Cardiovascular Medicine Book


Cardiac Rehabilitation

Aka: Cardiac Rehabilitation, Activity after Myocardial Infarction
  1. See Also
    1. Chest Pain
    2. Cardiac Risk Factors
    3. Angina
    4. Angina Diagnosis
    5. Unstable Angina
    6. TIMI Risk Score
    7. Acute Coronary Syndrome
    8. Acute Coronary Syndrome Immediate Management
    9. Acute Coronary Syndrome Adjunctive Therapy
    10. High Risk Acute Coronary Syndrome Management
    11. Moderate Risk Acute Coronary Syndrome Management
    12. Low Risk Acute Coronary Syndrome Management
    13. Myocardial Infarction Stabilization
    14. Serum Cardiac Markers
    15. Electrocardiogram in Myocardial Infarction
    16. Echocardiogram in Myocardial Infarction
    17. Goldman Criteria for ICU Chest Pain Admission
  2. Background
    1. Cardiac Rehabilitation is under-utilized by Medicare-eligible indications (only 14-31% participation)
    2. Cardiac Rehabilitation has great efficacy as a secondary prevention tool
  3. Indications
    1. Medicare reimbursed indications (3 sesssions per week for 3 months)
      1. Following acute Myocardial Infarction (STEMI or non-STEMI) in the last 12 months
      2. Status-post Coronary Artery Bypass Graft (CABG)
      3. Status-post Percutaneous Coronary Intervention (PCI)
      4. Stable Angina Pectoris
      5. Status-post Vascular Surgery
      6. Status-post Heart Transplantation
      7. Status-post Heart Valve Repair or Replacement
      8. Recent CVA (women only)
    2. Other indications
      1. Stable Congestive Heart Failure with reduced left-ventricular ejection fraction
      2. Peripheral Arterial Disease
      3. Status-post Ventricular Assist Device placement
      4. Pacemaker or Implantable Cardioverter-Defibrillator
  4. Protocol: Cardiac Rehabilitation Phases
    1. General
      1. Standard programs
        1. Exercise training program for a total of a 36 session program over 12 weeks
        2. Medicare covers up to two, 1 hour sessions per day
      2. Intensive programs (limited availability)
        1. Intensive programs may include up to 72 sessions over up to 18 weeks
        2. Medicare approved programs
          1. Dean Ornish Program for Reversing Heart Disease
          2. Pritikin Intensive Cardiac Rehab Program
          3. Benson-Henry Institute Cardiac Wellness Program
    2. Phase I Cardiac Rehabilitation (during hospitalization for acute event or procedure)
      1. Supervised, structured early Physical Activity
      2. Patient Education
      3. Risk stratification (low level, graded, Exercise tolerance testing)
    3. Phase II Cardiac Rehabilitation (Early Outpatient)
      1. Supervised Physical Activity program
        1. Reassess symptom-limited Exercise tolerance
        2. Custom tailored Exercise Prescription for 30 minutes daily and 5 days weekly
      2. Monitoring of Blood Pressure, pulse, cardiac rhythm
        1. Maintain Blood Pressure <140/90 mmHg
      3. Nutrition counseling
        1. May involve education on cooking and grocery shopping
        2. Diabetes Mellitus Type II control with Hemoglobin A1C <8%
        3. LDL Cholesterol <100 mg/dl (preferable <70 mg/dl)
        4. Body Mass Index reduction towards goal of <27 kg/m2 (ideally <25 kg/m2)
      4. Cardiac Risk Factor modification
        1. Tobacco Cessation
      5. Reassess cardiac symptoms at rest and with activity
      6. Psychosocial support to screen for and manage Major Depression
    4. Phase III Cardiac Rehabilitation (Late Outpatient)
      1. Maintain and reinforce phase I and II management
      2. Reinforce medication use, Patient Education
  5. Protocol: Activity restrictions following acute Myocardial Infarction
    1. Gradually increase activity over 6-8 weeks following MI
    2. Return to work by 8 weeks after MI
    3. Activity program may start by 3-4 weeks after MI
    4. Sexual activity restarted at 4-6 weeks after MI
      1. See Sexual Intercourse after Myocardial Infarction
  6. Protocol: Other Measures
    1. Influenza Vaccine each year
  7. Efficacy
    1. Reduced Angina, Dyspnea, and Fatigue
    2. Reduced Major Depression after acute coronary event
    3. Exercise performance improved
    4. Activities of Daily Living (ADL) performance improved
    5. Quality of life improved
    6. Decreased re-hospitalization rate
    7. Decreased work absence
    8. Reduced age-adjusted cardiovascular mortality by 50%
    9. References
      1. Bondestam (1995) Am J Cardiol 75:767-71 [PubMed]
      2. Milani (2007) Am J Med 120(9): 799-806 [PubMed]
  8. References
    1. Leon (2005) Circulation 111(3): 369-76 [PubMed]
    2. Stephens (2009) Am Fam Physician 80(9): 955-60 [PubMed]
    3. Servey (2016) Am Fam Physician 94(1): 37-43 [PubMed]
    4. Wenger (2008) J Am Coll Cardiol 51(17): 1619-31 [PubMed]

Myocardial Infarction (C0027051)

Definition (MEDLINEPLUS)

Each year over a million people in the U.S. have a heart attack. About half of them die. Many people have permanent heart damage or die because they don't get help immediately. It's important to know the symptoms of a heart attack and call 9-1-1 if someone is having them. Those symptoms include

  • Chest discomfort - pressure, squeezing, or pain
  • Shortness of breath
  • Discomfort in the upper body - arms, shoulder, neck, back
  • Nausea, vomiting, dizziness, lightheadedness, sweating

These symptoms can sometimes be different in women.

What exactly is a heart attack? Most heart attacks happen when a clot in the coronary artery blocks the supply of blood and oxygen to the heart. Often this leads to an irregular heartbeat - called an arrhythmia - that causes a severe decrease in the pumping function of the heart. A blockage that is not treated within a few hours causes the affected heart muscle to die.

NIH: National Heart, Lung, and Blood Institute

Definition (NCI_FDA) Gross necrosis of the myocardium, as a result of interruption of the blood supply to the area, as in coronary thrombosis.
Definition (NCI_CTCAE) A disorder characterized by gross necrosis of the myocardium; this is due to an interruption of blood supply to the area.
Definition (NCI) Gross necrosis of the myocardium, as a result of interruption of the blood supply to the area, as in coronary thrombosis.
Definition (CSP) gross necrosis of the myocardium, as a result of interruption of the blood supply to the area.
Definition (MSH) NECROSIS of the MYOCARDIUM caused by an obstruction of the blood supply to the heart (CORONARY CIRCULATION).
Concepts Disease or Syndrome (T047)
MSH D009203
ICD10 I22, I21
SnomedCT 66514008, 266288001, 155304006, 194796000, 233824008, 22298006
LNC LP98884-7, MTHU035551, LA14274-7, LA10558-7
English Myocardial Infarct, Infarctions, Myocardial, Myocardial Infarction, Myocardial Infarctions, Infarcts, Myocardial, Myocardial Infarcts, HEART ATTACK, Infarct, Myocardial, Infarction, Myocardial, MI, Myocardial infarction (MI), Attack heart (NOS), Infarct myocardial, cardiac infarction, Myocardial Infarction [Disease/Finding], attacking heart, heart attacks, attack hearts, infarctions myocardial, infarcts myocardial, myocardial infarctions, Infarction;heart, myocardial infarcts, Infarction;myocardial, AMI, attacks coronary, attacks hearts, coronary attack, disorder infarction myocardial, myocardial necrosis, syndrome myocardial infarction, heart attack, mies, Heart Attack, Attack - heart, Cardiac infarct, myocardial infarction, myocardial infarction (diagnosis), MI, MYOCARDIAL INFARCTION, MYOCARDIAL INFARCTION, MYOCARDIAL INFARCTION, (MI), INFARCTION (MI), MYOCARDIAL, -- Heart Attack, Cardiovascular Stroke, Cardiovascular Strokes, Stroke, Cardiovascular, Strokes, Cardiovascular, Myocardial infarct, Myocardial infarction, Heart attack, MI - Myocardial infarction, Cardiac infarction, Infarction of heart, Myocardial infarction (disorder), cardiac; infarction, infarction; myocardial, Cardiac infarction, NOS, Heart attack, NOS, Infarction of heart, NOS, Myocardial infarction, NOS, Heart Attacks, Infarctions (Myocardial), Myocardial infarction NOS, Attack coronary, heart infarction
German MYOKARDINFARKT, Koronarattacke, Herzanfall, MI, Herzanfall (NNB), HERZANFALL, Herzinfarkt, Myokardinfarkt
Dutch hartaanval, hartinfarct, hartaanval (NAO), MI, cardiaal; infarct, infarct; myocard, myocardinfarct, Hartinfarct, Infarct, myocard-, Myocardinfarct
French Crise coronaire, IM, Crise cardiaque SAI, Crise cardiaque, CRISE CARDIAQUE, INFARCTUS DU MYOCARDE, IDM (Infarctus Du Myocarde), Infarctus du myocarde, Infarctus myocardique
Italian MI, Attacco cardiaco, Attacco coronarico, Attacco cardiaco (NAS), Infarto del miocardio, Infarto miocardico
Portuguese Ataque coronário, Ataque do coração, Ataque cardíaco NE, EM, ATAQUE CARDIACO, ENFARTO DO MIOCARDIO, Enfarte do miocárdio, Infarto do Miocárdio
Spanish IM, Crisis coronaria, Ataque al corazón, Ataque al corazón (NEOM), Infarto miocárdico, ATAQUE CARDIACO, INFARTO DE MIOCARDIO, Infarto al Miocardio, ataque al corazón, infarto cardíaco, infarto de corazón, infarto de miocardio (trastorno), infarto de miocardio, Infarto de miocardio, Infarto del Miocardio
Japanese 心臓発作(NOS), 冠発作, 心臓発作, カンホッサ, シンゾウホッサNOS, シンゾウホッサ, シンキンコウソク, 冠状動脈梗塞, 心筋梗塞, 冠動脈梗塞, 心筋梗塞症
Swedish Hjärtinfarkt
Czech infarkt myokardu, Srdeční záchvat, Srdeční záchvat (NOS), IM, Koronární záchvat, Infarkt myokardu
Finnish Sydäninfarkti
Polish Świeży zawał serca, Zawał serca świeży, Zawał mięśnia sercowego, Zawał serca
Hungarian Coronaria roham, Szívroham (k.m.n.), Szívroham, Infarctus myocardii, Szívizom infarctus, MI
Norwegian Hjerteinfarkt, Hjerteattakk, Myokardinfarkt
Derived from the NIH UMLS (Unified Medical Language System)

Cardiac rehabilitation (C0700431)

Definition (CCC) Actions performed to restore cardiac health
Definition (MEDLINEPLUS)

Cardiac rehabilitation (rehab) is a medically supervised program to help people who have

The goal is to help you return to an active life, and to reduce the risk of further heart problems. A team of specialists will create a plan for you that includes exercise training, education on heart healthy living, and counseling. You will learn how to reduce your risk factors. These may include disorders such as high blood pressure, high blood cholesterol, overweight or obesity, diabetes. Smoking, lack of physical activity, and depression are other risk factors.

NIH: National Heart, Lung, and Blood Institute

Definition (NCI) A medically supervised program to improve the health and well-being of people who have heart problems. This may include exercise training, education on heart healthy living, and/or counseling to reduce stress. (ACC)
Definition (NCI_CDISC) A medically supervised program to improve the health and well-being of people who have heart problems. This may include exercise training, education on heart healthy living, and/or counseling to reduce stress.
Definition (NIC) Promotion of maximum functional activity level for a patient who has experienced an episode of impaired cardiac function that resulted from an imbalance between myocardial oxygen supply and demand
Concepts Therapeutic or Preventive Procedure (T061)
SnomedCT 183378000, 151613007, 313395003
LNC LP29869-2, MTHU013092
English Cardiac rehabilitation, Cardiac Care: Rehabilitative, cardiac rehabilitation, cardiac rehabilitation (treatment), rnrx cardiac rehabilitation (treatment), rnrx cardiac rehabilitation, rnox provide cardiac rehabilitation therapy, rnox provide cardiac rehabilitation therapy (treatment), Cardiac rehabilitation treatment, rehabilitation cardiac, cardiac rehabilitation therapy, therapy cardiac rehabilitation, cardiac rehabilitation treatments, Cardiac rehabilitation therapy, Cardiac Rehabilitation, Heart Diseases--Rehabilitation, Cardiac care: rehabilitative, Cardiac rehabilitation (regime/therapy), Cardiac rehabilitation (procedure)
Italian Terapia di riabilitazione cardiaca
Japanese 心リハビリテーション療法, シンリハビリテーションリョウホウ
Czech Rehabilitace při onemocnění srdce
Hungarian Cardialis rehabilitációs kezelés
Spanish rehabilitación cardíaca (procedimiento), rehabilitación cardíaca (régimen/tratamiento), rehabilitación cardíaca, Terapia de rehabilitación cardiaca
Portuguese Terapia de reabilitação cardíaca
Dutch hartrehabilitatietherapie
French Réadaptation fonctionnelle cardiaque
German Herzrehabilitationstherapie
Derived from the NIH UMLS (Unified Medical Language System)

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