Definition

Cardiac Rehabilitation is the sum of activities by which patients with cardiac

disease, in partnership with a multidisciplinary team of health professionals are
encouraged to support and achieve and maintain optimal physical and
psychosocial health.

vInitially, rehabilitation was offered mainly to people recovering from a

myocardial infarction (MI), but now encompasses a wide range of cardiac
problems.
vCR begins as soon as possible in intensive care units, only if the patient is in
stable medical condition. Intensity of rehabilitation depends on the patient's
condition and complications in the acute phase of disease.
Cardiac rehab programs worldwide
 Goals of Cardiac Rehabilitation

!The main goal of cardiac rehabilitation is to promote secondary

prevention and to enhance quality of life among cardiac patients
 Me dical Go als So cial Go als Psycho lo gical Go als Be havio ural He alth Se rvice
Go als Go als

Improve Cardiac Return to work if To restore self To quit all forms of To directly reduce
Function appropriate and/ or confidence smoking medical costs
previous level of
functional capacity

Reduce the risk of To pr omote in d epen den ce Relieve anxiety and To make heart To pr om ote early
sudden death and re- in ADLs for th ose wh o are depression in pt.s and healthy dietary m obilisation an d
infarction compromised their careers decisions discharge from
hospital

Relieve symptoms such To relieve or manage To be physically To reduce cardiac

as breathlessness and stress active related hospital
angina admission

Increase Work Capacity To restore good sexual To adhere to

health medication regimes

Prevent progression of underlying

atherosclerotic process
 Individual Risk Assessment

ØCardiac Rehabilitation can be adapted to meet individual

needs, thus a careful assessment and evaluation of the CV
risk factor profile of the patient should be undertaken at the
beginning of the programme.
ØRisk factors should be evaluated using validated measures
which take into account other comorbidities
RISK FACTORS

Non Modifiable Modifiable

Age Excessive alcohol intake

Gender Dyslipedemia

Personal Cardiac History Hypertension

Family History of CVD Obesity

Diabetes (unless prediabetes) Smoking

Physical Inactivity

Anxiety/Depression

Hostility

Stress
 Before exercise training
ØClinical risk stratification is suitable for low to moderate risk
patients undergoing low to moderate intensity exercise
ØExercise testing and echocardiography are recommended for high
risk patients and/or high intensity exercise
ØFunctional exercise capacity should be evaluated before and on
completion of exercise training.
 On examination:
vVitals: PR (pulse rate), RR (respiratory rate), BP (blood presure),
SpO2, ECG findings
v Respiratory examination
v Circulatory Examination
v Neurological examination
 Measurements
v Exercise capacity
v Quality of life surveys
v Weight
v Waist circumference
v Lipids
v Glucose/HbA1C
v Telemetry monitoring occurs during exercise sessions
v Nutritional survey tool
v Stress level
 Benefits of Cardiac Rehabilitation
qOffset deleterious pyschologic and physiologic effects of bed rest during
hospitalization

q Provide additional medical surveillance of patients

qEnable patients to return to activities of daily living within the limits imposed
by their disease

qPrepare the patient and the support system at home to optimize recovery
followed by hospital discharge
q Reduces cardiovascular and total mortality

q Does not increase non-fatal reinfarction rate

q Improves myocardial perfusion

q May reduce progression of atherosclerosis when combined with aggressive diet

q No consistent effects on hemodynamics, LV function or visible collaterals

q No consistent effects on cardiac arrhythmias

q Improves exercise tolerance without significant CV complications

q Improves skeletal muscle strength and endurance in clinically stable patients

q Promotes favorable exercise habits

q Decreases angina and CHF symptoms

Participation in cardiac rehabilitation programs should be available to all
cardiac patients who require it. Age is not and should not be a barrier to
cardiac rehabilitation participation. However, consideration of patient
safety results in the following specific inclusion/exclusion criteria
applying to participation.
 Indication for Cardiac Rehabilitation
q Medically stable post MI
q Coronary Artery Bypass Surgery
q Percutaneous Coronary Intervention
q Stable Angina
q Stable heart failure (NYHA I-III)
q Cardiomyopathy
q Cardiac Transplantation
q Implantable Cardioverter Defibrillator
q Valve Repair/Replacement
q Insertion of Cardiac Pacemaker (with one or more other inclusion criteria)
q Peripheral Arterial Disease
q Post Cerebral Vascular Disease
q At risk of coronary artery disease with diagnosis of diabetes, dyslipedemia, hypertension
 Contraindications for Cardiac Rehabilitation
ABSOLUTE Contraindications

1. A recent significant change in

4. Uncontrolled ventricular
the resting ECG suggesting
infarction or other acute cardiac dysarhythmia
events 5. Uncontrolled atrial dysarhythmia
2. Recent complicated myocardial that compromises cardiac function
infarction 6. 3rd degree A-V block
3. Unstable angina
7. Acute congestive heart failure
8. Severe aortic stenosis
9. Suspected or known dissecting aneurysm
10. Active or suspected myocarditis or pericarditis
11. Thrombophlebitis or intracardiac thrombi
12. Recent systemic or pulmonary embolus
13. Acute infection
14. Significant emotional distress (psychosis)
Relative Contraindications
1. Resting diastolic blood pressure > 120
mmHg or resting systolic blood 4. Fixed-rate pacemaker (rarely used)

5. Frequent or complex ventricular

pressure >200 mmHg
ectopy
2. Moderate valvular heart disease
6. Ventricular aneurysm
3. Known electrolyte abnormalities
(hypokalemia, hypomagnesemia)
7. Cardiomyopathy, including hypertrophic cardiomyopathy
8.Uncontrolled metabolic disease (e.g. diabetes, thyrotoxicosis, or
myxedema)
9. Chronic infectious disease (e.g. mononucleosis, hepatitis, AIDS)
10.Neuromuscular, musculoskeletal, or rheumatoid disorders that are
exacerbated by exercise
11. Advanced or complicated pregnancy
 Cardiac Rehabilitation Phases
Cardiac rehabilitation typically comprises of four phases. The term phase is used to describe the
varying time frames following a cardiac event. The secondary prevention component of CR
requires delivery of exercise training, education, and counselling, risk factor intervention and
follow up.
 Phase I: In-hospital patient period
Objectives:

q Conditioning from acute event/ post-coronary artery bypass graft

q To make patient functionally independent
q To adjust with discharge from the hospital
q Psychological counselling
q Nutritional counselling
q Secondary prevention targetting
Phase I relates to the period of hospitalization following an acute cardiac event.

The duration of this phase may vary depending on the initial diagnosis, the
severity of the event and individual institutions, usually one week acute
event/post-operative.
During this phase:
oIndividuals typically undergo a risk factor assessment and risk stratification
oReceiving information regarding their diagnosis, risk factors, medications and
work/ social issues.
oInvolvement and support of the partner and family is facilitated and encouraged.
o Early mobilization and adequate discharge planning.
Acute Period—CCU (Coronary Care Unit):
q Activities of very low intensity (1–2 mets)
q Passive ROM (Passive Range of Motion) (1.5 mets)
q Upper extremity ROM (1.7 mets) Lower extremity ROM (2.0 mets)
qAvoid: isometrics (increases heart rate), valsalva (promotes arrhythmia),
raising the legs above the heart (can increase preload)
q Use protective chair posture—can reduce the cardiac output by 10%
q Bedside commode (3.6 mets) versus bedpan (4.7 mets)

!N.B.The metabolic equivalent of task (MET) is the objective measure of the ratio of the rate at which a person expends energy, relative
to the mass of that person, while performing some specific physical activity compared to a reference, set by convention at 3.5 mL of
oxygen per kilogram per minute, which is roughly equivalent to the energy expended when sitting quietly.
Subacute Period
qTransfer from the CCU (Coronary Care Unit) to either a telemetry unit
or to the medical ward.
q Activities or exercises of intensity (3–4 mets)
qROM exercise: intensity can be gradually increased by increasing the
speed and/or duration;
qEarlyambulation: starting in the room and then corridors of the ward,
treadmill walking starting from a slow stroll to a regular slow walk and
gradually increasing as tolerated
 Phase II: Post-discharge period
Objectives:
v Functional goals
§Exercise training under supervision/ at home
§Nutritional Counseling:
•Dietitian Appointment /Weight Management:
•Mediterranean style diet
•Goal: BMI 18.5-24.9. Waist circumference <102 cm men; <89 cm women
v Psychosocial goals
§Anxiety/depression management
§Assessment of Nicotine use/Counseling on smoking cessation
Phase II: This phase will define the stage of cardiac rehabilitation that occurs immediately after
discharge, in which higher levels of surveillance, monitoring of ECGs, and intensive risk factor
modification occurs

q This phase is typically a period of four to six weeks.

q It focuses on:
health education and resumption of physical activity, however the structure of this
phase may vary dramatically from centre to centre.
q It may take the format of:
telephone follow up, home visits, or individual or group education sessions.
qEither way, some form of contact is maintained with the patient, facilitating
ongoing education and exchange of information.
Tests Lipid Management. Goals:

◦LDL <70 mg/dL

◦Non-HDL cholesterol < 100 mg/dL
◦Total LDL particle concentration < 800 nmol/L
◦Glucose: Goals < 100 for non-diabetic patients
◦Hemoglobin A1c < 7.0% for diabetic patients
ØCardiovascular conditioning exercise a minimum of 40
minutes/day, 7 days/week
ØTarget heart rate or perceived exertion recommendation should
be maintained for at least 20 minutes per session
ØExercise Training: aerobic, stretching, strengthening, balance
exercises
 Aerobic Exercise Prescription

Ø Each aerobic exercise program should begin with a warm-up phase of 5

minutes at lower intensity
Ø The conditioning phase should be maintained for at least 20 minutes
ØThen, a cool down phase a low intensity for at least 5 minutes is
performed.
Ø Goal 30-40 minutes aerobic exercise everyday
q Stretching/Flexibility Exercises
q Balance Exercises

Single stance Forward left lift

 Phase III: Cardiac Rehabilitation and
secondary prevention
Objectives:
Ø Functional goals
– Exercise training under supervision
Ø Psychosocial goals
– Return to work
– Return to hobbies and lifestyle
– Anxiety/depression management
Ø Secondary preventive targets
Structured exercise training with continual educational and
psychological support and advice on risk factors. We should take a
menu-based approach and be individually tailored.
Typically lasts at least 6 weeks with patients exercising 2/7 minimum.
Exercise class will consist of warm-up, exercise class, cool down – may
also include resistance training with active recovery stations where
appropriate
Exercise prescription based on:

Ø Clinical status
Ø Risk Stratification
Ø Previous activity
Ø Future needs
 Phase IV: Maintenance
Objectives:
Ø Maintenance of achieved functional status
Ø Return to work
– Return to hobbies and lifestyle modifications
Ø Secondary preventive targets
Phase IV: This phase constitutes the components of long-term
maintenance of lifestyle changes and professional monitoring of clinical
status.
ØIt is when patients leave the structured Phase 3 programme and continue
exercise and other lifestyle modifications indefinitely.
Ø This may be facilitated in the CR unit itself or in a local leisure centre.
ØAlternatively, individuals may prefer to exercise independently and Phase
4 may involve helping them set a safe and realistic maintenance
programme.
Home Based Exercise Program
Follow up evaluation performed by a physician at 3-6-9 and12 months.
Then every 6 or 12 months.
Evaluation include:
q Physical exam
q Review exercise program
q Laboratory test: lipid profile, glucose, liver function tests, creatinine
q Review nutrition plan
q Adjust medications as needed
q Control of weight
 CARDIAC REHABILITATION OF SPECIAL
GROUPS
Heart Transplantation
The heart is denervated (loss of vagal inhibition to the SA
node), therefore, physiologic response is somewhat different
then the one seen in a post-CABG (Coronary artery bypass
surgery) patient.
1. High resting heart rate
2. Lower peak exercise heart rate
3. Post exercise recovery rate—slow return to resting level
§ At maximum effort—the work capacity, cardiac output, systolic BP, and
the total O2 consumption (VO2) are lower
§Pre transplantation, rehabilitative strength training may enhance
preoperative and operative recovery
§ Five- and ten-year survival is about 82% to 74% respectively
§ Accelerated arthrosclerosis occurs following transplantation
Exercise Prescription
Intensity of exercise is based on the following:

§Percentage of maximum oxygen consumption or maximum workload

performed on stress test
§Anaerobic threshold
§Duration frequency and types of exercise follow the same principles as those
with other types of cardiac problems
§During exercise testing, ischemia is not presented as angina, therefore,
ECG changes and other symptoms should be followed
Stroke
§ Acute MI and acute stroke
§ CABG (Coronary artery bypass surgery) and acute stroke
§According to the studies, as much as 77% of stroke patients have some
form of co-existing cardiac disease, these complications include:
• Hypertension
• Angina
• Myocardial infarction
• Congestive Heart Failure
• Rhythm disturbances
Stroke Exercise Testing Modality
q Treadmill ambulation, if tolerated
q Stationary bicycle/ergometer modified for involved leg (ace wrap)
q Portable leg ergometers that allow for seating in a wheelchair or arm chair
qArm ergometer modified for involved hand or using one-handed arm
ergometer
qTelemetry monitoring of level surface ambulation or general conditioning
classes
Hemiplegic Ambulation Compared to Normal Ambulation
Speed—40% to 45% slower
Energy cost—50% to 65% higher
 AMERICAN HEART ASSOCIATION DIET

Step 1 Diet
Ø 8% to 10% of the day’s total calories form saturated fat
Ø 30% or less of the day’s total calories from fat
Ø Less than 300 mg of dietary cholesterol a day
Ø Just enough calories to achieve and maintain a healthy weight
Step 2 Diet
If do not lower cholesterol enough on Step 1 diet or if patient are at a
high risk for heart disease or already have heart disease:
Ø Less than 7% of the day’s total calories from saturated fat
Ø 30% or less of the day’s total calories from fat
Ø Less than 200 mg of dietary cholesterol a day
Ø Just enough calories to achieve and maintain a healthy weight
Readmission/Mortality After Myocardial Infarction for
Cardiac Rehabilitation Participants and Non-Participants
Cumulative Hospitalizations Over
Time for Medicare Beneficiaries
Receiving Ventricular Assist
Devices in 2014,
Stratified by Participation in
Cardiac Rehabilitation Cumulative
hospitalizations were calculated
adjusted for age, sex, race, census
region, comorbidities, discharge to
an inpatient rehabilitation facility
or skilled nursing facility, and
length of stay.
Shaded areas represent 95%
confidence intervals.
Patient complaints pre- and post Cardiac Rehab
 Why is Cardiac Rehabilitation
Important??
Cardiac Rehabilitation will give to
the patients the tools, knowledge, and
motivation needed to fight the
progression of cardiovascular disease
with their “heart and soul”!
References
1. Dr Ravi Khatri, Cardiac Rehabilitation. PMR PG Teaching.
2. Carmen M. Terzic, MD, PhD., Cardiovascular Rehabilitation. Online curriculum.
3. Dr. Vinod K. Ravaliya, MPT, Cardiac Rehabilitation.
4. Dalal et al., Cardiac rehabilitation. BMJ. 2015; 351.
5. Cardiac Rehabilitation. On: https://www.physio-pedia.com/Cardiac_Rehabilitation
6. British Heart FoundationBritish Heart Foundation - Joining a Cardiac Rehabiltation
Programme Available from https://www.youtube.com/watch?v=TRvYqn-a-
gk&feature=emb_logo
7. Cardiac rehabilitation. Available
from: http://www.pnmedycznych.pl/spnm.php?ktory=369