CR

• Cardiac Rehabilitation


  The sum of activities required to ensure patients the best possible physical, mental and social conditions so that they may resume and maintain as normal a place as possible in the community
• Cardiac Rehabilitation


  A medically supervised program designed to improve the cardiovascular health for people have experienced heart attack, heart failure, angioplasty or heart surgery
• Cardiac Rehabilitation Team


  • Physician
  • Physical Therapist
  • Nurse
  • Occupational Therapist
  • Psychologist
  • Dietician or Nutritionist
  • Exercise Physiologist
• Rehabilitation in general

  • Comprehensive
  • Multidisciplinary
  • Long term
  • Medical evaluation
  • Prescribed exercise
  • Risk factor modification
  • Counseling/Education
• Cardiac rehab outcomes

  • Improved psychosocial well-being
  • Mortality reduction of approximately 25%
  • No increase in morbidity or mortality
  • Improved exercise tolerance for CAD and CHF
  • Decreased symptoms in CAD and CHF
  • Multi-factorial interventions improve lipids
  • Multi-factorial rehab reduces cigarette smoking (16-26% will quit)
• Who Should Be Enrolled In Phase I Cardiac Rehab?

  • Stable myocardial infarcts
  • CABG patients
  • Patients who have had angioplasty
  • Patients who have had cardiac transplantation
  • Patient with non cardiac diseases and have several risk factors
• Who Should Not Do Phase I?

  • Patients with unstable angina
  • Patients with acute CHF
  • Patient's with uncontrolled rhythms
  • Patients with a systolic BP >200 mm Hg
  • Patients with acute pericarditis
  • Patients with recent emboli or clots
  • Patients with severe cardiomyopathies
  • Patients with uncontrolled DM
  • Patints with severe AS
  • Patient with third degree AV Block
• Ejection fraction (EF)


  The volumetric fraction of blood pumped out of the left and right ventricle with each heartbeat or cardiac cycle
• Low risk patients


  • Uncomplicated in acute phase
  • EF>=50%
  • No detectable residual ischemia
  • No complex arrythmias
  • Functional capacity>6 METs
• Intermediate risk patients


  • 31< EF < 49%
  • Exercise ST segment depression below 2 mm
  • No sustained ventricular arrhythmias
• High risk patients


  • Complications during acute phase
  • EF<30%
  • Myocardial ischemia with ST segment depression greater than 2 mm
  • Complex ventricular arrythmia at rest
  • Decrease in SBP>15mmHg during exercise
• Progression of rehab

  1. Adequate HR increase

  2. Adequate SBP rise to within 10-40 mmHg from rest

  3. No new rhythm or ST change on telemetry rhythm strip

  4. No cardiac symptoms such as palpitation, dyspnea, excessive fatigue or CP
• RECOMMENDATION FOR MONITORING

  • Lowest risk for exercise prescription
  • Moderate risk for exercise prescription
  • Highest risk for exercise prescription
• ET before starting cardiac rehab

  1. ET is useful, especially those after recent MI, but not all patients, undergo such testing

  2. Patients who did not undergo exercise testing before the program can exercise at a heart rate 20 beats faster than their resting value

  3. month 1→ rest HR+20 to 30 percent rest HR

  4. month 2→ rest HR+20 to 40 percent rest HR

  5. month 3→ rest HR+20 to 50 percent rest HR
• Modified Bruce Exercise Test Protocol


  Stage, Speed, Grade, Time, METs
• Four step of cardiac rehab

  • Phase 1: Inpatient rehabilitation
  • Phase 2: outpatient rehabilitation
  • Phase 3: Supervised rehabilitation
  • Phase 4: Maintenance
• Phase I


  1. Phase I of CRP begins when the patient is admitted to the hospital and ends on discharge

  2. The goals of exercise in this phase are to avoid the deleterious effect of bed rest by making a gradual transition from passive rang of motion to active range of motion with low intensity, short duration exercise and ambulation

  3. Duration: Usually 4-6 days

  4. Mode of exercise: Active free exercise, Breathing exercise, Walking, Ascending and descending stairs

  5. In MI patient& CABG should be started as soon as the patient's condition is stabilized(24-48h)
• Examples of initial activity

  • Step 1: Rest in bed until stable, Sit up in bed with assistance, Stand at bedside with assistance, Perform self-care activities while seated
  • Step 2: Sit up in bed independently, Walk in room and to bathroom, Perform self-care activities in bathroom
  • Step 3: Sit and stand independently, Walk in hall with assistance: 5 to 10 minutes, 2 or 3 times a day
  • Step 4: Walk in hall: 5 to 10 minutes, 3 or 4 times a day, Walk down stairs with assistance
• Examples of increases in activity

  1. Mode: Walking in hospital hall

  2. Frequency: Early mobile (days 1 to 3) - 1 or 2 times a day, Later mobile (days 2 to 4) - 3 or 4 times a day

  3. Intensity: Heart rate 10-20 beats above your resting heart rate, Rating of perceived exertion (RPE) of 11 (light exertion), Stop when you get tired

  4. Time: Intermittent bouts, 3 to 5 minutes, Rest periods at your discretion, 1 to 2 min. shorter than exercise bout, To progress, initially increase to 10 to 15 min., then increase intensity, Include stair climbing when your doctor says it's okay
• General guidelines for exercise priscription(for recommendation)

  1. Week 1: walk 3-5 min. Continuously 3-4 times daily

  2. Week 2: walk 6-10 min. Continuously 3 times daily

  3. Week 3: walk 11-15 min. Continuously 2 times daily
• Phase 1.5 (post discharge phase)


  1. Begin after the patient returns home from the hospital

  2. Team member check the patient's medical status

  3. This phase of recovery include low-level exercise & physical activity

  4. Risk reduction strategies are emphasized again

  5. After 2-6 weeks of recovery at home the patient is ready to start CR phase 2
• Phase 2


  1. Multifaceted outpatient rehabilitation, lasting 2-3 mo.

  2. Emphasizes safe physical activity to improve conditioning with continued behavior modification aimed at smoking cessation, weight loss, healthy eating, and other factors to reduce disease risk

  3. Initiate an exercise prescription
• Exercise program design


  1. Warm-up period

  2. Conditioning period

  3. Cool-down period
• Warm-up period


  1. Static stretching

  2. Dynamic R.O.M

  3. Low level dynamic aerobic activity (25-40% of pt's F.C)
• Conditioning period


  • To increase caloric expenditure(weight management)
  • To improve overall F.C
  • To delay the onset of symptoms
  • To maintain current functional ability
  • To improve muscle tone or strength
  • To optimize activities of A.D.L(activity of daily living)
• In conditioning period cosider


  • Frequency
  • Intensity
  • Mode
  • Duration
  • Rate of progression
• Frequency affected by


  • Overall goal of CR program
  • Functional ability of the patient
  • The type and intensity of activity
  • The patient interests
  • Level of personal commitment &recent activity history
• Average rehab. Program frequency
• Frequency of exercise


  • Individual with functional capacity above 5 METs - 3to 5 sessions/weeks exercise at moderate intensity and duration
  • Individuals with functional capacity 3- 5 METs - 1- 2sessions/day
  • Individual with functional capacity < 3 METs - sessions several times/day for about 5 m each session
• Intensity can be determined by


  • Work load, MET's & exercise intensity
  • Heart rate and & exercise intensity
  • RPE & exercise intensity
  • Oncet of symptom & exercise intensity
• Work load, MET's & exercise intensity

  • %VO2max is the better measure for prescribing exercise intensity
  • %VO2max is the maximum milliliters of oxygen consumed in 1 minute / body weight in kilograms
  • The metabolic equivalent(MET) is a unit of sitting/resting oxygen uptake (3.5ml O2 per kilogram of body weight per minute(ml kg-1min-1)
  • Maximum oxygen consumption is dependent on the ability of the oxygen transport system to deliver blood and the ability of cells to take up and utilize oxygen in energy production
• Heart rate and & exercise intensity

  The Karvonen Formula: 220 - Age= Predicted MHR- RHR(average of 3 mornings)= HRR, HRRx.50( )+ RHR= Minimum Training Threshold, HRRx .85 ( )+ RHR= Maximum Training Threshold
• Onset of symptom & exercise intensity

  Onset of symptom should be an absolute determinant of the upper limit of exercise intensity
• Work load, MET's & exercise intensity


  Gaskell concludes %VO2max is the better measure for prescribing exercise intensity
• %VO2max


  The maximum milliliters of oxygen consumed in 1 minute / body weight in kilograms
• Metabolic equivalent (MET)


  A unit of sitting/resting oxygen uptake (3.5ml O2 per kilogram of body weight per minute)
• Maximum oxygen consumption


  • Dependent on the ability of the oxygen transport system to deliver blood and the ability of cells to take up and utilize oxygen in energy production
• Metabolic equivalent of energy expenditure for varying levels of activity

  • Resting
  • Light
  • Moderate
  • Vigorous
  • Maximal
• Karvonen Formula


  1. 220 - Age= Predicted MHR

  2. Predicted MHR - RHR(average of 3 mornings)= HRR

  3. HRRx.50( )+ RHR= Minimum Training Threshold

  4. HRRx .85 ( )+ RHR= Maximum Training Threshold
• Target heart rate


  50%-85% of Maximum Heart Rate