Introduction

Cardiovascular disease  (CVD) is one of the leading causes of death worldwide

and is the leading cause of death in the United States.

Cardiac rehabilitation is a complex, interprofessional intervention customized

to individual patients with various cardiovascular diseases such as:

 Heart Attack
 Coronary artery disease  (CAD),
 Heart failure
 Myocardial infarctions
 Patients who have undergone cardiovascular interventions such as
coronary angioplasty or coronary artery  bypass grafting [1].

Cardiac rehabilitation program

Cardiac rehabilitation programs aim to limit the psychological and

physiological stresses of CVD, reduce the risk of mortality secondary to CVD,
and improve cardiovascular function to help patients achieve their highest
quality of life possible. Accomplishing these goals is the result of improving
overall cardiac function and capacity, halting or reversing the progression of
atherosclerotic disease, and increasing the patient's self-confidence through
gradual conditioning [1]

CR ere the process by which patients with cardiac disease, in partnership with
a multidisciplinary team of health professionals are encouraged to support
and achieve and maintain optimal physical and psychosocial health. The
involvement of partners, other family members, and carers is also
important”[2]

They require a team approach, including a multidisciplinary the

multidisciplinary team including:


 Cardiologist/Physician and co-coordinator to lead cardiac
rehabilitation
 Clinical Nurse Specialist
 Physiotherapist
 Clinical nutritionist/Dietitian
 Occupational Therapist
 Pharmacist
 Psychologist
 Smoking cessation counselor/nurse
 Social worker
 Vocational counselor
 Clerical Administration [3]
It is essential that all cardiac rehabilitation staff have appropriate training,
qualifications, skills, and competencies to practice within their scope of
practice and recognise and respect the professional skills of all other
disciplines involved in providing comprehensive cardiac rehabilitation. The
cardiac rehabilitation team should actively engage and effectively link with the
general practitioner and practice nurses, sports and leisure industry where
phase IV is conducted, community pharmacists and other relevant bodies to
create a long-term approach to CVD management. [4]

Description

Indication
Cardiac rehabilitation should be offered to all cardiac patients who would
benefit: [6]

 Recent myocardial infarction
 Acute coronary artery syndrome
  Chronic stable angina
 Congestive heart failure
 After coronary artery bypass surgery
 After a percutaneous coronary intervention
 Valvular surgery [1]
 Cardiac transplantation
CR begins as soon as possible in intensive care units  (only if the patient is in
stable medical condition). Intensity of rehabilitation depends on the patient's
condition and complications in the acute phase of disease. [7] Randomized
controlled trials and systematic analysis show that early mobilization
improved physical function (distance walked during the 6-min walking test
improved by 54 m) at the discharge in patients after cardiac surgery.
[8]
 Another prospective randomized clinical trial improved postoperative
functional capacity (6-minute walk test) shorten the duration of mechanical
ventilation, dependence on oxygen therapy, and reduced the time of hospital
stay in patients who underwent elective Coronary artery bypass graft
surgery[9].

Goals of Cardiac Rehabilitation

Comprehensive cardiac rehabilitation program should contain specific core
components.

These components should optimize cardiovascular risk reduction, reduce

disability, encourage active and healthy lifestyle changes, and help maintain
those healthy habits after rehabilitation is complete. Cardiac rehabilitation
programs should focus on:

 Patient assessment nutritional counseling
 Weight management
 Blood pressure  management
 Lipid management
 Diabetes management
 Tobacco cessation
 Psychosocial management
 Physical activity  counseling
 Exercise training [1]

Individual Risk Assessment

CR can be tailored to meet individual needs thus a thorough assessment and
evaluation of the CV risk factor profile of the patient should be undertaken at
the beginning of the programme. This should be accompanied by ongoing
assessment and reassessment throughout and upon completion of the
programme. [4]

Risk factors should be evaluated using validated measures which take into
account other co-morbidities [2][3][10].

RISK FACTORS

Non Modifiable Modifiable

Age Excessive alcohol intake

Gender Dyslipedemia

Personal Cardiac History Hypertension

Family History of CVD Obesity

Diabetes (unless prediabetes) Smoking

Physical Inactivity

Anxiety/Depression

Hostility

Stress
Other factors to consider

 Family Support
 Social History
 Occupation

Cardiac Rehabilitation Participation

Participation in cardiac rehabilitation programs should be available to all
cardiac patients who require it. Age is not and should not be a barrier to
cardiac rehabilitation participation [4]. However, consideration of patient safety
results in the following specific inclusion/exclusion criteria applying to
participation in the Phase III exercise component. [11]
Inclusion Exclusion

Medically stable post MI Unstable Angina

Coronary Artery Bypass Surgery Ischaemic changes on ECG

Percutaneous Coronary Intervention Resting systolic BP >200mmHg or resting

diastolic BP >110 mmHg

Stable Angina Orthostatic BP drop >10mmHg with

symptoms

Stable heart failure (NYHA I-III) Critical aortic stenosis (peak pressure
gradient >50mmHg with aortic valve orifice
<0.75cm2

Cardiomyopathy Acute systemic illness or fever

Cardiac Transplantation Uncontrolled atrial or ventricular

arrhythmias

Implantable Cardioverter Defibrillator Uncontrolled sinus tachycardia (>120bpm)

Valve Repair/Replacement Uncompensated CHF

Insertion of Cardiac Pacemaker (with Acute systemic illness

one or more other inclusion criteria)
 Peripheral Arterial Disease 3rd degree AV block with no pacemaker

Post Cerebral Vascular Disease Acute pericarditis/myocarditis

At risk of coronary artery disease with Recent embolism

diagnosis of diabetes, dyslipedemia,
hypertension

Thromobophlebitis

Uncontrolled diabetes

Severe orthopediac problems

Other metabolic problems such as acute

thyroiditis, hypo-hyperkalaemia,
hypovolemia

Phases of Cardiac Rehabilitation

Cardiac rehabilitation consists of 3 phases.

Phase I: Clinical phase

This phase begins in the inpatient setting soon after a cardiovascular event or
completion of an intervention. It begins by assessing the patient's physical
ability and motivation to tolerate rehabilitation. Therapists and nurses may
start by guiding patients through non-strenuous exercises in the bed or at the
bedside, focusing on a range of motion and limiting hospital deconditioning.
The rehabilitation team may also focus on activities of daily living (ADLs) and
educate the patient on avoiding excessive stress. Patients are encouraged to
remain relatively rested until completion of treatment of comorbid conditions,
or post-operative complications. The rehabilitation team assesses patient
needs such as assistive devices, patient and family education, as well as
discharge planning.

Phase II: Outpatient cardiac rehab

Once a patient is stable and cleared by cardiology, outpatient cardiac

rehabilitation may begin. Phase II typically lasts three to six weeks though
some may last up to up to twelve weeks. Initially, patients have an assessment
with a focus on identifying limitations in physical function, restrictions of
participation secondary to comorbidities, and limitations to activities. A more
rigorous patient-centered therapy plan is designed, comprising three
modalities: information/advice, tailored training program, and a relaxation
program. The treatment phase intends to promote independence and lifestyle
changes to prepare patients to return to their lives at home.

Phase III: Post-cardiac rehab. Maintenance

This phase involves more independence and self-monitoring. Phase III

centers on increasing flexibility, strengthening, and aerobic conditioning.

Goal: facilitate long term maintenance of lifestyle changes, monitoring risk

factor changes and secondary prevention. [12]

Options:

 Educational sessions
 Support groups
 Telephone follow up
 Review in clinics
 Outreach programmes
 Exercise program organised by qualified phase IV gym instructor
 Links with GP and primary health care team
 Ongoing involvement of partners/spouses/family [4]
A randomized controlled study shows positive outcomes with the internet-
based remote home-based cardiac rehabilitation program [13]
NB There is also a pre-surgery phase, where the patient starts cardiovascular
rehabilitation. A small number of studies demonstrate that the post-surgical
pathway is better tolerated by patients [1].

Sample format of a cardiac rehabilitation class

1. Check in (vitals assessed)
2. Warm Up (15 mins)
3. Main class (30 mins)
4. Cool down (10 mins)
5. Monitoring and reassessment of vitals and check out
[14]

Warm-Up

Purpose: Prepare the body for exercise by raising the pulse rate in a graduated
and safe way

Effects:

 redistributes blood to active tissues

 increases muscle temperature and speed of muscle action and
relaxation
 prepares the mind
 prepares the muscle for the ROM involved for the conditioning
period
Should include pulse raising activities (5 minutes) eg) marching on the spot,
walking, low-level cycle followed by stretching of the major muscle groups (5
mins) followed by more pulse raising activity.

NB: should try to keep feet moving at all times to maintain HR and body temp
and avoid pooling.

Main Class
For group rehab circuit training seems most popular. Depending on CV status
and functional capacity patients may adopt an interval or continuous
approach to the circuit.

Separate stations are set out and participants spend a fixed amount of time at
each aerobic station (30secs-2mins) before moving onto the next station
which may be rest or active recovery in the form of resistance work targeted at
specific muscle groups.

Resistance work as set out by ACSM 2006 – 10-15 reps to moderate fatigue of
8-10 exercises. [15][16]

Individualisation of the CV component can be achieved by varying; duration

spent at each CV station, intensity (increase resistance, speed or ROM),
period of rest, overall duration of the class [17]

Cool Down

10 minutes at the end

Goal: bring the body back to its resting state

Should incorporate movements of diminishing intensity and passive

stretching of the major muscle groups.

Necessary because of;

 Increased risk of hypotension

 Older hearts take longer to return to resting levels
 Raised sympathetic activity during exercise increases the risk of
arrhythmias immediately post exercise. [17] 

Health and Safety

A study in France reviewing the safety of cardiac rehabilitation found the
cardiac arrest rate was 1.3 per million patient hours of exercise [1]
Patient shouldn’t exercise if they are generally unwell, symptomatic or
clinically unstable on arrival;

 Fever/acute systemic illness

 Unresolved/unstable angina
 Resting BP systolic >200mmHg and diastolic > 110mmHg
 Significant drop in BP
 Symptomatic hypotension
 Resting/uncontrolled tachycardia (>100bpm)
 Uncontrolled atrial or ventricular arrhythmias
 New/recurrent symptoms of breathlessness, lethargy, palpitations,
dizziness
 Unstable heart failure
 Unstable/uncontrolled diabetes [18] [4]
Need to consider the following;

 Local written policy clearly displayed for the management of

emergency situations
 Rapid access to emergency team in hospital or via ambulance
 Regular checking and maintenance of all equipment
 Drinking water and glucose supplements available as required
 Access to and from venue, emergency exits, toilets and changing
areas, lighting, surface and room space checked to ensure they’re
appropriate
 Enough space for patient traffic and safe placement of equipment
 Adequate temperature and ventilation
 Medications of patients and their associated effects

Assessment and Outcome Measures

It is essential to;

set and evaluate the effectiveness of an exercise programme

 provide objective feedback to the patient
 facilitate evidence-based practice
Measures can be used as both a baseline measure and exit outcome measure.
These may include;

 HR and BP @ rest and during exercise

 RPE
  Bodyweight
 BMI
 Waist circumference
Measures of functional capacity;

 6MWT
 shuttle walk test
 chester step test

Exercise Testing and Risk Stratification

A patient having a stress test. Electrodes are attached to the patient's chest and
connected to an EKG machine. The EKG records the heart's electrical activity. A blood
pressure cuff is used to record the patient's blood pressure while he walks on a
treadmill. [19]
EACPR, ACCPVR, CACR, ESC and AHA all recommend exercise testing as
part of a patient’s initial assessment for cardiac rehabilitation. Exercise
testing allows for the following;

 Diagnosis – identification of patients with CHD and the severity of

the disease
 Prognosis – identification of low, moderate and high risk patients
 Evaluation – establishment of the effectiveness of a selected
intervention
 Measurement of functional capacity – used as a basis for advice re
ADLs and development of a formal exercise prescription
  Measurement of acute exercise responses – BP, HR, ventilator
responses and detection of exercise induced arrhythmias
 To provide an appropriate training target HR [16]
Exercise ECG using an incremental protocol is most commonly used and
before acceptance into the phase III programme a symptom limited test is
customary. Usually uses the Bruce Protocol

Criteria for terminating a test [16]:

Horizontal or downsloping ST segment depression >2mm – indicates ischaemia

Marked drop in systolic BP >20mmHG – indicates poor LV fxn or severe

coronary disease

Serious arrhythmias – ventricular tachycardia

Patient fatigue and/or excessive breathlessness at low workloads – poor fxnl

capacity or more serious problems such as heart failure

Negative Test Positive Test

Normal haemodynamic response Significant ECG changes

Completion of a workload equivalent to the Inappropriate HR/BP response

second stage of the Bruce protocol (7 METs) to the incremental workload.

NB: when carrying out the test patients HR, BP and 12 lead ECG must be
constantly assessed. Once test has terminated recovery monitoring must be
continues for a minimum of 6 secs or until the ECG returns to its pretest
appearance. [16]
Risk Stratification [11]

Definition: “Evaluation of the patient to assess the degree of risk of future

cardiac events associated with exercise”[2]

Low Risk (all Moderate Risk High Risk (anyone

characteristics listed (any one or a or a combo)
must be present to combination of
remain @ lowest these findings)
risk)

Uncomplicated MI, Functional capacity <5- Severely depressed LV

CABG, angioplasty 6 METs function

Funct. Capacity >6 METs Mild – moderate Complex arrhythmias

depressed LV @rest or during exercise)
dysfunction (EF 31-
49%)

No resting/exercise Mild – moderate Decreased systolic BP of

induced complex ischaemia in >15mmHg during
arrhythmias exercise/recovery exercise/ failure of BP to
rise consistently with
exercise workloads

No sig. LV dysfunction Exercise induced MI complicated by

(EF >50%) STsegment depression CHF/cardiogenic
of 1-2mm or reversible shock/complex ventricular
ischaemic effects arrhythmias

Normal heamodynamic Presence of angina or Severe CAD and marked

response during exercise relevant symptoms at (>2mm) exercise induced
high levels of exertion ST segment depression
 (>7 METs)

Absence of CHF Survivor of cardiac arrest

Absence of angina/other Complicated MI or

sig symptoms revascularisation
procedure

Absence of clinical Presence of clinical

depression depression

Risk stratification is important as it will have a bearing on staffing required

and group mixing. It’s also something that has to be taken into account when
determining the level of monitoring a patient requires and when setting their
Target Training HR.

Requirements for cardiac rehabilitation

Facilities and Equipment

The minimum facilities necessary to provide a cardiac rehabilitation service

are:

 Separate office space and facilities for cardiac rehabilitation staff

 An Education Room furnished with seats, TV and DVD player and
with a selection of information booklets and DVDs provided. The
size of the education room will depend upon the number of
participants (patients, spouses, and staff) in the education sessions
and given resources.
 It is recommended that the exercise warm-up area and the exercise
room combined should be approximately 300m2
 The exercise room should be air-conditioned
 In addition, patients should have access to
 Toilet
 Shower and changing room

 Available drinking water
Equipment in the exercise room may include

Central monitor and Treadmill Versa climber Chairs Music

telemetry system

Equipped emergency Dual cycle Hand crank Rowing Glucometer

trolley, portable ergometer Machine
suction, defibrillator
and oxygen

Automated Blood Bicycle Multigym Stethoscope Measuring

Pressure Recording ergometer weights system tape
Machine e.g. and/or dumb
Dinamap bells