CARDIAC REHABILITATION
dr. Deddy Tedjasukmana, SpKFR (K), MARS, MM, MPM, SH
Curriculum Vitae
Surveyor Akreditasi RS (KARS) sejak tahun 2015
CARDIAC REHABILITATION – dr. Deddy Tedjasukmana, SpKFR (K) MARS MM MPM, SH .
CARDIAC REHABILITATION
Cardiac rehabilitation is coordinated program, multifaceted
interventions designed to optimize a cardiac patient's
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”
==> Concept : Early mobilisation
Secondary prevention
(Circulation,2005)
OVERVIEW
INTRODUCTION PHASE OF EXERCISE COUNSELING
. .
CARDIAC TRAINING IN AND
REHABILITATION CARDIAC EDUCATION
REHAB
CARDIAC REHABILITATION – dr. Deddy Tedjasukmana, SpKFR (K) MARS MM MPM
CARDIAC REHABILITATION TEAM
Clinical Nurse
Doctor Staff Nurse
Specialist
Medical Social
Physiotherapist Dietician
Worker
Occupational
Pharmacist Psychologist
Therapist
Vocational
Counsellor
CARDIAC REHABILITATION CONCEPT
• Mortality and morbidity reductions in patients
receiving exercise-based cardiac rehabilitation.
• how much can be attributed to cardiovascular
risk factor improvements?
CARDIAC REHABILITATION – dr. Deddy Tedjasukmana, SpKFR (K) MARS MM MPM
INTRODUCTION
30% 15%
Cardiovascular
diseases cause ± 15% is caused
most of death by ACS
in worldwide
The prevalence
increases with
lifestyle
changes
CARDIAC REHABILITATION – dr. Deddy Tedjasukmana, SpKFR (K) MARS MM MPM | Fuster V, Walsh RH and Harrington 13th edition, 2011.
PREVALENCE
• A common heart disease found in
adults are coronary heart disease and
heart failure.
• Prevalence of coronary heart disease
diagnosed by doctors in Indonesia
about 0,5 % and 1,5 % with symptoms
• Prevalence of heart failure diagnosed by
doctors in Indonesia about 0,13 % and
0,3 % with symptoms
CARDIAC REHABILITATION – dr. Deddy Tedjasukmana, SpKFR (K) MARS MM MPM | Fuster V, Walsh RH and Harrington 13th edition, 2011.
CANDIDATES
Post ACS
Post PCI Pheriperal vascular
desease
Post CABG Post Cardiac transpantation
CHF Stable Congenital heart desease
Post Implantable device
Warner MM. Cardiac Rehabilitation Past, Present and Future: An Overview. Cardiovasc Diagnose-Therapy. 2012
Restore the patient to achieve optimal conditions
(physically, mentally, socially, and vocationally) GOALS
Increase the functional capacity
Increase coronary bloodflow
Increase collateral system
Improve the efficiency of the cardiovascular
system
Improve the risk factors
Increase the activities of daily living
Increase the quality of life
French DP, Illness Perceptions Predict Attendance at Cardiac
Rehabilitation Following Acute Myocardial Infarction 2006
CARDIAC REHABILITATION MANAGEMENT
Phase 1 • Inpatient
Phase 2 • Outpatient
Phase 3 • Maintenance
History
Complete physical examination to help identify risk factors
History of smoking, exercise intolerance, unexplained dyspnea, or cough,
evidence of COPD
Pulmonary Function Test / Spirometry:
Predicting postoperative complication in patients
Identify high risk patients for whom aggressive perioperative
management is warranted
PREOPERATIVE EVALUATION
History
Complete physical examination to help identify risk factors
History of smoking, exercise intolerance, unexplained dyspnea, or cough,
evidence of COPD
Pulmonary Function Test / Spirometry:
Predicting postoperative complication in patients
Identify high risk patients for whom aggressive perioperative
management is warranted
POST
Post-operative Management OCCUPATIONAL THERAPY PHYSICAL THERAPY WORD OF THE
STEP OPERATIVE NURSING ACTIVITY ACTIVITIES ACTIVITIES DAY
DAY
I 1 Up in bad and chair Introduce self and Introduce self and Cardiac
program program rehabilitation
II 2 Self-feeding beside Life style assessment, Walking short Risk factors
commode walking work simplification, distances active
short energy conservation assisted range of
motion, or 1-3
METs Calisthenics
III 3 Walk in hall x 3 Activity precaution Walk in hall x 3 1-4 METs level
bathroom privileges pulse monitoring METs level
partial self-bath in smoking cessation calisthenics
bed
IV 4 Walk ad lib. Partial ADLs and METs Walk ad lib. 2-4 METs level
self-bath out of bed smoking cessation METs level
3-4 hours calisthenics
V 5 Walk ad lib. Relaxation training Walk ad lib. 3-5 Discharge
Increasing distances smoking cessation METs level planning
calisthenics
Work equivalents as Stair-climbing
appropriate
FIVE-STEP PROGRAM OF INPATIENT CARDIAC
REHABILITATION
FOR SURGICAL PATIENT
POD - 1
Active assisted ROM exercise
Chest physical therapy
Up in chair
Level activity 1 – 2 Mets
Source: AHA 2004, Krusen 1990
POD - 2
Active ROM exercise
Self feeding
Bed side commode
Walking short distance
Level activity 1 – 3 Mets
Source: AHA 2004, Krusen 1990
POD - 3
Partial self bath in bed
Walk in hall (3 times)
Level activity 1 – 4 Mets
Source: AHA 2004, Krusen 1990
POD - 4
Out of bad 3 -4 hours
Walking ad lib
Partial self bath
Self care
Level activity 2 – 4 Mets
Source: AHA 2004, Krusen 1990
POD - 5
Walk ad lib increasing distance
Level activity 3 – 4 Mets
Planning discharge
Counseling program
Source: AHA 2004, Krusen 1990
OUTPATIENT SETTING (PHASE 2)
Goals :
• Increase physical capacities and
endurance
• Remove depression and anxiety
• Nutritional, vocational, and sexual
education and counceling
• Physical endurance achieve 6 METs
with exercise trainning for 4-8 weeks
RISK STRATIFICATION ON EXERCISE
LOW RISK MEDIUM RISK HIGH RISK
• No significant left ► Left ventricel dysfunction ► Decrease function of left
ventricle dysfunction (EF = 40-49%) ventricle (EF<40%)
(EF>50%) ► Survive from cardiac
• No complex dysrhitmic ► Present symptom of arrest or sudden death
during rest or induced angina during medium ► Complex ventricle
by exercise degree exercise (5-7 dysrhitmia during rest or
• Normal hemodinamic METs) exercise
during exercise or rest ► Abnormal Hemodinamic
during exercise
• No Angina during ► Present symptom of
exercise or rest
angina during low degree
• Fungsional capacity > exercise (< 5 METs)
7.0 METs ► Worsen clinical symptoms
AACPR. Guidelines for Cardac Rehabilitation and Secondary Prevention Programs. 2013
ASSESMEN FUNCTIONAL 6MWT
PRESCREBING EXRECISE
Assessment Interpretation Prescription
F Frequency
I Intensity
T Time
T Type
PHASE OF CARDIAC REHABILITATION
Phase 2
Phase II may consist of one or more of the Following.
- Exercise program
- Starting wiith six minute walk test
- Risk stratification
- Patient attend individual/Group sessions
WHY EXERSICE?
Exercise protect the heart by: Reducing blood pressure
Keeping body weight healthy
Keeping cholesterol levels healthy
Lowering blood sugar
Lowering stress, depression and anxiety
Improving circulation, muscle tone & strength
Improving our sense of well-being
PARAMETER AFTER PHASE II
Parameter Expected standard
Functional 5-6 METs
Capacity
Health Status Normal hemodynamic response during exercise
No angina or stable angina pectoris
HR < 90x /min and stable blood pressure or controlled
on rest (< 140/90 mmHg, HR < 90x /min)
Physical Daily acitivites ( 6 METs)
endurance
TARGETS
Week Velocity Distance Time
(km/hr) (km) (minutes)
2 2 1 30
3 3 1,5 30
4 4 2 30
5 4,5 2,25 30
6 5 2,5 30
7 5,5 2,75 30
8 6 3 30
PRESCRIBING INITIAL TRAINING
Component Initial Recommendation
Warming up Stretching, light calisthenic, 5 – 10 minutes
Frequency Duration
o 3-5 days / week o 20-30 minutes
Endurance Training Intensity Type
o 2-4 METs Walking, Treadmill, ergometer,
o 11-14 Borg scale
Weight training involving multiple muscle groups
Resistance Training
Cooling down 5-10 minutes
ACSM. Exercise Management for Persons with Chronic Diseases and Disabilities. 2010
TARGET ACTIVITIES IN PHASE II
Recreatio
nal and
Back to social
work acitivity
Driving
Sexual
Walking activity
3 km
Carrying exercise
things
Climbing
up stairs
Household
Acitivity
Warner MM. Cardiac Rehabilitation Past, Present and Future: An Overview. Cardiovasc Diagnose Therapy. 2012
Lee et al (2011). Compared the effect of body weight
reduction and exercise capacity on overall and CV mortality
Overall mortality was reduced by 39% among patients in whom an
increase in exercise capacity was noted
An increase in exercise capacity by 1 MET was associated with a
reduction in total and CV mortality by 15–19%.
BMI changes did not correlate significantly with total mortality
CV mortality among men with an increase in body weight was 39%
higher compared to men with a decrease in body weight.
A decrease in exercise capacity was associated with increased total
and CV mortality
These findings indirectly indicate a major role of increased exercise
capacity in the effects cardiac rehabilitation, while body weight
reduction is of lesser importance
PHASE OF CARDIAC REHABILITATION
Phase 3
Consist of
- Formal education sessions
- Exercise programme
- Strengthening exercice
PHASE OF CARDIAC REHABILITATION
Phase 3
• Goals :
• Increase functional capacity
• Life style changes
• Prevent disease progressivity and regression
• Physical endurance 6-8 METs
• Increase Quality of life
AACPR. Guidelines for Cardac Rehabilitation and Secondary Prevention Programs. 2013
CARDIAC REHABILITATION
Cardiac CONSULTATION
Rehabilitation Consultation
• Exercise training routine
• Activities of Daily Living (ADL)
• Sports activities
• Leisure activities
• Working activities
• Sexual activities
• Modifying risk factors
CARDIAC REHABILITATION – dr. Deddy Tedjasukmana, SpKFR (K) MARS MM MPM SH
PHASE OF CARDIAC REHABILITATION
Phase 3
• Goals:
• Target functional capacity patient 6-8 METs
• Duration 3-6 months
• Done with minimal supervision
• At the end of this phase, treadmill test to start lifelong phase
• Lifelong phase: to maintain endurance patient
• Stretching 5-10 minutes
Flexibility • Aerobic exercise 20-30 minutes
Training
• Cooling down 5-10 minutes
• Walking with target 3-4 km in 30 minutes
Endurance • Walking can be done with low weight dumbell
Training
• 8-10 different exercises should be done involving multiple muscles
• Choose exercise that is safe, effective and easy
Strength Training
RETURN TO WORK
• Return to sedentary or light work is delayed 2-4
weeks after discharge from inpatient CR
• For physically demanding jobs, return to work is
delayed 4-6 week, allowing for surgical wound
healing and greater functional recovery
• If patients cannot return safety to work, a disability
evaluation is indicated
RETURN TO SEX
• Sexual activity is an important component of quality
of life
• Cardiac patients are often fearful of triggering
myocardial infarction (MI) during intercourse
• General principles — The management of sexual
activity in patients with cardiovascular disease is
based on physical endurance
• Exrecise training important for preparation in
cardiac patient
RSCM CARDIAC
REHABILITATION
CENTER
CARDIAC REHABILITATION – dr. Deddy Tedjasukmana, SpKFR (K) MARS MM MPM , SH
THANK YOU
