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Cardiac Rehabilitation after Myocardial Infarction


Aashish S Contractor*

Abstract
cardiac rehabilitation / secondary prevention programs are recognized as integral to the comprehensive care of
patients with coronary heart disease (cHd), and as such are recommended as useful and effective (class I) by
the American Heart Association and the American college of cardiology in the treatment of patients with cHd.
The term cardiac rehabilitation refers to coordinated, multifaceted interventions designed to optimize a cardiac
patients physical, psychological, and social functioning, in addition to stabilizing, slowing, or even reversing the
progression of the underlying atherosclerotic processes, thereby reducing morbidity and mortality.
cardiac rehabilitation, aims at returning the patient back to normal functioning in a safe and effective manner
and to enhance the psychosocial and vocational state of the patient.
The program involves education, exercise, risk factor modification and counselling.
A meta-analysis based on a review of 48 randomized trials that compared outcomes of exercise-based rehabilitation
with usual medical care, showed a reduction of 20% in total mortality and 26% in cardiac mortality rates, with exercise-
based rehabilitation compared with usual medical care.
risk stratification helps identify patients who are at increased risk for exercise-related cardiovascular events
and who may require more intensive cardiac monitoring in addition to the medical supervision provided for
all cardiac rehabilitation program participants. during exercise, the patients EcG is continuously monitored
through telemetry, which serves to optimize the exercise prescription and enhance safety. The safety of cardiac
rehabilitation exercise programs is well established, and the occurrence of major cardiovascular events during
supervised exercise is extremely low.
As hospital stays decrease, cardiac rehabilitation is assuming an increasingly important role in secondary prevention.
In contrast with its growing importance internationally, there are very few cardiac rehabilitation centers in India at the
present moment.

oronary heart disease (cHd) is a major cause of mortality What is Cardiac Rehabilitation?
c and morbidity in India. The reported prevalence of cHd in
Indian adults has risen 4-fold over the last 40 years (to a present The term cardiac rehabilitation refers to coordinated,
level of around 10%), and even in rural areas the prevalence multifaceted interventions designed to optimize a cardiac
has doubled over the past 30 years (to a present level of around patients physical, psychological, and social functioning,
4%).1 Within the spectrum of cHd, myocardial infarction (MI) in addition to stabilizing, slowing, or even reversing the
is the leading cause of death. For those who survive an MI, the progression of the underlying atherosclerotic processes, thereby
prevention of subsequent coronary events and the maintenance reducing morbidity and mortality.4,5
of physical functioning are the major challenges.2 Secondary In essence, cardiac rehabilitation services are comprehensive
prevention is an essential part of the contemporary care of the programs involving education, exercise, risk factor modification
patient with cHd. cardiac rehabilitation/secondary prevention and counselling, designed to limit the physiological and
programs are recognized as integral to the comprehensive care psychological effects of heart disease, reduce the risk of death
of patients with cHd and as such are recommended as useful or recurrence of the cardiac event, and enhance the psychosocial
and effective (Class I) by the American Heart Association and and vocational state of patients.6
the American college of cardiology in the treatment of patients Inpatient Cardiac Rehabilitation after MI
with cHd.3 After an MI, the goal is to mobilize the patient as soon as
he is clinically stable. A patient is considered stable if there is
Table 1: Patient Mobilization Guidelines for Inpatient no new or recurrent chest pain in the past eight hours; creatine
cardiac rehabilitation kinase and/ or troponin levels are not rising; no new signs of
uncompensated heart failure and no new significant, abnormal
Frequency: Early mobilization: 2 to 4 times per day. rhythm or EcG changes in the past eight hours.
Exercise intensity: Once the patient is stable, he should be made to sit at the edge
Post-MI: Maintain heart rate (Hr) less than 120 beats/min or Hr at
of the bed during the first day, and then gradually mobilized
rest + 20 beats/min throughout the hospital stay. during mobilization the goal
should be to keep the heart rate below120 beats/min, or if the
rate of perceived exertion (rPE) < 13 on a 6-20 borg scale patient has a high resting heart rate, then the goal should be to
Exercise Type: Walking keep the heart rate within 20 beats above resting heart rate. The
patient should be made to walk within the room at first, and
Duration: Intermittent bouts lasting 2 to 5 minutes
then in the corridors for about 2-5 minutes, three to four times
a day. Progression of activity depends on the initial assessment
Head of department: Preventive cardiology & cardiac rehabilitation,
*
as well as the daily assessment of the patient and may vary
Asian Heart Institute, bandra-Kurla complex, bandra (E), from a rapid increase in activity tolerance in the low-risk
Mumbai-400051
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Table 2: Comprehensive Risk Reduction Guidelines for Patients with CHD. (Adapted from Ref 18,19)
Lipid management
Evaluation: Obtain fasting measures of total cholesterol, HDL, LDL, and triglycerides.
Repeat lipid profiles at 4-6 weeks after hospitalization and at 2 months after initiation of, or change in lipid-
lowering medications
Goal: Primary goal: LDL < 100 mg/dl; further reduction of LDL < 70 mg/dl is reasonable
Secondary goals: HDL > 40 mg/dl, total cholesterol < 200 mg/dl, triglycerides < 150 mg/dl
Intervention: In patients with LDL > 100 mg/dl, provide nutritional counselling and weight management; consider adding drug
therapy. Statins are the drug of choice, unless contraindicated.
In patients with HDL < 40 mg/dl, emphasize exercise, smoking cessation, and consider targeted drug therapy.
Hypertension management
Evaluation: Measurement of resting BP on two or more visits.
Assess current treatment and compliance.
Goal: Optimal BP is < 120/80 mmHg
Intervention: For patients with systolic BP >130 mmHg or diastolic bP > 85 mmHg initiate lifestyle modification (including
exercise, weight management, moderate sodium restriction, alcohol moderation and smoking cessation). Add drug
therapy for patients with diabetes, heart failure, or renal failure.
For patients with systolic BP > 140 mmHg or diastolic bP> 90 mmHg initiate lifestyle modification and drug
therapy.
diabetes management:
Evaluation: Obtain fasting plasma glucose measurements in all patients and HbA1c in diabetic patients to monitor therapy.
Goal: Near normal fasting plasma glucose(< 100 mg/dl)and near normal HbA1C (<7)
Intervention: Appropriate hypoglycemic therapy (including weight control, exercise, and if needed oral hypoglycemic agents
and/or insulin).
Monitor glucose levels before and / or after exercise sessions. Instruct patient regarding identification and
treatment of post exercise hypoglycaemia. Exercise with caution if blood glucose > 300 mg/dl (evaluate for urine
ketones as well), after consulting with a physician.
Smoking / Tobacco:
Evaluation Document smoking and / or tobacco consumption habits in detail, including amount and duration.
Assess the readiness to change on the part of the patient.
Goal: Complete cessation.
Intervention: Provide individual education and counselling. Encourage patient to quit at each and every visit.
Provide nicotine replacement and pharmacological therapy as appropriate.
Weight management
Evaluation: Measure weight, height, and waist circumference. Calculate body mass index (BMI).
Goal: BMI 21-25 kg/m2, waist < 35 inches in men and < 31 inches in women.
Intervention: For patients who do not meet the goal criteria, advice a reduction in total caloric intake, and increase in energy
expenditure through a combined program of diet, and exercise.
The initial goal of weight loss therapy should be to reduce body weight by approximately 10% from baseline. With
success, further weight loss can be attempted , if indicated.
Psychosocial management
Evaluation Identify patients with clinically significant depression, anxiety, anger, and substance abuse.
Goal: To minimize the patients psychosocial distress.
Intervention: Stress management and individual or group education to help the patient adjust to his/her disease.
When needed, refer the patient to appropriate mental health specialists for further treatment.

patient (uncomplicated MI or a patient without left ventricular concern about the safety of unsupervised exercise after discharge
dysfunction) to a slower progression in higher risk or more led to the development of highly structured rehabilitation
debilitated patients, such as those with heart failure.7 programs that were supervised by physicians and included
The goals of inpatient rehabilitation are to assist the patient in electrocardiographic monitoring. The focus of these programs
becoming ambulatory; to prepare the patient and family to cope was almost exclusively on exercise.8 A meta-analysis based on
with the psychological and emotional stress that accompanies a a review of 48 randomized trials that compared outcomes of
coronary event; and to educate the patient about coronary risk exercise-based rehabilitation with usual medical care, showed a
factor modification. The guidelines for patient mobilization for reduction of 20% in total mortality and 26% in cardiac mortality
inpatient cardiac rehabilitation are enlisted in Table 1. rates, with exercise-based rehabilitation compared with usual
medical care. 5 Over time, cardiac rehabilitation programs
Outpatient Cardiac Rehabilitation
have evolved, to comprehensive cardiovascular risk reduction
The outpatient program can be begun once the patient has left programs, with exercise being an integral component of the
hospital and has clearance from his/her physician. depending program, but not the only component.
on the patients clinical condition, and the severity of the MI, the
Since, hospital stays for MI has dramatically decreased over
outpatient program, is typically begun two to four weeks after
time, thereby reducing the opportunity for in-hospital risk factor
the event. Cardiac rehabilitation programs were first developed
interventions, outpatient cardiac rehabilitation programs have
in the 1960s, once the benefits of ambulation during prolonged
gradually broadened their scope to become an important avenue
hospitalization for coronary events had been recognized.
for secondary prevention.2
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Table 3: Contraindications for Exercise in Outpatient Table 5: Comparison of Effects of Aerobic Endurance
Cardiac Rehabilitation. ( From Ref 10) Training with Strength Training on Health and Fitness
Variables. (From Ref 11)
1. Unstable angina
2. Resting systolic BP (SBP) > 200 mm Hg or resting Diastolic BP Aerobic Resistance
Variable
(DBP) > 110 mm Hg that should be evaluated on a case-by-case Exercise Exercise
basis. Indicates values increase; , values decrease; 0, values remain
unchanged; 1 arrow, small effect; 2 arrows, moderate effect; 3 arrows,
3. Orthostatic BP drop of >20 mm Hg with symptoms. large effect; HDL, high-density lipoprotein cholesterol; and LDL, low-
4. Critical aortic stenosis (i.e., peak SBP gradient of > 50 mm Hg density lipoprotein cholesterol.
with an aortic valve orifice area of <0.75 cm2 in an average-size Body composition
adult. bone mineral density
5. Acute systemic illness or fever Percent body fat
Lean body mass 0
6. Uncontrolled atrial or ventricular dysrhythmias
Muscle strength 0
7. Uncontrolled sinus tachycardia (> 120 beats per min). Glucose metabolism
8. Uncompensated cHF. Insulin response to glucose challenge
basal insulin levels
9. Third-degree atrioventricular (AV) block wihout pacemaker.
Insulin sensitivity
10. Active pericaditis or myocarditis. Plasma lipids and lipoproteins
11. recent embolism HdL cholesterol 0 0
12. Thrombophlebitis LdL cholesterol 0 0
Triglycerides 0
13. Resting ST-segment depression or elevation (> 2mm).
Cardiovascular dynamics
14. Uncontrolled diabetes mellitus. resting heart rate 0
15. Severe orthopedic conditions that would prohibit exercise. Stroke volume, resting and maximal 0
cardiac output, rest 0 0
16. Other metabolic conditions, such as acute thyroiditis,
hypokalemia, hyperkalemia or hypovolemia cardiac output, maximal 0
SbP at rest 0 0
Table 4: Summary of Aerobic Exercise and Resistance dbP at rest 0 0
Training Recommendations for Patients with CHD
VO 2max 0
Frequency: Submaximal and maximal endurance time
Aerobic: Structured exercise 3-5 days per week (lifestyle physical Submaximal exercise rate-pressure product
activity daily) basal metabolic rate 0
resistance: 2-3 days per week Health-related quality of life 0 0

Intensity: Components of Cardiac Rehabilitation


Aerobic: 60-85% of Hrmax (Predicted Hrmax = 220 age of person). A comprehensive cardiac rehabilitation program should aim
resistance: Moderate (avoid breath holding and excessive straining) to identify each patients risk factors, establish risk reduction
goals and then help the patient achieve these goals through
Time (duration): lifestyle modification, supervised exercise, and medications.
Aerobic: 20- 60 minutes Table 2 lists the major risk factors, their evaluation, goal values,
and suggested intervention. For maximum efficacy the program
Resistance: 10-15 repetitions; 3 sets of 8-10 different exercises for both
staff should coordinate their efforts with the patients personal
upper and lower body
physician.
Type of exercise:
Physical Activity / Exercise
Aerobic: Walking, running, cycling, swimming, etc. Physical activity can be defined as bodily movement
resistance: Hand weights, elastic bands, machine weights. produced by skeletal muscle that requires energy expenditure
and promotes health benefits. Exercise can be defined as
Special Considerations:
planned, structured, and repetitive bodily movement done
Monitor for abnormal signs and symptoms, i.e., chest pain or to improve or maintain one or more components of physical
pressure, dizziness, and dysrhythmias. fitness.9 Over the years research has shown that an increase
High-intensity exercise may precipitate cardiovascular complications in leisure time physical activity, as well as structured exercise
in post-MI patients. training, play an important role in reducing cHd mortality.
Patients with stable angina should always carry nitroglycerin and be Exercise Prescription
educated in its use. A comprehensive exercise prescription for the cardiac patient
Heart rate guidelines may not be applicable to patients taking drugs,
includes activities performed in formal supervised programs,
which slow down the heart rate, e.g. beta-blockers. as well as everyday physical activities. The exercise program
should prescribe the appropriate mode, frequency, intensity, and
Lift weights through a full range of motion and avoiding breath- duration of exercise, which should be tailored to the individuals
holding
cardiovascular and general medical status. However, there are
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some patients for whom exercise is contraindicated, as listed Risk stratification helps identify patients who are at increased
in Table 3. risk for exercise-related cardiovascular events and who may
A summary of the exercise prescription is given in Table 4. require more intensive cardiac monitoring in addition to the
After two to four weeks of participation in a traditional aerobic medical supervision provided for all cardiac rehabilitation
exercise program, low-to-moderate risk patients should initiate program participants.4
resistance training. Prescribed and supervised resistance training Return to Work
(rT) enhances muscular strength and endurance, functional Although improvement in functional capacity and the
capacity and independence, and quality of life while reducing associated reduction in cardio-respiratory symptoms may
disability in persons with cHd. 11 enhance a cardiac patients ability to return to work, factors
both endurance and strength training can elicit substantial unrelated to physical fitness appear to have a greater influence
increases in physical fitness. Table 5 summarizes many of these on whether a patient returns to work after a cardiac event. These
benefits and attempts to weigh them according to the current include socioeconomic and worksite-related issues and previous
literature. Endurance training induces greater improvements in employment status. The educational and vocational counselling
aerobic capacity and associated cardiopulmonary and metabolic components of cardiac rehabilitation programs should further
variables and more effectively modifies cHd risk factors. improve the ability of a patient to return to work.4 Therefore, the
resistance training enhances muscular strength, endurance, and time to return to work, after an MI can vary greatly from about
muscle mass to a greater extent.11 two weeks, to upwards of six weeks.
Nutrition Counselling Patient Participation in Cardiac Rehabilitation
It is necessary to assess the dietary habits of the patient International guidelines and experts recommend the use
to obtain an estimate of total caloric intake, as well as daily of cardiac rehabilitation after MI. As hospital stays decrease,
consumption of saturated fat, cholesterol, sodium, and other cardiac rehabilitation is assuming an increasingly important
nutrients. Patients should be recommended a diet low in fat role in secondary prevention.17 In contrast with its growing
(especially saturated fat), and high in complex carbohydrates. 3 importance, there is little contemporary information on the use
As a general guideline, the diet should consist of 50-60% of cardiac rehabilitation after MI, in India and essentially no
calories from carbohydrates, up to 30% from fat (with published data on the same.
saturated fat forming 10% or less), and 10-15% from protein.
Individualized plans should be formulated, depending on the References
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