Cardiac Rehabilitation Cardiac Rehabilitation

ObjectivesObjectives

To gain an understanding of:

Aims and benefits of cardiac rehabilitation Cardiac rehabilitation pathway Assessment Risk stratification Exercise session Monitoring Safety Transfer to Phase IV

Principle of Cardiac RehabilitationPrinciple of Cardiac Rehabilitation

Enable the patient to regain full physical, psychological and social status

Promote secondary prevention to optimise long term prognosis

Comprehensive cardiac rehabilitation

Patient groupsPatient groups

Acute cardiac event Awaiting or post revascularisation Stable angina Stable heart failure Post valve surgery Post heart transplantation Post ICD insertion

Benefits of Cardiac RehabilitationBenefits of Cardiac Rehabilitation

↓ angina ↓ blood pressure ↓ anxiety and

depression ↓ hospital

admissions

↑ lipid profile ↑ functional capacity ↑ compliance with

lifestyle modification ↑ confidence ↑ return to work ↑ return to leisure

activities↓ mortality by 31% (Taylor et al,2004)

Cardiac Rehabilitation TeamCardiac Rehabilitation Team

Multi-professional Overall coordinator Interdisciplinary working Multi tasking / skill extension

Rehabilitation services should be available from people trained in:

Cardiology Exercise Lifestyle intervention Psychological treatments SIGN 2002

Phases of CRPhases of CR

Phase I In-patient stay

Phase II Post discharge at home(2 – 6 weeks)

Phase III Out-patient careHospital or communityDelivered by health care services

(6 -12 weeks)

Phase IV Long term maintenanceDelivered by leisure services

Pre Phase 1Pre Phase 1

Pre operative sessions for patients/spouse. Invited along to local CR site. Provide with information regarding surgery, hospital

stay, and planned follow up. Very well received and demonstrating positive

outcomes.

Phase IPhase I

Education about cardiac event / condition

Risk factor modification Symptom management Counselling & support Early mobilisation Referral to and contact

details for Phases II and III

Under care of GP• assessment of cardiac risk• assessment of physical, psychological and

social needs for cardiac rehabilitation• provision of lifestyle advice and psychological

interventions• Community nurse involvement

Often a neglected phase – patients can feel isolated

Phase IIPhase II

Phase IIPhase II

Delivered by:

Home visitTelephone contactTelephone help lineHeart manual

Problems at this stageProblems at this stage

Symptoms Medication titration Conflicting advice Inequity of cover throughout Grampian

Phase IIIPhase III

Timeframe 2 – 6 weeks post event

Venue hospital / community

Duration 8 weeks

twice week

Assessment at Phase IIIAssessment at Phase III

• Current clinical / cardiac status• Investigations / results• Risk stratification• Medication• Psychological status• Functional capacity assessment• Calculation of THR• Physical limitations• Personal goals• Habitual activity

Functional capacity testsFunctional capacity tests

Sub maximal Bruce / Modified Bruce Protocol Shuttle Walk test 6 minute walk test Cycle ergometer Chester step test

Risk StratificationRisk Stratification

Risk Stratification: The process of determining the level of risk of a

patient having a further cardiac event whilst exercising

Criteria used: cardiac history current cardiac status

Risk Stratification CriteriaRisk Stratification Criteria

Risks associated with exercise:

Extensive myocardial damage Poor LV pumping capacity Residual ischaemia Ventricular arrhythmias

Criteria checklist and AACVPR Stratification to risk stratify

Risk stratification determinesRisk stratification determines

Exercise prescription • Exercise intensity

Level of monitoring & supervision

Contraindications to Phase III exercise component

Contraindications to Phase III exercise component

unresolved unstable angina resting BP 200 / 110mmhg significant unexplained drop in blood

pressure during exercise resting tachycardia > 100 bpm uncontrolled atrial or ventricular arrhythmias unstable heart failure unstable / uncontrolled diabetes fever (febrile illness)

Screening and InductionScreening and Induction

Checklist prior to each session: Changes in symptoms/ medication Heart rate and BP measurements Home activity Problems / concernsInduction should include an explanation of: the aims of the programme the exercises and equipment to be used and any exercise

adaptations pulse monitoring/safe target heart rate ranges the use of ratings of perceived exertion (RPE) reporting abnormal symptoms

Conditioning ComponentConditioning Component

FITT principle

Both circuit or gym designs used

Monitoring

Progression

Safety

Home programmeHome programme

To support the phase III exercise sessions

Walking

Activities similar to those performed under supervision

Home exercise record

Education ComponentEducation Component

Heart disease, investigations and procedures

Risk factors for CHDEffects and benefits of exerciseHealthy eatingMedicationRelaxation / stress management

Psychological ComponentPsychological Component

Screening:Quality of life tools Anxiety and depression

Intervention:Motivational InterviewingCognitive Behavioural TherapyCounsellingRelaxation / Stress management

Health BeliefsHealth Beliefs

Health beliefs are central to a person’s management of their CHD.

They are formed from a variety of sources and influence perception of their illness and how to cope with it.

What are Health Beliefs?What are Health Beliefs?

When people have a diagnosis, illness or injury they generate beliefs in these 5 areas to help them to understand and respond to their health event:

Identity Cause Consequence Time line Cure / control

Leventhal el al., (1997)

IdentityIdentity

Diagnostic label Symptoms Type of people who have the same condition

Typical beliefs may include:‘I only had a heart attack.’‘It’s only men that get heart problems.’‘I’m like my Dad, he had problems with

his heart and veins.’

CauseCause

The patients perception as to why they have CHD may include:• Family history• Stress• Smoking• Bad luck

Accurate identification of risk factors are crucial Research shows misconceptions about causes of

CHD.

ConsequencesConsequences

This is the patient’s perception of the longer term impact and implications of their CHD on their lifestyle, family and friends.

Beliefs may include:• ‘My heart is weak and damaged, I’ll never be the

same again.’• ‘If I manage my risk factors, I can reduce the

chances that I have if I have another heart attack.’

TimelineTimeline

The length of time patients expect their illness to last will have an effect on their other health beliefs and how much that may do to modify their lifestyle positively.

• Beliefs that may be held could include:‘I have only had a heart attack, once I have finished my

rehabilitation I will be fine.’ ‘CHD is for life, I must change my lifestyle to manage my

condition.’

Cure / ControlCure / Control

Patients who believe that their condition is manageable/controllable are more likely to make a better physical and recovery:• ‘If I give up smoking and take up exercise I can reduce my

chances of problems in the future.’

Patients who wrongly perceive that their condition is cured or uncontrollable may not address their risk factors:• ‘I have had a bypass operation and now I am cured.’• It runs in the family, it was bound to happen, that’s life!’

Implications for Long TermImplications for Long Term

Beliefs are strongly held

Consider patient’s beliefs & experiences Can promote a good recovery and facilitate effective

management of patient’s recovery. Can also hinder recovery and prevent an individual

adjusting and managing condition.

Transfer to Phase IVTransfer to Phase IV

Ensure medically and psychologically stable Criteria required for transfer from Phase III to IVEnsure individual can:

• exercise independently and safely• self-monitor effectively • recognise warning signs and symptoms• identify goals for lifestyle change & risk factor reduction• identify psychological goals• demonstrate knowledge of their cardiac condition• demonstrate compliance to home-based activities

Fast track protocols

Long term management plan Long term management plan

Risk factor monitoring & management Local exercise opportunities / resources Details of medical follow up Long-term exercise advice Support services for behaviour change

maintenance Local support group information Phase III CR team contact details

SummarySummary

Principle and benefits

Phases

MDT Team

Exercise component of Phase III

Psychological component

Discharge and Transfer to phase IV

Risk Stratification