122: Cardiac Rehabilitation

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CHAPTER 122

Cardiac Rehabilitation

Alan M. Davis, MD, PhD

Synonyms

None

ICD-9 Codes

410.00–410.92  Acute myocardial infarction

411.0–411.89   Other acute and subacute forms of ischemic heart disease

412   Old myocardial infarction

413.0–413.9  Angina pectoris

414.0–414.9  Other forms of chronic ischemic heart disease

428.0-428.9    Congestive heart failure

429.2      Cardiovascular disease, unspecified

V42   Cardiac valve replacement status

V42.1     Cardiac transplant status

V43.2     Implantable heart assist system insertion status

V45.81   Aortocoronary bypass status

ICD-10 Codes

I21.3  ST elevation (STEMI) myocardial infarction of unspecified site

I25.2  Old myocardial infarction

I25.9  Chronic ischemic heart disease, unspecified

I20.9  Angina pectoris, unspecified

I50.9  Heart failure, unspecified

I25.10 Atherosclerotic heart disease of native coronary artery without angina pectoris

Z95.2  Presence of prosthetic heart valve

Z95.812  Presence of fully implantable artificial heart

Z95.811  Presence of heart assist device

Z95.1  Presence of aortocoronary bypass graft

Definition

Cardiac rehabilitation is the integrated treatment of individuals after cardiac events or procedures with the goals of maximizing physical function, promoting emotional adjustment, modifying cardiac risk factors, and addressing return to previous social roles and responsibilities. The American Heart Association 2012 update estimates cardiovascular disease prevalence to be 86,200,000 people in the United States; coronary heart disease affects 16,300,000. Of those with coronary heart disease, 7,900,000 have had myocardial infarction, 9,000,000 have angina pectoris, 5,700,000 have heart failure, and 650,000 to 1,300,000 have congenital cardiovascular defects.

Cardiovascular diseases have continued to be the leading cause of mortality in both men and women for more than a century and accounted for 32.8% of all deaths in 2008 [1]. Cardiac rehabilitation supports those who survive to change their lifestyle, to maximize their functional capacity and quality of life, and to decrease their risk for future cardiac events. Cardiac rehabilitation may benefit individuals after acute coronary syndrome, cardiac surgery (coronary artery bypass graft, valve replacement, transplantation, ventricular reduction surgery, correction of congenital heart defect), and compensated congestive heart failure. Cardiac rehabilitation comprehensively addresses risk factor modification and secondary prevention through exercise training, smoking cessation, diet modification, evaluation and treatment of psychosocial stressors, education about the disease process, return to work, and maximizing the medical treatment of comorbidities (such as diabetes mellitus, hypertension, and obesity). In a meta-analysis of exercise-based cardiac rehabilitation programs, cardiovascular mortality was decreased 26%, overall mortality was decreased 13%, and hospital readmissions were reduced 31% compared with usual care in patients with myocardial infarction, percutaneous interventions, coronary artery bypass graft, or known cardiac disease [2].

Symptoms

The individual with a recent cardiac event or procedure frequently complains of decreased endurance for walking or climbing stairs, increased dyspnea during physical activity, and fatigue. If arrhythmia is present, the patient may feel palpitations. Chest pain may accompany physical exertion or emotional stress. Pain due to surgical incisions of the extremities or chest wall may also be present. Symptoms of heart failure, such as orthopnea and paroxysmal nocturnal dyspnea, may also be present. The person may feel anxious about any type of physical exercise, resumption of sexual activities, and return to work. In many cases, the patient may have symptoms suggesting depression, such as emotional lability, listlessness, poor sleep with frequent or early morning awakenings, and lack of interest in previously enjoyed activities.

Physical Examination

Observation of the patient should look for signs of depression and anxiety. During the examination of the cardiac patient, the clinician will search for signs of complications after the cardiac event or cardiac procedure. Findings of congestive heart failure or fluid overload, such as dyspnea at rest, rales, decreased basilar lung sounds, pleural or pericardial rub, dependent edema, elevated jugular venous distention, or S3 gallop, should be evaluated. Palpation of decreased or absent pulses in the extremities may suggest the common comorbidity of peripheral vascular disease. Wounds such as sternotomies, vascular harvest sites, chest tube insertion sites, pacemaker insertion sites, and arterial puncture sites should be carefully examined for appropriate healing or signs of infection before exercise programs are prescribed. Manual muscle testing of the extremities provides an indication of the degree of skeletal muscle atrophy due to decreased physical activity. Observation of the patient should look for signs of undue dyspnea during standing and ambulation. The patient should be able to comfortably walk at a slow cadence unless there is marked congestive heart failure or lung disease.

Functional Limitations

Functional limitations due to cardiac disease alone are related to the workload the myocardium can sustain before signs of cardiac dysfunction result. Overall endurance is decreased. The degree and severity of cardiac impairment may limit a patient’s physical progress and ultimate maximum level of function. The patient may later return to physically demanding activity, such as heavy labor or competitive tennis (both 8 metabolic equivalents or METs), after rehabilitation that follows uncomplicated coronary angioplasty or stenting without myocardial infarction. However, for the patient who experienced myocardial infarction complicated by congestive heart failure and arrhythmia, the 3 to 5 METs required for walking to a neighbor’s home or performing the household chores may be limited by dyspnea. Further compromise of progress is related to the common comorbidities of obesity, cerebrovascular disease, intrinsic lung disease, diabetes mellitus, and peripheral vascular disease. Impairment due to neurologic, rheumatologic, or orthopedic disease may require specific adaptations to allow conditioning and strengthening exercise.

Most patients with uncomplicated cardiac disease are able to ambulate and perform their self-care on discharge from the hospital. A slow stroll and being able to perform basic activities of daily living are not adequate for most individuals and do not predict excellent quality of life for the individual not referred to rehabilitation. Cardiac rehabilitation maximizes the person’s functional restoration, allowing return to work, social roles, and recreational activity. Despite the known benefits of cardiac rehabilitation, the majority of eligible individuals are not enrolled [3].

Emotional stress and an individual’s response to it may also produce functional limitations when return to social roles and responsibilities is considered. This may range from anxiety about physical exertion to major reactive depression. Dysfunction such as ischemia, arrhythmia, or even sudden death may be produced by emotional demands such as anxiety [46]. This is likely to be due to increased sympathetic drive in the autonomic nervous system, which predisposes the individual to more endothelial damage and cardiac arrhythmias mediated by catecholamines. Depression accounts for approximately the same (35%) risk for myocardial infarction as smoking does [7]. This argues strongly for a clear psychological screening of patients with cardiac events. Patients whose depression was diagnosed and treated by selective serotonin reuptake inhibitors (SSRIs) at the time of their initial myocardial infarction had 43% less new myocardial infarction and cardiac death compared with treatment with non-SSRIs [8]. This is due to an antiplatelet aggregation effect unrelated to aspirin or clopidogrel bisulfate (Plavix).

Diagnostic Studies

The clinician should evaluate the patient’s lipid profile to guide pharmacologic and dietary management of hyperlipidemia and hypercholesterolemia. Tight diabetes control may decrease the rate of atheroma formation, and glycosylated hemoglobin (HbA1c) level is used to ascertain the recent success of blood glucose control [9]. Calculation of body mass index assists in targeting ideal body weight.

For the individual with dyspnea on exertion and the comorbidity of lung disease, pulmonary function testing will clarify the contribution of obstructive or restrictive lung disease to the symptoms. Treatable conditions, such as reactive airways and hypoxia during exercise, should be addressed before beginning of cardiac rehabilitation for maximal benefit. Combined ventilatory gas analysis by use of a metabolic cart and electrocardiographic monitoring may differentiate cardiac versus pulmonary exercise-induced dyspnea, chest pain, or fatigue. This may be especially useful in patients with congestive heart failure [10].

A symptom-limited functional exercise test with a metabolic cart is administered 2 to 6 weeks after adequate time for healing and provides the best guide to exercise prescription. The specific timing of exercise testing depends on the amount of myocardium damage, the amount of time needed for healing of surgical sites, the need for return to work, and the practice pattern of the clinician administering the test. As opposed to commonly performed diagnostic exercise test protocols, such as the Bruce protocol, that seek to elicit cardiac symptoms, functional exercise testing documents work capacity and cardiopulmonary function. Functional exercise testing protocols start at a lower exercise intensity level than common diagnostic protocols do and increase fewer METs per stage. Treadmill testing following a ramp, modified Naughton, or Naughton-Balke protocol is especially well suited to guide cardiac rehabilitation exercise training because these protocols use smaller increments of intensity that more accurately portray functional capacity. Alternatively, bicycle ergometer protocols may also use smaller gradations of exercise intensity. Bicycle ergometry protocols should be considered for individuals with balance deficits, mild neurologic impairment, or orthopedic limitations.

Echocardiographic, pharmacologic, or nuclear medicine exercise stress testing should be considered for patients with marked lower extremity limitations, severe debility, or electrocardiograms that are difficult to interpret. Most patients have had many electrocardiograms during their hospital stay or evaluation. In the outpatient setting, electrocardiograms should be ordered if there is a change in clinical status, such as new symptoms (e.g., the resumption of angina). For the most part, patients are also monitored by telemetry during at least the initial part of their cardiac rehabilitation.

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