Dr.

Luh Kamiati, SpKFR

Bagian Ilmu Kedokteran Fisik dan Rehabilitasi
FK .UNUD/ SMF.Rehabilitasi Medik,RSUP Sanglah,
Denpasar

DEFINITIONS:
Cardiac Rehabilitation is a multidisciplinary
program of education and exercise
established to assist individuals with heart
disease in achieving optimal physical,
psychological, and functional status within the
limits of their disease

Cardiac rehabilitation

is the process by which patients with cardiac

disease, in partnership with a multidisciplinary
team of health professionals, are encouraged
and supported to achieve and maintain
optimal physical and psychosocial health.
The involvement of partners, other family

members, and carers is also important.

Cardiac Rehabilitation Program

consist of :
Primary preventions

Focus on the reduction of cardiac risk factors :

- education, ideally started in schools with parental support
- physical activity ( decrease obesity, lower SBP, modifies
lipid profiles )
- should begin in childhood
- in order to establish helthy behavior patterns of life

Secondary prevention
-

include all of the features of primary prevention programs

decreases second cardiac event
lowers mortality post-MI
improve hypertension and Diabetes management

GOALS OF THE CARDIOVASCULAR

REHABILITATION
To prevent the harmful effects of prolonged

immobilization.
To develop cardiovascular fitness after acut illness
To maximize exercise tolerance and ADL performance
To control risk factors for coronary artery disease (CAD)
To provide guidelines for safe activities and work
To help patiens cope with perceived stressor
To improve quality of life
through program : - education
- behavior modification
- secondary prevention and exercise-- to resume
activities of normal life without significant cardiacsymptom

Candidates for Cardiac

Rehabilitation
Myocardial Infarction
Post CABG
Post coronary angioplasty
Post valve replacement
Postvalvuloplasty
Post surgical congenital cardiac
Post cardiac transplatation
Compensated CHF / Cardiomyopathy
Chronic stable angina
Risk Factor CAD

Contra Indication Exercise

Heart rate increase > 50 / minute
BP systolic > 210 mmHg, Diastolic > 110 mmHg
Unstable angina
Heart failure acute
Uncontrolled arrhytmias
Moderate / severe aortic stenosis
Decompensated CHF
Acute systemic illness/ fever
Active pericarditis/myocarditis
Embolism
Thrombophlebhitis acute
Resting ST diplacement > 3 mm
Uncontrolled diabetes

Coronary Artery Disease ( CAD )

Risk Factors
Reversible risks :

Sedentary lifestyle
Cigarette smoking
Hypertension
Low HDL cholesterol ( < 0.9
mmol/L [35 mg / DL ] )
Hypercholesterolemia ( >
5.20 mmol/L [200 mg / DL ])
High lipoprotein A
Abdominal obesity
Hypertriglyceridemia ( >2.8
mmol/L [250 mg / DL] )
Hyperinsulinemia
Diabetes mellitus

Irreversible risks :
Age
Male gender
Family history of premature

CAD ( before age 55 in a

parent or sibling )
Past history of CAD
Past history of occlusive
peripheral vascular disease
Past history of
cerebrovascular disease

Outcome Cardiovascular
Rehab
Decreased length of hospital stay.
More rapid and complete resumption of usual

activities
Increased self confident
Fewer readmission
Less psychological distress
Improve quality of life

MYOCARD INFARCT ( MI )
Post MI Rehabilitation

Classic model as first described by Wenger et al

:
Phase I (acute phase)
Phase II (convalescent phase)
Phase III
(training phase)
Phase IV
(maintenance phase)

Phase I :
Acute Phase Rehabilitation
Immediately following the MI up to discharge :
Early mobilization to prevent complication of
prolonged immobilization
Alleviation of anxiety and depression
Establish modifiable risk factor reduction
strategies
Prescription and education with guidelines for
activity and work after discharge

Phase II :
Convalescent Phase
Its done at home
Rehabilitation
Continues the program started in phase I
until the myocardial scar has matured :
To achieve cardiovascular conditioning and
fitness via aerobic exercise
To achieve control modifiable risk factors
using physical activity,psychosocial and
pharmacologic interventions and lifestyle
changes
To an early return to work

Phase III
The Training Phase
Usually starts after 4 6 weeks
Conditioning exercise program and education

Phase IV
The Maintenance phase
To keeping the aerobic conditioning gains
Be taught risk-factor modifications

CARDIOMYOPATHY
the most common cardiomyopathies are

the dilated and hypertrophic varieties.

Careful exercise training may result in
sufficient peripheral cardivascular and
musculoskeletal adaptation for there to be
significant improvement in effort tolerance.
Can transform a totally dependent person
into one capable of independent self-care
and even of training for a sedentary job.

Exercise capacity may not correlate

with left ventricular function in the

individual patient
The special needs of patient with

cardiomyopathies include strict medical

management of congestive failure and
arrhythmias ( need long-term
anticoagulation in dilated
cardimyopathy )

Only low-intensity exercise should be

undertaken by patients with

hypertropic cardiomyopathy because
of the increased risk of sudden death

CHF Rehabilitation
EFFECT EXERCISE:
Improvement exercise tolerance
Improvement cardiopulmonary function
Reduce patient symptoms

Guideline for Exercise in

CHF
Aerobic exercise
Intensity

: sub maximal
Duration
: 20 45 min
Frequency
: 2 5 X/week
Prolonged warm ups and cool downs
Avoided isometric exercise

GUIDELINE FOR GRADUATED ACTIVITY AFTER DISMISSAL

FROM THE HOSPITAL AFTER A MYOCARDIAL INFARCTION
table 21 5, Sinaki M , Basic Clinical Rehabilitation Medicine,St.Louis,
Mosby, 1993
ACTIVITY

METs

mL 02. kg-1
.min -1

Kcal / min
(70 kg person
)

WEEK 1
Any light activity that can be done
while sitting
Walking, 1 2 mph , on level
Stationary cycling , minimal
resistance
Light household work
dishes or meal
preparation ( alternate with
rest periods )
dusting
sweeping
Personal hygiene
shaving
showering
dressing

1.5 - 3

5 - 11

2-4

GUIDELINE FOR GRADUATED ACTIVITY AFTER DISMISSAL

FROM THE HOSPITAL AFTER A MYOCARDIAL INFARCTION
ACTIVITY

METs

mL 02. kg-1
.min -1

Kcal / min
(70 kg person
)

WEEK 2
Increased social activity
playing cards at home
visiting neighbors
card riding
Walking, 2 - 4 mph , on level
Stationary cycling , slight resistance
increased household work
bed making
ironing
minor appliance repair
bench work
supervising farm work

11 - 14

4-5

GUIDELINE FOR GRADUATED ACTIVITY AFTER DISMISSAL

FROM THE HOSPITAL AFTER A MYOCARDIAL INFARCTION

ACTIVITY

METs

mL 02. kg-1
.min -1

Kcal / min
(70 kg person
)

WEEK 3
Driving with another driver present
Household work, vaccuming
Resumption of sexual intercourse
Social activity
movies
church
conceds
walking, 3 4 mph
Stationary cycling , slight resistance
Lifting , 10 15 lb

14 - 15

5-6

GUIDELINE FOR GRADUATED ACTIVITY AFTER DISMISSAL

FROM THE HOSPITAL AFTER A MYOCARDIAL INFARCTION
tabel 21 5, Sinaki M, Basic Clinical Rehabilitation Medicine, St.Louis,
Mosby,1993
ACTIVITY

METs

mL 02. kg-1
.min -1

Kcal / min
(70 kg person
)

WEEK 4
Potential return to part-time work
Driving alone
Light gardening
Pitch and pull golfing
Social group activities
club meetings
parties
dancing
grocery shopping ( no heavy lifting )
walking, stationary cycling

<6

18 21

6-7

Phases of Cardiac
Rehabilitation

Table 21-3. Sinaki M, Basic Clinical Rehabilitation Medicine, St. Louis, Mosby,
1993

Phase

Type of Program

Duration

inpatient

days

Outpatient, immediate interval after

hospitalization

2 12 weeks

Late recovery period

Minimum of 9
months beyond
phase 2

Maintenance program

indefinite

Mayo Clinic Inpatient Physical Activity Protocol

for Cardiac Rehabilitation
Table 21.4, Sinaki M, Basic Clinical Rehabilitation Medicine, St. Louis, Mosby, 1993

Days of Program
Sta
ge

6Day
Plan

9Day
Plan

12Day
Plan

Use bedside commode. Begin physical

therapy range of-motion exercises to
each extremity. Sit at side of bed for 5 to
10 minutes

Sit in chair for 5 to 15 minutes twice daily.

Begin education program at bedside.
Continue physical therapy describe above

Sit in chair for up to 30 minutes twice

daily. Continue physical therapy describe
above

Activity Schedule

Mayo Clinic Inpatient Physical Activity Protocol

for Cardiac Rehabilitation
Table 21.4, Sinaki M, Basic Clinical Rehabilitation Medicine, St. Louis, Mosby, 1993

Days of Program
Sta
ge
2

6-Day
Plan

9Day
Plan

12Day
Plan

Move to step-down area. Bathe above

waist, shave, and comb hair. Begin selfexercise program supervised by physical
therapist. Sit in chair for 60 to 120
minutes twice daily.

continue self-exercise program supervised

by physical therapist. Begin ambulation
with physical therapist . Sit in chair for 90
150 minutes twice daily. Begin attending
education classes and discussion groups

Take wheelchair shower and use bathroom

ad lib. Continue physical therapy as

Activity Schedule

Mayo Clinic Inpatient Physical Activity Protocol

for Cardiac Rehabilitation
Table 21.4, Sinaki M, Basic Clinical Rehabilitation Medicine, St. Louis, Mosby, 1993

Days of Program
Sta
ge

6Day
Plan

9Day
Plan

12Day
Plan

Activity Schedule

Move to general cardiovacular ward . Dress

in street clothes if desire. Be up and
around room as tolerated. Begin climbing
stairs with physical therapist.

11

Take predismissal graded-exercise test.

Continue physical therapy as described
above. Take standing shower.

12

Receive final intructions before going

home

BORG PERCEIVED EXERTION SCALE

Table 21-6, Sinaki M, Basic Clinical Rehabilitation Medicine, St.Louis, Mosby,
1993

SCALE

EXERTION

6
7

Very, very light

8
9

Very light

10
11
12

Fairly light

13
14

Somewhat hand

15
16

hard

17
18

Very hard

19
20

Very, very hard