EXMD4742 prac exam printout.docx.pdf

Case study patients will involve common diagnoses seen in cardiac rehab: - Coronary artery bypass surgery (CABG) (KMIT) - a surgery to restore blood flow to the heart by bypassing blocked coronary arteries. - avoid chest strain during recovery - regular c...

Case study patients will involve common diagnoses seen in cardiac rehab: - Coronary artery bypass surgery (CABG) (KMIT) - a surgery to restore blood flow to the heart by bypassing blocked coronary arteries. - avoid chest strain during recovery - regular checks of HR, rhythm, and BP - gradual reintro of aerobic exercise and resistance exercises to improve CV endurance and strength - Consider - KMIT - perform exercises with limited range of motion in the upper body, pretending that the pt is in a tube - Ask relevant subjective Q’s - objective tests - Manual HR and Rhythm check - Resting BP - SPO2 - Sternal stability assessment - ECG if possible - Ex Cap. 6MWT - NeuroMusc. strength (30s or 5x STS) - Depression and QOL Q’s - Risk stratification - Moderate to high risk - monitor for: - Residual coronary artery disease - Arrhythmias (common post-surgery) - Post surgical complications (wound infections, sternal instability) - perform sternal stability assessment - Contraindications to exercise - Temporary contraindications - Unstable vital signs: uncontrolled hypertension, arrhythmias or angina during rest or low intensity exercise - sternal instability: consider KMIT - Severe shortness of breath or signs of HF: monitor fluid retention, swelling or weight changes - Permanent contraindications: generally none unless the pt develops long term complications - Clinical consideration for exercise prescription - Aerobic Exercise: Begin with low-intensity activities like walking or cycling, starting at 10-20 minutes per session, 3-5 days per week. Target heart rate should be below 20 bpm over resting rate, with an RPE of 9-11. Gradually increase duration and intensity as tolerated. - Resistance Training: Avoid resistance training for the first 6-8 weeks due to sternal healing. After clearance, introduce light resistance exercises (1-2 sets of 10-15 reps) focusing on lower body movements to minimize chest strain. - Sternal Precautions (KMIT): Use “Keep Your Move in the Tube” principles to avoid excessive chest strain by keeping movements  controlled, arms close to the body, and avoiding lifting more than 5-10 lbs in the early stages of recovery. - Monitoring: Perform regular checks of heart rate and rhythm, blood pressure, and ECG during exercise to detect complications like arrhythmias or ischemia. Progress intensity and frequency gradually, depending on patient tolerance. - Progression: Aim for moderate-intensity aerobic exercise (40-60% of HRR) for 30-60 minutes, 4-5 days per week, after 8 weeks, alongside light resistance exercises to improve overall strength and endurance. - Aerobic exercise 1: Walking - F = 3-5 days p/w - I = RPE 9-11 - T = start with 10min → progress to 20-30min - T = walking on flat ground, treadmill or outdoor - Clinical reasoning: low impact accessible form of aerobic exercise that promotes CV fitness without excessive strain on the sternum. Up circulation Down deconditioning Down Blood clot risk Instructions for Patient (First Session): 1. Warm-up (5 minutes): Start with a slow walk on flat ground or on a treadmill. Keep your arms relaxed at your sides and take deep, steady breaths. The goal is to slowly elevate your heart rate and warm up your muscles. RPE (Rating of Perceived Exertion) should be 6-8 (very light). 2. Main Exercise (Walking): Walk at a comfortable pace, aiming for a RPE of 9-11 (light exertion). Your breathing should be steady, and you should be able to maintain a conversation. Duration: Start with 10-15 minutes at a comfortable pace, with the goal of eventually increasing to 30 minutes as you progress. Intensity: Keep heart rate within 20 bpm above your resting heart rate. If you feel any chest discomfort, unusual shortness of breath, or dizziness, stop and rest. 3. Symptom Management: If you experience angina or chest pain, stop immediately and take note of how intense the pain is. Use your prescribed GTN spray if necessary. Keep a close eye on shortness of breath or unusual fatigue. If you feel faint or lightheaded, stop and sit down. 4. Cool-down (5 minutes): After your walk, reduce your speed to a slow pace for 5 minutes. This will help bring your heart rate down gradually. Breathe deeply to help oxygen flow and avoid dizziness. RPE should come back down to 6-8 during the cool-down. - Aerobic Ex 2: Stationary cycling - F = 3-5 days p/w - I = RPE 9-11 - T = start with 10min → progress to 20-30min  - T = cycling at steady pace avoiding high resistance - Clinical reasoning: controlled aerobic exercise with low stress on sternum, it is suitable for pt with limited mobility or joint issues and can be monitored for intensity. - Resistance exercise 1: Leg press (6-8 weeks after) - F= 2 days p/w - non consecutive - I= light resistance, 1-2 sets of 10-15 reps at 30-40% of 1RM - T= 1-2 sets with 2 min rest between sets - T= seated leg press, focus on Lower body strength - Clinical reasoning: after initial healing period - leg press strengthening lower body muscles without strain on sternum. Up functional capacity, walking and stairs + reduce falls risk Instructions for Patient (First Session): 1. Preparation: Sit comfortably in the leg press machine with your back flat against the seat. Place your feet shoulder-width apart on the platform, ensuring that your knees are aligned with your toes. Adjust the seat so that your knees are bent at a 90-degree angle. 2. Movement: Starting position: Hold onto the handles at the sides and take a deep breath in. Press the platform away from you using both legs, pushing through your heels while exhaling. Slowly extend your knees but avoid locking them out at the top. Lower the platform back to the starting position in a controlled manner, bending your knees as you inhale. Make sure to keep your back firmly against the seat. Perform 1 set of 10-15 repetitions with light resistance. 3. Pacing & Form: Focus on a slow and controlled movement, aiming for 2 seconds up and 2 seconds down. This ensures you engage your muscles without straining your chest or lower back. Avoid lifting your hips off the seat or using momentum to complete the movement. Keep the effort smooth and steady. 4. Symptom Management: If you feel any pain in your chest, legs, or joints, stop the exercise immediately. Monitor for any signs of fatigue, shortness of breath, or dizziness. If any occur, take a rest and alert your clinician. 5. After the Exercise: Once you finish your set, rest for 1-2 minutes before performing a second set (if prescribed). Check in with how you’re feeling between sets. Always keep communication open with your clinician to ensure your safety during the exercise. - Resistance ex 2: Seated row (6-8 weeks after) - F= 2 days p/w - non consecutive - I= light resistance, 1-2 sets of 10-15 reps at 30-40% of 1RM - T= 1-2 sets with 2 min rest between sets - T= seated row with controlled  - Clinical reasoning: seated row strengthens the upper back and arms while minimizing strain on the chest and considering KMIT. Improves posture and upper body function. - Percutaneous coronary intervention (Stent) - a procedure to open up narrowed or blocked coronary arteries which supply blood to the heart. improving blood flow to the heart in pt with CAD. - Ask relevant subjective Q’s - Manual HR and Rhythm check - Resting BP - SPO2 - ECG if possible - Ex Cap. 6MWT - NeuroMusc. strength (30s or 5x STS) - Depression and QOL Q’s - Risk stratification - Low risk: no residual ischemia post stent, good functional capacity and no or minimal symptoms + no significant arrhythmias or HF post surgery - moderate risk: residual ischemia or some symptoms of angina during moderate exertion, hypertension and diabetes (comorb) are under control, reduced functional capacity post stent - high risk: recurrent angina or signs of ischemia post PCI, uncontrolled comorb + low functional capacity or significant arrhythmias - Contraindication to exercise - unstable angina, or recurrent chest pain post surgery - significant arrhythmias or unstable HF - uncontrolled hypertension 180/110 or higher - recent MI or complications from PCI - Clinical considerations for exercise prescription - intensity: being with low to moderate intensity, depending on functional capacity and risk. Use RPE 4-6 and 40-60% of max HR - type of exercise: - Aerobic: cycling, walking, swimming - improve CV endurance - 150min moderate per week over 5 days - Resistance: light resistance training to improve strength while minimizing stress on CV system - 2-3 days p/w, major muscle groups, 2sets x10-15 - Avoid isometric exercises (heavy lifting) as this will increase BP - monitor in early stages, track symptoms of chest pain, dizziness, or shortness of breath. educate patient on recognizing signs such as chest discomfort, fatigue or dyspnea  - Aerobic Exercise: Walking - Frequency: 5 days per week - Intensity: Low to moderate (40-60% of maximum heart rate or 4-6 on the Rate of Perceived Exertion (RPE) scale) - Time: Start with 20-30 minutes, gradually increasing as tolerated - Type: Walking on a flat surface, either outdoors or on a treadmill - clinical reasoning: walking is low impact, accessible and low impact, easy for monitoring post PCI. Improves CV endurance without excessive stress on heart. - Aerobic Exercise: Stationary Cycling Frequency: 3-5 days per week Intensity: Moderate (40-60% of maximum heart rate or 4-6 on the RPE scale) Time: 15-30 minutes, gradually increasing duration as fitness improves Type: Stationary cycling on a recumbent or upright bike - Clinical reasoning: controlled environment to monitor all comorb and risks while improving CV endurance and not having great strain on the heart. Low loading and suitable for pt with joint issues or mobility. - Resistance Exercise: Seated Dumbbell Shoulder Press - Frequency: 2-3 days per week - Intensity: Light (50-60% of 1RM, starting with light weights such as 1-3 kg) - Time: 1-2 sets of 10-15 repetitions - Type: Seated dumbbell shoulder press - clinical reasoning; targets upper body strength while miantaining seated position which is safer for post PCI pt. start with light weights, prevent overexertion and prevents high BP or HR. progress slowly. - Resistance Exercise: Bodyweight Squats (Chair-assisted if needed) - Frequency: 2-3 days per week - Intensity: Light to moderate (using body weight or chair assistance to begin) - Time: 1-2 sets of 10-15 repetitions - Type: Bodyweight squats or chair-assisted squats - Clinical reasoning: lower body strength and functional mobility while increasing ability to complete ADL’s independently. chair provides stability and reduces falls risk. low impact on CV system while increasing lower body strength Aerobic Exercise: Walking Warm-Up (5-10 minutes): Begin with gentle movements like arm circles and leg swings. Walk at an easy pace for 5 minutes to gradually increase your heart rate. Main Exercise: Intensity: Aim for 40-60% of maximum heart rate (RPE of 4-6, moderate intensity where you can talk comfortably but feel exertion). Walk for 15-30 minutes, depending on your comfort level. Symptom Management: If you experience chest pain, shortness of breath, or unusual fatigue, stop immediately and rest. Cool-Down (5-10 minutes):  Gradually slow down your pace for 5 minutes. End with gentle static stretches focusing on your legs and back. Resistance Exercise: Bodyweight Squats (Chair-Assisted) 1. Starting Position: Stand with your feet shoulder-width apart, in front of a chair. 2. Movement: Slowly bend your knees and lower your hips as if sitting back in the chair. Keep your back straight, and don’t let your knees go beyond your toes. Once your thighs are parallel to the ground (or as low as comfortable), press through your heels to stand back up. 3. Repetitions: Perform 1-2 sets of 10-15 reps. Demonstration: Guide the assessor through the exercise, emphasizing form and breathing (inhale on the way down, exhale when standing up). - Myocardial infarction (STEMI / NSTEMI) - occurs when blood flow to a part of the heart is blocked, leading to damage of the heart muscle. 2 classifications: - STEMI: more severe type, complete blockage of a coronary artery results in significant damage to the heart muscle - ECG shows ST-segment elevation, indicating a full thickness injury to heart wall - NSTEMI: - Partial blockage of a coronary artery, causing less extensive heart damage. - ECG does not show ST segment elevation but may reveal other signs of ischemia - Ask relevant subjective Q’s - Manual HR and Rhythm check - Resting BP - SPO2 - ECG if possible - Ex Cap. 6MWT - NeuroMusc. strength (30s or 5x STS) - Depression and QOL Q’s - RIsk stratification - Post MI patients are at moderate to high risk for future cardiac events, especially those with left ventricle ejection fraction (LVEF) or comorbidities like hypertension and diabetes - Contraindication/precautions: - Unstable angina, significant arrhythmias and uncontrolled hypertension are contraindications - patients on Beta blockers require adjusted exercise intensity  - Safe to exercise after medical clearance, engage in low to moderate intensity exercise with aerobic and resistance training, beginning with light intensity and close monitoring - clinical consideration - Gradual progressive overload to reduce rick of impaired cardiac output - symptoms of angina must be closely watched - Aerobic exercise 1 walking - F = 3-5 days p/w - I = 40-60% of VO2max or RPE9-11 - T = 10-30 min per session - T = low impact walking on flat surface - clinical reasoning: safe low impact. UP CV endurance, no strain on heart, gradual adaptation of CVS, monitoring breathlessness or chest discomfort - AerEx 2 cycling - F = 3 days p/w - I = 40-60% of VOmax or RPE 9-12 - T = 20-25 min - 5min warm up and cool down - T = stationary cycling- non weight bearing - clinical reasoning: controlled movement with minimal risk of injury or imbalance. Up CV health and maintain moderate intensity avoid overexertion - Rx EX 1 Seated leg press - F = 2-3 days per week - I = 30-40% of 1RM (light to moderate load) - T = 1-2 sets of 10-12 repetitions - T =: Lower body resistance exercise focused on strengthening the quadriceps, hamstrings, and glutes. - Clinical reasoning: Seated leg press is a functional exercise that promotes lower body strength without placing undue stress on the cardiovascular system. This is important for improving daily activities like walking and standing, while maintaining heart safety through controlled intensity. - Rx EX 2 seated chest press - F = 2 days per week - I = 30-40% of 1RM - T = 1-2 sets of 10-12 repetitions - T = Upper body resistance exercise focusing on the chest, shoulders, and arms. - Clinical Reasoning: The seated chest press helps improve upper body strength and endurance, especially for activities of daily living (ADLs). Keeping the intensity moderate and using seated equipment ensures safety and allows for better control of effort, minimizing strain on the heart. Aerobic Exercise: Walking Warm-up: 5-10 minutes at a slow pace. Main Exercise: Walk for 20 minutes at a moderate pace (RPE 9-11). Cool-down: 5 minutes at a slow pace. Monitoring: Watch for chest pain, shortness of breath, and adjust intensity accordingly. Resistance Exercise: Seated Leg Press Setup: Seated, back against the seat, knees at 90 degrees. Exercise: Push platform with legs, avoiding full knee extension. Start with light weight (30-40% 1RM), 1 set of 10-12 reps.  Breathing: Exhale while pushing, inhale while lowering. Monitoring: Ensure controlled movements and check for comfort. Both exercises emphasize safety, gradual intensity, and careful symptom monitoring. - Heart failure with reduced ejection fraction (HFREF) - HFREF is a condition where the left ventricle cannot pump blood efficiently leading to a reduced EF (typically 40% or less). meaning the heart struggles to pump enough blood for the body's needs - Ask relevant subjective Q’s - Manual HR and Rhythm check - Resting BP - SPO2 - weight changes - signs of liquid retention (swelling and Oedema) - ECG if possible - Ex Cap. 6MWT - NeuroMusc. strength (30s or 5x STS) - Depression and QOL Q’s - Risk stratification - low risk if stable HFREF w no recent hospitalizations and higher or equal 35% EF - moderate risk if history of mild symptoms and lower than 35% EF but stable on optimal medical management - high risk if recent hospitalization for HF or significant arrhythmias and presence of significant comorbidities - Contraindications to exercise - Absolute con - uncontrolled arrhythmias and hypertension (180 over 110 or high) - severe aortic stenosis or recent myocardial infarction - Relative con - moderate to severe HF symptoms - significant pulmonary hypertension - recent hospitalization for HF exacerbation - clinical considerations for exercise prescription - diagnosis : HFREF requires careful consideration of intensity and volume - pathophysiology: compromised cardiac output and need for gradual progression - procedure: cardiac rehab program indicated - symptoms: monitor for dyspnea, fatigue, and signs of worsening heart failure - comorbidities: diabetes or hypertension - Aerobic ex 1 - walking - F = 3-5 days p/w - I = RPE 11-13 approx 40-60% of VO2 reserve - T = 20-30 min per session gradually increasing to 40 min as tolerated - T = walking on flat surface - clinical reasoning: low impact, easily modified and measurable according to the pt functional capacity and tolerance, moderate intensity to improve CV  endurance without exacerbating symptoms. gradual progression allows for adaptation while minimizing the risk of HF symptoms - Aerobic ex 2 - stationary cycling - F = 3-5 days p/w - I = RPE11-13 approx. 40-60% of VO2 reserve - T = 15-20min gradually increase to 30-40min as tolerated - T = stationary cycling - clinical reasoning: low impact, reduces load on joints, controlled environment, low to moderate intensity for pt of HFREF, UP CV fitness while reducing the risk of overexertion. adjusted for resistance allowing for gradual strength gain without excessive strain - Resistance Ex 1 BW exercises - F = 2 days p/w non consecutive - I = light to moderate intensity RPE 11-13 - T = 2 sets of 8-12 reps of each exercise - T = Box squats, wall push ups, situps, bench tricep dips - clinical reasoning: BW exercise focus on improving functional strength and stability for ADL’s, light to moderate intensity ensures safely while providing challenge to allow for neuromuscular gains strength and endurance. - Resistance Ex 2 resistance bands exercises - F = 2 days p/w non consecutive - I = RPE 11-13 - T = 2 sets of 10-15 reps - T = Resistance bands squats, seated rows, chest press, bicep curls, tricep extensions - clinical reasoning: Safe intro to resistance training, strengthen main muscles groups without putting excessive strain on CV system, RT bands allow for easy manipulation of factors such as weight, positions and grips 1. Aerobic Exercise: Walking (Treadmill or Outdoor) Warm-Up: Start with 5 minutes of slow walking at an easy pace (RPE 9-10) to gradually increase heart rate and loosen muscles. Main Exercise: Walk for 20 minutes at a moderate pace (RPE 11-13), aiming for a steady, comfortable rhythm. Intensity Monitoring: Use the RPE scale to stay within 11-13, ensuring you can talk without difficulty. Symptom Management: If you experience shortness of breath, dizziness, or chest discomfort, slow down immediately and inform me. Cool-Down: Finish with a 5-minute slow walk (RPE 9-10) to bring your heart rate down gradually. 2. Functional Resistance Exercise: Sit-to-Stand Instructions: Sit in a sturdy chair with your feet flat on the ground, hip-width apart. Cross your arms over your chest. Slowly stand up using only your legs, focusing on pushing through your heels. Lower yourself back down slowly and repeat for 8-12 reps. Form Cues: Keep your back straight and engage your core while standing.  Intensity: Start with 1-2 sets of 8-12 repetitions, adjusting based on comfort. Use RPE 11-12 for a light but manageable effort. Progression: As you get stronger, we can increase repetitions or add resistance (e.g., holding a small weight). - Open heart valve surgery (KMIT) - Procedure to repair or replace a damaged heart valve. It involves opening the chest and stopping the heart so the surgeon can work on the valve. The valves may need repair due to conditions like stenosis or leakage. - Ask relevant subjective Q’s - Manual HR and Rhythm check - Resting BP - SPO2 - sternal stability assessment - ECG if possible - Ex Cap. 6MWT - NeuroMusc. strength (30s or 5x STS) - Depression and QOL Q’s - Risk Stratification - patients at a moderate to high risk for cardiac events based on age, surgery type, and comorbidities such as heart failure, diabetes or hypertension - ContraIn for exercise - unstable angina, severe heart failure, uncontrolled arrhythmias, or signs of infection are contraindication - Safety to exercise - Once cleared by a cardiologist, patients can engage in low to moderate intensity exercise under supervision, with close monitoring of HR and BP - Aerobic ex 1 - Walking - F = 3-4 times p/w - I = RPE 11-13, HR 20-30BPM above resting - T = 10-15min then gradual increase to 30min - T = continuous walking on flat surface - Clinical reasoning: Walking is a low-impact activity that improves cardiovascular endurance without overstressing the heart. It allows for easy heart rate and symptom monitoring, making it safe for early recovery. - Aerobic ex 2 - stationary cycling - F = 3x p/w - I = RPE 11-13 - T = 10 min gradual increase to 20-30 min - T = Steady state cycling with no resistance or light resistance - Clinical reasoning: low impact, improving aerobic capacity, controlled intensity and lower risk of CV strain - Resistance ex 1 - seated leg press - F = 2x pw - I = RPE 9-12 2x8-12 - T = 10-15 min 2-3 min rest between sets - T = controlled concentric and eccentric movements  - Clinical reasoning: strengthen lower body, less strain on heart and joint, seated leg press works large muscle groups and safely lower CV demand - Resistance ex 2 - seated bicep curls - F = 2x pw - I = RPE 10-12 2x10-15 reps - T = 10-12 min with rest between sets 2 mins - T = slow controlled reps with proper breathing to lower strain on heart - clinical reasoning: upper body resistance training helps restore muscle hypertrophy without putting pressure on the heart, using light weights will help build strength gradually while ensuring a safe recovery and considering the KMIT 1. Aerobic Exercise: Walking Warm-up: Begin with 5-7 minutes of slow walking to gradually increase heart rate. Main Session: Walk for 10 minutes at a light intensity, using the RPE scale (11-13). The pace should allow for easy conversation. Symptom Management: Monitor for chest pain, dizziness, or shortness of breath; stop immediately if symptoms occur. Cool-down: Finish with 5 minutes of slow walking, focusing on deep breathing to lower heart rate. 2. Functional Resistance Exercise: Seated Leg Press Starting Position: Sit on the leg press machine with back flat and feet hip-width apart on the platform. Execution: Slowly press the platform away, extending legs without locking the knees. Return to the starting position with control. Repetitions: Perform 1-2 sets of 8-12 reps at a light intensity, avoiding holding your breath during the exercise. - Stable angina - chest pain or discomfort that occurs with exertion or stress and is typically relieved by rest or medication. Often a symptom of CAD, where the heart muscle does not receive enough blood due to narrowed or blocked coronary arteries. - Ask relevant subjective Q’s - Manual HR and Rhythm check - Resting BP - SPO2 - ECG if possible - Ex Cap. 6MWT - NeuroMusc. strength (30s or 5x STS) - Depression and QOL Q’s - risk stratification - low risk: asymptomatic at rest, good functional capacity, no significant comorbidities - moderate risk: symptoms with mild exertion, controlled comorbidities, slightly impaired functional capacity - high risk: symptoms at rest, uncontrolled comorbidities, history of recent acute coronary events - contraIn to exercise - Unstable angina or recent myocardial infarction  - severe aortic stenosis - uncontrolled hypertension - significant arrhythmias or severe heart failure - Exercise prescription considerations - low to moderate intensity 40-60% of max HR - aerobic activities (walking cycling), flexibility training and strength training - 150min of moderate-intensity exercise weekly, short sessions if needed - monitor for angina - teach symptom recognition and proper use of meds - Aerobic ex 1 - Walking - F = 3-4 times p/w - I = RPE 11-13, HR 20-30BPM above resting - T = 10-15min then gradual increase to 30min - T = continuous walking on flat surface - Clinical reasoning: Walking is a low-impact activity that improves cardiovascular endurance without overstressing the heart. It allows for easy heart rate and symptom monitoring, making it safe for early recovery. - Aerobic ex 2 - stationary cycling - F = 3x p/w - I = RPE 11-13 - T = 10 min gradual increase to 20-30 min - T = Steady state cycling with no resistance or light resistance - Clinical reasoning: low impact, improving aerobic capacity, controlled intensity and lower risk of CV strain - Resistance ex 1- BW squats - F = 2-3days pw - I = 50-70% of 1RM - start with BW for beginners - T = 1-2 sets of 10-15 reps - T = BW squats or assisted squats using a box or chair - Clinical reasoning: BW squats enhance lower body strength and functional mobility. start with BW to allow the patient to focus on form without straining the heart. - resistance ex 2 - Shoulder press DB - F = 2-3 days pw - I = 50-70% 1RM starting with light weights - T = 1-2 sets of 10-12 reps - T = seated DB press - Clinical reasoning: this exercise targets upper body strength while maintaining a stable seated position, safer for CV conditions. using light weights minimizes risk of excessive exertion, allowing for effective strength training without triggering angina symptoms - Aerobic Exercise: Walking - Warm-Up (5-10 minutes): - Dynamic movements: Arm circles, leg swings, and gentle torso twists. - Easy walking: Walk slowly for 5 minutes to prepare the body. - Main Exercise: - Duration: Aim for 30 minutes (start with 10-15 minutes if needed). - Intensity: Target 40-60% of maximum heart rate using the Rate of Perceived Exertion (RPE) scale (aim for 4-6 on the scale). - Symptom Management:  - Monitor for chest discomfort or unusual fatigue; stop if symptoms occur and rest. - Cool-Down (5-10 minutes): - Slow down walking: Gradually reduce pace for 5 minutes. - Static stretches: Focus on major muscle groups to enhance flexibility. - Resistance Exercise: Bodyweight Squats - Preparation: Stand with feet shoulder-width apart, engage the core. - Instructions: - Squat down: Bend knees, push hips back, keeping chest up and back straight. - Return to standing: Press through heels to stand up, ensuring knees don’t extend beyond toes. - Repetitions: Perform 1-2 sets of 10-15 repetitions; rest as needed. - Breathing: Inhale when lowering, exhale when standing up. - Demonstration: guide the patient through the squat, emphasizing form and breathing. - These instructions aim to provide a safe and effective exercise session for a patient with stable angina, ensuring proper warm-up, exercise management, and cool-down strategies. Medications 1. coronary artery bypass graft CABG a. Beta blockers: reduced HR and prevent arrhythmias post surgery b. Nitrates: Occasionally used to manage chest pain post surgery c. Calcium channel blockers: sometimes used if beta blockers are contraindicated to control HR and BP d. ACE inhibitors/ARB: long term management of BP and reduced risk of HF e. Diuretics: used if fluid retention occurs post surgery 2. Percutaneous coronary intervention (stent) a. beta blockers: prescribed to reduce stress on heart and control HR b. Nitrates: relieve angina post surgery c. Calcium channel blockers: used in pt with refractory angina or instead of beta blockers d. ACE inhibitors/ARB: long term BP management and protect heart function e. Diuretics: used incase of fluid retention post surgery 3. Myocardial infarction (STEMI/NSTEMI) a. Beta blockers: post MI to reduce morality, control HR, and reduce O2 demand b. Nitrates: manage chest pain in acute phase of MI  c. Calcium channel blockers: considered in pt who cannot take beta blockers or manage angina d. ACE inhibitors/ARB: given to all post MI pt to improve heart function, reduce BP and prevent remodeling e. Diuretics: used in HF post MI or if fluid overload occurs 4. HFREF a. Beta Blockers: core to reduce mortality and improve heart function b. Digoxin: used in symptomatic HF to improve contractility and control arrhythmias c. Diuretics: essential to manage fluid overload and reduce symptoms such as oedema d. ACE inhibitors/ARB: main therapy to reduce mortality, improve heart function and prevent disease progression e. Nitrates and Calcium channel blockers: sometimes used for symptom management. 5. Open heart valve surgery a. Beta blockers: used to manage arrhythmias or prevent excessive stress on the heart post surgery b. diuretics: used post surgery to manage fluid retention or reduce strain on heart c. ACE inhibitors/ARB: may be used if the pt has concurrent HF or hypertension d. nitrates and calcium channel blockers: rarely used unless pt has underlying angina or BP issues. 6. Stable angina a. Beta blockers: first line therapy to reduce HR and prevent angina attacks by lowering O2 demand b. Nitrates: used for immediate relief of angina symptoms and sometimes in long acting forms to prevent episodes c. calcium channel blockers: used when beta blockers are insufficient or contraindicated, especially in vasospastic angina d. ACE inhibitors/ARB: used to manage hypertension and reduce overall CV risk e. Diuretics: rarely used unless there’s concurrent HF or fluid retention Subjective: ⮚ What are your symptoms? What are the triggers for your symptoms? How have your symptoms been before and after the intervention? How do the symptoms feel? Do you know how to treat your symptoms/do you have an action plan for your symptoms? ⮚ How are you feeling today? ⮚ What medications are you currently taking? Have you taken all your medications before today’s session? ⮚ What would you like to achieve with this cardiac rehabilitation program? What goals do you have for yourself with this program? ⮚ What are your current levels of physical activity? Do you play any sport or do any structured exercise?  ⮚ What are your current barriers to physical activity/exercise? Motivation, time, knowledge, MSK injuries? ⮚ Ask about other co-morbidities o Have you ever smoked cigarettes? Have you ever considered quitting? What barriers are stopping you from quitting? o Do you drink alcohol? o T2D – how long have you had T2D for? What medications are you taking for it, or are you lifestyle controlled? What symptoms does this condition cause for you? o HF – have you noticed a change in your weight of around 2kg in the last 2 days? What symptoms does this condition cause for you? Have you discussed with your other specialists about dietary adjustments and 4Ws? o Pacemaker – for what reason did you get the pacemaker? What are the triggers for dysrhythmia? What kind of pacemaker do you have? What are your intervention thresholds? Sequence of therapy? Objective: ⮚ Manual HR and rhythm check ⮚ Resting BP ⮚ Oxygen saturation (SPO2) ⮚ Anthropometry (height, weight, hip/waist circumference) ⮚ BGL (for diabetes) ⮚ Sternal stability assessment (if open heart surgery) ⮚ ECG (if possible) ⮚ Weight changes (HF) ⮚ Signs of liquid retention like swelling and oedema (HF) ⮚ Foot check (diabetes) ⮚ Exercise capacity test (Maximal, GXT, or 6MWT/LCDW) ⮚ Neuromuscular strength (1RM, 1RM equation estimations, 30 s STS, 5STS) ⮚ Depression and QOL questionnaire Impression: Risk stratification: refer to slide Contraindications: refer to slide Considerations:  ⮚ Risk stratification + presence of HFrEF informs intensity of exercise prescription (refer to slide) ⮚ If CAD/angina – monitor for symptoms of angina and SOB + educate on angina management. Keep HR 10bpm below anginal threshold ⮚ If HF – reduced exercise tolerance due to leg fatigue, skeletal muscle dysfunction, lactate accumulation at lower work rate, decreased CO leads to increased SOB. Exertional hypotension may occur ⮚ If taking BP lowering meds (ARB, ACEI, CCB, nitrate) – monitor for hypotension ⮚ If open heart surgery (e.g. CABG, mitral valve replacement) – monitor for symptoms of pain and sternal instability + upper body restrictions with median sternotomy (Keep your moves in the tube) ⮚ If have AF – ensure compliant with taking anticoagulants, monitor for irregular ventricular rates, HR should be assessed manually, age-predicted HR not valid, HR not valid for intensity measure ⮚ If have pacemaker – 3-4 wks after implant avoid rigorous UE activities and prescribe LE activities. 4-6 wks, avoid elevating arms above 90 degrees. For ICF, maintain HR 10-15 bpm below defibrillation threshold, for patients with history of ICD discharges, choose modalities where lose of consciousness would be less harmful. ⮚ ECG monitoring if available ⮚ If on HR changing meds like BB – intensity monitoring should not rely on HR only as predictive max HR equations aren’t accurate ⮚ For people with diabetes – monitor for signs of hypoglycemia, post session BGL reading to ensure safe to drive ⮚ For people on diuretics – increase risk of volume depletion, orthostatic hypotension, dehydration -> so BP response in ex and recovery should be monitored with symptoms, and extended cooldown can be helpful to prevernt post-ex hypotension. ⮚ BB and diuretics can impair thermoregulatory function ⮚ Extended warm-up for stable angina, CHF, VVI or metabolic sensing pacemakers ⮚ Prolonged cool down for stable angina, CHF, patients with pacemakers, patients on diuretics/multiple BP meds ⮚ Additional relevant education based on risk factor profile – smoking, mental health, sedentary lifestyle, hypertension, high cholesterol etc. ⮚ Consideration for past sport/PA and their goals (e.g. past in swimming, rehab structured to help patient be able to swim again + education on return to sport) Exercise plan: Other resources: