In a comprehensive cardiac rehabilitation program, the different forms of physical training may put patients at risk, although a review of the literature has shown that cardiac or orthopedic events rarely occur. This may be further limited through adequate safety precautions. The risk is fully outweighed by the benefits of participation, independent of the indication for enrollment:
after myocardial infarction (MI), percutaneous coronary intervention, coronary artery bypass grafting, in patients with chronic heart failure or in patients with implantable cardioversion devices (ICD).1–3
Dynamic Exercise Training
There are few reports on the risks for cardiac patients of participating in physical training pro- grams and these concern mainly dynamic exercise training.4–7
Collecting data by means of a questionnaire or a telephone interview, Haskell reported in 1978 from the United States a rate of one cardiac arrest per 111,996 patient-hours of physical exercise.4 Van Camp and Peterson found in 1986 a cardiac arrest rate of one per 32,593 training hours.5Data from Cantwell showed in 1993 a major event rate of one per 31,226.6
More recently, VanHees et al. published a hos- pital-based program from Belgium with a rate of one cardiac arrest per 29,214 patient-hours. The use of antiarrhythmic agents and the presence of ST depression at baseline were predictive of com- plications requiring resuscitation in the course
of the program. During an observation period of 20 years two patients suffered an acute myo- cardial infarction and four patients developed ventricular tachycardia with temporary loss of consciousness.7
According to the author’s experience from a Swedish program, four cardiac arrests occurred during high-intensity physical training from 1980 to 1995, which were successfully resuscitated. This indicates a larger cardiac arrest rate of approxi- mately one per 10,000 training hours, which may be explained by the inclusion of patients at high risk (large size MI with persisting moderate heart failure).8
Resistance Training
Over the years, training modalities have been extended from mainly dynamic exercise for coro- nary patients at low risk to more extensive models combining dynamic exercise with resistance training9or even exercise in swimming pools at a thermoneutral water temperature (32–35°C).
Patients at higher risk, for example with moderate chronic heart failure, patients waiting for cardiac transplant and post-transplant patients, and patients with an ICD, are more often enrolled in adapted physical training.10,11
Resistance training is widely utilized and appears to be safe: there is one report of more than 26,000 maximal dynamic strength assessments done without a single cardiovascular event.12 However, resistance training may be hazardous for a small percentage of the population. Haykowsky
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Safety Aspects of Cardiac Rehabilitation
Bo Hedbäck
465
466 B. Hedbäck
Contraindications
Even though most patients are eligible for physi- cal training programs, there are still contraindica- tions for participation: the presence of unstable angina, symptomatic ventricular arrhythmia, and/or insufficiently stabilized or severe heart failure.
Patients with unstable angina should be referred immediately to cardiological care for further investigation. Therefore we recommend that the cardiac rehabilitation (CR) staff inquire about the state of health of patients before the training session starts in order to detect signs of angina or other significant symptoms (heart failure, infectious disease, side-effect of medication).
Patients with symptomatic ventricular arrhyth- mias (dizziness or fainting) should not be allowed to participate in exercise training. A referral to a cardiologist is needed and after adequate medica- tion or if needed an ICD, they may join or re-enter the program.
Patients with chronic heart failure should be stable and on optimal medication. They should be informed to contact a physician before joining the program if symptoms of worsening heart failure occur during daily activities.
Safety Precautions
Safety in a physical training program commences with an adequate risk stratification of the patient independent of the type of exercise training that will be provided. All relevant data from the patient’s medical history, the acute care period, the ongoing medication, and planned therapy should be available for the CR team. Information to the participants on the content of the program must be given, the patient should be reassured about the risks of exertion but at the same time be encour- aged to report any symptoms before, during and directly after exercise. An individually targeted training intensity and duration is needed to reduce the risk of overstraining the patient.
ECG telemetry monitoring remains a contro- versial issue, as monitoring will have a consider- able economic impact on the program, which can not be motivated by health-economic gains. Yet, if et al.13reported three cases of nonfatal subarach-
noid hemorrhage associated with weight-lifting training. This was probably due to a previously innocuous intracranial aneurysm which ruptured in response to a marked increase in intracerebral pressure caused by the effort. For the estimated 1%
of the population with an undetected intracranial aneurysm, resistance training may be inappropri- ate but at present most cases remain undiagnosed.
Resistance training may even cause injuries from the musculoskeletal system. Shaw et al.14 have proposed a standardized questionnaire to evaluate injuries and complaints of muscular soreness which cause the individual to alter or stop the physical training.
Hydrotherapy
Physical training in water may lead to hemody- namic adaptations which might be clinically rele- vant for heart failure patients,15but when training is restricted to patients with mild to moderate heart failure the benefits may well be obtained.
This type of training may be an attractive alterna- tive for elderly patients, in whom arthritic joint and osteoporotic complaints limit conventional physical exercise.16However, special safety precau- tions must be taken as cardiopulmonary resuscita- tion in a wet environment may be dangerous.
The Risk Today?
No study covers the last decade in which the acute management of the coronary patient has changed the clinical picture of the participant in cardiac rehabilitation. On the one hand, if fewer patients have residual ischemia after a cardiac event, this would result in a lower level of risk of complica- tions during exercise. On the other hand, the early studies included mainly patients at low risk. Today more elderly and high-risk patients are enrolled in the physical training programs, for example patients with chronic heart failure, ICD or with transcutaneous epidural analgesia (TEDA). Even if this may increase the risk of adverse events one might assume that the landwinnings of modern cardiology will lead to a considerably lower event rate than one per 30,000 patient-hours of training.
56. Safety Aspects of Cardiac Rehabilitation 467
telemetry monitoring is available, patients with a low left ventricular ejection fraction (<30%), with an increase of arrhythmia during exercise (ven- tricular extrasystole, occurrence of atrial fibrilla- tion), and patients with known severe coronary artery disease and/or signs of residual ischemia during exercise testing (≥2mV) may be candi- dates for ECG surveillance.
Furthermore, the number of patients with implantable defibrillators is now increasing and a considerable rise in ICD patients participating in exercise training is noted. These patients need continuous ECG monitoring and supervision by a physician during the training sessions because of the risk of arrhythmias causing appropriate or even inappropriate shocks. Reports in the litera- ture demonstrate that exercise training for ICD patients is safe, feasible and produces favorable results if carefully supervised by qualified staff.
Even ICD malfunctions and other technical prob- lems can be detected early.10,11
A well-trained staff is essential for safety and we refer to earlier chapters in this book that address this issue. The head of the CR unit is responsible for safety management and control. If this is not a cardiologist, a named cardiologist should be included in the CR team in order to assure the medical quality of the program and its safety.
An automatic or semi-automatic DC-converter should be available at the training sessions during a phase II program as well as an emergency kit with medication that may be needed. In the unlikely event of a cardiac arrest, the patient should undergo immediate DC-conversion and be transported to the nearest coronary care unit.
All staff members should be trained in cardiopulmonary resuscitation and retraining should be performed at least once yearly.
This should include fast transport of the patient to the coronary care unit. If the training facility is situated outside the hospital, emergency equipment should be available at the premises and emergency medical care available at short notice.
Phase III programs (maintenance programs) are usually located outside medical facilities in training halls, sports clubs, gymnasia, etc. Here we recommend basic knowledge in resuscitation among the leaders, a plan for alerting acute
medical support and, if funds are available, access to automatic DC-converting equipment.
In summary we recommend careful risk stratification before a cardiac patient enters the program, complete referral documentation from acute care, an individually targeted exercise program with a choice of training options, well-trained and attentive staff, resuscitation training with regularly tested equipment, and ECG monitoring in restricted cases. Provided these conditions are fulfilled, the cardiac rehabil- itation program will provide a safe and effective service.
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Aneurysmal subarachnoid hemorrhage associated
