what information do you get when a patient comes into CR
-current medical history
-physical exam upper body, lower body
-resting ECG
-current medications
-CVD risk profile
smoking risk factor goals
-no exposure to firsthand or secondhand smoking
dislipidemia risk factor goals
LDL<100mg/dL
total cholesterol <200mg/dL
TG<150mg/dL
HDL>40mg/dL
hypertension risk factor goals
<120/<80mmHg
physical activity risk factor goals
>150 minutes of moderate intensity exercise per week (up to 300)
or
>75 minutes of vigorous intensity exercise per week (up to 150)
resistance training 2x weekly
BMI risk factor goals
BMI 18.5-24.9
diabetes and insulin resistance risk factor goals
FBG <100mg/dL
HbA1c
normal<6%
pre diabetes 6-6.4%
diabetes>6.5%
what constitutes a low risk patient (with exercise)
-no complex ventricular dysrythmia during exercise testing or recovery
-no angina or significant symptoms during exercise or recovery
-no hemodynamics (HR/SBP) during exercise or recovery
-functional capacity over 7 METS
ALL HAVE TO BE PRESENT
what constitutes a low risk patient (non-exercise)
-ejection fraction >50%
-uncomplicated MI or revascularization procedure
-no complicated ventricular dysrhythmia
-absence of CHF
-no signs or symptoms
-absence of depression
what constitutes a moderate risk patient
-significant angina symptoms at high levels of exertion >7 METS
-mild to moderate ischemia
-functional capacity <5METS
-resting ejection fraction 40-49%
ANYONE OR COMBO OF
what constitutes a high risk patient (exercise)
-complex ventricular dysrhythmia
-significant angina symptoms at low levels of exertion <5METS
-high silent ischemia
-abnormal hemodynamics with exercise (decreasing SBP instead of increase)
-ANY ONE OR COMBO OF
what constitutes a high risk patient (non-exercise)
-ejection fraction <40%
-history of cardiac arrest or sudden death
-complex dysrhythmia
-complicated MI or revascularization
-CHF
-signs or symptoms
-depression (mentally)
what should you educate your patients about when starting CR
-being alert for warning signs and changes like chest angina, dizziness, SOB, weight gain
-alert their care giver on changes in their condition
-importance of adhering to their exercise program
-importance of proper warm up and cool down for exercise safe
what kinds of things do you monitor during exercise
-preexercise you monitor weight, BP, BG, medication changes
-ECG monitoring
-adjust exercise based on current clinical status before exercise and upon response
-always supervise until patient leaves
-home programs adjusted/monitored according to patient's
exercise intensity for patients without symptoms
40-80% of max HR/VO2R/VO2 peak
2-4METS
RPE 11-14
exercise intensity for patients with symptoms
exercise intensity 10bpm below onset of symptomatology like:
-angina
-abnormal BP
>2mm ST segment depression
-echocardiographic evidence of ischemia during exertion
-increase of ventricular dysrhythmias
-2nd or 3rd degree AV block
-complex ECG rhythm
-int
general exercise guidelines
20-60 minutes per session
most or all days per week
walking, cycling, stair climbing, elliptical, arm/leg ergometer, rowing
timeline for patients starting resistance training after MI or cardiac surgery
5 weeks after including 4 weeks of participation in supervised CR program
timeline for patients starting resistance training after PTCA/PCI
3 weeks after including 2 weeks of participation in supervised CR program
patients can only begin resistance training if no evidence of:
-acute CHF
-uncontrolled dysrhythmias
-severe valve disease
-uncontrolled/moderate HTN (SBP>160, DBP>100)
-unstable symptoms
ICR criteria that must be fullfilled in order for the program to be effective
-patients reimbursed by medicare
-services frequent and rigorous
-multiple diverse sessions daily and 72 in total
-significant improvements in LDL, TG, BMI, SBP, DBP, and need for medication
-must address multiple CVD risk factors (nutrition/stress manage
outcome goals for all CR
-decreased mortality and morbidity
-improved lipid profile
-improved BP
-decreased incidence and severity of angina
-reduced dependence on medication therapy
-reduced number of hospital visits
-reduced need for surgical intervention
-lowered depression/an
what is a modifiable risk factor
-tobacco use
-dyslipidemia
-hypertension
-physical inactivity
-diabetes
-psychosocial considerations
-obesity
-emerging risk factors
what are some effects of nicotine on the body
-triggers catecholamine NT to be released and increase HR and BP
-myocardial O2 demand increases
-peripheral artery vasoconstriction
-platelet activation increases
-ventricular ectopy/fibrillation
-decrease HDL
-increase LDL
-carbon monoxide injures endot
what is the motivational interview in reference to
-smoking cessation
what are the 5 Rs of the motivational interview
relevance-importance
risks
rewards
roadblocks-barriers to quitting
repetition
what is the main goal in treating dyslipidemia
-reduces CVD mortality, recurring events, hospitalizations, and progression of atherosclerosis
secondary causes of dyslipidemia
-diabetes
-hypothyroidism
-nephrotic syndrome
-obstructive liver disease
-drugs that raise LDL and lower HDL
treatment guidelines for dyslipidemia of a heart patient
-LDL goal is <100mg/dL with statins
-weight loss
-increased physical activity
-use niacin or fibrates for high TG or low HDL
-omega 3 is an alternative for fibrates
ways to diagnose HTN without BP (eye)
-retinopathy or hemorrhage
ways to diagnose HTN without BP (neck)
-carotid bruits
-distended jugular
-enlarged thyroid
ways to diagnose HTN without BP (heart)
-increased rate
-size
-murmur
-arrythmia
-abnormal signs
ways to diagnose HTN without BP (abdomen)
-enlarged kidney
-masses
-abnormal aortic pulses
ways to diagnose HTN without BP (extremities)
-diminished peripheral pulses
-edema
ways to diagnose HTN without BP (brain)
-complete neurologic evaluation