VO2 and cardiac rehabilitation - Société Française de Cardiologie

24èmes Journées Européennes de la Société Française de Cardiologie
15-18 janvier 2014
VO2
and cardiac
rehabilitation
Clinical case report
Catherine MONPERE, MD
Cardiac Rehabilitation Center BOIS GIBERT – 37510 BALLAN MIRE (F)
VO2 and cardiac
rehabilitation (CR)
 CONFLICT
 NONE
OF INTEREST
DECLARED
VO2 and cardiac rehabilitation (CR)
Cardio respiratory stress test : indications in CR
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High physical demand (vocational or sport activities)
In heart failure (HF) patients
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Prescription of exercise training
Validation of heart transplant indication
Optimization of pronostic parameters after reconditioning
Vocational assessment
VO2 and cardiac rehabilitation (CR)
Clinical case report
VO2 and cardiac rehabilitation (CR)
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Despite LV dysfunction physical performance in young patients may
be moderately decreased
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Higher % of sedentary jobs
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Critical socio economic context : work is a vital necessity
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Improvement in symptomatology and prognosis in HF patients
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Need to evaluate adequation between job demands and medical
and functional status :
role of VO2 test ?
VO2 and cardiac rehabilitation (CR)
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PHYSICAL DEMAND AT THE WORK PLACE :
A RISK FACTOR ??
-LONG TERM MODERATE ENDURANCE TRAINING
IN CHF PATIENTS IMPROVES LONG-TERM VITAL PROGNOSIS
ANDQOL
(BELARDINELLI.R JACC 2012
EXTRA-MATCH STUDY BMJ 2004)
VO2 and cardiac rehabilitation (CR)
Combined training :
endurance + low resistance
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Does not induce deleterious LV
remodelling
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Higher results on sub max
performances,
muscular strenght,
QOL compared to endurance training
alone
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Becker PJ. Eur Heart J 2008
Schmid JP. Eur J Cardiovasc Prev Rehabil
2010
VO2 and cardiac rehabilitation (CR)
Clinical case report
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POU … S. 44 years-old woman
No medical history
Risk factors : HBP, smoking
December 2012 : hospitalisation for pulmonary oedema
revealing idiopathic dilated cardiomyopathy (DMC)
Echocardiography : global hypokinesia EF =15 % ED LV = 66 mm
Apical thrombus 16 x 5 mm
Evolution M6 :
Treatment : oral anticoagulant, beta-blockers, EC A inhibitors,
spironolactone , furosemide .
NYHA = 3
Echocardiography : LVEF : 38 % EDLVD = 65 mm. Thrombus = 0
VO2 and cardiac rehabilitation (CR)
Clinical case report
Profession : cashier in a downtown supermarket
Characteristics of the job :
- Work sitting at the cash register
- Physical demand:
- pulling paletts : 30 kg
- handling fruits and vegetables
- Exposure at cold (cold room), or briefly warm
atmosphere (baker's oven) .
- Stress due to shift work and low-secured environment
VO2 and cardiac rehabilitation (CR)
VO2 and cardiac rehabilitation (CR)
Clinical case report VO2 before CR
90 W 1 mn 69 % TMHR (122
mn-1)
BP : 90/60 to 150/60 mmHg
No arrhythmia
Stop for fatigue and dyspnea
VO2 peak 16.4 ml/mn/kg-1
(72 % th.) RER 1.20
T1/2 VO2 : 110 sec (N=80  20 sec)
VE max 49.57 l mn-1
VE/VCO2 slope : 28.8 (N=20 to 25)
VO2 and cardiac rehabilitation (CR)
Clinical case report
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Determination of SV 1
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50 W HR : 85/mn
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VO2 : 9.5 ml/mn/kg-1
(58 % PEAK VO2)
VO2 and cardiac rehabilitation (CR)
 Severity
criteria ?
Prognostic criteria :
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 Training
?
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Peak VO2 > 14 ml/mn
> 55 % theorical value
T½ VO2 time > 80 sec
Early SV1
20 sessions
Endurance bike training
Segmental callisthenics
Walk
VO2 and cardiac rehabilitation (CR)
Clinical case report VO2 before and after CR
Peak VO2
16,4 (4,8 METS)
19,5 (6 METS)
72 %
86 %
50 W
(9,5 ml/mn-1)
(58 % VO2 mx)
80 W
(13 ml/mn-1)
(66 % VO2 mx)
28,8
27
Watts mx
90
110
1/2T VO2 (sec)
110
100
% Théor VO2
SV1
VE/VCO2 slope
+ 3,2 ml
Conclusion : improvement peak VO2 and SV1
VO2 and cardiac rehabilitation (CR)
•Kaplan Meier event-free survival curve /
response to training (increase %Predicted
Peak VO2 > 6%)
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155 pts (54  12 y)
20 training sessions
Follow- up 16  6 months
27 cardiac events (death,
transplant, hospitalization)
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High initial BNP level and
lack of improvement in VO2
have strong pronostic value
for adverse events
Tabet JY et al Circulation heart failure
2008.
VO2 and cardiac rehabilitation (CR)
FACTORS INFLUENCING RTW
CLINICAL AND
FUNCTIONAL
PARAMETERS
ENERGY REQUIREMENT
OF THE JOB
LEGAL CONSIDERATIONS
PSYCHO-SOCIAL
ASPECTS
VO2 and cardiac rehabilitation (CR)
Clinical case report
How to evaluate adequation between physical condition and
physical constraints at work
Exercise capacities
Cardio respiratory
stress test
(Peak Mets,SV1,
corresponding HR)
Physical demand
at workplace
Abacus :
Compendium of
Physical activities
Med and Sciences in
Sports Exer)
Simulation of
workplace or
record at work
Evaluation of metabolic and cardiovascular demands
Niveau
d'activité
Activités domestiques
et de loisir
TRES LEGER se laver
< 3 METS
se raser
s'habiller
écrire
faire la vaisselle
50 watts
passer l'aspirateur ou balayer
lentement
conduite automobile
jardinage léger : taille des rosiers,
tonte de gazon sur tracteur,
semailles
petit bricolage (modélisme …)
loisirs : pêche, billard, croquet
LEGER
laver les vitres
(3 A 5 METS) cirer les parquets
faire les lits
porter des charges de 7 à 15 kgs
50 - 70 watts jardinage : usage tondeuse tractée
ratissage léger, binage
bricolage : peinture intérieure,
pose de papiers peints
loisirs : danse à rythme modéré
MODERE
porter des charges de 15 à 30 kgs
(5-7 METS)
laver une voiture
jardinage : bêchage en terre légère
70 - 100 watts usage d'une tondeuse manuelle à plat
fauchage lent, conduite petit
motoculteur
Activités
professionnelles
travail assis
travail de bureau
dactylographie
réparation électronique, mécanique de
précision
travail en position debout (vendeur, portier)
conduite de tracteur, camion
(en tenant compte de la législation)
travail à la chaîne, à cadence et charges
moyennes
travail de garage (réparation auto)
magasinage
construction d'un mur (mélange mécanique
du ciment, pose de pierres et de briques)
menuiserie légère
travaux du bâtiment, menuiserie lourde
(charpente, réfection extérieure)
travail de plâtrier
maniement du marteau pneumatique,
pelletage lent
VO2 and cardiac rehabilitation (CR)
Evaluation of metabolic and cardiovascular demands
(from Haskell 1978 ; Compendium of physical activities Ainsworth B.E 2000)
LOURD
7-9 METS
porter des charges de 30 à 40 kgs
bricolage : scier du bois, pelletage lourd
jardinage : bêchage lourd
100 - 140 watts loisirs : danse à rythme rapide,
randonnées en montagne
TRES LOURD porter des charges de plus de 40 kgs
> 9 METS
montée rapide d'étages
jardinage : pelletage lourd, fauchage
> 140 watts rapide
entretien industriel lourd
maniement d'outils lourds (tronçonneuse,
outillage de terrassement …)
chargements de camions
bûcheronnage
travail lourd de manœuvre
VO2 and cardiac rehabilitation (CR)
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To allow good tolerance at
the work place, the peak
exercise work load should be
at least twice the average
physical
requirement
of
occupational tasks for a 6/8
hours work duration.
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Some cases need
jobsimulation
or
on-site
evaluation
to
determine
cardiovascular responses to
specific work tasks.
VO2 and cardiac rehabilitation (CR)
Clinical case report
Peak VO2 = 19,6 ml/mn/kg-1 ( 6 METS)
Mean charge for a 6-8H work duration : < 40 % VO2 mx (Haskell
1989) or 2,5 METS = 7,8 ml/mn/kg-1 = HR 95/mn
According to abacus :
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Work sitting  1,5 METS
Walking slowly with light charges < 10 kg = 3 METS
Walking quickly with light charges < 10 kg = 4 METS
Pull pallets = 30 kg
= 7 METS
However :
These values are determined from healthy patients.
Other parameters to consider :
- environmental conditions : hot and cold air temperatures, pollution,
noise ...
- working and rest hours : deleterious effect of « 3x8h », transport …
- type of exercise encountered : dynamic, static, arm-shoulder exercises
VO2 and cardiac rehabilitation (CR)
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Peak VO2 = 19,6 ml/mn/kg-1
( 6 METS) Mx HR : 133/mn
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Mean charge for 6-8H work
< 40 % VO2 mx (Haskell
1989)
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For our patient : 2,5 METS =
7,8 ml/mn/kg-1 = HR  90/mn
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Work place simulation
Rest HR : 64/mn
Slow walking +carrying
8 kgs weight : 85/mn
Faster walk+carrying
8 kgs weight :106/mn
Handling fruit :117/mn
Same work -20°C :126/mn
dyspnea
Pulling trolls > 30 kgs :
130/mn
VO2 and cardiac rehabilitation (CR)
In summary for this patient:
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Possibility of return to work after modifications of work
characteristics
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Evolution to team-management job, fixed hours,part
time.
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Role of vocational physician ++
+
VO2 and cardiac rehabilitation (CR)
Return to work (RTW) in heart failure (HF) patients :
work simulation
VO2 and cardiac rehabilitation (CR)
VO2 and cardiac rehabilitation (CR)
CARDIAC REHABILITATION : an opportunity to optimize
RTW counselling in HF patients
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lenght of stay of 3 to 4 weeks > hospital stay
stabilisation of cardiac condition and improvement of physical
capacities assessed by VO2
psychological support : decrease of fear of RTW
pluridisciplinary approach : GP, vocational physician,
cardiologist, physiotherapist, psychologist …
better knowledge :
-of the workplace
-psycho social job stress
- identification of barriers to RTW
Post rehabilitation cardio-pulmonary stress test gives
relevant informations on RTW counselling