Cardiac Exercise Prescription, Referral & Rehabilitation - Case Study Example

Cardiac Rehabilitation: Case Report, Prescription and Discussion Personal details: Peter (changed due to confidential reasons) Age: 64 years Sex: Male Occupation: Lorry driver (retired), currently unemployed Presenting Complaints: Discomfort in the central portion of the chest on and off since 1 week on exertion. History of presenting complaints: Discomfort and feeling of tightness in the central portion of the chest since 1 week. The discomfort is mainly noticed while performing certain activities like climbing stairs, walking long distances and carrying water cans. The pain typically lasts for 5 to 10 minutes and subsides with rest. The pain is non-radiating and is not associated with other symptoms like nausea, vomiting, cough, breathlessness, palpitations, syncopal attacks, expectoration, edema or fever. The patient also complains of easy fatiguibility since 15 days. Past Medical History (Non-cardiac): He has hypertension since 10 years and is on antihypertensives and aspirin. He has high blood cholesterol levels which has reduced after initiation of cholesterol lowering agents. Peter suffered from major illness at 20 years of age when more than half his lung was damaged due to pneumonia. He underwent 2 hernia operations, one for right inguinal hernia 10 years ago and a repeat surgery for the same hernia 6 years ago. His stay in the hospital during that period was uneventful. Peter does not have diabetes mellitus. There are no known allergies identified in him. Cardiac History: The patient is a known case of myocardial ischemia, diagnosed 4 years ago when he was treated with placement of stents. 17 months ago he suffered from myocardial ischemia. Currently, he is admitted for angina due to ischemic heart disease. Ischemic heart disease or IHD or coronary heart disease is a condition in which there is oxygen deprivation to the muscles of the heart as a result of decreased blood flow and perfusion and is accompanied by inadequate removal of the products of metabolism (Zevitz, 2006). This is the most common form of heart disease and a leading cause of premature death in the developed countries (Zevitz, 2006). The hallmark feature of this condition is imbalance between the supply and demand of oxygen of the myocardium which can occur either due to increased myocardial oxygen demand or decreased myocardial oxygen supply or both. Ischemia to the myocardium results from disease in the coronary arteries. The disease is most often due to formation of atheroma and its consequences like thrombosis. Of all the arteries in the body, coronary arteries are at increased risk of developing atheroma (Maseri et al, 1992). Personal history: As a lorry driver, Peter used to enjoy eating fatty food, especially take away Chinese foods. The patient has regular diet and sleep. His bowel and bladder habits are regular. The patient was a smoker and used to smoke about 60 cigarettes a day. 3 years ago, the number came down to 10 per day. He has given up smoking now for the past one month. He does not take alcohol. He is not addicted to illicit drugs. He leads an active life and walks about half an hour a day for 5-6 days a week, of which atleast 10 minutes is brisk walking. His hobbies are racing and gardening. Family history: Both his parents were diabetic and hypertensive. However, there is no family history of heart disease. Peter is married and has one daughter and five sons, who are source of some stress to him. Education: Peter did not undergo proper schooling. He studied in a technical school for 3 years. He started working as a lorry driver since the age of 15. He did not receive any education about cardiac disease. Patient mentioned that if he received any such education earlier, he would have cut down on smoking. Risk Factor Profile: Modifiable risk factors: 1. Blood pressure-Hypertension since 10 years, blood pressure on admission 138/80mmHg 2. Hypercholesterolemia 3. Smoking 4. Unhealthy diet: fatty food, take aways 5. Stress Non-modifiable risk factors: 1. Age 2. History of cardiac ischemic attack 3. Male gender There are many risk factors for the development of ischemic heart disease. Advanced age is one of the most important risk factors. As age advances, the number and size of the plaque increases and thus increases the risk of coronary artery event. Men are at increased risk of development of IHD than women (Zevitz, 2006). However, the risk is same after menopausal age in women. Family history of coronary artery disease increases the risk of ischemic heart ailment. This is either due to genetic factors or due to similar diet, eating habits, lifestyle and smoking. Research has shown that 40% of risk of developing IHD can be attributable to genetic factors and 60% to environmental factors. Also, it is important to note that other risk factors like hyperlipidemia, hypercholesterolemia and hyperfibrinogenemia are also influenced by genetic factors (Zevitz, 2006). The most avoidable cause of IHD is smoking. Hypertension, both systolic and diastolic, increase the risk of IHD. Hypercholesterolemia contributes to premature coronary artery disease. Diabetes mellitus allows diffusion of existing coronary atheroma and thus increases the risk of IHD. Diabetes is frequently associated with obesity and physical activity, both of which are again risk factors for IHD. Obesity, by itself, is an independent risk factor for IHD. Heavy consumption of alcohol is associated with hypertension and increases the risk of cardiac events. Deficiency of polysaturated fatty acids or PUFA in the diet is associated with increased incidence of IHD. Low levels of antioxidants like vitamin C and vitamin E are independent risk factors for coronary artery disease (Zevitz, 2006). Physical Activity History: Peter is an active person. After recovery from his first cardiac episode, he performed exercises and walking regularly. He walks at least 30 minutes for 5-6 days a weeks, during which time, 10 minutes s brisk walking. He loves gardening and spends some time regularly in the morning in the garden watering plants, cleaning, trimming plants, etc. He avoids using vehicles for very short distance travel and prefers to walk. Even inside the house, he performs house hold work. He has been prescribed some moderate aerobic exercises by the physiotherapist and he follows the prescription. He recognizes the need to exercise regularly and remain active. Regular exercise in the form of brisk walking or cycling or swimming for atleast 20 minutes for 2-3 times in a week increases HDL cholesterol, lowers blood pressure, decreases blood clotting and promotes collateral vessel formation and thus reduces the risk of IHD (Zevitz, 2006). Hence lack of physical activity is considered as one of the risk factors for IHD. Patients expectations: 1. Goals of the patient: a) To prevent another episode of angina or cardiac event. b) To be able to remain as mobile and as active as possible. c) To prevent or postpone development of onset of diabetes. d) To keep blood pressures within normal limits. e) To keep cholesterol and triglyceride levels within normal limits. f) To lead a normal life g) To enjoy his family life h) To cut down on bad habits like eating fatty foods and smoking. 2. Motivation: Patient is self-motivated to exercise regularly and perform various physical activities. Infact, he considers exercise, walking and other forms of physical activity as past times. He feels that because he did not receive proper education about cardiac prevention earlier, he could not take proper measures and hence developed ischemic heart disease. Now he intends to prevent further cardiac events and admissions to hospitals. 3. Barriers to exercise: NIL Rehabilitation exercise prescription Cardiac rehabilitation programmes are defined by the WHO as "the sum of activities required to ensure the best possible physical, mental and social conditions, so that the cardiac patient may resume as normal a place as possible in the life of the community" (Cited in Hedback, 2001, pg. 153). The cardiac rehabilitation programme is a medically supervised programme which is aimed to help patients with cardiac disease to recover quickly physically, mentally and socially. It includes strategies like cessation of smoking, lifestyle modification including appropriate diet and physical activity, exercise training, management of blood lipid levels, stress reduction strategies, psychosocial counseling and occupational assessment and counselling. These components have been recommended by the Working Group on Cardiac Rehabilitation of the European Society of Cardiology (Cited in Hedback, 2001, pg. 153). Various studies have demonstrated the benefits of these rehabilitation programmes in terms of secondary prevention. This aspect is important because, it has been estimated that almost half of the patients who have undergone CABG develop a recurrent event like cardiac death, myocardial infarction or revascularization within 10-12 years after the first procedure (Hedback et al, 2001, pg. 153). There are four phases of care described in cardiac rehabilitation programme (Pryor, p.495). These are: Phase-1: in-hospital period (5-7 days). Phase-2: convalesce stage (2-6 weeks). Phase-3: Supervised out patient programme (6-12 weeks) Phase-4: Long term maintenance program in the community Follow up is one of the important parts of rehabilitation programme. This includes visits at 6 weeks, 4 months, 8 months and 12 months (Hedback, 2001, pg. 153). During each visit, the physician examines the patient and assesses risk factors and educates the individual accordingly. Referrals to other specialties are made during these visits. Those with hyperlipidemia are referred to dietician. Physiotherapists and psychological counselors also are involved in these stages. Exercise stress testing is routinely done four to six weeks after CABG surgery and signals the beginning of a cardiac rehabilitation program. Initial rehabilitation consists of a 12 week program of gradually increasing monitored exercise lasting one hour three times a week (Kullick, 2007). The exercise tests are performed during follow-up visits. The exercise training is started after the first exercise test under the guidance of a physiotherapist (Hedback et al, 2001, pg. 153). The exercise recommended is graded exercise. For those who are assessed as low- to moderate risk, aerobic low to moderate intensity exercise is recommended. The staff who is guiding these exercises must have received basic training in basic life support. For those who are assessed as high risk, the exercise training is done in a hospital setting so that proper resuscitation is provided if necessary. The aim of exercise training should be secondary prevention rather than just restoration of physical activity. Exercise training must be delayed in those who experience anterior myocardial infarction because these patients are likely to have poor left ventricular function and may have detrimental effect on the remodeling of the myocardium. This aspect is still debated. There is a diversity of exercise program regimens that are offered in cardiac rehabilitation. Patients in early stages of recovery benefit from low-intensity aerobic exercises than high-intensity exercises. This regimen also ensures compliance and safety. Resistance exercises, though not much recommended may aid return to full function without having any detrimental effects on the heart. The greatest improvement in the quality of life is noted in high frequency training programme, especially in younger patients. Similar benefits with exercise training are noted in elderly patients as in the middle-aged (Pryor and Prasad, 2002). The cardiac rehabilitation programmes are cost effective. The decrease in financial burden is due to fewer hospitalizations and increased productivity in terms of occupation (Aedes et al, 1992). Physical activity prescription: Peter will be recommended graduated exercise of low intensity and short dynamic stretches for warm up. Aims of warm-up exercises are to increase the blood supply of the myocardium, increase the flexibility of the soft tissues and mobilise the joints. The next phase will be the conditioning phase. In this phase exercises will be recommended twice a week and these will be done under supervision for a minimum of 8 weeks. Peter will also be given a home exercise programme. The intensity of the exercise will be low to moderate. The target heart rate range for the patient is 160 per minute. The training duration recommended is 20-30 minutes, during which time continuous aerobic activity is done. The exercise intensity will be monitored and modified according to the Borg RPE scale and also monitoring of the heart rate. The next phase is the cool down phase in which low intensity exercises and short stretches are prescribed. Peter will be supervised for 15 minutes after the exercise. Following the 8 weeks of supervised aerobic exercise programme, resistance training will be prescribed to help Peter return to activities that are physically demanding like gardening. After the phase-3 phase, phase-4 rehabilitation is recommended which is basically a community based activity. The main aim of physical rehabilitation prescription in this phase is compliance to exercise in the long term. Hence phase 4 exercises must be enjoyable and also convenient to the patient. The equipment that may be used for phase-4 rehabilitation are cycling and treadmill. Even in this phase, the components of physiotherapy remain the same as in phase 3. Secondary events are common in patients with ischemic heart disease. The commonly encountered secondary events are myocardial ischemia, myocardial infarction and cardiac arrhythmia. Hedback et al (2001) evaluated the effects of the cardiac rehabilitation programme in patients who underwent CABG in a hospital in Sweden. They followed these patients for 10 years. Their study showed a significant reduction in cardiac events and readmissions to hospital in those who underwent comprehensive cardiac rehabilitation. Regular physical activity must be recommended to increase exercise capacity. The individuals should aim to be physically active for atleast 20-30 minutes a day to the point of slight breathlessness (NICE guidelines). This stage should be attained step by step. Home training programme can be initiated after the initial supervision phase. This consists of instructions for exercise to be performed at home 3 to 5 times a week as discussed in the above section. Psychosocial support: Peter will be advised appropriate diet based on the traditional eating habits of the individual and the family. In other words, individualized advice will be given for daily diet, keeping in mind the requirements of the whole family. Peter will be advised not to take supplements containing beta-carotene, folic acid or antioxidants like Vitamin E or C. He must consume atleast 7 g of omega 3 fatty acids per week. This is available for non-vegetarians who can eat two to four portions of oily fish. Mediterranean-style diet is the most recommended diet (NICE guidelines, 2007). Peter will be advised to strictly refrain from smoking. If necessary, intensive support service will be given to him to help quit smoking. If Peter is not able to give-up smoking despite counselling, pharmacotherapy will be recommended (NICE guidelines, 2007). Peter will be advised weight control as per the recommended Body Mass Index. The physician and physiotherapists deliver training sessions which also involve education and stress relieving (Hedback et al, 2001, pg. 153). Those who have depression or need psychosocial support are referred to appropriate support groups. Peter will receive psychological support as needed. Depression is prevalent in patients with coronary heart disease. It has been estimated that 20% of patients with coronary heart disease suffer from depression. This can affect the outcome of cardiac events because depressed patients have lower exercise capacity, reduced high-density lipoprotein cholesterol level, and higher triglyceride levels. They also are known to have lower scores for mental health, energy or fatigue, general health, pain, overall function, well-being, and total quality of life. Added to these, individuals who are depressed are anxious and hostile and have problems of somatization (Milani et al, 1996, p. 726). Milani et al (1996) evaluated the effect of cardiac rehabilitation and exercise training on depression after major cardiac events. They reported that after cardiac rehabilitation, the depressed cardiac patients had marked improvements in the symptoms of depression, anxiety, somatization and hostility. They also had better quality of life. Their exercise capacity increased and serum lipid profile was better. The researchers concluded with an advice that depressed patients must referred to and made to attend formal cardiac rehabilitation programs after major cardiac events. Similar reports were presented by Milani & Lavie (1998) who studied the effects of cardiac rehabilitation on depression in the elderly with coronary heart disease. In a study by Maines et al (1997), the researchers reported that there was 39% reduction in the anxiety scores, 35% reduction in the depression scores and 37% reduction in somatization in patients with major coronary events who underwent cardiac rehabilitation and exercise programs. Justification for physical exercise prescription in cardiac rehabilitation Several studies have proven the benefits of physical exercise in secondary prevention in ischemic heart disease. Gordon-Larse, Boone-Heinonen and Sidney et al (2009) conducted a cross sectional study on 2364 participants enrolled in the Coronary Artery Risk Development in Young Adults study, also known as CARDIA study. In the study, association between walking or biking to work with body mass index, body weight, fitness, cardiovascular risk factors, objective moderate-vigorous physical activity and serum measures of insulin, glucose and lipid were assessed separately using sex-stratified multivariable logistic regression modeling. In this study, 16.7 percent of participants commuted to work actively. After controlling for age, sex, race, smoking, education, income and physical activity index excluding walking, men with active commuting had decreased risk of cardiovascular disease, decreased risk of obesity, decreased insulin levels and decreased triglyceride levels. From this study it is evident that active commuting decreases risk of cardiovascular disease and must be recommended as a modality for maintaining health. Teramoto and Golding (2009) investigated the effects of regular exercise on the lipid levels of plasma that cause coronary artery disease. The study was conducted on 20 sedentary men and these men were asked to participate in an exercise program for 20 consecutive years. The exercise program included moderate exercise of 45 min per day, 3.5 days a week. The lipid levels tested were LDL cholesterol, HDL cholesterol, total cholesterol and triglycerides. The data of the study was analyzed using suitable statistical software. From the results it was deducted that all the lipid values improved significantly during the study. One interesting aspect noted in the study was that the largest changes occurred in the first year of participation and thereafter, gradual improvements were noted every year. Thus, positive effects on plasma lipid levels occur due to regular exercise implying decreased risk of coronary artery disease. Coghill and Cooper (2008) conducted a study to investigate the effectiveness of home-based physical activity program in decreasing lipid levels in patients with hypercholesterolemia with intentions to decrease the risk of coronary artery disease that arises consequent to hypercholesterolemia and sedentary lifestyle. The study was conducted in Bristol England and involved 67 hypercholesterolaemic individuals with mean age of 55.1 years. The exercise program instituted was brisk walking in which 300kCal were burnt. The program was carried on for 12 weeks. Activity logs and accelerometers were used to ascertain and monitor compliance. The results showed that such an exercise program lowered triglyceride levels and increased HDL levels. From the results, it was concluded that 12 weeks of moderate intensity walking is sufficient to decrease triglyceride levels and improve HDL levels significant enough to decrease risk of coronary artery disease. Leon, Casal and Jacobs (1996) conducted a study to investigate the epidemiologic evidence that 2000kCal of moderate physical activity reduces the risk of coronary artery disease. For the purpose of this study, 22 healthy men aged between 22-44 years with sedentary lifestyle and with slightly overweight, normolipemia and normotension were employed for the study. The study was a randomised controlled trial. The physical activity implemented in this study was walking for 45 minutes at 5.15 km per hour on treadmill at 2% grade for 5 days a week. Another physical activity involved was climbing 10 floors of stairs at a time for total of 50 floors without prescribed heart rate targets. The physical activity regimens were continued for 12 weeks. The outcomes measured in this study were body weight, percent body fat, mean systolic blood pressure, diastolic blood pressure, mean plasma lipid levels and lipoprotein levels. The results of the study revealed that such an exercise regimen caused a trend in loss of weight and fat. Though there was no effect noted on mean blood pressure, an increase in diastolic pressure was noted during exercise. Another important finding in the study is the decrease in triglyceride levels and rise in HDL cholesterol levels, both of which prevent coronary artery disease. However, the effects of this activity did not last for a long time, during the second half of the study indicating that such a moderate exercise did not decrease risk factors for coronary artery disease. Rankovic, Milicic, Savic et al (2009) investigated the effects of aerobic physical exercise on systematic inflammatory response in patients with stable coronary disease. The need for this study arose because inflammation is an important factor in the pathogenesis of atherosclerosis and increases the risk of coronary artery disease. Hence any intervention like physical activity which lowers inflammation, decreases the risk of further events in already established coronary artery disease. The study by Rankovic et al (2009) was a randomized controlled trial. 29 males and 23 females were enrolled in this study. The study group was subjected to aerobic physical training for total 6 weeks, first 3weeks in a rehabilitation center and the next 3 in home setting. From the results of the study it was evident that moderate aerobic exercise caused significant reduction in inflammatory state and this was evident from decrease in CRP and VCAM-1 levels. Thus, this study proves the importance of moderate physical activity in the prevention of coronary artery disease at primary and secondary level. Most of the studies that have been reviewed have proved a positive association between increased physical activity and decreased risk of coronary artery. The decreased risk is mainly because of decrease in triglyceride levels, decrease in obesity, increase in HDL cholesterol and decrease in inflammatory factors. Individualized phase IV prescription for Peter Phase IV prescription involves no ECG monitoring and minimal supervision. Since Peter is comfortable with performing exercise program at home, the prescription is tailor-made for performance at home. The following are the phase IV prescription components for Peter. Warm-up advice for Peter consists of graduated low intensity exercise involving short dynamic stretches. The aim of warm- up exercise is to increase myocardial blood supply, increase the flexibility of soft tissues and also to mobilize joints. For the conditioning phase, the frequency of exercise is 3 days a week initially, which must be increased to 5 days a week, gradually. Low to moderate exercise is most suitable for Peter. The type of exercises recommended are aerobic exercises as they have been found to be most useful. Peter is advised to use a heart rate alarm for monitoring of his heart rate. The recommended peak exercise heart rate is 10 breaths per minute less than the appropriate threshold. The exercises are set in such a manner that they are set below the upper limit for exercise like onset of angina and other symptoms of cardiovascular insufficiency, more than or equal to 1mm of ST segment depression, rise is systolic blood pressure of more than 240mmHG or diastolic blood pressure of more than 110mmHg, increase in the frequency of ventricular arrhythmias, significant changes in the ECG and other symptoms and signs of exercise intolerance. The desired duration of activity is 20-60 minutes of intermittent or continuous activity. Duration of activity must be inversely proportional to the intensity of activity. The person can also accumulate in short bouts of activity of 10- 15 minutes. The rate of progression must be dependent on the functional capacity of the patient and the prognosis. On an average, the expected progress is over 3 -6 months to 1000 kCal/week. The aim of progress would be to achieve 20-30 minutes of exercise every 1-3 weeks. Peter preferred using a bicycle and thread mill. The initial intensity recommended for him is 2-3 METs, i.e., 100-300 Kgm/min on bicycle ergometer or 1.5- 5km/hr. The threshold heart rate for him is 120 per minute, which is 20 beats per minute, above his resting heart rate. He is advised to gradually increase using RPE. For resistance training, he is advised to use approximately 50 percent of 1RM or use of other modes of resistance like hand weights and bands. Peter is advised 10 different exercises that focus on large group muscles all over the body, 2-3 days a week. Peter is advised to start with 1 set of 10-15 reps to moderate fatigue using the 10 different exercises. He is advised to increase 1-2 kg per week for arms and 3-5 kg per week for legs. The RPE for this is 11-14. Valsalva procedures must be avoided. Exercise must be followed by a cool down phase and it must include low intensity exercise and short stretches. References Ades, P.A, Huang, D, Weaver, S.O. (1992). Cardiac rehabilitation participation predicts lower rehabilitation costs. American Heart Journal, 123, 916-21. Coghill, N., and Cooper, A.R.(2008). The effect of a home-based walking program on risk factors for coronary heart disease in hypercholesterolaemic men. A randomized controlled trial. Prev Med., 46(6), 545- 551. Gordon-Larsen, P., Boone-Heinonen, J., Sidney, S., Sternfeld, B., Jacobs D.Jr and Lewis, C.E. (2009). Active commuting and cardiovascular disease risk: the CARDIA study. Arch Intern Med., 169(13), 1216-23. Hedback, B., Perk, J., Hornblad, M. and Ohlsson, U. (2001). Cardiac rehabilitation after coronary artery bypass surgery: 10-year results on mortality, morbidity and readmissions to hospital. Journal of Cardiovascular Risk, 8, 153–158. Kullick, D. (2007). Coronary Artery Bypass Graft Surgery. Medicinet, Retrieved on 1st Feb, 2011 from http://www.medicinenet.com/coronary_artery_bypass_graft/article.htm#1whatis. Leon, A.S., Casal, D., Jacobs, D. Jr. (1996). Effects of 2,000 kcal per week of walking and stair climbing on physical fitness and risk factors for coronary heart disease. J Cardiopulm Rehabil., 16(3), 183-92. Maines, T.Y., Lavie, C.J., Milani, R.V. (1997). Effects of cardiac rehabilitation and exercise programs on exercise capacity, coronary risk factors, behavior, and quality of life in patients with coronary artery disease. South Med J., 90(1), 43-9. Maseri, A., Crea, F., Kaski, J.C., Davies, G. (1992). Mechanisms and significance of cardiac ischemic pain. Prog Cardiovasc Dis., 35(1),1-18 Milani, R., Lavie, C. (1998). Prevalence and effects of cardiac rehabilitation on depression in the elderly with coronary heart disease. Am J Cardiol., 10, 1233-6. Milani, R., Lavie, C., Cassidy, M. (1996). Effects of cardiac rehabilitation and exercise training programs on depression in patients after major coronary events. American Heart Journal, 132 (4), 726-732. NICE guidelines. (2007). MI: secondary prevention. National Institute for Health and Clinical Experience. Retrieved on 1st Feb, 2011 from http://www.nice.org.uk/nicemedia/pdf/CG48QuickRefGuide.pdf Pryor, J.A., and Prasad, S.A. (2002). Physiotherapy for Respiratory and Cardiac Problems: Adults and Paediatrics. United States: Elsevier Health Sciences. Ranković G, Milicić B, Savić T, Dindić B, Mancev Z, Pesić G. (2009). Effects of physical exercise on inflammatory parameters and risk for repeated acute coronary syndrome in patients with ischemic heart disease. Vojnosanit Pregl., 66(1), 44-8. Teramoto, M., Golding, L.A. (2009). Regular exercise and plasma lipid levels associated with the risk of coronary heart disease: a 20-year longitudinal study. Res Q Exerc Sport., 80(2), 138-45. Zevitz, M. E. (2006). Myocardial ischemia. Emedicine from WebMD. Retrieved on 1st Feb, 2011 from http://emedicine.medscape.com/article/156065-overview Read More