CARDIAC REHABILITATION PROGRAM

Transcription

1 CARDIAC REHABILITATION PROGRAM By *~LoOKTao LoOKTao~*

2 ONCE UPON A TIME ~ 50 yrs AGO MYOCARDIAL INFARCTION ABSOLUTE BED REST 6-8 wks Was it right?

3 MYOCARDIAL HEALING DAYSAFETERMI. MICROSCOPICMORPHOLOGICFINDINGS 1-3 HOURS WAVYMYOCARDIALFIBERS 4-12 HOURS COAGGULATIONNECROSIS, LOSSSTRIATION, PMN. INFILTRATION 1-3 DAYS TOTALLOSSOFNUCLEI &STRIATION 3-7 DAYS MACROPHAGEANDMONONUCLEI INFIITRATIONBEGINS 10-21DAYS FIBROVASCULARRESPONSE 7 wks FIBROSIS

4 In the past s Post MI pt. bed rest for 4-6 wks 1940s Tinsley Harrison..? Absolute bed rest 6-8 wks. in MI pt. 1950s MI Rx w/ minimum of 6-8 wks of hospitalization Armchair regimen as Rx of acute coronary thrombosis

5 In the past 2 81 pts w/ acute coronary thrombosis received armchair treatment starting at 2 nd of hospitalization. During hospitalization of days there re 8 deaths(9.9%), but overall experience considered highly favorable, especially enhanced sense of well being Levine SA, Lown B. JAMA 1952;148; s Post MI bed rest shortened 2-3 wks. Monitoring in coronary care units document safety of ambulation Cain et al...report safety effectiveness of early ambulation program for CABG

6 In the past 3 Inpatient exercise for pts following AMI. Outpatient supervised exercise for low risk pts following AMI. 4-6 mo. from MI. 30 day mortality decreased to 15% 1970s ROM in bed. Cardiac Rehab in Canada 1980s - Sivarajan et al...made success in Pre discharge exercise stress test Home-based exercise following AMI. Exercise training of high risk pt including CHF

7 In the past s Cardiac Rehab promoted as standard of care w/ a multidisciplinary approach. CACR was established.

8 Physiology of prolong bed rest Venous blood pool in lower legs Increased capillary hydrostatic pressure Increased interstitial fluid Decreased circulatory volume Decreased venous return Increased resting heart rate

9 Circulatory response of acute gravitation stress Sudden change from supine to upright position venous return cardiac output trigger carotid sinus& aortic arch heart rate plasma renin arteriolar constriction BP.= CO x total peripheral resistance

10 *Postural hypotension *Transient cerebral insufficiency *Immobilization syndrome *Impaired circulatory homeostasis

11 What is Cardiac Rehabilitation? The enhancement & maintenance of CV health through individualized programs designed to optimize physical, psychological, social, vocational & emotional status. This process includes identification & modification in an effort to prevent disease progression & recurrence of cardiac events.

12 Risk factors of CAD Uncorrectable Correctable Controllable - Age - Male - Genetic - Smoking - Physical inactivity - Obesity - Emotion - Diabetes - Hypertension - Dyslipidemia

13 Cardiac rehabilitation program Step 1 : basic program or inpatient program Step 2 : advanced or ambulatory program Step 3 : maintenance program

14 Basic or Inpatient Cardiac rehabilitation program

15 Objective 1.To prevent the effects of bed rest 2.To assist the pts achieve self care& activity of daily living(adl) sitting ADL#2METS standing ADL#3METS 3.Pt can start low intensity exercise

16 Objective 4. To relieve pt s anxiety&mental stress 5. To start early risk factors modification&general care

17 Characters C 1. Graduated physical activity w/ progressive intensity in upright position C 2. Undersupervision *for safety* early detection of symptom& sign of cardiac insufficiency or exertional intolerance??...or it would be normal hemodynamic responses??

18 Normal hemodynamic response to dynamic & static exercise Parameter Dynamic Static Heart rate Systolic blood pressure Diastolic blood pressure

19 Cardiac insufficiency ก,,, ก ก กก กก 2. -> ก >120 / - กก >20-30 /

20 4. - กก >200/100 mmhg - กก >20 mmhg 5. EKG( ก) - Supraventricular tachycardia -ST displacement (3 mm.) - Ventricular tachycardia - Left bundle branch block - 2 nd, 3 rd degree AV-block - PVC - ก ก - PVC > 3 ก - R-on T PVC - multifocal PVC (30%)

21 C 3. Low intensity exercise training - กก >20-30 /. ก (RPE) - ก -RPE 9-12

22 Rate Perceived Exertion (RPE) Borg scale ÿ 7 8 ก ก 12 ก 13 ก ก 14 ก 15 ก

23 Assessment before entering program To assess for clinical stable as : No angina pectoris or angina like symptom within 8 hrs 2. No s/s of uncompensated heart failure 3. No contraindicated or malignant arrhythmia To detected & aware some exercise precaution : low fever, insomnia, dizziness etc.. For risk stratification

24 Risk stratification (1) Low Risk 1. Uncomplicated MI, CABG, PTCA, artherectomy 2. Functional capacity>6mets 3. No resting or exercised-induced myocardial ischemia 4. No resting or exercised-induced complex arrhythmias 5. Left ventricular ejection fraction>50%

25 Risk stratification (2) Intermediate Risk 1. Failure of comply w/ exercise intensity prescription 2. Functional capacity<6mets 3. Exercise-induced myocardial ischemia (1-2 mm ST-segment or reversible ischemic defects(ecg or nuclear cardiology) 4. LVEF31-49%

26 Risk stratification (3) High Risk 1. Survival of sudden cardiac death 2. MI complicated by CHF, cardiogenic shock, and/or complex ventricular arrhythmias 3. SBP>15 mmhg during exercise or failure to rise w/ workload 4. Severe CAD& marked exercise-induced MI (>2 mm ST-segment ) 5. Complex ventricular arrhythmias at rest or appearing or w/ exercise 6. LVEF <30%

27 Functional class ÿ Class 1 : > 7 METS Class 2 : 5-6 METS Class 3 : 3-4 METS Class 4 : 1-2 METS

28 Program format Step by step NK. Wenger promote step approach 5,7,8 steps 1METS Benefits 5 METS easily understood as graduated physical activity reliable interpersonal communication

29 What to do in each step(1) 1.Activity(self care, ADL) Bed position Sitting balance& endurance training Sitting, ADL training Standing balance& endurance training Standing ADL training ADL in room&toilet 2.Exercise(calisthenics exercise) avoid isometric exercise 1 MET 5METS 5-10 times for each exercise number

30 What to do in each step (2) 3. Walking exercise After good standing balance Benefits Simulate ADL at home Learning by doing for home daily walking program Determinants 1.fixed duration: 1,2, 5.10 mins 2.fixed distance: 15-25, 100 matres& back Twice a day Included down& upstairs training

31 What to do in each step (3) 4.Teaching(education, counseling) Brief, simple, easy& short session Example:- Heart anatomy What is CHD? What is bypass surgery? CHD risk factors Diet control Wound care Home daily walking program Discharge planning Hospital base exercise program offering

32 Inpatient rehabilitation, 5-step MI program revised 1996: Grady Memorial Hospital Step 1-2: supervised exercise Active& passive ROM all ext in bed Ankle PF & DF repeat hourly when awake Unit activity Partial self-care Self feeding Dangle legs on side of bed Bedside commode Sit in chair15 min 1-2 times/day

33 Stage 2 ( 3 METS) 2A : sit in chair or on bedside min* tid almost ADL in chair, bedside commode 2E: exercise 1-6 * 5-10 repetition bid. 2w:1) bedside standing 1-2 min& gradually standing balance training. 2) make alternated steps. 3) walk in room or around bed slowly w/ supervision 2T: easily understanding about dz eg. CAD-CABG CABG, MS-MVR MVR etc.

34 Inpatient rehabilitation, 5-step MI program revised 1996: Grady Memorial Hospital Step 5: supervised exercise Cont. Above activities Check pulse counting Walk up flight of steps Walk500 ft. Bid Cont. Home exercise instruction Inform& offer outpatient exercise program Unit activity Cont. All previous activities Pre-discharge EST (as proper)

35 Trainer rainer Who?... 1.Physician 2.Nurse 3.Physical therapist 4.Exercise physiologist

36 Minimal requirement 1. Good understanding& skill for inpatient program. 2. Early detection of sign/symptom of exertion intolerance. 3. CPR: basic life support 4. EKG interpretation especially arrhythmia.

37 Where CCU ICU Intermediate Ward Seperate room

38 How Guided instruction of CDI cardiac-rehab guideline easily done for any med persons need skill&practice

39 Benefits of inpatient cardiac rehabilitation program 1. Good QOF. 2. &prevent disability. 3. Shorten length of hospital stay. 4. Initiate, create pt s health behavior. 5. Develop good relationship b/w pt& trainer.

40 Outcome Patrawut et al1998, The result of phase1 CRP *Self care 93.2% complete ADL independent or undersupervision 6.8% partial ADL assisted *Walking ability 78% >100 m.&1flight up&downstair 10.2% >100 m. only 8.5% room to nurse station(~30 m.) 3.4% around bed(~10 m.)

41 Summary *Good program Effectiveness Simple Flexibility Valid Efficacy of trainer

42 ก ก กก ก (Home daily walking exercise)**

43 ก กก ก... ก ก กก ก ก ก ก กก ก ก 300 mg/dl ก, ก... กก ก ก กก ก ก ก ( ) กก 100 /, กก 200/100 mmhg กก ก ก ก ก ก

44 ก กก ก... ก ก,, ก ก ก ก ก กก ก ก ก กก ก 1-2 ก ก ก ก ก ก,, ก กก ก

45 ก กก ก,,, - ก ก ก ก -ก ก ก ก ก ก ก(isordil (isordil) ก ก ก ก กก ก,

46 กก ก ก ก กก ก... ก กก ก กก ก ก ก ก ก,, ก ก ก ก ก ( ) ก ก ก ก 1 ก ก ก ก กก ก

47 กก ก ก ก กก ก, ก กก ก, ก ก ก ก ก ก กก ก ก กก ก ก... - ก (warm up) - ก กก ก - ก (cool down) ก กก ก 30 ;#5

48 กก ก ก 1). ก ก ก 2). - ก 3). 4). ก 5). ก 6). ก

49 กก ก ก 1.) ก 2.) 3.) ก ก 4.) ก ก 5.) กก ก ก ก 6.) ก

50 กก ก... ก ก ก ก... กก ก isordil ก 1 ก ก 5 3 ก ก ก

51 ก กก ก กก กก ก ก ก ก ก กก ก ก ก ก ก... -, - ก - ก ก ก

52 ก ( ) ก ก ก 2 ก ก ก ( ) กก ก ก

53 ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก

54 ก ก ก ก ก ก ก ก ก 2 3 ก ก ก 3 ก ก ก

55 ก ก ก ก ก ก ก ก

56 ก ก ก ก ก ก ก ก ก ก ก ก ก

57 ÿ