Cardiac Rehabilitation after Myocardial Infarction

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1 SUPPLEMENT TO JAPI december 2011 VOL Cardiac Rehabilitation after Myocardial Infarction Aashish S Contractor * Abstract Cardiac rehabilitation / secondary prevention programs are recognized as integral to the comprehensive care of patients with coronary heart disease (CHD), and as such are recommended as useful and effective (Class I) by the American Heart Association and the American College of Cardiology in the treatment of patients with CHD. The term cardiac rehabilitation refers to coordinated, multifaceted interventions designed to optimize a cardiac patient s physical, psychological, and social functioning, in addition to stabilizing, slowing, or even reversing the progression of the underlying atherosclerotic processes, thereby reducing morbidity and mortality. Cardiac rehabilitation, aims at returning the patient back to normal functioning in a safe and effective manner and to enhance the psychosocial and vocational state of the patient. The program involves education, exercise, risk factor modification and counselling. A meta-analysis based on a review of 48 randomized trials that compared outcomes of exercise-based rehabilitation with usual medical care, showed a reduction of 20% in total mortality and 26% in cardiac mortality rates, with exercise-based rehabilitation compared with usual medical care. Risk stratification helps identify patients who are at increased risk for exercise-related cardiovascular events and who may require more intensive cardiac monitoring in addition to the medical supervision provided for all cardiac rehabilitation program participants. During exercise, the patients ECG is continuously monitored through telemetry, which serves to optimize the exercise prescription and enhance safety. The safety of cardiac rehabilitation exercise programs is well established, and the occurrence of major cardiovascular events during supervised exercise is extremely low. As hospital stays decrease, cardiac rehabilitation is assuming an increasingly important role in secondary prevention. In contrast with its growing importance internationally, there are very few cardiac rehabilitation centers in India at the present moment. Coronary heart disease (CHD) is a major cause of mortality and morbidity in India. The reported prevalence of CHD in Indian adults has risen 4-fold over the last 40 years (to a present level of around 10%), and even in rural areas the prevalence has doubled over the past 30 years (to a present level of around 4%). 1 Within the spectrum of CHD, myocardial infarction (MI) is the leading cause of death. For those who survive an MI, the prevention of subsequent coronary events and the maintenance of physical functioning are the major challenges. 2 Secondary prevention is an essential part of the contemporary care of the patient with CHD. Cardiac rehabilitation/secondary prevention programs are recognized as integral to the comprehensive care of patients with CHD and as such are recommended as useful and effective (Class I) by the American Heart Association and the American College of Cardiology in the treatment of patients with CHD. 3 Table 1: Patient Mobilization Guidelines for Inpatient cardiac rehabilitation Frequency: Early mobilization: 2 to 4 times per day. Exercise intensity: Post-MI: Maintain heart rate (HR) less than 120 beats/min or HR at rest + 20 beats/min Rate of perceived exertion (RPE) < 13 on a 6-20 Borg scale Exercise Type: Walking Duration: Intermittent bouts lasting 2 to 5 minutes * Head of Department: Preventive Cardiology & Cardiac Rehabilitation, Asian Heart Institute, Bandra-Kurla Complex, Bandra (E), Mumbai What is Cardiac Rehabilitation? The term cardiac rehabilitation refers to coordinated, multifaceted interventions designed to optimize a cardiac patient s physical, psychological, and social functioning, in addition to stabilizing, slowing, or even reversing the progression of the underlying atherosclerotic processes, thereby reducing morbidity and mortality. 4,5 In essence, cardiac rehabilitation services are comprehensive programs involving education, exercise, risk factor modification and counselling, designed to limit the physiological and psychological effects of heart disease, reduce the risk of death or recurrence of the cardiac event, and enhance the psychosocial and vocational state of patients. 6 Inpatient Cardiac Rehabilitation after MI After an MI, the goal is to mobilize the patient as soon as he is clinically stable. A patient is considered stable if there is no new or recurrent chest pain in the past eight hours; creatine kinase and/ or troponin levels are not rising; no new signs of uncompensated heart failure and no new significant, abnormal rhythm or ECG changes in the past eight hours. Once the patient is stable, he should be made to sit at the edge of the bed during the first day, and then gradually mobilized throughout the hospital stay. During mobilization the goal should be to keep the heart rate below120 beats/min, or if the patient has a high resting heart rate, then the goal should be to keep the heart rate within 20 beats above resting heart rate. The patient should be made to walk within the room at first, and then in the corridors for about 2-5 minutes, three to four times a day. Progression of activity depends on the initial assessment as well as the daily assessment of the patient and may vary from a rapid increase in activity tolerance in the low-risk

2 52 SUPPLEMENT TO JAPI december 2011 VOL. 59 Lipid management Hypertension management Table 2: Comprehensive Risk Reduction Guidelines for Patients with CHD. (Adapted from Ref 18,19) Obtain fasting measures of total cholesterol, HDL, LDL, and triglycerides. Repeat lipid profiles at 4-6 weeks after hospitalization and at 2 months after initiation of, or change in lipidlowering medications Primary goal: LDL < 100 mg/dl; further reduction of LDL < 70 mg/dl is reasonable Secondary goals: HDL > 40 mg/dl, total cholesterol < 200 mg/dl, triglycerides < 150 mg/dl In patients with LDL > 100 mg/dl, provide nutritional counselling and weight management; consider adding drug therapy. Statins are the drug of choice, unless contraindicated. In patients with HDL < 40 mg/dl, emphasize exercise, smoking cessation, and consider targeted drug therapy. Measurement of resting BP on two or more visits. Assess current treatment and compliance. Optimal BP is < 120/80 mmhg For patients with systolic BP >130 mmhg or diastolic BP > 85 mmhg initiate lifestyle modification (including exercise, weight management, moderate sodium restriction, alcohol moderation and smoking cessation). Add drug therapy for patients with diabetes, heart failure, or renal failure. For patients with systolic BP > 140 mmhg or diastolic BP> 90 mmhg initiate lifestyle modification and drug therapy. Diabetes management: Obtain fasting plasma glucose measurements in all patients and HbA 1 C in diabetic patients to monitor therapy. Near normal fasting plasma glucose(< 100 mg/dl)and near normal HbA 1 C (<7) Appropriate hypoglycemic therapy (including weight control, exercise, and if needed oral hypoglycemic agents and/or insulin). Monitor glucose levels before and / or after exercise sessions. Instruct patient regarding identification and treatment of post exercise hypoglycaemia. Exercise with caution if blood glucose > 300 mg/dl (evaluate for urine ketones as well), after consulting with a physician. Smoking / Tobacco: Evaluation Weight management Psychosocial management Evaluation Document smoking and / or tobacco consumption habits in detail, including amount and duration. Assess the readiness to change on the part of the patient. Complete cessation. Provide individual education and counselling. Encourage patient to quit at each and every visit. Provide nicotine replacement and pharmacological therapy as appropriate. Measure weight, height, and waist circumference. Calculate body mass index (BMI). BMI kg/m 2, waist < 35 inches in men and < 31 inches in women. For patients who do not meet the goal criteria, advice a reduction in total caloric intake, and increase in energy expenditure through a combined program of diet, and exercise. The initial goal of weight loss therapy should be to reduce body weight by approximately 10% from baseline. With success, further weight loss can be attempted, if indicated. Identify patients with clinically significant depression, anxiety, anger, and substance abuse. To minimize the patient s psychosocial distress. Stress management and individual or group education to help the patient adjust to his/her disease. When needed, refer the patient to appropriate mental health specialists for further treatment. patient (uncomplicated MI or a patient without left ventricular dysfunction) to a slower progression in higher risk or more debilitated patients, such as those with heart failure. 7 The goals of inpatient rehabilitation are to assist the patient in becoming ambulatory; to prepare the patient and family to cope with the psychological and emotional stress that accompanies a coronary event; and to educate the patient about coronary risk factor modification. The guidelines for patient mobilization for inpatient cardiac rehabilitation are enlisted in Table 1. Outpatient Cardiac Rehabilitation The outpatient program can be begun once the patient has left hospital and has clearance from his/her physician. Depending on the patient s clinical condition, and the severity of the MI, the outpatient program, is typically begun two to four weeks after the event. Cardiac rehabilitation programs were first developed in the 1960s, once the benefits of ambulation during prolonged hospitalization for coronary events had been recognized. Concern about the safety of unsupervised exercise after discharge led to the development of highly structured rehabilitation programs that were supervised by physicians and included electrocardiographic monitoring. The focus of these programs was almost exclusively on exercise. 8 A meta-analysis based on a review of 48 randomized trials that compared outcomes of exercise-based rehabilitation with usual medical care, showed a reduction of 20% in total mortality and 26% in cardiac mortality rates, with exercise-based rehabilitation compared with usual medical care. 5 Over time, cardiac rehabilitation programs have evolved, to comprehensive cardiovascular risk reduction programs, with exercise being an integral component of the program, but not the only component. Since, hospital stays for MI has dramatically decreased over time, thereby reducing the opportunity for in-hospital risk factor interventions, outpatient cardiac rehabilitation programs have gradually broadened their scope to become an important avenue for secondary prevention. 2

3 SUPPLEMENT TO JAPI december 2011 VOL Table 3: Contraindications for Exercise in Outpatient Cardiac Rehabilitation. ( From Ref 10) 1. Unstable angina 2. Resting systolic BP (SBP) > 200 mm Hg or resting Diastolic BP (DBP) > 110 mm Hg that should be evaluated on a case-by-case basis. 3. Orthostatic BP drop of >20 mm Hg with symptoms. 4. Critical aortic stenosis (i.e., peak SBP gradient of > 50 mm Hg with an aortic valve orifice area of <0.75 cm 2 in an average-size adult. 5. Acute systemic illness or fever 6. Uncontrolled atrial or ventricular dysrhythmias 7. Uncontrolled sinus tachycardia (> 120 beats per min). 8. Uncompensated CHF. 9. Third-degree atrioventricular (AV) block wihout pacemaker. 10. Active pericaditis or myocarditis. 11. Recent embolism 12. Thrombophlebitis 13. Resting ST-segment depression or elevation (> 2mm). 14. Uncontrolled diabetes mellitus. 15. Severe orthopedic conditions that would prohibit exercise. 16. Other metabolic conditions, such as acute thyroiditis, hypokalemia, hyperkalemia or hypovolemia Table 4: Summary of Aerobic Exercise and Resistance Training Recommendations for Patients with CHD Frequency: Aerobic: Structured exercise 3-5 days per week (lifestyle physical activity daily) Resistance: 2-3 days per week Intensity: Aerobic: 60-85% of HRmax (Predicted HRmax = 220 age of person). Resistance: Moderate (avoid breath holding and excessive straining) Time (duration): Aerobic: minutes Resistance: repetitions; 3 sets of 8-10 different exercises for both upper and lower body Type of exercise: Aerobic: Walking, running, cycling, swimming, etc. Resistance: Hand weights, elastic bands, machine weights. Special Considerations: Monitor for abnormal signs and symptoms, i.e., chest pain or pressure, dizziness, and dysrhythmias. High-intensity exercise may precipitate cardiovascular complications in post-mi patients. Patients with stable angina should always carry nitroglycerin and be educated in its use. Heart rate guidelines may not be applicable to patients taking drugs, which slow down the heart rate, e.g. beta-blockers. Lift weights through a full range of motion and avoiding breathholding Table 5: Comparison of Effects of Aerobic Endurance Training with Strength Training on Health and Fitness Variables. (From Ref 11) Variable Aerobic Resistance Exercise Exercise Indicates values increase;, values decrease; 0, values remain unchanged; 1 arrow, small effect; 2 arrows, moderate effect; 3 arrows, large effect; HDL, high-density lipoprotein cholesterol; and LDL, lowdensity lipoprotein cholesterol. Body composition Bone mineral density Percent body fat Lean body mass 0 Muscle strength 0 Glucose metabolism Insulin response to glucose challenge Basal insulin levels Insulin sensitivity Plasma lipids and lipoproteins HDL cholesterol 0 0 LDL cholesterol 0 0 Triglycerides 0 Cardiovascular dynamics Resting heart rate 0 Stroke volume, resting and maximal 0 Cardiac output, rest 0 0 Cardiac output, maximal 0 SBP at rest 0 0 DBP at rest 0 0 Vo 2 max 0 Submaximal and maximal endurance time Submaximal exercise rate-pressure product Basal metabolic rate 0 Health-related quality of life 0 0 Components of Cardiac Rehabilitation A comprehensive cardiac rehabilitation program should aim to identify each patient s risk factors, establish risk reduction goals and then help the patient achieve these goals through lifestyle modification, supervised exercise, and medications. Table 2 lists the major risk factors, their evaluation, goal values, and suggested intervention. For maximum efficacy the program staff should coordinate their efforts with the patient s personal physician. Physical Activity / Exercise Physical activity can be defined as bodily movement produced by skeletal muscle that requires energy expenditure and promotes health benefits. Exercise can be defined as planned, structured, and repetitive bodily movement done to improve or maintain one or more components of physical fitness. 9 Over the years research has shown that an increase in leisure time physical activity, as well as structured exercise training, play an important role in reducing CHD mortality. Exercise Prescription A comprehensive exercise prescription for the cardiac patient includes activities performed in formal supervised programs, as well as everyday physical activities. The exercise program should prescribe the appropriate mode, frequency, intensity, and duration of exercise, which should be tailored to the individual s cardiovascular and general medical status. However, there are

4 54 SUPPLEMENT TO JAPI december 2011 VOL. 59 some patients for whom exercise is contraindicated, as listed in Table 3. A summary of the exercise prescription is given in Table 4. After two to four weeks of participation in a traditional aerobic exercise program, low-to-moderate risk patients should initiate resistance training. Prescribed and supervised resistance training (RT) enhances muscular strength and endurance, functional capacity and independence, and quality of life while reducing disability in persons with CHD. 11 Both endurance and strength training can elicit substantial increases in physical fitness. Table 5 summarizes many of these benefits and attempts to weigh them according to the current literature. Endurance training induces greater improvements in aerobic capacity and associated cardiopulmonary and metabolic variables and more effectively modifies CHD risk factors. Resistance training enhances muscular strength, endurance, and muscle mass to a greater extent. 11 Nutrition Counselling It is necessary to assess the dietary habits of the patient to obtain an estimate of total caloric intake, as well as daily consumption of saturated fat, cholesterol, sodium, and other nutrients. Patients should be recommended a diet low in fat (especially saturated fat), and high in complex carbohydrates. 3 As a general guideline, the diet should consist of 50-60% calories from carbohydrates, up to 30% from fat (with saturated fat forming 10% or less), and 10-15% from protein. Individualized plans should be formulated, depending on the presence of risk factors, such as diabetes, hypertension, and hypercholesterolemia. Psycho-Social Rehabilitation After an MI, some of the common psychological reactions that patients may experience are: low mood, tearfulness, sleep disturbance, irritability, anxiety, acute awareness of minor somatic sensations or pains, poor concentration and memory. It should be explained to the patient that these symptoms are normal, that they are universal, and are part of the natural course of recovery following any potentially life threatening event. 12 Psychological factors are strong risk factors for CHD and adversely affect recovery after major CHD events. Although most of the attention has been directed at depression, other adverse psychological characteristics, including anxiety and hostility, may also be significant CHD risk factors. Studies have demonstrated reductions of between 40% and 70% in the prevalence of depression, anxiety, and hostility after cardiac rehabilitation. 13 Studies have also shown that depressed patients with CHD who attended a formal cardiac rehabilitation program, had nearly a 70% reduction in mortality risk. It has been found that only small improvements in exercise capacity may produce profound improvements in depression and depression-related mortality. 13,14,15 Safety Use of a risk stratification schema, to evaluate patients on entry into cardiac rehabilitation programs is essential to optimize patient management and minimize potential risk. The relative safety of medically supervised, physician directed, cardiac rehabilitation exercise programs is well established. The occurrence of major cardiovascular events during supervised exercise ranges from 1/50,000 to 1/120,000 patient-hours of exercise, with only 2 fatalities reported per 1.5 million patienthours of exercise. 16 Risk stratification helps identify patients who are at increased risk for exercise-related cardiovascular events and who may require more intensive cardiac monitoring in addition to the medical supervision provided for all cardiac rehabilitation program participants. 4 Return to Work Although improvement in functional capacity and the associated reduction in cardio-respiratory symptoms may enhance a cardiac patient s ability to return to work, factors unrelated to physical fitness appear to have a greater influence on whether a patient returns to work after a cardiac event. These include socioeconomic and worksite-related issues and previous employment status. The educational and vocational counselling components of cardiac rehabilitation programs should further improve the ability of a patient to return to work. 4 Therefore, the time to return to work, after an MI can vary greatly from about two weeks, to upwards of six weeks. Patient Participation in Cardiac Rehabilitation International guidelines and experts recommend the use of cardiac rehabilitation after MI. As hospital stays decrease, cardiac rehabilitation is assuming an increasingly important role in secondary prevention. 17 In contrast with its growing importance, there is little contemporary information on the use of cardiac rehabilitation after MI, in India and essentially no published data on the same. References 1. Reddy K S. India Wakes Up to the Threat of Cardiovascular Diseases. Journal of American College of Cardiology 2007;50: Ades P A. Cardiac rehabilitation and secondary prevention of coronary heart disease. New England Journal of Medicine 2001;345: Balady G J, Williams M A, Ades P A, Bittner V, Comoss P, Foody J M, Franklin B, Sanderson B, Southard D. Core Components of Cardiac Rehabilitation/Secondary Prevention Programs: 2007 Update: A Scientific Statement From the American Heart Association, Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; the Councils on Cardiovascular Nursing, Epidemiology and Prevention, and Nutrition, Physical Activity, and Metabolism; and the American. Association of Cardiovascular and Pulmonary Rehabilitation. Circulation 2007;115: Leon A S, Stewart K J, Thompson P D, Williams M A, Lauer M S, Franklin B A, Costa F, Balady G J, Berra K A. Cardiac Rehabilitation and Secondary Prevention of Coronary Heart Disease: An American Heart Association Scientific Statement From the Council on Clinical Cardiology (Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity), in Collaboration With the American Association of Cardiovascular and Pulmonary Rehabilitation. Circulation 2005;111; Taylor RS, Brown A, Ebrahim S, Jolliffe J, Noorani H, Rees K, Skidmore B, Stone JA, Thompson DR, Oldridge N. Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized trials. American Journal of Medicine 2004;116: Wenger NK, Froelicher ES, Smith LK, Ades PA, Berra K, Blumenthal JA, Certo CM, Dattilo AM, Davis D, DeBusk RF, Drozda JP Jr, Fletcher BJ, Franklin BA, Gaston H, Greenland P, McBride PE, McGregor CG, Oldridge NB, Piscatella JC, Rogers FJ. Clinical Practice Guidelines No. 17: Cardiac Rehabilitation as Secondary Prevention. Rockville, Md: US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, National Heart, Lung and Blood Institute; AHCPR Publication American Association of Cardiovascular and Pulmonary

5 SUPPLEMENT TO JAPI december 2011 VOL Rehabilitation. Guidelines for Cardiac Rehabilitation and Secondary Prevention Programs. 4th edition. Champaign, Ill: Human Kinetics; Chapter 4, Cardiac Rehabilitation in the Inpatient and Transitional Settings; Pashkow FJ. Issues in Contemporary Cardiac Rehabilitation: A Historical Perspective. Journal of American College of Cardiology 1993;21: Leon AS. Physical Activity and Cardiovascular Health: A National Consensus, Champaign, IL: 3-4: Human Kinetics: American College of Sports Medicine (ACSM). ACSM s Guidelines for Exercise Testing and Prescription; 8 th Edition. Lippincott Williams & Willikans; Chapter 9, Exercise Prescription for Patients with Cardiac Disease; p Williams M A, Haskell W L, Ades P A, Amsterdam E A, Bittner V, Franklin B A, Gulanick M, Laing S T, Stewart K J,. Resistance Exercise in Individuals With and Without Cardiovascular Disease: 2007 Update: A Scientific Statement From the American Heart Association Council on Clinical Cardiology and Council on Nutrition, Physical Activity, and Metabolism. Circulation 2007;116; Thompson D R, Lewin R LP; British Heart Foundation Rehabilitation Research Unit, Department of Health Studies, University of York, UK. Coronary Disease Management of the Post-Myocardial Infarction Patient: Rehabilitation and Cardiac Neurosis. Heart 2000;84: Milani R V, Lavie C J. Impact of cardiac rehabilitation on depression and its associated mortality. American Journal of Medicine 2007;120: Lavie C J, Thomas R J, Squires R W, Allison T G, Milani R V. Exercise Training and Cardiac Rehabilitation in Primary and Secondary Prevention of Coronary Heart Disease. Mayo Clinic Proc 2009;84: Lichtman J H, Bigger JT Jr, Blumenthal J A, et al. Depression and coronary heart disease: recommendations for screening, referral, and treatment: a science advisory from the American Heart Association Prevention Committee of the Council on Cardiovascular Nursing, Council on Clinical Cardiology, Council on Epidemiology and Prevention, and Interdisciplinary Council on Quality of Care and Outcomes Research. Circulation 2008;118: Franklin B A, Bonzheim K, Gordon S, Timmis G C. Safety of medically supervised cardiac rehabilitation exercise therapy: a 16-year follow-up. Chest 1998;114: Brandi J W, Jacobsen S J, Weston S A, Killian J M, Meverden R A, Allison T G, Reeder G S, Roger V L. Cardiac Rehabilitation After Myocardial Infarction in the Community. Journal of American College of Cardiology 2004;44: AHA / AACVPR scientific statement. Core components of cardiac rehabilitation / secondary prevention programs. Circulation 2000;102: Smith S C, Allen J, Blair S N, Bonow R O, Brass L M, Fonarow G C, Grundy S M, Hiratzka L, Jones D, Krumholz H M, Mosca L, Pasternak R C, Pearson T, Pfeffer M A, Taubert K A. AHA/ACC Guidelines for Secondary Prevention for Patients With Coronary and Other Atherosclerotic Vascular Disease: 2006 Update: Endorsed by the National Heart, Lung, and Blood Institute. Circulation 2006;113;

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