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Cardiac Rehabilitation
and the High Risk Patient
Ma. Paz Mildred F. Luque, MD, FPCP, FPCC
HEART INSTITUTE
St. Luke's Medical Center
Quezon City ♥ Global City
High-risk patients
Severe LV dysfunction
Severe exercise-induced ischemia, ST-segment
depression of greater than 0.2 mV on an ECG,
multiple perfusion defects on exercise nuclear
stress testing, or multiple dyskinetic LV segments
on stress echocardiography
Complex ventricular arrhythmias or a history of
previous sudden cardiac arrest
Hypotensive response to exercise
Low functional capacity
Patient's inability to self-monitor his/her heart
rate
Components of a program
Medical evaluation
Prescribed exercise
Education
Counselling of patients with cardiac
disease
Short term goals
"Reconditioning" the patient sufficiently
enough to allow him/her to resume
customary activities
Limiting the physiologic and psychological
effects of heart disease
Decreasing the risk of sudden cardiac
arrest or reinfarction
Controlling the symptoms of cardiac
disease
Long term goals
Identification and treatment of risk factors
Stabilizing or reversing the atherosclerotic
process
Enhancing the psychological status of the
patients
Risk stratification
Assessment of the patient's functional
capacity
Educational and psychosocial status
Whether alternatives to traditional cardiac
rehabilitation can be used
Whether the patient is suffering from
myocardial ischemia, ventricular
dysfunction, or arrhythmias
Heart Failure
Limited exercise capacity
Low cardiac output
Reduced muscle blood flow
Skeletal muscle dysfunction
Deconditioning
Effects of exercise
Clinical
Enhanced peak VO2, possibly peak cardiac
output due to a higher workload achieved, and
leg blood flow during exercise
Improved muscle energetics
Improvement in symptoms
Effects of exercise
Pathophysiologic
Reduced sympathetic tone and increased
vagal tone at rest
Reduced neurohumoral activity with
decreased resting levels of angiotensin,
aldosterone, vasopressin and natriuretic
peptide
Improvement in endothelial function
Reduction in plasma levels of proinflammatory
cytokines
No ventilatory, hemodynamic,
autonomic, or clinical factor at baseline
predicts the outcome with exercise training
in patients with heart failure
Effects of exercise training
Hemodynamics
Functional capacity
Improves measures of left ventricular function
and hemodynamics
Improvement in maximal exercise tolerance
Patient outcome
Reduce heart failure related hospitalization
Improve health-related quality of life
HF Action Trial
2331 patients with left ventricular ejection
fraction ≤35 percent and NYHA class II to
IV HF
Randomly assigned to either a supervised
exercise training program or usual care
including education and recommendation
of regular exercise
Background medical therapy was
optimized
Median follow-up was 30 months
HF Action Trial
Modest but significant decrease in allcause mortality or all cause hospitalization
(after adjusting for baseline prognostic
variables) with the exercise training
program
Significant reduction in cardiovascular
mortality or HF hospitalizations
High level of safety during and after the
training sessions
Significant improvement in health status
Exercise recommendations
Patients with stable class II to class III HF
who do not have advanced arrhythmias,
and who do not have other limitations to
exercise
Exercise intensity of 70 percent of heart
rate reserve, three days per week for six to
eight weeks
Exercise guidelines
Longer warm-up period
Begin at 40 to 60 percent VO2max for
intervals of two to six minutes separated by
one to two minutes of rest
Gradually increase length of the exercise
interval by one to two minutes until the
patient tolerates 30 minutes of continuous
exercise
Self care
Actions aimed at maintaining physical
activity, avoidance of behaviors that can
worsen the condition and detection of the
early symptoms of deterioration
Linked to symptom control, functional
capacity, QOL, hospital admissions,
prognosis, reduced mortality
Precipitating factors in deterioration: nonadherence to diet or medication regimen,
inappropriate use of medications,
infections arrhythmia, ischemia
Cardiac Transplantation
Abnormal levels of
functional capacity
Marked deconditioning prior to transplant
due to heart failure
Surgical denervation
Corticosteroid therapy
Peripheral vasoconstriction
Pre-transplantatiion
For stable outpatients, exercise as an
adjunct to pharmacologic therapy during
the entire waiting period
Preferred timing of referral is during the
hospital stay for the transplant event
For patients on home inotropic therapy, a
monitored program in a cardiac
rehabilitation center
Pre-transplantation
For patients on inotropic support who are
being monitored hemodynamically, activity
will vary depending upon patient mobility
Limited data suggest that exercise training
may be beneficial in patients who receive a
left ventricular assist device (LVAD) as a
bridge to transplantation
Immediate post-op
Prior to removal of the chest tubes and
pacer wires, passive and active range of
motion plus incentive spirometry
Once out of bed in a chair, leg raising and
hip girdle exercises
Once the patient is able to stand,
ambulation is initiated
Prior to discharge, exercise on a stationary
bicycle ergometer and/or treadmill.
Predischarge cardiopulmonary exercise
test
Post-hospital prescription
Intensity
Duration
Frequency
Progression
Resistance exercise
Exercise guidelines
Exercise in 15 to 30 minute sessions three
to five times per week
Avoid repetitive lifting of greater than a few
pounds
Maintain RPE at 10 to 13
ICD
Baseline information
ICD detection threshold setting in beats per
minute
Whether the device is set for ventricular
tachycardia or ventricular fibrillation
Rapid onset setting
Sustained ventricular tachycardia settings
ICD mode of therapy
Beta-blockers
Exercise
Avoid contact sports
Swimming possible unless arrhythmia is
triggered by swimming; must be
accompanied at all times
Snorkeling not recommended
SCUBA diving should not be undertaken
Avoid exposure to strong magnetic or
electrical fields or a powerful radio source
Physical activity & exercise
Aerobic skilled flowing movement,
muscular endurance, flexibility
Progress slowly
Monitor intensity using heart rate or
perceived effort
Warm up and cool down
Avoid static exercise when you are holding
tight or resisting strongly and holding your
breath
Most exercise should be performed
standing
Physical activity & exercise
Most exercise should be performed
standing
Avoid excessive shoulder range movement
and or highly repetitous vigorous range
movements
Continuous physical activity of 30 minutes
or more most days of the week
Chronic Kidney Disease
Cardiovascular Disease
Leading cause of death regardless of CKD
stage
As renal function declines, all cause and
cardiovascular mortality increases
exponentially
40% of patients with established CVD have
concomitant CKD
Worse prognosis
Worse revascularization outcomes
Higher procedural complication rates
CVD risk factors and CKD
Traditional risk factors are rampant in the
CKD population
U-shaped mortality curve associated with
cholesterol and hypertension levels with an
increased risk of death for both extremes
of measurement
Qualitatively and quantitatively different
risk factor exposure
Burden of CKD-associated non-traditional
risk factors
Physical fitness and CKD
Limited physical function across amny
subjective and objective domains
Deficits in measures of cardiopulmonary
fitness (walking distance/time, treadmill,
cycle ergometry) and strength
Association between declining exercise
performance and creatinine over time,
independent of hemoglobin level
Beneficial effects
Physical fitness
Blood pressure
Psychosocial
function
Lipid parameters
Hemoglobin levels
Measures of
arterial stiffness
Quality of life
Cardiorespiratory
parameters
Renal functional
parameters
Barriers to participation
Socio-economic
Logistic
Patient-related
Biased referral
patterns
Special considerations
Hemoglobin
Direct relationship with exercise capacity
Treatment with erythropoesis-stimulating
agents (i.e., erythropoietin) improves exercise
capacity and VO2 peak
Strength training and resistance exercises
Intrinsic muscle changes contribute more to
poor performance than do limitation in oxygen
supply
1997 study showed strength training alone
can improve VO2 peak in CKD patients
Psychological stressors and
adjustments
Higher stress levels
Alteration in social and role responsibilities,
dependence and interdependence issues
and uncertainty about the future
Intensify as CKD progresses and need for
renal replacement therapy draws nearer
Cardiac rehabilitation provides an
opportunity to foster coping skills and help
patients adjust to these stressful changes
Dietary counseling
Maintenance of optimal nutrition
Prevent or minimize metabolic
derangements of CKD
Retard the progression of renal failure
Cardiac rehabilitation & CKD
Regular structured exercise
Dietary intervention
Psychosocial counselling
Life skills and coping skills retraining
Pharmacologic intervention
Elderly
Elderly
High risk of disability after coronary event or
hospitalization for heart failure
Complications of MI and myocardial
revascularization are more frequent at an
advanced age
Prolonged hospitalization leads to
deconditioning
Less referral to and participation in cardiac
rehabilitation
Physical activity
Improvements in gait, balance, overall
functional capacity and bone health
Increase quality of life
Physical activity
Cardiovascular fitness
At least 30 minutes of moderate intensity
exercise on most, if not all, days of the week
Exercise mode that does not impose excessive
orthopedic stress; and is accessible, convenient
enjoyable
Start low and individually progress according to
tolerance and preference
Measured peak heart rate preferable to agepredicted heart rate because of underlying CAD
Physical activity
Resistance training
Begin first 8 weeks with little resistance
One-set of 8-10 multi-jointed exercises that
include all major muscle groups
Set should include 15 repetitions at RPE of 1213
Number of repetitions increased before the
resistance
Physical activity
Flexibility
Improvement in ability to perform ADL, balance
and agility
Reduction in injury potential
For every major joint of the body, at least 2 to 3
times per week
Thank you
for your kind attention