Contents

Search

cardiac rehabilitation

Use of counseling, education, nutrition & exercise to develop & maintain a desirable level of physical, social & psychologic functioning after onset of cardiovascular illness. Indications: 1) precipitating events a) myocardial infarction - only 1/3 of survivors undergo cardiac rehabilitation after myocardial infarction [11] b) acute coronary syndrome [17] c) PCI, coronary angioplasty, coronary stent placement d) coronary artery bypass graft (CABG) e) valve repair/replacement [13] f) angina g) cardiomyopathy h) cardiac transplant 2) contributing factors a) hypertension b) peripheral vascular disease c) medically complex patients, taking multiple cardiac or other medications d) patients with multiple cardiac risk factors 3) stable coronary artery disease - including those with myocardial ischemia [5] 4) heart failure [18] - frail elderly benefit the most from intensive physical cardiac rehabilitation after hospitalization for acute heart failure [18] 5) abnormal exercise stress test that does not meet criteria for a positive test [5] Clinical significance: Benefits: 1) decreased mortality 2) improves functional capacity [17] a) peripheral training effects b) myocardial training effects? 3) improves medication adherence [17] 4) improves risk factors a) weight reduction b) improved lipid profile c) decreased blood pressure d) improved glucose utilization Procedure: Objectives: 1) prevent adverse effects of prolonged bedrest 2) identify/modify chronic risk factors 3) facilitate return to lifestyle/work 4) provide medical survellance during recovery 5) facilitate psychological/social adaptation Program Structure: 1) phase 1: acute hospitalization - education goals - self assessment of response to exertion - symptom recognition - risk factors/modification - appropriate home exercise 2) phase 2: immediate outpatient - goals - adequate fitness for daily life/occupation - normal hemodynamic response to exercise - normal or unchanged EKG at peak exercise - satisfactory understanding of: - cardiovascular disease - medications - risk factors - appropriate execution of exercise - recognition of adverse symptoms of exercise 3) phase 3: long-term outpatient - less intensely supervised - maximum of 10 patients/therapist 4) phase 4: home/community gym 5) home-based cardiac rehabilitation as effective as hospital/medical center-based rehabilitation [2,3,8] 6) home-based cardiac rehabilitation is a reasonable option for patients with cardiovascular disease at low-to-moderate risk [12] 7) 12-week program with personalized, one-on-one training from a physical therapist - continued elements of program at home out to 6 months [14] - improvements in balance, walking ability, & strength, followed by gains in 6-minute walk & measures of physical functioning, frailty, & quality of life [14]* - benefits more pronounced in patients LV diastolic dysfunction (HFpEF) [14] - death & rehospitalizations unaffected [14] Risk stratification: 1) low risk a) uncomplicated clinical course in hospital b) no evidence of myocardial infarction c) functional capacity > 7 METS on ETT* d) normal left ventricular function (LVEF > 50%) e) no significant ventricular ectopy 2) intermediate risk a) ST segment depression 2 mm flat or downsloping b) reversible defects on myocardial perfusion study c) moderate to good left ventricular function (LVEF > 35-40%) d) changing pattern or new onset of angina 3) high risk a) prior myocardial infarction, involving 35% or more of left ventricle b) LVEF < 35% at rest c) fall in systolic blood pressure during exercise, or failure to rise > 10 mm Hg d) functional capacity < 5 METS, with 1] hypotensive blood pressure response, or 2] >= 1 mm ST segment depression e) ST segment depression 2 mm or more at peak heart rate of 135/min or less f) high-grade ventricular ectopy g) congestive heart failure while in hospital * ETT: exercise tolerance testing Exercise prescription: 1) intensity of exercise a) target heart rate: 1] resting heart rate + 10-20 bpm 2] Karvonen formula: rest* + (desired % of rest) x max rest: resting heart rate; max maximum heart rate b) keep heart rate below ischemic threshold c) beta blockade 2) mode a) treadmill walking b) exercise cycling c) resistance training ( avoid after CABG) 3) frequency: generally 3 times/week 4) duration: a) goal: 20-30 minutes of aerobic exercise 3 times/week b) high risk: start with 7-10 minute session 5) levels of monitoring a) high risk: blood pressure monitoring b) high risk: telemetry, phase 2 6) special precautions a) avoid upper extremity resistance exercise after CABG b) appropriate warm up & cool down Complications: Red Flags: 1) outflow tract obstruction a) aortic stenosis b) hypertrophic obstructive cardiomyopathy 2) exacerbation of congestive heart failure 3) uncontrolled diabetes

Specific

cardiopulmonary rehabilitation

General

rehabilitation

References

  1. Genova, A, UCLA Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 12-15, 2001
  2. Oerkild B et al Home-based cardiac rehabilitation is as effective as centre- based cardiac rehabilitation among elderly with coronary heart disease: results from a randomised clinical trial. Age Ageing. 2011 Jan;40(1):78-85. Epub 2010 Sep 15. PMID: 20846961
  3. Clark AM et al A meta-analysis of randomized control trials of home-based secondary prevention programs for coronary artery disease. Eur J Cardiovasc Prev Rehabil. 2010 Jun;17(3):261-70 PMID: 20560165
  4. Dalal HM, Zawada A, Jolly K, et al Home-based versus centre-based cardiac rehabilitation: Cochrane systematic review and meta-analysis. BMJ. 2010 Jan 19; 340:b5631 PMID: 20085991
  5. Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013 - Geriatric Review Syllabus, 9th edition (GRS9) Medinal-Walpole A, Pacala JT, Porter JF (eds) American Geriatrics Society, 2016 - Geriatric Review Syllabus, 11th edition (GRS11) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2022
  6. Ferrara N, Corbi G, Bosimini E et al Cardiac rehabilitation in the elderly: patient selection and outcomes. Am J Geriatr Cardiol. 2006 Jan-Feb;15(1):22-7. Review. PMID: 16415643
  7. Suaya JA, Stason WB, Ades PA et al Cardiac rehabilitation and survival in older coronary patients. J Am Coll Cardiol. 2009 Jun 30;54(1):25-33. PMID: 19555836
  8. Taylor RS, Dalal H, Jolly K Home-based versus centre-based cardiac rehabilitation. Cochrane Database Syst Rev. 2015 Aug 18;(8):CD007130. Review. PMID: 26282071
  9. Menezes AR, Lavie CJ, Forman DE et al Cardiac rehabilitation in the elderly. Prog Cardiovasc Dis. 2014 Sep-Oct;57(2):152-9. Review. PMID: 25216614
  10. Lawler PR, Filion KB, Eisenberg MJ. Efficacy of exercise-based cardiac rehabilitation post- myocardial infarction: a systematic review and meta-analysis of randomized controlled trials. Am Heart J. 2011 Oct;162(4):571-584.e2. Review. PMID: 21982647
  11. Fang J, Ayala C, Luncheon C, Ritchey M, Loustalot F. Use of Outpatient Cardiac Rehabilitation Among Heart Attack Survivors - 20 States and the District of Columbia, 2013 and Four States, 2015. MMWR Morb Mortal Wkly Rep 2017;66:869-873 https://www.cdc.gov/mmwr/volumes/66/wr/mm6633a1.htm
  12. Thomas RJ, Beatty AL, Beckie TM et al Home-Based Cardiac Rehabilitation. A Scientific Statement From the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Heart Association, and the American College of Cardiology. Circulation, May 2019 PMID: 31082266 https://www.ahajournals.org/doi/pdf/10.1161/CIR.0000000000000663
  13. Patel DK, Duncan MS, Shah AS et al Association of Cardiac Rehabilitation With Decreased Hospitalization and Mortality Risk After Cardiac Valve Surgery. JAMA Cardiol. Published online October 23, 2019. PMID: 31642866 https://jamanetwork.com/journals/jamacardiology/article-abstract/2753611
  14. Stiles S Novel Rehab Program Fights Frailty, Boosts Capacity in Advanced HF. Medscape - May 16, 2021. https://www.medscape.com/viewarticle/951244
  15. O'Neill D, Forman DE. Never too old for cardiac rehabilitation. Clin Geriatr Med. 2019;35(4):407-421 PMID: 31543175 PMCID: PMC7241425 Free PMC article https://www.geriatric.theclinics.com/article/S0749-0690(19)30049-7/fulltext
  16. Schopfer DW, Forman DE. Cardiac rehabilitation in older adults. Can J Cardiol. 2016;32(9):1088-1091 PMID: 27297002 https://www.onlinecjc.ca/article/S0828-282X(16)00226-9/fulltext
  17. Medical Knowledge Self Assessment Program (MKSAP) 19 American College of Physicians, Philadelphia 2022
  18. Kitzman DW, Whellan DJ, Duncan P et al Physical Rehabilitation for Older Patients Hospitalized for Heart Failure. N Engl J Med. 2021 Jul 15;385(3):203-216 PMID: 33999544 PMCID: PMC8353658 Free PMC article https://www.nejm.org/doi/10.1056/NEJMoa2026141 - Pandey A, Kitzman DW, Nelson MB et al. Frailty and effects of a multidomain physical rehabilitation intervention among older patients hospitalized for acute heart failure: A secondary analysis of a randomized clinical trial. JAMA Cardiol 2023 Jan 4; [e-pub]. PMID: 36598761 PMCID: PMC9857661 (available on 2024-01-04) https://jamanetwork.com/journals/jamacardiology/fullarticle/2799721