CARDIAC REHABILITATION 

1. Cardiopulmonary rehabilitation is a very important part of the rehabilitation of chronic cardiac or lung conditions , 
2. Physical therapy has an integral role in the rehabilitation of such cases , patients undergo open heart surgeries are eligible for that kind of rehabilitation as soon as their case is stable , 
3. This rehabilitation can assist the patient to cope up with his new life and improves his quality of life, 
4. Physical therapy uses some types of supervised exercises to achieve that goal like endurance and resistance exercise using treadmills, bicycles and even free weights

Goals of Cardiac Rehabilitation:

1. Restore and improve cardiac function 
2. Reduce disability 
3. Identify and improve cardiac risk factors 
4. Increase cardiac conditioning. 
5. enhance quality of life among cardiac patients

Phases of Cardiac Rehabilitation: 

Phase I 
During acute inpatient hospitalization up to discharge 

Phase II 
Post discharge period (Supervised ambulatory outpatient ) 

Phase III 
Cardiac Rehabilitation, Secondary prevention and Education program 

Phase IV 
Maintenance phase in which physical fitness and risk factor reduction are accomplished in a minimally supervised or unsupervised 

NB: Metabolic equivalent (MET): Resting metabolic unit—1 MET = 3.5 ml O2 consumed per kilogram of body weight per minute

Cardiac Rehabilitation phase I: acute inpatient hospitalization up to discharge 2-5 days

• Acute Period—CCU (Cardiac Care Unit) 
• Subacute Period— Transfer from the CCU to either a telemetry unit or to the medical ward 

Acute Period—CCU (Cardiac Care Unit) closely monitored

Goal : 

-reduce risk of thrombi 
-maintain muscle tone 
-Reduce orthostatic hypotension, maintain joint mobility. 

• Activities of very low intensity (1–2 Mets) 
• Passive ROM (1.5 mets) 
• Upper extremity ROM (1.7 mets) 
• Lower extremity ROM (2.0 mets) 
• Avoid: isometrics (increases heart rate), valsalva (promotes arrhythmia), raising the legs above the heart (can increase preload)

Subacute Period: 

• Activities or exercises of intensity (3–4 mets) 
• ROM exercise: intensity can be gradually increased by increasing the speed and/or duration; may add mild resistance or low (1–2 lbs.) weight, Energy cost of low grade ambulation 
• regular slow walk = 2–3 mets 
• Propelling wheelchair = 2–3 mets 
• Post-surgical patients' greater emphasis is placed on upper extremity ROM and lifting activities are restricted, generally for 6 weeks. DR. AHMED ABDELHALIM 
• Avoid: isometrics (increases heart rate), valsalva (promotes arrhythmia), raising the legs above the heart (can increase preload)

Cardiac Rehabilitation phase II:

the stage of cardiac rehabilitation that occurs immediately after discharge 

AIMES: 

• Improve functional capacity. 
• Progress toward full resumption of activities of daily living, habitual and occupational activities.

PROGRAM: 

• Frequency: 3-4 sessions/week. 
• Duration: 30-60 minutes with 5-10 minutes of warm-up and cooldown. 
• Programs :single mode of training (e.g., walking)or multiple modes using a circuit training approach (e.g., treadmill, cycle ergometer, arm ergometer); 
• strength training. 
• Slow walk 2 mph 2–3 mets 
• Brisk walk 3–5 mph 4–5 mets 
• Jog walk 5 mph 9 mets

Cardiac Rehabilitation phase III:

• Location: outpatient clinic, or clinical facilities. 
• Improve and/or maintain functional capacity. 
• Entry level criteria: functional capacity of 5 METs, clinically stable angina 
• Progression to 50-85% of functional capacity, 3-4 time /week, 45 minutes or more/session. Exercise class will consist of : 

1. Check in (vitals assessed)
2. Warm Up (15 mins) 
3. Main class (30 mins) may also include resistance training with active recovery 
4. Cool down (10 mins) - Monitoring and reassessment of vitals

Phase 4:

— Life Long maintenance Program and lifestyle changes (diet and Psychological support) , At least 6 months, BUT Should continue life long Not Include Clinical Supervision Or Ecg Monitoring Goal: maintain functional capacity, If the patient stops exercising, the benefits gained from phase III can be lost in a few weeks Location: Home or community based facility 
— Patient can be self monitor, used scale : 
— -Rate of Perceived Exertion measure of fatigue, asked to rate his fatigue with a number on the scale based on his perception of the difficulty of the activity, quantify patient’s overall feelings and sensations during the stress of physical activity .. so It determine that a training effect can be achieved by : exercising at a level of somewhat hard (13 to 16 on the older scale) 
— or somewhat strong (4 to 5 on the new scale) 
— and replace heart rates (for example: when the patient is taking certain drugs that may alter the heart-rate response to exercise such as beta blockers) in providing feedback on exercise intensity, Help patient monitor themselves and determine his target HR. Daily exercise routine not less than 5 days / week . 60 to 90 mins per day,

  consist of:

• Warm Up (15 mins) 
• Main exercise session (30 - 45 mins) inclide: stretching, aerobic exercise, and strength training. 
• Cool down (10 mins )

Possible Effects of Physical Training/CardiacRehabilitation 

• Decreased HR at rest and during exercise; improved HR recovery after exercise. 
• Increased stroke volume. 
• Increased myocardial oxygen supply and myocardial contractility; myocardial hypertrophy. 
• Improved respiratory capacity during exercise. 
• Improved functional capacity of exercising muscles 
• Reduced cardiovascular mortality 
• Decreased risk of other arrhythmias 
• Improved general health, Decreased serum lipoproteins 
• Improved exercise tolerance 
• Improved ability to survive until transplant, and improved recovery from transplant 

Reasons to stop exercise – Inpatient 

1. HR>130bpm or >30bpm above pre-ex level 
2. Diastolic BP >110mmHg 
3. Decrease in systolic BP > 10 mmHg 
4. Significant ventricular or atrial arrhythmias 
5. Second or third degree heart block 
6. Signs/symptoms of exercise intolerance – angina or dyspnea

Exclusion Criteria & Contraindications to Exercise 

• Unstable angina. 
• Unstable or acute heart failure. 
• Unstable diabetes. 
• New or uncontrolled atrial or ventricular arrhythmias. 
• Resting or uncontrolled tachycardia (> 100bpm). 
• Resting systolic blood pressure > 180mmHg & / or resting diastolic blood pressure > 100mmHg 

NB: 

Heart Rate Reserve & Target Heart Rate 

1) Heart Rate Reserve (HRR): 
— HRR = (Maximum HR – Resting HR) 
— Ex: If maximum heart rate is 200 and resting heart rate is 70 Heart rate reserve (HRR) = 200-70 = 130 bpm 

2) Target Heart Rate (THR) = % of HRR + RHR
— Moderate-intensity THR zone = 50–70%(HRR) + RHR. 
— High-intensity THR zone = 70–85%(HRR) + RHR. 
Ex above: Moderate intensity (60%)x130 + 70 = 148 bpm