rehabilitation for patients with cardiovascular disease mr 梁芳甄醫師 ma 黃書群醫師

Rehabilitation for Patients with Cardiovascular Disease MR MA

Book Reading ACSM's Resource Manual for Guidelines for Exercises Testing and Prescription Chapter 35 Exercise Prescription in Patients with Cardiovascular Disease Braddom Chapter 34 Cardiac Rehabilitation DeLisa Chapter 83 Cardiac Rehabilitation

Background 18 ~ 65 years old healthy adults need 1.Moderate-intensity activity at least 30 minutes on 5 days per week Or Vigorous-intensity aerobic activity at least 20 minutes on 3 days per week 2.Resistance training involving the major muscle groups at least 2 days per week Exercise is also recommended for the elderly or people with illness

Canadian Family Physician, http://www.cfpc.ca/cfp/2002/jan/vol48-jan-cme-1.asp DeLisa Table 83-7

Cardiac Rehabilitation 1.Introduction of Cardiac Rehabilitation 2.Disease-Specific Effects on Physiologic Responses and Fitness 3.Scientific and Physiologic Rationale for Exercise Therapy in Patients with Heart Disease 4.Morbidity, Mortality, and Safety of Cardiac Rehabilitation 5.Exercise Prescription and Programming

Definition Cardiac rehabilitation is an interdisciplinary team approach to patients with functional limitations secondary to heart disease

Goals Restore patients to their optimal medical, physical, psycological, social, emotional, sexual, vocational, and economic status compatible with the severity of their heart disease Prevention of heart disease Primary screen healthy people to identify and treat risk factors Secondary to improve heart disease risk factors and limit further morbidity and mortality

Cardiovascular Response during Exercise Heart Rate Normal Achieving HR within 2 standards deviations of an age-predicted maximum value Decreasing HR to baseline fairly quickly during recovery

Cardiovascular Response during Exercise Heart Rate Abnormal Chronotropic Incompetence Failure to achieve 85% predicted maximum HR (without medication effect) Predict CAD and associated with increased risk of Mortality/Morbidity Abnormal HR recovery alking: decrease in HR < 12 bpm / 1 minute Supine: decrease in HR < 22 bpm / 2 minutes Predict future cardiac mortality

Cardiovascular Response during Exercise Blood Pressure Normal DBP: Constant or slightly decrease SBP: Increase progressively about 8~12 mmHg/MET, with a plateau at peak exercise Abnormal In patients with CAD, SBP during exercise may respond normally or may disproportionately increase or inappropriately decrease

Cardiovascular Response during Exercise Blood Pressure Abnormal Exertional hypertension: SBP > 250 mmHg or DBP > 115 mmHg Exertional hypotension: Compare to resting BP, SBP decrease 10mmHg Exertional systolic hypertension/hypotension would increase cardiac event risk Increase DBP 10mmHg Often a marker for future hypertension

Cardiovascular Response during Exercise Cardiac Output and Oxygen uptake Normal Peak VO2: 30~45 ml/kg/min CAD patient Peak VO2 reduction 20% Due to Cardiac Output Cardiac Output = Heart Rate x Strove volume Heart Rate Chronotropic incompetence Strove Volume Left ventricular dysfunction With Exercise Training VO215~30%

Oxygen Consumption 1 MET (Metabolic Equivalent) = Oxygen consumption at resting = Basal metabolic rate At rest, 70kg man O2 consumption = 3.5ml oxygen/ minute/ Kg of BW Braddom Figure 34-1 Relationship between oxygen consumption and intensity of work being performed.

LevelSelf-careHouseholdRecreationalVocational Light (1-3 metabolic equivalents, METS) Sponge bathing Shaving Dressing or undressing Preparing light meals Setting table Dusting Walking 2 mph Writing Reading Playing piano Typing Light machine work Lifting

ACSM s TABLE 35-2. Pathophysiologic Effects of Exercise and Exercise Training Pathophysiologic VariableAcute ExerciseChronic Exercise Training Vascular Vascular stenosisPartial regression (>2200 kcalwk -1 ) Coronary collaterals Endothelial dysfunction Capillary flow Autonomic nervous symptoms Parasympathetic Sympathetic Hemostatic Fibrinogen Factor VII Platelet aggregation Fibrinolysis Viscosity 1400 kcal per week showed improved cardiopulmonary fitness >1500 kcal per week demonstrated the slowest rate of disease progression >2200 kcal per week showed regression of CAD

Morbidity, Mortality, and Safety of Cardiac Rehabilitation Total cardiovascular mortality are reduced in patients following myocardial infarction who participate in cardiac rehabilitation exercise training The 1995 Agency for Heath Care Policy and Research (AHCPR) Clinical Practice Guidelines for Cardiac Rehabilitation Cardiac rehabilitation reduced all-cause mortality by approximately 25% Taylor RS, Brown A, Ebrahim S, et al. Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials. Am J Med. 2004;116:682 692.

Classification of Cardiac Rehabilitation Inpatient phase Minimize the de-conditioning time Education about risk factors and lifestyle modification Early outpatient phase Maintenance phase Follow-up phase Differing based on extent of supervision and monitoring, subject independence, and time from the event Improve exercise performance and modify cardiac risk factors

Cardiac Test Rest/ Exercise cardiac test should be performed before prescription Cardiac Testing Resting EKG, CXR, 2D- echo, Holter exam, Coronary angiography, Cardiac exercise stress test Cardiac exercise stress test is generally safe, and adverse outcomes are infrequent

Cardiac Exercise Stress Test Modality Treadmill, Bicycle, Arm ergometers Dipyridamole, Adenosine End point Normal EST = 85% age/gender predicted HR max Symptom-limited maximum EST Low-level submaximal EST HR = 120 70% HR max Peak MET = 5

Braddom Box 34-6 Contraindications to exercise stress testing Absolute Acute myocardial infarction (within 2 days) High-risk unstable angina Uncontrolled cardiac arrhythmias causing symptoms of hemodynamic compromise Symptomatic severe aortic stenosis Uncontrolled symptomatic congestive heart failure Acute pulmonary embolus or pulmonary infarction Acute myocarditis or pericarditis Acute aortic dissection Relative Left main coronary artery disease Moderate stenotic valvular heart disease Electrolyte abnormalities A Severe arterial hypertension (> 200 mmHg systolic blood pressure and/or 110 mmHg diastolic blood pressure) Tachyarrhythmias or bradyarrhythmias Hypertrophic cardiomyopathy and other forms of left ventricular outflow tract obstruction Mental or physical impairment leading to inability to exercise adequately High-degree atrioventricular block

Contraindications to Exercise Unstable angina Resting ST depression > 2mm Uncontrolled arrhythmias Critical aortic stenosis Uncompensated congestive heart failure Resting SBP > 200mmHg or DBP >110mmHg Fall in SBP > 10mmHg with exercise Symptomatic orthostatic SBP drop 10-20 mmHg

Comorbidities Impacting the Safety of Exercise DiabetesHypoglycemia AnticoagulationProgressive bruise or INR > 5.0 Visual and Cognitive Impairment Need close supervision Wound and Skin IntegritySacral pressure sores require pressure relief Rheumatologic, Neurologic, Orthopedic, or Balance disorders Warrant close attention

Exercise Pattern - Aerobic Training Braddom Figure 34-6 Braddom Figure 34-5Braddom Figure 34-4

Braddom Box 34-4 Adaptations noted with aerobic training Functional Higher peak work rate Reduced disturbance of body function Enhanced rate of recovery after exercise Cardiovascular and pulmonary Increased stroke volume and peak CO Increased respiratory muscle strength, maximal voluntary ventilation Reduced dyspnea Musculoskeletal Increased flexibility Increased muscle, tendon, and cartilage strength Increased bone density Increased lean muscle mass Reduced body fat percentage Biochemical Increased aerobic enzyme concentration Endocrine Reduced stress hormone release Psychologic Improved depression and anxiety

Exercise Pattern Resistance Exercise Moderate-intensity dynamic resistance exercise (defined as 50% 60% of one repetition maximum [1RM]) results in improved muscle strength and endurance A small reduction of 3 and 4 mm Hg for resting systolic blood pressure and diastolic blood pressure, respectively A commonly recommended resistance-training program involves performing one set of eight to 10 regional exercises, performed 2 to 3 days per week Isometric exercises are not recommended because of a potential significant rise in systolic and diastolic blood pressure

Exercise Pattern Resistance Exercise Time to Start Resistance Exercise Catheterization with or without PCI 3 weeks later Recover from an uncomplicated MI 5 weeks later CABG surgery or valve surgery involving a sternotomy avoid upper-limb resistance training until sternal healing has occurred), generally 6 to 12 weeks after surgery

Target Heart Rate HR Reserve Method (Karvonen Method) HRR = HRmax HRrest HRmax = 220 age Target HR = ( HRmax HRrest ) x % + HRrest HRmax 200, HRrest 80 HR reserve = 200 80 = 120 If 80% HRR Target HR = 80 + 120 x 80% = 176

IllnessIntensityComments Coronary artery disease 40/50%-85% of HRRTo affect mortality, frequency, duration, and intensity of training should sum to yield a weekly energy expenditure .1,500 kcalwk -1.a,b Angina or equivalent 40/50%-85% of HRR with necessary adjustment to keep upper HRR limit to no more than 10 beats below ischemic threshold Consider a prophylactic nitroglycerin 15 min before anticipated exertion if symptoms limit routine ADLs or ability to exercise. Myocardial infarction 40/50%-85% of HRRAchieve 1,500-2,000 kcal of energy expenditure through physical activity each week.a,b PTCA with or without stent 40/50%-85% of HRRAchieve 1,500-2,000 kcal of energy expenditure through physical activity each week.a,b ACSM s Table 35-4 Summary of Unique Exercise Prescription Issues among Patients with Cardiovascular Disease

IllnessIntensityComments CABG or valve surgery 40/50%-85% of HRR Restrict upper-body movement until sternum is healed (6-12 wk). Heart failure40/50%-70% of HRR If needed, initially guide exercise intensity at 60% of HRR and adjust duration to three bouts of 10 min each, progressing to 30-40 min. Cardiac transplant RPE 11-14Restrict upper-body resistance exercises until sternum is healed (6-12 wk). Pacemaker, ICD, biventricul ar, RCT 10% below activation threshold Avoid activities that stretch the arms. After 8 wk, nonballistic activities may be resumed, and ballistic activities may be resumed after 12 wk. ACSM s Table 35-4 Summary of Unique Exercise Prescription Issues among Patients with Cardiovascular Disease

Coronary Artery Disease Intensity 40/50%-85% of HRR To affect mortality, frequency, duration, and intensity of training should sum to yield a weekly energy expenditure 1500 kcal/ week Total energy expenditure is more important than duration or type of activity

Braddom Box 34-1 Risk Factors for Coronary Artery Disease Modifiable Physical inactivity Hypertension Smoking Dyslipidemia Overweight or obesity Diabetes Metabolic syndrome Non-modifiable Increasing age Gender: male > female Prior history: cardiac, peripheral vascular, or cerebrovascular disease Family history: genetics Cultural or socioeconomic

ACSM s Table 35-3 Summary of Effects of Cardiorespiratory Exercise Training on Selected Cardiovascular Risk Factors Risk FactorEffect SmokingBy itself: little or no effect Exercise should be part of a comprehensive smoking cessation program Lipid abnormalities CholesterolLittle or no effect LDL cholesterolLittle or no effect HDL cholesterolMild to moderate increase HypertensionReduces incidence (especially among white men) SystolicReduced: average, 6 mm Hg DiastolicReduced: average, 5 mm Hg ObesityExercise alone: mild effect Exercise should be part of a comprehensive weight- management program

Angina Exercise, lifestyle behavior changes, and medical compliance 40/50%-85% of HRR Patients with evidence of exercise-induced ischemia (i.e., angina, ECG changes), the upper HR for exercise training should be set 10 or more beats below the HR or RPP Goal for patients with angina To perform routine daily activities at a lower RPP, thus reducing the amount of angina/ fatigue they experience To increase the amount of work, home activity, or exercise they can perform at a given RPP

Angina Patients need to recognize and understand their symptoms first Patients regularly experience angina at relatively low workloads (e.g., 2 METs) to take one sublingual nitroglycerin about 15 minutes before starting their warm-up. Exercise in a pain-free manner and at slightly higher workloads A longer warm-up (10 min) to minimize or avoid ischemia

Myocardial Infarction Start at the lower end of their training intensity (40% 60% of HR reserve method) Three nonconsecutive days of cardiac rehabilitation per week, with each exercise session consisting of a 5- to 10-minute warm-up and cool- down period Progressively increase exercise intensity and duration up to 85% of HR reserve method and 20 to 60 minutes Encouraged to adopt an active life style, including exercise and daily activities, so that they expend >1500 kcal each week

Revascularization (Coronary Artery Bypass Graft and Percutaneous Coronary Intervention) Signs of ischemia during exercise are often eliminated after revascularization Patients undergoing PCI Recommendations for exercise programming for patients after PCI are generally the same as for other patients with CAD Because patients undergoing PCI frequently do not experience myocardial damage or extensive surgery, they can sometimes begin cardiac rehabilitation, return to work, and resume ADLs much sooner Cardiac rehabilitation can begin within 48 hours after PCI

Revascularization (Coronary Artery Bypass Graft and Percutaneous Coronary Intervention) Patients undergoing CABG surgery Begin rehabilitation as early as 2 weeks after surgery, with the initial focus on aerobic-type exercises All upper-body exercise should be limited to ROM and light repetitive activities until 4 to 8 weeks after surgery Following the initial wound healing, patients should be able to exercise up to 85% of HR reserve method, 3 to 4 days per week, for 20 to 60 minutes After the sternum is healed at 6 to 12 weeks, patients can then begin a resistance-training program similar to other patients with cardiovascular disease

Valve Dysfunction/Repair/Replacement Heart valve abnormalities Increase the work the heart due to reducing effective cardiac output Myocardial hypertrophy Mild diastolic dysfunction or a decrease in ventricular distensibility Exercise will not improve or change the function of the valves, but it will help to improve the efficiency of oxygen extraction by the skeletal muscles and improve the work capacity of the individual

Valve Dysfunction/Repair/Replacement The majority of valve abnormalities can be corrected with surgical procedures. Patients follow the same guidelines as CABG patients following surgery Patients on warfarin for mechanical valves or atrial fibrillation should avoid contact sports

Heart Failure Exercise intolerance Peak exercise capacity reduced 30% to 40% in patients with heart failure Several mechanisms to explain the exercise intolerance A reduction in peak cardiac output (~40%) Chronotropic incompetence Reduced stroke volume The ability to increase blood flow to the more metabolically active skeletal muscles during exercise is attenuated Abnormalities in the skeletal muscle, such as a reduction in myosin heavy chain I isoforms, reduced activity of the enzymes associated aerobic metabolism, and a reduction in fiber size

Heart Failure Moderate exercise is generally safe and results in improvements in many aspects Exercise training increases ejection fraction and decreases LV end-diastolic volume Patients with decompensated heart failure should not be involved in an exercise program More opportunity for rest, then progressively increase to 30 minutes or more. The upper end of exercise intensity at 60% of HR reserve method, based on patient's condition ECG monitoring or not

Cardiac Transplant Cardiac transplant recipients continue to experience exercise intolerance after transplantation This exercise intolerance is believed to be primarily attributable to the absence of efferent sympathetic innervation of the myocardium, affecting heart rate and contractility responses, residual skeletal muscle abnormalities developed before transplantation because of heart failure, and decreased skeletal muscle strength

Cardiac Transplant After transplantation, many differences Elevated resting HR (often >90 bpm) Elevated systolic and diastolic BPs at rest Attenuated increase in HR during submaximal work Lower peak HR and peak stroke volume Greater increase in plasma norepinephrine during exercise Delayed slowing of HR in recovery Elevated systolic and diastolic BPs at rest, partly attributable to increased plasma norepinephrine and the immunosuppressive medications (i.e., cyclosporine and prednisone) Delayed HR in recovery is thought to be attributable to increased levels of plasma norepinephrine, exerting its positive chronotropic effect in the absence of vagal efferent innervation

Cardiac Transplant In the first year after surgery, it is best to simply disregard all HR-based methods because of the abnormal HR control in these patients Cardiac transplant patients undergo exercise training Exercise capacity increases by about 15% to 40% Resting HR is unchanged or decreases slightly Peak HR increases Little change in peak stroke volume or cardiac dimensions Quality of life is favorably altered A progressive resistance training program started 6 to 12 weeks after transplant surgery and performed twice per week

DeLisa Table 83-2 Borg Scales for Rating Perceived Exertion 15-Grade scale10-Grade Scale 6No exertion at all0Nothing 7Extremely light 8 0.5Very, very light (just noticeable) 9Very light 10 1Very light 11Light 12 2Light (weak) 13Somewhat hard 14 3Moderate 15Hard (heavy)4 16 5Heavy (strong) 17Very hard6 18 7Very heavy 19Extremely hard8 20Maximal exertion9 10Very, very heavy (maximal)

Pacemakers, Implantable Cardiac Defibrillators, and Arrhythmias In general, the exercise training prescription is unaltered for patients with these devices. Exercise intensity in patients with an ICD should be set at least 10 beats below the programmed firing threshold Avoid activities that stretch the arms. After 8 wk, nonballistic activities may be resumed, and ballistic activities may be resumed after 12 wk.

Summary The inclusion of exercise in the treatment of these patients is beneficial because of its favorable effects on risk factors, symptoms, functional capacity, physiology, and quality of life. All patients with cardiovascular disease should be encouraged to participate in exercise because of its real or likely positive impact on mortality and morbidity.

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rehabilitation for patients with cardiovascular disease mr 梁芳甄 醫師 ma 黃書群 醫師

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rehabilitation for patients with cardiovascular disease mr 梁芳甄醫師 ma 黃書群醫師