Cardiac rehab

1. JAMIA MILLIA ISLAMIA
CENTRE FOR PHYSIOTHERAPYAND REHABILITATION SCIENCES
SUBJECT: PHYSIOTHERAPY IN CARDIOPULMONARY
CONDITIONS(BPT402)
TOPIC: CARDIC REHABILITATION CONSIDERATION FOR PATIENTS
WITH PTCA
CLASS: BPT 4TH YEAR
PRESENTATION DATE: 21.1.2021
SUBMITTED TO: DR. JAMALALI MOIZ
SUBMITTED BY: SAMEERA FAIZVI

2. INTRODUCTION:
• Percutaneous transluminal coronary angioplasty (PTCA) also called percutaneous
coronary intervention (PCI) is a minimally invasive procedure to open blocked or
stenosed coronary arteries allowing unobstructed blood flow to the myocardium.
• The blockages occur because of atherosclerosis which affects the coronary
arteries.
• Patients with CAD usually present with exertional chest pain, or with dyspnea
with exertion.
• In acute myocardial infarction, there is plaque rupture with platelet aggregation,
and acute thrombus formation, which results in a sudden occlusion of the coronary
artery. These patients present with acute chest heaviness, diaphoresis, and nausea.
Urgent PTCA is often required to limit myocardial damage.

4. Cardiac rehabilitation
• Cardiac rehabilitation programs consist of primary prevention and secondary
prevention with cardiac rehabilitation after manifestation of cardiac disease.
• Primary prevention programs focus on the reduction of cardiac risk factors.
Increased physical activity decreases obesity, lowers SBP, and modifies lipid
profiles.
• Secondary risk-factor modification programs include all of the features of primary
prevention programs. Secondary prevention decreases second cardiac events and
lowers mortality post-MI.

6. Special Considerations for Patients Following PCI
• Potential for restenosis or coronary thrombosis at PCI sites and ongoing disease
progression.
• Patient minimization of seriousness of CHD and idea that patient has been
“cured”.
• Importance of comprehensive services for secondary prevention of CHD.

7. Practice Considerations for Patients Who Have Undergone PCI
Class I recommendation: Referral of patients following PCI to CR/SP
• Inpatient CR/SP services are very limited, Because PCI patients are discharged
within 24 h of the procedure. Thus, the use of an automatic referral strategy to
outpatient CR/SP at the time of discharge is particularly helpful
Class II recommendation: Exercise testing after discharge post-PCI
• It is used to guide activity counseling or exercise training (or both) in a CR/SP
program.
• Results of exercise testing performed 1 to 3 days following PCI may be beneficial
for the prediction of subsequent restenosis and may facilitate earlier return to work
and daily living activities.

8. Risk Stratification before Discharge in the Absence of Invasive
Intervention in Patients with Non–ST-Segment Elevation (NSTE)
Acute Coronary Syndrome (ACS)
• Circumstance: Percutaneous Coronary Intervention (PCI)
• Recommendation: “In patients entering a formal cardiac rehabilitation program
after PCI, treadmill exercise testing is reasonable.” (class II-a reasonable to
perform)
• Recommendation: “Routine periodic stress testing of asymptomatic patients after
PCI without specific clinical indications should not be performed.” (class III-no
benefit).

9. Select Evidence-Based Recommendations Regarding the Utility of
Clinical Exercise Testing among Patients with Heart Disease
• Patients without complications who have not undergone coronary angiography and
who might be potential candidates for revascularization should undergo
provocative testing before hospital discharge.
• In patients with non-infarct coronary artery disease who have undergone
successful PCI of the infarct artery and have an uncomplicated course, it is
reasonable to proceed with discharge and plans for close clinical follow-up with
stress imaging within 3 to 6 weeks.

10. Intervention Strategies for Revascularization or Valve Patients
• The goal for each patient is the prevention of reocclusion and advancing
atherosclerosis, as well as optimal exercise tolerance.
• The common problem for rehabilitation staff is to help patients understand that the
disease has not been cured by the procedure and that secondary prevention is
important for preventing subsequent clinical issues.

11. Inpatient rehabilitation
• Patients are encouraged to remain relatively rested until completion of treatment
of comorbid conditions, or post-operative complications.
• Guidelines for the inpatient CR program should focus on the following
a) Current clinical status assessment
b) Mobilization
c) Identification and provision of information regarding modifiable risk factors and
self-care.
d) Discharge planning with a home PA and activities of daily living (ADL) plan
and referral to outpatient CR.
• Activities and programs during the early recovery period will depend on the size
of the MI and the occurrence of any complications while recovering.
• These activities should include self-care; arm and leg range of motion (ROM);
postural changes; and limited, supervised ambulation.

12. • Post-PCI patients can begin exercise training as outpatients almost immediately
after hospital discharge.
• If the groin was used for catheter access, care should be taken to ensure that the
access site is healing appropriately before the patient begins lower extremity
exercise.
• Incomplete revascularization is also possible with PCI, which increases the
possibility of exercise-induced signs and symptoms of residual myocardial
ischemia.
• CR/SP staff should stress to patients who have undergone PCI the importance of
adherence to preventive medications, particularly antiplatelet agents.
• Stressing the importance of secondary prevention is especially important for PCI
patients, particularly in those without a previous MI or angina pectoris.

13. • Testing can be safely performed at 3–4 weeks after surgery. The exercise test
should determine maximal functional capacity, maximal HR, exercise blood
pressure response, exercise-induced arrhythmias, and anginal threshold.
• A complete education program to help modify risk factors and supervised and
unsupervised home programs can help with the management of risk of recurrent
heart disease.
• Cardiac rehabilitation after PCI has two stages: the immediate postoperative
period and the later maintenance stage.
• The in-hospital period usually only lasts 5–7 days. This phase has three parts:
a. Intensive mobilization starting postoperative day 1
b. Progressive ambulation and daily exercises
c. Discharge planning
d. Exercise prescription for the maintenance stage

14. • Early mobilization has several benefits, including decreasing effects of immobility
and preventing cardiac deconditioning.
• Days 2–5: It include progressive ambulation and daily exercise.
• Initial ambulation aims for assistance with distances of 150–200 feet, followed by
independent ambulation by the third day.
• In the last few days prior to discharge, the patient is given a program of self-
monitored exercise that allows for a gradual return to previous levels of activity.
• Patients should be stratified according to risk into either low-, moderate, or high-
intensity programs:
• A low-intensity program is in the area of 2–4 METs, with a target HR of 65–75%
of maximum HR. A moderate-intensity program is from 3 to 6.5 METs, with target
HR 70–80% of maximum HR. A high-intensity program is from 5 to 8.5 METs
with a target HR of 75–85% of maximum HR.

15. • A level of exercise that equals a rating of perceived exertion (RPE) of 13 on the
Borg scale is a level of training where the patient can be safely prescribed in the
outpatient setting.
• The inpatient program for high-risk patients has to be tailored to the specific needs
of the patient in cooperation with the patient’s cardiologist.

18. REFERENCE:
• Cardiac rehabilitation by Mathew N. Bartels
• Guidelines for Cardiac Rehabilitation and Secondary Prevention Programs. 5th ed.
Champaign (IL): Human Kinetics; 2013.
• https://health24/medical/heart/heart-and-exercise/recommended-exercise-
programme-for-a-healthy-heart-20160531
• https://phoenixcardiology.wordpress.com/2016/06/01/exercise-and-coronary-
artery-disease
• ACSM guidelines for exercise testing and prescription