cardiac rehabilitation presented by: dr. ramesh tharwani consultant cardiologist choithram hospital
TRANSCRIPT
Cardiac Rehabilitation
Presented By:
Dr. Ramesh Tharwani
Consultant Cardiologist Choithram Hospital
“Integrated Treatment to regain physical function, promoting emotional
adjustment, secondary prevention of cardiac events and lead active life.”
Target Patient Groups
• Following Myocardial Infarct
• Post PTCA/CABG
• Chronic Stable Angina
• Congestive Heart Failure
• Pacemaker/Valve surgery
Coronary artery bypass surgery
Coronary Intervention
Long Term Mortality Benefits
GOALS
• Daily Activities Active lifestyle
• Emotional/Psychological adjustment
• Diet/Exercise
• Sexual Activity
• Risk Factor Reduction
• Smoking cessation
Assessment• SYMPTOMS : Chest Pain, SOB, Palpitations
• EXAMINATION : CHF, Wound, Concurrent Illness, Musculo-Skeletal disease, Emotional Status(Anxiety/Depression)
• DIAGNOSTIC STUDIES : Lipid Profile, Hb A1C, PFT
• ECG before exercise/Telemetry
• STRESS TEST : Sub maximal modified NAUGHTON’S
> 5-7 METS
> 80-85% THR
• ERGOMETER : Knee/Lower limb problems, Neuro/Ortho Limitation
• ECHO : LV functions, RWMA
• STRESS THALLIUM : Viable Myocardium
Useful in patients with abnormal ECG’s like LBBB, WPW
• VO2 Max with Stress Test to differentiate between Cardiac and Pulmonary dyspnoea.
Initial Phase
• Risk Factor Reduction : Optimal Medical Management Avoid Increase/Decrease BP, No Angina on daily activities
• Smoking Cessation : Psycho Counseling + Drugs (Buprobion HCL, Nicotine Patch)
• Diet Advice : Low Cholesterol, Less than 30% calories from fats
• Decrease Emotional Stress : Relaxation Techniques, YOGA
Initial Phase contd..
• Sexual Activities : 3-5 METS, 2 flight stair Test• Return to Work/ Recreational Activities :
> 3-5 METS Self Care/Daily activities> 5-7 METS Sedentary Work (Table Work)> More than 7 METS Normal Vocational activities (Back To Work). Avoid Heavy physical work.
• Playing Tennis 4-7 METS• Golf 2-5 METS • Volley ball 3-4 METS
Exercise Training (Rehabilitation)
• Walking for 15-30 mins /3-5 times a week• Patient can still talk while walking (Brisk Walk for
initial 2 weeks)• Contra indication to exercise training
>Unstable Angina>Resting BP more than 200 mm/ 100 mm Hg>Postural BP drop to more than 20 mm Hg>Aortic Stenosis>Acute illness or fever>Uncontrolled Atrial or Ventricular Arrhythmias>Uncontrolled CHF>Recent ST Displacement(More than 3 mm Hg)>Musculo-Skeletal Disorders
Exercise Prescription
• Aerobic Exercise preferred than resistive or weight training
• Walking/Cycling• Intensity/Frequency/Duration will depend on
tolerance• THR (220- Age in years) try to achieve 80-85%
THR• 66% MET of level of completed TMT or 25
watts less than completed stage on cycle Ergometer
• Borg scale target 11-15
Exercise Prescription contd.• Exercise session
Warm Up (2-5 mins) Stimulus (conditioning 20-30 mins) Cool Down (5-10 mins, slow speed, prevents low BP and joint pains)
• Graded Exercise with telemetry in high risk population recommended.
• 1-3 months Target 7-8 METS followed by self directed maintenance
Benefits of Cardiac Rehabilitationin old age
Benefits of Exercise Training work capacity fatigue
Heart rate during Exercise
RPP
symptoms of CHF
Atherogenicity by maintaining body weight HDL
TG platelet aggregation
• Improve blood glucose level
• Improves coronary blood flow and myocardial perfusion
Benefits of Exercise Training contd.
• Endurance Training VO2 max 10-40%, BP, HR
BMD
• Positive changes in body composition body weight (1-3 kg), % fat (1-3%)
• Positive metabolic changes insulin sensitivity, cholesterol
• Resistance Training strength 150%
Conclusions
• Cardiac rehab is feasible and safe in an octagenarian patient population
• Exercise training yields clinically significant functional and metabolic improvements for both men and women– 33% in exercise time– 20% in functional capacity (est. METs)– 9% in HDL cholesterol
Potential Treatment complications
• MACE ( Massive Adverse Cardiac Events)
1 per 300,000 hours of exercise
• SCD ( Sudden Cardiac Death )
1 per 800,000 person hours of exercise
• Proper Selection of cases/ avoiding Contra indications to exercise training can minimize the risk.
Thank you all