EXERCISE TRAINING FOR THE CORONARY PATIENT

Dr.Aminuddin Arifin,SpRM

GOALS OF CORONARY REHABILITATION

THE ULTIMATE GOAL OF CORONARY REHABILITATIVE SERVICES IS TO HELP PATIENTS WITH CORONARY HEART DISEASE (CHD) RESUME ACTIVE AND PRODUCTIVE LIVES FOR AS LONG AS POSIBLE,WITHIN THE LIMITATIONS IMPOSED BY THEIR DISEASE PROCESS.

OBJECTIVES FOR ACCOMPLISHING THIS INCLUDE

1.

2.

3.

Attainment of optimal physiologic,psychosocial,vocational and recreational status. Prevention of progression or reversal of the underlying atherosclerotic process. Reduction of risk of reinfarction and sudden death and alleviation of angina pectoris.

POTENTIAL BENEFITS OF EXERCISE TRAINING FOR CORONARY PATIENT

1.Counteracts the deleterious effects of physical inactivity 2.Improves functional capacity 3.Improves cardiovascular efficiency 4.Improves coronary blood flow 5.Reduces atherogenic risk factors for CHD 6.Reduces recurrent CHD events 7.Improves psychological well-being and quality of life

CATEGORIES OF CORONARY PATIENTS WHO ARE POTENTIAL CANDIDATES FOR REHABILITATIVE EXERCISE TRAINING
1.Patients after Myocardial Infarction 2.Patients after CABG 3.Patients after PTCA 4.Patients with Angina Pectoris 5.Patients with Left Ventricular Dysfunction and Congestive Heart Failure 6.Patients after Heart Transplantation 7.Patients with Implanted Pacemakers

GUIDELINES FOR RISK STRATIFICATION FOR PATIENTS IN CORONARY REHABILITATIVE EXERCISE PROGRAME

LOW - Uncomplicated clinical course in hospital - No evidence of myocardial ischemia - Functional capacity >/= 6 METs - Normal left ventricular function (EF>/=50%) - Absence of significant ventricular ectopy

INTERMEDIATE - ST segment depression >/= 2mm flat or downsloping - Reversible thallium defects - Moderate to good left ventricular function (ejection fraction 35 49 %) - Changing patterns of or new development of angina pectoris

HIGH - Prior myocardial infarction or infarct involving >/=35% of the left ventricle - EF < 35% at rest - Fall in exercise systolic blood pressure or failure of systolic blood pressure to rise >/= 10 mmHg on exercise test - Persistent or recurrent ischemic pain 24 hours or more after hospital admission

Functional capacity < 3 METs with hypotensive blood pressure response or 1mm ST segment depression Congestive heart failure syndrome in hospital >/= 2mm ST segment depression at peak heart rate </= 135 beats/min High-grade ventricular ectopy

CONTRAINDICATION FOR EXERCISE FOR CORONARY PATIENTS

Absolute contraindication :

Unstable angina pectoris Recent acute myocardial infarction and unstable condition Uncontrolled hypertension with resting systolic blood pressure of >200 mmHg or diastolic blood pressure of >110 mmHg Inappropriate asymptomatic postural or exertional blood pressure response Serious atrial or ventricular arrhythmias Second- or third-degree heart block Recent embolism (systemic or pulmonary) Acute or chronic thrombophlebitis Dissecting aneurysm Fever of >100F Exercise sternal movement after CABG (contraindication for upper-extremity and trunk ROM exercise) Uncompensated heart failure Active pericarditis or myocarditis Severe aortic stenosis (>50mmHg gradient) and idiopathic hypertrophic subaortic stenosis Acute systemic illness

Relative contraindication :

Resting diastolic blood pressure of >100mmHg or resting systolic blood pressure of >180mmHg Inappropriate increase in blood pressure during exercise Hypotension Moderate aortic stenosis (25-50mmHg gradient) Compensated heart failure Significant emotional stress or psychological disorder Pericarditis associated withv CABG Resting ST segment depression of >2mm Poorly controlled diabetes mellitus Neuromuscular, musculoskeletal, or arthritic disorders that would prevent activity Excessive incisional drainage after CABG Sinus tachycardia (>120 beats/min) at rest New ECG change after CABG or acute myocardial infarction that are diagnostic or suggestive of new infarction Ventricular aneurism Symptomatic anemia (hematocrit of < 30%)

FASE I PROGRAM REHABILITASI JANTUNG (Donna schramm,Anjali jain)

STAGE MET AKTIVITAS
Pompa pergelangan kaki, latihan nafas dalam, dan batuk ; PAAROM semua extremitas, makan minum sendiri.

1 2 3 4 5 6

1.5 1.5 1.5 1.5- 2 1.5- 3 1.5- 3

Sda, duduk ditepi tempat tidur, duduk di kursi AROM, latihan peregangan, berdiri, duduk di kursi, jalan pelan-pelan Berjalan diawasi sejauh 25 m, berpakaian mandiri Berjalan bebas di ruang rawat, berjalan 30 100 m, naik sepeda statis selama 3 menit tanpa tahanan, senam ringan. Berjalan 150 m 2 set, sepeda statis 5 menit, belajar menghitung nadi

FASE II REHABILITASI JANTUNG

STAGE WAKTU 3-4 Mgg diawasi 4 Mgg 4-5 Mgg 5 Mgg 5-6 Mgg AKTIVITAS
2 x 8 mnt sepeda statis 35% MET dari treadmil 2 x 8 mnt ergometer lengan 30% MET dari treadmil 12 mnt treadmil 50% MET dari treadmil 2 x 8 mnt sepeda statis 45% MET dari treadmil 2 x 8 mnt ergometer 35% MET dari treadmil 12 mnt treadmil 60% MET dari treadmil Sda, ditambah treadmil 70% MET dari treadmil 12 mnt sepeda statis 45% MET dari treadmil 2 x 8 mnt ergometer lengan 45% MET dari treadmil 12 mnt treadmil 75% MET dari treadmil 15 mnt sepeda statis 45% MET dari treadmil

1 2 3 4 5

6 7

6 Mgg Tak diawasi 6-7 Mgg

2 x 8 mnt ergometer lengan 45% MET dari treadmil 15 mnt treadmil 75% MET dari treadmil

15 mnt sepeda statis 3.7 MET 2 x 8 mnt ergometer lengan 4.5 MET 14 mnt treadmil 3.9 MET 3 5 mnt mesin dayung tahanan rendah
15 mnt sepeda statis 4.9 MET 2 x 8 mnt ergometer lengan 5.5 MET 20 mnt treadmil 3.9 MET 15 mnt sepeda statis 4.9 MET 2 x 8 mnt ergometer lengan 6.4 MET 22 mnt treadmil 6 MET 15 mnt sepeda statis 6.1 MET 2 x 8 mnt ergometer lengan 6.4 MET 25 mnt treadmil 6 MET 15 mnt sepeda statis 6.1 MET 25 mnt ergometer lengan 6 MET

8 9 10 11

7 Mgg 9 Mgg 11 Mgg 12 Mgg

12

12 Mgg

15 mnt sepeda statis 6.1 MET 25 mnt ergometer lengan 6 MET 27.5 mnt treadmil 6 MET 15 mnt sepeda statis 6.1 MET 25 mnt ergometer lengan 6 MET 30 mnt treadmil 6 MET

13

13 Mgg

PROGRAM REHABILITASI JANTUNG

FASE LOKASI
Rawat inap Rawat jalan

LAMANYA
7 14 hari 8 12 minggu hidup

AKTIVITAS
Perawatan diri sendiri, berjalan jarak dekat; target 1.5 km dlm 30mnt (3MET) Pemeliharaan jantung progresif 1 jam 3 x per minggu; target 3 km dlm 30 mnt (6 MET) Pemeliharaan jantung 1 jam 3 x seminggu

I
II

III Komunitas Seumur

TERIMA KASIH