ST elevation myocardial infarction cardiac rehabilitation
| Myocardial infarction | |
| ICD-10 | I21-I22 |
|---|---|
| ICD-9 | 410 |
| DiseasesDB | 8664 |
| MedlinePlus | 000195 |
| eMedicine | med/1567 emerg/327 ped/2520 |
| Cardiology Network |
 Discuss ST elevation myocardial infarction cardiac rehabilitation further in the WikiDoc Cardiology Network |
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Associate Editor: Cafer Zorkun, M.D., Ph.D. [2]
Patient information for Cardiac Rehabilitation click here
Overview
Cardiac rehabilitation is a multidisciplinary service which requires close cooperation, adequate level of knowledge and skills. A comprehensive cardiac rehabilitation program should be considered in all patients after acute myocardial infarction, coronary artery bypass surgery and percutaneous coronary angioplasty. Furthermore, all patients with coronary artery disease should receive a personal written invitation to attend a cardiac rehabilitation program. [1]
Although, the worldwide known benefits of cardiac rehabilitation, its effects to reducing short and long term mortality and morbidity, and despite the widespread endorsement of its use, cardiac rehabilitation is vastly underutilized, with less than 30% of eligible patients participating in a rehabilitation program after a cardiovascular disease [2][3][4]
Important reasons for this gap in participation of a cardiac rehabilitation program are numerous, but the most critical and probably potentially most correctable reasons revolve around obstacles in the initial referral of patients to cardiac rehabilitation programs mainly by cardiologists and other related specialists [1]
Historical Background
In the 1930s, patients with acute myocardial infarction were advised to observe 6 weeks of absolute bed rest.
Chair therapy was introduced in the 1940s.
By the early 1950s, 3-5 minutes of daily walking was advocated, beginning at 4 weeks after diagnosis of acute myocardial infarction.
Clinicians gradually began to recognize that early ambulation avoided many of the complications of bed rest, including pulmonary embolism (PE), and it did not increase the risk.
However, concerns about safety of unsupervised exercise remained strong, which led to the development of structured physician - supervised rehabilitation programs that included clinical supervision, as well as electrocardiographic monitoring.
In the 1950s, Hellerstein set out his thoughts for the comprehensive rehabilitation of patients recovering from acute cardiac events. He advocated a multi-disciplinary approach to the rehabilitation program. His approach has been adopted by the so-called cardiac rehabilitation programs throughout the world.
Despite multiple advances in clinical cardiology, Hellerstein's original ideas have not been improved upon significantly. However, due to changing patient demographics, many more patients now have the opportunity to receive the benefits offered by cardiac rehabilitation.
Nowadays, a multifactorial intervention, including aggressive risk factor modification, is an integral part of present day cardiac rehabilitation programs.[5]
Essentials of Cardiac Rehabilitation
The main goals of cardiac rehabilitation programs are to prevent further cardiovascular events by empowering patients to initiate and maintain lifestyle changes, improve quality of life through the identification and treatment of psychological distress and facilitate the patient's return to a full and active life by enabling the development of their own resources.
All patients should be referred to comprehensive cardiac rehabilitation irrespective of age. Women's needs should be addressed in comprehensive cardiac rehabilitation programs
Cardiac rehabilitation is an essential and the most important part of secondary prevention of cardiovascular diseases. The main components of a cardiac rehabilitation program are as follow: [6] [7] [8][1]
- A=Aspirin use
- A=Anti anginal therapy
- B=Beta blocker use
- B=Blood pressure control
- C=Cholesterol lowering therapy
- C=Cigarette smoking cessation
- D=Diabetes Mellitus control
- D=Diet
- E=Exercise
- E=Education (patient and family education)
Members of an ideal cardiac rehabilitation program
- Cardiologists
- Neurologists
- Endocrinologists
- Nephrologists
- Internists
- General practitioners
- Independent practitioner associations (IPAs) and primary health organisations (PHOs)
- Primary health care nurses
- Cardiac rehabilitation nurses
- Cardiac Society members
- Disease state management nurses
- Exercise physiologists
- Dietitians
- Cardiac rehabilitation club representatives
- Medical and nursing colleges
- Health insurance policy makers and/or representatives
- Government (Ministry of Health) representatives
Inpatient Rehabilitation
The term inpatient rehabilitation refers to early initiation of rehabilitation program during entire hospitalization period. This stage is for patients hospitalized for heart disease. This time frame focuses on education and safe progression of activity.
- Early mobilization of patient
- Patient and family education regarding heart disease and risk factor modification: Spouse, partner and family members should be offered access to an appropriate support group and be involved in all stages of the cardiac rehabilitation process
- Arranging evaluation for cardiac rehabilitation program following discharge
Outpatient Rehabilitation
Cardiac rehabilitation programs should be offered within the primary care setting for which workforce development is required. Moreover this, rural patients need options for cardiac rehabilitation at their home or within a primary care setting.
Psychosocial Management
- Assessment of level of social support needed
- Monitoring symptoms of depression and anxiety
- Advice on return to vocational activity, driving and return to sexual activity
- Referral to home or hospital based comprehensive cardiac rehabilitation program
Smoking Cessation
Assessment of tobacco use
Regardless of its daily use, smoking should be stopped immediately.
Strongly encouraging patient and family to stop smoking and avoid smoke
This is one of the main parts of chronic stable angina pectoris management. Smoking cessation and avoidance of exposure to environmental tobacco smoke at work and home is recommended.
For an ideal smoking cessation program; a physician should ask and advise to stop smoking, assess the progress, guide or help to get an assistance to quit and arrange a special aid for her/his patents to stop smoking).
After detailed evaluation, a nicotine replacement therapy (NRT) or sustained release bupropion (SRB) should also be administered when necessary.
The cardiovascular effects of nicotine, such as increases in heart rate with small rises in blood pressure, have provoked some concerns about the use of nicotine replacement therapy in patients with coronary artery disease. However, nicotine patches have been used successfully in heart disease patients without any adverse effects. Similarly, after initial and detailed evaluation for its contraindications, it is suggested that nicotine replacement therapy may be initiated as early as 2–3 days after acute myocardial infarction and that it may be used in all patients with stable angina pectoris and cardiac arrhythmias.[9]
Facilitation of counseling, pharmacotherapy (such as nicotine replacement therapy and antidepressants) and cessation programs as appropriate
Nicotine replacement therapy should be applied under a specialist's control. Contraindications to nicotine replacement therapy may include hypersensitivity to nicotine, recent myocardial infarction with any complications, unstable angina pectoris or progressive angina, Prinzmetal's angina and severe cardiac arrhythmias.
Exercise Programs
Vigorous exercise may trigger an acute myocardial infarction or sudden cardiac death but regular exercise protects against to these disorders. Case crossover studies suggest the risk of acute myocardial infarction is on average 6 times higher during and for 1 hour after vigorous exercise. This relative increase in risk of fatal cardiac events is much greater in sedentary individuals and less for those who exercise regularly. [1]
The risk of an acute cardiac event increases by up to 100-fold during vigorous exercise in individuals with underlying coronary artery disease. Similar studies also suggest the risk of sudden cardiac death is also higher during vigorous exercise especially for the normally individuals with sedentary life style. However, performed clinical trials of exercise based cardiac rehabilitation suggest an overall benefit from regular exercise in low to moderate risk patients after acute myocardial infarction, implying the increase in risk during and after vigorous exercise is likely to be balanced by a lower, long-term cardiovascular risk with specialist controlled, regular moderate exercise.[10] [9] [1]
Assessment of exercise risk, preferably with exercise test to guide prescription
Cardiovascular risk is much higher in patients with impaired left ventricular function, severe coronary artery disease with inducible myocardial ischemia, recent myocardial infarction and in patients with severe ventricular arrhythmias. Excessive and vigorous exercise programs are not recommended in these patients although reliable evidence on the balance of risks and benefits is limited. The risks of exercise may be reduced by assessing risk prior to exercise training, by recommending low to moderate intensity activity at the beginning, and for patients at moderate or higher risk, by exercising initially in a formal cardiac rehabilitation program.
Exercise program of low to moderate intensity
Initiation of regular and controlled physical activity of 30 to 60 minutes, 7 days per week (minimum 5 days per week) is strongly recommended.
All patients should be encouraged to obtain 30 to 60 minutes of moderate-intensity aerobic activity, such as brisk walking and swimming. These exercises may be supplemented by an increase in daily activities (such as walking breaks at work, gardening or household work).
The patient’s risk should be carefully assessed with a physical activity history. Where appropriate, an exercise test is useful to guide the exercise prescription.
Patient education regarding cardioprotective dietary pattern
In all patients with cardiovascular disease, the adoption of a cardioprotective dietary pattern is strongly recommended.
This dietary pattern includes large servings of fresh fruit, fresh vegetables and whole grains, low fat dairy products, small servings of unsalted nuts and seeds regularly and fish or legumes frequently in place of fatty meat and full fat dairy products.
Small lean meat servings can be part of this dietary pattern.
Blood pressure increases after caffeine intake, but the increase is not clinically significant until 400 mg of caffeine (i.e., 2 to 4 cups of coffee, depending on strength and brewing method) is ingested.
Advice on alcohol consumption
There is no evidence of benefit with any amount of alcohol consumption on prevention of cardiovascular disease. Limit alcohol intake to 2 drinks a day for men and 1 drink a day for women.[9] [1]
Individually planned nutritionally balanced diet for overweight or obese patients
- Advice to a patient to encourage a high intake of fruits and vegetables (5 to 9 servings/day).
- Suggest to a patient to eat grain products, with an emphasis on whole grains (≥6 servings/day).
- Suggest to a patient to eat at least 2 servings of fish per week
- Limit total fat intake in patients diet to <30% and saturated fat to <7% of energy. [9]
Replace dietary saturated fats and trans fatty acids with monounsaturated and polyunsaturated fats (including foods rich in omega-3 fatty acids).
Food sources of omega-3 fatty acids include fatty fish (such as salmon), flaxseed and flaxseed oil, soybean oil, canola oil, and nuts.
- Limit amounts of dairy products to 2 to 4 servings of low fat or fat free items per day.
Pharmacotherapy
All medications will require consideration of side effects and contraindications. Using of Sildenafil, Tadalafil and Vardenafil is contraindicated for patients receiving any form of nitrate therapy. Their chronic use may cause hearing loss.[11] Treatment with these drugs should be stopped at least 48-72 hours before starting the nitrate therapy. [12]
Lipid lowering medications
- Fasting lipid profile
- Drug therapy (statin generally most appropriate; consider adding fibrate if low high-density lipoprotein HDL or high triglycerides). Interaction between statins and NSAIDs (e.g. diclofenac sodium) and effect of grapefruit juice should be kept in mind.
The cornerstones of anti-lipid therapy and management[9];
- If baseline LDL-Cholesterol is ≥100 mg/dL, LDL lowering drug therapy should be initiated in addition to therapeutic lifestyle changes. When LDL lowering medications are used in high risk or moderately high risk persons, it is recommended that intensity of therapy be sufficient to achieve a 30% to 40% reduction in LDL-Cholesterol levels.
- If baseline LDL-C is 70 to 100 mg/dL, it is reasonable to treat LDL-C to <70 mg/dL. If on-treatment LDL-C is ≥100 mg/dL, LDL lowering drug therapy should be intensified.
- If Triglycerides are 200-499 mg/dL, the sum of non–HDL Cholesterol levels should be <130 mg/dL. Moreover this, further reduction of non–HDL Cholesterol to <100 mg/dL is reasonable, if Triglycerides are ≥200 to 499 mg/dL.
- Therapeutic options to reduce non–HDL-C are: ’’’Niacin”’ can be useful as a therapeutic option to reduce non–HDL-C (after LDL-C lowering therapy) or ’’’Fibrate”’ therapy as a therapeutic option can be useful to reduce non–HDL-C (after starting to LDL-C–lowering therapy).
- If Triglycerides are ≥500 mg/dL, therapeutic options to lower the Triglycerides to reduce the risk of pancreatitis are fibrate or niacin; these should be initiated before LDL-Choesterol lowering therapy. The goal is to achieve non–HDL-C <130 mg/dL if possible.
- If LDL-Cholesterol <70 mg/dL is the chosen target, consider drug titration to achieve this level to minimize side effects and cost of therapy. When LDL-Cholesterol level of <70 mg/dL is not achievable because of high baseline LDL-Cholesterol levels, it is generally possible to achieve reductions of >50% in LDL-Cholesterol levels by either statins or any other LDL-Cholesterol lowering drug combinations.
- Treatment with anti lipid drug combinations is beneficial for patients on lipid lowering therapy who are unable to achieve LDL-Cholesterol <100 mg/dL.
Blood pressure control
Recommended blood pressure should be ≤140 mm Hg or ≤130/80 mm Hg for patients with diabetes mellitus and chronic kidney disease. For hypertensive patients with well established coronary artery disease, it is useful to add blood pressure medication as tolerated, treating initially with beta blockers and/or ACE inhibitors, with addition of other drugs as needed to achieve target blood pressure.
Lifestyle modification and regular assessments
Addition of blood pressure medication individualized to patient characteristics
- Limit sodium intake to 6 grams per day
- Anger management: Consider and advice to control stress and use relaxation techniques. Many clinicians believe that relaxation techniques help alleviate feelings of stress, which is often a contributing factor to heart disease, and relieve chest pain. Such practices might include the use of meditation, progressive muscle relaxation, breathing exercises, yoga, self-hypnosis, or biofeedback.
- Increase physical activity within the patient’s limitation.
Antiplatelet agents
- Aspirin indefinitely [if aspirin contraindicated, consider warfarin or thienopyridine derivatives [(e.g. ticlopidine, clopidogrel)]
Beta blockers
Beta blocker therapy is definitely essential unless contraindicated.
ACE inhibitors
Angiotensin-converting enzyme (ACE) inhibitors: ACE inhibitor therapy indefinitely in high-risk, post myocardial infarction patients ( anterior myocardial infarction, previous myocardial infarction, left ventricular dysfunction or congestive heart failure)
Chronic therapy in other diseases and conditions
- Controlling of other concomitant disorders such as diabetes mellitus, hypertension, kidney diseases and anemia is essential, related medication should applied in close cooperation with related specialist and should not be interrupted.
- Diabetes management should include lifestyle modification and measures to achieve HbA1c (glucohemoglobin) in normal range.
Long Term Maintenance
This is a maintenance program that provides a safe and enjoyable atmosphere for individuals who have completed phase II (outpatient based rehabilitation) and wish to continue on with their lifestyle choices and changes adopted during their phase II program.
- Patients with diabetes mellitus and kidney disorders warrant priority for cardiac rehabilitation.
- Comprehensive cardiac rehabilitation programs should include vocational guidance to facilitate an appropriate and realistic return to work.
- For patients who see work as a potential barrier to participation in an outpatient based program, options such as home based cardiac rehabilitation should be considered.
- Comprehensive cardiac rehabilitation programs should include discussion of sexual activity in an open, frank and sensitive manner.
- Randomized, controlled secondary prevention trials like the Heart and Estrogen / Progestin Replacement Study (HERS), HERS-II and the Women’s Health Initiative (WHI) have suggested that hormone replacement therapy does not reduce cardiovascular events or mortality in patients with stable angina pectoris. Therefore current recommendations and practice guidelines do not support the use of hormone replacement therapy to reduce the risk of heart disease.
Monitoring outcomes and follow up as needed
Sexual Activity
- Common sexual problems encountered by cardiac patients include impotence and premature or delayed ejaculation in men and reduced libido in both men and women.
These difficulties may be due to underlying disease (systemic atherosclerosis, peripheral arterial disease, diabetes mellitus, medications (e.g, statins, beta blockers, diuretics), depression, and fear in both the patient and his or her partner of precipitating a cardiac event.
- Maximum heart rate during sexual intercourse averages 120 bpm, which is similar to heart rates associated with other routine activities in and around the house. There for patients with cardiovascular disorders should not have any restrictions under normal conditions and controlled medications.
- Patients should be informed about the possible hemodynamic response with an unfamiliar partner or surroundings and after eating or consuming alcohol (it is greater than normal conditions).
- Adapting less strenuous positions, such as side-to-side rather than missionary positions, can reduce cardiac stress.
- Patients may start sexual activity 2-3 weeks following an uncomplicated acute myocardial infarction. They must be instructed to report any untoward symptoms to the physician or member of the rehabilitation team.[13][1]
Contraindications of Cardiac Rehabilitation
- Poorly controlled hypertension
- Uncompensated heart failure
- Uncontrolled severe arrhythmias
- Severe residual, treatment resistant angina
- Severe cardiac ischemia, advanced left ventricular dysfunction, or frequent arrhythmias during exercise testing
- Exaggerated exercise reactions as hypertensive or any hypotensive systolic blood pressure response to exercise
- Unstable concomitant medical problems (e.g, poorly controlled or "brittle" diabetes mellitus, diabetes prone to hypoglycemia, ongoing febrile illness, active transplant rejection) [14]
Sources
- The 2004 ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction [15]
- The 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction [9]
References
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 Thomas RJ, King M, Lui K, Oldridge N, Piña IL, Spertus J (2007). "AACVPR/ACC/AHA 2007 performance measures on cardiac rehabilitation for referral to and delivery of cardiac rehabilitation/secondary prevention services". Circulation. 116 (14): 1611–42. doi:10.1161/CIRCULATIONAHA.107.185734. PMID 17885210. Unknown parameter
|month=ignored (help) - ↑ Cortés O, Arthur HM (2006). "Determinants of referral to cardiac rehabilitation programs in patients with coronary artery disease: a systematic review". Am. Heart J. 151 (2): 249–56. doi:10.1016/j.ahj.2005.03.034. PMID 16442885. Unknown parameter
|month=ignored (help) - ↑ Thomas RJ, Miller NH, Lamendola C; et al. (1996). "National Survey on Gender Differences in Cardiac Rehabilitation Programs. Patient characteristics and enrollment patterns". J Cardiopulm Rehabil. 16 (6): 402–12. PMID 8985799.
- ↑ "Receipt of cardiac rehabilitation services among heart attack survivors--19 states and the District of Columbia, 2001". MMWR Morb. Mortal. Wkly. Rep. 52 (44): 1072–5. 2003. PMID 14603183. Unknown parameter
|month=ignored (help) - ↑ Singh VN Cardiac Rehabilitation http://www.emedicine.com/pmr/topic180.htm. Access date:27.01.2008
- ↑ Hurst's The Heart, Fuster V, 12th edition, 2008
- ↑ Mayo Clinic's Cardiology, A Concise Textbook of Cardiology, 3rd edition, 2007
- ↑ Topol's Textbook of Cardiovascular Medicine, Topol E, 3rd edition, 2007
- ↑ 9.0 9.1 9.2 9.3 9.4 9.5 Antman EM, Hand M, Armstrong PW; et al. (2008). "2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: developed in collaboration With the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee". Circulation. 117 (2): 296–329. doi:10.1161/CIRCULATIONAHA.107.188209. PMID 18071078. Unknown parameter
|month=ignored (help) - ↑ Cardiac Rehabilitation, Summary and Resource Kit, New Zealand Guidelines Group (NZGG) Published in 2002 and reviewed in 2005 ISBN: 0-473-08826-6
- ↑ Food and Drug Administration
- ↑ Cheitlin MD, Hutter AM, Brindis RG; et al. (1999). "ACC/AHA expert consensus document. Use of sildenafil (Viagra) in patients with cardiovascular disease. American College of Cardiology/American Heart Association". J. Am. Coll. Cardiol. 33 (1): 273–82. PMID 9935041. Unknown parameter
|month=ignored (help) - ↑ Singh VN Cardiac Rehabilitation http://www.emedicine.com/pmr/topic180.htm. Access date:27.01.2008
- ↑ Singh VN Cardiac Rehabilitation http://www.emedicine.com/pmr/topic180.htm. Access date:27.01.2008
- ↑ Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, Hochman JS, Krumholz HM, Kushner FG, Lamas GA, Mullany CJ, Ornato JP, Pearle DL, Sloan MA, Smith SC, Alpert JS, Anderson JL, Faxon DP, Fuster V, Gibbons RJ, Gregoratos G, Halperin JL, Hiratzka LF, Hunt SA, Jacobs AK (2004). "ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction)". Circulation. 110 (9): e82–292. PMID 15339869. Unknown parameter
|month=ignored (help)
Additional Resources
- American Heart Association
- Clinical Trial Results: An Up-to-Date Resource of Cardiovascular Research
- National Guidelines Clearinghouse
- National Library of Medicine at National Institute of Health
- The MD TV: A Comprehensive Audio Visual Resource of Cardiovascular Science
Cardiac Rehabilitation Centers
In alphabetical order
- Beth Israel Deaconess Medical Center
- Brigham & Women's Hospital Cardiovascular Rehabilitation Center
- Cleveland Clinic Foundation Cardiac Rehabilitation Center
- Duke University Medical Center
- Massachusetts General Hospital Cardiac Rehabilitation Center
- Mayo Clinic Cardiac Rehabilitation Center
- Mount Sinai School of Medicine Cardiovascular Institute and Center for Cardiovascular Health
- New York Presbyterian Hospital - The University Hospital of Columbia and Cornell - Rehabilitation Center
- Yale University School of Medicine Cardiac Rehabilitation Center