Up until the 1950’s, strict bed rest was considered to be the best medicine after a heart attack.

After discharge, moderately stressful exercise such as climbing a flight of stairs was discouraged for a year or more.

“The patient is to be guarded by day and night by a nurse and helped in any way to avoid voluntary movement or effort”Thomas Lewis 1933

Lewis suffered a myocardial infarction at the age of 45 and gave up his 70-cigarette-a-day habit, being one of the first to realise that smoking damaged the blood vessels

↓20-25% in Physical work capacity after 3 wks

↓700-800ml circulating blood volume after 7-10 days producing orthostatic hypotension

↑Blood viscosity predisposing to thromboembolic events

↓10-15% in muscle mass and strength per week

Rehabilitation starts immediately

SO WHAT DOESTHE RESEARCH SAY ??????

Research shows mortality is reduced in post cardiac event in patients who participate in cardiac rehab due to multi risk factor reduction

Controllable vs. Uncontrollable

Age > 60

Sex: male and postmenopausal women

Family history of heart disease Men<55yrs Women<65yrs

1. SMOKING

Smokers ↑ 2 - 4

Good news is that in the year after you quite smoking your risk of future problems drops by 50%. After 15 years your risk is as low as someone that never smoked.

High Blood Pressure: 140/90 or >.

Immediate: After exercise systolic may decrease for several hours.

Long term: At Rest B.P may be reduced moderately

BMI >25 waist circumference• Male > 100cm• Female > 90cm

Being overweight is bad for your health.

• Exercise can decrease and control your weight

• Decrease total fat and intra abdominal fat

Diet: unhealthy diet is going to lead to obesity

TOTAL > 5.18mmol

High Cholesterol: The higher your LDL (Bad cholesterol) > your risk for heart disease. The higher your HDL (good cholesterol) the lower your risk of Coronary Heart Disease.

12 weeks of endurance training increase HDL and decrease Triglyceride levels

Diabetes > 5.5mmol/L (fasting)Diabetes: Having diabetes puts you in the highest heart attack risk category. Prediabetic Risk of developing heart disease is high.

Physical activity can prevent and control Type 2 diabetesImprove glucose tolerance and insulin needs

Exercise will also help you manage stress Decrease in anxiety and depression. Exercise will enhance feelings of well being.

“ Persons who remain sedentary have the highest risk for all-cause and cardiovascular disease mortality”

Heart Rate Resting heart rate 10 – 15 bpm

Stroke Volume (average volume of blood ejected per heart beat) Stroke Volume

Cardiac Output Cardiac Output

USA – 2 million potential candidates for cardiac rehabilitation only 10 – 20 % participate

Although physicians consider physical training is important for comprehensive care of these patients, the referral is very scarce. Doctors are vital to any cardiac rehab program.

Medical insurance

There’s no medication that can give the same benefits without side affects

Too Young?

Prevention is better than cure

1 death per 1.5 million episodes of exercise

The overall benefits of exercise far outweighsThe small risk of exercise.

Albert et al(2000)

It is a professionally supervised program to help people recover from Heart attacks, Heart surgery and help patients reduce risk factors.

• Phase 1 (inpatient): Physiotherapist

• Phase 2 (outpatient): 1 to 2 weeks after hospital

discharge: Walking Program

• 2 to 6 weeks Physio/Biokineticist

• Phase 3 (outpatient): 6weeks up to 12 weeks

following hospital discharge. Biokineticist

• Phase 4 (outpatient): Limited supervision if no

complications after 12 weeks

Muscle wasting

Safer exercise

Supervision

Companionship

Recovery is so much faster

Cardiac support system

Formal rehabilitation

Guidance on medication, exercise, diet, stress control.

First of it’s kind in South Africa Started April 2013

Only five Blue Zones exist in the entire world where people commonly live past 100 years

Common elements:

Active lifestylesHealthy diet

Okinawa, Japan. Women live longer in Okinawa than anywhere in the world

mountains of Sardinia, Italy Nicoya Peninsula of Costa Rica Ikaria, Greece where they have 50%

lower rates of heart disease, 20% less cancer, and almost zero dementia.

Loma Linda, California

"The secret of good health is to move," says 88-year-old Hoei Tabaru, who keeps in shape spearing octopus from the sea, picking vegetables in his garden and by biking through his village on the island of Okinawa. Tabaru, who has never driven a car, hopes modern technology will not transform island life. "The world is too easy today," he says, "at least for an old man like me." Other traits the people living in the blue zones have in common include, less stress and more socializing, strong emphasis on family, a fresh natural plant based diet (eat lots of beans), very little red meat and they exercise daily. Living their lives with a sense of purpose was a big factor. It insures they look forward to getting up in the morning.

U.S. National Institute on Aging, scientists focused on these longevity

30 % is to have good genes

70% right lifestyle

Not nomadic anymore (activity has decreased)

Alcohol

Diet has changed from Bushfood to maize

Stress

FREQUENCY

INTENSITY

TYPE

TIME

PROGRESSION OF PHYSICAL ACTIVITY

According to ACSM 4 –7 days per week. IDEAL: First 2-4 weeks walking daily 4-6 weeks 2 days supervised cardiac

classes 4 days walk At 6 – 12weeks: 3 days supervised

classes (biokineticist) and 3 days walking.

When starting with resistance training a day rest between is recommended.

The American Heart association recommends a Target Heart Rate of 40 –75% of Maximal Heart Rate .

Maximum Heart Rate: 220 –Age Karvonen Method: Cardiac PatientsTHR = (220-Age) – RHR x (intensity) + RHRNb: Beta blockers subtract 10bmin

Beta-Blocker decreases Heart Rate Exercise intensity can also be prescribed

at a HR below the ischemic threshold. A pacemaker is normally set at 10% below ischemic threshold.

Radial or Carotid pulse palpitation Heart Rate Monitor

BORG SCALE (Rate of Perceived Exertion) Especially important to use in initial

rehabilitation and heart transplant patients. After 1 year 1/3 of transplant patients exhibit normal heart rate response.

RPE of 3 –5 (40 –60%) initially and 4–7 (50 –75%) after 12 weeks

A variety of exercises is recommended

to improve all components of physical activity

Cardiovascular Muscular strength and endurance Flexibility Balance and agility

According to American Heart Association 20 –60min depending on your intensity.

i.e.: the higher your intensity the lower your duration

Patients with limited capacities should exercise daily but shorter sessions eg: 10min

Progress over a 3-6 month period to a level of moderate (50% MHR) to vigorous exercise (75%MHR).

Do exercises that you enjoy. In addition to formal exercises

patients should be encouraged to gradually return to general activities

eg: household chores, yard work and shopping.

The truth is until now patients have received little councelling about this.

American Heart Association (2013) have just published guidelines.

A study last year on 1900 heart attack patients revealed the following.

→One third of women received instructions about resuming sexual activities after they left hospital

→Less than half of men got councelling →44% of these patients still hadn’t had

sex a year later.

After a cardiac event some men experience problems with or maintaining an erection

Can be emotional stress or in rare cases by medication such as beta blockers

Consult with GP Men who use medication for erectile

dysfunction must never use Nitroglycerine for angina. Its dangerous as your B.P can fall dangerously low which can lead to death

Fewer than 1% of Heart attacks come from having sex.

No evidence that having sex ↑ your risk of having another heart attack.

Like any exercise, sex is good for the heart

You can have sex as soon as you feel ready (normally 4-6 weeks) after event.

Avoid having sex immediately after a heavy meal

Don’t drink too much alcohol before having sex

Find a position that is comfortable for you

Ask your partner to take the more active role.

Consult your doctor should you get any chest pain during sex

Chest pain Abnormal shortness of breath Unusual Fatigue Dizziness Palpitations

How…- Slow walking or biking with no/light resistanceWhy…Gradually improves blood flow to heartand exercising musclesIncrease body temperatureHelps prevent injuries, muscle soreness

Initially use interval training (fartlec)

Endurance: Rowing, step ups, more cycling, walking, swimmingMuscle strength: Light weights, resistance bands, own body exercises

How…- Easy walking or biking with no resistance,

Why…Prevents muscle stiffness and sorenessReturn the heart, lungs, and muscle activity to resting levelsCool down will minimize the potential for Arrhythmic episodes

Any exercise is better than no exercise

Initially a formal program is best

Combination of endurance and strengthening to encompass all parts of the body.