Cardiac Rehabilitation: Myocardial infarction
Cardiac rehabilitation is also called cardiac rehab.
Cardiac rehabilitation is a multidisciplinary and systematic approach to exercise training and risk factor management and monitoring and support of compliances.
Cardiac rehabilitation required a team approach including a multidisciplinary and multi-disciplinary team include the Physician, Nurse, Physical therapist, Occupational therapist, Exercise physiologist, Nutritionist, and Social service caseworker.
Indications:
Myocardial infarction
Acute coronary artery syndrome
Chronic stable angina
Congestive cardiac failure
Coronary artery bypass surgery
Cardiac transplantation.
Goals:
Cardiac rehabilitation programs should focus on:
Nutrition modification
Weight management
Blood pressure Management
Lipid management
Diabetes management
Tobacco cessation
Exercise training and
Stress management.
Phases of Cardiac Rehabilitation:
Cardiac rehab begins in the hospital and extends indefinitely into the maintenance phase.
Cardiac Rehabilitation consist of 3 phases:
Phase 1: Inpatient/Hospital-based patients. Starts within 24 hours after admission until discharge.
Phase 2: Exercise training period. Starts within 2 weeks of hospital discharge
Phase 3: the maintenance period.
Phase 1: Inpatient Cardiac Rehab
The length of hospital stay is 3 to 5 days for an uncomplicated MI (no post-MI angina, malignant arrhythmias, or heart failure).
Inpatient Cardiac Rehab uses the team approach based on activity progression, patient education, and hemodynamic, and ECG monitoring, with medical and pharmacological Management.
The role of physical therapist is to monitor activity tolerance, prepare for discharge, educate the patient to recognize adverse symptoms with activity, support risk factors modification techniques, provide emotional support, and collaborate with other team members.
Vital sign monitoring occurs before, after, and during activity. The intensity of activity is considered to be low level and perceived exertion for the patient should be comparable to the "fairly light range" of the Borg RPE scale.
There are a variety of inpatient cardiac rehab programs, frequently progressive based on levels of increasing energy costs.
Level 1. The patient is in the intensive Care unit (ICU) and is stable; generally, physical therapy interventions do not begin until after the first 24 hours from admission or until the patient has been stable for 24 hours.
Activities of daily living (ADL)
Bed exercises
Perform ankle pumps
Perform deep-breathing exercises
Use the commode, if hemodynamically stable.
Level 2. Once the patient has been hemodynamically stable for 24 hours.
He may progress out of bed (OOB). The therapist should check the sign of orthostatic hypotension.
The patient's feet should be supported on a stool to assist venous return if they are not able to touch the floor.
Sitting on an upright chair for 15 to 30 minutes 2 to 4 times a day. "Do" something while seated, such as washing, eating, or visiting with family.
Commode privileges
If the patient has had a large MI or requires a slow progression to upright positions, then use a reclining chair to gradually assume the upright position.
Perform ankle pumps, knee extension.
Monitoring of vital signs for hemodynamic stability and appropriate activity response.
Level 3. Patients are instructed to gradually increase their ambulations. One approach is to educate patients to judge their ambulation in terms of time instead of distance.
example: "I want you to walk for 2 minutes" vs "I want you to walk 200 feet".
Walking up to 5 minutes 3 to 4 times a day
Standing leg exercises
Sit on side of bed or in the bathroom to wash
Manual save
Bathroom privileges
Level 4.
Walking up to 5-7 minutes 3-4 times/day
Standing trunk exercises
Independent or assisted ambulation in the hall.
Level 5.
Walking 8-10 minutes 3-4 times/day
Arm exercise
Standing shower
Independent hall ambulation.
Level 6.
Progressive walking
Stairs climbing foot over foot with planned rest halfway.
Home exercise program:
The physical therapist established activity guidelines during the first 4 to 6 weeks after myocardial infarction while the myocardium is healing.
During this healing phase, the physical activity involves a gradual increase in walking time, with a goal of 20 to 30 minutes of walking 1 to 2 times per day at 4 to 6 weeks after myocardial infarction.
Patients are encouraged to walk comfortably, dress appropriately, and to try to exercise in ambient temperature (indoors).
For safety reasons, the patient should be monitored on similar equipment before independently beginning to exercise at home.
This is not the time for the patients to try the new types of exercise modality but to stay with what is familiar e.g. walking.
The patient's day will be a combination of rest and low-level activity including walking and lower extremity and upper extremity mobility.
The patient should be encouraged to try to change the position or activity every 1 to 2 hours.
Phase 2: Outpatient cardiac rehab
Patients commonly undergo symptom-limited exercise tolerance test (ETT) at 4 to 6 weeks after myocardial infarction (MI). Based on the result of the test either positive (+) for ischemia on negative (–) for ischemia, an exercise prescription is prescribed.
For negative (–) exercise tolerance test (ETT)
A common exercise prescription would be 70% to 85% of the peak heart rate achieved on the test or an equally effective alternative would be 65% to 80% of maximum heart rate.
Negative test does not mean the patient is disease-free and that vulnerable plaques may exist, or a conservative prescription may be a choice.
For positive (+) exercise tolerance test (ETT)
The exercise prescription becomes simple: during aerobic training, it is important to keep myocardial volume oxygen consumptions (MVO2) below the patient's Ischemic MVO2.
MVO2 is the product of heart rate and systolic blood pressure and also called rate pressure product (RPP = HR x SBP).
Blood pressure will vary during use of different piece of exercise equipment owing in part to the differences in muscle recruitment.
For example: if a patient has an HR of 100 beats per minute and blood pressure of 140/80 mm Hg while exercising on the treadmill, and and heart rate of 100 bpm and blood pressure of 160/80 mmHg while exercising on stationary bicycle, the bicycle is costing the myocardium more energy than treadmill, even though heart rate is same.
Depending on the patient Ischemic threshold or rate product pressure, it is possible that angina may occur on a bicycle but not on the treadmill.
A good safety tip is to not exceed 90% of ischemic rate pressure product.
Strength training:
The American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) conclude that resistance exercise has been shown to be a safe and effective method for improving strength, and cardiovascular endurance, modifying risk factor, and enhancing self-efficacy in low-risk cardiac patients.
AACVPR guidelines further state that resistance training should not begin until the patient has been in a cardiac Rehab program for at least 3 weeks and is at least 5 weeks post-MI or 8 weeks post-CABG.
The resistance training may begins with the use of plastic bags and light and weight and progress to load that allow 12 to 15 repetitions comfortably.
Guidelines for resistance training include the following:
Exercising large muscle groups before small
Stressing exhalation with exertion
Avoiding a sustained, tight grip
Focusing on RPE 11 to 13
Using slow, control movements
Stopping exercise with any warning of uncomfortable signs and symptoms of angina.
Phase 3
The patient has stabilized and requires ECG monitoring only if signs and symptoms necessitate.
Endurance training and risk factor modification are continuous.
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