Professional Documents
Culture Documents
KEY POINTS
• Most current clinical event risk predication or stratification models
were developed primarily to predict events in pre symptomatic patients
i.e., those without documented coronary artery disease.
• Coronary artery calcium scoring Budoff et al., 2008, 2009; Derano et al., 2008; Folsom et al., 2008; Lakoski et al., 2007;
Nair et al., 2007, 2008; Nasir et al., 2007; Schiele & Moneveau. 2009
• However, recent data has confirmed that both high sensitivity CRP
(hs-CRP) and the metabolic syndrome are independent, although
perhaps not terribly strong risk predictors for CVD events (Tall, 2004;
Rutter et al., 2004).
• Gender Male
Female
• Age Years (Maximum 80)
• Current Smoker Yes/no
• Systolic blood pressure mm/Hg
• Hs-CRP mg/dL
• Exercise history Determine habitual level of activity, type of exercise, frequency, duration and intensity.
• Work/Vocational history Emphasis on current physical and mental demands, nothing upper and lower extremily
requirements, estimated time to return to work.
• Musculoskeletal history Musculoskeletal problems or limitations – arthritis, joint swelling, back problems.
• Psychosocial history Living situation, martial and family status, transporation needs, family needs, domestic and
emotional problems, depression, anxiety or other psychological disorders.
Components of the Physical Examination
Component Description
• Vital Signs Resting heart rate and rhythm, blood pressure (as per Canadian) Hypertension Society
recommendations) respiratory rate + temperature and/or oxygen saturation level.
• Anthropometrical Determine body weight, height, MBl, waist to hip ratio, waist circumstance at the level of the
umbilicus, absence or presence of xanthoma or xantholasma.
• Cardiovascular Complete cardiovascular examination, with special attention to murmurs, gallops, clicks and
rubs, and the presence or absence of heart failure.
Palpation and auscultation of carotid, abdominal and femoral arteries.
• Procedure-related issues Examination of chest and leg wounds and vascular access areas in patients after coronary
bypass surgery or percutaneous coronary revascularization.
• Lower extremities Palpation and inspection of lower extremities for oedema or presence of arterial pulses and
skin integrity (particularly in those with diabetes)
Calculation of the Cardio Fitness Score
The calculation of the cardio fitness risk score involves a two step process
Exercise treadmill testing should be performed according to the Bruce Protocol (ACSM, 2000; Arena et
al., 2007, Ehrman et al., 2009; Thompson et al., 2009b). Once this is performed, the Duke Treadmill
Score (DTS) is calculated according to the following formula (Mark et al., 1991):
Where:
• Stretching following exercise may be preferable for sports for which muscular strength, power
and endurance are important for performance.
• Stretching exercise should involve the major muscle tendon groups of the body with > 4
repetitions per muscle group.
• Dynamic or ballistic stretching may be considered particularly for persons whose sports
activities include ballistic movements.
• Frequency
3 to 5 times per week
• Intensity
40% to 85% of HRR
• Conditioning
• Time
20 to 40 minutes
• Type
Aerobic and resistance training activities
• Cool- down
A minimum of 5-10 minutes of cardiovascular and / or muscular endurance type activities at a target heart rate of 60% of
maximum heart rate.
Rate of Exercise Program Progression
• Step 2 A light warm up 5 repetitions at 40% of the patients perceived or anticipated 1RM will
then be performed.
• Step 3 after a two minutes rest with light stretching. 1 repetition at 80% of the patient’s
perceived 1 RM will then be performed. Following completion of this lift, the patient will again rest for
two minutes.
• Following the rest period, take the patient as close as possible to their perceived 1RM if the
lift is successful, a rest period of two minutes will be allowed.
• This process, will continue increasing the resistance initially at 10 Ibs for lower body
(reducing to 5 Ib increments in all subsequent attempts) and increasing the
• Step 4 resistance initially at 5 Ibs for upper body (reducing to 5 Ib increments in all
subsequent attempts) and increasing the resistance initially at 5 Ibs for upper body (reducing
to 2.5Ib increments in all subsequent attempts) until a failed attempt occurs.
• Step 5 The 1RM value will reported as the weight of the last successfully completed lift.
• Step 6 The 1RM will then be established for each of the exercises in this manner during
the same session.
• Evidence suggests…
• Reducing Tip
• Should be restricted to a moderator RPE level (#5 on the 0-10 Borg Scale #
15 on the 6-20 scale).
• Measurements done after the lifting are not valid due to the large decrease in
pressure that takes place immediately after the final lift/ Wiecek et al. 1990)
Patient Safety and guidelines on ICD
• The major concern for all involved in the delivery of exercise
training in CR is a sudden, unexpected event without warning
signs or death due to a lethal ventricular for appropriate risk
stratification and, where appropriate, anti-arrhythmic therapy.
• Exercise related adverse rates with cardiac rehabilitation programs are extremely low.
• The use of continuous telemetry monitoring in cardiac rehabilitation programs has not been shown to
reduce or prevent adverse events or sudden cardiac death.
• Patient risk, is determined by recommended risk stratification, with respect to the likelihood of
exercise related events, i.e. short term cardiac event risk, is one of the principal determinants of the
need for telemetry monitoring.
• The usage, type and length of telemetry monitoring is at the discretion of the cardiac rehabilitation
program Medical Director.
• Trained professional cardiac rehabilitation staff are required to monitor telemetry equipment.
• Despite decades of exercise training within CR Programs, both supervised and unsupervised, there is
not clear consensus regarding the use of EKG telemetry monitoring.
Summary of FITT paradigm for patients in CR (Modified form
Pollack et al 2000).