EHR519 202430 Week 9 Revascularisation CHF testing & prescription.pdf

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Warning This material has been produced and communicated to you by or on behalf of Charles Sturt University in accordance with section 113P of the copyright act (Act). The material in this communication may by subject to copyright under the act. Any further reproduction or communication of this material by you may be the subject of copyright protection under this act. Do not remove this notice  EHR519 Week 9 Considerations, contraindications, exercise testing and prescription for: Revascularisation Chronic Heart Failure 2 Learning Outcomes be able to explain the pathophysiology of coronary artery disease; be able to explain common revascularisation procedures used to restore blood flow to the myocardium; be able to explain the pathophysiology of chronic heart failure be able to outline the risk factors, complications and co-morbidities that must be accounted for when applying exercise interventions to individuals with heart failure; be able to explain the diagnostic techniques and treatment procedures used in the treatment of chronic heart failure; 3 Revascularisation Restoration of perfusion to a body part or organ Myocardium = CABG and PCI / PTCA 4  Exercise in Patients with CAD Common for clients with CAD and associated pathologies to experience angina Angina symptoms are a cascade of events referred to as the ischemic cascade ~75% occlusion before ECG changes evident. 1. Increased plaque, = Imbalance between O2 supply and demand in the myocardium 2. Abnormal diastolic function (ventricular compliance and impaired filling) 3. Systolic abnormalities (effecting preload, afterload, ejection fraction, cardiac output etc.) 4. ECG changes – ST segment depression 5. Angina 5 Considerations - Medications 6 Cont…  Cardiac rehabilitation (CR) CR reduces the risk of future events international guidelines recommend patients have access to, and participate in CR (for secondary prevention) Modern CR are multidisciplinary; for patient assessments, risk profiles, dietary advice, psychosocial support, individualised exercise prescription and physical activity counselling NHF (Aust. & NZ) and ACRA have online resources that can provide referrers with a list of local services available for their patients Exercise-based CR reduces hospitalisations and MI rates, improves risk profile, exercise capacity and QAL in patients with coronary disease Graduated, structured exercise and physical activity are core components of comprehensive CR Exercise prescription (ExRx) and physical activity (PA) counselling benefits patients with numerous CV conditions (HF, AF, PVD, valvular diseases, pulmonary HT, recently cardio- oncology patients) CR should be patient centred, non-judgemental and respectful communication with patients/carers (= improved, engagement & outcomes) However, in doing so we need to follow evidence-based guidelines 8 Contraindications to exercise (cardiac rehab) 9  Stress Testing following Revascularisation Test Type Mode Protocol Clinical measures Clinical Implications Cardiorespiratory Treadmill Younger/fitter clients: Bruce, Ellestad HR and rhythm Arrhythmias (preferable) Older/deconditioned clients: BP Hemodynamics Naughton or Balke-Ware 12 lead ECG Myocardial ischemia Cycling Signs and Ischemic threshold Ramp protocol as they are more symptoms LV function tolerable RPE (6-20 scale) Dyspnea with Nuclear/echo exertion Unable to exercise: pharmacologic imaging, if testing instead prescribed Gas exchange analysis as prescribed Special Considerations – CABG Special Considerations – PTCA-stent Leg (or arm) and chest wounds 4-12 Reocclusion and recurrence of previous weeks healing symptoms 10 And Naughtons  Stress Testing following Revascularisation Benefits questionable port-CABG as coronary anatomy is known, but useful for CR-capacity, effects of medications etc. Best time for GXT post-CABG is resolved incision pain, blood volume and haemoglobin concentrations are normalised and skeletal muscle strength and endurance (associated with low level activity) is improving. Likely 4+ weeks post-surgery Greater accuracy of the client’s functional capacity, determining return-to-work capabilities and appropriate exercise prescription. Debate also for the timing of stress testing following PTCA Most literature suggests 1-2 days post-surgery to evaluate functional status Others have reported higher risk of thrombotic occlusion associated with exercise testing shortly after PTCA and concerns of re-occulsion Stent therapy – no controversy, stress testing post-surgery is safe, but like CABG coronary anatomy is known 12  Strength Testing following Revascularisation Test Type Mode Protocol Clinical measures Clinical Implications Resistance Isometric Peak Force and Torque Maximal strength Functional fitness Isotonic Repetition maximum protocol – BP Maintenance of Isokinetic 3 to 10RM – depending on level of HR ADLs after surgery conditioning, prior exercise and Signs and clinical condition Symptoms Special Considerations – CABG Healing at incision site No Valsalva 13  ROM Testing following Revascularisation Test Type Mode Protocol Clinical measures Clinical Implications ROM Trunk flexion Sit and Reach Posterior leg and Functional fitness Shoulder flexion, Goniometer lower back flexibility Maintenance of extension, Shoulder flexibility ADLs after surgery abduction Special Considerations Orthopaedic limitations that may affect testing 14  Exercise Prescription Inpatient – 2-5 days (CABG) or 1-2 days (PTCA-stent) Given the (short) period of time, most inpatient activity is ROM and ambulation, and education Outpatient programs Supervised Unsupervised At-home 15  Mode Frequency Intensity Duration Aerobic Walking, cycling, 4-7 d/week Asymptomatic – 40-85% 30 min rowing, stair stepper, 3d/week - HIIT HRmax Continuous or intermittent swimming, cross- RPE 11-16 (3 x 10min) – depending trainer on tolerance Symptomatic – Below ischemic or angina threshold RPE 11-16 Progression Inpatient - should start with some ambulation in hospital Week 1-4 post surgery: progress to 5 to 10 min of very light intensity multiple times a day. After 4 wk post-surgery, increase intensity to moderate levels, increase time to 15 to 30 min one or two times a day; After 6 wk or more post-surgery, working toward >30 min at moderate or better intensities OR slowly raise workload for HIIT.  Mode Frequency Intensity Duration Resistance Elastic bands 2-3d/week Select a weight such that the 12 to 15 reps, slowly Hand weights last repetitions feel somewhat increasing weight and intensity Free weights, or moderately hard without so that 8 to 10 reps provide Multistation machines inducing significant straining the appropriate response (bearing down and breath Equipment selection holding) based on patient progress (a rational progression is to use the equipment in the order listed) Progression - CABG Progression - PCI 1-4 wk post- surgery: CABS patients use little to no 1-4 wk post- surgery: PCI patients can generally start a bit resistance and primarily perform ROM exercises and earlier using light weights that can be completed for 12 to 15 some strengthening exercises that do not produce reps without producing a Valsalva effect. significant strain on the incision site. After 4 wk post-surgery: PCI patients should look to increase After 4 wk post-surgery CABS patients can start to efforts to moderate levels at this point, and ultimately all increase the amount of weight—can start with 12 to 15 revascularization patients should progress to multiple reps without Valsalva and should not have any clicking muscle group exercises, using enough resistance to or grinding of the sternotomy. produce muscular fatigue in 10 to 12 reps. Days per week and sets of each exercise should be Days per week and sets of each exercise should be individualized according to patient needs and goals individualized according to patient needs and goals Early phase discharge Mid-phase exercise Late-phase rehabilitative exercise exercise examples (2-4wks) examples (4-6wks) (6wks +) Seated leg extension (leg Lat pull-down weights) Dumbbell bent-over row Dumbbell bench press Seated or standing leg Seated row Dumbbell shoulder press curls (leg weights) Lateral dumbbell raise Front raise Standing calf raise Bicep curl (theraband) Wall push-up Triceps push-down Tricep kickback (theraband) 18  Special Considerations Incisional discomfort in chest, arm, and leg of surgical patient. Restrict upper extremity exercises until soreness resolves. Groin soreness in PCI (at catheter insertion site) Avoid HIIT in those with arrhythmia at near-maximal HR or symptoms of angina or abnormal blood pressure responses with exercise. Initial upper extremity exercises may be range of motion without resistance— progressing initially with elastic bands or 0.5 to 1.5 kg increments Slightly higher weight for movements that do not put sternal healing at risk Exercises should be selected that employ muscle groups involved in lifting and carrying. 19 Chronic Heart Failure 21  Exercise Testing Information vital for CHF clients given the high mortality risk and response to medication and appropriate exercise prescription Testing protocols are similar to those with CAD Modified Bruce, Naughton, Ramp cycle protocol Symptom-limited stress test with small workload increments Functional capacity including work rates and HR responses Needs to include ECG monitoring Identification of myocardial ischemia, ischemic thresholds, exercise-induced tachycardia, ventricular rate, atrial fibrillation Treadmill Bruce 30 s ramp protocol Cycle Ergometer Starting at ~20 W and 10 – 15 W/min increments. NOTE: VO2peak may be 10-15% lower on cycle ergo than treadmill Resuscitation and defibrillation should be available 22  Accurate assessment of functional capacity is vital for CHF patients Recommended use of a metabolic cart Key measures: VE-VCO2, VO2peak and % predicated VO2peak, ventilatory derived lactate threshold (V-LT) using the V-slope method. Avoid using prediction equations as they tend to over predict. V Slope Method in determining V-LT Plot VO2 vs VCO2 – identify VT as the where the slope of the VO2 plot increases disproportionate to VCO2, and the lines intersect. Identify blood lactate concentration at VT Functional Tests for musculoskeletal strength and endurance are useful for planning and evaluating exercise programs Timed up-and-go 6 MWT Sit-to-stand 23  Contraindications Clients with stable HF routinely undergo symptom-limited maximum cardiopulmonary exercise testing to evaluate cardiorespiratory function, and such testing has been shown to be safe Arrhythmias are common for clients with CHF If testing for ischemia, stress testing may be problematic as clients with CHF present with ECG anomalies at rest, which reduce the sensitivity of the test under exertion (i.e. LBBB, LVH, non-specific ST wave changes). Impaired thermoregulatory responses to heat exposure (Selig et al. 2010) Consider time-of-day, effect of medications, hydration, signs of heat illness, well-ventilated areas (if indoors) 24  Considerations - Medications Typically on a range of medications to reduce myocardial load and disease progression Medications that tend to improve aerobic capacity: Angiotensin converting enzyme inhibitors; Angiotensin receptor blockers; Digoxin; Diuretics; Nitrates Medications that have little effect: calcium channel blockers, statins, anti- arrhythmics and anti-thombogenics Chronic beta-adrenergic blockade – significant benefit on mortality and functional capacity Beta-blockers – mandatory in treatment of CHF: blunt HR responses Use RPE scale or actual work rates (based on prior testing) rather than HR responses 25 Considerations - Medications 26  Typical Chronotropic Responses Heart Rate Responses Lower peak HR and failure to meet >85% maximum HR (20% decrease) 180 mmHg or DBP >110 mmHg – absolute contraindication HR Tachycardia at rest – absolute contraindication Body mass Increase of more than 1-2 kg compared to previous few days (likely due to fluid retention that can lead to acute pulmonary oedema Questions relating to Chest pain (angina), worsening orthopnoea, exercise-induced dyspnoea, changes in physical and mental health and wellbeing ECG monitoring and pulse oximetry during early exercise sessions prior and during exercise 32  Exercise Prescription Clients with stable CHF, with medical clearance, are able to undertake an exercise program. Supervised 3+ weeks (progressively moved to HEP if no complications) Likely that a client with CHF has co-morbidities which need to taken into consideration during exercise prescription Moderate intensity exercise, including aerobic, resistance or a combination of the two will have clinical outcomes, improve functional capacity and improve QOL. Warm up and cool downs are highly recommended (particularly to reduce post- exercise hypotension) 33 Watch Week 9 Lecture Next week: pacemakers and defibrillators Read (as per last week) Ehrman Chapters 15 & 16 ESSA Position Stand – CHF Engage ECG part 2 Tutorial – Thursday Do Assessment 1 – Due Friday 3rd May 36