Rationale
Guideline development process
Level of evidence | Quality levels (intervention and prevention) |
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Level 1: study at A1 level or at least two independent A2 level studies | A1 Systematic review of at least two independent A2 level studies A2 Randomised, double-blind, comparative clinical trial of good quality and sufficient sample size |
Level 2: one study at A2 level or at least two independent B level studies | B Comparative study not meeting all criteria mentioned under A2 (including case-control studies and cohort studies) |
Level 3: one B or C level study | C Non-comparative study |
Level 4: expert opiniona
| D Opinions of experts, for instance the members of the guideline development team |
Comments, modification and financing
Clinical and research recommendations
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Clinical phase (phase I)
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Outpatient CR phase (phase II)
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Post-CR phase (Phase III)
Clinical phase (phase I)
Recommendation 1. Stay at intensive care unit (ICU) or coronary care unit (CCU) and mobilisation during the clinical phase (phase I)
Referral information | Reasons to terminate training | Outcome criteriaa
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Reason for referral | Angina | Able to function at a sufficient ADL level (including e.g. walking and self-care, with assistance if necessary) |
Date of hospital admission | Impaired pump function (shortness of breath disproportionate to exertion, abnormal fatigue disproportionate to exertion, increased peripheral / central oedema) | At least some knowledge of their CHF, and if applicable about the treatment such as surgery (sternotomy, wound recovery etc.) |
Diagnosis | Arrhythmias (high heart rate not in proportion to exertion, irregular heartbeat, changes in known arrhythmias) | The patient knows how to cope with their CHF symptoms and is able to increase exercise intensity and expand their ADL activities |
Date of event or treatment | Abnormal increase or decrease of blood pressure | |
Medication use (type and dosage regime) | Fainting | |
Complications and/ or comorbidities | Dizziness | |
Further diagnostic information deemed relevant by the cardiologist | Vegetative reactions (excessive perspiring, pallor) |
Outpatient CR phase (phase II)
Intake / assessment procedure
Contraindications | Excessive strain | Safety criteria |
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• Progressive increase in heart failure symptoms | • Severe fatigue or dyspnoea out of proportion to the level of exertion | • ICD Cardiologist informs physiotherapist about safe heart rate range First 6–8 weeks after implantation no (submaximal) strength training of the upper extremitiesa
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• Severe ischaemia of the cardiac muscle upon exertion | • Angina | |
• Respiratory frequency of more than 30 breaths per minute | • Unexpected increase in breathing rate (>40 breaths per minute) | |
• Dyspnoea while speaking | • Pulse pressure reduction (≥10 mmHg) | • Diabetes mellitus Check for wounds and sensory defects (monofilament test) Check blood glucose values before, during and after the exercise session. Blood glucose values ≤5 and ≥15 mmol/L are relative contraindications for exercising Retinopathy of grade ≥3 is a relative contraindication for training |
• Heart rate at rest >110 bpm | • Reduction of systolic blood pressure during exercise (>10 mmHg) | |
• Peak VO2 < 10 mL/kg/min | • Increasing ventricular or supraventricular arrhythmias | |
• Ventricular tachycardia upon increasing exertion | • Vegetative reactions such as dizziness or nausea | |
• Poorly controlled diabetes mellitus (in consultation with patient’s internal medicine specialist) | • Pulmonary problems No desaturation; this usually means that O2 saturation (SaO2) should remain ≥90 % during exercising (and should not fall by ≥4 %)+
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• Fever | ||
• Acute systemic diseases | ||
• Recent pulmonary embolism (<3 months ago) causing severe haemodynamic strain | ||
• Thrombophlebitis | ||
• Acute pericarditis or myocarditis | ||
• Haemodynamically serious aortic stenosis or mitral valve stenosis | ||
• Heart valve failure constituting an indication for surgical intervention | ||
• Myocardial infarction less than 3 weeks before the start of the training | ||
• Atrial fibrillation with rapid ventricular response at rest (>100 bpm) | ||
• Serious cognitive problems (memory, attention and concentration) | ||
• Weight gain of >3 kg within a few days, whether or not accompanied by increased dyspnoea at rest |
Treatment phase
Information / advice
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Improving patients’ understanding of their disorder, CR and illness beliefs;
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Education on a healthy active lifestyle;
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Recognising signs of deterioration (decompensation) of the CHF;
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Promoting compliance;
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Promoting effective ways of dealing with symptoms and exertion in daily life (level of dyspnoea and fatigue);
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Promoting return to work / occupational activities (where applicable, most patients are past retirement age).
Tailored training program
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Referred by a cardiologist and have no contraindications for training (Table 3);
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Functionally stable (i.e. no change in NYHA class) and on optimal medication for at least 3 weeks;
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NYHA Class II or III;
Recommendation 2. Aerobic endurance and/or interval training
• The patient’s current physical condition, based on the maximum or symptom-limited exercise test with gas analysis (spiro-ergometry) |
• Protocol used |
• The referring physician’s evaluation of the electrocardiogram before, during and after exercise (criteria for cardiac ischaemia, arrhythmias and the practical consequences of the findings) |
• Heart rate at rest, the maximum heart rate and recovery heart rate (especially during the first minute) |
• Maximum VO2max and wattage achieved (and the percentage of the predicted value) |
• Blood pressure changes at rest, during exercise and during the recovery phase |
• The reason for terminating the test and the level of the impairment (central or peripheral) |
• Medication use (type and dosage) |
• The patient’s subjective symptoms during the test (angina/ dyspnoea) and his/her Borg score |
• Spiro-ergometry: gas exchange parameters such as maximum oxygen uptake (VO2max), the percentage of predicted VO2max, O2 pulse, maximum respiratory minute volume (VE) (tidal volume and respiratory rate), respiratory exchange rate, anaerobic or ventilatory threshold, VE/VCO2 ratio, saturation and any other relevant parameters (e.g. VO2 oxygen uptake efficiency slope and the presence of respiratory oscillations) |
• The maximum voluntary ventilation, which may be derived (37.5× the forced expiratory volume (FEV1)) |
Recommendation 3. Submaximal strength training
Recommendation 4. Inspiratory muscle training (IMT)
Relaxation program
Recommendation 5. Relaxation therapy
Evaluation
• The patient has attained his/her goals at an optimum level |
• The patient has partially attained his/her goals, and it seems likely that he/she will be able to continue the training activities elsewhere, under supervision, and thus eventually attain these goals |
• The patient has not attained his/her goals and it seems likely that he/she has attained their maximum achievable level. Not all patients will improve their endurance capacity and therefore need for example to spread their energy expenditure and to deal with their dyspnoea in a functional way |
Goal | Evaluation instrument | When | Final outcome |
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Specific physical goals
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I. Optimising exercise capacity |
By physician
• Maximum or symptom-limited exercise test with gas analysis plus Borg RPE scale (6–20), and as desired scoring Anxiety, Angina and/or Dyspnoea | At start and end of CR and / or training program | Exercise capacity is at optimum or target level for this patient |
By cardiac rehabilitation coordinator
• Subjective physical score on KVL-H questionnaire | |||
By physiotherapist
• As for goals one and two • (modified) SWT • Possibly MET method and/or SAS | At start, every 4 weeks and at end of CR and/ or training program | Functional exercise capacity is at optimum or target level | |
II. Balancing exertion with physical abilities | • Compare subjective exercise capacity score with objective score • Ask about five most problematic activities (PSC) and score these on the Borg RPE scale (6–20); possibly score anxiety and/or angina and/or dyspnoea | At start and end of CR and / or training program, but also continuous evaluation to check for excessive strain | Patient (and partner) coping effectively with symptoms, that is, patient avoids excessive strain and (if possible) improves exercise capacity (goal one). Patient is able to spread his/her energy expenditure and to deal with the dyspnoea in a functional way |
III. Reducing fatigue, dyspnoea and inactivity | • Borg RPE scale (6–20) for fatigue and dyspnoea • Monitor Movement and Health (www.tno.nl) (in Dutch) | At start and end of CR and / or training program | Patient’s sensation of fatigue and dyspnoea is at optimum or target level. Patient has adopted a physically active lifestyle |
General physical goals
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1. Exploring one’s own physical limits | • Ask for five most problematic activities (PSC) • Ask patient to carry out problematic activities and possibly score them for duration and quality, perceived fatigue (Borg RPE 6–20) and in terms of anxiety and / or Angina and / or Dyspnoea (if indicated). • Monitoring heart rate and blood pressure | At start and end of CR and / or training program | Patient is aware of his/her own physical limits, i.e. knows what level of exertion is possible |
2. Learning to cope with physical limitations | Monitoring heart rate, measuring blood pressure and scoring on Borg scale before, during and after each session | Patient can cope with physical limitations and utilise his/her limited energy efficiently, and has achieved a balance between exertion and relaxation | |
3. Overcoming fear of physical exertion | • History-taking and observation • Questionnaire: see Multidisciplinary Guideline CR 2011 (www.nvvc.nl) (in Dutch) | At start and end of CR and / or training program | Patient is no longer afraid of exertion |
4. Developing an active lifestyle | • History-taking (motivational interviewing) • Monitor Movement and Health (www.tno.nl) (in Dutch) • Post-CR activities started | At start and at end of CR and / or training program | Patient has adopted an active lifestyle or is able to keep up the most active achievable lifestyle |
Focal points
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Acquiring information about secondary prevention | • Checklist for risk factors / unhealthy behaviour • Phase III activities started • Ability to cope effectively with symptoms • Ability to recognise signs of decompensation | At start and at end of rehabilitation and / or training program | Patient knows about healthy living and secondary prevention |
Goals of relaxation program | • Evaluation list • Using a flowchart | At interim and final evaluation of CR and / or relaxation program | Patient is familiar with the relaxation program and is able to relax |