1. Cardiac rehabilitation Ahmad Osailan

2. What is cardiac rehabilitation is a sum of coordinated interventions required to ensure best physical, psychological and social wellbeing, so that patient with chronic or acute post CVD, by their own effort can resume optimal functioning in society through improved health behaviour to slow or reverse the progression of the disease

3. Mission of Cardiac Rehab To restore and maintain an individual’s optimal physiological, psychological, social wellbeing.

4. Target Groups Coronary heart disease (CHD) – Exertional angina. – ACS (unstable angina or NSTEMI or STEMI) following medical/surgical management. – Revascularisation – Stable heart failure and cardiomyopathy Those at high risk of developing CVD: total CVD risk > 20% over 10 years or diabetes mellitus.

5. What are the outcomes mortality and morbidity hospital readmission risk factors physical activity and functional capacity psychological problems

6. Components of CR. Lifestyle: – Diet and weight management – Smoking cessation – Physical activity and exercise – Secondary prevention – Education Psychosocial care Long-term management strategy

7. Physical Activity Assess and risk stratify Develop individual exercise plan Teach FITT principle Regain/develop physical fitness Regain confidence in physical activity Develop long-term activity plan Self monitoring

8. Secondary Prevention Cholesterol management BP management Blood sugar management Cardio-protective drug therapy

9. Education CHD as a disease Treatment including medication Recovery process CHD risk factors Symptom management Living with CHD

10. Psychosocial Care Reduce fear and anxiety Assist with adjustment Promote positive attitude Facilitate behaviour change Identify need for further support

11. Phases of cardiac rehab Phase 1 inpatient phase Phase 2 immediate post discharge phase Phase 3 exercise training phase Phase 4 maintenance phase

12. Inpatient phase Pre-operation Clinical assessment: focusing on RHR, RBP, RR and O2 saturation Functional activities Risk factors assessment: Post- operation Education : focusing on : -Precautions and movements to be avoided -Importance of practising breathing Exercises -The stages of rehab after OP and the activities allowed after OP

13. Phase 1 Main aim: is to start changes in behavioural life style as soon as possible. Education of Risk factors and correction of misconceptions Addressing psychological issues. Gradual increase of activity and mobilization

14. Phase 1 Contraindications for mobilization: -High SBP and DBP (hypertension) 185 -Uncontrolled arrhythmias, (Afib) -Uncontrolled DM >250 mmol -O2 saturation < 85% -sever tachypnea RR > 40 -Sever Hypotension SBP<85

15. Phase 2 Aim: to promote self willingness to toward healthier life style. Following with patient via phone Patient should receive a booklet for self education.

16. Recommendations for exercises @ home Performing simple household activities Encourage walking more than using the car Walking duration should be gradual, the min is 10 min 3x per day Encourage use of stairs. Avoid stress

17. Phase 3 Outpatient phase Aim: to introduce the supervised tailored exercise sessions to patients. Full clinical assessment including exercise capacity assessment via: 6MWT or ISWT

18. ISWT

19. 6 MWT Course length Different prediction equations More simple than ISWT but less efficient

21. Exercise sessions According to BACR and SIGN guidelines: Frequency: 2-3/wk Intensity: at the beginning 60-65% of HRR and progression occurs gradually (old population Vs young population) Type: Mixture of Aerobic cardiovascular Exercise and some light resistance training exercises Duration: 60 min per session

22. Types of Exercises 10-15 min of warming up with ended by stretching. 20-30 min of conditioning exercises aerobic Exe (biking, treadmill, rowing, stepping....etc) and resistance exercise. 10- 15 min of cooling down and relaxation techniques.

23. Exercise session Exercises can be performed in a group or individualized. If in a group: intensity will be set from Low – moderate If individualised: Vary upon exercise capacity during assessment.

24. Things to consider during sessions Patients must feel slight breathlessness but not speechless! Intensity of Exercise must be increased gradually Heart rate must be monitored all the time during the session ( Polar HR, or Telemetry unit) Any signs of Sever SOB noticed, Exe intensity must be decreased Never stand still.

25. Phase 4 Aim: maintain the positive changes of healthy life style. But before advancement to phase 4 from phase 3 graduation criteria must be met: -Improvement in functional capacity -Ability to recognize symptoms of HA -Reports self exercises and daily activities

26. Who can Refer a Patient? Site-specific Policy:  Cardiologist  Primary Care Physician  Internist

27. Types of monitors during Exercise

28. Effects of Exercise on Risk factors Blood Pressure Taylor et al (2006) LDL (bad cholesterol) Joliffe et al (2001) HDL (good cholesterol) Insulin Sensitivity Glucose (sugar) Metabolism Body Fat Anxiety and Depression

29. Are exercises safe for cardiac patients?

30. Absolute risk vs. relative risk The chances of having MI in a healthy person during vigorous exe is 5 times normal. BUT: 56 more in less active person

31. Why it is safe to exercise cardiac patients ARCH inter MED: the risk of developing cardiac arrest during exercise is 1.3 in a million patient hours. Risks during exercise testing is higher 1.2 deaths /10000 test (2006)

32. Risk Factors Tobacco – Smoking and Chew – 50% decreased risk of CHD 1 year after cessation Hypertension – 90% middle-aged Americans will develop HTN – 35 million office visits/yr for HTN

33. Risk Factors Hyperlipidemia – 105,000,000 people with a tot chol > 200 – 10% reduction in Total Cholestrol = 30% reduction in incidence of CAD Physical Inactivity – $76 billion – > 60% of Americans don’t get sufficient exercise

34. Risk Factors Obesity – More than 50% women and 60% men are overweight or obese – Nearly 300,000 American adults die of causes related to obesity Diabetes – 58% reduction by lifestyle intervention – 75% of people w/DM die of CAD or vascular disease

35. Exercise Research  Direct relation between inactivity and cardiovascular mortality. Inactivity is an independent risk factor for of CAD.  Exercise capacity is a more powerful predictor of mortality among men than other established risk factors for CAD.  Physical fitness has been clearly associated with improvements in lipid profiles.

36. Evidence for cardiac rehab Joliffe et al (2001): Meta analysis shoed that exercise based CR reduce all cause mortality by 28% and cardiac mortality by 31%. Taylor et al (2006) Meta analysis shoed reduction in mortality by 28%. 50% of reduction attributed to risk factors.

37. Cost of Cardiac Rehabilitation The average cost per patient in 2006-7 was £413 Single day in a CCU costs £1,400 Angioplasty (does not reduce mortality) costs £3,000 Bypass surgery costs £8,000.

38. Cardiac Rehabilitation Saves Lives! No treatment in cardiac disease has stronger scientific evidence or a significantly greater impact on survival. The scientific evidence has been reviewed by many scientific and expert bodies over the last 30 years. Every review has come to the same conclusion that cardiac rehabilitation is an essential treatment. CR is only form of chronic disease management with an evidence base.