Cardiac rehabilitation &

prevention
Yusra Pintaningrum
SMF Jantung dan Pembuluh Darah
FK Universitas Mataram –RSUP NTB
 Goals of Cardiac Rehab

 Identify, modify, and manage risk factors to reduce

disability/morbidity & mortality
 Improve functional capacity

 Alleviate/lessen activity related symptoms

 Educate patients about the management of heart disease

 Improve quality of life

 Utilization Benefits:
 Reduced risk of fatal MI (<25%).
 Decreased severity of angina & need for anti-angina meds.
 Decreased hospitalizations.
 Decreased cost of physician office visits & hospitalizations
(<35%).
 Fewer ER visits.
CARDIAC REHABILITATION

Comprehensive long-term services involving:

1.Medical evaluation;
2. Prescribed exercise;
3. Cardiac risk factor modification;
4. Education, counseling and behavioral
interventions
 Rehabilitating the Heart

Benefits of Exercise
 Prevention of age related endothelial dysfunction due to
preservation or restoration of nitric acid
 Reduction in hemostatic factors

 Decrease in C-reactive protein

 Attenuation of age-related reductions in arterial

compliance and restoration is previously sedentary
individuals
 Rehabilitating the Heart

Benefits of Exercise (con’t)

 Restoration of ischemic pre-conditioning

 Reversal of age-related decline in maximum oxygen uptake (MET)

 Improved physical fitness, physical work capacity and endurance

 Enhanced flexibility

 Bone mass & Bone density

 Improved self image and self confidence

 Covered Diagnoses
1. Stable Angina
2. Post MI
3. Post CABG
4. Post Stent placement
5. Post valve surgery
6. Post transplant
 PHASES
Phase I: In-hospital
Phase 2: First three months
(36 sessions)
Phase 3: 3-12 Months
Phase 4: Maintenance
 Fase I : saat pasien masih dalam masa perawatan, tujuan utama fase
ini adalah mengurangi atau menghilangkan efek buruk dari
‘dekondisi’ akibat tirah baring lama, melakukan edukasi dini dan
agar pasien mampu melakukan aktifitas hariannya secara mandiri
dan aman.
Fase II, yang dilakukan segera setelah pasien keluar dari RS,
merupakan program intervensi untuk mengembalikan fungsi pasien
seoptimal mungkin, segera mengontrol faktor risiko, edukasi dan
konseling tambahan mengenai gaya hidup sehat.
Fase III dan IV merupakan fase pemeliharaan, dimana diharapkan
pasien tersebut telah mampu melakukan program rehabilitasi secara
mandiri, aman, dan mempertahankan pola hidup sehat untuk
selamanya, dibantu atau bersama-sama keluarga dan masyarakat
sekitarnya.
 PHASE 1

Early assessment
Mobilization
Risk Factor Management
 PHASE 1

1. Heart Rate increase of 5-20 beats above rest

2. BP rise 10-40 mmHG above rest
3. No new rhythm changes
4. No cardiac symptoms
 METABOLIC
EQUIVALENTS

Toileting 1-2 METS

Bathing 2-3 METS
Walking varies with speed
Upper Body 2-3.1 METS
Leg Calisthenics 2.5-4.5 METS
 METABOLIC
EQUIVALENTS

Stair Climbing down 2.5 METS

up 4.0 METS
 PHASE 1

Day 1: 1-2 METS bed rest/OOB

Day 2: 2-3 METS sitting/walking
Day 3-5: 2-4 METS
 PHASE 2

Generally, first 36 sessions (12 weeks)

Multidisciplinary approach
Individualized for each patient
 PHASE 2

Patient is evaluated at 1, 2 and 3

months for progress in the exercise,
dietary and psychological categories
and problems are identified and
addressed.
 PHASE 2

Exercise is limited until patient

graduates to the PHASE 3
program. Generally start with a
walking program and progress
to more strenuous as tolerated.
 PHASE 2

At the end of the 36 sessions, the patient

performs a repeat ETT and if he/she
attains a MET level of at least 7, he/she
is graduated into the PHASE 3.
 PHASE 3

Continues with exercise and medical

monitoring but now allowed to do
aerobics and more vigorous exercise
(basketball, raquetball, etc). Weight
training, resistance training and spin
classes are available.
 PHASE 4

Maintenance:
No longer requires medical supervision
but if chooses to stay in the program, it
is provided.
All exercises acceptable but regimen
approved by exercise physiologist.
WHAT DOES IT MEAN WHEN YOU SEND A PATIENT
TO THE CARDIAC REHABILITATION PROGRAM

A referral form must be filled

out or a RX written for
referral to the program and
outlining any restrictions.
 How can cardiovascular disease
prevention be used?
1.Principles of behaviour change

Key message

† Cognitive-behavioural methods are effective in

supporting

persons in adopting a healthy lifestyle

2 Smoking

Key messages

† Changing smoking behaviour is a cornerstone of

improved CVD health.

† Public health measures including smoking bans are

crucial for the public’s perception of smoking as an
important health hazard.
3. NUTRITION
4. PHYSICAL ACTIVITY
5. Management of psychosocial factors

Key message

† Psychological interventions can counteract

psychosocial stress

and promote healthy behaviours and lifestyle.

 6. Body weight

† Both overweight and obesity are associated with a risk of death

in CVD.
† There is a positive linear association of BMI with all-cause
mortality.
† All-cause mortality is lowest with a BMI of 20–25 kg/m2.
† Further weight reduction cannot be considered protective
against CVD.
 7. Blood pressure

† Elevated BP is a major risk factor for CHD, heart

failure, cerebrovascular disease, PAD, renal failure, and
atrial fibrillation.
8. Treatment targets in
patients type 2 diabetes
† Intensive management of hyperglycaemia in diabetes
reduces the risk of microvascular complications and, to a
lesser extent, that of cardiovascular disease.
† Intensive treatment of BP in diabetesa reduces the risk of
macrovascular and microvascular outcomes.
† Multiple antihypertensive drugs are usually required to
reach the target
 9. lipid

† Increased plasma cholesterol and LDL cholesterol are

among the main risk factors for CVD.

† Hypertriglyceridaemia and low HDL cholesterol are

independent CVD risk factors.

† Statin therapy has a beneficial effect on

atherosclerotic CVDoutcomes.
10. Antithrombotics