2. Low-risk Cardiac Patient Case Study Andrew Gerhard, H.BSc(Kin),C.K. Cardiac Rehabilitation Centre Hôpital régional de Sudbury Regional Hospital

3. Basic Demographics Mr. Homer Simpson 41 year old male Married, 3 children Employed at power plant Leisure activities include bowling, watching TV

4. Medical History 5-year history of angina on exertion Angina unstable over last 2½ years ‘Positive’ stress test result Angiogram: severe triple vessel disease Grade 1 ventricle, 65% ejection fraction CABG X5 three weeks ago

5. Coronary Risk Factors Modifiable DYSLIPIDEMIA On Pravachol with good control Total Chol: 3.63 mmol/l LDL Chol: 1.99 mmol/l HDL Chol: 1.29 mmol/l TC/HDL: 2.81 Triglycerides: 0.78 mmol/l

6. Coronary Risk Factors Modifiable Overweight Ht: 5’9” Wt: 255 lb. BMI: 39 Waist/hip ratio: 1.4

7. Coronary Risk Factors Modifiable PSYCHOLOGICAL ISSUES / STRESS no drug plan financial stress employer not co-operative in providing modified return to work

8. Coronary Risk Factors Nonmodifiable FAMILY HISTORY Homer’s brother died at age 51 from a MI

9. Clinical Examination Pulse: 80/min and regular Bp: 128/80 Chest and left leg incisions clean, dry and intact A / E clear bilaterally Mild edema to left ankle bilateral B/K TED stockings

10. Medications Pravachol - 40 mg OD Metoprolol - 50 mg BID EC ASA - 325 mg OD

11. Functional Capacity Routine stress test post CABG Completed Stage IV Bruce Protocol 12.5 METS (4.2 mph, 16% grade) Non-ischemic

12. Risk Stratification Risk of Disease Progression: 2.6 Risk of Acute Event: 0 Total score: 2.6

13. Risk Factor Management Obesity and Dyslipidemia Diet: Follow Canada’s Food Guide or AHA Step 1 diet Set reasonable weight goal Emphasize positive results from small weight loss

14. Risk Factor Management Obesity and Dyslipidemia Exercise: Expect compliance issues Provide frequent initial support Set specific goals / rewards Encourage social support

15. Risk Factor Management Obesity and Dyslipidemia Exercise: FITT principle F- 3 to 5 times a week I- HR 30 beats above resting T- From 15 minutes a day initial to 40 minutes per day after 3 months T- Walking or cycling

16. Risk Factor Management Stress Management Medication Expenses Explore less costly medication substitutions Ask physician for sample medications Explore “Trillium Foundation”

17. Risk Factor Management Stress Management Vocational Issues Can safely sustain work < 50% of max MET level (< than 6 METS) Corresponds to medium work level (up to 50lb handled on occasional basis) Need to have PDA of job

18. Risk Factor Management Stress Management Vocational Issues Fear plays biggest factor Employer not required to modify job Get help from OH&S department, LTD provider