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Cardiac Rehab Phase 2: Outpatient

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2 Cardiac Rehab Phase 2: Outpatient
Exercise sessions are individualized and goal-focused Compared to standard median time from hospital discharge (35 days), enrolling patients into cardiac rehabilitation 10 days after discharge significantly improved patient attendance. Centers across the country have significantly improved referral rates over the last decade due to automatic electronic referrals through EMR. Focus can start shifting in getting patients in to phase 2 sooner to improve function, prevent depression, decrease readmissions (added surveillance of patient), and reach post-op goals sooner. Quinn R. Pack, Mouhamed Mansour, Joaquim S. Barboza, et al

3 Old Exercise Prescription Example (Relative)
Resting HR = 80 bpm Maximal exercise HR = 180 Resting BP = 120/80 Maximal exercise BP = 180/90 Maximal METs obtained = 4 METs (walking) Cardiovascular (aerobic) Exercise Only

4 Using all of our Tools Rate Pressure Product (RPP)
HR x Systolic BP = RPP Borg’s RPE Scale (6-20) *Beta-blockers Respiratory Rate (Pulmonary patients) 180 Method vs APMHR Karvonen Formula Target HR = Resting HR + (0.6 [Maximum HR -Resting HR]). EKG & Symptomatology Maffetone 180 formula Subtract your age from 180. Modify this number by selecting among the following categories the one that best matches your fitness and health profile: a)  If you have or are recovering from a major illness (heart disease, any operation or hospital stay, etc.) or are on any regular medication, subtract an additional 10. b)  If you are injured, have regressed in training or competition, get more than two colds or bouts of flu per year, have allergies or asthma, or if you have been inconsistent or are just getting back into training, subtract an additional 5. c)  If you have been training consistently (at least four times weekly) for up to two years without any of the problems in (a) and (b), keep the number (180–age) the same. d)  If you have been training for more than two years without any of the problems in (a) and (b), and have made progress in competition without injury, add 5. 92 pound, 67-year old LVAD patient at Baylor boxing

5 New Exercise Prescription Example (Subjective)
Maximal RPP of 36,000 (ex: HR 180, Systolic BP 200) as cutoff during Aerobic Exercise: Bike, Treadmill, Row, Elliptical, etc. Goal: 8 METs; Stretch Goal: 10 METs (i.e. dancing, racquetball) Resistance Training: RPE ;6-15 reps; 2-3 sets utilizing major muscle groups In minimum of 2 out of 3 weekly sessions Goal-oriented exercise and functional training

6 ©Baylor Jack and Jane Heart and Vascular Hospital

7 Intensive Cardiac Rehab (ICR)
Exercise + Education in EACH session of CR Improved compliance Improved outcomes May be unrealistic for some CR centers i.e. scheduling, cost, staff availability how to make better nutrition choices, manage stress, stop smoking or maintain a positive attitude Patients on average attend 20 to 24 sessions of ordinary CR (out of 36). Medicare may cover up to 72 sessions of ICR and the average compliance is 48 sessions

8 Peripheral Artery Disease
Medicare covered diagnosis for Supervised Exercise Therapy 2017 36 sessions, may be approved for more if still symptomatic (intermittent claudication) i.e. Progressive Treadmill Protocol No physician supervision required **Exercise may be more more effective than peripheral angioplasty and stenting in reducing symptoms of PAD (intermittent claudication)

9 Updated Pulmonary Rehab Dx
Sarcoidosis of lung Pulmonary manifestations due to radiation Cystic Fibrosis Alveolar proteinases Unspecified acute lower respiratory infection Acute bronchospasm Chronic bronchitis Pulmonary fibrosis Coal workers pneumoconiosis Lung transplant Chronic respiratory conditions due to chemicals Need PFT & COPD Diagnosis 10-36 Sessions based on COPD severity May be able to reauthorize for more sessions based on insurance and diagnosis

10 Congestive Heart Failure
In 2014, CHF was added to the list of Medicare covered diagnoses for outpatient cardiac rehab Exercise is proven to decrease symptoms associated with CHF **Largely attributed to a delay in blood lactate accumulation Functional capacity significantly increases with effective cardiac rehab Improved exercise capacity = Improved quality of life = Longer Life MET levels are directly associated with life expectancy for those with CHF Anyone done a stress test or VO2 max test? mL/KG/min Arena R, Myers J, Williams MA Pina IL, Apstein CS, Balady GJ

11 Creative Rehab Programs
“Prehab” Concept Resolutions Program (Phase 3) Scholarship Program for all Transplant/VAD patients Lack of Insurance is a huge barrier Copays are another, meeting deductibles, and gate keepers Non-contracted insurance is another Patients may need supervised exercise but EF is ”too high” or received an LVAD but already did CR under CHF diagnosis ***Find what resources your healthcare system has available to implement other strategies to help cardiac patients and the community it serves.

12 Looking to the Future Research Publication in STS journal this year
AACVPR national poster presentation October, 2017 TACVPR, presentation 2017 University Medical Center & Calgary, Canada in-services 2017 Rome, Italy 2018 Inpatient Cardiopulmonary Exercise Lab Post PTCA sub-maximal exercise testing and improvement of phase 1 CR strategy Implementation of “Keep Your Move in the Tube” world-wide

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14 Thank you very much for your time!
Program info available via


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