Medical Cardiac Rehabilitation - A professional guide

About Author

Dr. Smruti Mandar Haval is from southern India and she has completed her education in M.B.B.S. D.N.B. in Family Medicine, She is also a Certified International Diabetic Educator 

and a PGD in Geriatrics and Diabetology.



Cardiac rehab


Cardiac rehabilitation is a professionally supervised program to help people recover from myocardial infraction, heart surgery and percutaneous coronary intervention (PCI) procedures such as stenting and angioplasty.


Cardiac rehabilitation programs usually provide education and counselling services to help heart patients increase physical fitness, reduce cardiac symptoms, improve health and reduce the risk of future heart problems, including heart attack.


WHO defines cardiac rehabilitation as sum of all activities require ensuring the best possible physical, mental and social conditions so that they may by their own efforts to resume as normal a place as possible in life of the community.



Benefits of cardiac rehabilitation

  • A reduced risk of major heart problems and death after a heart attack for those who participate in a cardiac rehab program that includes exercise.

  • Recovery after bypass surgery.

  • Decreased severity of angina and decreased need for medicines to control angina.

  • Reduced need for hospital stays because of heart problems. Costs for doctor visits and hospital stays are reduced for those who participate in cardiac rehab. Visits to the emergency room are also reduced.

  • Decreased blood pressure.

  • Reduced shortness of breath and less fatigue in people with heart failure.

  • Ability to exercise longer.

  • Ability to resume sexual activity safely.

  • Improved cholesterol and triglyceride levels.

  • Reaching and staying at a healthy weight.

  • Support to quit smoking.

  • Reduced emotional stress, depression, and anxiety.

Cardiac rehab can increase the quality of your life by improving your health overall; helping you lose weight, if you need to; reducing depression, stress, and anxiety; and helping to increase your self-esteem.


Patient selection


• Low risk patients following an acute cardiac event.

• Patients who have undergone coronary bypass surgery

• Patients with chronic, stable angina pectoris

• Patients who have undergone heart transplantation

• Patients with stable heart failure

• Patients with recent myocardial infarction


1. Risk factor management


Patient Assessment


• Evaluation: Medical History: Review current and prior cardiovascular medical and surgical diagnoses and procedure.

• Symptoms of cardiovascular disease

• Medications


Physical Examination


• Vitals: pulse rate and regularity, blood pressure, respiratory rate.

• Inspection: chest and lower extremities

• Palpation

• Auscultation


Investigations


Chest X ray, ECG,ABG, Complete blood count, ETT.


2. Nutritional Counseling


Evaluation


1. Obtain estimates of total daily caloric intake and dietary intake.

2. Assess eating habits.

3. Determine target areas for nutrition intervention

4. Interventions: prescribe specific dietary modifications.

5. Individualize diet plan acc to specific target areas.

6. Educate and counsel patient on dietary goals.


3. Weight management


Evaluation:


Measure weight, height and waist circumference. calculate BMI.


Interventions:


Establish short term and long term goals for weight reduction.(atleast 5% and preferably >10%at a rate of 1-2 lb/wk over a period of 6 months).Develop a combined diet, physical exercise program


4. Blood pressure Management


Evaluation


1. Measure seated resting blood pressure on >2 visits.

2. Measure blood pressure in both arms at program entry.

3. Take BP in all different position to rule out orthostatic hypotension

4. Interventions: If BP is 120-139 mm Hg systolic or 80 -89 mm Hg diastolic:

5. Provide lifestyle modifications.

6. If >140/90 mmHg then drug therapy along with L.S.M.


5. Lipid Management


Evaluation:


• Obtain fasting measures of total cholesterol, high density lipoprotein low density lipoprotein and triglycerides. Assess current treatment and compliance.

• Repeat lipid profiles at 4-6 weeks after hospitalization and at 2 months after initiation or change in lipid lowering medications.


6. Tobacco cessation


Evaluation


• Ask patient about the smoking status and use of other tobacco products.

• Document status as never smoked, former smoke, current smoked.

• Specify amount and duration of smoking.

• Determine readiness if he or she is now ready to quit.

• Assess for psychosocial factors that may impede success.


Interventions


• when readiness is not confirmed then use “5 Rs”.

• When readiness is confirmed then use “5 As”.

• Minimal: Individual education and counseling.

• Social support.


Relapse prevention:


• problem solving, practice scenarios.

• Optimal: Longer individual counseling

• Pharmacological support: Nicotine replacement therapy.

• Urge avoidance of exposure to second-hand smoke at work and home.


7. Psychosocial management


Evaluation:


• Identify psychological distress as indicated by significant levels of depression, anxiety, anger, social isolation, marital distress, sexual dysfunction/adjustment and substance abuse.


Interventions:


Offer individual with small group of education and counseling on adjustment to heart disease, stress management and health related lifestyle change.

• Include family members, domestic partners and significant others in such sessions.

• Develop supportive rehabilitation environment and community

• Teach and support self help strategies.

• In consult with primary healthcare provider, refer patient to appropriate mental health specialist for further evaluation and treatment


8. Diabetes Management:


Evaluation:


• Confirm presence or absence of diabetes in all patients before starting the exercise protocol.

• If patient is known to be diabetic, identify history of complications.

• Obtain history of symptoms related to above complications and reports of episodes of hypoglycemia or hyperglycemia


Identify physician to manage prescribed treatment regimen that include:


Medications

Diet and extent of compliance

Blood sugar monitoring method and extend of compliance.


Interventions:


Educate patient and staff to be alert for signs and symptoms of hypo and hyperglycemia.

In those taking insulin avoid exercise at peak insulin times. Teach patient self monitoring skills for use during unsupervised exercise.


9. Physical Activity Counselling


Evaluation


Assess current physical activity level(eg, questionnaire, pedometer).

Evaluate activities relevant to age, gender and daily life, such as driving, sexual activity, sports, gardening and household tasks.

Assess readiness to change behavior, self confidence, barriers to increased physical activity and social support in making positive changes.


Interventions:


  • Provide advice, support and counseling about physical activity and target exercise program to meet individual needs.

  • Encourage patients to accumulate 30-60 minutes per day of moderate-intensity physical activity on >5 days of the week.

  • Advice low impact aerobic activity to minimize risk of musculoskeletal injury.

  • Recommend gradual increase in volume of physical activity over time.


Contraindications


• Unstable angina.

• Uncontrolled high blood pressure or low blood pressure.

• Heart rhythm problems.

• Severe heart failure.

• Uncontrolled diabetes.


Warning signs


• Chest pain or pressure, or a strange feeling in the chest.

• Sweating.

• Shortness of breath.

• Nausea or vomiting.

• Pain, pressure, or a strange feeling in the back, neck, jaw, or upper belly, or in one or both shoulders or arms.

• Light-headedness or sudden weakness.

• A fast or irregular heartbeat.

Stroke.

• Sudden numbness, tingling, weakness, or loss of movement in your face, arm, or leg, especially on only one side of your body.

• Sudden vision changes.

• Sudden trouble speaking.

• Sudden confusion or trouble understanding simple statements.

• Sudden problems with walking or balance.

• A sudden, severe headache that is different from past headaches.

• Unexplained low heart rate

• Dramatically higher heart rate Abnormal blood pressure, including any of the following:

• Drop in systolic blood pressure

• Failure of systolic blood pressure to rise

• Excessive blood pressure (over 240/100 millimeters of mercury, or mm Hg)

Blood sugar below 80mg/dL) or above 250 mg/dL


10. Conclusion


Cardiac rehabilitation has four phases. Each phase is designed to meet the individual needs of each patient and includes cardiovascular risk-factor education and counselling, emotional support and exercise activities. Patients are referred to all phases by their family physician or cardiologist.


Depending upon the condition and how the patient responds to rehab, the patient might stay in a particular phase or move back and forth among the various phases. There is no set length of time that you must stay in a specific phase.



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