Cardiac Rehabilitation
Ajay Elias,
Physiotherapy Specialist
Karimbilackil,Mekkadanbu.PO.Muvattupuzha .Kerala,India
Characteristics:
General features: Longitudinal, Participatory, Preventive, Personalized to a limited extend
Components: Physiological, Vocational, Psychological, Educative.
Ideal Program:
Individualized, supervised, therapeutic, relaxing, dynamic, aerobic, viable intensity, enjoyable, educational, recreational, non – competitive.
Candidates:
Post MI, Post CABG, Post transplant, Post valvular.
Primary goals
1. Increase the functional capacity.
2. After natural history of cardiac disease.
Precautions
No heavy meals prior to exercise
Exercise in a cool environment
Drink water before & after exercises and allow sips during exercises.
Loose and comfortable dressing
Early morning and late evening are the best time for exercise.
Goals
Phase 1 prevent secondary complications of inactivity.
Phase 2 achieve strong scars in the area of ischemia
Phase 3 improve endurance and return to work if possible to previous activity itself
Phase 4 maintenance and endurance




PHASE 1
PHASE 2
PHASE 3
Name In Hospital Early Post Hospitalization Maintenance Phase

Timing
Admission to hospital 2 weeks post discharge or 6-8 week Post MI ,3-4 wee Post CABG

Duration Up to discharge hospital 8-12 weeks Life long

Condition Acute MI, CABG, Post angioplasty, Angina pectoris Phase 1 graduates, and CAD with risk factors Phase 2 graduates


Major goals Prevent deconditioning, Patient an family education, functional mobilization, early hospital discharge
Develop cardio vascular endurance, conditioning, complete return to work.
Maintain life time exercise program for CVS maintenance
Supervision Highly supervised Highly supervised Home program
Major activity Program of progressive activity Aerobic exercise for 15 to 20 min Aerobic exercise

Initial intensity 2-3 MET increasing 1 MET gradually 70- 80 % 70 – 75 %
Monitoring HR & BP HR HR

Others Pre-discharge stress test not more than 5 MET low fat diet. Most intensive and vigerous.5 min warm up & cool down. low intensity, high frequency
Nil



Guideline for Graduation

Age Male Female
49 or less 10 MET 8 MET
50-59 9 MET 7 MET
60-69 8 MET 6.5 MET
70 or above 7 MET 6.5 MET

Absolute contraindications
• Unstable angina with recurrent chest pain
• Untreated arrythemia
• Uncompensated CHF
• Advanced AV block
• Acute myocarditis or pericarditis
• Aortic stenosis
• Sever hypertrophy cardiac myopathy
• Uncontrolled hyper tension
• Acute M I
• Active endocarditis
• Active pulmonary embolism
• Pulmonary infarction
• DVT
• Acute systemic illness

Relative contraindications
• Pulmonary hypertension
• Arterial hypertension
• Moderate valvular disease
• Myocardial heart disease
• Electrolytic abnormalities
• Coronary obstruction L main
• Psychiatric disease




Facts on exercise physiology
 Aerobic capacity = measure the work capacity
 VO2 max
Maximum O2 consumption of whole body primarily due to skeletal muscle work.
Expressed in mlO2/Kg of body weight/Minute.
Represent aerobic capacity.
It is the plateau in a graph of total O2 consumption Vs work load.

 Cardiac out put increases with increase in work.
In early exercise CO elevation is due to augmented stroke volume (Frank Sterling Law.)
In late exercise CO elevation is due to increase in HR
So increase in CO is due to SV & HR.

 Cardiac out put has linear relation with VO2
The increase in O2 consumption ,the increased CO.
Max CO is primary determinant of Vo2 Max.

 HR has a linear relation with O2 consumption
The increase in O2 the increase in HR.
 Max HR decreases with age and regular exercise.
 MVO2
Myocardial O2 consumption
Has linear relation with both work load and VO2
HR & systolic BP are highly co related


 RPP rate pressure product

HR X systolic BP
100
If the RPP is high, there is increase in work on heart and increase in HR & systolic BP.
Activities where MVO2 is grater than VO2
Activities performed with upper limb,
Activities performed in supine at low intensity. During smoking, s tress after eating, in cold weather,

Purpose of exercise test
Cardiac risk stratification
Determine the functional capacity
Design optimal aerobic program.

Basic principals
Use the physiological response to exercise, to increase the physiological O2 demand on the myocardium, which increase MVO2 which can revel the ischemic changes via the ECG







Training effect of aerobics

Peripheral training effect
Increase O2 extraction and wider AV O2 difference grater skeletal muscle O2 uptake less O2 in venous blood less work for the heart
Myocardial training effect
At least 1 mm decrease in ST depression at same RPP.
Improved ventricular contractile function.
Wider coronary vessels
Aerobic training effects
Improved functional capacity
Increase in maximal CO2 & O2 consumption
Decrease in resting heart rate.
Rapid return to sub normal HR.

Goals
Decrease maximum O2 during sub maximal work load
Reduced cardiovascular risk.
Develop health productive behavioral mechanism wit increase quality of life.
Complete return to work.patient education

Fitness
It is a general term indicating a level of cardiovascular functioning for optimal performance and well being.
Fitness influenced by age, sex, hereditary, inactivity, and disease
It can measure
Time to run 1.5 mile
Distance run in 12 minute.
Endurance
It is the ability to work for prolonged period of time and ability to resist fatigue.
Depend up on O2 transport which is influenced by
Pulmonary function including diffusion and ventilation.
O2 binding capacity of blood. (Blood volume and hemoglobin)
Cardiac function (stroke volume and HR)
O2 extraction capacities (capillary density)
Muscular oxidative potential (mitochondrial enzymes)
Determinants of an individual endurance is based on maximal aerobic power
(VO2) max.
VO2 max is measure of the power capacity of the O2 transport system.
VO2 max id the maximum O2 volume can consume / minute.
VO2 max is also called aerobic capacity, aerobic power, max O2 up take, Max O2 consumption, endurance capacity.
VO2 max (ml/m) = HR (Bpm) x Stroke Volume XA-V O2 difference (ml/dl blood)(oxidative capacity of skeletal muscle.)
Endurance can increase by conditioning

Conditioning
It is the augmentation of the energy capacity of the muscle through an exercise program.
Depend up on sufficient intensity, duration, and frequency exercise.
Conditioning produces adaptation of organisum and reflective of endurance.
Adaptation
Deconditioning
Prolong bed rest.
Increase in resting HR, increase in HR in any exercise work load. & urinary excertion of calcium.
Decrease in stroke volume at rest, and Decrease in stroke volume, CO, Vital capacity. Maximum O2 uptake, circulatory blood volume, plasma volume, RBC & lean body mass.
Determinant of an exercise program
A. Intensity

 Most important factor
 To activate a conditioning response, intensity of the exercise must above the threshold stimulas
 Exercising a high intensity for a shorter period, grater increase in Vo2 max
1. THR: conditioning response will between 60 to 90 %of MHR that is 50 to 55 % of Max Vo2
asymptomatic adult 70 – 85%
cardiac patient 50 to 65%
Karvonen's formula
Heart rate reserve HRR HR max – HR rest
Exercise heart = HR rest + 70% HRR
Duration
duration
> Intensity 30 minute duration is optimal at 75% Vo2 max
Longer will increases the musculo skeletal complaints
Frequency
3- 4 times / week
The exercise program
Warm up
 Fasciculate circulator adjustment and minimizing O2 deficiency and the formation of lactic acid
 Increases the muscular O2 dissociation.
 Decrease the pulmonary vascular resistance and pulmonary circulation.
 Increase nerve conduction rate and muscle viscosity.

Physiological response to exercise

A. Increased O2 demand (Peripheral)
This demand met by increase in O2 transport, increase in extraction O2 from arterial blood, increase in aerobic capacity.

B. Increase cardiac O2 demand
It is met by increase systolic pressure, increase heart rate, increase myocardial aerobic capacity.

C. Cardio vascular changes
1. Changes at rest
 Reduction in resting HR
a decrease in sympathetic drive, decrease in norepinepherine & epinephrine
b increase in arterial rate due to
c increase in parasympathetic (vagal) tone
 Decrease in BP
a decrease in peripheral vascular résistance
b increase in blood volume & hemoglobin O2 carrying capacity
2. Changes at exercise
 Increase in HR
 Increase in SV (increase myocardial contractibility increase ventricular volume)
 Increase CO
 Increase extraction of O2 due to enzymatic and biochemical changes
 Increase VO2 max
 Increase blood flow/ kg of working muscle
 Decrease in myocardial O2 consumption

D. Respiratory changes
Larger lung volume
Larger diffusion capacity
E. Metabolic changes
 Muscle hypertrophy and increase capillary density
 Increase number and size of mitochondria, increase to generate ATP.
 Increase muscle myoglobin concentration. (Increase O2 transport, increase O2 diffusion)
 Decrese rate depletion of muscle glycogen at sub maximal level.
 (increase capacity to mobilize and oxidize fat)
 Glycogen sparing
 Decrease lactate level
E. Others
 Decrease body fat
 Decrease blood cholesterol and triglycerides
 Increase heat accumulation.
 Increase braking stage of bone, muscle and ligament.



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