Cardiac Rehabilitation

1. Cardiac Rehabilitation Eve Scarle Senior Physiotherapist and Lecturer in Exercise and Health Sciences

2. Aims of the session • Explanation of coronary heart disease and cardiac rehabilitation • Rationale for the use of physical activity in cardiac rehabilitation • Exercise prescription for Phase IV cardiac rehabilitation • Professional development opportunities in CR.

3. Group Task • Plan a short exercise regime you may use for a 50 year old patient who has suffered a heart attack 4 months ago. Consider the; • Frequency • Intensity • Duration • Progression • Type of exercise that you would prescribe for this patient • Are there any types of activity you think should be avoided?

4. Cardiovascular Disease (CVD) • CVD accounts for one of two of all deaths in UK accounting for approximately 238,000 deaths in 2002 • Leading cause of premature death in both men and women. • CHD most common form of CVD and is responsible for 60% of all deaths from CVD. Our Healthier Nation target – CHD and Stroke - reduce death rate in people under 75 years by two fifths

5. CARDIOVASCULAR DISEASE (CVD) STROKE CORONARY HEART DISEASE (CHD) PERIPHERAL VASCULAR DISEASE

6. Coronary Heart Disease (CHD) • Refers to the deposition of fatty substances in the lumen of the coronary arteries • This can start as early as the teenage years • Only when the artery is ~ 70% occluded do symptoms start to appear • Symptoms may appear as angina or a myocardial infarction (MI) • Angina occurs when demand for oxygen does not meet the supply as the coronary arteries are narrowed

8. Coronary Atherosclerotic Plaque

9. Atherosclerosis Atherosclerosis is the build up of fatty and fibrous material (atheroma) on the inside surfaces of arteries Atherosclerosis

10. Angina • A symptom of CHD • Occurs during ischaemia when supply of oxygen does not meet the demand for oxygen • When do you think individuals may get angina symptoms? • What will the symptoms be?

11. Exertion Stress Extreme temperatures After a heavy meal Chest pain /tightness/discomfort Burning/dull sensation Pain/heavy feeling in left arm or both Discomfort in throat, jaw or abdomen Short of breath on exertion Stable Angina

12. Myocardial Infarction (Heart Attack) • Occurs when a fatty plaque becomes unstable and ruptures • This causes a blood clot to form stopping blood getting any further • This leads to areas of myocardial ischaemia which if it persist can lead to tissue damage • Needs prompt management to limit damage and reduce complications

13. Coronary Artery Bypass Graft • Where narrowing occurs in multiple areas • Veins and arteries are harvested from elsewhere in the body and used to bypass the narrowing • This involves open heart surgery, being on the bypass machine and a prolonged recovery period

14. Coronary Angioplasty • Procedure done under local anaesthetic • Catheter passed from the groin up to the aorta • Then pass into the narrowed area and inflate a small balloon to squash plaque into the artery wall • Small cylindrical stents can be left in place to hold the artery open

15. Aims of Cardiac Rehabilitation ‘To promote physical, psychological and emotional recovery, enabling patients to achieve and maintain better health, with a reduced risk of death from continuing heart disease.’ (Effective Health Care, 1998)

16. History of Cardiac Rehabilitation • Cardiac rehab first started in the 1960s when the benefits of active mobilisation were recognised (Kavanagh et al, 1973). • Disease processes in CHD may be slowed or even reversed by the instigation of lifestyle modification (Ornish et al, 1990 and 1998; Berlardinelli et al, 2001). • National Service Framework for CHD (DoH, 2000) sets national standards for CHD management

17. What exactly is Cardiac Rehabilitation? • What is it? • Combination of exercise, education and counselling • How long does it last? • Varies across the country • Where does it occur? • Hospital and community-based

18. What exactly is Cardiac Rehabilitation? • Who is it delivered by? • Delivered by a ,multi-disciplinary team which can consists of:- • Counsellor • Nurse • Occupational therapist • Physiotherapist • Psychologist • Exercise physiologist • Phase IV instructor

19. Phases of CR Phase I In Hospital Phase II Immediate post discharge period Phase III Out-patient programme Phase IV Ongoing maintenance phase

20. Phase I • Acute phase in hospital • A member of the cardiac team provides specific information on:- • heart disease • management of chest pain • how to handle serious cardiac symptoms • gradual increase in PA • use of medication • risk factor modification and lifestyle changes • feelings and relationships • driving, insurance and airline travel.

21. Phase II • Patient at home under care of GP, lasts 2 - 6 weeks. • Often neglected phase of rehab. • Ideal time to reinforce important messages and behaviour change. • Telephone advice service • Home visiting

22. Phase III • Consists of exercise, health education, risk factor modification, relaxation and stress management, and occupational counselling. • Can take place in hospital or community • Exercise and education for up to 12 weeks. • Exercise aim is to educate individuals on safe and effective ways to make exercise a part of their lives

23. Phase IV • Community-based CR • Little community provision for this group and previous structured sessions make it difficult for patients to exercise independently. • British Association of Cardiac Rehabilitation (BACR) developed protocol for CHD patients to move from Phase III to Phase IV.

24. Phase IV • Aims of Phase IV:- • provide regular supervised CV training sessions • establish individualised ex. prescription for independent activity. • review participants progress over time (or regression) and amend prescription accordingly. • offer general advice and support in lifestyle changes • encourage independence , self help and self motivation.

25. Phase IV • Class format could take the following:- • integration of individuals with CHD into mainstream classes • specialist phase IV classes • one to one training • What are the disadvantages/advantages of these different sessions? Write down your ideas

26. Advantages Disadvantages Mainstream Class *Get back to normal life *Integration *Not geared up to heart patients *? correct exercise Phase IV Class *Social support *Regular exercise groups *Specifically for heart patients *Reinforce message that something is wrong with you *Does the exercise have progressions One-to-one training *Individual advice *Easy to progress exercise *No social support for other patients Classroom Task

27. Exercise Prescription for Phase IV • Inclusion criteria (BACR, 2003): • Post Myocardial infarction • Post coronary artery bypass graft (CABG) • Post angioplasty (with or without pre cardiac event) • Post transplant • Post valve replacement • Stable angina • Permanent pacemaker • Implanted defibrillator • Also partners/spouses encouraged to attend.

28. Phase IV Exercise Prescription • Frequency At least 3 times a week • Intensity 60-80% of max HR 13-15/3-5 RPE • Time 20-60 mins • Type Aerobic endurance training

29. Session components – Warm-up • Content • Pulse raising and mobility • Preparatory stretching. • Rationale • Gradual, progressive w/up extends ischaemic and angina threshold. Too strenuous can lead to arrhythmias and a reduced ejection fraction. • Duration • 15 mins. minimum. • Intensity • HR to within 20 bpm of training HR or RPE no higher than 10-11 on 6-20 scale.

30. Interval Training Approach • Effective in early stages of recovery and those who are deconditioned • Allows a greater total duration of exercise per session • Allows easy management of a group of individuals of differing abilities Ultimate Aim To achieve continuous cardiovascular work for 20- 60 minutes

31. Active Recovery • Low intensity activity e.g. walking at a slower speed • Alternative activity e.g. muscular strength work (with feet moving) • Can fit with different activities e.g. circuit programme, gym, walking, home programme

32. SQUATS BACK LUNGE AR STATION 5 EXERCISES SIDE STEPS BIKE HAMSTRING CURLS LEVEL 1 LEVEL 2

33. Session components –Cool down • Content • Recovery period, slow walking, gentle movements, large muscle groups, stretching. • Rationale • Older adults take longer to return to pre-exercise states due to aging and baroreceptor changes. • Increased risk of arrhythmias with increased intensity and lack of cool down • Duration • 10 mins. • Intensity • Reduced, aim to return to pre-exercise state

34. Session components – MSE • Content • Floor based has to be done out of main circuit • Could Integrate standing MSE as active recovery in the aerobic section. • Rationale • Increases strength and endurance of specific muscle groups • Duration • Dependent on location within class • Intensity • Low resistance high repetitions, 1 x10-15 reps • 8-10 exercises

35. Professional development opportunities in CR British Association for Cardiac Rehabilitation (BACR) • BACR - founded in 1993, national organisation for professional involved in CR. • Phase IV Exercise Instructor Training Module

36. Evidence of Benefit of CR • Improved survival (25-31% reduction) (1,2) • Improved functional capacity and VO2MAX (3) • Reduced angina (4) • Improved lipid profiles • Lowers BP (5) • Reduced anxiety and depression (6) • Increased confidence and well being (7) • Improved return to work and leisure (8) • Effect of improved health education in family and friends • Improved compliance with lifestyle modification

37. Rationale for the use of PA in CR • Jolliffe et al., 2001; • Enhanced coronary blood flow • Increased angina threshold • Improved peripheral muscle metabolism efficiency • Improved quality of life.

38. Review of lecture • What is cardiac rehabilitation? • Evidence base for exercise component in cardiac rehabilitation • Exercise prescription for Phase IV • Professional development opportunities in CR.

39. Group Task • Look back to your original ideas for exercise prescription • Is there anything you would change now you know more about the recommendations? • Dot down your ideas in your groups

40. References • O’Connor, G. Buring, J. & Yusuf, S. (1989) An Overview of Randomised Trials of Rehabilitation with Exercise after Myocardial Infarction, Circulation, 80, pp. 234-44. • Jolliffe, J. Rees, K. Taylor, R. Thompson, D. Oldridge, N. & Ebrahim, S. (2000) Exercise-Based Rehabilitation for Coronary Heart Disease (Cochrane Review). In: The Cochrane Library, Issue 2, Chichester: John Wilet and Sons Ltd. • Laughlin. M, Oltman. C, Bowles. D. (1998) Exercise Training-induced Adaptations in the Coronary Circulation, Medicine and Science in Sport and Exercise, 30, pp 352-60. • Stahle, A. Mattsson, E. Rydent, L. Unden, A. & Nordlandert, R. (1999) Improved Physical Fitness and Quality of Life following Training of Elderly Patients after Acute Coronary Events, European Heart Journal, 20, pp 1475-1484. • Ades, P. Waldmann, M. & Gillespie, C. (1995) A Controlled Trial of Exercise Training in Older Coronary Patients, Journal of Gerontology, 50A (1), M7-11. • Dugmore, L. Tipson, R. Phillips, M. Flint, E. Strentford, N. Bone, M. and Littler, W. (1999) Changes in Cardiorespiratory Fitness, Psychological Well-Being, Quality of Life, and Vocational Status following a 12-month Cardiac Exercise Rehabilitation Programme, Heart, 51, pp. 359-66.

41. References • Westin, L. Carlsson, B. Israelsson, B. Willenheiner, R. Cline, C. & McNeil, T. (1997) Quality of Life in Patients with Ischaemic Heart Disease: A Prospective Controlled Study, Journal of Internal Medicine, 242, pp. 239-247. • Petrie, K. Weinman, J. Sharpe, N. & Buckley, J. (1996) Role of Patient’s View of their Illness in Predicting Return to Work and Functional Capacity after Myocardial Infarction: Longitudinal Study, British Medical Journal, 312, pp. 1191-94. • Department of Health (1999) Saving Lives: Our Healthier Nation, London: The Stationery Office. • Department of Health (2000) The National Service Framework for Coronary Heart Disease, London: HMSO. • Law, M. Morris, J. (1998) By how much does Fruit and Vegetable Consumption reduce the Risk of CHD?, European Journal of Clinical Nutrition, 52, pp. 549-556. • Marckmann, P. and Gronbaek, M. (1999) Fish Consumption and Coronary Heart Disease Mortality. A Systematic Review of Prospective Cohort Studies, European Journal of Clinical Nutrition, 53 (8), pp. 585-590.