Cv 16: Social Aspects Of Cv Disease

Front 1

What are the general features of Cardiac Rehab?

Back 1

- Secondary prevention program
- Multi-phase program
- Includes education and exercise components (individualized to patient and disease)

Front 2

What are the phases of Cardiac Rehab?

Back 2

- Phase I - inpatient
- Phase II - outpatient
- Phase III/IV - maintenance

Front 3

What happens during Phase I of Cardiac Rehab?

Back 3

- Inpatient based program
- Education: disease specific and address individual risk factors
- Exercise: ambulate as appropriate to increase endurance (monitor vitals), ROM, review any lifting restrictions

Front 4

Who is eligible for Phase I of Cardiac Rehab (in-patient)?

Back 4

Any patient with a physician's order

Front 5

What happens during Phase II of Cardiac Rehab?

Back 5

- Out-patient based program *Must complete home-care before starting*
- 60 minute sessions up to 3 days/week
- Home exercise prescriptions given (should be working 5 days/week)

- Staffed by exercise physiologists and RNs (ACLS - advanced cardiovascular life support certified)
- Physician supervised (review charts)
- May meet w/ dietician

- Continue disease and risk factor specific education
- Identify individual goals

- Telemetry / vital monitored exercise begins
- Aerobic and resistance exercise
- Keep HR within guidelines, adjust as CV endurance improves

Front 6

Who is eligible for Phase II of Cardiac Rehab (out-patient)?

Back 6

- Physician order is required
- Often dictated by insurance coverage
- Possibly diagnosis-dependent: STEMI, NSTEMI, PTCA/stent, CABG, VAD, valve repair/replacement, transplant
- Coverage for CHF and CM is limited (but may be increasing)

*Must complete home-care before starting*

Front 7

What happens during Phase III/IV of Cardiac Rehab?

Back 7

- Out-patient maintenance exercise program
- Non-monitored exercise
- Self-pay program
- Allows patients to continue to exercise w/ Exercise Physiologists or RNs available

Front 8

Who is eligible for Phase III/IV of Cardiac Rehab (out-patient)?

Back 8

Anyone who is willing to pay on their own (self-pay)

Front 9

What are the benefits of Cardiac Rehab?

Back 9

- 21-34% reduction in long-term, all-cause, and CV mortality rate
- Benefits persist for 5 years

Front 10

What percent of eligible candidates for Cardiac Rehab are utilizing it?

Back 10

- General: 11-30% depending on where you are in country
- Post-MI: 14-35%
- Post-CABG: 31%

Front 11

What groups of people have the lowest participation in Cardiac Rehab?

Back 11

- Women
- Minorities
- Socio-economically disadvantaged
- Elderly

Front 12

How does the length of participation in Cardiac Rehab affect the benefits?

Back 12

Patients who went the full 36 visits had the best outcomes regarding risk of MI and death

Front 13

What kind of exercise should be incorporated in Cardiac Rehab?

Back 13

- Aerobic exercise
- Resistance exercise

Front 14

What are the levels of risk stratification for patients w/ CVD?

Back 14

Low
- EF >50%
- Uncomplicated MI/PCI
- Absence of ventricular disrhythmias, CHF, S/S post-event ischemia

Moderate
- EF = 40-49%
- Angina or equivalent only at high exertion
- Mild to moderate level of silent ischemia during exercise testing or recovery (<2 mm ST depression)

High
- EF <40%
- History of cardiac arrest
- Complex dysrhythmia, MI, and/or PCI
- Presence of CHF
- S/S of post-event ischemia
- Abnormal hemodynamics w/ exercise testing
- High level of ischemia during exercise testing/recovery (>2mm ST depression)

Front 15

Low Risk Characteristics
- EF?
- Complications (arrhythmias / CHF / ischemia)

Back 15

- EF >50%
- Uncomplicated MI/PCI
- Absence of ventricular disrhythmias, CHF, S/S post-event ischemia

Front 16

Moderate Risk Characteristics
- EF?
- Complications (arrhythmias / CHF / ischemia)
- EKG findings?

Back 16

- EF = 40-49%
- Angina or equivalent only at high exertion
- Mild to moderate level of silent ischemia during exercise testing or recovery (<2 mm ST depression)

Front 17

High Risk Characteristics
- EF?
- Complications (arrhythmias / CHF / ischemia)
- EKG findings?

Back 17

- EF <40%
- History of cardiac arrest
- Complex dysrhythmia, MI, and/or PCI
- Presence of CHF
- S/S of post-event ischemia
- Abnormal hemodynamics w/ exercise testing
- High level of ischemia during exercise testing/recovery (>2mm ST depression)

Front 18

What principle helps guide the exercise prescriptions?

Back 18

FITT Principle
- Frequency: goal >5 days/week
- Intensity: use HR / perceived exertion / anginal threshold
- Time: ≥30 minutes
- Type: variable and dictated by what patient prefers

Front 19

What are the Frequency principles?

Back 19

How often they exercise:
- Goal of at least 5 days/week of aerobic exercise
- 2-3 days/week of resistance exercise
- Stretching can be done daily

Start small and build towards goals

Front 20

What are the Intensity principles?

Back 20

How hard they exercise:
- Based on HR guidelines
--- Rest +30 bpm (standard goal)
--- 85% of age-predicted max and 85% of max HR achieved on GXT
- Anginal threshold
- Rating of Perceived Exertion (RPE): 11-13 (HR = ~score x10)

Front 21

What is the RPE Scale? Use?

Back 21

- Rating of Perceived Exertion
- From 6 (very, very light) to 20 (maximum effort)
- 11-13 is the goal (fairly easy to somewhat hard)
- Useful when patient is on β-blocker, because their HR may not reflect their level of exertion
- Convert score by multiplying by 20 to determine approx. HR

Front 22

What are the Time principles?

Back 22

How long they exercise:
- Goal of at least 30 minutes
- Continuous or intermittent is fine

Front 23

What are the Type principles?

Back 23

What modality of exercise:
- Based on patients preferences, availability, and any co-morbid conditions

Front 24

What are the benefits of exercise?

Back 24

Improves:
- BP
- Lipid levels: ↓TG and ↑HDL
- Insulin resistance / blood sugar control
- Stress management
- Weight control

Front 25

What are some suggested heart-healthy diets?

Back 25

- ATP III: focus on lean protein, whole grain, low-fat/fat-free dairy, 5 fruits/veggies per day

American Heart Association: focus on 4.5 cups fruits/veggies per day, 2 servings of fish / week, fiber rich grains daily, limited salt (1500 mg), limited soda (36 oz), nuts/legumes/seeds, <2 servings of processed meat

DASH Diet: limit salt intake (1500-2400 mg), whole grains, 4+ servings of fruits, 4+ servings of veggies, 2-3 servings of low-fat/non-fat dairy, <2 servings of lean meet, nuts/seeds/legumes, limited fats/sweets

Front 26

What is the recommended intake of salt and water for a patient w/ heart failure?

Back 26

- Sodium: <2g / day w/ moderate to severe heart failure
- Fluids: <2L / day for patients w/ serum Na+ <130 mEq/L (includes anything liquid at room temp)

Front 27

What percent of patients in US are non-compliant with medications?

Back 27

30-50% of adults

Front 28

What are some reasons for medication non-compliance?

Back 28

- Misunderstanding
- Patient is feeling better (thinks they don't have to keep taking it)
- Cost of meds / lack of insurance
- Side effects of meds (or fear of side effects)

Front 29

What are some ways to improve medication compliance?

Back 29

- Pill box
- Assistance via pharmaceutical companies
- $4 medication list (Walmart / Target)
- Educate on possible side effects and encourage them to contact staff before stopping any meds
- Don't use yes/no questions