Exercise Management CABG and PTCA Chapter 07

Exercise Management – CABG and PTCA CABG – Coronary Artery Bypass Graft Surgery PTCA – Percutaneous Transluminal Coronary Angioplasty, aka. Percutaneous Coronary Intervention Coronary Artery Occlusion Pathophysiology Coronary Atherosclerosis Significant Plaque Occlusion >75 % Progression of disease requires revascularization

Exercise Management – CABG and PTCA Purpose of Revascularization ↑Myocardial blood flow and O2 delivery beyond an obstructive arterial lesion ↓ or eliminate myocardial ischemia, including ST-segment changes, angina, ventricular arrhythmias, or combinations thereof ↓ cardiovascular mortality and morbidity Movie Demonstration PTCA (PCI)

Exercise Management – CABG and PTCA Indications for CABG (follows cardiac cath.) Relief of angina when pharmacologic therapy is ineffective When PTCA is contraindicated Prolong life in patient with multiple artery, or main artery disease, in patient with ventricular dysfunction due to vascular disease Preserve LV function, especially following an MI that has already compromised LV function

Exercise Management – CABG and PTCA CABG are performed on patients who have multiple vessel disease and poor ventricular function, and poor LV ejection fraction. Complications include infarction following surgery and (saphenous) grafts tend to remain open 90% at 1 year, 80% at 5 years, and 60% at 11 years post surgery. Mammary grafts have 93%, 10 yr patency (remain open) The greatest incidence of graft occlusion occurs between 5-8 years post surgery Total relief of angina is typically 70% at 5 years, approx. 50% are asymptomatic at 10 years

Exercise Management – CABG and PTCA Indications and Concerns for PTCA Originally the choice for single vessel disease Now used to treat multiple vessel disease, impaired LV function, and to open an acute occlusion during an MI If PTCA fails then CABG is used during surgery PTCA is less invasive and requires a shorter hospital stay Arterial injury, thrombosis, and restenosis are the major complications of PTCA PTCA stints can now be coated with anti-thrombic agents to help prevent restenosis.

Exercise Management – CABG and PTCA Indications and Concerns for PTCA (PCI) Risks and Complications: Low risk symptomatic patients may not benefit any more from PCI than with conservative treatments PCI may involve: Bleeding at the catheter insertion site Blood clot or damage to the blood vessel at the insertion site Blood clot within the vessel treated with PCI Infection at the catheter insertion site Cardiac dysrhythmias /arrhythmias MI Rupture of Coronary Artery

Exercise Management – CABG and PTCA Benefits of PTCA (PCI) Increases myocardial blood flow, thus: Correct ischemic complications reflected in exercise ECG response (T wave inversion and ST-depression) Reduce angina on exertion Increase PWC (physical work capacity) Improve Oxygen supply and demand (MVO2) and improve contractility and hemodynamic function May improve post-exercise chronotropic impairment, and reduce the risk of hypotensive response (reducing likelihood of pre-syncope)

Exercise Management – CABG and PTCA Effects of Exercise Training Many results are similar to those with post MI ↑ Max Vo2 (mean 20%) ↓ myocardial demand (↓ Submax HR and SBP for given workload) ↑ glucose metabolism, ↓ insulin resistance, and other typical changes in blood lipid profiles. In patients with stable CAD, PTCA (PCI) who undertook a 12 month training program resulted in a higher (event-free) survival rate. Each 1 MET increase in exercise appears to confer 8-17% reduction in mortality.

Exercise Management – CABG and PTCA Management and Medications Attempt to slow, halt, or reverse the progression of atherosclerosis through medication and health behavior management (diet, exercise, stress management), while maintaining the integrity of the vasculature addressed during surgery. Poor prognosis includes: 1) recurrent angina, 2) pre-syncope, syncope, and 3) threatening forms of ventricular ectopy (multiform PVC, couplets, V-tach ) Repeat PTCA is the usual treatment for restenosis.

Exercise Management – CABG and PTCA Recommendations for Exercise Testing Exercise testing may begin earlier than for post MI patients (CABG = 3-5 weeks, PTCA 2-5 weeks) Cycle and Treadmill Tests commonly used with CABG due to incision pain in the sternum area Retest procedures should follow for any patients who are symptomatic within 5 years, and all patients after five years. The combination of perfusion and exercise testing can detect ischemia and restenosis.

Exercise Management – CABG and PTCA Recommendations for Exercise Testing Supine cycle ergometry and echocardiography may be used to dectect wall function abnormalities and provide prognostic information for risk assessment if clinical restenosis. ST-segment changes, CP, or both present in the follow-up exercise test (2-5 weeks) may be indicative or restenosis .

Exercise Management – CABG and PTCA

Exercise Management – CABG and PTCA Recommendations for Programming (see chart p. 63, also below) Significant increases in functional capacity and ADL will occur in the weeks following CABG and PTCA ( improved myocardial supply) CABG and PTCA patients can typically begin exercise programming sooner and at a more accelerated rate than post MI patients. ROM exercises are indicated for CABG patients and contraindicated with excessive sternal movements. Individuals with > 4 MET capacity and who complete 12 week programs have less mortality risk

Exercise Management – CABG and PTCA Recommendations for Programming (see chart p. 63) CABG and PTCA may begin inpatient exercise rehabilitation sooner than post MI and; Progress at a more accelerated rate, and Devote more attention to upper extremity ROM CABG focused ROM - 1) Shoulder ROM exercises; 2) Hip ROM exercises; Ankle ROM exercises.

Exercise Management – CABG and PTCA

Exercise Management – CABG and PTCA End of Presentation