Preventive Rehabilitation and assessment of Coronary Heart Disease.

Dr. Ravinder Narwal

The Evidence For Physical Activity In Reducing CVD Risk.

Physical inactivity is associated with an increased risk for CVD and physical activity has been shown to reduce the risk (Leon et al., 1987; Paffenbarger et al., 1993; Hu et al., 2000; Pate et al., 1995; Thompson et al., 2003).

The Evidence For Physical Activity In Reducing CVD Risk.

Meta-analyses of randomised controlled studies post myocardial infarction showed a reduction in overall mortality of at least 20% over a three-year follow-up period (Oldridge et al., 1988; OConnor et al., 1989; Jolliffe et al., 2000).

Diagnosis Fxnl. Capacity AMI +++ CABG +++ Stable +++ angina PCI +++ CHF +++ Cardiac +++ Transplant Valve Repl. +++

The Evidence
+++ ++ +++ ++ +++ +

QOL Morbidity Mortality

+++ ++ +

Fewer events, reduced all cause mortality ++ + ? 20-34%

++ ? ++ ++ + ? + ? ?
Am Heart J. Nov. 2006. 152(5):835-41

Other reported benefits of exercise are:

Improved fibrinolysis. Enhanced coronary blood flow. Reduced arrhythmias. Improved peripheral muscle metabolism efficiency. Decreased prevalence/improved control of diabetes. Reduction in obesity.
(ACSMs Resource Manual for Guidelines for Exercise Testing and Prescription Fifth Edition [pages 104-105]).

Effects of Exercise Physiology

Cardioprotective Effects

Antiatherosclerotic

Psychologic

Antithrombotic

Antiischemic

Antiarrhythmic

Lipids BPs adiposity insulin sensititivy inflammation

Depression Stress Social support

Platelet adhesiveness Fibrinolysis fibrinogen blood viscosity

Myocardial O2 demand Coronary flow endothelial dysfunction

Vagal tone adrenergic activity HR variability

The Patient Pathway.

Risk Stratification.

1. 2. 3.

Patient risk stratified in hospital to determine which category they fall into: High risk Medium risk Low risk High risk hospital rehabilitation. Medium/Low risk community.

Health Screening.

Referred to community cardiac rehabilitation nurse for further screening. Nurse decides if patient is suitable for: Phase III exercise classes. Home exercise programme. Not suitable for exercise intervention.

1. 2. 3.

Fitness Assessment 1.

Aim: to ascertain baseline fitness level and assess patients suitability to commence Phase III exercise classes.

Three Functional Capacity Tests.

One of the following tests is used to assess the patients baseline fitness level before commencing an exercise programme:

1.

2.
3.

6-minute walk test. 12-minute shuttle walk test. Chester step test.

The Shuttle Walking Test.

S.J. Singh, M.D.L. Morgan, A.E. Hardman

10 metres

Information Obtained From Assessment.

Duration and rate of work achieved. Heart rate and blood pressure response. Heart rate and exercise response at peak exercise. Rating of perceived exertion (RPE).

Phase III Exercise Programming.

F Frequency: 2-3 weekly. I Intensity: 60%-75% of Maximal Heart Rate (12-13 RPE Borg
Scale).

T Time: 20 minutes conditioning period (not inclusive of warmup or cool-down).

T- Type: Aerobic, endurance training.

The FITT Principle Applied to HealthRelated Components of Fitness

Exercise Class Format.

Circuit or gym based programme. Continuous exercise or interval work. Mixture of cardiovascular and muscular endurance work. Emphasis on improving cardiovascular fitness.

Fitness Assessment 2.

Aim: to ascertain any changes to fitness level and assess patients suitability to commence Phase IV rehabilitation exercise classes.

Phase IV Exercise Programming.

F Frequency: At least 3 times weekly. I Intensity: 60%-80% of Maximal Heart Rate (13-15 RPE Borg
Scale).

T Time: 30 minutes conditioning period (not inclusive of warmup or cool-down).

T- Type: Aerobic, endurance training.

Fitness Assessment 3.

Aim: to ascertain fitness level on completion of Phase IV exercise classes before commencing independent exercise in the community.

Ongoing Independent Exercise.

Home exercise programme. GP Referral gym membership. Cardiac Health walks in Regents Park. Step-o-meter programme.

Chief Medical Officers Recommendation For Physical Activity (2004 DoH).

F Frequency: 5 or more days of the week . I Intensity: Moderate intensity physical activity (brisk walking). T Time: Accumulation of >30 minutes per day (not inclusive of
warm-up or cool-down).

T- Type: Aerobic, endurance training. Lifestyle activity or

structured exercise or sport.

Future Trends.

Primary prevention for those at risk of CHD.