Cardiac Disease Role of Occupational Therapist

A case with Valvular Replacement(Psychosocial and Vocational Issues)

14th June 2008 by Alexandra Fung OTI, TWEH

Contents Overview of Cardiac Rehabilitation Case study Mr. C Questions and Answers

According to 2005 CDARS, no of cardiac patients for potential rehabilitation :

AMI CHF CABG Pacemaker Other IHD Total 4000 10275 475 110 14439 30299

In fact, according to various literature, the percentage of cardiac patients engaging in cardiac rehabilitation is rather low, only 20-30%, where drop-out rate was high in all countries.

HKE
PYNEH Cardiac specialty - Yes OT Education mainly, individual case referral

HKW
QM Cardiac specialty - Yes OT Education mainly, individual case referral

KE
UCH Cardiac specialty - Yes OT program Yes

KW
CMC Cardiac specialty - Yes OT program Yes

KC
QE Cardiac specialty - Yes OT program Yes

NTE
AHMLN Cardiac specialty - Yes OT program Yes

NTW
TM Cardiac specialty - Yes OT program Yes (phase II, III)

RH Cardiac specialty Yes OT Education mainly, individual case referral TWEH Cardiac specialty - Yes OT program Yes (phase I, II,III)

TWH Cardiac specialty - Yes OT program Yes (phase II, III)

HHH TKO Cardiac Specialty - No

PMH Cardiac specialty - Yes OT - Education mainly, individual case referral KW WTS OLMH YC Cardiac Specialty - No

KH BH Cardiac specialty - No

NDH SH TP CCH Cardiac Specialty - No

PO Cardiac Specialty - No

GH Cardiac specialty - Yes OT Education mainly, individual case referral MMRC DK FYK Cardiac Specialty - No

TSKH Cardiac specialty - Yes OT program No

WCH SJ Cardiac Specialty No

Overview of cardiac disease

Heart Disease

Coronary Artery Disease (CAD)

Valvular Heart Disease (VHD)

Congestive Heart Failure (CHF) +- RSC

Arrhythmias +- ICD / pacemaker

Congenital Heart Disease

Acute Myocardial Infarction (AMI)

Acute Coronary Stenosis (ACS)

Ischemic Heart Disease (IHD)

Hypertensive heart failure

Cardiac muscular disease

1. Investigations
Non-invasive

Invasive

2. Surgery

3. Medications
Anti-Anginal Drugs Antiarrythmic Drugs Anticoagulant Drugs Antiplatelet Agents Blood Pressure-Lowering Drugs Cholesterol-Lowering Drugs Glycoprotein IIb/IIIa Receptor Antagonists Thrombolytics

4. Cardiac Rehabilitation
In-patient Patient assessment Exercise Training Risk factor management Nutritional Counseling Vocational counseling Psychosocial intervention

Out-patient

Community

5. Secondary and Primary Preventions

Secondary preventions Modifiable risk factors Nutritional Counseling Lipid Management Hypertension management Smoking cessation Weight management Diabetes Management Psychosocial Management Physical Activity Counseling Primary preventions society level Risk factor screening Blood pressure and lipid control Dietary intake Physical activity Weight management Smoking Cessation

Care-flow of cardiac patients

Medical care unit

AE admission or Clinical admissions Coronary Care Unit

Phase I Light supervised exercise like walking the hallway, education to patient

General Medical Ward

Rehabilitation Hospital
Phase II Early out-patient outrehabilitation, normally 2-6 weeks after discharge Phase IIII On-going out-patient Onoutrehabilitation normally from 6-14 weeks after discharge Phase IV A wellness program in community settings with minimal supervision

Discharge home

Ambulatory Rehabilitation centre

Community Based rehabilitation

CASE STUDY
Name : Mr. C Sex / Age : M / 49 Medical history : 29/8/07 Admitted due to fever and general discomfort, diagnosed as infective endocardiatis (IE) receiving a course of antibiotics with underlying mild mitral valve regurgitation 5/10/07 fair response to antibiotics resulted in heart failure, severe aortic valve regurgitation and mitral valve regurgitation 12/10/07 mitral valve repairment and aortic valve annuloplasty done 12/10/07-21/10/07 CCU care (GH) 22/10/07-26/10/07 General medical ward (PYNEH) 27/10/08 - 10/11/07 In-patient cardiac rehabilitation (TWEH) 19/11/07- 14/3/08 Out-patient cardiac rehabilitation (TWEH)

What is infective endocarditis? Infective endocarditis is an infection of the heart's inner lining (endocardium) or the heart valves. Infective endocarditis occurs when bacteria in the bloodstream (bacteremia) lodge on abnormal heart valves or other damaged heart tissue. Endocarditis rarely occurs in people with normal hearts, people with certain preexisting heart conditions are at increased risk for endocarditis. Some of these conditions include having... an artificial (prosthetic) heart valve a history of previous endocarditis heart valves conditions such as rheumatic fever various kinds of congenital heart defects hypertrophic cardiomyopathy According to the American Heart Association, there are about 29,000 cases of endocarditis diagnosed a year.

Social History : Live with wife whos working as clerk, one daughter whos still studying at secondary school Occupations : Assistant branch manager of a local bank Lifestyle : Nil exercise and no specific leisure pursuit, had family gathering once a week but mostly spend at shopping malls nearby Investigations: Exercise stress test 5.4 METS achieved (non-positive) limited by lower limb fatigue and SOB Echo : LVEF 30 % (global hypokinesia), LVIDd 59.7mm, LVIDs 54.2mm Medications : including warfrain, carvedilol

OT Initial Assessment (November 2007) : 1) Physical and functional examination * UL full ROM but mild sternal wound pain on movement, muscle strength proximal grade 4, distal grade 5 * Sternal wound : Healed with no discharge , measures around 17 cm x 0.2 cm x 0.1cm, pink color, complain mild dysaethesia * ADL : Fully independent, IADL : Able to manage light IADL task but not strenuous IADL * Ambulatory state : able to walk 1 FOS up and down 2) Functional status by using Specific Activity Scale of Goldman (SAS) * Class II ~ 5-7 METS 13 * Monitored functional task Carry 20 lbs weight level ground for 80 meters HR 80/bpm 95/bpm (56% of age predicted max HR), SpO2 99% 90/58mmhg, RPD 0 2, RPE 6 97%, BP 85/55mmhg 11, 14nil c/o chest

discomfort, mainly exertional fatigue

3 ) Work issues by exploring work capacity evaluation (WPC) and vocational plan Occupational title : 11-3031.02 - Financial Managers, Branch or Department Direct and coordinate financial activities of workers in a branch, office, or department of an establishment, such as branch bank, brokerage firm, risk and insurance department, or credit department. Task : Establish and maintain relationships with individual and business customers, and provide assistance with problems these customers may encounter. Examine, evaluate, and process loan applications. Plan, direct, and coordinate the activities of workers in branches, offices, or departments of such establishments as branch banks, brokerage firms, risk and insurance departments, or credit departments. Network within communities to find and attract new business. Approve or reject, or coordinate the approval and rejection of, lines of credit and commercial, real estate, and personal loans. Open and operate stock accounts of clients, handling transactions and related record Supervise subordinates and overlook clients accounts

Skills Time Management Managing one's own time and the time of others. Instructing Teaching others how to do something. Monitoring Monitoring/Assessing performance of yourself, other individuals, or organizations to make improvements or take corrective action. Service Orientation Actively looking for ways to help people. Judgment and Decision Making Considering the relative costs and benefits of potential actions to choose the most appropriate one. Work Styles Integrity Job requires being honest and ethical. Attention to Detail Job requires being careful about detail and thorough in completing work tasks. Dependability Job requires being reliable, responsible, and dependable, and fulfilling obligations. Leadership Job requires a willingness to lead, take charge, and offer opinions and direction. Cooperation Job requires being pleasant with others on the job and displaying a goodnatured, cooperative attitude

4) Psychological state * Stress VAS 9/10 * Hospital Anxiety and Depression scale (HADS) : Anxiety 10/21, Depression 6/21 * Complain disturbed sleep with worries on adaptation to change in life especially loss of worker role 5) Quality of life by using WHOQOL with different domains analysis * Quality of life in relation to illness explored * Physical 14/20 * Psychological 15/20 * Social 16/20 * Environmental 15/20 18 6) Lifestyle * Sedentary lifestyle, spend most of the time on job * No exercise habit, nil any leisure pursuit * Nil diet control, often dine out

Return to work- a part of social readjustment after CHD. (Journal of cardiopulmonary rehabilitation 2004, 24)

Local study on cardiac illness and psychosocial well-being : Chan DSK et al (2007) Psychosocial outcomes of Hong Kong Chinese diagnosed with acute coronary syndromes : a prospective repeated measures study -Psychosocial problems measured by Chinese HADS and State esteem scale scale were prevalent in coronary patients Colin et al (2004) An examination of psychometric properties of the Hospital Anxiety and Depression Scale in Chinese with acute coronary syndrome -HADS was confirmed to be a useful screening instrument to assess symptoms of psychological distress in ACS patients. AJ Michael et al (2004) Patients with acute myocardial infarction and unstable angina have significant level of anteceding stress. - Patient with MI had higher odds of psychosocial factor relating to stress Doris Fu et al (2004) Correlates of psychological distress in elderly patients with congestive heart failure. - High level of psychological distress esp. depression were found in patients with CHF

PROBLEMS : 1)Physical and functional decreases activity tolerance and upper limb strength * Decreased activity tolerance compared with premorbid state * Decreased upper limb strength after open chest surgery * Risk of developing hypertrophic scarring 2) Work patient on sick leave, very hesitated and had no concrete plan on return to work upon 6 weeks from operation * Clerical duties mainly, PDC sedentary * Rather long work hours with regular overtime, high work related stress, with intensive demand on accuracy, concentration and responsiveness especially in the stock market * Able to cope with the physical demand in terms of capacity, but psychologically not ready to handle the job related pressure 3) Psychological anxious and decreased subjective well-being * Symptom of poor sleep and subjective general loss of energy * Worry about loss of worker role, and anxious about change in financial status 4) Lifestyle sedentary and lack of concept on health maintenance * Need to redesign a health promoting and satisfying lifestyle * A change in lifestyle is needed as secondary prevention

Training target and comment from the rehabilitation team : * Training : target HR 86 138 (50-80% age predicted) , new THR after stress test 112-129 (50- 80% heart rate reserve) RPE 10-11 * Stratification for risk of events according to AACVPR guideline : high * Refer clinical psychologist

AACVPR Stratification of risk for cardiac events during exercise prescription patient at high risk Presence of complex ventricular arrthymias during exercise testing or recovery Presence of angina or other significant symptoms (e.g. unusual shortness of breath, light headedness or dizziness at low levels of saturation < 5 METS High level of silent ischemia (ST depression 2mm from baseline) during exercise or recovery Presence of abnormal hemodynamics with exercise testing (chronotropic incompetence or decreasing systolic BP with increasing workloads) or recovery Rest ejection fraction < 40% History of cardiac arrest, or sudden death Complex dysrhythmias at rest Complicated MI or revascularization procedure Presence of signs or symptoms of post event / post procedure ischemia Presence of clinical depression

Special consideration in patients with valvular surgery Valvular disease involve either stenosis (e.g. due to degenerative calcification, rheumatic disease) OR regurgitation (e.g. rheumatic disease, infections, valve prolapse) that allows inadequate or retrograde blood flow through the heart valves Surgical intervention include annuloplasty which tightens the annulus of valve OR valvular replacement with mechanical valve Patients with valvular surgery like other open heart surgery (e.g. CABG) usually were more deconditioned and results in lower functional capacity and needs progressive and longer period of rehabilitation Upper extremity exercise (especially resistance training) should be avoided until the sternum is stable and wound healed Sternal wound should be well taken care of to observe signs of wound infection and development of hypertrophic scarring Exercise training intensity should be kept under the threshold that precipitates onset of symptoms as it indicates that the cardiac output is not capable of meeting demand of exercise Anticoagulation therapy is very important and would mostly be long term where precautions for injuries and bleeding should be reminded

OT Treatment : 1. Maintenance of sternum stability and prevention of hypertrophic scarring of chest wound *Sternum stability application of chest vest to protect the sternal site and provide support during activities that involves sternal and ribcage movement like cough * Wound care avoid sunlight, look for signs of infection * Scar prevention education on scar prevention and application of cicacare gel sheet

2. Upper limb functional training and reconditioning (UL ergometry / UL resistance training apparatus like Incline Board with weight / Weight Carrying activities ) * Start with mobilization activities, and progress to graded resistance training upon 8-12 weeks after surgery * Lower training heart rate is targeted on UL training (recommended 50%-60% of LL training target HR) * UL training often produce greater work than LL training in terms of systolic blood pressure and perceived exertion due to relevant smaller muscle mass

3. Vocational counseling Goal : Verify if the job is dangerous for the employee, and also ensure that the employee is capable of handling the related vocational activities Regulatory restrictions (e.g. handling of machinery, driving commercial and heavy vehicles) Vs Organizational restrictions (e.g. work alternating hours, night and atypical hours) Vs Technical restrictions (e.g. the workplace environment like exposure to heat, working at heights, working in confined area, exposure to chemical substance, carbon monoxide, passive smoking etc) Risk evaluation : Physiological limits linked to level of physical fitness including strength, tolerance and skills mainly long work hours with no other physical limits; Psychological limits linked to coping with stress, adaptation to illness, anxiety and depression Treatment : Discussion and training with patient on enhancement of stress coping skills, time management and delegation skills, through situational analysis and cognitive restructuring techniques Suggest patient to trial discussion with company on his condition and the corresponding measures that the company can offered, part-time trial was stepped out and patient can gradually cope with the job.

4. Stress management and relaxation class * Counseling on stress coping with identification of stressor and bodily response, promotion of positive thinking with CBT technique * Practice of various relaxation techniques like deep breathing, use of progressive muscular relaxation, patient attend group classes once a week with home practice introduced

5. Lifestyle modifications * Education on concept of healthy lifestyle and self management of disease * Happiness inducing occupations with self-review, use of log sheet introduced

OUTCOME (March 2008) : 1)Physical and functional decreases activity tolerance and upper limb strength * SAS Class II I, Monitored functional task : Carry 24 lbs for 1 FOS up/down, HR 72 96 (57% age predicted max HR), SpO2 99% 98%, BP 88/58mmhg 95/60mmhg,RPD 0 2, RPE 6 9, asymptomatic * ADL and IADL fully independent, activity tolerance 4-5 FOS * No more sternal wound pain, scar measures 10cm x 0.1 cm with flesh color, not raised, no signs of hypertrophy * Upper limb ROM full, muscle strength grade 5 2) Work patient on sick leave, very hesitated and had no concrete plan on return to work upon 6 weeks from operation * Patient had discuss with his employer and has started part-time duty after lunar new year i.e. Feb 2008 with decrease of work load especially the stock market at the moment * Patient regained confidence at work and returned full duty on April 2008

3) Psychological anxious and decreased subjective well-being * Sleeping improved and subjective improve general wellness * Stress VAS 9/10 4/10 * HADS Anxiety 10/21 6/21, Depression 6/21 2/21 * QOL Physical 14/20 16/20, Psychological 15/20 16/20, Social 16/20 16/20, Environmental 15/20 16/20 4) Lifestyle sedentary and lack of concept on health maintenance * Had regular exercise (three times a week, light jogging 30 mins), diet control * Spend more time on enjoyable activities especially family gathering like tracking, going to parks 5) Other professional findings *Exercise stress test : 5.4 METS changes *Echo : LVEF 30 % 42.5%

13.4 METS achieved with nil ischemic ST