Cardiac Intervention/Cardiac Rehab 2024 PDF

Cardiac Intervention/Cardiac Rehab Heidi Tymkew PT, DPT, MHS Board Certified Clinical Specialist in Cardiovascular & Pulmonary Physical Therapy Exercise Prescription F: Frequency (how often) I: Intensity (how hard) T: Time (duration or how long) T: Type (mode or what kind) Should...

Cardiac Intervention/Cardiac Rehab Heidi Tymkew PT, DPT, MHS Board Certified Clinical Specialist in Cardiovascular & Pulmonary Physical Therapy Exercise Prescription F: Frequency (how often) I: Intensity (how hard) T: Time (duration or how long) T: Type (mode or what kind) Should include a warmup and cool down with all exercise sessions Need to monitor vital signs during exercise training  Determine Maximum Heart Rate If a formal exercise test has been performed, then that max HR should be used and not a calculated HR Methods to determine Max Heart Rate Max HR = 220-age (healthy individuals < 40 years of age) Max HR = 208 – (0.7*age) (for older adults or those with pathology) Tanaka Method Example: 60-year-old male Method #1 - Max HR = 220 – age = 220-60 = 160 bpm Method #2 – Max HR = 208 – (0.7*60) = 208 – 42 = 166 bpm  Determine Target HR Zone Ways to determine the target HR zone Target HR = Max HR x intensity Heart Rate Reserve (Karvonen Formula) HHR = ([Max HR – Resting HR] * Intensity) + Resting HR Example: 60-year-old male at a 40-60% exercise intensity; had an exercise stress test that determined his max HR to be 166 bpm and his resting HR is 66 Method #1: 166 * 40% = 66 bpm and 166* 60% = 100 bpm Method #2: ([166-66]*40%) + 66 = 106 bpm ([166-66]*60%) + 66 = 126 bpm  Intensity (ACSM, 2022) Intensity % Heart Rate % Max HR RPE (6-20 Scale) Reserve Very light 96 Very hard maximal (RPE > 18)  Normal Vital Sign Response Heart Rate Gradual increase in rate with an increase in workload - HR ↑’es 10 beats per MET level SBP Gradual increase in with an increase in workload - SBP ↑’es 10 beats per MET level DBP + 10 mmHg with any activity Respiratory Gradual increase with workload Rate SpO2 Stays the same or increases  ▪ Excessive increase in heart rate ▪ Flat or Decrease in heart rate ▪ Hypertensive BP response (SBP > 210 mmHg and/or DBP > 110 mmHg) ▪ A decrease in SBP by > 10 mmHg with activity Abnormal Response to ▪ Failure of SBP to increase with increase of activity Exercise ▪ Changes in DBP > + 10 mmHg ▪ A significant change in cardiac rhythm Cardiac Rehabilitation Multidisciplinary, comprehensive exercise, education and behavior modification program that is designed to improve the physical and emotional condition of individuals with heart disease  Improves physical fitness Reduces hospitalization & mortality Benefits of Reduces CV risk factors (HTN, DM, Cardiac Obesity, Smoking) Rehab Reduces stress and anxiety Improves quality of life  Cardiac Rehab Utilization Only 19-34% of patients eligible for cardiac rehab participate in the program 25% of Medicare patients Potential Barriers Lack of physician referral Lack of perceived need/awareness of CR Limited healthcare coverage/cost Work/home responsibilities Distance to facility Transportation Language barriers https://www.heart.org/-/media/Files/About-Us/Policy- Research/Fact-Sheets/Clinical-and-Post-Clinical-Care/FACTS- Cardiac-Rehab.pdf 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 that may benefit from structured exercise and/or patient education based on physician referral & consensus of rehabilitation team (ACSM 11th Ed, CH 8)  Contraindications for Cardiac Rehab Unstable angina Active pericarditis or myocarditis Uncontrolled hypertension (resting SPB > Recent embolism (pulmonary or systemic) 180mmHg, resting DBP > 110mmHg) Acute thrombophlebitis Orthostatic blood pressure drop of >20 Aortic dissection mmHg with symptoms Acute systemic illness or fever Uncontrolled diabetes mellitus Significant aortic stenosis (valve area < 1.0cm2) Severe orthopedic injuries that would Uncontrolled atrial or ventricular prohibit the exercise arrhythmias Other metabolic conditions such as acute Uncontrolled sinus tachycardia (>120 bpm) thyroiditis, hypokalemia, hyperkalemia, or hypovolemia (until adequately treated) Uncompensated heart failure Severe psychological disorder Third-degree atrioventricular block without pacemaker (ACSM 11th Ed, CH 8) Cardiac Rehab Phases 1 2 3 4 Phase I Phase II Phase III Phase IV Acute, hospital Early outpatient or Training and Disease prevention Begins when patient intensive monitoring maintenance program medical stable after Within days of discharge End of phase II → High risk for infarction MI, CABG, PTCA, valve → 6-12 weeks, depends indefinitely, large group due to risk factor profile, repair, CHF or heart on patient needs/MD exercise, continued those that wish to be transplantation referral progress in exercise followed by supervision program on trained personnel  Inpatient Cardiac Rehab Occurs during the hospitalization after an acute cardiac event or procedure Early mobilization Assessment of the patient’s level of readiness for physical activity Identification of and education about CVD risk factors Comprehensive discharge planning Referral to outpatient cardiac rehab Inpatient Cardiac Rehab Parameters for Inpatient Cardiac Rehab No new or recurrent chest pain in previous 8 hours Stable or falling Troponin values No indication of decompensated heart failure (i.e., resting dyspnea and bibasilar rales) Normal cardiac rhythm and stable EKG for previous 8 hours Hemodynamically stable (AACVPR, 2013 & Hillegass, 2017) FITT Recommendations for Inpatient Cardiac Rehabilitation (ACSM 11th Ed, Chapter 8) Aerobic Flexibility Frequency 2-4 sessions/ day for the first 3 days of the hospital Minimally once per day but as stay often as tolerated Intensity Seated or standing HRrest + 20 bpm for patients with Very mild stretch discomfort MI, + 30 bpm for patients recovering from heart surgery, Upper limit of 210 mmHg) or DBP (> 110 mmHg) Drop in SBP (>10 mmHg) with low level exercise Symptoms with activity 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 EKG abnormality  Overview of cardiac condition Potential Benefits of exercise Monitoring of activity (HR, BP, RPE) Education Home exercise program Topics for Post surgical precautions Inpatient Sternal precautions Pacemaker precautions Cardiac Post cardiac cath precautions Rehab Outpatient cardiac rehab PT Goals for the Acute Care Setting Cardiac Rehab Phases 1 2 3 4 Phase I Phase II Phase III Phase IV Acute, hospital Early outpatient or Training and Disease prevention Begins when patient intensive monitoring maintenance program medical stable after Within days of discharge End of phase II → High risk for infarction MI, CABG, PTCA, valve → 6-12 weeks, depends indefinitely, large group due to risk factor profile, repair, CHF or heart on patient needs/MD exercise, continued those that wish to be transplantation referral progress in exercise followed by supervision program on trained personnel Outpatient Cardiac Rehab (Phases II-III) Traditional center-based CR Traditional – 36 sessions; 3 days/wk x 12 weeks Intensive – 72 sessions; 3-4 hours/day x 2 days/wk x 9 weeks Incorporates exercise and in-depth education about nutrition, stress management, sleep and activity Pritikin ICR program Ornish Program Home based CR May be an option for clinical low to moderate patients who are eligible for CR but cannot attend a traditional center-based program  MI within past 12 months CABG surgery Medicare Current stable angina Heart valve repair or replacement Coverage Coronary angioplasty or stent for Cardiac Heart or heart-lung transplant Stable chronic heart failure (HFrEF) Rehab EF < 35% Stable on medical therapy without hospitalization x 6 weeks Cardiac Rehab Components Development & implementation/supervision of a safe and effective personalized exercise plan Cardiovascular risk factor assessment & counseling on aggressive lifestyle management Education & support to make health lifestyle changes to reduce the risk of a secondary cardiac event Monitoring with a goal to improve blood pressure, lipids/cholesterol, and diabetes mellitus Psychological/stress assessment & counseling Communication with each patient’s physician and other health care providers regarding progress & relevant medical issues Return to appropriate vocational & recreational activities (ACSM 11th Ed, CH 8) Cardiac Risk Stratification – Low Risk Uncomplicated MI, CABG, angioplasty, or atherectomy Absence of CHF or signs/symptoms indicating post event ischemia Functional capacity  7 METs (if measured) Asymptomatic with exercise or in recovery, including absence of angina No resting or exercise- induced complex dysrhythmias Ejection fraction  50% Normal hemodynamic and EKG response to exercise and in recovery Absence of clinical depression or depressive symptoms (AACVPR Risk Stratification) Cardiac Risk Stratification – High Risk Ejection fraction < 40% Complex ventricular dysrhythmias (VT > 6 beats/min; multiform PVCs) at rest or with exercise Signs/symptoms including angina, dizziness, light-headedness or dyspnea at low levels of exercise (< 5 METs) Maximal functional capacity of less than 5.0 METs (if measured) MI or cardiac surgery complicated by CHF, shock, and/or signs/symptoms of post procedure ischemia Survivor of cardiac arrest Abnormal hemodynamics with exercise, especially flat or decreasing SBP with increase workload Significant silent ischemia (ST depression 2mm or greater without symptoms) with exercise or in recovery Clinically significant depression or depressive symptoms (AACVPR Risk Stratification) Cardiac Risk Stratification – Moderate Risk Ejection fraction 40%-50% Mild to moderate silent ischemia (ST depression less than 2mm) with exercise or in recovery Signs/symptoms including angina at “moderate” levels of exercise (60-70% of maximal functional capacity) or in recovery (AACVPR Risk Stratification) FITT Recommendations for Outpatient Cardiac Rehab (ACSM 11th Ed, Chapter 8) Aerobic Resistance Flexibility Frequency Minimally 3 days/ week, preferable 2-3 non-consecutive days/week >/= 2-3 days/ week with 5 days/ week daily being most effective Intensity With an exercise test, use 40-80% Perform 10-15 repositions of each To the point of feeling of exercise capacity using HRR, exercise without significant fatigue; tightness or discomfort VO2R, or VO2peak RPE 11-13 on a 6-20 scale or 40-60% of 1-RM Without exercise test, use seated or standing HRrest + 20 bpm to + 30 bpm or an RPE of 12-16 on scale of 6-20 Time 20-60 minutes 1-3 sets; 8-10 different exercise 15 second hold for static focused on major muscle groups stretching; >/= 4 repetitions of each exercise Type Arm Ergometer, upper and lower Select equipment that is safe and Static & dynamic stretching (dual action) extremity ergometer, comfortable for the patient to use focused on major joints of upright and recumbent cycles, the limbs & lower back; recumbent stepper, rower, consider PNF elliptical, stair climber, treadmills 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 with activity 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 EKG abnormality Resistance Training in Cardiac Rehab Safe in low to moderate risk cardiac patients Low weight and high reps Improvements seen after resistance training Increase in muscle strength and exercise capacity Increase in self-esteem and quality of life Reduction in frailty May improve glucose control in people with DM  Patient Eligibility for Resistance Training Resistance training should be individualized Should not require greater RPE or cardiovascular demands than aerobic exercise Participation in resistance training may begin after: A minimum of 5 weeks post MI A minimum of 8 weeks post CABG or any time of heart surgery A minimum of 2 weeks post-PTCA Exclusion Criteria for Resistance Training Uncontrolled CHF Uncontrolled arrhythmias Severe valvular disease Uncontrolled HTN (SBP ≥ 160mmHg or DBP ≥ 100mmHg) Exertional hypotension (>15mmHg) Unstable symptoms Severe orthopedic problems Marfan’s syndrome Enlarging aortic aneurysms Severe pulmonary hypertension FITT Recommendations for Outpatient Cardiac Rehab (ACSM 11th Ed, Chapter 8) Aerobic Resistance Flexibility Frequency Minimally 3 days/ week, preferable 2-3 non-consecutive days/week >/= 2-3 days/ week with 5 days/ week daily being most effective Intensity With an exercise test, use 40-80% Perform 10-15 reps of each exercise To the point of feeling of exercise capacity using HRR, without significant fatigue; RPE 11-13 tightness or discomfort VO2R, or VO2peak on a 6-20 scale or 40-60% of 1-RM Without exercise test, use seated or standing HRrest + 20 bpm to + 30 bpm or an RPE of 12-16 on scale of 6-20 Time 20-60 minutes 1-3 sets; 8-10 different exercise 15 second hold for static focused on major muscle groups stretching; >/= 4 repetitions of each exercise Type Arm Ergometer, upper and lower Select equipment that is safe and Static & dynamic stretching (dual action) extremity ergometer, comfortable for the patient to use focused on major joints of upright and recumbent cycles, the limbs & lower back; recumbent stepper, rower, consider PNF elliptical, stair climber, treadmills  Self monitoring - HR/BP Use of RPE scale Outpatient Benefits of exercise Cardiac Home exercise program Rehab Temperature precautions Signs/symptoms of exercise intolerance Education Energy conservation (PT specific) Relaxation Risk factor modification Cardiac Rehab Phases 1 2 3 4 Phase I Phase II Phase III Phase IV Acute, hospital Early outpatient or Training and Disease prevention Begins when patient intensive monitoring maintenance program medical stable after Within days of discharge End of phase II → High risk for infarction MI, CABG, PTCA, valve → 6-12 weeks, depends indefinitely, large group due to risk factor profile, repair, CHF or heart on patient needs/MD exercise, continued those that wish to be transplantation referral progress in exercise followed by supervision program on trained personnel  Self-pay supervised exercise program Maintenance Vital signs and I/T use of EKG in phase III Phase of No monitoring in phase IV Cardiac Mainly consists of endurance training Rehab Lifelong exercise  Post Sternotomy May have sternal precautions for 6+ weeks Monitor for signs/ symptoms of sternal instability (pain/discomfort, sternal Special Patient movement/instability, and sternal clicking) Populations in Pacemaker & AICD Cardiac Rehab Pacemaker precautions 3+ weeks Know pacemaker modes, HR limits & ICD rhythm detection prior to exercise With ICD, HRpeak should be 10-15 bpm below threshold  Case #1 Mr. X is a 65-year-old male who is admitted to the hospital with an acute MI. After 2 days in the CCU he is cleared to begin Phase I Cardiac Rehab. His resting vital signs include: HR 65, BP 126/70, SpO2 98% on RA What would his exercise prescription look like? Include specifics about his target heart rate would be. What education would you provide?  Case #1 What would his PT goals be? What is your discharge recommendation?  Case #1 Mr. X is walking down the hallway and starts to complain of being dizzy and fatigued. When you look at him, he looks a bit pale. What do you do?  Case #1 Mr. X’s ECG looks like this. What rhythm is he in?  Case #1 Mr. X is now going to Outpatient Cardiac Rehab 6 weeks later. He has completed an exercise stress test which shows his max heart rate to be 140 bpm. His resting vital signs are: HR 65, BP 110/70, SpO2 99% Write out your exercise prescription for this patient and include HR range. What education would you provide?  Case #1 While Mr. X is exercising on the treadmill during Outpatient Cardiac rehab you notice the following rhythm on the EKG. What do you do?  Case #2 Mrs S is a 50-year-old female who Minutes Speed HR BP had an anterior MI 7 days ago. She 1 1.0 78 126/80 has done well with her cardiac rehab 2 1.0 80 128/82 program, so she is going to walk on a 3 1.0 85 132/80 treadmill in the PT department. You 4 1.0 90 140/80 record the following data during the 5 1.0 90 140/80 first TM exercise session. 6 1.5 93 135/80 Resting HR 75 bpm, BP 122/78 7 1.5 95 135/80 She had no complaints or 8 1.5 95 133/78 arrhythmias during the session 9 1.5 97 130/78 10 1.5 97 128/78  Case #2 What is your assessment of Mrs S’s exercise response? What would you recommend for Mrs. S’s next TM exercise session?