Cardiac Rehabilitation Exercise Training for CHD

Jina Choo, RN, PhD

July 4, 2003

Statistics_1



2002 KNSO (Korean National Statistical Office)

• • Cardiac disease : third killer (34.2/100,000Koreans) From 1991 to 2001 : the death rate of CHD increased by 88% 

2003 AHA (American Heart Association)

• From 1990 to 2000 : the death rate from CHD declined 7.6% • CHD caused 1 of 5 deaths in the US

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Statistics_2

 New or recurrent coronary attack : 47% will be recurrent attacks  25% of men and 38% of women : die within 1 year after having an initial recognized MI (Framingham Heart Study, NHLBI)  Within 6 years after a recognized heart attack 18% of men and 35% of women : another heart attack 22% of men and 46% of women : disabled with heart failure

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Coronary Risk Factors

         Cigarette smoking Elevated LDL cholesterol/Decreased HDL cholesterol Hypertension Physical inactivity Obesity Diabetes mellitus High fibrinogen High LP(a), Homocysteine Psychosocial Factors • • • • Anxiety Depression Social isolation Chronic Life Stress

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Definition of CR

 The World Health Organization (WHO) • “Sum of activity required to ensure cardiac patients the best possible physical, mental, and social conditions so that they may be their own efforts regain as normal as possible a place in the community and lead an active life”  The concept of secondary prevention • To lessen the chance of a subsequent cardiac event and to slow and perhaps stop the progression of the disease process

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Cardiac Rehabilitation Goals

Exercise Stress Management Smoking Cessation

Secondary Prevention Goals

Lipid and weight control

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History Perspectives(1)

   1950’s • Bed rest for an acute myocardial infarction (AMI) was during 6-8 weeks.

• • Followed by 6 months of physical limitations Objective was to reduce cardiac workload In the late 1950’s • Armchair sitting and early mobilization proved safe by Levine & Lown In the 1960’s • Hellerstein and Wenger established the early inpatient-outpatient model of cardiac rehabilitation.

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Historical Perspective(2)

   Emory university • 14 step inpatient program with documentation, eventually exercise ambulation and education was viewed favorably.

Since the 1970’s • there have been many clinical research trials, initially in Europe and subsequently in Canada and the U.S.

1988-9 • a meta-analysis of all of these studies demonstrated an average decrease in mortality of 25% using cardiac rehabilitation (O’Connor et al., 1989; Oldridge et al., 1988) .

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Historical Perspective(3)

  Since 1985 through the 1990’s • more patients have been eligible for cardiac rehabilitation: • Coronary Artery Bypass Graft Surgery (CABG) • PTCA • Other catheter-based procedure Since 1994 • Cardiac rehab and prevention team of Samsung Medical Center have started and established the inpatient and outpatient CR program

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Exercise and Secondary Prevention

 Regular physical activity : negatively associated with long-term cardiovascular mortality (Leon, 1987; Kannel, 1986; Paffenbarger, 1993)  500-3500Kcal per week : reduced the risk of mortality (Paffenbarger, 1986)

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Reduced 10-year Cumulative Cardiac Mortality Hamalainen, Luurila, Kallio, et al., 1989

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Terminology

  VO 2 peak(oxygen consumption or uptake) =cardiac output * avDO 2 MET(metabolic equivalent)  =3.5 O 2 ml/kg/min RPP (rate-pressure product) =MO 2 (myocardial oxygen uptake) = systolic blood pressure (mmHg)*heart rate(bpm)/100  RPE (rate of perceived exertion)  AT (anaerobic threshold) point

Cardiac Rehab 2003

Terminology : VO

2

peak

  VO 2 peak: peak oxygen uptake ml/kg/min  C.O.* avDO 2 • C.O. = stroke volume * heart rate • avDO2(arteriovenous oxygen difference)  3.5ml/kg/min • 1 MET (metabolic equivalent)

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Terminology : MET (metabolic equivalents) 3.3 METs

walking(3mph)

4.5 METs

vacuum

5 METs

sexual life

2.5-5 METs

Golf

4.5-7.0 METs

Swimming

6.0 METs

Dancing

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Terminology: RPE

     Rating of perceived exertion Introduced by Borg in the early 1960s Important adjunct to HR in the monitoring the intensity of training in cardiac patients.

Related to the amount of strain or fatigue 15-point scale 15-point category RPE scale 6 No exertion at all 7 Extremely light 8 9 Very light 10 11 Light 12 13 Somewhat hard 14 15 Hard(heavy) 16 17 Very hard 18 19 Extremely hard 20 Maximal exertion

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Effects(1): Aerobic Capacity VO

2

peak

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Choo, et al.(1997).

VO

2

peak

36 35 34 33 32 31 30 29 28 27 Mean -0.8%

18.3%,

26 Pre Post Pre Post Control Training

** P<0.01 versus control group VO 2 max: maximal oxygen uptake

**

P<0.01

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The Improvement of Aerobic Capacity

  Fick equation: VO2 = C.O.* avDO 2 avDO2 increase • • • • Increase in blood volume Capillary density Oxygen extraction from capillary blood Mitochondrial enzymes of oxidative metabolism

Capillary: Pre-training Capillary: Post-training

 C.O. increase has been controversial

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Effects(2) : Improvement of Sx

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Effects(2) : lower RPP

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Effects(2) : Anginal Threshold

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Choo, et al.(1997).

RPP

submax Mean 180 -3.8% 160 140 120 100 80 60 40 20 0 Pre Post Control Pre Post Training

-16.8%, *P<0.05

* P<0.05 versus control group RPPsubmax: submaximal rate-pressure product (HR × SBP/10 2 )

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Choo, et al.(1997).

Anaerobic Threshold

1.6

Mean 1.4

1.2

1 0.8

0.6

0.4

0.2

0 Pre Post Control -7.6% Pre Post Training

21%, *p<0.05

* P<0.05 versus control group

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Effects(3) : Lipid Profiles

authors Rogers et al.

Brizida et al.

Choo et al.

year n 1987 9 CADs 1996 49 CADs 1998 19 CADs exercise 12 mo 6 yrs 3-4 mos 9 mos 8 wks lipid HDL 18% HDL 39% HDL 12.5% NS HDL 19.5% HDL 9% NS •

HDL increase

•

1200-2200Kcals/week energy expenditure needs

• (Durstine et al., 2002)

Exercise duration > 9 months

(Brizida et al., 1996)

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Effects(4) : Heart Rate Variability

authors year n Malfatto et al. 1996 30 MIs Tygesen et al. 2001 62 MI & CABGs Choo et al.

2003 31 MIs exercise 12 wks 3 mos HRV index SDNN, rMSSD LF, HF & LF/HF ratio SDNN 8 wks SDNN, rMSSD NS LF, HF & LF/HF ratio NS

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Effects(5) : Psychological factors

authors Milani et al.

year 1996 338 n CADs exercise 3 mos (36sns) 16 wks Blumenthal et al. 1999 156 MD • Exercise • Antidep • Mixed Choo et al.

2003 31 MIs 8 wks lipid Depression(+) Anxiety(+) Depression(+) - Hamilton/Beck Anxiety(+) Depression(-)

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Effects(6) : Quality of Life

authors Oldridge et al.

Lavie et al.

year n 1991 201 MI Int.

8 wks -ex -relaxation 1995 458 CAD 3-4mo (36sns) Yoshida et al.

Choo et al.

2001 51 MI 2002 47 CAD 2 wks -ex -consult 8 wks lipid QOL(+) >65yrs ex. capacity(+) QOL(+) Anxiety(+) QOL(+) ex. capacity(+) QOL(+)

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Effects of Cardiac Rehab on QOL in 2002

47 CAD subjects Age-Sex-EF matching CR group N=31 Phase II cardiac rehabilitation

Quality of Life

Ferrans and Powers’ Quality of Life Index(QLI) Cardiac version III Control group N=16 Usual care 72-item scale: Part I: satisfaction Part II: importance 4 domains:  Health and functioning  Social and economic  Psychological and spiritual  Family (4) (16) (8) (7 )

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Results-Overall QOL

score 35 30 25 20 15 10 5 0 Gp C Gp CR CR: cardiac rehabilitation C: Control * 11%

baseline 8 weeks

8 weeks baseline * p< .05 between two groups

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Long-term Effects of Exercise Training

Physiologic

↑VO 2 peak ↓ MVO 2 for given workload ↑Muscle strength and endurance ↓Blood fibrinolytic activity ↓Platelet aggregation ↓Catecholamine ↑Heart rate variability

Symptomatic

↓Angina ↓Dyspea ↓Claudication ↓Fatigue

Anatomic

↓Progression of disease ↑Regression of disease

Psychological

↓Anxiety and depression ↑Confidence and self-esteem ↑Knowledge

Epidemiologic

↓Morbidity ↓Mortality

Risk factors

↓Smoking ↓Total cholesterol and TG ↑HDL cholesterol ↓Obesity ↓Hypertension

Economic

↓Cases of disability ↓Visits to physician’s office ↓Medication

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Multi-phase

 Phase I  Phase II  Phase III  Phase IV Inpatient Outpatient Community-based Maintenance 5-14days 1-3mo 6-12mo 12mo~

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Clinical Contraindications for CR

             Unstable angina Resting SBP>200 mmHg or resting DBP>110 mmHg should be evaluated on a case-by-case basis Orthostatic blood pressure drop of >20 mmHg with symptoms Critical aortic stenosis Acute systemic illness or fever Uncontrolled atrial or ventricular arrhythmias Uncontrolled sinus tachycardia(>120 beats/min) Uncompensated CHF 3 AV block (without pacemaker) Active pericarditis or myocarditis Recent embolism Thrombophlebitis Resting ST segment displacement(>2mm) et al.

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Risk Stratification(1) -

AACVPR Criteria

Signs & Symptoms Cardiac Cath Thallium Scan EchoCG SL-GXT LVEF Myocardial Ischemia Complexity of Arrhythmia Functional Capacity (MET) Low Moderate • •

Exercise Duration / Intensity ECG Monitoring / Close Clinical Supervision

High

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Risk Stratification(2) -

AACVPR Criteria

  Lowest Risk • • • • • No significant LV dysfunction(EF>50%) No resting or exercise-induced complex dysrhythmias Absence of CHF Asymptomatic including absence of angina Functional capacity >7 METS Highest Risk • • • • • • Decreased LV function (EF<35%) Survivor of cardiac arrest or sudden death Complex ventricular dysrhythmia at rest or with exercise MI or cardiac surgery complicated Abnormal hemodynamics with exercise Sings/symptoms including angina pectoris at low levels of exercise(<5.0 METs) or in recovery • Functional capacity <5.0METs

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GXT: Graded Exercise Test

 SL-GXT • Symptom-limited GXT  Protocol • • Bruce Protocol Modified Bruce protocol  To measure the below index • • • • VO 2 peak Maximal HR Resting HR AT point

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Exercise Prescription

   FITT • F requency · I ntensity · Duration ( T ime) · Mode ( T ype) Setting target HR and target RPE • Based on SL-GXT • Without GXT – Target HR  resting HR + 20bpm • Consider ischemia – 10bpm below the ischemia Progression • Duration : each 5min/week increase • Intensity : 0.5 METs/wk increase • Frequency>>Duration>>Intensity

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Exercise Needed for an Optimum Effect

 ACSM recommends • Minimal caloric threshold : 800-900Kcal/week • 300 Kcal/session, 3 days/week • 200 Kcal/session, 4 days/week • To achieve optimal physical activity levels • Closer 2000 kcal/week

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Comparison of Progression of Training

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Useful Equation for Caloric Cost of Exercise

 METs x 3.5 x body weight in kg/200 = kcal/min  For example • 3.3 x 3.5 x 50(kg)/200 = 3.0kcal/min, 180 kcal/hr

3.3 METs

walking(3mph)

Based on ideal caloric threshold

• 1000 kcal/wk  5.5 sessions/wk • 2000 kcal/wk  11sessions/wk

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Phase I Exercise Prescription

 Intensity RPE<13 Post-MI • HRrest+20 Post-surgery • HRrest+30 To tolerance if asymptomatic  Duration Intermittent bouts lasting 3-5min Rest periods lasting 1-2min shorter than exercise bout duration Total duration of up to 20min  Frequency Early mobilization days 1-3 3-4 times per day Later mobilization beginning on day 3 2 times per day  Progression Initially increase duration to 10-15min of continuous exercise, then increase intensity

ACSM Guidelines for Inpatient Mobilization

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Phase I

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Hospital Discharge Planning

  To perform 5 METs GXT  Individualized Home Activity Instruction • • Pulse taking technique and RPE(11-12) Sign and symptoms of exercise intolerance  Consider phase II referral

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Phase II Exercise Prescription

     Frequency : 3-4 sessions/week Intensity : initial intensity • Initial target HR by VO 2 peak • 55-70%(ACSM & AACVPR) • 50-60%(AHA) • Initial RPE 12-13 Duration : 20-60min(minimum 20min) continuous or intermittent Mode : walking, jogging, stationary cycling arm-leg cycle ergometry, stairclimbing Progression : frequency >> duration >> intensity

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Intensity

 Target Heart Rate and RPE HR max % HR reserve % (Karvonen’s method) VO 2peak % the most ideal RPE Heart rate at Ischemic point AT point

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Classification of Intensity of Exercise

%HR max <35 35-59 60-79 80-89 >90 %VO 2peak <30 30-49 50-74 75-84 >85 RPE Class of Intensity <10 Very light 10-11 12-13 14-16 Light Moderate Heavy >16 Very Heavy

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Target Heart Rate using VO

2peak

%

THR 95bpm VO2peak 20.3ml/kg/min  VO2peak 20.3ml/kg/min  Intensity 60%  12.2ml/kg/min

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Heart rate reserve using Karvonen method

Target HR : 81bpm ((99-63)*0.5)+63=81 Target RPE : 12-13

Resting HR: 63 Maximal HR: 99

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Phase II: Warm Up & Cool Down Exercise

  Warm Up • • • Duration: 7-15 min Intensity: 40-50% VO2peak Mode : Stretch, ROM exercise Cool Down • • • Duration: 5-10 min Intensity: 40% VO2peak Mode : Stretch, ROM exercise

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Phase II: Conditioning Phase

   Duration: 20-60min • Continuous << Intermittent • Exercise/Resting bout >1 • 8E-3R-8E-3R-8E-3R = 31min Initial Intensity • • 55-70%(ACSM & AACVPR) 50-60%(AHA) Mode • • • • Walking, Treadmill Stationary Cycling Arm Ergometer Stairmaster

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ECG Monitoring / Clinical Supervision

 AACVPR guidelines • Lowest risk • Up to 18 sessions • 30 days • Moderate risk • Up to 24 sessions • 60-90 days • Highest risk • 24 sessions • 90 days

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Phase II CR

Patient had angina and CABS Assessed patient risk status Patient classified as

low risk

•VO 2peak 8 METs •EF 60% •No ischemia •Absence of significant ventricular arrhythmia

AACVPR criteria Cardiac Rehab 2003

Phase II: Exercise Training

Frequency Duration : 3 sessions/week :10-min warm up & cool down 3-cycle int-conditioning for 33-45 min Progression Intensity Week %HRR THR RPE Mode 1 60 137 12 8E-3R Treadmill/Bike 2 60 137 13 10E-3R 3 4 65 140 13 10E-3R Stairmaster 5 Arm-ergometer 6 65 140 13 12E-3R Light resistance 7 8

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smoke?

No High blood lipid?

Phase II CR Education

Yes Dietary education, Counseling Overweight?

No High blood pressure?

No Diabetes Mellitus?

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Functional Capacity

Outcome Variables Pre Post Difference(%) VO2peak(ml/kg/min) 27.3(8) 30.3(9) 11.0 AT(L/min) 1.2 1.6 33.3

RPPsubmax(bpm*mmHg/100) 178 150 -15.7

RHR(bpm) 96 83 -13.5

RSBP(mmHg) 111 102 -8.1

Exercise duration(sec) 822 962 17.0

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Analysis of Diet Intake

Outcome Variables Pre Post Difference(%) Daily Total Calories(Kcal) 1,993 1,582 -20.6 CHO(g) 288 272 -5.6

Protein(g) 74 55 -25.7

Fat(g) 61 37 -39.3

Cholesterol(mg) 430 259 -39.8

Na(mg) 6,344 4,836 -23.8

Diet knowledge(score) 48 62 29.2

HbA1c(mg/dl) 8.3 6.5 -21.7

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Lipid profile

Outcome Variables Pre Post Difference(%) T-chol(mg/dl) 202 138 -31.7 HDL-chol(mg/dl) 52 44 -15.4

LDL-chol(mg/dl) 138 78 -43.5 TG(mg/dl) 61 82 34.4

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Compliance and Adherence

 The long-term success of an secondary prevention program is directly related to patient compliance  Adherence rates for exercise training program • • • • 80% for the first 3 months 60-71% at 6 months 45-60% at 12 months 30-50% at 2-4 years

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Cardiac Rehabilitation: TES program

Exercise Training Essentials of TES program



Exercise Prescription Frequency: 3/week Intensity: 40-50% HRR or VO 2peak Enhancement of Self-Efficacy Duration: 55 mins Mode: Treadmill, Bicycle etc



Exercise Training 8weeks, 24sessions Group training



Vicarious Persuasion Education, Goal setting Counseling on capacity



Modeling



Having a time with a model person Enactive Attainment Learning by experience Achievement evaluation and

   

Providing Social Support Telephone Counseling Problem Solving Group Therapy Multidisciplinary Counseling Reinforcement



Physiologic Feedback

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