I’m starting to push more in to the cardiac side of things. As well as this being the original intent of this blog years ago, it is also because your focus should also be shifting. If you are treating COVID-19 patients, you need to start focusing on their heart. The patients who did a stent in the ICU are likely very deconditioned. We know that deconditioning is not just a skeletal muscle condition, it is also a cardiac muscle condition, and interventions need to target both types of muscle. So it’s time to start building up that aerobic capacity. However, if your patient is deconditioned (whether it be COVID-19 related or just plain old frailty or immobility), you need to be thinking about the effects this has on their cardiac function. Odds are they have a decreased ejection fraction (EF).
What is an Ejection Fraction?
Ejection fraction is the measure of amount of blood ejected from a heart ventricle, typically the Left ventricle is considered when we talk about EF. Questions about ejection fraction show up often on licensing exams because you really have to know the numbers to know what normal is. It’s a fine line with little wiggle room.
55% or more is considered normal
55 – 50% is considered borderline
50% or less is considered reduced
How Is Ejection Fraction Reduced?:
There are so many ways this can happen. We mentioned above about deconditioning which is probably the most common way we see this happen in so many people. But with deconditioning, there is typically an underlying cause. These can include:
- Long Term Illness
- Left Ventricle Hypertrophy (Cardiomyopathy)
- Uncontrolled High Blood Pressure
- Heart Valve Dysfunction
- Damage from MI
Do these things sound familiar? They are all associated with heart failure. And ejections fractions are directly associated with heart failure. Like we discussed here, heart failure can come with a reduced or preserved ejection fraction. We will talk more about this in another post.
What impact does that have?
People who have decreased Left Ventricular EFs have increased health care costs! Just look at that list above: hypertension, cardiomyopathy, valve dysfunction, MI. We know those are all associated with large amounts of medical intervention including medications, rehab, and surgeries. The dollar signs amount. BUT, if you thought we just became the “frontline” against cardiopulmonary diseases due to COVID-19, you’d be wrong. Well-prescribed aerobic exercise is the key to success, recovery, and prevention for all of the items on that list. Let’s talk a little more about that.
Can Ejection Fraction be Improved?
Why, Yes. Yes it can.
Sure, there are other ways to improve ejection fraction, like:
- CABG procedure. Increasing blood flow to the cardiac muscle increases its oxygenation and nutrient supply and therefore its contractile power.
- Aortic Valve Replacement. If the valve is leaky, blood is flowing out when the muscle isn’t contracting, so when the muscle does contract, there isn’t as much blood left to be ejected. Replacing the valve fixes the leak.
- β-Blockers (Metoprolol in particular). Stabilizing the heart rhythm improves contractility because all fibers can work together instead of having errant electrical activity interfering with contractility.
But we know these things come with other heavy medical burdens, side effects, and drug interaction risks. So the obvious best choice is going to be an intervention that decreases need for medications, prevents surgical intervention, and has little inherent risk. Enter aerobic exercise! Of course, it isn’t that simple, is it? Or everyone would be doing it on their own. People who have a reduced ejection fraction have reduced oxygenated blood flow from their heart. That means they are in the category of “having a dam built upstream”. Read this post for more on that.
Pre-surgical participation in Cardiac Rehabilitation programs decreased the cost of care for people who underwent surgical intervention. Post-surgical participation in cardiac rehab programs also decreased the cost of care for people who underwent surgical intervention. Can you imagine if we did both??? Utilizing well-prescribed aerobic exercise with appropriate vitals monitoring, functional outcome measures, and patient centered goals is going to get these patients back on track to a normal life. There, of course, are some cases where exercise is not the only answer, but it needs to be used in combination with other interventions. That’s even more reason for PTs and OTs to be involved. Our advanced knowledge of medications, comorbidities, and the effects they have on the body and exercise are what these patients really need.
Patients can’t cardiovert themselves. They can’t bypass themselves. They can’t prescribe for themselves (even though some try!). But they CAN exercise for themselves! With your professional guidance, of course! Empower them to take control.
Who does the cardiac rehabilitation at your facility or system? Tell me below in the comments!
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Ades, P. A.,Huang, D., Weaver, S. O. (1992). Cardiac rehabilitation participation predicts lower rehospitalization costs. American Heart Journal. Volume 123(4):916-921. Retrieved from https://www.sciencedirect.com/science/article/abs/pii/000287039290696S.
Engelmeier, R. S., O’Connell, J. B., Walsh, R., Rad, N., Scanlon, P. J., & Gunnar, R. M. (1985). Improvement in symptoms and exercise tolerance by metoprolol in patients with dilated cardiomyopathy: a double-blind, randomized, placebo-controlled trial. Circulation, 72(3), 536–546. https://doi.org/10.1161/01.cir.72.3.536
Mayo Clinic. (2020). Ejection fraction: what does it measure?. Retrieved from https://www.mayoclinic.org/ejection-fraction/expert-answers/faq-20058286
Roma-Rodrigues C, Fernandes AR. Genetics of hypertrophic cardiomyopathy: advances and pitfalls in molecular diagnosis and therapy. Appl Clin Genet. 2014;7:195-208
Sabbah H. N. (2004). Biologic rationale for the use of beta-blockers in the treatment of heart failure. Heart failure reviews, 9(2), 91–97. https://doi.org/10.1023/B:HREV.0000046363.59374.23
Tucker, W. J., Beaudry, R. I., Liang, Y., Clark, A. M., Tomczak, C. R., Nelson, M. D., Ellingsen, O., & Haykowsky, M. J. (2019). Meta-analysis of Exercise Training on Left Ventricular Ejection Fraction in Heart Failure with Reduced Ejection Fraction: A 10-year Update. Progress in cardiovascular diseases, 62(2), 163–171. https://doi.org/10.1016/j.pcad.2018.08.006
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