CARDIAC REHABILITATION

Ns. Susanna Luida H,SKp,CVRN

 CARDIAC REHABILITATION
WHO Bebeberapa kegiatan yg mempengaruhi
penyebab penyakit, serta memastikan kondisi
fisik, mental & sosial pasien terjaga baik,
sehingga dapat berusaha sendiri menjaga atau
memperbaiki kehidupan bermasyarakat yang
baik

Keseluruhan upaya yg digunakan pd pasien

National Heart penyakit jantung,agar dapat menjalani
Foundation of
kehidupan secara aktif & menyenangkan
Australia
serta mencegah serangan jantung ulang.
 Tujuan Umum
1. Memaksimalkan aktifitas fisik, fungsi
psikososial & sosial sehingga
seseorang dengan penyakit jantung
dapat menjalani kehidupannya
kembali percaya diri
2. Memperkenalkan & mendorong
perilaku hidup sehat yang dapat
meminimalkan resiko kejadian
serangan jantung lebih lanjut
Tujuan khusus
1. Memfasilitasi & memperpendek periode pemulihan setelah
serangan jantung akut
2. Mendukung strategi untuk mencapai tujuan bersama yang
telah disepakati dalam program pencegahan sekunder
3. Mengembangkan & memelihara ketrampilan merubah
kebiasaan manajemen diri sendiri dalam jangka panjang
4. Memperkenalkan penggunaaan fasilitas layanan kesehatan
yang tepat termasuk kesesuaian terapi & dokter

(National Heart Foundation of Australia, 2004)

Target yang harus dicapai
— Berhenti total merokok & menghindari lingkungan merokok
— Mencapai berat badan ideal sesuai tinggi badan
— Terkontrolnya tekanan darah dengan diet, olahraga atau pengobatan
hingga TDS < 140 mmHg dan TDD < 90 mmHg.
— Terkontrolnya gula darah, dengan target kadar HbA1C<7%
— Terkontrolnya kadar lemak darah,dengan kadar kolesterol LDL <
100 mg/dL, pada penderita berisiko tinggi < 70 mg/dL, selanjutnya
mengontrol kolesterol non-HDL dan trigliserida
— Kebiasaan olahraga rutin, 5-7 kali/minggu , 30-60 menit per sesi
latihan
What is cardiac rehabilitation ?
— “Cardiac rehabilitation services are comprehensive, long-term
programs involving medical evaluation, prescribed exercise,
cardiac risk factor modification, education, and counselling.
These programs are designed to limit the physiologic and
psychological effects of cardiac illness, reduce the risk for
sudden death or re-infraction, control cardiac symptoms,
stabilize or reverse the atherosclerotic process, and enhance
the psychosocial and vocational status of patients”

BACPR, AACVPR/ACC/AHA 2007, 2012 Performance Measures on Cardiac Rehabilitation, J. Am. Coll. Cardiol.
2007;50;1400-1433.
 Components of Cardiac Rehabilitation
— CR provides specific core
components of care to
optimize CV risk reduction,
reduce disability and
promote healthy behaviors,
including long-term
adherence
W2eBOP Cardiac Rehabilitation
Outcome Domains
Goals of CR

1. FUNCTIONAL CAPACITY IMPROVEMENT

2. SYMPTOMS ALLEVIATE
3. DISABILITY REDUCTION
4. RISK FACTORS MODIFICATION
Clinical Indications and Contraindications for
Inpatient and Outpatient Cardiac
Rehabilitation
— INDICATION
— Medically stable post-myocardial infarction (MI)
— Stable Angina
— Coronary artery bypass graft surgery (CABG)
— Percutaneous Transluminal Coronary Angioplasty (PTCA) or other
transcatheter procedure
— Compensated Congestive Heart Failure (CHF)
— Cardiomyopathy
— Heart or other organ transplantation
— Other cardiac surgery, including valvular and pacemaker insertion
(including implantable cardioverter defibrillator (ICD)
— Peripheral Arterial Disease (PAD)
— High – Risk cardiovascular Disease (CVD) ineligible for
surgical intervention
— Sudden Cardiac Death Syndrome
— End-stage renal disease
— At risk for coronary artery disease (CAD) with diagnoses of
diabetes mellitus, dyslipidemia, hypertension, obesity, or
other diseases and conditions
— Other patients who may benefit from structured exercise
and/ or patient education based on physician referral and
consensus of the rehabilitation team
CONTRAINDICATIONS
— Unstable angina
— Resting systolic BP(SBP) > 200 mm Hg or resting diastolic
BP (DBP) > 110 mm Hg that should be evaluated on a case-
by-case basis
— Orthosttic BP drop of > 20 mm Hg with symptoms
— Critical aortic stenosis (i.e., peak SBP gradient of > 50 mm
Hg with an aortic valve orifice area of < 0.75 cm^2 in an
average – size adult)
— Acute systemic illness or fever
— Uncontrolled atrial or ventricular dysrhymthmias
— Uncontrolled sinus Tachycardia (>120 beats min ^ -1)
— Uncompensated CHF
— Third-degree atrioventricular (AV) block without pacemaker
— Active pericarditis or myocarditis
— Recent embolism
— Thrombophlebitis
— Resting ST-segment depression or elevation (>2mm)
— Uncontrolled diabetes mellitus (See Chapter 10 for additional
information on exercise prescription recommendations for
individuals with diabetes mellitus.)
— Severe orthopedic conditions that would prohibit exercise
— Other metabolic conditions, such as acute thyroiditis,
hypokalemia, hyperkalemia, or hypovolemia.
 Multidisciplinary Team
Psychologic
Counseling / Nutritional Exercise
Return to counselling Training
Work
Dietician Physiotherapist
Psychologist/ Social Service
Expert

PATIENT

Pneumonologist Psychologist
Cardiologist/Nurse Cardiologist
Optimized
Smoking Education /
Medical
Cessation Information
Therapy
Cardiac Rehabilitation Phases
—Phase 1 – Intra Hospital
—Phase 2 – Early Ambulatory (<1
year after acute event)
—Phase 3 – Maintenance (>1 year
after acute event)
Timing Acute Phase Early Recovery Late recovery Maintenance
Phase phase phase
Location ICU/CCU General Outpatient/amb Community
Cardiovascular ulatory exercies center
ward rehabilitation
center
Purpose Return to daily Returning to Establish new Comfortable life
life society lifestyle
Contents Functional Pathophysiologic Prevention of
Assessment al/functional recurrence
assessment
Care Planning Mental Maintain better
status/psychologi lifestyle
cal assessment
Bedside physical Modification of
therapy coronary risk
factors
Sitting/Standing
test
30-100 m
walking test
Phase 1
1. Untuk mengatasi akibat negatif dari tirah baring
(deconditioning), baik oleh karena sakit jantung
atau karena tindakan bedah ataupun intervensi
lainnya
2. Menurunkan tingkat kecemasan
3. Pasien mampu melakukan aktifitas dasar sehari-
hari
 Phase 2
— Mengatasi perkembangan penyakit lebih jauh/
progresifitas penyakit
— Persiapan kembali bekerja atau aktifitas rekreasi atau
aktifitas sehari-hari yang optimal termasuk aktifitas
sexual
— Membuat dan membantu pasien melakukan program
latihan secara aman dan efektif
Phase 3
1. Melanjutkan program untuk mengatasi
progresifitas penyakit
2. Memelihara kondisi paling optimal dan
melanjutkan pola hidup sehat secara
mandiri
3. “Home base” program, telemonitoring
Phase 4
1. Adalah program rehabilitasi kardiovaskular yang
mandiri dilakukan oleh klien di rumah, di lingkungan
atau di masyarakat
2. Tuuan : memelihara dan mempertahankan kondisi
kesehatan yang paling optimal secara mandiri
3. Lamanya seumur hidup
4. Program : Pengontrolan faktor resiko, latihan fisik
secara mandiri, evaluasi rutin tingkat keampuan, faktor
risiko, hasil tindakan/intervensi
Klasifikasi Risiko
Pasien risiko tinggi :
— EST <= 5 METs
— Iskemia saat latihan ->angina / ST depresi 2 cm/gambaran
ECG/shortness of breath
— Disfungsi ventrikel kiri berat (EF <=30%)
— Aritmia ventrikular saat istirahat, aritmia ventrikular bertambah
dengan latihan pada fase pemulihan EST
— Menurunnya TDS >=15 – 20 mmHg dg latihan
— Serangan jantung < 6 bulan, dengan komplikasi aritmia ventricular
— Syok atau gagal jantung saat serangan jantung < 3 bulan
Pasien risiko intermediate :
— EST test 6-9 METs
— Iskemia saat latihan -> ST depresi < 2mm
— Serangan jantung tanpa komplikasi, CABG atau angioplasty
paska serangan jantung dg maksimal kapasitas fungsional <= 8
METs

Pasien Resiko Rendah :

EST > 9 METS
 Guide to Secondary Prevention of
Cardiovascular Disease
Physical Activity
— Goal: At least 30 minutes, 7 days per week (minimum 5
days per week) of moderate-intensity physical activity on
most (and preferably all) days of the week.
— Moderate – intensity Activities (40% to 60% of maximum
capacity) are equivalent to a brisk walk (15-20 min per
mile)
— It is reasonable for the clinician to recommend
complementary resistance training at least 2 days per
week
Exercise Training
— ACSM 2007
— All healthy adults aged 18 to 65 years old need
moderate-intensity aerobic physical activity for a
minimum of 30 minutes on 5 days each week or
vigorous –intensity aerobic physical activity for a
minimum of 20 minutes on 3 days each week.
— Every adult should perform activities that maintain or
increase muscle strength and endurance a minimum of
2 days each week.
Aerobic (Cardiovascular Endurance)
Exercise
How much exercise is enough for health/fitness
benefits ?
— Frequency
— Intensity
— Time(Duration)
— Type or mode
 Structured exercise programming
1. Warm-up EXERCISES AND WALK 5-10 minutes RPE scale 0-
2 (Able to sing or whistle)
2. Cardiac Walk , number of minutes prescribed by your cardiac
rehab team. RPE scale 3-6 Able to talk comfortably
3. Cool Down. Walk and Exercise 5-10 minutes . RPE scale 0-2,
able to sing or whistle
 Monitoring
— Denyut jantung
— Tekanan Darah
— Saturasi Oksigen
— Penilaian Intensitas Aktvitas Fisik dengan Borg Scale
Tanda dan gejala yang perlu dievaluasi
— Keluhan :
— Angina
— Orthopnoea,
— Dyspnea
— Paroxysmal Nocturnal Dyspnea
— Palpitasi
— Pusing
— Pemeriksaan Fisik
— Bengkak kaki,
— Fatigue,
— Berat badan naik > 2,3 kg dalam 2 atau 3 hari
— Asites
— Kelemahan tungkai bawah
— Abnormalitas asuskultasi jantung & paru
Education / Information

— CAD Education / HF Education

— Identification of Risk Factors
— Modification of Lifestyle
— Adherence to therapy
For Risk factors control and lifestyle
modification
— Smoking Cessation
— Dyslipidemia Control
— Hypertension Control
— Weight Control
— Diabetes Control
— Sedentarism Combat
Take Home Messages
— Lifestyle interventions are a complement to medical therapy
and should focus on realistic goals:
— Moderate to vigorous physical activity >=150 min/week
— High fibre, low saturated fatty acid diet
— Weight reduction/stabilisation , no weight gain
— Smoking cessation
— Medical Therapy Should be target driven :
— LDL < 75md/dl
— HbA1c<7%
— BP<140/8 mmHg