A

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
Q

What Ax are required for PPM/ ICD?

A
  • reason for device
  • triggers for dysrhythmias
  • type of pacemaker
  • indiivdual intervention threshold
  • sequence of therapy
48
Q

What are some Ex cosniderations for PPM and ICD?

A
  • 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
Q

What is HIIT?

A

Alternating periods of high intensity (anaerobic) Ex with periods of lower intensity or no Ex

HIIT is relative to the patient!

50
Q

What is the difference between HIIT and SIT?

A

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
Q

Is HIIT safe?

A

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
Q

What does research/evidence say about HIIT in cardiac patients?

A
  • 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
Q

What are the benefits of HIIT?

A
  • 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
Q

Explain the relationship between peak VO2 and survival.

A

For every 1ml/kg/min increase in fitness during CR reduces CV events by 21% and all-cause mortality by 13%

55
Q

Is HIIT similar to M/VIPA?

A

HIIT = 5.3ml/kg/min
MICT = 4.5

56
Q

Who is suitable for HIIT?

A

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
Q

How is HIIT prescribed using RPE and HR range?

A
  • 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
Q

What are some strategies for clinicians in prescribing HIIT in CR?

A
  • 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
Q

What are some considerations for HIIT progression in CV patients?

A

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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