Cardiac Rehabilitation

Introduction

CR.jpg

“Cardiac Rehabilitation is the process 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. The involvement of partners, other family members and carers is also important”[1]

Cardiac rehabilitation is an accepted form of management for people with cardiac disease. Initially, rehabilitation was offered mainly to people recovering from a myocardial infraction (MI), but now encompasses a wide range of cardiac problems.[2]

To achieve the goals of cardiac rehabilitation a multidisciplinary team approach is required. The multidisciplinary team members include:

  • Cardiologist/Physician and co-coordinator to lead cardiac rehabilitation
  • Clinical Nurse Specialist
  • Physiotherapist
  • Clinical nutritionist/Dietitian
  • Occupational Therapist
  • Pharmacist
  • Psychologist
  • Smoking cessation counsellor/nurse
  • Social worker
  • Vocational counsellor
  • Clerical Administration[3]

It is essential that all cardiac rehabilitation staff have appropriate training, qualifications, skills and competencies to practice within their scope of practice and recognise and respect the professional skills of all other disciplines involved in providing comprehensive cardiac rehabilitation.The cardiac rehabilitation team should actively engage and effectively link with the general practitioner and practice nurses, sports and leisure industry where phase IV is conducted, community pharmacists and other relevant bodies to create a long term approach to CVD management.[4]

Description

Indication

Cardiac rehabilitation should be offered to all cardiac patients who would benefit.[2] CR is mainly prescribed to patients with ischaemic heart disease, with myocardial infarction, after coronary angioplasty, after coronaro-aortic by-pass graft surgery and to patients with chronic heart failure. CR begins as soon as possible in intensive care units, only if the patient is in stable medical condition. Intensity of rehabilitation depends on patient's condition and complications in acute phase of disease.[5]

Goals of Cardiac Rehabilitation

The main goal of cardiac rehabilitation is to promote secondary prevention and to enhance quality of life among cardiac patients[4]

Medical Goals Social Goals Psychological Goals Behavioural Goals Health Service Goals
Improve Cardiac Function Return to work if appropriate and/or previous level  of functional capacity To restore self confidence To quit all forms of smoking To directly reduce medical costs
Reduce the risk of sudden death and re-infarction To promote independence in ADLs for those who are compromised Relieve anxiety and depression in pt.s and their careers To make heart healthy dietary decisions To promote early mobilisation and discharge from hospital
Relieve symptoms such as breathlessness and angina To relieve or manage stress To be physically active To reduce cardiac related hospital admission
Increase Work Capacity To restore good sexual health To adhere to medication regimes
Prevent progression of underlying atherosclerotic process

Individual Risk Assessment

CR can be tailored to meet individual needs thus a thorough assessment and evaluation of the CV risk factor profile of the patient should be undertaken at the beginning of the programme. This should be accompanied by ongoing assessment and reassessment throughout and upon completion of the programme.[4]

Risk factors should be evaluated using validated measures which take into account other co-morbidities[1][3][6].

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

Other factors to consider

  • Family Support
  • Social History
  • Occupation

Cardiac Rehabilitation Participation

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[4]. However, consideration of patient safety results in the following specific inclusion/exclusion criteria applying to participation in the Phase III exercise component.[7]

Inclusion Exclusion
Medically stable post MI Unstable Angina
Coronary Artery Bypass Surgery Ischaemic changes on ECG
Percutaneous Coronary Intervention Resting systolic BP >200mmHg or resting diastolic BP >110 mmHg
Stable Angina Orthostatic BP drop >10mmHg with symptoms
Stable heart failure (NYHA I-III) Critical aortic stenosis (peak pressure gradient >50mmHg with aortic valve orifice <0.75cm2
Cardiomyopathy Acute systemic illness or fever
Cardiac Transplantation Uncontrolled atrial or ventricular arrhythmias
Implantable Cardioverter Defibrillator Uncontrolled sinus tachycardia (>120bpm)
Valve Repair/Replacement Uncompensated CHF
Insertion of Cardiac Pacemaker (with one or more other inclusion criteria) Acute systemic illness
Peripheral Arterial Disease 3rd degree AV block with no pacemaker
Post Cerebral Vascular Disease Acute pericarditis/myocarditis
At risk of coronary artery disease with diagnosis of diabetes, dyslipedemia, hypertension Recent embolism
Thromobophlebitis
Uncontrolled diabetes
Severe orthopediac problems
Other metabolic problems such as acute thyroiditis, hypo-hyperkalaemia, hypovolemia

Phases of Cardiac Rehabilitation

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.[8]

Appropriate referral pathways should be set up so appropriate patients can be identified and invited to attend. Referrals should be invited by cardiologist/physician, cardiothoracic surgeon, cardiac team, cardiac rehab co-ordinator, G.P., CCU nurses or members of the MDT. All referrals should include the following;

  • Patients name, age, address and contact number
  • Type of cardiac event and date of event
  • Cardiac history, complications and meds
  • Reason for referral
  • Referring persons name and contact number, date of request
  • Clinically relevant information – results of exercise stress test, echo, fasting lipid profile and fasting glucose profile[1]

Phase I: In hospital patient period

Phases of Cardiac Rehabilitation
2-5 days

Member of Cardiac Rehab team (CRT) should visit the patient to;

  • Give support and information to them and their families re: heart disease
  • Assist the patient to identify personal CV risk factors
  • Discuss lifestyle modifications of personal risk factors and help provide an individual plan to support these lifestyle changes
  • Gain support from family members to assist the patient in maintaining the necessary progress
  • Plan a personal discharge activity programme and encourage the patient to adhere to this and commence daily walks
  • Inform patients regarding phase II and phase III programs if available and encourage their attendance

At this stage emphasis is on counteracting the negative effects of a cardiac event not promoting training adaptations (Woods, 2010). Activity levels should be progressed using a staged approach which should be based on the patient’s medical condition. Patient should be closely monitored for any signs of cardiac decompensation.

Educational sessions should be commenced providing information re:

  • The cardiac event
  • Psychological reactions to the event
  • Cardiac pain/symptom management
  • Correction of cardiac misconceptions

The use of educational materials such as the heart manual and leaflets from the Irish Heart Foundation should be considered.

Patient should be provided with an individual plan for self care and lifestyle changes based on their clinical assessment and identified risk factors. A discharge plan including exercise instructions should also be formulated.

Patient should also have some form of psychosocial assessment either via interview or use of a self reporting questionnaire such as HADS, Health Related QoL.

Referrals to other members of the MDT and follow up visits should also be made during this time.[4]

Phase II: Post discharge period

Goals:

  • Reinforce cardiac risk factor modification
  • Provide education and support to patient and family
  • Promote continuing adherence to lifestyle recommendations.[9]

SIGN 2002 – state the importance of addressing any psychological distress or poor social support issues as these two factors have been identified as being powerful predictors of outcome post MI irrespective of the degree of physical impairment.[1]

Support and education can be provided through

  • Home visits
  • Phone calls
  • Outpatient reviews

Provision of educational classes (individual/group)

Use of the heart manual

Could also look into establishing links with GP, practice nurses, primary care team and chest pain services.

Gradual activity and low level exercise regime may commence once stable. Intensity will increase over a varying period of time depending on diagnosis and procedure and is done under guidance of the cardiologist

ACSM suggest 4-6 weeks post MI and post sternotomy unless otherwise directed by cardiologist/cardiothoracic surgeon[10][11]

Phase III: Cardiac Rehabilitation and secondary prevention

Structured exercise training with continual educational and psychological support and advice on risk factors[1]

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.[7]

Phase III compromises of all the following;

Exercise prescription based on

  • Clinical status
  • Risk Stratification
  • Previous activity
  • Future needs[10]

Education for patient and family re:

  • Cardiac anatomy and physiology
  • Recognition of cardiac pain and symptom management
  • Risk factor identification and management
  • Benefits of PA
  • Energy conservation techniques/graded return to ADLs
  • Cardio protective healthy eating
  • Benefits and entitlements
  • Stress management and relaxation techniques
  • Counseling and behaviour modification
  • Smoking cessation
  • Vocational counseling [4]

Sample format of a cardiac rehabilitation class

  1. Check in (vitals assessed)
  2. Warm Up (15 mins)
  3. Main class (30 mins)
  4. Cool down (10 mins)
  5. Monitoring and reassessment of vitals and check out

Warm Up

Purpose: Prepare the body for exercise by raising the pulse rate in a graduated and safe way

Effects:

  • redistributes blood to active tissues
  • increases muscle temperature and speed of muscle action and relaxation
  • prepares the mind
  • prepares the muscle for the ROM involved for the conditioning period

Should include pulse raising activities (5 minutes) eg) marching on the spot, walking, low level cycle followed by stretching of the major muscle groups (5 mins) followed by more pulse raising activity.

NB: should try to keep feet moving at all times to maintain HR and body temp and avoid pooling.

Main Class

For group rehab circuit training seems most popular. Depending on CV status and functional capacity patients may adopt an interval or continuous approach to the circuit.

Separate stations are set out and participants spend a fixed amount of time at each aerobic station (30secs-2mins) before moving onto the next station which may be rest or active recovery in the form of resistance work targeted at specific muscle groups.

Resistance work as set out by ACSM 2006 – 10-15 reps to moderate fatigue of 8-10 exercises.[12][13]

Individualisation of the CV component can be achieved by varying; duration spent at each CV station, intensity (increase resistance, speed or ROM), period of rest, overall duration of the class[10]


Cool Down

10 minutes at the end

Goal: bring the body back to its resting state

Should incorporate movements of diminishing intensity and passive stretching of the major muscle groups.

Necessary because of;

  • Increased risk of hypotension
  • Older hearts take longer to return to resting levels
  • Raised sympathetic activity during exercise increases the risk of arrhythmias immediately post exercise.[10] 

Phase IV: Maintenance

Goal: facilitate long term maintenance of lifestyle changes, monitoring risk factor changes and secondary prevention.[9]

Options:

  • Educational sessions
  • Support groups
  • Telephone follow up
  • Review in clinics
  • Outreach programmes
  • Phase IV exercise programme organised by qualified phase IV gym instructor
  • Links with GP and primary health care team
  • Ongoing involvement of partners/spouses/family[4]

Health and Safety

Patient shouldn’t exercise if they are generally unwell, symptomatic or clinically unstable on arrival;

  • Fever/acute systemic illness
  • Unresolved/unstable angina
  • Resting BP systolic >200mmHg and diastolic > 110mmHg
  • Significant drop in BP
  • Symptomatic hypotension
  • Resting/uncontrolled tachycardia (>100bpm)
  • Uncontrolled atrial or ventricular arrhythmias
  • New/recurrent symptoms of breathlessness, lethargy, palpitations, dizziness
  • Unstable heart failure
  • Unstable/uncontrolled diabetes[14][4]

Need to consider the following;

  • Local written policy clearly displayed for the management of emergency situations
  • Rapid access to emergency team in hospital or via ambulance
  • Regular checking and maintenance of all equipment
  • Drinking water and glucose supplements available as required
  • Access to and from venue, emergency exits, toilets and changing areas, lighting, surface and room space checked to ensure they’re appropriate
  • Enough space for patient traffic and safe placement of equipment
  • Adequate temperature and ventilation
  • Medications of patients and their associated effects

Assessment and Outcome Measures

It is essential to;

  • set and evaluate the effectiveness of an exercise programme
  • provide objective feedback to the patient
  • facilitate evidence based practice

Measures can be used as both a baseline measure and exit outcome measure. These may include;

  • HR and BP @ rest and during exercise
  • RPE
  • Body weight
  • BMI
  • Waist circumference

Measures of functional capacity;

  • 6MWT
  • shuttle walk test
  • chester step test

Exercise Testing and Risk Stratification

A patient having a stress test. Electrodes are attached to the patient's chest and connected to an EKG machine. The EKG records the heart's electrical activity. A blood pressure cuff is used to record the patient's blood pressure while he walks on a treadmill.[15]
EACPR, ACCPVR, CACR, ESC and AHA all recommend exercise testing as part of a patient’s initial assessment for cardiac rehabilitation. Exercise testing allows for the following;
  • Diagnosis – identification of patients with CHD and the severity of the disease
  • Prognosis – identification of low, moderate and high risk patients
  • Evaluation – establishment of the effectiveness of a selected intervention
  • Measurement of functional capacity – used as a basis for advice re ADLs and development of a formal exercise prescription
  • Measurement of acute exercise responses – BP, HR, ventilator responses and detection of exercise induced arrhythmias
  • To provide an appropriate training target HR[13]

Exercise ECG using an incremental protocol is most commonly used and before acceptance into the phase III programme a symptom limited test is customary. Usually uses the Bruce Protocol

Criteria for terminating a test[13]:

Horizontal or downsloping ST segment depression >2mm – indicates ischaemia
Marked drop in systolic BP >20mmHG – indicates poor LV fxn or severe coronary disease
Serious arrhythmias – ventricular tachycardia
Patient fatigue and/or excessive breathlessness at low workloads – poor fxnl capacity or more serious problems such as heart failure
Negative Test Positive Test
Normal haemodynamic response Significant ECG changes
Completion of a workload equivalent to the second stage of the Bruce protocol (7 METs) Inappropriate HR/BP response to the incremental workload.

NB: when carrying out the test patients HR, BP and 12 lead ECG must be constantly assessed. Once test has terminated recovery monitoring must be continues for a minimum of 6 secs or until the ECG returns to its pretest appearance.[13]

Risk Stratification[7]

Definition: “Evaluation of the patient to assess the degree of risk of future cardiac events associated with exercise[1]

Low Risk (all characteristics listed must be present to remain @ lowest risk) Moderate Risk (any one or a combination of these findings) High Risk (anyone or a combo)
Uncomplicated MI, CABG, angioplasty Functional capacity <5-6 METs Severely depressed LV function
Funct. Capacity >6 METs Mild – moderate depressed LV dysfunction (EF 31-49%) Complex arrhythmias @rest or during exercise)
No resting/exercise induced complex arrhythmias Mild – moderate ischaemia in exercise/recovery Decreased systolic BP of >15mmHg during exercise/ failure of BP to rise consistently with exercise workloads
No sig. LV dysfunction (EF >50%) Exercise induced STsegment depression of 1-2mm or reversible ischaemic effects MI complicated by CHF/cardiogenic shock/complex ventricular arrhythmias
Normal heamodynamic response during exercise Presence of angina or relevant symptoms at high levels of exertion (>7 METs) Severe CAD and marked (>2mm) exercise induced ST segment depression
Absence of CHF Survivor of cardiac arrest
Absence of angina/other sig symptoms Complicated MI or revascularisation procedure
Absence of clinical depression Presence of clinical depression

Risk stratification is important as it will have a bearing on staffing required and group mixing. It’s also something that has to be taken into account when determining the level of monitoring a patient requires and when setting their Target Training HR.

Requirements for cardiac rehabilitation

Facilities and Equipment

The minimum facilities necessary to provide a cardiac rehabilitation service are:

  • Separate office space and facilities for cardiac rehabilitation staff
  • An Education Room furnished with seats, TV and DVD player and with a selection of information booklets and DVD’s provided. The size of the education room will depend upon the number of participants (patients, spouses, and staff) in the education sessions and given resources.
  • It is recommended that the exercise warm-up area and the exercise room combined should be approximately 300m2
  • The exercise room should be air-conditioned
  • In addition, patients should have access to
    • Toilet
    • Shower and changing room
    • Available drinking water[4]

Equipment in the exercise room may include[4]

Central monitor and telemetry Treadmill Versa climber Chairs Music system
Equipped emergency trolley, portable suction, defibrillator and oxygen Dual cycle ergometer Hand crank Rowing Machine Glucometer
Automated Blood Pressure Recording Machine e.g. Dinamap Bicycle ergometer Multigym weights system and/or dumb bells Stethoscope Measuring tape

Staffing Levels

ACPICR 2009 – minimum staff to patient ratio should be 1:5 but this will vary depending on the risk stratification profile of the class. For higher risk patients will have increased staff ratio eg) 1:3

SIGN 2002 guidelines: Staff should have basic life support training and the ability to use a defribillator required for low-moderate risk patients[1]

Resources

References

  1. 1.0 1.1 1.2 1.3 1.4 1.5 1.6 Scottish Intercollegiate Guidelines Network (SIGN) Cardiac rehabilitation: a national clinical guideline, 2002      
  2. 2.0 2.1 Pryor JA, Prasad SA. Physiotherapy for Respiratory and Cardiac Problems. Philadelphia: Elsevier Ltd, 4th Edition, 2008: 14 (470 - 494).
  3. 3.0 3.1 American Association of Cardiovascular and Pulmonary Rehabilitation Robertson, L (Ed.) (2006) Cardiac Rehabilitation Resource Manual. Champaign: Human Kinetics.
  4. 4.0 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 4.9 Irish Association of Cardiac Rehabilitation Guidelines 2013
  5. Cardiac rehabilitation. Available from: http://www.pnmedycznych.pl/spnm.php?ktory=369 (accessed 22.12.2013)
  6. British Association of Cardiac Rehabilitation. “Risk Factors” in Brodie, D. ed. (2006) Cardiac Rehabilitation: An Educational resource. Buckinghamshire: Colourways Ltd.
  7. 7.0 7.1 7.2 American Association of Cardiovascular and Pulmonary Rehabilitation: Guidelines for Cardiac Rehabilitation and secondary prevention programs 2004
  8. American Association of Cardiovascular and Pulmonary Rehabilitation Williams, M.A. (Ed.) (2004) Guidelines for Cardiac Rehabilitation and secondary Prevention programs. Champaign: Human Kinetics.
  9. 9.0 9.1 British Association for Cardiovascular Prevention and Rehabilitation. (2012) The BACPR standards and core components for cardiovascular disease prevention and rehabilitation 2012. 2nd Edition. London: British Cardiovascular Society.
  10. 10.0 10.1 10.2 10.3 Association of Chartered Physiotherapists in Cardiac rehabilitation (2009) Standards for Physical Activity & Exercise in the Cardiac Population.
  11. American College of Sports Medicine. ACSM's Guidelines for Exercise Testing and Prescription. Philadelphia :Lippincott Williams & Wilkins, 2000
  12. Bjarnason-Wehrens, B. Mayer-Berger, W. Meister, E.R. Baum, K. Hambrecht, R. And Gilen, S. (2004) ‘Recommendations for resistance exercise in cardiac rehabilitation. Recommendations of the German Federation for Cardiovascular Prevention and Rehabilitation’. European Journal of Cardiovascular Prevention and Rehabilitation, 11(4):352-61.
  13. 13.0 13.1 13.2 13.3 American College of Sports Medicine (2006) Guidelines for Exercise Testing and Prescription. 7th Edition. Baltimore, Maryland: Lippincott Williams & Wilkins.
  14. American Diabetes Association (2013) ‘Standards of Medical Care in Diabetes—2013’, Diabetes Care, 36: S11-S66.
  15. https://www.nhlbi.nih.gov/health/health-topics/topics/stress/during