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Phase I Cardiac Rehabilitation

Phase I Cardiac Rehabilitation I. The Major Objectives Of Phase I Include: A. Patient and Family Education : Patient and family education involves implementing a risk modification program after the patient's personal and family risks have been identified. The program needs to include the children of the patient because they have not come to the point in their lives where their risk factors have begun to exert negative anatomical or physiological changes. Since the children do not yet have any signs or symptoms of cardiac disease, Phase I education can impact them in a positive manner by changing their behaviors and modifying their cardiac risk factors. The patient and family education program should include discussions on dietary changes for healthier eating, stress reduction, determining what activities are safe to do at home, smoking cessation, is sexual activity safe for the patient and their spouse to engage in, and long term management of hyperlipidemia and blood pressure reduction. B. Preventing The Deleterious Effects Of Bedrest : This will involve mobilizing the patient as soon as they become medically stabilized. This will involve a low level walking program that will prevent problems of bedrest - muscle atrophy, blood clot formation, pneumonia, and general lethargy. The patient is being prepared to return to home with eventual goal of returning to work or to the normal activities of daily living that the patient was engaged in before they sustained their myocardial infarction. C. Safe Discharge To Home : Phase I is designed to assess the patient's ability to return home with enough physical stamina to conduct their activities of daily living in a safe manner. This assessment is important for the patient, the family and the physician. Phase I is meant to be preventative and diagnostic. It is meant to be preventative in the sense that in most cases the patient is medically stable at discharge. The physician wants to clearly understand at what level the patient will function at home. Therefore, Phase I will determine the ADL level at which the patient is expected to function. At discharge, the patient should understand what activities are safe and which activities should be avoided for the next several weeks. Phase I is meant to be diagnostic because most patients will be required to submit to a low level graded exercise test either at discharge or within two weeks after discharge from the hospital. The physician will assess the heart rate and blood pressure responses to the exercise test and will record at what point during the test the patient states they have symptoms as a result of the exercise intensity such as chest pressure, chest pain, numbness and tingling in the extremities, shortness of breath, fatigue, dizziness, etc. By knowing when symptoms of cardiac ischemia occur, the physician can set the MET level above which this patient's activities at home should not exceed. MET values for most ADL's have been determined. By knowing what the maximal METs at which the patient can reasonably work at home can assure that the ADL's are appropriate for the patient's disease condition. After the low level graded exercise test has been performed and the patient discharged home, Phase II cardiac rehab will shortly commence.

II. Who Should Participate In Cardiac Rehabilitation ? The patients who are medically stable or who can be stabilized are candidates for cardiac rehabilitation. They include the following : Patients With Myocardial Infarctions Who Are Medically Stable Patients Who Have Had A Coronary Artery Bypass Graft Surgery (CABG) Patients Who Have Had Angioplasty Patients Who Have Undergone Cardiac Transplant Surgery Patients With Other Cardiac Diseases Who Are Medically Stable Patients Who Have Several Risk Factors Who Are Hospitalized For Other Reasons Who Should Not Participate In Cardiac Rehabilitation ? Patients With Unstable Angina - i.e. - Refractory To Pharmacological Management Patients Who Are In Acute Congestive Heart Failure Patients Who Have Uncontrolled Dysrhythmias Patients Who Have Resting BP's >200/100 mm Hg Patients Who Have Moderate To Severe Aortic Stenosis Patients Who Are In Third Degree AV Block Patients With Acute Pericarditis Patients Who Are Being Acutely Treated For Recent Embolic Events Patients With A Resting ST Segment Depression Greater Than 3-4 mm
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Patients With Uncontrolled Diabetes Mellitus Patients With Moderate To Severe Cardiomyopathies Patients With Orthopedic Problems Which Preclude Them From Exercise

III. Phase I Goals 1. Clear the patient for any skeletal, muscle or orthopedic problems - ROM, pectus excavatum, pectus carinatum, scoliosis, joint swelling, gross muscle weakness, etc. 2. Clear the patient for any pulmonary problems that would limit activity - i.e. - thoracic deformities, obstructive or restrictive pathologies, presence of adventitious sounds (crackles, wheezes, bronchophony, egophony, whispered pectoriloquy, stridor), etc. 3. Return the patient home and to the workplace with the patient having a clear understanding about what are the safe activities they can participate in without reinjuring their hearts. 4. Decrease the patient's pain and fear of living. 5. Increase the patient's physical work capacity. 6. Help the patient to modify their coronary risk factors through education. 7. Give objective information back to all members of the cardiac rehab team.

IV. Who Makes Up The Cardiac Rehabilitation Team ? 1. 2. 3. 4. 5. 6. 7. The Physician The Physical Therapist The Nurse The Occupational Therapist Psychologist The Dietician or Nutritionist The Exercise Physiologist

V. The Evaluation Evaluation Process A. Medical Chart Review B. Patient Interview C. Patient's Examination D. Evaluation Of Patient's Tolerance For Exercise Phase I cardiac rehab should begin once the patient has been declared by the primary care physician to be medically stable. In an uncomplicated myocardial infarction (MI) this may be as soon as 1-2 days after being admitted for an MI. It is common in these days of managed care to see an uncomplicated MI patient being discharge to home in 7-10 days after admission. So, time is short and must be filled with pertinent information and physical evaluation for the patient's sake. All members of the rehab team, therefore, are crucial to the patient's safe discharge to home. A. Medical Chart Review Here are some questions you should be asking as you do the chart review. 1. What is the patient's diagnosis - MI, aortic stenosis, CABG, etc. 2. Was the patient defibrillated ? The patient may complain of chest pain or have burns on the chest from being cardioverted. Once a patient has been defibrillated, about 60% of these patients will go into ventricular fibrillation resulting in a second or a third defribillation experience. 3. Has the patient undergone a CABG ? Many patients think their "cardiac problems" have been cured and they will be angry as they have another MI after a CABG. It will be important for you to anticipate that anger and realize that it is not directed at you. 4. Know what the EKG report says about the patient. 5. Did the patient receive Tissue Plasminogen Activator (TPA) or Streptokinase to try to break up clots in the early diagnostic stages of the heart attack. 6. Did the physician document the rise of serum cardiac enzymes in the early stages of the heart attack ? This would be found in the blood lab workup and would refer to creatine kinase (CK), aspartate aminotransferase (AST) and lactate dehydrogenase (LDH). These enzymes have the following pattern : Enzyme Name Initial Rise Time To Peak Return To Baseline

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Creatine Kinase (CK) Lactate Dehydrogenase (LDH)

4-6 Hrs

24-36 Hrs

3-4 Days 4-5 Days 10-14 Days

Aspartate Aminotransferase (AST) 12-18 Hrs 36 Hrs 6-10 Hrs 2-4 Days

7. Look at the lipid panels also found in the blood lab reports. 8. Look for the echocardiogram report. This report will tell you whether the septum or the ventricular wall is hypokinetic or akinetic. Also wall thickness will have been assessed. Ejection fraction will have been measured - an EF of >60% is normal; <40% EF is ominous and an EF of <18% is probably going to exclude the patient from meaningful exercise. 9. Was the patient taken to the catheterization lab for coronary angiography ? The cath report will tell you which vessels are blocked and by what % are they blocked. 10. Read the pulmonary function test to see if the patient has a history of obstructive or restrictive lung disease. 11. What medications is the patient taking ? 12. Read the nurses notes. B. Patient And Family Interview Ask the patient why they are in the hospital. They may not understand all that is happening to them. Ask the patient what kinds of symptoms they had in the past before their admission to the hospital - i.e. - did they have chest pain, chest pressure, pressure or pain that radiated into the left arm. Were any anginal equivalents ever noticed like jaw pain, navel pain, low back pain, pain that radiated into the right arm, numbness and tingling in the fingers. Anginal equivalents are any sign or symptom that can alert the patient they are having problems with their heart - alternative signs other than chest pain and pressure. Find out if the patient had any predisposing risk factors like diabetes mellitus, peripheral vascular disease, hypertension, hyperlipidemia, significant family history, etc. Was the patient a smoker and if they were how long did they smoke ? Ask the patient if they have stopped smoking and have them give you a specific date when they stopped. Sometimes they will say they have stopped but they stopped as the ambulance rolled them into the Emergency Department at the hospital. The patient will often not remember what has been said in the early days of his/her admission. For this reason, it is crucial to include family members in all of the education sessions with the patient. It is important to assess the family to see how willing the extended family, outside of the home, are willing to help once the patient returns home. Does the family love the patient and have a sense of duty to help once he/she returns home. Is the spouse supportive or critical ? A person with good family support will likely recover and rehabilitate sooner. If the MI is not too severe, the patient may well be able to return to his/her vocation. Try to assess the patient's willingness to return to work. The patient may have been employed as a manual laborer. Does the patient acknowledge that manual labor may not be appropriate anymore ? How willing is he/she to undergo job retraining in order to continue being the financial support to the family ? Does the patient have hobbies and interests that may sustain them in leisure times ? What is the psychological profile of your patient ? Do they need a psychiatric consult to help them over times of depression and denial ? C. Patient's Physical Exam 1. 2. 3. 4. 5. 6. 7. Does the patient have normal ROM ? Is there any detectable atrophy in any of the limbs ? What is the gross over all muscle strength for the arms and for the legs ? Is the skin color normal ? Are all of the pulses normal and bilaterally equal ? Check the pedal, radial, carotid, popliteal, and brachial pulses. Are there any surgical incisions on the thorax or the extremities ? Are there any palpable areas on the chest wall that are painful ? Is there normal anterior/posterior excursion of the chest on inhalation ? Do the lower ribs flare out to the sides on deep inspiration ? 8. Take the patient's blood pressure on both arms. Are they equal side-to-side ? D. Evaluation Of The Patient's Tolerance Of Exercise Next, the Physical Therapist needs to do the self care evaluation on the patient. Essentially this involves determining if the patient can do a variety of self care activities in the supine position, sitting up at the edge of the bed and in standing. This involves such activities as brushing your teeth, combing your hair, washing your face, shaving, putting on your clothes, socks and shoes. If the patient can do all of the standard self care activities in supine, sitting and standing without having any complaints of dizziness, unusual fatigue, syncope, chest pain, or the appearance of an exaggerated heart rate, blood pressure or an EKG dysrhythmia, then the patient has passed the self-care evaluation. Now, the patient can begin a walking program that is heavily monitored and progresses slowly. It looks something like this : 1. 2. 3. 4. The patient is hooked up to a telemetry unit so that their heart rate and rhythm can be constantly monitored. The patient's blood pressure is measured every 3-4 minutes while they are out of bed. The patient is slowly walked by the therapist x 25 - 50 feet after which there is a short rest period on a chair. If no unusual HR, BP or EKG readings were seen, then the walk is repeated and overtime lengthened according to the patient's subjective feelings as well as the HR, BP and EKG responses. 5. Activity is progressed as long as the patient tolerates the exercise. At the end of Phase I, the patient will be walking several times a day with increasing distances in a patient with an uncomplicated MI. If the patient displays unusual symptomatology during the walking times - EKG dysrhythmias, shortness of breath, the development of crackles in the lungs where none existed prior to exercise, sharp increases in HR and BP with light activity, onset of syncope, vertigo, and other stress symptoms - they must be

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referred to their primary care physician before additional exercise times are undertaken. If all has gone well for the patient, they will be discharged to home after the completion of a low level graded exercise stress test. The test looks something like this : Stage Speed (mph) % grade Duration (min) Met Level I II III IV 1.7 mph 1.7 mph 1.7 mph 2.5 mph 0% 5% 10% 12% 3 minutes 3 minutes 3 minutes 3 minutes 2.3 METs 3.5 METs 4.6 METs 6.8 METs

Most patients with an uncomplicated moderate sized MI will be able to complete stage IV. Often, the physician will give the patients about two weeks at home for additional recovery and then have the patient submit to a Bruce treadmill protocol. The Bruce protocol is significantly more aggressive than the low level graded exercise stress test. The patient has now completed Phase I cardiac rehab and will progress now on to Phase II cardiac rehab.

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