This document discusses cardiac rehabilitation (CR) programs. It provides an overview of CR, including that it is an underutilized treatment for cardiovascular disease. CR aims to improve physical and emotional condition through exercise, education, and behavior modification. Eligible patients include those who have had a heart attack, stents, bypass surgery, heart failure, or stroke. The document outlines the components of a CR program, including exercise training, education sessions, assessments, and a team-based approach. It discusses measuring outcomes like improved physical fitness and reducing risk factors. Finally, it emphasizes the benefits of CR in improving physical function, mental health, and quality of life.

1. 22ND OCTOBER 2019
Exercising at all ages – the Cardiac
Rehabilitation experience

2. Overview
 Cardiac Rehabilitation: An underutilized Class 1
Treatment for Cardiovascular Disease
 CR is a comprehensive exercise, education and behaviour
modification program designed to improve the physical
and emotional condition of patients with heart disease.
 Prescribed to control symptoms, improve exercise
tolerance, and improve overall quality of life
 The primary goal of CR is to enable the participant to
achieve his/her optimal physical, psychological, social
and vocational functioning through exercise training and
lifestyle change.
AACVPR American Association of Cardiovascular and Pulmonary Rehabilitation

3. Eligible patients for referral to CR include:
 Class 1 indication for:
 Myocardial infarction, coronary stents, CABG, stable
angina, heart failure, heart valve surgery, congenital
heart disease.
 Mild to moderate Stroke
____________________________________

4. Addressing Needs
 Class 1 treatment post heart attack, coronary stents, coronary
bypass surgery, valve surgery. Standards - AACVPR ESC
 Improved clinical outcomes after stroke, ICD, cardiac arrest,
atrial fibrillation, heart failure.
 HOW- post-procedure information, then early clinical
outpatient programs – twice per week over 8 weeks (at Mater)
 Assessments – includes Treadmill stress tests pre and post.
 ECG telemetry – monitoring exercise intensity, ST changes,
rhythm
 Team approach to prevention and supports. Psychologist
essential.

5. Programme, and outcomes measured
 Referral
 Invitation Letter to Patient for Introductory session
 Exercise test (TMET, Bruce or Modified Bruce)
 Programmes, 8 weeks, with 10 patients per group.
 16 exercise sessions, telemetry monitoring, exercise
circuit on equipment.
 8 group talks
 1 individual session, CV risk factors and feedback.
 Psychological questionnaires (HADs) pre and post,
bloods, BP (ABPM if indicated), referrals/signposting as
indicated. Reports to Consultant and GP.
 Evaluation and Database

6. Exercise, Physical Activity, Physical Function
 Physical Activity PA, is defined as any bodily movement produced by
skeletal muscles that result in energy expenditure. PA encompasses
exercise, sports and physical activities performed as part of daily living,
occupation, leisure or active transportation.
 Exercise is a subcategory of PA that is planned, structured and
repetitive for improvement or maintenance of physical fitness.
 Physical Function is the capacity of an individual to perform the
physical activities of daily living. (Garber C et al)

7. Exercise – in practice
 Aerobic – walking, cycling, swimming
 150 minutes per week – good health, 300 minutes
per week for prevention
 Strength-training, twice per week
 Balance
 Flexibilty
 Value of monitoring and group-training

8. Outcomes measured
 Improvement to physical functioning is the focus of
the clinical exercise component of Cardiac Rehab.
 Measurements in the form of Cardiopulmonary
treadmill test, or ECG exercise test
 Metabolic equivalents: A MET is the ratio of the rate
of energy expended during an activity to the rate of
energy expended at rest.
 1-MET increase in Cardiorespiratory Fitness (CRF) is
associated with a 25% reduction in mortality. (Mayo
Clinic). Mater: average 2.5-3 MET improvement.

9. Measuring and addressing outcomes
 Physical: fitness, functioning – return to daily
activities/work
 Prevention:Risk factors – lipids, HbA1C, Blood
pressure, smoking, diet, alcohol
 Emotional adjustment: Stress, vulnerability,
confidence, anxiety, overwhelm, depression, post-
trauma.
 Patient safety and experience.

10. Improve access and capacity
 Early CR: Remodelling of heart, knowledge,
optimum prevention and meds, anxiety,
confidence
 Need for investment in Hospital-based and
Outreach programs programmes – Clinical
Governance and expertise, safety, standards,
Outcomes
 Links with Community-based exercise programs.

11. Psychological impact:
“Approx. 33% of people need further psychological support:
- to cope with the anxiety or sense of feeling overwhelmed
- they need help to adapt to their new lifestyle differently and figure
out how to care for themselves differently, including their emotional
care . Often this is the first brush with mortality which can be a very
shocking experience, as human beings we operate in a certain level of
denial of our mortality in order to cope with our day to day so that
when this is challenged we can feel in shock and vulnerable and
usually find it difficult to be in need of care or feel fragile.
- The most common emotional difficulties in the aftermath of cardiac
event include anxiety, low mood & overwhelm, grief, frustration,
difficulties adjusting and less frequently post traumatic symptoms.”
- Dr. Sinead Mulhern, Principal Clinical Psychologist at MMUH

12. The patient experience - feedback
 Recent focus group by IHF
 “Absolute need for these programs in hospitals –
need for clinical staff and monitoring crucial in early
part of recovery”
 “A place where issues are picked up – critical aspect”
 “The sense of vulnerability after treatment”
 “The group dynamic really helped”

13. Rationale for change at all ages
 Physical function
 Activities of daily living
 Independence
 Return to work
 Return to sports
 Confidence
 Mental health

16. •CASP-19
•Control – the ability to actively participate in
one’s environment (eg My age prevents me
from doing the things I would like to do)
•Autonomy – the right of the individual to be
free from the unwanted interference of others
(e.g., ‘I can do the things that I want to do’).
•Self-realisation – the fulfilment of one’s
potential (e.g., ‘I feel that life is full of
opportunities’).
•Pleasure – the sense of happiness or
enjoyment derived from engaging with life (e.g.,
‘I look forward to each day’).
TILDA Health and wellbeing > 50’s 2009-2016

17. Control
1.1 My age prevents me from doing the things I would like to do
2.2 I feel that what happens to me is out of my control
3.3 I feel free to plan for the future
4.4 I feel left out of things
Autonomy
5.5 I can do the things that I want to do
6.6 Family responsibilities prevent me from doing what I want to do
7.7 I feel that I can please myself what I do
8.8 My health stops me from doing things I want to do
9.9 Shortage of money stops me from doing things I want to do
Pleasure
10.10 I look forward to each day
11.11 I feel that my life has meaning
12.12 I enjoy the things that I do
13.13 I enjoy being in the company of others
14.14 On balance, I look back on my life with a sense of happiness
Self-realisation
15.15 I feel full of energy these days
16.16 I choose to do things that I have never done before
17.17 I feel satisfied with the way my life has turned out
18.18 I feel that life is full of opportunities
19.19 I feel that the future looks good for me