CARDIAC REHABILITATION

PROTOCOL
GOALS OF CARDIAC REHAB
Limit the physiological and psychological effects of cardiac illness
Reduce risk of sudden death or reinfarction
Control cardiac symptoms
Stabilize or reverse atherosclerotic process
CLINICAL INDICATIONS FOR CARDIAC REHAB
Medically stable post MI
Stable angina
CABAG
PTCA (percutaneous transluminal coronary angioplasty)
Compensated heart failure
Heart transplant or other cardiac surgical interventions
Peripheral arterial disease
High risk for CAD w/ diagnosis of DM, dyslipidemia, hypertension of
obesity
End-stage renal failure
CONTRAINDICATIONS
Unstable angina
Resting systolic >200 mmHg or resting diastolic >110 mmHg
Orthostatic BP pressure drop >20 mmHg w/ symptoms
Critical aortic stenosis
Acute systemic illness/fever
Uncontrolled atrial/ventricular arrhythmias
Third degree atrial ventricular block w/out pacemaker
Active pericarditis or myocarditis
Recent embolism
Thrombophlebitis
Resting ST segment depression or elevation >2 mm
Uncompensated CHF
Other conditions that prohibit exercise
CARIDAC REHABILITATIONS PHASES
PHASE I: INPATIENT CARDIAC REHABILITATION
Begins when pt is medically stable
Phase I consist of
o Patient/family education
o Self care evaluation
o Continuous monitoring of vitals
o Group discussion
o Low-level exercise
Average length of Phase I is dependent of length of hospital stay ~ 3-5
days
PHASE I EXERCISES
AROM
Ambulation
Self-care
PROCEDURE
Medical evaluation
o Stable w/ no recurrent chest pain for 8 hours
o No new signs of uncompensated heart failure such as dyspnea
@ rest w/ bilateral basilar crackles
o No new significant or abnormal rhythms
o Stable creatine kinase and troponin levels
Monitoring and safety
o Have patient report chest discomfort, dyspnea or faintness
o Discontinue exercise for any of the following adverse responses
HR > 130 BPM or >30 BPM above resting HR
DBP > 110 mmHg
Decrease in SBP > 10 mmHg
2
nd
or 3
rd
degree heart block
Signs/symptoms including angina, marked dyspnea,
EKG changes that suggest ischemia
ACTIVE EXERCISE
Active UE/LE exercises may begin 24 hrs. after bypass and 2 days
after MI
Sitting to standing progression 1-3 METS
Dont stress incisions
AEROBIC EXERCISE
MODE progressive, supervised level walking (2-3 METS) to
walking up and down stairs or treadmill (3-4 METS)
INESITITY RPE <13
o Post-MI: HR <120 BPM or <20 BPM above resting HR
o Post-surgical: >30 BPM
DURATION intermittent bouts of 3-5 min, progressing to 10-15
min of continuous activity
FREQUENCY
o 1
st
3 days 3-4 times daily
o >3 days 2 times per day w/ increase duration
PROGRESSION
o According to patient tolerance
o Progression can take place provided that
There is adequate HR increase
Adequate rise in systolic BP (10-40 mmHg)
No new dysrhythmias or ST changes
No cardiac symptoms palpitations, dyspnea, angina,
excessive fatigue
EXPECTED OUTCOMES FROM PHASE I
Walk 5-10 min continuously or 1000 feet 4X daily
Walk down and up one flight of stairs independently
Know safe HR and limits to exercise
Recognize abnormal sighs/symptoms suggesting exercise intolerance
Promote rapid/safe return to activities of daily living
Prepare pt for home support system

PHASE II: INTERMEDIATE OUTPATIENT
Comprehensive program that includes exercise, risk factor reduction,
education, consulting about diet and disease management
Begins after hospital discharge and last 12 weeks
PROCEDURE
Medical evaluation
o Recommended that patient has stress test with EKG
o HR and rhythm
o Signs/symptoms
o ST segment changes
o Exercise capacity
o Risk stratification
o Target HR for exercise
o Initial level of work for exercise
Prior to exercise conduct a physical examination that includes
o Medial history
o Cardiovascular disease risk profile
o BMI or waist-hip ratio
o Auscultation of lung sounds
o Palpation and inspection of extremities for arterial pulses
o Incision examination after CABAG or PTCA
o Orthopedic and neuromuscular status
Monitoring and safety
o For low risk patients w/ known stable CAD
6-10 sessions of ECG/BP monitoring and medical
supervision
o For moderate to high risk and/or unable to self regulate
continuous ECG/BP monitoring and medical supervision is
recommended until safety established usually in 12+
sessions
DISCONTINUE EXERCISE
Plateau or decrease in HR w/ increase in workload
SBP plateaus or falls or >250 mmHg
DBP > 115 mmHg
ST segment depression > 1mm
Ventricular dysrhythmias
Angina or other symptoms of cardiac insufficiency
AEROBIC EXERCISE
MODE rhythmic activities that use large muscle groups and can
be performed continuously/safely
o Walking, dancing, hiking, bicycling
INTENSITY can be based off HR, METS and RPE
o Patients w/out exercise test take resting HR + 20 BPM
o MaxHR 220-AGE
Can take a % for training
o METS
o RPE
12-16 = somewhat hard hard corresponding to 40-
85% max capacity
11-13 = fairly light making it an appropriate upper
level during initial phase
14-16 = may be an appropriate higher intensity
training later rehab
DURATION
o 15-20 minutes continuous or intermittent exercise for 1
st

month
o 25-30 minutes during next 3-4 months (improvement stage)
o 40+ minutes after 6 months (maintenance phase)
o Interval training may be appropriate for patients who cant
continuously exercise
FREQUENCY 3-5 X weekly
EXPECTED OUTCOMES FOR PHASE II
Promote active lifestyle thru increase participation
Improved functional capacity
Lower cardiovascular risk factors
Improve symptoms and physiological characteristics
Improve patient understanding