Rehabilitation foRehabilitation fo arrhythmia Dearrhythmia, … · 2012-11-23 · Rehabilitation...
Transcript of Rehabilitation foRehabilitation fo arrhythmia Dearrhythmia, … · 2012-11-23 · Rehabilitation...
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Rehabilitation foRehabilitation foRehabilitation foarrhythmia De
Rehabilitation foarrhythmia Dearrhythmia, De
valvular hearrhythmia, De
valvular hevalvular hevalvular heAsst. Prof. Visal Kanta
Director RehabAsst. Prof. Visal Kanta
Director RehabDirector, RehabSamitivej S
k @
Director, RehabSamitivej S
k @ravkn@yaravkn@ya
or patients withor patients withor patients withefibrillator andor patients withefibrillator andefibrillator and art diseaseefibrillator and art diseaseart disease art disease aratanakul, MD., FIMSbilitation Centeraratanakul, MD., FIMSbilitation Centerbilitation CenterSrinakarinh
bilitation CenterSrinakarinhahoo.comahoo.com
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CircuCircu
PumpingPumpingp gp g
ulatoryulatory
ElectricityElectricityElectricityElectricity
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rhythmiasrhythmias
Exercise induced a
Arrhythmia that coyexercise
arrhythmiay
ntradicted for
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e-threatening arrhythe-threatening arrhythLethal
Long QTg
Burgadag
VF, VT,
Non Lethal
exercise induced
Too fast or too s
hmiahmia
d arrhythmiay
slow
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nciples of Arrhythmia Renciples of Arrhythmia Re
Treat or look at the pa
Evaluation the patients
ventilation
Oxygenation
HR, BP
Signs of inadequate
ecognition and Mxecognition and Mx
atient.... not monitor
s
e organ perfusion
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art with simple oart with simple o
Is there any P ?
Is there any too long
Is there any bizarre Q
Is there other part tha
Is there any abnorma
Is there any abnorma
Is there any change d
onesones
for PR ?
QRS ?
at too long ?
al on ST ?
al T ?
during exercise ?
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ercise considerationsercise considerationshythmic patient y p
Need EST and moNeed EST and mo
No contraindicationNo contraindication
No exercise-induceNo exercise induce
Fixed percentage oFixed percentage oCeiling < 10-20 be
RPE might not wor
s fors for
onitoringonitoring
nn
ed arrhythmiased arrhythmias
of MHR withof MHR with eats of arrhythmia
rk well
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o contraindicatioo contraindicatio
Uncontrolled HR >
HIgh ST depression
High grade PVC
2nd or 3rd degree b
VT
onsons
120 BPM
n
block
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li t PVCalignant PVCs
• Frequent PVCsq
• Multiform PVCs
• Runs of consecutiv
• R on T phenomenop
• PVC during AMIg
ve PVCs
on
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acemakersacemakers
Single or dual chamber
Pacemakers now store lotsreviewed at follow up eg %reviewed at follow-up eg %
Now extremely programmaNow extremely programmaalgorithms
Rate responsiveness (HR i
AF suppression (pacing the
Rate drop acceleration resp
s of information that can be% time spent in AF% time spent in AF
able with many features &able with many features &
n response to activity)
e atria)
ponse
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ventricular paceventricular pacelso known as Cardiac Resynchronization
herapy (CRT)herapy (CRT)
May be patients for whom chronic RV pacy p pbecoming problematic
leads usually (atria, RV and LV)
acing both ventricles in a timed manneracing both ventricles in a timed manner lowing resynchronisation
Optimises cardiac output by allowing ppropriate ventricular filling and co-ordinontraction
emakersemakersn
cing g
nated
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plantable Cardiac Deplantable Cardiac DeAbilit to DC shock for VF VTAbility to DC shock for VF, VT
700-800 Volts or 30-40 Joules700-800 Volts or 30-40 Joules
Most now can also deliver ATP (anti-tach(pacing) to attempt to reduce need for shoherapy
Extremely complex devices that have maprogrammable featuresprogrammable features
Set-up and management is often quite triSet up and management is often quite trieg in the presence of AF
Most devices are also able to pace althoumost patients do not have a primary paci
efibrillators (ICDs)efibrillators (ICDs)
hy yock
any
ckycky
ugh ng
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ication for device impication for device imp
PacemakersSSS AVB CHB CI CSSS, AVB, CHB, CI, Cbradycardia, Symptomy , y pTrifasicular block, Neu(CSS VVS situationa(CSS, VVS, situationa
Biventricular pacemaBiventricular pacemaCHF with LBBB & lowCHF with LBBB & lowon echo, long PR withNYHA class IV
plantplant
Ch i AF i hChronic AF with matic Bifasicular block / urally mediated syncope al syncope)al syncope)
kers (CRT P)kers (CRT-P)w EF(<35%) dysynchronyw EF(<35%), dysynchrony h poor haemodynamics,
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ication for device impcat o o de ce pImplantable Cardiac DImplantable Cardiac D
Primary indication; sigy ; garrhythmia eg Long QTwith NSVT & poor EFwith NSVT & poor EF
Secondary indication;Secondary indication;
Biventricular ICD (CRBiventricular ICD (CR
CHF with LBBB & lCHF with LBBB & ldysynchrony on echaemodynamics, N
plantp a tDefibrillators(ICDs)Defibrillators(ICDs)nificant risk of life threateniT, Brugada, DCM, Post MI
survival of a VT or VF arresurvival of a VT or VF arre
T-D)T D)
ow EF(<35%)ow EF(<35%), ho, long PR with poor
NYHA class III or IV, prio
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Psychological ChaPsychological ChaExercise in Patiente c se at e t
racters and racters andts with AICDts t C
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Please close youPlease close you
What do you think if youWhat do you think if you it/accident badly ????/ y
Then next several mfire and you
ur eye and thinkur eye and think
sit in a car thatsit in a car that
minutes that car gou struck inside
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ychological compychological compPatientPatient
– DepressionDepression– AnxietyRelatives
– AnxietyFear– Fear
ponentsponents
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actshere are both sides of st
actshere are both sides of stfference/ no difference/etween patient with/witore spouse anxiety if thain problems with type
tudies: there aretudies: there are e in psychologcal variablp y gthout AICDhere is/are shock storm(e D personality(distresse
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people experience?
ACUTE PHASE (Hosp
Initial Euphoria – I’ve sInitial Euphoria I ve s
Increased anxiety andIncreased anxiety and
Mi tiMisconceptions
pital)
survivedsurvived
depressiondepression
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“You will be alricaref
Interp
?
“If I am not careIf I am not care
ight if you are g yful”
reted
eful I will die”eful I will die
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“You were lucYou were luc
InterpInterp
“I won’t betim
cky this time”cky this time
pretedpreted
??
e lucky next me”
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“It i l“It is only a
I tInterpr
??
“Something terri
i ”a warning”
t dreted
ble is yet to come”
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OOR DISCHARGEOOR DISCHARGE
DepressedDepressed
AnxiousAnxious
Misattribution of somatic s
Physical Deconditioned – fe
Over/under involvement sp
Sexual difficulties
Time off work / lifestyle cha
symptomsy p
ear avoidance
pouse/partners
anges
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46% reduction non‐fatal cardiac events
41% reduction in mortality
years follow up (Ref: Linden et al 199 years follow up (Ref: Linden et al 199
xercise based interventions may have
ositive effect of patients – physical abi
mprove some physiological measures o
but do not impact onbut do not impact on
ood lipids
orbidity
ll t litverall mortality
sufficient evidence re psychological ap y g
s
96)96)
ility to exercise
of cardiac disease
nd social outcomes
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xercise in Patientxercise in Patient
Important thing is to clah l i l blpsychological problems
as you couldas you could
with AICDwith AICD
arify state of d fi h hs and fix them as much
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ercise considerationsercise considerationsCD patient Fixed VS. adjustable ratej
Monitor systolic pressures
Extended warm-up and co
ICD: ECG monitoring/pulse
Rate modulated pacemakeMHRR method of Karvonen
Fixed percentage of MHRFixed percentage of MHR
RPE
s for pacemakers for pacemaker
ool down
e to titrate intensity
ers intensity:
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Cardiac Rehabbilitation in VHD
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it ti f E /mitation of Ex/a
overprotected by thp y
overprotected by thp y
Physical conditionsy
ti itctivity
heir parentsp
heir environment
s
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ormalized of exeormalized of exepacitypacity
Age of surgeryg g y
Pulmonary hypertey yp
Method of correctio
erciseercise
ension
on
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Left-to-right shuntsAtrial septal defectVentricular septal defec
V l l h t l i dValvular heart lesions and Aortic stenosisAortic stenosisPulmonary valve diseasPulmonary valve diseasCoarctation of the aorta
Cyanotic congenital heart dTetralogy of FallotTransposition of the gre
ctb t ti liobstructive anomalies
seseadisease
eat arteries
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i l t l d frial septal defecright volume overload
increased pulmonary b
resulting in pulmonary
normal or only slightly i
exercise capacity
the age at surgery has influenceinfluence
th i it
t (ASD)ct (ASD)
blood flow
hypertension
impaired aerobic
been shown to
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entricular septalentricular septalleft ventricular volume ovl ft t i l dil t tileft ventricular dilatationhigher pulmonary to systehigher pulmonary to systeThe relative shunt fractioThe relative shunt fractioto decrease with the increexerciseexerciseExercise performance haExercise performance habe slightly decreased whage-matched controls
defect defectverload resulting in
emic flow ratioemic flow ration has been shownn has been shown easing intensity of
ave been shown toave been shown to en compared with
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onditions the decronditions the decrpacitySpacityAS
Pulmonary valve diseaPulmonary valve disea
Tetralogy of Fallotgy
Transposition of the gre
rease Ex.rease Ex.
asease
eat arteries
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Any QuestionAny Questionnsns