CARDIAC REHABILITATION

Betty Matteson, BA. MS Program Director Paula Miller, MD Medical Director UNC Cardiac Rehabilitation

Rehabilitating the Heart

13.7 million patients in the US have CHD (50% MI / 50% angina) Men 7% 13% 16% 22% Prevalence ages 40-49 ages 50-59 ages 60-69 Ages 70-79 Women 5% 8% 11% 14%

Rehabilitating the Heart

MI described first in 1912 by Herrick Generally confined to bed for 2 months. 1930s: Mallory et al described evolution of MI over 6 weeks from the initial event and ending up with a scar resulted in strict bed rest for 6-8 weeks. (Return to normalcy rare)

Background

Mortality was 30-40%

Cardiac Rehabilitation Infancy 1960s

Initially thought inappropriate for: Elderly patients CHF patients

Patients with angina

Patients with arrhythmias

Rehabilitating the Heart

1940s: Beginning to question the prolonged bed rest chair therapy Newman & Co-workers early ambulation 3-5 minutes of walking 2 x daily during the 4th week Brummer (1956) Early ambulation within 14 days of the event. 1961 Cain et al reported on graded activity program

Background

Available Medications
Morphine Nitroglycerin Digitalis

Rehabilitating the Heart

Late 1960s: 3 weeks hospitalization was clinically routine in the US 1970s early mobilization (UK) Boyle, Hutter, Bloch, Abraham and Asso confirmed no significant difference in the occurrence of angina, re-infarction,heart failure or death; Bloch demonstrated greater disability in those who had not performed early mobilization.

Cardiac Rehabilitation Infancy: 1980-1990s

Expanded populations:
Post CABG Post PCI CHF Angina Valvular Heart Disease

CARDIAC REHABILITATION
Comprehensive long-term services involving:
1.Medical evaluation;

2. Prescribed exercise;
3. Cardiac risk factor modification;

4. Education, counseling and behavioral interventions

Rehabilitating the Heart

Physical Activity and Coronary Disease Several studies have shown a strong inverse relationship between habitual exercise and fitness and the risk of CAD
Harvard study 2000 kcal/wk 29% reduction (equivalent and additive to other life style measures)

Rehabilitating the Heart

Benefits of Exercise
Prevention of age related endothelial dysfunction due to preservation or restoration of nitric acid Reduction in hemostatic factors Decrease in C-reactive protein Attenuation of age-related reductions in arterial compliance and restoration is previously sedentary individuals

Rehabilitating the Heart

Benefits of Exercise (cont) Restoration of ischemic pre-conditioning Reversal of age-related decline in maximum oxygen uptake (MET) Improved physical fitness, physical work capacity and endurance Enhanced flexibility Bone mass & Bone density Improved self image and self confidence

Rehabilitating the Heart

Increase in leisure activities Increase in sexual interest and function Improved sleep status Enhanced optimism

IMPROVED Quality of Life

Rehabilitating the Heart

Low risk: 8 METs - 3 weeks after cardiac event No symptoms Intermediate Risk < 8 METs 3 weeks after cardiac event Angina with moderate or intense exercise History of CHF

Rehabilitating the Heart

High Risk 1. < 5 METs 3 weeks after cardiac event 2. Exercise induced hypotension 3. Ischemia induced at low levels of exercise 4. Persistence of ischemia after exercise 5. Sustained arrhythmia

Rehabilitating the Heart

Costs: 1. Cost effectiveness: $4950 per year of life saved (compared favorable to other measures except smoking cessation) 2. Cost utility/quality-adjusted life years: $3293

Rehabilitating the Heart

Compared with other treatments More cost effective than: Single vessel by-pass CABG surgery Cholesterol lowering drugs Similar to: Beta blocker therapy Less cost effective than: Smoking cessation

1. 2. 3. 1. 1.

Rehabilitating the Heart

Cardiac has become an intrinsic part of the care of the patient with CVD Demand will increase with; 1) Shorter hospital stays 2) Aging population 3) Advanced cardiac interventions

Rehabilitating the Heart

ELVD Trial
Evaluated efficacy of exercise in patients with first MI and EF <40% 6 month training program increased exercise capacity and LVEF (34%->38%) with no change in volumes (no dilatation)

Rehabilitating the Heart

BENEFITS
1. Improvement in CHF symptoms and VO2 (RELATED TO LEFT VENTRICULAR FUNCTION) 2. Improved functional capacity after MI (20%) 3. Significant reduction in MORTALITY

GOALS
1. Improvement in Functional Capacity 2. Ability to perform self care and ADLs 3. Functional Independence

POSITIVE FINDINGS
Documented in the Literature
Improvement in exercise tolerance

Improvement in symptoms
Improvement in lipid levels Cessation of smoking Improvement in well being Reduction in stress

Reduction in Mortality

WHY DONT MORE PEOPLE GO?

It is estimated that approximately 1/3 of all patients eligible for Cardiac Rehabilitation ever make it to a programand women are even less likely to get there!!!!

WHY DONT MORE PEOPLE GO?

Lack of access Reimbursement issues Lack of MD referral Reluctance to alter life styles

Covered Diagnoses
1. Stable Angina
2. Post MI 3. Post CABG 4. Post Stent placement 5. Post valve surgery 6. Post transplant

PHASES
Phase I:
Phase 2: Phase 3:

In-hospital
First three months

(36 sessions)
3-12 Months

Phase 4:

Maintenance

PHASE 1
Early assessment Mobilization Risk Factor Management

PHASE 1
1. Heart Rate increase of 5-20 beats above rest
2. BP rise 10-40 mmHG above rest

3. No new rhythm changes

4. No cardiac symptoms

METABOLIC EQUIVALENTS
Toileting Bathing Walking 1-2 METS 2-3 METS varies with speed

Upper Body

2-3.1 METS
2.5-4.5 METS

Leg Calisthenics

METABOLIC EQUIVALENTS

Stair Climbing

down 2.5 METS

up 4.0 METS

PHASE 1
Day 1: 1-2 METS bed rest/OOB Day 2: 2-3 METS sitting/walking Day 3-5: 2-4 METS

PHASE 2

Generally, first 36 sessions (12 weeks)

Multidisciplinary approach
Individualized for each patient

PHASE 2
1. Exercise Prescription (based on ETT/Six minute walk test) 2. Dietary Evaluation

3. PFTs & Body Fat Evaluation Evaluation

4. Psychological Evaluation 5. Flexibilty and Grip Strength

PHASE 2

Patient is evaluated at 1, 2 and 3 months for progress in the exercise, dietary and psychological categories and problems are identified and addressed.

PHASE 2

Exercise is limited until patient graduates to the PHASE 3 program. Generally start with a walking program and progress to more strenuous as tolerated.

PHASE 2

At the end of the 36 sessions, the patient performs a repeat ETT and if he/she attains a MET level of at least 7, he/she is graduated into the PHASE 3.

PHASE 3

Continues with exercise and medical monitoring but now allowed to do aerobics and more vigorous exercise (basketball, raquetball, etc). Weight training, resistance training and spin classes are available.

PHASE 4
Maintenance:
No longer requires medical supervision but if chooses to stay in the program, it is provided. All exercises acceptable but regimen approved by exercise physiologist.

WHAT DOES IT MEAN WHEN YOU SEND A PATIENT TO THE CARDIAC REHABILITATION PROGRAM

A referral form must be filled out or a RX written for referral to the program and outlining any restrictions.

EXERCISE PRESCRIPTION

220 AGE = E (E ) (.60)=A (E) (.80) = B

Range is HR between A and B

EXERCISE PRESCRIPTION
70 year old individual 220-70 = 150 (150)(.60) = 90 (150) (.80) = 120 Target Range = 90-120 Based only on age Tends to give a little lower range

EXERCISE PRESCRIPTION
Peak HR from ETT-Rest HR= E (E) ( .60) = A

(E) (.80) = B
Lower rate = A + Rest HR Higher Rate = B + Rest HR

70 year old individual

Peak HR = 150, Rest HR = 60

150 60 = 90 (90)(.60)= 54 (90)(.80) = 72 54 + 60 = 114

72 = 60 = 132
HR Range = 114-132 Takes in to consideration the patients baseline fitness.

RATINGS OF PERCEIVED EXERTION RPE

BORG:
6-20 LINEAR WITH WORD ANCHORS THAT DESCRIBE THE INTENSITY (Perceived Exertion of 1216 correlates to HR response of 60-85%) 0-10 EXPONENTIAL DESIGN WITH WORD ANCHORS (Perceived Exertion of3-6 corresponds to HR response of 60-85%).

BORG SCALES 6 Nothing at all 7 Very, very light 9 - Very light 11 Light 12 13 Somewhat hard 15 Hard 0 Nothing at all .5 Very, very light 1 Very light 2 Light 3 Moderate 4 Somewhat hard 7 Very hard

17 Very hard
19 Very, very hard

10 Very, very hard

FIVE KEY FACTORS

1. Frequency 2. Intensity 3. Mode 4. Duration

5. Rate of Progression

MODE
Any activity that uses a large muscle group in a rhythmical and repetitive fashion at the appropriate intensity and duration results in an improved Functional Capacity.

Resistance Training
Decreased reps, increase weight
MUSCLE STRENGTH Increased reps, decrease weight TONING 2 sets/activity 2-3 sessions/week

PROGRESSION
Level of Fitness Prior Activity History Health Status Age Personal Preferences Goals

CALORIC EXPENDITURE
1-2 #/WEEK
(faster loss results in loss of lean body mass and dehydration) 3500-700 kcal/week 500-1000 kcal/day

Calculation of Caloric Expenditure

1 MET = 1kcal/kg per hour of activity

e.g. 120 kg patient exercising for 30 minutes at 5 METS (FC = 10 METS) Kcal/session = (5 METS) x (120 kg) x 90.5 hr) = 300

EXERCISE AND REHABILITATION

A VITAL PART OF WELLNESS AND HEALING