Cardiac Rehabilitation Flashcards

Question

End of Phase 1: Home Discharge * Maintain ______ mobilization * Gradually increase en\_\_\_\_\_ * Maximum heart rate as previously determined by low level ETT * In Classic program (phase II) a six week program to allow for scar formation * Exercise \_*-*\_ times per week at \_*-*\_ METs maximum * \_\_\_-\_\_\_ minute sessions at target HR set by d/c ETT * 5 minute warm up/cool down sessions

Answer 1

* Maintain early mobilization * Gradually increase endurance * Maximum heart rate as previously determined by low level ETT * In Classic program (phase II) a six week program to allow for scar formation * Exercise 3-5 times per week at 4-5 METs maximum * 20-30 minute sessions at target HR set by d/c ETT * 5 minute warm up/cool down sessions

Answer 2

* Classically (phase III) 6 weeks post MI, Symptom limited full level ETT performed * Screen out arrhythmias, ischemia * Set target heart rate * Now with revascularization, start as soon as possible * Monitoring with each increase in level * Patient self monitoring * Borg Scale * Heart rate

Answer 3

* Usual program as outpatient * 3 sessions a week minimum * 6-8 weeks in duration, can be longer * Up to 4 hours per session * Cross training * Always start with warm up/cool down – 20-30 minutes on each piece of apparatus * Newer models may include at home

Answer 4

* Most important phase * Benefits of training can be lost in a few weeks of being sedentary * Regular exercise necessary * Minimum of 2 to 3 times a week * At least 30 minutes of exercise per session excluding warm up and cool down * Role for maintenance/wellness program

Answer 5

1. **_Tobacco cessation_** 2. **BP Control**: \<140/90 mmHg or \<130/80 in DM or renal disease • 3. **Lipid control goals:** LDL-C \<100 mg/Dl for TG \>200, non HDL-C \<130 mg/Dl 4. **Physical activity:** 30+ minutes for at least 5 days a week 5. **Weight management:** BMI 18.5 to 24.9 1. and waist \<40 inches in men and \<35 inches in women 6. **DM:** HgbA1c \<7% 7. **Depression**: Evaluate for depression 1. If present =\> treat 8. **Exercise capacity**: Assess with ETT 1. Develop individual training program 9. **Medications**: Assess current meds 1. Assure beta blockade 2. Assure antiplatelet agent 3. Assure cholesterol lowering agent 4. Assess BP control medications 10. **Assess medication adherence and knowledge**

Answer 6

* Classical program used prior to revascularization * Patients now with smaller initial MI * Shorter recovery * Re-vascularized at presentation * Available to all post MI patients, only offered to about 10-20% of patients * Limitations of access and referral

Answer 7

* Use patient oriented guidelines * **RPE =** **rating of perceived exertion** is a great method for patients to self monitor * **Heart rate targets** also great * Easier now with wearable technologies * Can track activity levels as well.

Answer 8

* Intensity in general terms * 85% Max HR is a target in normal individuals * 60% Max HR is a target in diseased individuals * Karvonen’s Technique of target heart rate * Duration: 20-30 minutes of aerobic exercise * Frequency: 3 to 5 times/week * Specificity: Should be task specific

Answer 9

* Most insurance carriers and Medicaid follow Medicare Guidelines • * Only available for the following: * Post MI * Post CABG, Post Valvuloplasty * Stable Angina * Post transplant * CHF (started 1/2015) * Not for Arrhythmias, other diagnoses

Answer 10

* Modified Cardiac Rehabilitation Programs * Spread over more than 12 weeks – up to 6 months for 366 sessions * Intensive Cardiac Rehabilitation * Double the sessions in 12 weeks – 72 sessions * Big focus on lifestyle modification * At home cardiac rehabilitation * One benefit from COVID-19 emergency changes in care delivery * Has payment guaranteed through 12/31/2023 * Same rates as in person CR

Answer 11

* Medical supervision * Trained staff - Physiologists/nurses/PT’s * Mixed strength/endurance/flexibility training * Education components must be present * Nutritional counseling * Smoking cessation * Support groups * Maintenance support

Answer 12

* *If* exercise was a medication, it would be the highest selling pharmaceutical of all time * *However*, since exercise is work, it is grossly underutilized for almost every condition for which it would be appropriate

Answer 13

* **Angina Pectoris** * Begin once medical management optional * Includes training and maintenance phases * **Cardiac arrhythmias** * Use limits set by ETT * Proceed normally in patients with AICD * Avoid AICD firing rate with stress testing and exercise program

Answer 14

* **Immediate post op period** * **Mobilize starting POD #1** * **Progressive mobilization POD 2-5** * **Discharge planning and exercise prescription** * Symptom limited ETT 3 to 4 weeks post surgery * Phase 2 when healing complete * Maintenance Phase 3 * Three types of programs * Low, moderate, high intensity

Answer 15

* Patients with ejection fraction \< 30% * Multiple medical problems * High risk of sudden death * Deconditioned * Depressed * Low endurance * Fatigue * Altered physiology * Lack of normal response to exercise * Possible decrease in ejection fraction, stroke volume, and blood pressure * Cardiac output may not increase sufficiently to generate a dynamic exercise response * Can have prolonged fatigue post exertion

Answer 16

* Increased oxygen extraction * Lower heart rate at submaximal exercise * Increased maximum workload * Can improve functional level

Answer 17

* Prolonged warm ups and cool downs * Dynamic exercise preferred over isometrics * Target heart rate 10 bpm below any significant endpoint * Start and advance under close supervision * Continuous telemetry for severe left ventricular dysfunction

Answer 18

* Graded exercise tolerance test for all patients before starting exercise program * Rule out arrhythmias, angina, or atypical exercise response * Contraindications to rehabilitation * **Unstable angina** * **Decompensated CHF** * **Unstable arrhythmias**

Answer 19

* Treat patients with congestive failure as those patients in cardiomyopathy * In presence of anticoagulation use low impact exercises * After valve replacement surgery * Program is similar to post CABG patient * Training can increase work capacity by up to 60%, rate pressure product by up to 15%

Answer 20

* High correlation of CAD with PVD * PVD affects up to 5% age \< 50 years * PVD affects over 20% age \>70 years * PVD common in patients undergoing bypass surgery

Answer 21

* Smoking is the major risk factor * Hypertriglyceridemia * Diabetes Mellitus * Elevated cholesterol * Overlap with CAD risk factors

Answer 22

* Historically **community** ambulation recommended * More recently supervised exercise on **treadmills** or with other lower extremity exercises * Most recent work has been done with constant load treadmill protocols

Answer 23

**Supervised** **treadmill** **training most effective** * Protocol devised by WR Hiatt, et al * Three sessions per week * 5 minute warm up and 5 minute cool down * Exercise at a level that creates **claudication pain in 3 to 5 minutes** (as found from exercise test) * Gradual increase to \>10 minutes over time * Increase speed and grade gradually to target of 3 miles per hour, 50 minute training session * Guidelines published by the American College of Sports Medicine * 20-30 minutes of interval exercise * Increase to 40-60 minutes over 4 to 6 weeks * Maximum heart rate as determined by exercise testing * Airdyne arm-leg ergometry, arm ergometry, water aerobic exercises are alternative exercises

Answer 24

* Studies demonstrate * Averag**e increase in pain free walking distance** of 134% , range from 44-290% * Average increase in peak **walking time** of 96%, range from 25-183% * Graded treadmill exercises show **increases in maximum oxygen consumption and maximum exercise performance**

Answer 25

* Standard treadmill and bicycle stress testing not possible if claudication limiting * Upper extremity ergometry possible * Risk stratification can be done with pharmacologic stress testing * Cardiac catheterization in patients at high risk or with positive stress test

Answer 26

* Improvement not clearly understood * Multiple theories exist * Increased blood flow * Altered blood viscosity * Improved muscle oxidative metabolism * Improved fatty acid metabolism * Improved gait efficiency

Answer 27

* Patients can monitor exertion at home * Use rating of perceived exertion through the Borg scale * Can do self pulse monitoring * Ambulation exercises can be used in proficient prosthetic ambulators

Answer 28

* Cardiac rehabilitation will increase the exercise tolerance and peak oxygen consumption of patients with PVD * PVD patients will be able to ambulate better after exercise training * Cardiac stress testing can be done and has a useful role in the management of patients with PVD and amputation

Answer 29

* Poor correlation with LV EF * **Assessed with VO2max** * VO2max reduced in CHF due to: * CO response * Skeletal muscle blood flow * Skeletal muscle abnormalities: * type I fibers * oxidative capacity * capillary density * Metabolic abnormalities: * early dependence on anaerobic metabolism * excess intramuscular acidification

Answer 30

* Often chronically in a low output state * Multi-organ system compromise common * Renal involvement * Hepatic failure * Pulmonary compromise * Muscle mass loss * Severe deconditioning

Answer 31

Psychosocial Issues in the Pre-Transplant Patient * Unemployment * Substance abuse history, cigarette use * Non-compliance * Obesity/Cardiopulmonary cachexia * Relative social isolation * Criminal record * History of psychiatric disorder

Answer 32

* Attempt to improve general conditioning * Graded exercise program * Preservation and restoration of ROM * Prevention of the effects of immobility * Prevention of decubitis * Prevention of deep venous thrombosis * Improvement of self image * Maintenance of appropriate nutrition * Attention to self care * Adaptive devices * Energy conservation techniques * Mobility issues * Use of assistive devices as needed * Use of wheelchair/scooter for longer distances * LVAD Patients * General conditioning program

Answer 33

* Heart rate typically high (100 bpm) * Loss of vagal inhibition * Decreased stroke volume * Increased sensitivity to plasma catecholamines * Resting hypertension * Renal effect of cyclosporine * Effect of corticosteroids * Diastolic dysfunction * Increased myocardial stiffness * Possible myocardial ischemia from accelerated coronary artery disease * Side effect of immunosuppressive medications * Prolonged ischemic time of donor heart * Near normal resting cardiac output * Increased A-V oxygen difference

Answer 34

* Graded aerobic conditioning program * Begin as soon as possible post-operatively * Early program at low levels of intensity * Progress to an aerobic program by discharge * Post transplant exercise tolerance test * Allows estimation of aerobic capacity * Goal is aerobic exercise for 30-60 minutes/day at least three to five times per week * Consider inpatient rehabilitation * For patients with complications or concomitant disability (e.g. post operative stroke, PVD, etc.) * Severe deconditioning * Address self care needs * Taking medications * Address patient education about rejection * Difficulties due to side effects of medications

Answer 35

* Precise cardiac effect of exercise training * Cardiac parameters * Cardiovascular risk factors * Functional capacity * Incidence of cardiac events * Precise vascular effect of exercise training * Mechanisms of increased ambulation * Dosage and types of aerobic training * Continuous Aerobic Training (CAT) * High Intensity Interval Training (HIIT)

Answer 36

* Increased availability of cardiac rehabilitation * Increased referral for cardiac rehabilitation * Increased coordination of in-patient and out-patient services * Improved community education programs * Improved aftercare and compliance with stage 3 (IV) rehabilitation

Cardiac Rehabilitation Flashcards

(64 cards)