Heartwise is primarily concerned with prescribing doses of aerobicand toning exercise, based on the FITT principle that confer and maintain measurable physiological changes known to reduce chronic illness symptoms and mortality.

Aims of the Service

Cardiac rehabilitation is defined by the World Health Organization (1) as: “.The sum of activities required to influence favorable the underlying cause of the disease, as well as the best possible, physical, mental and social conditions, so that they (people) may, by their own efforts preserve or resume when lost, as normal a place as possible in the community. Rehabilitation cannot be regarded as an isolated form or stage of therapy but must be integrated within secondary preventions services of which it forms only one facet” The service provides a comprehensive Cardiac Rehabilitation programme to the population of South Tipperary. The Cardiac Rehabilitation Service provides support and education via a service that includes:

• Psychological support to both the patients and their families.
• Information regarding their condition.
• Lifestyle advice to patients (and their families) that have had a myocardial infarction, (MI) revascularization or other cardiac event.
• Education to facilitate the identification of risk factors for Coronary Heart Disease (CHD) to enable them to adopt lifestyle changes and promote a healthier way of life

Cardiac Rehabilitation programs are designed to limit the physicaland psychological effects of cardiac illness, reduce the risk of sudden death or re-infarction, control cardiac symptoms, stabilize or reverse the atherosclerotic process and enhance the psychosocial and vocational status of selected patients.

Scope of the Service

• To provide a structured programme of care designed to help cardiac patients recover quickly and improve their overall physical/ mental and social functioning.
• To provide access to a specialist team
• To provide a patient centered service
• To help patients overcome their fears and become fully active and integrated into society 3
• To help patients slow or even reverse the progression of diseasethrough changes in lifestyle, thereby reducing the risk of heart disease or another cardiac episode.
• To improve health outcomes for those suffering with long term cardiac conditions

Heartwise staff

A minimum of one instructor will be present in each class at all times. This instructor must be BACPR (British Association of Cardiac Prevention and Rehabilitation), First Aid and Defibrillator qualified.

The principles underlying safe and effective exercise prescription for individuals with coronary heart disease

Safety is the paramount consideration for the delivery of the program.

The criteria for accepting clients are as follows,

• Stable angina
• Post-myocardial infarction (MI)
• Post-coronary artery bypass graft surgery (CABAGS)
• Post percutaneous coronary intervention (PCI)
• Stable chronic heart failure
• Post valve replacements
• Implanted cardioverter defibrillator (ICD)
• Post cardiac transplant
• The opportunity for inclusion of spouses/partners and family members as support may be considered. However, such participants should be subject to a comprehensive screeningprior to starting exercise.

Contraindications to exercise.

• Unstable angina
• Unstable or acute heart failure
• Unstable Diabetes
• New or uncontrolled arrythmias
• Resting or uncontrolled tachycardia
• Resting SBP > 180 mm Hg or Resting DBP >100 mm Hg
• Symptomatic hypotension
• Febrile Illness

Criteria for assessing suitability to exercise

• Clinically stable ie there has been no change in symptoms orsignificant change in medication during the preceding month
• Able to sustain activities to a minimum of 5 MET’s i.e. walking at 4mph
• Able to monitor and regulate intensity of their activity
• Able to recognize their optimum level of exercise intensity
• Able to acknowledge the importance of and demonstrate a commitment to modifying risk related behavior.

Reasons for referring a client to their GP

• Deteriorating exercise performance/functional capacity despite apparent compliance with the prescribed exercise regimen and medication.
• Worsening or angina or development of unstable angina despite apparent compliance with the prescribed medication.
• Worsening of other symptoms, i.e. suspected arrhythmias, excessive breathlessness despite apparent compliance with the prescribed medication.
• Any further cardiac event
• Uncontrolled tachycardia (>100bpm)
• Resting SBP >180 Hg
• Resting DBP > 100 Hg
• Symptomatic hypotension

Aims and Objectives

The aims and objectives of Heartwise are to complement the role of the primary healthcare team. Heartwise will continuously reflect on the partnership with all relevant bodies including, local HSE, GP’s, Phase III coordinator’s and any private entities providing a coronary care service.

Heartwise will

• Provide regular supervised aerobic and toning exercise sessions
• Establish individual exercise prescription for additional independent physical activity
• Offer general advice and support in maintaining lifestyle changes associated with risk factor reduction.
• Encourage independence, self – help and self-motivation.
• Review on a regular basis participants progress (or regression) and to alter the prescription accordingly; or in the case of new symptoms or deterioration in functional capacity of unknown cause – refer back to the primary care team.

Before starting exercise sessions each individual should have advised the instructor of,

• Any change in their symptoms. i.e. new or worsening chest pains
• Any change in medication
• Any test results. ie blood pressure or cholesterol level
• Any new or worsening joint problems
• Any general feeling of being unwell

During any exercise session each individual will advise the instructor of

• Any angina, chest discomfort or dizziness
• Any joint problems
• Any general feelings of being unwell

GTN:

If any person has been prescribed with GTN spray this should be brought to the class even if not used on a regular basis. The classinstructor should also be informed.

Key Principles of each class delivered

Key Principles of each class delivered

• F Frequency at least 2 times per week
• I Intensity 40% – 70% HRR
• T Time 30 – 60 minutes of exercise
• T Type Aerobic and toning exercises

Warm Up

The warm up, inclusive of pulse raising, mobility and preparatory stretching should be 15 minutes in duration.By the end of the warm up period participants should achieve a heart rate withing 20 bpm below the lower end of their training heart rate of if RPE is being used no higher than 3 on the CR-10 scale and 10 or 11 on the 6 – 20 scale.

Conditioning Component

Depending on the fitness level of individual participants, clients perform differing durations of continuous aerobic exercise before spending time in active recovery. A less able client would do one aerobic station followed by one toning station where as a fitter client may complete four aerobic stations before performing a toning activity. The conditioning component will last at least 30 mins.

Progression

The exercise regimen may be progressed through various combinations of increasing duration, frequency or intensity of training. However, as endurance training is the main objective of the program an increase in the duration of aerobic work is the most important method of progressing a program.

Monitoring Intensity

Participants are told to make a mental note of their rating of perceived exertion towards the end of each bout of CV work, so they can write it down in their program card or report it to the instructor. Spot checks should be carried out by the instructor throughout the class.

Cool Down

The cool down should be more gradual to reduce the risk of increased hypotension and reduce high levels of catecholamines that increase the risk of arrhythmias. The cool down should last for 10 minutes, returning heart rates to pre-exercise levels.

Flexibility

There are no significant differences in training needs between individuals with coronary heart disease compared with apparentlyhealthy individuals. Proprioceptive neuromuscular facilitation stretches are not generally appropriate due to the isometric contraction involved in the procedure leading to increased blood pressure.

New Client’s

New clients will be thoroughly familiarized with the format of the class to avoid confusion. The instructor will monitor new clients to ensure their safety and enjoyment of the class.

Hours of operation

The Cardiac rehabilitation service is available from Monday to Friday and is open from 8am to 8pm. Closing for Lunch from 1pmto 2pm

Programme records and confidentiality

Before joining the programme, referred individuals agree to the transfer form, that includes personal and medical information being given to Heartwise staff. Maintaining the confidentiality of the information supplied becomes the responsibility of the instructor and this must be taken seriously. Any information transferred on to computers must be password protected. The manager will have overall responsibility for confidentiality of all records. If the programme ceases any forms should be returned to the participant or to whoever initiated the referral. All information stored on computer should be deleted.

Facilities

• Changing room and toilet facilities
• Treatment Room

Infection Prevention

The service will be delivered in accordance with and compliance to Heartwise Infection Prevention Policies. All machines will be cleaned before the start of each class. Each machine will be cleaned when the participants move onto a new machine within their training pod and before entering a new pod.

Responsibilities

Both directors are responsible for the facilities operational and financial accountability for service delivery.