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Cardiac Rehabilitation

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Cardiac Rehabilitation, Activity after Myocardial Infarction

  • See Also
  1. Chest Pain
  2. Cardiac Risk Factors
  3. Angina
  4. Angina Diagnosis
  5. Unstable Angina
  6. TIMI Risk Score
  7. Acute Coronary Syndrome
  8. Acute Coronary Syndrome Immediate Management
  9. Acute Coronary Syndrome Adjunctive Therapy
  10. High Risk Acute Coronary Syndrome Management
  11. Moderate Risk Acute Coronary Syndrome Management
  12. Low Risk Acute Coronary Syndrome Management
  13. Myocardial Infarction Stabilization
  14. Serum Cardiac Markers
  15. Electrocardiogram in Myocardial Infarction
  16. Echocardiogram in Myocardial Infarction
  17. Goldman Criteria for ICU Chest Pain Admission
  • Background
  1. Cardiac Rehabilitation is under-utilized by Medicare-eligible indications (only 14-31% participation)
  2. Cardiac Rehabilitation has great efficacy as a secondary prevention tool
  • Indications
  1. Medicare reimbursed indications (3 sesssions per week for 3 months)
    1. Following acute Myocardial Infarction (STEMI or non-STEMI) in the last 12 months
    2. Status-post Coronary Artery Bypass Graft (CABG)
    3. Status-post Percutaneous Coronary Intervention (PCI)
    4. Stable Angina Pectoris
    5. Status-post Vascular Surgery
    6. Status-post Heart Transplantation
    7. Status-post Heart Valve Repair or Replacement
    8. Recent CVA (women only)
  2. Other indications
    1. Stable Congestive Heart Failure with reduced left-ventricular ejection fraction
    2. Peripheral Arterial Disease
    3. Status-post Ventricular Assist Device placement
    4. Pacemaker or Implantable Cardioverter-Defibrillator
  • Protocol
  • Cardiac Rehabilitation Phases
  1. General
    1. Standard programs
      1. Exercise training program for a total of a 36 session program over 12 weeks
      2. Medicare covers up to two, 1 hour sessions per day
    2. Intensive programs (limited availability)
      1. Intensive programs may include up to 72 sessions over up to 18 weeks
      2. Medicare approved programs
        1. Dean Ornish Program for Reversing Heart Disease
        2. Pritikin Intensive Cardiac Rehab Program
        3. Benson-Henry Institute Cardiac Wellness Program
  2. Phase I Cardiac Rehabilitation (during hospitalization for acute event or procedure)
    1. Supervised, structured early Physical Activity
    2. Patient Education
    3. Risk stratification (low level, graded, Exercise tolerance testing)
  3. Phase II Cardiac Rehabilitation (Early Outpatient)
    1. Supervised Physical Activity program
      1. Reassess symptom-limited Exercise tolerance
      2. Custom tailored Exercise Prescription for 30 minutes daily and 5 days weekly
    2. Monitoring of Blood Pressure, pulse, cardiac rhythm
      1. Maintain Blood Pressure <140/90 mmHg
    3. Nutrition counseling
      1. May involve education on cooking and grocery shopping
      2. Diabetes Mellitus Type II control with Hemoglobin A1C <8%
      3. LDL Cholesterol <100 mg/dl (preferable <70 mg/dl)
      4. Body Mass Index reduction towards goal of <27 kg/m2 (ideally <25 kg/m2)
    4. Cardiac Risk Factor modification
      1. Tobacco Cessation
    5. Reassess cardiac symptoms at rest and with activity
    6. Psychosocial support to screen for and manage Major Depression
  4. Phase III Cardiac Rehabilitation (Late Outpatient)
    1. Maintain and reinforce phase I and II management
    2. Reinforce medication use, Patient Education
  1. Gradually increase activity over 6-8 weeks following MI
  2. Return to work by 8 weeks after MI
  3. Activity program may start by 3-4 weeks after MI
  4. Sexual activity restarted at 4-6 weeks after MI
    1. See Sexual Intercourse after Myocardial Infarction
  • Protocol
  • Other Measures
  1. Influenza Vaccine each year
  • Efficacy
  1. Reduced Angina, Dyspnea, and Fatigue
  2. Reduced Major Depression after acute coronary event
  3. Exercise performance improved
  4. Activities of Daily Living (ADL) performance improved
  5. Quality of life improved
  6. Decreased re-hospitalization rate
  7. Decreased work absence
  8. Reduced age-adjusted cardiovascular mortality by 50%
  9. References
    1. Bondestam (1995) Am J Cardiol 75:767-71 [PubMed]
    2. Milani (2007) Am J Med 120(9): 799-806 [PubMed]
  • References
  1. Leon (2005) Circulation 111(3): 369-76 [PubMed]
  2. Stephens (2009) Am Fam Physician 80(9): 955-60 [PubMed]
  3. Servey (2016) Am Fam Physician 94(1): 37-43 [PubMed]
  4. Wenger (2008) J Am Coll Cardiol 51(17): 1619-31 [PubMed]