Cardiac Rehabilitation

2011/13 Australian Health Survey

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To raise money to support its Education and Literacy Programs, UNICEF collaborates with companies worldwide — international as well as small- and medium-sized businesses. Pain with the next bowel movement leads to constipation, hardened stools that continue to produce cyclic problems. If the coagulation profile is abnormal then consider hematologic disease of the newborn and manage with vitamin K. Cardiac, neurogenic, genitourinary, skeletal and chromosomal changes and syndromes are the cornerstones of mortality. Many times, the cellular damage caused by these synthetic concoctions may not surface for months or even years. Some 40 million labour days were financed in to assist in a campaign which prevented the depletion of some 9 million tons of pasture.

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Diet, Medications, or Both? Markowitz is a pediatric gastroenterologist who practices in the Department of Pediatric Gastroenterology and Nutrition at Children's Hospital, Greenville Hospital System University Medical Center and specializes in caring for children and teens diagnosed with EoE. He will be sharing his expertise and experiences regarding the development of EoE management plans in newly diagnosed patients.

Understand the importance of using the current diagnostic criteria for eosinophilic esophagitis EoE. Recognize the role of amino acid-based formula these patients. Explore the development of an EoE management plan. Attend this educational webinar to learn about the first and only hypoallergenic formula with prebiotics and probiotics: In this webinar, you will also review the extensive clinical trials platform behind this exciting innovation, as well as practical information and available tools for this new formula.

To review medical and scientific rationale for the addition of prebiotics and probiotics to hypoallergenic infant formula. To share the main results of the 3 clinical trials behind Neocate Syneo Infant. To discuss the unique blend of prebiotics and probiotics in Neocate Syneo Infant. To review the practical use of Neocate Syneo Infant and tools available to support patients on the product.

Please join Kelly A. Her talk covers advances in the knowledge of the infant intestinal microbiome in health and disease. This was part of a Satellite Symposium, Emerging Evidence: Discuss the development of the human gastrointestinal tract.

Explain the optimal nutrition provided by human milk. Understand the impact of pre- and probiotics on intestinal health. A growing body of evidence highlights the importance of the gut microbiota in early life.

Research shows that infants with cow milk allergy may have a gut dysbiosis. Please join speaker, Christina West, MD, PhD for a 1-hour educational webinar to explore the role of specific pre- and probiotics in addressing this gut dysbiosis.

To explore the role of the infant gut microbiota in health and allergic disease. To discuss the role of specific pre- and probiotics in addressing dysbiosis. The gut microbiota is an area of growing interest and clinical research. The gut microbiota is receiving increasing attention related to its relationship with immune disorders, including allergic conditions. Demonstrate that children may present with multi-system allergic disease. Show altered mechanisms of development of sensitization and tolerance.

Discuss clinical research investigating synbiotics in allergic conditions. Share a case study demonstrating co-occurrence of gastrointestinal and allergic symptoms.

Cow milk allergy is one of the most confirmed food protein allergies in early childhood. Dietary management is vital in managing this condition. Understand the role of human milk in infants with cow milk allergy. Discuss role of maternal diet when managing cow milk allergy. Distinguish differences in composition and categorization of specialized pediatric formulas. Understand the proper use of specialized pediatric formulas based on currently available evidence.

Join Marijn Warners, MD, PhD-fellow, for a free educational webinar to discuss her new research on the effectiveness of an elemental diet in the management of adult patients with EoE.

Dietary treatment with elimination of disease triggering allergens is an effective treatment option since it could provide a long-term and drug-free solution. Elemental amino acid-based diets are highly effective in children, and this new research supports its use in successfully managing adult patients with EoE. Evaluate the effect of an amino acid-based formula diet on eosinophilic inflammation, endoscopic signs and symptoms of adult EoE patients. Describe the contribution of abnormal esophageal barrier function in the pathophysiology of EoE.

Explain the role of an amino acid-based formula diet in restoring esophageal mucosal integrity and induces histologic remission in adult EoE patients.

Explore the role of an impaired small intestinal mucosal integrity in the pathophysiology of EoE. Her current research focuses on understanding the pathophysiology of esophagel mucosal integrity in eosinophilic esophagitis, the effect of dietary treatment in EoE and the validation of different outpoints used in clinical trails in EoE.

Warners completed two consecutive internships in surgery and urology at The University Medical Center Groningen and St. Feeding problems are common in children with ASD and can result from a variety of reasons e. In addition, they may present in a variety of ways — often disrupting eating and mealtimes.

Define ASD diagnostic characteristics and how these relate to the mechanics of eating. Discuss prevalent underlying medical problems such as gastrointestinal issues and food allergies that may contribute to disrupted eating patterns in children with ASD.

Dietary management of EoE has been shown to be an effective option for children and is gaining great acceptance for adults. To learn about the different types of elimination diets. To become familiar with feeding issues that may develop as a result of EoE.

To be able to provide patients and families with survival skills to help them be successful with their elimination diet.

There is a general lack of awareness about FPIES, which has led to this condition being frequently misdiagnosed. This is an ideal educational opportunity for those looking to enhance their knowledge and skills on FPIES management. At the conclusion of the webinar, participants should be able to: Nirmala Gonsalves and Bethany Doerfler for a Nutricia Learning Center educational webinar focused on transitioning teens with EoE from pediatric to adult care.

Describe the clinical features of EoE across the age spectrum and discuss the evidence for dietary management approaches.

Explore transition of care in EoE from teens to adulthood. Understand the role enteral nutrition plays in the intestinal rehabilitation process. Discuss the ways diet modifications can reduce the complications of long-term TPN.

Please join speaker Dr. Describe the most commonly occurring GI symptoms and potential nutritional deficits in children with ASD. When, Which Approach, and Why? Please join speakers Dr. Lurie Children's Hospital of Chicago for a free one hour presentation on the dietary management of eosinophilic esophagitis. Define and describe the prevalence and clinical spectrum of eosinophilic esophagitis. Describe the different dietary approaches to managing eosinophilic esophagitis. Understand the principles underlying elimination diets and the importance of avoiding cross-contamination.

Recognize the varying disease processes that fall under the diagnosis of cow milk allergy. Appreciate nutritional risks associated with cow milk allergy. Understand the role of nutrition management in the care of a child with cow milk allergy.

Describe symptoms, prevalence and the most causative foods associated with gastrointestinal food allergy.

Understand different aspects of an elimination diet including avoidance of causative foods, symptom management and nutritional adequacy.

November 29, Please join Dr. Review the nutritional management of patients with short bowel syndrome. Learn about the possible nutritional deficiencies of an infant with short bowel syndrome. Review the role enteral nutrition plays in the intestinal adaptation. Identify GI conditions that typically lead to compromised gut health in the neonate such as necrotizing enterocolitis and short bowel syndrome. Recognize key indicators of feeding success or intolerance, including manifestations of food allergies.

Incorporate various nutritional strategies to help manage compromised gut health in the newborn. March 21, Please join Dr. February 4, Please join Dr. Explore current treatment options for GI food allergy. Evaluate when to refer for GI food allergy consultation. Stimulating intestinal function with prebiotics. Supporting oral feeding in malabsorptive patients. Identify specific characteristics of feeding issues in the young child and older child with EoE.

Understand that medical treatment alone may not remediate symptoms of feeding dysfunction in children with EoE. Recognize criteria for referral to a feeding specialist. The seven key signs of acid reflux in a baby. Myths and misconceptions about the care and treatment of a baby with colic.

Join our speakers Laurie Bernstein and Fran Rohr in a discussion about the Simplified PKU Diet and how this approach could potentially increase diet adherence and enjoyment of a more normalized approach to food for patients with PKU. By partaking in this webinar, participants will be able to: Understand the rationale for using the simplified diet.

Teach the simplified PKU diet to their patients. Share best practices around this approach to PKU management. What Do We Know? Join us for a 1 hour educational webinar with Dr. At the end of this webinar, participants will be able to: Understand the relationship between plasma levels and brain uptake of essential amino acids. The cardiac rehabilitation programs benefit women and men equally. The risk stratification process is very valuable for cardiac patients; it serves as the basis for individualizing the prescription of exercise training and for assessing the need and extent of supervision required.

The risk stratification process is based on the assessment of the patient's functional capacity, on the patient's educational and psychosocial status, on whether alternatives to traditional cardiac rehabilitation can be used, and on whether the patient is suffering from myocardial ischemia, ventricular dysfunction, or arrhythmias.

The term functional capacity refers to the maximum ability of the heart and lungs to deliver oxygen and the ability of the muscles to extract it. Functional capacity is measured by determining the maximal oxygen uptake VO 2 max during incremental exercise. In most patients, a rough calculation of functional capacity can be performed by using multiples of 1 MET metabolic equivalent, 3. In complicated patients, such as those with severe left ventricular LV dysfunction and congestive heart failure CHF , the functional capacity can be ascertained with greater accuracy by using cardiopulmonary exercise CPX testing.

Most cardiac rehabilitation facilities, however, are not currently equipped for CPX. Skeletal muscle performance, such as deconditioning or in the presence of concurrent, noncardiac illness. Every attempt should be made to recognize the potential effects of these factors on functional capacity in order to minimize risk of the individualized reconditioning program that is being formulated.

Symptomatic or asymptomatic silent myocardial ischemia may limit the patient's exertional capacity by causing limiting angina, dyspnea, or fatigue. Fixed LV dysfunction or damage may be present in the absence of angina. Patients with LV dysfunction develop early dyspnea and easily become fatigued.

Cardiopulmonary exercise testing preferably should be performed to determine the functional capacity in an objective manner. Exercise intolerance in patients with LV dysfunction is due to skeletal muscle hypoperfusion resulting from inadequate cardiac output that can be better quantified by measuring VO 2 max. Ventricular irritability and complex ventricular arrhythmias require assessment through the use of signal-averaged electrocardiogram ECG or electrophysiologic studies.

Appropriate medical or device treatments should be undertaken whenever feasible prior to beginning phase 2 of the cardiac rehabilitation program. Very close surveillance is necessary in patients with significant cardiac arrhythmias during their exercise training routines.

Concomitant rhythm monitoring with telemetry, Holter or event monitoring should be considered. In many cases of serious arrhythmias, therapy remains controversial and the safety of is exercise unclear; such uncertainties complicate the decision-making process. Patients with severe ventricular arrhythmias and uncontrolled supraventricular arrhythmias should be excluded from exercise training unless proper evaluation and effective therapy has been instituted.

Patients with devices, such as pacemakers and defibrillators, should be carefully monitored during exercise. Rate-responsive pacemakers are quite helpful even for those patients who are completely pacemaker-dependent. In case of implantable cardioverter defibrillators ICDs , exercise training can be provided as long as underlying arrhythmias are controlled with pharmacotherapy.

Heart rate should be kept well below the threshold at which the antitachycardia algorithm of the ICD begins. Exercise does provide some benefit, but severe cases may require specific therapy that has been shown to enhance the benefits derived from subsequent cardiac rehabilitation. The promotion of self-efficacy and control over one's activities is of paramount importance for boosting self-confidence. Coronary-prone behavior CPB is known as a cardiac risk factor, but its effect on prognosis is unclear.

Some data suggest that the modification of CPB can improve the coronary disease prognosis. Initially, continuous ECG monitoring is recommended for most patients during cardiac rehabilitation exercise training; however, clinicians may decide whether to use continuous or intermittent ECG monitoring.

After the initial period, the use of electrocardiography depends on the clinical judgment of the supervising physician. In carefully selected patients, alternatives to the traditional supervised group or individual cardiac rehabilitation program have been examined.

These alternatives, which are applicable primarily to very low-risk patients, include the following options:.

Heart rate recovery HRR following maximal exercise has been found to be a predictor of all-cause mortality. In a study, Streuber and colleagues hypothesized that aerobic exercise training could improve HRR in patients who have suffered heart failure, because athletes are known to have accelerated HRR, while cardiac rehabilitation has been shown to positively effect such recovery in patients with coronary artery disease CAD.

The results indicated that in patients with heart failure who have low exercise capacity, even short-term aerobic training can aid HRR. Cardiac rehabilitation initially was designed for low-risk cardiac patients.

Now that the efficacy and safety of exercise have been documented in patients previously stratified to the high-risk category, such as those with congestive heart failure CHF , the indications have been expanded to include such patients. Exercise training benefits persons with the following cardiac conditions:. Coronary bypass [ 20 ]. Valve surgery [ 21 ]. Cardiac transplantation [ 21 ]. Exercise prescription depends on the results of exercise testing, which often includes cardiopulmonary exercise CPX testing.

Patients with limitations due to chronic obstructive pulmonary disease COPD , peripheral vascular disease PVD , stroke, and orthopedic conditions still can be trained in the exercises through special techniques and adaptive equipment eg, use of arm-crank ergometer.

Unstable concomitant medical problems eg, poorly controlled or "brittle" diabetes, diabetes prone to hypoglycemia, ongoing febrile illness, active transplant rejection [ 22 ].

In such patients, every effort should be made to correct these abnormalities through optimization of medical therapy, revascularization by angioplasty or bypass surgery, or electrophysiologic testing and subsequent antiarrhythmic drug or device therapy. Patients should then undergo retesting for exercise prescription. Two forms of exercise tests are performed in patients following an acute cardiac event: Furthermore, CPX also may be performed, particularly in patients with cardiomyopathy or CHF, to determine objectively the patient's exercise capacity.

A representative schedule might begin exercise at intervals, such as days following uncomplicated acute myocardial infarction MI , days following angioplasty, or days after bypass surgery. Submaximal exercise testing is not necessarily safer than symptom-limited testing. In fact, the submaximal strategy may have certain disadvantages; it can lead to inappropriate limitation in the patient's routine activities and exercise training and to a significant delay in the patient's return to work.

The use of submaximal exercise may also result in a failure to elicit important factors in prognosis, such as ischemia, cardiac dysfunction, and arrhythmia.

Incremental exercise is employed, using modified Naughton protocol for treadmill or modified protocols on a bicycle ergometer. Concomitant minute-to-minute breath analysis and measurement of oxygen consumption and elimination of carbon dioxide are performed to determine VO 2 max, which is the most objective method of determining functional capacity in patients with cardiac dysfunction, valvular disease, or recent acute cardiac event.

Modified Bruce or Naughton protocols typically are used during the testing phase, because the standard Bruce protocol has been modified to avoid too abrupt an increase in METs by METs per stage. The modified Naughton protocol starts at a lower MET workload and increases by 1 MET per stage, thus allowing better-tolerated gradual progression in exercise and a more accurate assessment of exertional capacity.

Severe abnormalities found on stress testing may contraindicate exercise training until they have been corrected. Less severe abnormalities, such as the development of the above symptoms at high workloads, may not necessarily contraindicate exercise training; however, certain modifications and closer surveillance may be required, including ECG monitoring. Some reports have questioned early exercise training following acute anterior MI, suggesting that it may lead to abnormal scar formation.

Nonetheless, evidence is strong that moderate exercise training is not associated with worsening LV function in patients following acute anterior MI. Phase 2 of a cardiac rehabilitation program is initiated based on the result of the exercise testing, and the exercise prescription is individualized.

Three main components of an exercise training program are listed below. Patients usually need to allow minutes for each session, which includes a warm-up of at least 10 minutes. The intensity prescribed is in relation to one's target heart rate. Aerobic conditioning is emphasized in the first few weeks of exercise.

Strength training is introduced later. Patients usually should exercise at an RPE of Exercise sessions should begin with 10 minutes of warm-up, during which light calisthenics and muscular stretching are performed to avoid muscle injury and to bring about a graded increase in heart rate. This warm-up period is followed by 40 minutes of aerobic exercise eg, walking, jogging, bicycling and a final 10 minutes of cool-down period involving muscular stretching.

The cool-down period is very important. Gradual cool-down prevents ventricular arrhythmias, which may occur in patients with coronary disease on abrupt cessation of exercise. The patient's peak heart rate is noted. Most patients are able to do so by months. A follow-up treadmill test should be performed at weeks after the patient starts the program, and the result should be used to fine-tune the exercise training.

In patients with myocardial ischemia, exercise training still can be performed safely. The maximal heart rate should be kept 10 beats per minute bpm lower than the heart rate at which ischemia occurred. Closer surveillance and ECG monitoring are recommended in patients following myocardial ischemia. Patients with arrhythmias also need ECG monitoring. Patients with CHF require a much more modified exercise program.

Also, in those with type 2 diabetes who have a hypertensive response to exercise, an increased left ventricular mass, and a higher risk of mortality, exercise training and dietary restrictions are advised. Schultz et al determined in their study that, after 1 year of these lifestyle modifications, patients significantly diminished their exercise blood pressure; however, their cardiac size remained the same.

Phase 3 - A lifetime maintenance phase in which physical fitness and additional risk-factor reduction are emphasized. Phase 1 includes a visit by a member of the cardiac rehabilitation team, education regarding the disease and the recovery process, personal encouragement, and inclusion of family members in classroom group meetings.

See the images shown below. Some older patients may serve as volunteers and share their experiences about learning to live with heart disease. Team members include cardiac nurses, exercise specialists, physical therapists, occupational therapists, dietitians, and social workers. In the coronary care unit, assisted range-of-motion exercises can be initiated within the first hours.

Low-risk patients should be encouraged to sit in a bedside chair and to begin performing self-care activities eg, shaving, oral hygiene, sponge bathing. On transfer to the step-down unit, patients should, at the beginning, try to sit up, stand, and walk in their room. Subsequently, they should start to walk in the hallway at least twice daily either for certain specific distances or as tolerated without being unduly pushed or held back. Standing heart rate and blood pressure should be obtained followed by 5 minutes of warm-up or stretching.

Walking, often with assistance, is resumed, with a target heart rate of less than 20 beats above the resting heart rate and an RPE of less than Starting with minutes of walking each day, exercise time gradually can be increased to up to 30 minutes daily.

They must also ensure that phase 1 patients get referred to appropriate local, convenient, and comprehensive phase 2 programs. Better understanding of how to keep the heart healthy and strong is emphasized. Team members work with patients and family members.

Team members check the patient's medical status and continuing recovery; they should offer reassurance as the patient regains health and strength. This phase of recovery includes low-level exercise and physical activity, as well as instruction regarding changes for the resumption of an active and satisfying lifestyle.

Patients who have completed hospitalization and weeks of recovery at home can begin phase 2 of their cardiac rehabilitation program. The physician and cardiac rehabilitation staff members formulate the level of exercise necessary to meet an individual patient's needs see images below.

Constant medical supervision is provided; this includes supervision by a nurse and an exercise specialist, as well as the use of exercise ECGs. In addition to exercise, counseling, and education about stress management, smoking cessation, nutrition, and weight loss also are incorporated into this phase.

Phase 3 of cardiac rehabilitation is a maintenance program designed to continue for the patient's lifetime. The exercise sessions usually are scheduled 3 times a week. Activities consist of the type of exercises the patient enjoys, such as walking, bicycling, or jogging. A registered nurse supervises these classes. Phase 3 programs do not usually require medical or nursing supervision.

Common sexual problems encountered by cardiac patients include impotence, premature or delayed ejaculation, and reduced libido in men and women. These difficulties may be due to medications eg, beta blockers, diuretics , depression, or fears by the patient and his or her partner of precipitating a cardiac event.

Maximum heart rate during sexual intercourse averages bpm, which is similar to heart rates associated with other routine activities in and around the house.

The hemodynamic response is greater with an unfamiliar sex partner, in unfamiliar surroundings, after eating, or after consuming alcohol. Adapting less strenuous positions — for example, using a side-to-side arrangement rather than the missionary position — can reduce cardiac stress.

Patients may start sexual activity weeks following an uncomplicated myocardial infarction. They must be instructed to report any untoward symptoms to the physician or to a member of the rehabilitation team. Cardiac rehabilitation provides many benefits for patients. The most important of these are discussed in this section. Cardiac rehabilitation exercise training for patients with coronary heart disease or congestive heart failure CHF leads to objectively verifiable improvement in exercise capacity in men and women, regardless of age.

The nonfatal infarction rate is 1 patient per , patient-hours; the cardiac mortality rate is 1 patient per , patient-hours. The benefits are even greater in patients with diminished exercise tolerance.

This beneficial effect does not persist long-term after completion of cardiac rehabilitation without a long-term maintenance program. They establish policies, approve programs and decide on administrative and financial plans and budgets.

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