Monitoring for complications

Phase I of the CR program is conducted when the patient is susceptible to major complications, such as bleeding, myocardial infarction, pulmonary embolism, deep vein thrombosis (DVT), cardiac arrhythmias, stroke, wound dehiscence, wound infection, CHF, hypotension/hypertension, electrolyte disturbance, and cardiac tamponade. The physiatrist involved in CR must be familiar with the procedure performed and its complications to adequately monitor the symptoms and understand the meaning of the clinical presentation. Careful monitoring of blood pressure, heart rate, oxygen (O ₂ ) saturation, and respiratory rate at rest and during physical activities helps with early diagnosis of these complications. Some of the complications include

• 1.
  

  Dyspnea, tachycardia, and a sudden decrease in a previously normal O ₂ saturation to less than 90%, can be caused by a variety of conditions, such as pulmonary embolism, exacerbation of CHF, pneumonia, increasing pleural effusion, and atelectasis. The workup commonly includes chest radiograph, arterial blood gas analysis, venous Doppler scan (to rule out DVT), and spiral computed tomography (to rule out pulmonary embolism).

  
  
• 2.
  

  Fever might be due to urinary tract infection (UTI), pneumonia, surgical wound infection, endocarditis, sepsis caused by intravenous catheters, DVT, or pulmonary embolism.

  
  
• 3.
  

  Hypotension, which is a frequent clinical finding during CR, is commonly medication induced. Combination of high doses of diuretics, β-blockers, and ACE inhibitors is recommended for the treatment of acute cardiac events, which often induces hypotension during rehabilitation. Observation of orthostatic hypotension during exercises can be a sign of hypovolemia (due to diuretics). The usage of high doses of β-blockers can cause hypotension along with bradycardia. Dose adjustments of these medications can often be accomplished in a rehabilitation setting. If medication-induced hypotension is ruled out as a cause of hypotension, the loss of postural reflexes due to prolonged bed rest or autonomic dysfunction is considered as the potential cause (especially for patients with diabetes mellitus).

  
  
• 4.
  

  Hypertension increases the workload of the heart and must be treated promptly to decrease the chance of cardiac injury.

Exercise program

Absolute contraindications for inpatient or outpatient exercise program as per American College of Sport Medicine include (1) unstable angina, (2) exacerbation of CHF, (3) uncontrolled tachycardia (more than 100 BPM), (4) uncontrolled arrhythmia, (5) second- or third-degree atrioventricular (AV) block without pacemaker, (6) ST segment displacement for more than 3 mm at rest, (7) resting blood pressure more than 200/110 mm Hg, (8) moderate-to-severe aortic stenosis, (9) active myocarditis or pericarditis, (10) fever with temperature above 100°F or acute systemic illness, (11) dissecting aneurysm, (12) idiopathic hypertrophic subaortic stenosis, (13) recent embolism or thrombophlebitis, and (14) significant drop in resting systolic blood pressure (more than 20 mm Hg).

Precautions

• 1.
  

  Sternal precautions must be specified in the rehabilitation prescription for therapy if the patient had a sternotomy. Patients should avoid pushing, pulling, or lifting weight more than 4.5 kg for approximately 6 weeks after surgery. After the patient is discharged home, the patient is restricted from driving a car for approximately 6 weeks after the sternotomy. Patient must be instructed not to twist his/her body, and take small steps while turning.

  
  
• 2.
  

  Restriction of isometric exercises must be specified because of the increase in heart rate.

  
  
• 3.
  

  Raising legs above the heart level should be avoided to prevent a potential increase of preload.

  
  
• 4.
  

  Performing Valsalva maneuver should be avoided due to the potential of induction of an arrhythmia.

  
  
• 5.
  

  Heart rate should be maintained less than 100 BPM or is not allowed to increase more than 20 BPM above the resting level during exercise for patients on β-blockers.

  
  
• 6.
  

  Systolic blood pressure is maintained less than 200 mm Hg and diastolic blood pressure less than 110 mm Hg during exercise. Exercise must be stopped if systolic blood pressure drops more than 20 mm Hg below the resting level during activities.

  
  
• 7.
  

  O ₂ saturation must be maintained above 92% at rest and with physical exertion.

  
  
• 8.
  

  Activity-induced changes in electrocardiogram (ECG) have to be monitored. Activities have to be stopped if patient has ST segment displacement greater than 2 to 3 mm, ventricular tachycardia, new onset of left bundle branch block, second- or third-degree AV block, frequent multifocal premature ventricular contractions (PVCs).

  
  
• 9.
  

  Exercise sessions have to start with warm-up activities and end with a cooldown period to prevent exercise-induced hypotension.

Medications

Accurate and timely information about the patient’s medications is very important in the management of the patient undergoing CR. A complete list of medications has to be available at the time of the patient’s admission to the CR unit. Attention must be paid to medications with potentially serious side effects. Such medications include

• 1.
  

  Warfarin for patients with mechanical or mitral valve replacement or repair

  
  
• 2.
  

  Clopidogrel for patients who underwent cardiac stent placement

  
  
• 3.
  

  Diuretics for the treatment and prevention of CHF

  
  
• 4.
  

  Digoxin for the management of atrial fibrillation.

Information about the most recent dose and recommendations for the future use of these medications have to be stated in the discharge summary. In addition, information regarding discontinued medications and the reasons for their discontinuation (eg, side effects, such as gastrointestinal hemorrhage, hemorrhagic stroke while on anticoagulants, severe bradycardia or hypotension in response to β-blockers or deterioration of kidney function while on diuretics) must be provided at the time of transfer of patient to the rehabilitation unit.

Communication between medical providers

The care for the cardiac patient is carried out by a chain of medical providers: primary care physician, medical and surgical consultants, nursing staff, dieticians, laboratory services, physical and occupational therapists, and other allied health professionals. Without reliable communication between all members of the team, it is very difficult to provide safe care to the cardiac patient.

The SBAR (situation, background, assessment, and recommendation) technique for the exchange of information among clinicians was introduced recently. This communication technique can be very helpful in ensuring that complete information is shared between clinical staff. In SBAR, situation refers to the problem that needs to be addressed; background provides key information and a context for the problem; assessment refers to the clinician’s understanding of the problem in the context of the patient’s condition; recommendation is the clinician’s recommended course of action.

Example: Information about nontherapeutic international normalized ratio (INR) may be endorsed from one clinician to another as: “INR is not therapeutic today, follow INR tomorrow.” Using the SBAR method, the message can be delivered in the following manner:

S (Situation): INR is 1.5 and not in therapeutic range today.

B (Background): Patient underwent aortic valve replacement with mechanical valve 2 weeks ago. Patient is on warfarin with a target INR between 2.5 and 3.5;

A (Assessment): Patient underwent aortic valve replacement and requires warfarin to maintain INR between within 2.5 and 3.5; however, the current INR indicates that it is not in the therapeutic range. He is currently receiving warfarin, 4 mg, which was started 2 days ago. Heparin was started today;

R (Recommendation): Follow-up INR level tomorrow. If INR is within therapeutic range, discontinue Heparin. If INR is not therapeutic, increase Coumadin dose to 5 mg and repeat INR in 1 day.

The SBAR method creates a more complete message about the patient’s situation and helps the next provider to avoid serious mistakes in further management.

Exercise program

Exercise activities in phase II are higher in metabolic demand compared with phase I, and require even more supervision in the cardiac gym. At the beginning of phase II, a submaximal stress test is usually done. Depending on the results of the test and patient’s risk, the physiatrist generates an individualized prescription for the intensity, duration, and frequency of exercise within safe parameters. The Karvonen method may be used in this situation together with the Guidelines for Risk Stratification of Cardiac Patients created by American Association of Cardiovascular and Pulmonary Rehabilitation. The age-adjusted method to calculate the target exercise heart rate can also be used; however, it is less specific and accurate for the patient with multiple comorbidities. The cardiac risk stratification guidelines must be applied to determine the program’s intensity that the patient can safely tolerate (low, low-to-moderate, or moderate intensity). Contraindications for the exercise program in phase II are the same as those in phase I of CR.

Sexual counseling

The safety of sexual activities after cardiac events or surgery must be discussed with the patient while he/she is still in the hospital. From the authors’ observation, the medical provider is often the initiator of this conversation. In general, it is recommended to avoid sexual activities for approximately 4 to 6 weeks after cardiac surgery. The patient must be taught simple self-testing techniques to assess his/her readiness to resume sexual activities safely. The ability to walk for 10 minutes at a speed of 3 miles per hour, followed by climbing 2 flights of stairs (approximately 22 steps) with each stair 17 cm in height within 10 seconds (or 2 steps/s), provides evidence that the patient may safely tolerate sexual activity.

Return to work considerations

Returning to work is an important goal of CR if the patient was working before the cardiac event, and plans to return back to work. The ability to safely return back to work should be evaluated by the end of phase II of the CR program.

Patients often return to their previous work, with the exception of heavy manual labor. In these cases, modification of duty or altering the nature of the job needs to be considered.

Patient education

Education of the cardiac patient is imperative for the rehabilitation team. The educated patient becomes a conscious member of the team and an active participant. Education improves the patients’ understanding of his/her cardiac disease, and improves compliance with their medications, diet, and exercise. The topics for education are

• 1.
  

  Cardiac risk modification program, which includes hyperlipidemia control, hypertension control, diet modification, smoking cessation, diabetes mellitus control, stress management, adherence to exercise program.

  
  
• 2.
  

  Each patient must have a working knowledge of his/her medications, their indications, dosing schedule, and side-effects.

  
  
• 3.
  

  Education about the symptoms of CHF, such as shortness of breath, weight gain, lower extremity edema, and cardiac pain, helps to alert the patient and prevent major deterioration of his/her medical condition.

  
  
• 4.
  

  Sternal precautions.

  
  
• 5.
  

  Education of safe sexual practice after cardiac event.

From the authors’ experience, teaching conducted in small groups of participants with similar diagnoses and experiences improves the learning ability of patients and promotes open discussions of common problems encountered by cardiac patients and exchange of ideas about “healthy lifestyle.”