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Cardiac Rehabilitation
Aka: Cardiac Rehabilitation, Activity after Myocardial Infarction
- Background
- Cardiac Rehabilitation is under-utilized by Medicare-eligible indications (only 14-31% participation)
- Cardiac Rehabilitation has great efficacy as a secondary prevention tool
- Indications
- Medicare reimbursed indications (3 sesssions per week for 3 months)
- Following acute Myocardial Infarction (STEMI or non-STEMI)
- Status-post Coronary Artery Bypass Graft (CABG)
- Status-post Percutaneous Coronary Intervention (PCI)
- Stable Angina Pectoris
- Status-post Vascular Surgery
- Status-post Heart Transplantation
- Status-post Heart Valve Repair or Replacement
- Other indications
- Stable Congestive Heart Failure
- Peripheral Arterial Disease
- Status-post ventricular assist device placement
- Protocol: Cardiac Rehabilitation Phases
- Phase I Cardiac Rehabilitation (during hospitalization for acute event or procedure)
- Supervised, structured early Physical Activity
- Patient Education
- Risk stratification (low level, graded, Exercise tolerance testing)
- Phase II Cardiac Rehabilitation (Early Outpatient)
- Supervised Physical Activity program
- Reassess symptom-limited Exercise tolerance
- Custom tailored Exercise Prescription for 30 minutes daily and 5 days weekly
- Monitoring of Blood Pressure, pulse, cardiac rhythm
- Maintain Blood Pressure <140/90 mmHg
- Nutrition counseling
- Diabetes Mellitus Type II control with Hemoglobin A1C <8%
- LDL Cholesterol <100 mg/dl (preferable <70 mg/dl)
- Body Mass Index reduction towards goal of <27 kg/m2 (ideally <25 kg/m2)
- Cardiac Risk Factor modification
- Tobacco Cessation
- Reassess cardiac symptoms at rest and with activity
- Psychosocial support to screen for and manage Major Depression
- Phase III Cardiac Rehabilitation (Late Outpatient)
- Maintain and reinforce phase I and II management
- Reinforce medication use, Patient Education
- Protocol: Activity restrictions following acute Myocardial Infarction
- Gradually increase activity over 6-8 weeks following MI
- Return to work by 8 weeks after MI
- Activity program may start by 3-4 weeks after MI
- Sexual activity restarted at 4-6 weeks after MI
- See Sexual Intercourse after Myocardial Infarction
- Efficacy
- Reduced Angina, Dyspnea, and Fatigue
- Reduced Major Depression after acute coronary event
- Exercise performance improved
- Activities of Daily Living (ADL) performance improved
- Quality of life improved
- Decreased re-hospitalization rate
- Decreased work absence
- Reduced age-adjusted cardiovascular mortality by 50%
- References
- Bondestam (1995) Am J Cardiol 75:767-71
- Milani (2007) Am J Med 120(9): 799-806
- References
- Leon (2005) Circulation 111(3): 369-76
- Stephens (2009) Am Fam Physician 80(9): 955-60
- Wenger (2008) J Am Coll Cardiol 51(17): 1619-31