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Indications of Patient Instability and Treatment should be withheld

Acute rehab or Inpatient cardiac rehab (regular PT)


Orthostatic BP drop > 20 mmHg with symptoms
Resting SBP > 200 mmHg or resting DBP > 110 mmHg
2nd or 3rd degree Heart blocks
> 10 PVC per minute, multifocal PVCs
ECG changes associated w/ischemia (ST segment depression OR elevation > 2mm)
New onset (<24hrs) of A-fib
Chest pain w/ new ST changes on ECG
MI or extension of MI w/in previous 2 days
Acute aortic dissection/stenosis
Uncontrolled metabolic diseases
Psychosis or other unstable psychologic condition

Contraindications for STARTING Inpatient or Outpatient Cardiac Rehab


ABSOULTE RELATIVE
Acute MI (w/in 2 days) Left Main coronary stenosis
Unstable angina not stabilized by meds Moderate stenotic valvular heart disease
Uncontrolled cardiac arrhythmias causing Electrolyte abnormalities
s/s or hemodynamic compromise
Acute PE or pulmonary infarction Severe arterial hypertension
Acute myocarditis or pericarditis Tachyarrhythmias or bradyarrhythmia
Acute aortic dissection Hypertrophic cardiomyopathy, outflow obstructions
Mental or physical impairment- unable to exercise
High degree AV block

INDICATIONS TO STOP EXERCISE:


Cardiac Rehab Phase I
ABSOULTE
HR > 130 BPM or > 30 BPM above RHR
DBP ≥ 110 mm Hg SBP ≥ 200
Decrease in SBP > 10 mmHg
Significant ventricular or atrial dysrhythmias
2nd or 3rd degree heart block
s/s including angina, marked dyspnea, and ECG changes
Cardiac Rehab Phase II
ABSOULTE
Plateau or decrease in HR or SBP w/increase in work
SBP > 250 mmHg or DBP > 115 mmHg
ST depression > 1mm
2nd or 3rd degree heart block
Ventricular dysrhythmias
Angina or other s/s of cardiovascular insufficiency

Normal/Exercise testing/(not in cardiac rehab)


ABSOULTE RELATIVE
SBP Drop ≥ 10 mmHg w/ increased work ST or QRS changes or marked axial shift
Angina mod-severe (3/4) Arrhythmias other than VT (e.g. multifocal PVC)
Increasing nervous system s/s: ataxia, Fatigue, SOB, wheezing, leg pain, claudication
dizziness, near syncope
s/s of poor perfusion/ischemia Bundle branch block-can’t be distinguished from VT
Technical difficulties in monitoring ECG or BP Increased chest pain
Subject’s desire to stop Hypertensive response: >250 SBP or > 115 DBP
Sustained VT > 2 mm ST segment depression
ST elevation ≥ 1.0 mm

◦ References = acute care handbook, scorebuilders, o’sullivan


EXERCISE PRESCRIPTION GUIDELINES:
NORMAL (not cardiac rehab):
Aerobic Exercise
*NOTE*
Dynamic arm exercise (UBE) = smaller muscle mass and lower VO2 max than bicycling
 HR will be higher
 SV lower
 SBP and DBP higher

1. Intensity
a. 40-85% of max on exercise tolerance test
b. Heart Rate % Calculation:
i. Lower THR = HRmax x 55%
ii. Upper THR = HRmax x 90%
iii. HRmax = 220- age
c. Heart Rate Reserve (HRR) or Karvonen formula:
i. Lower THR = [(HRmax -HRrest )x 40%] + HRrest
ii. Upper THR = [(HRmax-HRrest) x 85%] + HRrest
d. RPE (6-20 scale)
i. 13-14 = ~ 70% of HRmax (somewhat hard)
e. METs
i. 40-85% of METmax
ii. Can use Karvonen formula
1. [(METmax- 1) x (40-85%)] + 1
2. Duration
a. 20-60 minutes of continuous or intermittent activity (minimum of 10 minute bouts
of intermittent)
b. Lower intensity exercise > 30 minutes
c.
3. Frequency
a. 3-5 days/week
CARDIAC REHAB PHASE I: INPATIENT
When to begin Active Exercise:
 Post-CABG = 24 hours
o Avoid lifting, pushing, pullin for 4-6 weeks post-sx.
 Post- MI = 2 days
General Exercise Guidelines:
 Begin with activities of low intensity (2-3 METs) sitting- standing- level walking
Aerobic Exercise:
1. Mode:
a. level walking (2-3 METs)
b. Walking up/down steps and TM walking (3-4 METs)
2. Intensity:
a. RPE < 13 (6-20 scale)
i. Between 11-13
3. Duration:
a. Intermittent bouts of 3-5 minutes to start
b. Progress to 10-15 minutes continuous activity
4. Frequency
a. Days 1-3: 3-4 x a day
b. Days 3 to Discharge: 2-3x a day
5. Progression Guidelines:
a. Adequate increase in HR
b. Adequate rise in SBP (10-40mmHg w/work)
c. No new dysrhythmias or ST changes
d. No cardiac symptoms
Special Considerations:
 Post- MI
o HR < 120 BPM or < 20 BPM above RHR
o Limited 70% HR max and/or 5 METs until 6 weeks post-MI
 Post- Surgery.
o HR < 130 BPM or < 30 above RHR
Goals for Discharge (graduate to Phase II)
1. ≥ 5 METs tolerated
2. Walk 5-10 minutes continuously, or 1000 feet, 4x daily
3. Walk up/down 1 flight of stairs independently
4. Know HR and RPE limits, s/s of intolerance to activity, prepared for return home
CARDIAC REHAB PHASE II: OUTPATIENT
General Guidelines:
 Exercise test and ECG recommended prior to
 Low risk pt. w/stable CAD: 6-12 sessions of ECG and BP monitoring and medical
supervision recommended
 Moderate-High risk pt.: continuous ECG and BP monitoring and medical supervision
recommended until safety is established ≥12 sessions
Aerobic Exercise:
1. Intensity
a. Heart Rate
i. Without exercise test = Standing RHR + 20 BPM
ii. % of Max HR
1. Karvonen Formula [(HRmax-RHR0+ (40-85%)] + RHR
2. HRmax x (55-90%)
iii. METs
1. [(METmax-1+ (40-85%)] + 1
iv. RPE
1. Initial phases = 11-13 (“fairly light” to “somewhat hard”)
2. Middle phase =12-16 = “somewhat hard” to “hard”
a. Corresponds to 40 -85% of Max capacity
3. Higher intensity training = 14-16
2. Duration
a. Month 1: 15-20 minutes of continuous or intermittent exercise
i. 3-5 minute intervals with equal rest periods for intermittent
b. Months 3-4: 25-30 minutes
c. Month 6 on: greater than 40 minutes
3. Frequency:
a. 3-5 days/week
Goals for Discharge:
 9 MET functional capacity
o 8-12 MET is average norm
 ≥ 40 minutes of exercise
 50-85% exercise capacity toleration
 Able to self-monitor safely
RESISTANCE TRAINING:
 Strength training can be initiated after 3 weeks in cardiac rehab:
o Begin with elastic bands and light (1-3lb) weights
o Progress to moderate loads (12-15 reps)
o RPE: 11-13
o RPP (HR x BP) shouldn’t exceed prescribed (if indicated)
Special Considerations:
 Post MI: strength training after 5 weeks
o Remain under 70% HRmax or 5 METs post- MI
 Post- CABG: strength training after 6-8 weeks (UE)
o Lower extremity resistance training ok as soon as medically cleared
 PTCA: Strength training 3 weeks post-op

PULMONARY REHAB:
Aerobic Exercise:
1. Intensity:
a. [(HRmax-RHR+ (40-85%)] + RHR
b. ≥ 50% peak O2 consumption
c. Sub-max dyspnea rating

d. 60-80% max exercise tolerance


e. RPE 4-6 on (0-10 scale) or 12-16 on (6-20 scale)
f. O2 Saturation > 90%
2. Duration
a. Minimum 30 minutes accumulated exercise
b. Interval training (30 seconds – 3minutes w/equal rest time)
3. Frequency
a. 3-5 days/week