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Cardiac Rehabilitation

A. Exercise Tolerance Testing


: Exercise Tolerance Test (ETT). (Graded Exercise Test) . 1
:a. Purpose
To determine physiological responses during a measured exercise
stress (increasing workloads); allows the determination of
.functional exercise capacity of an individual
Serves as a basis for exercise prescription. Symptom-limited (1)
ETT is typically adrninistered prior to start of Phase II outpatient
cardiac rehabilitation program and following cardiac rehabilitation
.as an outcome measure
Used as a screening measure for CAD in asymptomatic (2)
.individuals
ETT with radionuclide perfusion: assists in the diagnosis of (3)
.suspected or established cardiovascular disease
:b. Testing modes
Treadmill and cycle ergometry (leg or arm tests) allow for (1)
.precise calibration of the exercise workload
Step test (upright or sitting) can also be used for fitness (2)
.screening, healthy population
:c. ETT may be maximal or submaximal
.Maximal ETT: defined by target end-point heart rate (1)
Age-adjusted maximum heart rate (AAMHR): 220 minus age of (a)
.individual
Heart-rate range (Karvonen formula): 60-80% (HR max - (b)
.resting HR) + resting HR = target HR
Submaximal ETT: symptom-limited, used to evaluate the early (2)
recovery of patients after MI, coronary bypass, or coronary
.angioplasty

:d. ETT may be Continuous or Discontinuous


Continuous ETT: workload is steadily progressed usually in 2 or (1)
.3 minute stages
Discontinuous ETT: allows rest in between workloads/stages, (2)
.used for patients with more pronounced CAD
: Monitoring: during exercise and recovery . 2
a. Patient appearance, signs and symptoms of exertional
:intolerance; check for
.Persistent dyspnea (1)
.Dizziness or confusion (2)
.Anginal pain (3)
.Severe leg claudication (4)
.Excessive fatigue (5)
.Pallor, cold sweat (6)
.Ataxia, incoordination (7)
.Pulmonary rales (8)
b. Changes in HR: HR increases linearly as a function of
increasing workload and oxygen uptake (V02), plateaus just before
.maximal oxygen uptake (V02max)
c. Changes in BP: systolic BP should rise with increasing
.workloads and V02; diastolic BP should remain about the same
d. Rate-pressure product (RPP): the product of systolic BP and
HR (the last two digits of a 5 digit number are dropped) is often
used an index of myocardial oxygen consumption (MV02)
.Increased MV02 is the result of increased coronary blood flow (1)
.Angina is usually precipitated at a given RPP (2)
:e. Rating of perceived exertion (RPE)

Original Borg scale: rates exercise intensity using numbers (1)


from 6 to 20, with descriptors from very, very light to very, very
.hard
RPE increases linearly with increasing exercise intensity and (2)
.correlates closely to V02max and heart rate
An important measure for individuals who do not exhibit the (3)
typical rise in HR with exercise (e.g., on medications that depress
.HR, beta blockers)
f. Pulse oximetry: measure arterial oxygen saturation levels
.(Sa02) before, during, and after exercise
:g. ECG changes with exercise: healthy individual
Tachycardia: heart rate increase is directly proportional to (1)
.exercise intensity and myocardial work
.Rate-related shortening of QT interval (2)
.ST segment depression, upsloping, less than 1rom (3)
.Reduced R wave, increased Q wave (4)
. Exertional arrhythmias: rare, single PVC (5)
h. ECG changes with exercise: an individual with myocardial
:ischemia and CAD
.Significant tachycardia: occurs at lower intensities of exercise (1)
Exertional arrhythmias: increased frequency of ventricular (2)
.arrhythmias during exercise and/or recovery
ST segment depression; horizontal or downsloping depression, (3)
greater than 1 rom below baseline i indicative of myocardial
.ischemia
.i. Delayed, abnormal responses to exercise: occur hours later
.Prolonged fatigue (1)
.Insomnia (2)

.Sudden weight gain due to fluid retention (3)


Ambulatory monitoring (telemetry): continuous 24 hour ECG . 3
monitoring; allows documentation of ST segment depression or
elevation, silent ischemia, arrhythmias associated with daily
.activity
Transtelephonic ECG monitoring: used to monitor patients as . 4
.they exercise at home
. Determine activity level: METs (metabolic equivalents) . 5
a. MET: the amount of oxygen consumed at rest (sitting); equal to
.3.5 ml/Kg per min
b. MET levels (multiples of resting V02) can be directly determined
during ETT: using collection and analysis of expired air; not
.routinely done
c. MET levels can be estimated during ETT during steady state
exercise; the max V02 achieved on ETI is divided by resting V02;
.highly predictable with standardized testing modes
d. Can be used to predict energy expenditure during certain
.activities (Table 3-5)

B. Exercise Prescription
Contraindications for entry into inpatient/outpatient exercise .1
:programs
.a. Unstable angina
b. Resting systolic BP >200 mmHg or resting diastolic BP >110
.mmHg evaluated on a case by case basis
.c. Orthostatic BP drop of >20 mmHg with symptoms
.d. Critical aortic stenosis
.e. Acute systemic illness or fever

.f. Uncontrolled atrial or ventricular dysrhythmias


.g. Uncontrolled sinus tachycardia, >120 bpm
.h. Uncompensated congestive heart failure
.I. 3rd degree A-V heart block (without pacemaker)
.j. Active pericarditis or myocarditis
.k. Recent embolism
.I. Thrombophlebitis
.m. Resting ST segment displacement >2 mm
.n. Uncontrolled diabetes (resting glucose >400 mg/dL)
.o. Severe orthopedic problems that would prohibit exercise
p. Other metabolic problems, such as acute thyroiditis,
.hyperkalemia, hypovolemia, etc
Signs and symptoms below which an upper limit for exercise .2
:intensity should be set
a. Onset of angina or other symptoms of cardiovascular
.insufficiency
b. Plateau or decrease in systolic blood pressure, systolic blood
.pressure >240 mmHg, or diastolic blood pressure>110 mmHg
.c. >1 mm ST-segment displacement, horizontal or downsloping
d. Radionuclide evidence of LV dysfunction or onset of moderate to
.severe wall motion abnormalities during exertion
.e. Increased frequency of ventricular arrhythmias
f. Other significant ECG disturbances, e.g., 2 or 3 AV block, atrial
.fibrillation, SVT, complex ventricular ectopy, etc
.g. Other signs/symptoms of intolerance to exercise
h. Peak exercise HR should be approximately 10 bpm below the
.HR associated with any of the above criteria

: Guidelines for exercise prescription .3


:a. Type (modality)
Cardiorespiratory endurance activities: walking, jogging, or (1)
cycling recommended to improve exercise tolerance; can be
maintained at a constant velocity; very low interindividual
.variability
Dynamic arm exercise (arm ergometry): uses a smaller muscle (2)
mass, results in lower V02max (60-70% lower) than leg ergometry;
at a given workload, HR will be higher, stroke volume lower;
.systolic and diastolic BPs will be higher
Other aerobic activities: swimming, crosscountry skiing; less (3)
frequently used due to high inter-individual variability, energy
.expenditure related to skill level
Dancing, basketball, racquetball, competitive activities should (4)
.not be used with high risk, symptomatic and low fit individuals
Early rehabilitation: activity is discontinuous (interval training), (5)
with frequent rest periods; continuous training can be used in later
.stages of rehabilitation
:Warm-up and cool-down activities (6)
Gradually increase or decrease the (a)
intensity of exercise, promote circulatory and muscular adjustment
.to exercise
Type: low intensity cardiorespiratory endurance activities, (b)
.flexibility (ROM) exercises, functional mobility activities
.Duration: 5-10 minutes (c)
Abrupt beginning or cessation of exercise is not safe or (d)
.recommended
Resistive exercises: to improve strength and endurance in (7)
:clinically stable patients

Usually prescribed in later rehabilitation, after a period of (a)


.aerobic conditioning
Moderate intensities are typically used (e.g., 40% of maximal (b)
.voluntary contraction)
Monitor responses to resistive training using rate-pressure (c)
.product (incorporates BP, a safer measure)
Precautions: carefully monitor BP, avoid breath-holding, (d)
Valsalva response (may dramatically increase BP and work of
.heart)
Contraindicated for patients with: poor left ventricular function, (e)
ischemic changes on EKG during ETT, functional capacity less
.than 6 METs, uncontrolled hypertension or arrhythmias
Relaxation training: relieves generalized muscle tension and (8)
:anxiety
Usually incorporated following an aerobic training session and (a)
.cool-down
Assists in successful stress management and life-style (b)
.modification
b. Intensity: prescribed as percentage of functional capacity
revealed on ETT, within a range of 40 to 85% depending upon
initial level of fitness; typical training intensity is 60-70% of
functional capacity; lower training intensities may necessitate an
increase in training duration; most clinicians use a combination of
HR, RPE, and METs to prescribe exercise intensity (eliminate
.problems that may be associated with individual measures)
:Heart rate (1)
Percentage of maximum heart rate achieved on ETT; without (a)
an ETT, 220 minus age is used (for upper extremity work, 220
minus age minus 11 is used). 70-85 % HRmax closely corresponds
.to 60 to 80% of functional capacity or V02 max

Estimated HR max is used in cases where submaximal ETT (b)


.has been given
Heart rate range or reserve (Karvonen formula, see previous (c)
description). more closely approximates the relationship between
.HR and V02 max
Problems associated with use of HR alone to prescribe (d)
:exercise intensity
Beta blocking or calcium channel blocking medications: affect
.ability of HR to rise in response to an exercise stress
Pacemaker: affects ability of HR to rise in response to an
.exercise stress
Environmental extremes, heavy arm work, isometric exercise
.and Valsalva may affect HR and BP responses
Rating of Perceived Exertion, the original Borg RPE scale (6- (2)
:20)
RPE values of 12-13 (somewhat hard) correspond to 60% of (a)
.HR range
.RPE of 16 (hard) corresponds to 85% of HR range (b)
Useful along with other measures of patient effort if beta- (c)
.blockers or other HR suppressers are used
Problems with use of RPE alone to prescribe exercise intensity: (d)
. Individuals with psychological problems (e.g., depression)
.Unfamiliarity with RPE scale; may affect selection of ratings
:METs, or estimated energy expenditure (V02) (3)
40-85% of functional capacity (maximal METs) achieved on (a)
.ETT
Problems associated with use of METs alone to prescribe (b)
:exercise intensity

With high intensity activities (e.g. jogging), need to adopt a


discontinuous work pattern: walk 5 minutes, jog 3 minutes to
.achieve the desired intensity
Varying skill level or stress of competition may affect the
.known metabolic cost of an activity
Environmental stresses (heat, cold, high humidity, altitude,
wind, changes in terrain such as hills) may affect the known
.metabolic cost of an activity
:c. Duration
Conditioning phase may vary from 15 to 60 minutes, depending (1)
.upon intensity; the higher the intensity, the shorter the duration
Average conditioning time is 20-30 minutes for moderate (2)
.intensity exercise
Severely compromised individuals may benefit from multiple, (3)
short exercise sessions spaced throughout the day (e.g., 3-10
.minute sessions)
Warm-up and cool-down periods are kept constant, e.g., 5-10 (4)
.minutes each
:d. Frequency
Frequency of activity is dependent upon intensity and duration; (1)
the lower the intensity, the shorter the duration, the greater the
.frequency
Average: 3-5 sessions/week for exercise at moderate (2)
.intensities and duration, e.g., >5 METs
Daily or multiple daily sessions for low intensity exercise, e.g., (3)
.<5 METS
:e. Progression
:Modify exercise prescription if (1)
.a. HR is lower than target HR for a given exercise intensity

b. RPE is lower (exercise is perceived as easier) for a given


.exercise
c. Symptoms of ischemia (e.g., angina) do not appear at a given
.exercise intensity
Rate of progression depends on age, health status, functional (2)
.capacity, personal goals, preferences
As training progresses, duration is increased first, then (3)
.intensity
:f. Consider reduction in exercise/activity with
.Acute illness: fever, flu (1)
.Acute injury, orthopedic complications (2)
Progression of cardiac disease: edema, weight gain, unstable (3)
.angina
.Overindulgence: e.g., food, caffeine, alcohol (4)
Drugs: e.g., decongestants, bronchodilators, atropine, weight (5)
.reducers
Environmental stressors: extremes of heat, cold, humidity; air (5)
.pollution
g. Exercise prescription for post-PTCA (percutaneous
:transluminal coronary angioplasty)
Wait to exercise approximately 2 weeks post-PTCA to allow (1)
.inflammatory process to subside
.Use post-PTCA ETT to prescribe exercise (2)
h. Exercise prescription post-CABG (coronary artery bypass
:grafting)
.Limit upper extremity exercise while sternal incision is healing (1)
.Avoid lifting, pushing, pulling for 4 6 week post-surgery (2)

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