1. Cardiac Rehabilitation Presented By: Dr. Ramesh Tharwani Consultant Cardiologist Choithram Hospital

2. “Integrated Treatment to regain physical function, promoting emotional adjustment, secondary prevention of cardiac events and lead active life.”

3. Target Patient Groups Following Myocardial Infarct Post PTCA/CABG Chronic Stable Angina Congestive Heart Failure Pacemaker/Valve surgery

4. Coronary artery bypass surgery

5. Coronary Intervention

6. Long Term Mortality Benefits

7. GOALS Daily Activities  Active lifestyle Emotional/Psychological adjustment Diet/Exercise Sexual Activity Risk Factor Reduction Smoking cessation

8. Assessment SYMPTOMS : Chest Pain, SOB, Palpitations EXAMINATION : CHF, Wound, Concurrent Illness, Musculo-Skeletal disease, Emotional Status(Anxiety/Depression) DIAGNOSTIC STUDIES : Lipid Profile, Hb A1C, PFT ECG before exercise/Telemetry STRESS TEST : Sub maximal modified NAUGHTON’S > 5-7 METS > 80-85% THR

9. ERGOMETER : Knee/Lower limb problems, Neuro/Ortho Limitation ECHO : LV functions, RWMA STRESS THALLIUM : Viable Myocardium Useful in patients with abnormal ECG’s like LBBB, WPW VO 2 Max with Stress Test to differentiate between Cardiac and Pulmonary dyspnoea.

10. Initial Phase Risk Factor Reduction : Optimal Medical Management Avoid Increase/Decrease BP, No Angina on daily activities Smoking Cessation : Psycho Counseling + Drugs (Buprobion HCL, Nicotine Patch) Diet Advice : Low Cholesterol, Less than 30% calories from fats Decrease Emotional Stress : Relaxation Techniques, YOGA

11. Initial Phase contd.. Sexual Activities : 3-5 METS, 2 flight stair Test Return to Work/ Recreational Activities : > 3-5 METS Self Care/Daily activities > 5-7 METS Sedentary Work (Table Work) > More than 7 METS Normal Vocational activities (Back To Work). Avoid Heavy physical work. Playing Tennis 4-7 METS Golf 2-5 METS Volley ball 3-4 METS

12. Exercise Training (Rehabilitation) Walking for 15-30 mins /3-5 times a week Patient can still talk while walking (Brisk Walk for initial 2 weeks) Contra indication to exercise training > Unstable Angina >Resting BP more than 200 mm/ 100 mm Hg >Postural BP drop to more than 20 mm Hg >Aortic Stenosis >Acute illness or fever >Uncontrolled Atrial or Ventricular Arrhythmias >Uncontrolled CHF >Recent ST Displacement(More than 3 mm Hg) >Musculo-Skeletal Disorders

13. Exercise Prescription Aerobic Exercise preferred than resistive or weight training Walking/Cycling Intensity/Frequency/Duration will depend on tolerance THR (220- Age in years) try to achieve 80-85% THR 66% MET of level of completed TMT or 25 watts less than completed stage on cycle Ergometer Borg scale target 11-15

14. Exercise Prescription contd. Exercise session  Warm Up (2-5 mins)  Stimulus (conditioning 20-30 mins)  Cool Down (5-10 mins, slow speed, prevents low BP and joint pains) Graded Exercise with telemetry in high risk population recommended. 1-3 months Target 7-8 METS followed by self directed maintenance

15. Benefits of Cardiac Rehabilitation in old age

16. Benefits of Exercise Training  work capacity  fatigue  Heart rate during Exercise  RPP  symptoms of CHF  Atherogenicity by maintaining body weight  HDL  TG  platelet aggregation Improve blood glucose level Improves coronary blood flow and myocardial perfusion

17. Benefits of Exercise Training contd. Endurance Training –  VO 2 max 10-40%,  BP,  HR –  BMD Positive changes in body composition –  body weight (1-3 kg),  % fat (1-3%) Positive metabolic changes –  insulin sensitivity,  cholesterol Resistance Training –  strength 150%

18. Conclusions Cardiac rehab is feasible and safe in an octagenarian patient population Exercise training yields clinically significant functional and metabolic improvements for both men and women –33%  in exercise time –20%  in functional capacity (est. METs) –9%  in HDL cholesterol

19. Potential Treatment complications MACE ( Massive Adverse Cardiac Events) 1 per 300,000 hours of exercise SCD ( Sudden Cardiac Death ) 1 per 800,000 person hours of exercise Proper Selection of cases/ avoiding Contra indications to exercise training can minimize the risk.

20. Thank you all