Cardiac Rehabilitation:

Transcription

1 Cardiac Rehabilitation: supervised physical exercise programme in practice Adam Staron MD, PhD Prince Sultan Cardiac Center, Riyadh

2 DISCLOSURE No conflict of interest

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4 Exercise test protocols Treadmill --Bruce/ modified Bruce --Cornell --Weber --Lehman --Balke Ware --Naughton --Stanford --ramp (Kaminsky, AACVPR, ACSM) and individualised ramp Bike --10W/2- or 3 min or 25 W/2- or 3 min or 50W/2- or 3 min --ergo-ramp (10 W/min, 15W /min, 20W /min etc) or steep ramp (Meyer)

5 Protocols & MET range --Bruce Modified Bruce 4,6-7 --Balke Ware Naughton 5,4-6,4 --ramp (Kaminsky, AACVPR, ACSM) ergo-ramp 10W/min 4-8

6 Bruce protocol Grade Time(min) Vel.(km/h) Incl.(%) emet 1 3 2,7 10 4, ,0 12 7, , , , , , , , ,4

7 Naughton protocol Grade Time (min) Vel (km/h) Incl.(%) emet 1 1 1,6 0 1, ,2 0 2, ,2 3,5 3, ,2 7 4, ,2 10,5 5, ,2 14 6, ,2 17,5 7,4

8 Ramp protocols -avoid large increments in workload -uniform haemodynamic response -there is a need for activity scale to estimate predicted FC (DASI/VSAQ) -individualised protocol (ramp rate) with targeted test duration

9 Polish Ramp 5 test protocol Grade Test time (min) Vel (km/h) Incl.(%) emet 1 Start 1,5 0 1,7 2 01:00 1,5 0 1,7 3 04:00 2,2 2,5 2,5 4 07:00 2,9 5 3,6 5 10:00 3,6 7,5 5,0 6 13:00 4,3 10 6,7 7 16:00 5,0 12,5 8,7

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11 Aerobic training parameters Training parameter Training Frequency (F) Training Intensity (I) Training Time (T) Training Type (T) Training Volume (V) Training Progression (P) Description Number of sessions per day or per week METs, VO2, Wat/ TRHR, RPE Borg Duration of single training or total time per week Eg. bike, walking etc. V= F x I x T Progression rate

12 Component Frequency Intensity Time Type Recommendation AACVPR 2013: Ideally 4-7d/wk EACPR 2010: Most days/wk, at least 3,preferably 6-7d/wk AACVPR 2013: 40-80% HR max or VO2 reserve or VO2 peak RPE 11-16/ 10bpm below event HR ;<36 sessions EACPR: 50-80% of peak oxygen consumption or of peak HR 40-60% HRR/10-14 RPE AACVPR 2013: min/session EACPR 2010: At least min,preferably min; >3 session/wk, 2-16 weeks AACVPR 2013: Walking,cycling,stair climbing,eliptical trainers EACPR 2010: Walking,jogging,cycling,swimming,rowing,stair climbing, eliptical trainers and aerobic dancing

13 ACSM 2013: Component Volume Progression Recommendation >1000 Met/min/wk >2000 kcal/wk >7000 steps/day Individuallly-tailored to patient tolerance 1-5 min per session/5-10% per week

14 40-80% VO2 peak 50-85% HR max 40-70% HRR RPE

15 40-80% VO2 peak 50-85% HR max 40-70% HRR RPE

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19 Stable angina pectoris Chronic CAD (no isch.)/pci Light-moderate exercise intensity X (below isch.threshold) x Moderate-high exercise intensity X (below isch. threshold) x High-severe exercise intensity X (below isch. threshold) x Pacemaker X x ICD X x Chronic AF X x CABG X x x Valve surgery X x CHF X x x HTX x x x

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21 Guiraud et al. High-intensity interval training in cardiac rehabilitation. Sports Med Jul 1;42 (7):

22 a = 50 60% of peak VO2, 60 70% of peak heart rate, Borg scale, no shortness of breath. b = 85 90% of peak VO2, 90 95% of peak heart rate, Borg scale, shortness of breath c = 50 70% of peak heart rate. d = at least 60 70% of peak VO 2, at least 65 75% of peak heart rate Viviane M et al. Aerobic interval training and continuous training equally improve aerobic exercise capacity in patients with coronary artery disease: The SAINTEX-CAD study International Journal of Cardiology, Volume 179, 2015,

23 Mayo Clinic Experience MIIT at 60%-70% HRR/ RPE Initially 5-15 minutes Progress to minutes (+warm-up/cool-down) 2-3 supervised sessions/week (includes resistance training), 2-3 independent sessions/week HIIT when patients performs 20 minutes of MIT (second week of CR)

24 Stable angina pectoris Chronic CAD (no isch.)/pci Light-moderate exercise intensity X (below isch.threshold) x Moderate-high exercise intensity X (below isch. threshold) x High-severe exercise intensity X (below isch. threshold) Pacemaker X x ICD X (20 beats below fire rate) X (20 beats below fire rate) x Chronic AF X x CABG X x x Valve surgery X x CHF X x x HTX x x x

25 Light-moderate exercise intensity Moderate-high exercise intensity High-severe exercise intensity Stable angina pectoris X (below isch.threshold) X (below isch. threshold) X (below isch. threshold) Chronic CAD (no isch.)/pci x Pacemaker X x ICD X x Chronic AF X x CABG X x x Valve surgery X x CHF X x x HTX x x x x x

26 Light-moderate exercise intensity Moderate-high exercise intensity High-severe exercise intensity Stable angina pectoris X (below isch.threshold) X (below isch. threshold) X (below isch. threshold) Chronic CAD (no isch.)/pci x Pacemaker X x ICD X x Chronic AF X x CABG X x x Valve surgery X x CHF X x x HTX x x x x x

27 Light-moderate exercise intensity Moderate-high exercise intensity High-severe exercise intensity Stable angina pectoris X (below isch.threshold) X (below isch. threshold) X (below isch. threshold) Chronic CAD (no isch.)/pci x Pacemaker X x ICD X x Chronic AF X x CABG X x x Valve surgery X x CHF X x x HTX x x x x x

28 Peak oxygen uptake&6mwt <65 years > 65 years <10ml/kg/ min or <300m ml/kg/min or m >18 ml/kg/min or >450m CONTINUOUS RESPIRATORY RESISTANCE LIIT CONTINUOUS RESPIRATORY RESISTANCE IT (active) CONTINUOUS RESPIRATORY (in case of respiratory muscle weakness) RESISTANCE HIIT CONTINUOUS RESPIRATORY RESISTANCE LIIT (active ) CONTINUOUS RESPIRATORY RESISTANCE (active) CONTINUOUS RESPIRATORY ( in case of respiratory muscle weakness) RESISTANCE HIIT Piepoli M et al. Exercise training in heart failure: from theory to practice. A consensus document of the Heart Failure Association and the European Association for Cardiovascular Prevention and Rehabilitation. Eur J Heart Fail Apr;13(4):

29 HIIT in HF

30 -multicenter study -12 weeks of training with different intensity and duration -follow-up of 1 year -total of 209 patients with heart failure high intensity = moderate intensity

31 Light-moderate exercise intensity Moderate-high exercise intensity High-severe exercise intensity Stable angina pectoris X (below isch.threshold) X (below isch. threshold) X (below isch. threshold) Chronic CAD (no isch.)/pci x Pacemaker X x ICD X x Chronic AF X x CABG X x x Valve surgery X x CHF X x x HTX x x x x x

32 Component Frequency Recommendation 2-3 non-consecutive days/wk Intensity AACVPR 2013: to moderate fatique/ RPE % 1-RM progressing to 60-70% 1-RM ACSM 2013: Initial load 30-40% 1-RM for upper- and 50-60% 1-RM for lower-body/ RPE Time Type Volume No specific duration of training identified for effectiveness Rest intervals 2-3 min between each set of repetitions calisthenics,hand weights, pulleys, dumbbells, free weights,machine weights reps/set Progression AACVPR 2013: may be increased by 5% Repetitions>resistance>sets>time of rest

33 Flexibility (ACSM 2013) Component Frequency Intensity Time Type Volume Progression Recommendation 2-3d/wk with daily being most effective Stretch to the point of slight discomfort Holding a static stretch for sec, in older individuals holding a stretch for 30-60sec may confer greater benefit Static,dynamic, ballistic, proprioceptive 60 sec as reasonable target for total stretching for each exercise Unknown

34 Neuromotor (ACSM 2013) Component Frequency Intensity Time Type Volume Progression Recommendation >2-3d/wk An effective intensity has not been determined >20-30 min/d Balance, agility, coordination and gait exercises eg Tai ji, yoga Optimal volume is not known Methods for optimal progression are not known

35 Home based cardiac telerehabilitation

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40 Load-repetition relationship for resistance training % 1-RM Repetitions possible

41 Population Sets, repetitions Stations Frequency Cardiac patients: ACSM 2013: AHA 2007: AACVPR 2004: Initially 1 set,10-15 reps 1set,10-15 reps 1 set, reps 8-10 exercises 8-10 exercises 6-8 exercises 2-3d/wk -II- -II-

42 Diagn. AACVPR ACSM Post-CABG 1-3 lb hand weights on CR programme entry Upper-extremity moderate to heavy resistance training 3 months after CABG 1-3 lb hand weights during convalescence and recovery Flexibility and ROM at 48 hrs after CABG 50% of 1-RM at 3 months Post-MI 1-3 lb hand weights on CR programme entry 50% of 1-RM at 5 weeks if 4 weeks of endurance training have been completed 50% of 1-RM at 3 months 1-3 lb hand weights 2 weeks after MI Flexibility and ROM at 48 hrs after MI 50% of 1-RM at 4-6 weeks Pacemeker/ICD No specific guidelines Do not raise arm on affected side above shoulder for 2 weeks

43 Resistance-HF Stages Objectives Intensity Repetitions I-pre-training Learn technique <30% 1RM RPE<12 II-endurance III-strength Improve endurance Increase muscle mass 30-40% 1-RM RPE % 1-RM RPE<

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45 AACVPR/AHA JACC % VO2 EACPR Eur J H Fail %->70-80% VO2

46 in a rhythmical manner at a moderate to slow controlled speed through a full range of motion, avoiding breath holding and Valsalva by exhaling during the exertion phase and inhaling during the relaxation phase between upper- and lower-body work involve the major muscle groups of the extremities allow initially for repetitions at low level of resistance (30-40% 1-RM upper body and 50-60% 1-RM lower body) rate-pressure product check

47 EACPR: at 70-85% of HR max or at 70-85% HR at the onset of ischaemia At 50% of the HR max in high-risk patients (LV dysfunction, coronary disease severity, ageing,vco-morbidities)

48 Alternating relatively brief periods of intense aerobic exercise with periods of mild/moderate intensity aerobic exercise or passive recovery Used by athletes for many decades Elicits a greater training stimulus and results in greater improvements in VO2peakand other markers of CV health: endothelial function, LV function, and CV risk factorsthan moderate intensity training (MIT) in CVD patients

49 Begin with 2-3 intervals of seconds at RPE interspersed with 1-5 minutes of MIT HIT modes of exercise: jog or walk with incline on treadmill, increased watts on ergometer Progress to 5 intervals of 1-4 minutes at RPE during minutes of training HIT performed only during supervised sessions

50 Concern: HIT is Not Mentioned in the Guidelines ACSM Guidelines (8thedition, 2010) on exercise intensity for CVD outpatients: RPE 11-16, 40% to 80% HRR (or VO2R or %VO2peak) AACVPR Guidelines (4thedition, 2004): 50% to 80% of capacity, RPE Neither guideline addressed HIT

51 High-Intensity Aerobic Interval Training (HIIT) Versus Moderate Intensity Training (MIT) Alternating short periods of more intense training (80%+ of capacity, RPE >14) with periods of less intense training ( 60%) or rest Used by athletes to optimize VO2peak, anaerobic threshold Moderate intensity training: 40% to 70% of capacity; RPE 11-14; typically used

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53 ACSM 2013: Component Frequency Intensity Time Type Recommendation Most days/wk, at least 3,preferably most days/wk Multiple short daily sessions (1-10min) for the patients with very limited exercise capacities 40-80% of peak oxygen consumption or HRR RPE Warm-up and cool-down 5-10min (static stretching,rom,light intensity aerobic activity(<40% peak oxygen consumption,<64% HR max,<11 RPE) Conditioning phase min Walking,jogging,cycling,swimming,rowing,stair climbing, eliptical trainers and aerobic dancing

54 HIT in Early Outpatient CR at Mayo Clinic Patients begin the program within 1-2 weeks of hospital dismissal CPX for non-cardiothoracic surgery patients, 6-minute walk for patients with surgery MIT at 60%-70% HRR, RPE 12-14, starting at 5-15 minutes, progressing to minutes (+warm-up/cool-down), 2-3 supervised sessions/week (includes resistance training), 2-3 independent sessions/week HIT is introduced when patients can perform 20 minutes of MIT (second week of CR)

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56 Treadmill METs= 0.98 (cycle ergometer METs)

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58 Volume (energy expenditure)&progression METx3,5 x body weight(kg) x t(min) x 5/1000 METx body weight(kg) xt (h) kcal/wk MET-min/wk 1-5 min/session or 10-20%/week Increase time->intensity

59 How to design intensity? -RPE (11-16) -trhr --%HRR( Karvonen) % x(hr max-hr rest)+hr rest --%Hrmax (not recommended on beta-blockade) --HR below event threshold (Hr event-10) -%V02 or % V02 reserve % MET or %MET reserve (MET peak-met rest)+met rest; MET rest=1 --%PWR (peak work rate in wats) usually combination RPE/Karvonen/PWR methods

60 Continuous training parameters: Ex test individualized ramp test If ex test on treadmill PWR (wat) estimation=46,323+8,555xpeakmet F: 2-3/wk; 5/wk if in-hospital CR I: 30-70% PWR(METR)/RPE 9-14 T:3-5 min warm-up->10-40min-> 3-5 min cool-down

61 Interval training parameters: Ex test individualized ramp If Meyer steep ramp test MSEC calculation -if on treadmill PWR (wat)=46,323+8,555xpeak MET F: 2-3/wk; 5/wk if in-hospital I:55-90%PWR(METR)/50-80%MSEC Meyer passive rest wat or active rest 30-50% PWR If treadmill passive recovery 2 METs (2km/h, incl 0), active recovery %METR T:3-5 min warm-up->10-240s load/15-180s regeneration->cool down

62 Warm up 5-10 min (30-40%HRR, MET-R, <11 RPE) Conditioning phase min Cool-down 5-10 min Stretching