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

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