Podcast
Questions and Answers
What is the appropriate target heart rate range for Mr. X during Phase I Cardiac Rehab?
What is the appropriate target heart rate range for Mr. X during Phase I Cardiac Rehab?
Which of the following is NOT a common goal for physical therapy in cardiac rehabilitation?
Which of the following is NOT a common goal for physical therapy in cardiac rehabilitation?
What is the first step you should take when Mr. X complains of dizziness and looks pale?
What is the first step you should take when Mr. X complains of dizziness and looks pale?
Following an exercise stress test revealing a max heart rate of 140 bpm, what should Mr. X's calculated target exercise heart rate be?
Following an exercise stress test revealing a max heart rate of 140 bpm, what should Mr. X's calculated target exercise heart rate be?
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Observing an abnormal EKG rhythm during Mrs. S's treadmill session, what should be your primary response?
Observing an abnormal EKG rhythm during Mrs. S's treadmill session, what should be your primary response?
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After assessing Mrs. S's exercise response, which recommendation is most appropriate for her next treadmill exercise session?
After assessing Mrs. S's exercise response, which recommendation is most appropriate for her next treadmill exercise session?
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What should be included in the educational component for Mr. X regarding his cardiac rehabilitation?
What should be included in the educational component for Mr. X regarding his cardiac rehabilitation?
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Which vital sign response during Mrs. S's treadmill exercise session indicates a successful adaptation to exercise?
Which vital sign response during Mrs. S's treadmill exercise session indicates a successful adaptation to exercise?
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Which formula is appropriate for determining the maximum heart rate in individuals over 40 years of age?
Which formula is appropriate for determining the maximum heart rate in individuals over 40 years of age?
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What response is considered abnormal during exercise monitoring in cardiac patients?
What response is considered abnormal during exercise monitoring in cardiac patients?
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What is the primary benefit of cardiac rehabilitation?
What is the primary benefit of cardiac rehabilitation?
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Which of the following is a contraindication for participating in cardiac rehabilitation?
Which of the following is a contraindication for participating in cardiac rehabilitation?
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In phase I of cardiac rehab, how soon after stabilization post-MI does the program typically begin?
In phase I of cardiac rehab, how soon after stabilization post-MI does the program typically begin?
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Which of the following describes the ideal intensity for resistance training in cardiac patients?
Which of the following describes the ideal intensity for resistance training in cardiac patients?
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What does the Karvonen formula help determine?
What does the Karvonen formula help determine?
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What percentage of patients eligible for cardiac rehab actually participate in the program?
What percentage of patients eligible for cardiac rehab actually participate in the program?
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Which vital sign abnormality is a sign of excessive exercise intensity?
Which vital sign abnormality is a sign of excessive exercise intensity?
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When might resistance training begin for a patient post-myocardial infarction?
When might resistance training begin for a patient post-myocardial infarction?
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What percentage of maximal functional capacity represents moderate risk in patients undergoing exercise?
What percentage of maximal functional capacity represents moderate risk in patients undergoing exercise?
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In phase II of cardiac rehab, what is their exercise frequency recommendation?
In phase II of cardiac rehab, what is their exercise frequency recommendation?
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What is an expected normal response of systolic blood pressure during exercise?
What is an expected normal response of systolic blood pressure during exercise?
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Study Notes
Cardiac Intervention/Cardiac Rehab
- Heidi Tymkew is a Board Certified Clinical Specialist in Cardiovascular & Pulmonary Physical Therapy.
- Cardiac Rehab is a multidisciplinary program focused on improving the physical and emotional well-being of individuals with heart disease.
Exercise Prescription
- Exercise prescription should include warm-up and cool-down periods with each session.
- Vital signs should be monitored during exercise training.
- The components of exercise prescription include: frequency, intensity, time, and type.
Determine Maximum Heart Rate
- Use the maximum heart rate calculated from a formal exercise test, not a calculated one if one has been performed.
- Methods to determine maximum heart rate for healthy individuals under 40 years of age = 220 - age.
- Methods to determine maximum heart rate for older adults or those with pathology = 208 - (0.7 x age).
- Tanaka Method can also be utilized.
Determine Target HR Zone
- Target HR = Maximum HR x intensity.
- Karvonen Formula = ([Maximum HR - Resting HR] * Intensity) + Resting HR
- Example using Karvonen Calculation = ([166 – 66] * 40%) + 66= 106 bpm
- Example using Karvonen Calculation = ([166 – 66] * 60%) + 66 = 126 bpm
- Intensity levels are determined by % Heart Rate Reserve and % Maximum HR.
Intensity Chart
- This chart shows different intensity levels based on % Heart Rate Reserve, % Maximum HR, and Rate of Perceived Exertion (RPE) scale.
- Different intensity levels (very light, light, moderate, vigorous).
Normal Vital Sign Response
- Heart rate, Systolic Blood Pressure (SBP), Diastolic Blood Pressure (DBP), Respiratory rate, and SpO2 all gradually and proportionally increase in rate with workload.
- HR increases by 10 beats per MET level
- SBP and DBP increases by 10 beats per MET level.
- SBP will increase by + 10mmHg with any activity, whilst DBP will increase gradually with workload.
- SpO2 values remain the same or may increase.
Abnormal Response to Exercise
- Excessive increase in heart rate
- Flat or decrease in heart rate
- Hypertensive BP response (SBP > 210 mmHg and/or DBP > 110 mmHg)
- Decrease in SBP by > 10 mmHg with activity
- Failure of SBP to increase with increase in activity
- Changes in DBP > + 10 mmHg
- A significant change in cardiac rhythm
Cardiac Rehabilitation
- A multidisciplinary program for individuals with heart disease involving exercise, education, and behavior modifications to improve emotional and physical well-being.
- Includes topics such as lipid lowering, depression and anxiety counselling, self-support counselling, group education, blood pressure management, cholesterol & blood sugar 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 hospitalization 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.
- 25% of Medicare patients who are eligible do not participate in the program.
- Potential barriers: Lack of physician referral, lack of perceived need/awareness of Cardiac Rehab, limited healthcare coverage/cost, work/home responsibilities, distance to facility, transportation, and language barriers.
Team Members
- Medical Director
- Program Coordinator
- Nurse
- Physical Therapist
- Exercise Physiologist
- Dietician
- Behavior Specialist/Psychologist
- Social Worker
Indications for Cardiac Rehab
- Medically stable post-myocardial infarction
- Stable angina
- Coronary artery bypass graft or valve surgery
- Coronary angioplasty or stent
- Stable heart failure (caused by either systolic or diastolic dysfunction)
- Heart transplantation
- Peripheral arterial disease
- At-risk for coronary artery disease (with diagnosis of diabetes mellitus, dyslipidemia, hypertension, or obesity)
- Other patients based on physician referral and consensus of the cardiac rehabilitation team.
Contraindications for Cardiac Rehab
- Unstable angina
- Uncontrolled hypertension (resting SBP > 180mmHg, resting DBP > 110mmHg)
- Orthostatic blood pressure drop of >20 mmHg with symptoms
- Significant aortic stenosis (valve area < 1.0cm²)
- 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 (pulmonary or systemic)
- Acute thrombophlebitis
- Aortic dissection
- Acute systemic illness or fever
- Uncontrolled diabetes mellitus
- Severe orthopedic injuries (inhibiting exercise)
- Other metabolic conditions (acute thyroiditis, hypokalemia, hyperkalemia, or hypovolemia)
- Sever psychological disorder
Inpatient Cardiac Rehab
- Occurs during hospitalization after a cardiac event or procedure.
- Includes early mobilization, assessment of readiness for physical activity, identification and 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 previous 8 hours
- Stable or falling Troponin values
- No indication of decompensated heart failure
- Normal cardiac rhythm and stable EKG for previous 8 hours
- Hemodynamic stability
FITT Recommendations for Inpatient Cardiac Rehabilitation
- Frequency: 2-4 sessions/day for first 3 days of hospital. Stay
- Intensity: Seated or standing HR rest + 20 bpm for MI patients; + 30 bpm for heart surgery. Upper limit of <=120 bpm (that corresponds to an RPE <=13).
- Time: Starts with intermittent walking bouts (3-5 minutes). Gradually increase duration; the rest time is shorter than the duration of the exercise bout;
- Type: Walking or other aerobic modes (treadmill, cycle).
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) with low level exercise.
- Symptoms with activity include Angina, Excessive dyspnea, Excessive fatigue, Confusion or dizziness, Signs of pallor, cold sweat, ataxia, Change in heart sounds with activity, Change in lung sounds with activity, and EKG abnormality.
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
(This section is blank in the provided text, so no details are available).
Outpatient Cardiac Rehab (Phases II-III)
- Traditional Cardiac Rehab programs are 36 sessions (3 days/wk x 12 weeks), or Intensive programs are 72 sessions (3-4 hours/day x 2 days/wk x 9 weeks).
Home-Based Cardiac Rehab
- May be an option for patients eligible for Cardiac Rehab but unable to attend a traditional program.
Medicare Coverage for Cardiac Rehab
- Criteria for coverage include MI within 12 months, CABG surgery, current stable angina, heart valve repair/replacement, coronary angioplasty/stent, heart or heart-lung transplant, stable chronic heart failure (HFrEF) with EF ≤35%, and stable on medical therapy without hospitalization for 6 weeks.
Cardiac Rehab Components
- Development and implementation/supervision of a safe and personalized exercise plan
- Cardiovascular risk factor assessment and counseling on lifestyle management
- Education and support to reduce risk of secondary cardiac events
- Monitoring of BP, cholesterol, and diabetes
- Psychological assessment and counseling
- Communication with physicians and healthcare providers
- Return to vocational and recreational activities
Cardiac Risk Stratification – Low Risk
- Uncomplicated MI, CABG, angioplasty, or atherectomy
- Absence of CHF or ischemia
- Functional capacity 7+ METs
- Asymptomatic during exercise and recovery
- No resting or exercise-induced complex dysrhythmias
- Ejection fraction ≥50%
- Normal hemodynamic and EKG response to exercise
- Absence of clinical depression
Cardiac Risk Stratification – High Risk
- Ejection fraction < 40%
- Complex ventricular dysrhythmias
- Signs/symptoms (angina, dizziness, dyspnea) at low exercise levels
- Maximal functional capacity < 5.0 METs
- MI or cardiac surgery complicated by CHF, shock, or post-procedure ischemia
- Survivor of cardiac arrest, or symptoms of such
- Abnormal hemodynamics with exercise
- Significant silent ischemia (ST depression ≥2 mm)
- Clinically significant depression or depressive symptoms
Cardiac Risk Stratification – Moderate Risk
- Ejection fraction 40-50%
- Mild to moderate silent ischemia (ST depression < 2mm)
- Signs/symptoms (angina) at moderate exercise levels (60-70% maximal functional capacity)
FITT Recommendations for Outpatient Cardiac Rehabilitation
- Aerobic: Frequency: Minimally 3 days/week, preferably 2-3 days/week; Intensity: Using HRR, VO2R, or VO2peak to attain 40-80% exercise capacity; Time: 20-60 minutes; Type: Arm ergometer, upper and lower (dual action) extremity ergometer, upright and recumbent cycles, recumbent stepper, rower, elliptical, stair climber, treadmills
- Resistance: Frequency: 2-3 non-consecutive days/week; Intensity: Performing 10-15 reps of each exercise without significant fatigue, RPE 11-13 (or 6-20 scale, or 40-60% of 1-RM); Time: 1-3 sets; 8-10 different exercises; Type: Equipment that is safe and comfortable, major muscle groups, focusing on major muscle groups
Cardiac Rehab Education Topics (PT specific)
- Self monitoring (HR/BP using RPE scale)
- Benefits of exercise
- Home exercise programs
- Temperature precautions
- Signs/symptoms of exercise intolerance
- Energy conservation
- Relaxation
- Risk factor modification
Maintenance Phase of Cardiac Rehab
- Self-pay supervised exercise program
- Vital signs and use of EKG in phase III
- No monitoring in phase IV
- Lifelong exercise (mainly endurance training)
Special Patient Populations in Cardiac Rehab
- Post Sternotomy: Sternal precautions (6+ weeks), monitor for sternal instability.
- Pacemaker & AICD: Pacemaker precautions (3+ weeks), know pacemaker/ICD modes, HR limits, and rhythm detection prior to exercise; With ICD, HRpeak should be 10–15 bpm below threshold.
Case #1 (65-year-old male with acute MI)
- Details on exercise prescription, target heart rate, and patient education are missing from the provided information..
Case #1 (65-year-old male with acute MI) -Additional Questions
- What would his PT goals be?
- What is your discharge recommendation?
- If he complains of dizziness and fatigue while walking, what do you do?
- What rhythm is he in based on ECG?
- Exercise prescription and HR range after completing outpatient program ( 6 weeks later)
- Describe the follow-up actions if he experiences a specific abnormal rhythm/condition (during outpatient cardiac rehab on treadmill)
Case #2 (50-year-old female with MI 7 days prior)
- Assessment of exercise response and recommendations for the next session are missing from the provided information.
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Description
Test your knowledge on cardiac rehabilitation protocols, including target heart rate calculations, physical therapy goals, and appropriate responses to patient concerns. This quiz covers important concepts for Phase I cardiac rehab, ensuring safe and effective patient management.
