Rehabil

7/23/2019 Rehabil

http://slidepdf.com/reader/full/rehabil 1/63

Rehabilitation for Patients with

Cardiovascular Disease

Asistent universitar

Ala Soroceanu

7/23/2019 Rehabil


Background

18 ~ 65 years old healthy adults need1. Moderate-intensity activity at least 30

minutes on 5 days per wee !r

"i#orous-intensity aero$ic activity at least %0minutes on 3 days per wee

%. &esistance trainin# involvin# the ma'or

muscle #roups at least % days per wee

()ercise is also recommended *or theelderly or people with illness！

7/23/2019 Rehabil


Cardiac Rehabilitation

1. +ntroduction o* ,ardiac &eha$ilitation

%. isease-Speci*ic (**ects on hysiolo#ic &esponsesand /itness

3. Scienti*ic and hysiolo#ic &ationale *or ()ercise

herapy in atients with eart isease

2. Mor$idity Mortality and Sa*ety o* ,ardiac

&eha$ilitation

5. ()ercise rescription and ro#rammin#

7/23/2019 Rehabil


Definition

Cardiac Rehabilitation, and

secondary prevention

Cardiac rehabilitation can be defined as the effort

toward cardiovascular risk factor reduction designedto lessen the chance of a subsequent event, to slow,

and perhaps stop the progression of cardiovascular

disease process. Multifactorial and multidisciplinary

approach is imperative to meet such challenges.

Long term comprehensive cardiac care programinvolves a close follow up, risk factor modification,

patient education, and psychological guidance

7/23/2019 Rehabil


Indication of Cardiac Rehabilitation

,ardiac reha$ilitation pro#rams are indicated *or

patients recoverin# *rom recent MI, following

coronary bypass, valve surgery or coronary

angioplasty, cardiac transplantation, patients

with stable angina or patient with compensatedchronic heart failure. traditionally cardiac

reha$ilitation has $een provided to some what

lower ris patient who could e)ercise without

#ettin# into trou$le.

7/23/2019 Rehabil


Contraindication of Cardiac

Rehabilitation

cardiac reha$ilitation services are

contraindicated in patients with severe

residual angina, uncompensated heartfailure, uncontrolled arrhythmias, poor

left ventricular out flow tract, and

unstable concomitant medical problems

7/23/2019 Rehabil


Goals

&estore patients to their optimal medical physical psycolo#ical social emotional se)ual vocational

and economic status compati$le with the severity

o* their heart disease

revention o* heart disease

4 rimary： screen healthy people to identi*y and treat

ris *actors 4 Secondary： to improve heart disease ris *actors and

limit *urther mor$idity and mortality

7/23/2019 Rehabil



1. +ntroduction o* ,ardiac &eha$ilitation

%. isease-Speci*ic (**ects on

hysiolo#ic &esponses and /itness


herapy in atients with eart isease2. Mor$idity Mortality and Sa*ety o* ,ardiac

&eha$ilitation


7/23/2019 Rehabil


7/23/2019 Rehabil


Cardiovascular Response during Exercise

Heart Rate

4 Normal

Achievin# & within % standards deviationso* an a#e-predicted ma)imum value

ecreasin# & to $aseline *airly uicly

durin# recovery

7/23/2019 Rehabil



Heart Rate 4 Abnormal

,hronotropic +ncompetence /ailure to achieve 857 predicted ma)imum &

without medication e**ect9: redict ,A and associated with increased riso* Mortality;Mor$idity

A$normal & recovery

Ｗ alin#< decrease in & = 1% $pm ; 1 minuteSupine< decrease in & = %% $pm ; % minutes: redict *uture cardiac mortality

7/23/2019 Rehabil



Blood ressure

4 Normal >< ,onstant or sli#htly decrease

S>< +ncrease pro#ressively a$out 8~1%

mm#;M( with a plateau at pea e)ercise

4 Abnormal +n patients with ,A S> durin# e)ercise may

respond normally or may disproportionately

increase or inappropriately decrease

7/23/2019 Rehabil



Blood ressure

4 Abnormal

()ertional hypertension< S> ? %50 mm# or> ? 115 mm#

()ertional hypotension<

,ompare to restin# > S> decrease 10mm#≧

: ()ertional systolic hypertension;hypotension would

increase cardiac event ris

+ncrease > 10mm#≧

: !*ten a marer *or *uture hypertension

7/23/2019 Rehabil



!ardiac "utput and "#ygen upta$e

4 @ormal： ea "!%< 30~25 ml;#;min

4 ,A patient： ea "!% reduction %07≧ ue to ,ardiac !utput

,ardiac !utput B eart &ate ) Strove volume

4 eart &ate： ,hronotropic incompetence

4 Strove "olume： Ce*t ventricular dys*unction

◎Dith ()ercise rainin# : "!%E15~307

7/23/2019 Rehabil


Oxygen Consuption

1 M( Meta$olic

(uivalent9

B !)y#en consumption at

restin#B >asal meta$olic rate

At rest F0# man !%

consumptionB 3.5ml o)y#en; minute; G#

o* >D

>raddom /i#ure 32-1

&elationship $etween o)y#en

consumption and intensity o*

wor $ein# per*ormed.

7/23/2019 Rehabil



1. +ntroduction o* ,ardiac &eha$ilitation%. isease-Speci*ic (**ects on hysiolo#ic &esponses and

/itness

3. Scienti*ic and hysiolo#ic &ationale *or

()ercise herapy in atients with eart

isease

2. Mor$idity Mortality and Sa*ety o* ,ardiac &eha$ilitation


7/23/2019 Rehabil


!scheic cascade

he temporal seuence o* cellular hemodynamicelectrocardio#raphic and symptomatic

e)pressions occurrin# durin# ischemia<

+m$alance $etween Myocardial o)y#en supply and demand

:+schemic event

:A$normalities in iastolic *unction

:A$normalities in Systolic *unction

:(GH chan#es such as S-se#ment depression

:atient may or may not e)perience An#ina

7/23/2019 Rehabil


!scheic cascade

A*ter the myocardial o)y#en supply anddemand im$alance is corrected at the

cellular level the process is reversed<

An#ina resolves

:(GH chan#es

:+mprovement in Systolic *unction:@ormaliIation o* iastolic *unction

7/23/2019 Rehabil


!scheic cascade

atients with ,A studied durin# ischemia 4 emodynamic a$normalities： nearly all

4 &adionuclide evidence o* #lo$al or re#ional wall motiona$normalities： 807

4 (GH： 507

4 Symptomatic evidence o* ischemia： 307

Some patients such as M or under#one cardiactransplant e)perience S-se#ment depression withoutan#ina i.e. silent an#ina9 whereas others may e)perience

an#ina without S-se#ment depression.

>er#er J &eduto CA Johnstone ( et al. Hlo$al and

re#ional le*t ventricular response to cycle e)ercise in

coronary artery disease< assessment $yuantitative

radionuclide an#iocardio#raphy Am J Med. 1KFKL 66< 13-%1

7/23/2019 Rehabil


"yocardial Oxygen Deand

+ncrease myocardial o)y#en demand： increasin# &increasin# le*t ventricular preload and increasin#

myocardial contractility

Myocardial o)y#en consumption can $e relia$lyestimated $y

&ate –ressure roduct B & ) Systolic >

ou$le product9

he normal ma)imal e)ercise response results in a rate –

pressure product o* %5000 or hi#her

7/23/2019 Rehabil


"yocardial Oxygen #upply

/our *actors a**ect myocardial !% supply：1. ,oronary artery stenosis with endothelial dys*unction

%. Microvascular dys*unction

3. A$normalities o* the autonomic nervous system

2. A$normalities o* coa#ulation and *i$rinolytic systems

◎ (ndothelial dys*unction： arado)ical vasoconstriction iso$served in patients with ,A or chronic heart *ailure

may$e due to decreased production o* nitric o)ide

7/23/2019 Rehabil


A!%M’s TABLE 35-2. Pathophysiologic Effects of Exercise and Exercise Training

Pathophysiologic Variale Ac!te Exercise "hronic Exercise Training

Vasc!lar

Vascular stenosis !artial regression "#$$%% kcal&wk'()

Coronary collaterals

*ndothelial dysfunction +

Capillary flow

A!tono#ic ner$o!s sy#pto#s

!arasympathetic +

-ympathetic +

%e#ostatic

ibrinogen +

actor V//

!latelet aggregation +

ibrinolysis +

Viscosity +

=1000 cal per wee e)perienced the #reatest amount o* disease pro#ression

?1200 cal per wee showed improved cardiopulmonary *itness

?1500 cal per wee demonstrated the slowest rate o* disease pro#ression

?%%00 cal per wee showed re#ression o* ,A

7/23/2019 Rehabil



1. +ntroduction o* ,ardiac &eha$ilitation%. isease-Speci*ic (**ects on hysiolo#ic &esponses

and /itness



2. Mor$idity Mortality and Sa*ety o*

,ardiac &eha$ilitation


7/23/2019 Rehabil


"orbidity$ "ortality$ and #afety of Cardiac

Rehabilitation

otal cardiovascular mortality are reduced in patients *ollowin# myocardial in*arction who participate in cardiac reha$ilitation e)ercise

trainin# 4 he 1KK5 A#ency *or eath ,are olicy and &esearch A,&9

,linical ractice Huidelines *or ,ardiac &eha$ilitation

,ardiac reha$ilitation reduced all-cause mortality $y appro)imately %57 4 aylor &S >rown A ($rahim S et al. ()ercise-$ased

reha$ilitation *or patients with coronary heart disease< systematicreview and meta-analysis o* randomiIed controlled trials. Am J Med . %002L116<68% –6K%.

7/23/2019 Rehabil


Classification of Cardiac Rehabilitation

+npatient phase MinimiIe the de-conditionin# time

(ducation a$out ris *actors and li*estyle modi*ication

(arly outpatient phaseMaintenance phase

/ollow-up phase

i**erin# $ased on e)tent o* supervision andmonitorin# su$'ect independence and time *rom the

event

+mprove e)ercise per*ormance and modi*y cardiac ris

*actors

7/23/2019 Rehabil


7/23/2019 Rehabil


Phase I of CRP begins when the patient is

admitted to the hospital and ends on

discharge .The goals of exercise in this phase are

to avoid the deleterious effect of bed rest b

ma!ing a gradual transition from passive rang of

motion to active range of motion with low

intensit" short duration exercise and ambulation

hase + o* ,ardiac &eha$ilitation

7/23/2019 Rehabil


7/23/2019 Rehabil


The patient" who has completed hospitali#ation" has to undergo

through a pre discharge exercise tolerance test to determine his

functional capacit" before he can begin phase II of CRP" where

the phsician and cardiac rehabilitation staff members formulate

the level of exercise to meet an individual patient$s needs" based

on the result of exercise test. An exercise training usuall are

scheduled at a rehabilitation facilit with a constant medical

supervision including exercise electrocardiograms .In addition toexercise" counseling" and education about stress management"

smo!ing cessation" nutrition" and weight loss also incorporated

in this phase which ma last three to six months

hase ++ o* ,ardiac &eha$ilitation

7/23/2019 Rehabil


7/23/2019 Rehabil


0he main goals of phase // C1! are to improve functional

capacity, progress toward full resumption of habitual andoccupational activities and to promote positive life style

changes .*2ercise training in phase // is generally

administered three to four times per week. 3uration range

from as low as (% to (4 minutes per session, and graduallyincreasing up to 5% to 6% minutes per session as the level

of fitness improve. !rograms may offer a single mode of

training or a circuit mode of training in which the patient

spends a prescribed amount of time at one e2ercise station

before moving into the ne2t "e.g. treadmill, cycle ergo

meter ,arm ergo meter, weight.)

7/23/2019 Rehabil


Cardiovascular response to workduring training session is

monitored by number of factors,

including heart rate, blood

pressure, rhythm disturbance,

rate of perceived e2ertion andsign of e2ertional intolerance

7/23/2019 Rehabil


7fter performing another stress or cardiopulmonary

e2ercise test, !hase /// C1! "maintenance phase) is

usually initiated for individual who participated in phase/ and phase // "typically 6 to ($ weeks after

discharge) .0his phase is designed to continue for

patient8s life time, aiming for maintaing patient function,

promoting life long commitment to physical fitness andphysical health management. /n this phase, individuals

are e2pected to progress from supervision to self

regulation of their programs and the activities consist of

the type of e2ercise that the patient en9oys such as

walking bicycling or 9ogging. 1egular medical follow up

and periodic graded e2ercise test are required every 5

to 6 months or annually

7/23/2019 Rehabil


Cardiac %est

&est; ()ercise cardiac test should $e per*ormed $e*ore prescription

,ardiac estin#： &estin# (GH ,& %-echo olter e)am ,oronary an#io#raphy

,ardiac e)ercise stress test

◎,ardiac e)ercise stress test is #enerally sa*e and adverse

outcomes are in*reuent

7/23/2019 Rehabil


Cardiac Exercise #tress %est

Modality 4 readmill >icycle Arm er#ometers

4 ipyridamole Adenosine

(nd point

4 @ormal (S B 857 a#e;#ender predicted & ma)

4 Symptom-limited ma)imum (S 4 Cow-level su$ma)imal (S

HR & '()

*)+ HR ma#

ea$ M- &

7/23/2019 Rehabil


Braddo# Box 3&-' "ontraindications to exercise stress testing

Asol!te

• 7cute myocardial infarction "within $ days)•:igh'risk unstable angina•;ncontrolled cardiac arrhythmias causing symptoms of hemodynamic compromise•-ymptomatic severe aortic stenosis•;ncontrolled symptomatic congestive heart failure• 7cute pulmonary embolus or pulmonary infarction•

7cute myocarditis or pericarditis• 7cute aortic dissection(elati$e •Left main coronary artery disease•Moderate stenotic valvular heart disease•*lectrolyte abnormalities 7•-evere arterial hypertension "# $%% mm:g systolic blood pressure and<or ((%mm:g diastolic blood pressure)•0achyarrhythmias or bradyarrhythmias•:ypertrophic cardiomyopathy and other forms of left ventricular outflow tractobstruction•Mental or physical impairment leading to inability to e2ercise adequately•:igh'degree atrioventricular block

7/23/2019 Rehabil


Contraindications to Exercise

Nnsta$le an#ina

&estin# S depression ? %mm

Nncontrolled arrhythmias

,ritical aortic stenosisNncompensated con#estive heart *ailure

&estin# S> ? %00mm# or > ?110mm#

/all in S> ? 10mm# with e)erciseSymptomatic orthostatic S> drop 10-%0 mm#

7/23/2019 Rehabil


Coorbidities !pacting the #afety of Exercise

ia$etes ypo#lycemia

Anticoa#ulation ro#ressive $ruise or +@& ? 5.0

"isual and ,o#nitive+mpairment

@eed close supervision

Dound and Sin +nte#rity Sacral pressure sores reuire pressurerelie*

&heumatolo#ic @eurolo#ic!rthopedic or >alancedisorders

Darrant close attention

7/23/2019 Rehabil



1. +ntroduction o* ,ardiac &eha$ilitation%. isease-Speci*ic (**ects on hysiolo#ic &esponses

and /itness



2. Mor$idity Mortality and Sa*ety o* ,ardiac

&eha$ilitation


7/23/2019 Rehabil


Braddo# Box 3&-& Adaptations noted )ith aeroic training

*!nctional

:igher peak work rate1educed disturbance of body function*nhanced rate of recovery after e2ercise

"ardio$asc!lar and p!l#onary /ncreased stroke volume and peak C=/ncreased respiratory muscle strength, ma2imal voluntary ventilation

1educed dyspnea+!sc!los,eletal

/ncreased fle2ibility/ncreased muscle, tendon, and cartilage strength/ncreased bone density/ncreased lean muscle mass

1educed body fat percentageBioche#ical /ncreased aerobic en>yme concentration

Endocrine 1educed stress hormone release

Psychologic /mproved depression and an2iety

7/23/2019 Rehabil


Exercise Pattern – Resistance Exercise

Moderate-intensity dynamic resistance e)ercise de*ined as507 –607 o* one repetition ma)imum O1&MP9 results inimproved muscle stren#th and endurance

A small reduction o* 3 and 2 mm # *or restin# systolic

$lood pressure and diastolic $lood pressure respectively

A commonly recommended resistance-trainin# pro#raminvolves per*ormin# one set o* ei#ht to 10 re#ionale)ercises per*ormed % to 3 days per wee

+sometric e)ercises are not recommended $ecause o* a potential si#ni*icant rise in systolic and diastolic $lood pressure

7/23/2019 Rehabil


Exercise Pattern – Resistance Exercise

ime to Start &esistance ()ercise 4 ,atheteriIation with or without ,+： 3 wees later

4 &ecover *rom an uncomplicated M+： 5 wees later

4 ,A>H sur#ery or valve sur#ery involvin# a

sternotomy： avoid upper-lim$ resistance trainin#

until sternal healin# has occurred9 #enerally 6 to 1%

wees a*ter sur#ery

&C#"’ % bl '( * # f + i E i P i i

7/23/2019 Rehabil


llness ntensity "o##ents

"oronary arterydisease

&/50-150 of %(( To affect #ortality fre!encyd!ration and intensity of trainingsho!ld s!# to yield a )ee,lyenergy expendit!re 4.5,cal46),-.a

Angina ore!i$alent

&/50-150 of %(( )ithnecessary ad7!st#ent to

,eep !pper %(( li#it to no#ore than eats elo)ische#ic threshold

"onsider a prophylacticnitroglycerin 5 #in efore

anticipated exertion if sy#pto#sli#it ro!tine A8Ls or aility toexercise.

+yocardialinfarction

&/50-150 of %(( Achie$e 5-2 ,cal of energyexpendit!re thro!gh physical

acti$ity each )ee,.a

PT"A )ith or)itho!t stent

&/50-150 of %(( Achie$e 5-2 ,cal of energyexpendit!re thro!gh physicalacti$ity each )ee,.a

&C#" ’ s %able '()* #uary of +ni,ue Exercise Prescription

!ssues aong Patients with Cardiovascular Disease

&C#"’ % bl '( * # f + i E i P i i

7/23/2019 Rehabil


llness ntensity "o##ents

"AB9 or$al$es!rgery

&/50-150 of%(( (estrict !pper-ody #o$e#ent!ntil stern!# is healed :'-2),;.

%eart fail!re &/50-<0 of%((

f needed initially g!ide exerciseintensity at '0 of %(( and

ad7!st d!ration to three o!tsof #in each progressing to3-& #in.

"ardiactransplant

(PE -& (estrict !pper-ody resistanceexercises !ntil stern!# is

healed :'-2 ),;.Pace#a,er

"8i$entric!lar ("T

0 elo)acti$ationthreshold

A$oid acti$ities that stretch thear#s. After 1 ), nonallisticacti$ities #ay e res!#ed andallistic acti$ities #ay e

res!#ed after 2 ),.

&C#" ’ s %able '()* #uary of +ni,ue Exercise Prescription

!ssues aong Patients with Cardiovascular Disease

7/23/2019 Rehabil


Coronary &rtery Disease

+ntensity： 20;507-857 o* &&

o a**ect mortality *reuency duration and

intensity o* trainin# should sum to yield a weely

ener#y e)penditure： 1500 cal; wee

otal ener#y e)penditure is more important than

duration or type o* activity

7/23/2019 Rehabil


Braddo Box '*)- Risk .actors for Coronary

&rtery Disease

+odifiale • !hysical inactivity• :ypertension• -moking• 3yslipidemia• =verweight or obesity• 3iabetes• Metabolic syndrome=on-#odifiale • /ncreasing age

• ?ender@ male # female• !rior history@ cardiac, peripheral vascular, or cerebrovascular

disease• amily history@ genetics• Cultural or socioeconomic

&C#"’ % bl '( ' # f Eff f C di i

7/23/2019 Rehabil


&C#" ’ s %able '()' #uary of Effects of Cardiorespiratory

Exercise %raining on #elected Cardiovascular Risk .actors

(is, *actor Effect

>#o,ing By itself? little or no effect

Exercise sho!ld e part of a co#prehensi$e s#o,ingcessation progra#

Lipidanor#alities

"holesterol Little or no effect

L8L cholesterol Little or no effect

%8L cholesterol +ild to #oderate increase

%ypertension (ed!ces incidence :especially a#ong )hite #en;

>ystolic (ed!ced? a$erage ' ## %g

8iastolic (ed!ced? a$erage 5 ## %g

@esity Exercise alone? #ild effect

Exercise sho!ld e part of a co#prehensi$e )eight-#anage#ent progra#

7/23/2019 Rehabil


&ngina

()ercise li*estyle $ehavior chan#es and medical compliance

20;507-857 o* &&

atients with evidence o* e)ercise-induced ischemia i.e.

an#ina (,H chan#es9 the upper & *or e)ercise trainin#should $e set 10 or more $eats $elow the & or &

Hoal *or patients with an#ina

4 o per*orm routine daily activities at a lower & thusreducin# the amount o* an#ina; *ati#ue they e)perience

4 o increase the amount o* wor home activity ore)ercise they can per*orm at a #iven &

7/23/2019 Rehabil


&ngina

atients need to reco#niIe and understand their

symptoms *irst

atients re#ularly e)perience an#ina at relatively

low worloads e.#. % M(s9 to tae onesu$lin#ual nitro#lycerin a$out 15 minutes $e*ore startin# their warm-up.

:()ercise in a pain-*ree manner and at sli#htly hi#herworloads

A lon#er warm-up Q10 min9 to minimiIe or avoidischemia

7/23/2019 Rehabil


"yocardial !nfarction

Start at the lower end o* their trainin# intensity207 –607 o* & reserve method9

hree nonconsecutive days o* cardiacreha$ilitation per wee with each e)ercise session

consistin# o* a 5- to 10-minute warm-up and cool-down period

ro#ressively increase e)ercise intensity andduration up to 857 o* & reserve method and %0to 60 minutes

(ncoura#ed to adopt an active li*e style includin#e)ercise and daily activities so that they e)pend?1500 cal each wee

7/23/2019 Rehabil


Revasculari/ation 0Coronary &rtery Bypass Graft

and Percutaneous Coronary !ntervention1

Si#ns o* ischemia durin# e)ercise are o*teneliminated a*ter revasculariIation

atients under#oin# ,+ 4 &ecommendations *or e)ercise pro#rammin# *or

patients a*ter ,+ are #enerally the same as *or other patients with ,A

4 >ecause patients under#oin# ,+ *reuently do not

e)perience myocardial dama#e or e)tensive sur#erythey can sometimes $e#in cardiac reha$ilitation returnto wor and resume ACs much sooner

4 ,ardiac reha$ilitation can $e#in within 28 hours a*ter,+

7/23/2019 Rehabil


Revasculari/ation 0Coronary &rtery Bypass Graft and

Percutaneous Coronary !ntervention1

atients under#oin# ,A>H sur#ery 4 >e#in reha$ilitation as early as % wees a*ter sur#ery

with the initial *ocus on aero$ic-type e)ercises

4 All upper-$ody e)ercise should $e limited to &!M and

li#ht repetitive activities until 2 to 8 wees a*ter sur#ery 4 /ollowin# the initial wound healin# patients should $e

a$le to e)ercise up to 857 o* & reserve method 3 to

2 days per wee *or %0 to 60 minutes

4 A*ter the sternum is healed at 6 to 1% wees patientscan then $e#in a resistance-trainin# pro#ram similar to

other patients with cardiovascular disease

7/23/2019 Rehabil


2alve Dysfunction3Repair3Replaceent

eart valve a$normalities: +ncrease the wor the heart due to reducin# e**ective

cardiac output

: Myocardial hypertrophy

: Mild diastolic dys*unction or a decrease in ventriculardistensi$ility

()ercise will not improve or chan#e the *unction o* thevalves $ut it will help to improve the e**iciency o* o)y#en

e)traction $y the seletal muscles and improve the worcapacity o* the individual

7/23/2019 Rehabil


2alve Dysfunction3Repair3Replaceent

he ma'ority o* valve a$normalities can $ecorrected with sur#ical procedures.

atients *ollow the same #uidelines as ,A>H patients *ollowin# sur#ery

atients on war*arin *or mechanical valves oratrial *i$rillation should avoid contact sports

7/23/2019 Rehabil


4eart .ailure

()ercise intolerance：

ea e)ercise capacityreduced 307 to 207 in patients with heart *ailure

Several mechanisms to e)plain the e)ercise

intolerance： 4 A reduction in pea cardiac output ~2079

4 ,hronotropic incompetence

4 &educed stroe volume

4 he a$ility to increase $lood *low to the more meta$olically active

seletal muscles durin# e)ercise is attenuated 4 A$normalities in the seletal muscle such as a reduction in

myosin heavy chain + iso*orms reduced activity o* the enIymesassociated aero$ic meta$olism and a reduction in *i$er siIe

7/23/2019 Rehabil


4eart .ailure

Moderate e)ercise is #enerally sa*e and results inimprovements in many aspects

()ercise trainin# increases e'ection *raction anddecreases C" end-diastolic volume

atients with decompensated heart *ailure should not $e involved in an e)ercise pro#ram

More opportunity *or rest then pro#ressivelyincrease to 30 minutes or more.

he upper end o* e)ercise intensity at 607 o* &reserve method $ased on patientRs condition

(,H monitorin# or not

7/23/2019 Rehabil


Cardiac %ransplant

,ardiac transplant recipients continue toe)perience e)ercise intolerance a*ter

transplantation

his e)ercise intolerance is $elieved to $e

primarily attri$uta$le to the a$sence o* e**erent

sympathetic innervation o* the myocardium

a**ectin# heart rate and contractility responses

residual seletal muscle a$normalities developed $e*ore transplantation $ecause o* heart *ailure and

decreased seletal muscle stren#th

7/23/2019 Rehabil


Cardiac %ransplant

A*ter transplantation many di**erences：

4 (levated restin# & o*ten ?K0 $pm9 4 (levated systolic and diastolic >s at rest ★

4 Attenuated increase in & durin# su$ma)imal wor

4 Cower pea & and pea stroe volume

4 Hreater increase in plasma norepinephrine durin#e)ercise 4 elayed slowin# o* & in recovery ☆

★ (levated systolic and diastolic >s at rest partly attri$uta$le to

increased plasma norepinephrine and the immunosuppressivemedications i.e. cyclosporine and prednisone9

☆ elayed & in recovery is thou#ht to $e attri$uta$le to increasedlevels o* plasma norepinephrine e)ertin# its positive chronotropice**ect in the a$sence o* va#al e**erent innervation

7/23/2019 Rehabil


Cardiac %ransplant

+n the *irst year a*ter sur#ery it is $est to simply disre#ard all&-$ased methods $ecause o* the a$normal & control in these

patients

,ardiac transplant patients under#o e)ercise trainin#： 4 ()ercise capacity increases $y a$out 157 to 207

4 &estin# & is unchan#ed or decreases sli#htly

4 ea & increases

4 Cittle chan#e in pea stroe volume or cardiac dimensions

4 uality o* li*e is *avora$ly altered

A pro#ressive resistance trainin# pro#ram started 6 to 1% weesa*ter transplant sur#ery and per*ormed twice per wee

/e0isa -able 123( Borg %cales for Rating erceived #ertion

7/23/2019 Rehabil


5-Grade scale 0-Grade Scale

6 No exertion at all 0 Nothing

7 Extremely light

0!5

"ery# $ery light %&'st

noticea(le)

* "ery light

0

"ery light

+ight

,

, +ight %ea.)

/ Somehat hard

/ 1oderate

5 2ard %hea$y)

6

5 2ea$y %strong)

7 "ery hard 6

7 "ery hea$y

* Extremely hard

,0 1aximal exertion *

7/23/2019 Rehabil


Paceakers$ !plantable Cardiac Defibrillators$

and &rrhythias

+n #eneral the e)ercise trainin# prescription is unaltered*or patients with these devices.

()ercise intensity in patients with an +, should $e set at

least 10 $eats $elow the pro#rammed *irin# threshold

Avoid activities that stretch the arms. A*ter 8 w

non$allistic activities may $e resumed and $allistic

activities may $e resumed a*ter 1% w.

7/23/2019 Rehabil


#uary

he inclusion o* e)ercise in the treatment o*these patients is $ene*icial $ecause o* its*avora$le e**ects on ris *actors symptoms*unctional capacity physiolo#y and ualityo* li*e.

All patients with cardiovascular disease

should $e encoura#ed to participate ine)ercise $ecause o* its real or liely positiveimpact on mortality and mor$idity.

7/23/2019 Rehabil


Than!s for our attention！

Documents

Rehabil