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Questions and Answers
What should be the target heart rate range for Mr. X during his Phase I Cardiac Rehab?
What should be the target heart rate range for Mr. X during his Phase I Cardiac Rehab?
Which vital sign observation would indicate a need for immediate intervention when Mr. X complains of dizziness and fatigue?
Which vital sign observation would indicate a need for immediate intervention when Mr. X complains of dizziness and fatigue?
What is an appropriate discharge recommendation for Mr. X after his cardiac rehab?
What is an appropriate discharge recommendation for Mr. X after his cardiac rehab?
What is the primary goal of physical therapy for Mr. X during his initial rehab phase?
What is the primary goal of physical therapy for Mr. X during his initial rehab phase?
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What is the most critical action to take if an unusual rhythm is observed on Mr. X's EKG during exercise?
What is the most critical action to take if an unusual rhythm is observed on Mr. X's EKG during exercise?
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How should Mrs. S's exercise response be assessed during her treadmill session?
How should Mrs. S's exercise response be assessed during her treadmill session?
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If Mrs. S exhibits fatigue during her treadmill exercise, what is the best recommendation for her next session?
If Mrs. S exhibits fatigue during her treadmill exercise, what is the best recommendation for her next session?
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What should be included in Mr. X's educational content regarding his post-exercise care?
What should be included in Mr. X's educational content regarding his post-exercise care?
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What is the main purpose of cardiac rehabilitation?
What is the main purpose of cardiac rehabilitation?
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Which formula is used to calculate the Maximum Heart Rate for older adults?
Which formula is used to calculate the Maximum Heart Rate for older adults?
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When determining the Target Heart Rate zone, which of the following is true?
When determining the Target Heart Rate zone, which of the following is true?
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What is a potential barrier to cardiac rehabilitation utilization?
What is a potential barrier to cardiac rehabilitation utilization?
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Which of the following is NOT a contraindication for cardiac rehab?
Which of the following is NOT a contraindication for cardiac rehab?
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Which phase of cardiac rehabilitation is focused on disease prevention?
Which phase of cardiac rehabilitation is focused on disease prevention?
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What is an appropriate frequency recommendation for outpatient cardiac rehabilitation aerobic exercise?
What is an appropriate frequency recommendation for outpatient cardiac rehabilitation aerobic exercise?
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Which monitoring method is essential during exercise training in cardiac rehabilitation?
Which monitoring method is essential during exercise training in cardiac rehabilitation?
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In which situation should resistance training NOT be performed?
In which situation should resistance training NOT be performed?
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What is a normal vital sign response to exercise?
What is a normal vital sign response to exercise?
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What is the recommended intensity for aerobic exercise in outpatient cardiac rehabilitation without a prior exercise test?
What is the recommended intensity for aerobic exercise in outpatient cardiac rehabilitation without a prior exercise test?
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What is one of the psychological benefits of cardiac rehabilitation?
What is one of the psychological benefits of cardiac rehabilitation?
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What is the correct procedure for determining exercise intensity in cardiac rehab?
What is the correct procedure for determining exercise intensity in cardiac rehab?
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What is the most appropriate action to take if Mr. X is observed to be pale and complaining of dizziness during his rehabilitation session?
What is the most appropriate action to take if Mr. X is observed to be pale and complaining of dizziness during his rehabilitation session?
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In outpatient cardiac rehab, what should Mr. X's target heart rate range be if his maximum heart rate is determined to be 140 bpm?
In outpatient cardiac rehab, what should Mr. X's target heart rate range be if his maximum heart rate is determined to be 140 bpm?
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What is the appropriate recommendation for Mrs. S’s next treadmill exercise session after her initial session where she showed good response?
What is the appropriate recommendation for Mrs. S’s next treadmill exercise session after her initial session where she showed good response?
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Which of the following should be monitored continuously during Mr. X's exercise sessions to ensure safety?
Which of the following should be monitored continuously during Mr. X's exercise sessions to ensure safety?
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What does a stable blood pressure response during exercise suggest for Mrs. S during her treadmill training?
What does a stable blood pressure response during exercise suggest for Mrs. S during her treadmill training?
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If Mr. X exhibits an abnormal rhythm on the EKG while exercising, what priority action should be taken?
If Mr. X exhibits an abnormal rhythm on the EKG while exercising, what priority action should be taken?
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What important information should be emphasized in Mr. X's educational content post-exercise?
What important information should be emphasized in Mr. X's educational content post-exercise?
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Which of the following factors would indicate a need for further assessment during Mrs. S’s treadmill session if she starts to show arrhythmias?
Which of the following factors would indicate a need for further assessment during Mrs. S’s treadmill session if she starts to show arrhythmias?
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What is the primary goal of Phase II cardiac rehabilitation?
What is the primary goal of Phase II cardiac rehabilitation?
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What is one method used to calculate Maximum Heart Rate for healthy individuals under 40?
What is one method used to calculate Maximum Heart Rate for healthy individuals under 40?
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During exercise training, what indicates an abnormal response if a patient's SBP does not increase?
During exercise training, what indicates an abnormal response if a patient's SBP does not increase?
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What is the recommended frequency for aerobic exercise in outpatient cardiac rehabilitation?
What is the recommended frequency for aerobic exercise in outpatient cardiac rehabilitation?
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Which condition is a contraindication for resistance training in cardiac rehab?
Which condition is a contraindication for resistance training in cardiac rehab?
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What is the significance of a drop in SBP greater than 10 mmHg during low-level exercise?
What is the significance of a drop in SBP greater than 10 mmHg during low-level exercise?
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In assessing target heart rate, what is the recommended intensity for moderate exercise?
In assessing target heart rate, what is the recommended intensity for moderate exercise?
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What vital sign response is expected during increased workload?
What vital sign response is expected during increased workload?
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What is the abbreviation for the formula that assists in determining Target Heart Rate using resting heart rate?
What is the abbreviation for the formula that assists in determining Target Heart Rate using resting heart rate?
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Which phase of cardiac rehabilitation emphasizes exercise maintenance?
Which phase of cardiac rehabilitation emphasizes exercise maintenance?
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What is the correct identification for patients at low risk for cardiac events during rehabilitation?
What is the correct identification for patients at low risk for cardiac events during rehabilitation?
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What does the FITT principle represent in exercise prescription?
What does the FITT principle represent in exercise prescription?
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What is a key component of inpatient cardiac rehabilitation?
What is a key component of inpatient cardiac rehabilitation?
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Study Notes
Cardiac Intervention/Cardiac Rehab
- Heidi Tymkew is a Board Certified Clinical Specialist in Cardiovascular & Pulmonary Physical Therapy
- Cardiac rehabilitation is a comprehensive exercise, education, and behavior modification program that improves the physical and emotional conditions of individuals with heart disease.
Exercise Prescription
- Exercise prescriptions should include a warm-up and cool-down
- Vital signs should be monitored during exercise training
- Components of exercise prescription include Frequency, Intensity, Time, and Type (FITT).
Determine Maximum Heart Rate
- If a formal exercise test is done, the maximum heart rate (HR) from that test is used, not a calculated HR.
- Methods include calculating maximum heart rate (HR) as 220 minus the patient's age for healthy individuals under 40. For other patients, calculate maximum heart rate (HR) as 208 minus 0.7 times the patient's age. A third method is the Tanaka method.
Determine Target HR Zone
- Target HR can be calculated using the Karvonen formula: [ (Maximum HR – Resting HR) x Intensity] + Resting HR
- An example uses a 60-year-old male with a maximum HR of 166 bpm and a resting HR of 66.
Intensity
- Intensity is measured by percent of maximum heart rate reserve and with a rating of perceived exertion (RPE) scale of 6-20.
- A table defines different intensity levels based on percent of heart rate reserve and RPE scale.
Normal Vital Sign Response
- Heart rate (HR) gradually increases with workload, increasing approximately 10 bpm per metabolic equivalent (MET) level.
- Systolic blood pressure (SBP) gradually increases with workload, increasing approximately 10 bpm per MET level, and diastolic blood pressure (DBP) also increases, increasing by approximately 10 mmHg with activity.
- Respiratory rate and SpO2 gradually increase with workload.
Abnormal Response to Exercise
- Excessive heart rate increase
- Flat or decreasing heart rate
- Hypertensive blood pressure response (SBP > 210 mmHg, DBP > 110 mmHg)
- Decrease in SBP greater than 10 mmHg with activity
- Failure of SBP to increase with increase of activity
- Changes in DBP greater than 10 mmHg
- Any significant change in cardiac rhythm
Cardiac Rehabilitation
- Cardiac rehabilitation is a multidisciplinary program.
- Includes components like lipid lowering, blood pressure management, glucose control, weight management, smoking cessation, exercise counselling, on-site exercise sessions, exercise stress testing, and dietary counselling.
Benefits of Cardiac Rehab
- Improves physical fitness
- Reduces hospitalizations and mortality
- Reduces cardiovascular risk factors (HTN, DM, Obesity, Smoking)
- Reduces stress and anxiety
- Improves quality of life
Cardiac Rehab Utilization
- Only 19-34% of eligible patients participate in cardiac rehab programs
- 25% of Medicare patients participate
- Potential barriers include: lack of physician referral lack of perceived need/awareness of CR limited healthcare coverage/cost work responsibilities distance to facility transportation language barriers
Team Members
- The cardiac rehab team consists of a medical director, program coordinator, nurse, physical therapist, exercise physiologist, dietician, behavior specialist/psychologist, and social worker.
Indications for Cardiac Rehab
- Medically stable post-myocardial infarction (MI)
- Stable angina
- Coronary artery bypass graft (CABG) or valve surgery
- Coronary angioplasty or stent
- Stable heart failure
- Heart transplantation
- Peripheral arterial disease (PAD)
- At risk for coronary artery disease with diabetes mellitus, dyslipidemia, hypertension, or obesity
- Other patients benefiting from structured exercise and/or patient education based on physician referral and rehab team consensus
Contraindications for Cardiac Rehab
- Unstable angina
- Uncontrolled hypertension (resting SBP > 180 mmHg or DBP > 110 mmHg)
- Orthostatic blood pressure drop of >20 mmHg with symptoms
- Significant aortic stenosis (valve area < 1.0 cm²)
- Uncontrolled atrial or ventricular arrhythmias
- Uncontrolled sinus tachycardia (> 120 bpm)
- Uncompensated heart failure
- Third-degree atrioventricular block without pacemaker
- Active pericarditis or myocarditis
- Recent embolism
- Acute thrombophlebitis
- Aortic dissection
- Acute systemic illness or fever
- Uncontrolled diabetes mellitus
- Severe orthopedic injuries
- Other metabolic conditions
- Severe psychological disorder
Inpatient Cardiac Rehab
- Occurs in the hospital after an acute cardiac event or procedure.
- Involves early mobilization, readiness for physical activity assessment, education about CVD risk factors, comprehensive discharge planning, and referral to outpatient cardiac rehab.
Inpatient Cardiac Rehab Parameters
- No new or recurrent chest pain in the previous 8 hours.
- Stable or declining Troponin levels.
- No indication of decompensated heart failure (e.g., resting shortness of breath and bibasilar crackles).
- Normal cardiac rhythm and stable EKG results for the past 8 hours.
- Hemodynamically stable.
FITT Recommendations for Inpatient Cardiac Rehabilitation
- Frequency: 2-4 sessions/day for the first 3 days of hospitalization.
- Intensity: Seated or standing resting heart rate (HR) + 20 bpm for MI patients, and +30 bpm for heart surgery patients. Upper limit </= 120 bpm and </= 13 on RPE scale 6-20.
- Time: Begin with intermittent walking bouts (3-5 minutes); gradually increase duration. Aim for a 2:1 exercise/rest ratio.
- Type: Walking is the primary mode.
Adverse Responses to Inpatient Exercise
- Unusual HR increase (>50 bpm with low-level activity)
- Abnormally high SBP (>210 mmHg) or DBP (>110 mmHg)
- Drop in SBP (>10 mmHg) during low-level exercise
- Symptoms such as angina, excessive dyspnea, excessive fatigue, confusion, dizziness, signs of pallor, cold sweat, ataxia, change in heart sounds, change in lung sounds, or EKG abnormalities.
Potential Education Topics for Inpatient Cardiac Rehab
- Overview of cardiac condition
- Benefits of exercise
- Monitoring of activity (HR, BP, RPE)
- Home exercise program
- Post-surgical precautions
- Sternal precautions
- Pacemaker precautions
- Post cardiac cath precautions
- Outpatient cardiac rehab
PT Goals for the Acute Care Setting
- Specific goals are not included
Cardiac Rehab Phases
- Phase I: Acute/hospital phase -begins when patient is medically stable after MI, CABG, PTCA, valve replacement, CHF, or heart transplantation.
- Phase II: Early outpatient/intensive monitoring - within days of discharge to 6-12 weeks depending on patient needs and physician referral.
- Phase III: Training and maintenance phase- indefinite. Large-group exercise, continued progress, exercise program.
- Phase IV: Disease prevention program -high risk for infarction, risk factor profile monitored by trained personnel.
Outpatient Cardiac Rehab
- Traditional center-based CR: 36 sessions over 12 weeks. Intensive – 72 sessions over 9 weeks, 3-4hrs each day, 2 days/wk. Incorporates exercise and in-depth education about nutrition, stress management, sleep. Includes Pritikin ICR program and Ornish Program .
- Home-based CR: Option for patients eligible for CR but cannot attend traditional programs.
Medicare Coverage for Cardiac Rehab
- MI within the past 12 months
- CABG surgery
- Stable angina
- Heart valve repair or replacement
- Coronary angioplasty or stent
- Heart or heart-lung transplant
- Stable chronic heart failure (HFrEF)
- EF < 35%
- Stable on medical therapy without 6 weeks of hospitalization.
Cardiac Rehab Components
- Personalized exercise plan.
- Cardiovascular risk factor assessment & counselling on lifestyle changes.
- Education and support to reduce risk of secondary cardiac events.
- Monitoring for blood pressure, lipids, cholesterol, and diabetes.
- Psychological/stress assessment & counselling.
- Communication with other healthcare providers.
- Return to appropriate vocational & recreational activities.
Cardiac Risk Stratification
-
Low risk: Uncomplicated MI, CABG, angioplasty, or atherectomy. Absence of CHF; 7+ Mets. Asymptomatic with exercise; ejection fraction > 50%. No resting or exercise-induced complex dysrhythmias.
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High risk: Ejection fraction < 40%. Complex ventricular dysrhythmias. Signs or symptoms of angina, dizziness, lightheadedness, or dyspnea at low levels of exercise (<5 METs). Maximal functional capacity <5.0 METS.
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Moderate risk: Ejection fraction 40-50%. Mild to moderate silent ischemia. Signs/symptoms including angina at "moderate" levels of exercise (60-70% of maximal functional capacity).
FITT Recommendations for Outpatient Cardiac Rehabilitation
- Frequency: Minimally 3 days/week, preferably 2-3 non-consecutive days.
- Intensity: With an exercise test, use 40-80% of exercise capacity. Without an exercise test, use seated or standing HRrest + 20 bpm(+30 bpm for heart surgery patients) or an RPE of 12-16 on a scale of 6-20.
- Time: 20-60 minutes.
- Type: Various exercises, including arm ergometer, upper/lower (dual action) extremity ergometer, upright/recumbent cycles, recumbent stepper, rower, elliptical, stair climber, treadmills (1-3 sets); select equipment and different exercises.
Adverse Responses to Outpatient Exercise
- Unusual HR increase (> 50 bpm) with low-level activity.
- Abnormally high SBP (>210 mmHg) or DBP (>110 mmHg).
- Drop in SBP (>10 mmHg) with low-level exercise.
- Symptoms: angina, excessive dyspnea, excessive fatigue, confusion, dizziness, pallor/cold sweat/ataxia, change in heart sounds/lung sounds, EKG abnormalities.
Resistance Training in Cardiac Rehab
- Safe for low to moderate risk cardiac patients.
- Improves muscle strength and exercise capacity.
- Increases self-esteem, improves quality of life, and may improve glucose control.
Patient Eligibility for Resistance Training
- Individualized resistance training.
- Not requiring greater RPE or cardiovascular demand than aerobic exercise.
- Allowed after at least 5 weeks post-MI, 8 weeks post-CABG or heart surgery, and 2 weeks post-PTCA.
Exclusion Criteria for Resistance Training
- Uncontrolled CHF.
- Uncontrolled arrhythmias.
- Severe valvular disease.
- Uncontrolled hypertension (SBP ≥160mmHg or DBP ≥100mmHg).
- Exertional hypotension (> 15 mmHg).
- Unstable symptoms.
- Severe orthopedic problems.
- Marfan syndrome.
- Enlarging aortic aneurysms.
- Severe pulmonary hypertension.
Outpatient Cardiac Rehab Education (PT specific)
- Self-monitoring of HR/BP using the RPE scale.
- Benefits of exercise.
- Home exercise program.
- Precautions for exercise.
- Symptoms of exercise intolerance.
- Energy conservation.
- Relaxation techniques.
- Risk factor modification.
Maintenance Phase of Cardiac Rehab
- Self-supervised exercise program.
- Vital signs and EKG monitoring in phase III.
- No monitoring in phase IV.
- Mostly endurance training.
- Lifelong exercise.
Special Patient Populations in Cardiac Rehab
- Post Sternotomy: Sternal precautions (6+ weeks). Monitoring for sternal instability.
- Pacemaker & AICD: Precautions for 3+ weeks after placement. Knowing pacemaker modes and ICD rhythm detection limits are essential before exercise. With ICD, exercise HR peak should be 10-15 bpm below the threshold.
Case #1 (65-year-old male post-MI)
- Exercise prescription: Details about target heart rate will require additional information, such as resting heart rate and maximum heart rate from an exercise stress test.
- Patient education: Specific instructions.
Case #2 (50-year-old female post-anterior MI)
- Assessment of exercise response: Analysis of the exercise data provided, including a careful look at the trends of heart rate and blood pressure. Pay attention to any deviations in the patient's response or any problematic symptoms.
- Recommendation for the following session: Suggested adjustments to the session based on analysis, perhaps modifying the speed or incline gradually to prevent overexertion and enable patient to gradually increase tolerance.
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Description
Test your knowledge on the key principles of Phase I cardiac rehabilitation for patients like Mr. X and Mrs. S. This quiz covers target heart rates, vital sign observations, discharge recommendations, and assessment strategies. Gain insights into the primary goals of physical therapy during the initial rehabilitation phase.
