~~At program entry, the following assessments should be performed:
1. Medical and surgical history including the most recent cardiovascular event, comorbidities, and other pertinent medical history.
2. Physical examination with an emphasis on the cardiopulmonary and musculoskeletal systems.
3. Review of recent cardiovascular tests and procedures including 12-lead electrocardiogram (ECG), coronary angiogram, echocardiogram, stress test (exercise or imaging studies), revascularization, and pacemaker/implantable defibrillator implantation.
4. Current medications including dose, route of administration, and frequency.
5. Routine preexercise assessment of risk for exercise (see Chapters 3 and 5) should be performed before, during, and after each rehabilitation session, as deemed appropriate by the qualified staff and include the following:
-Blood pressure (BP)
-Body weight (weekly)
6. Symptoms or evidence of change in clinical status not necessarily related to activity (e.g., dyspnea at rest, light-headedness or dizziness, palpitations or irregular pulse, chest discomfort)
7. Symptoms and evidence of exercise intolerance
Change in medications and adherence to the prescribed medication regimen
8. Consideration of ECG surveillance that may consist of telemetry or hardwire monitoring, "quick-look" monitoring using defibrillator paddles, or periodic rhythm strips depending on the risk status of the patient and the need for accurate rhythm detection
1. Frequency: Exercise should be performed at least 3 d but preferably on most days of the week. Frequency of exercise depends on several factors including baseline exercise tolerance, exercise intensity, fitness and other health goals, and types of exercise that are incorporated into the overall program. For patients with very limited exercise capacities, multiple short (1-10 min) daily sessions may be prescribed. Patients should be encouraged to perform some of these exercise sessions independently (i.e., without direct supervision) following the recommendations outlined in this chapter.
2. Intensity: Exercise intensity may be prescribed using one or more of the following methods:
-Based on results from the baseline exercise test, 40%-80% of exercise capacity using the HR reserve (HRR), oxygen uptake reserve (VO2R), or peak oxygen uptake (VO2peak) methods
-RPE of 11-16 on a scale of 6-20 (6)
-Exercise intensity should be prescribed at a HR below the ischemic threshold; for example, <10 beats, if such a threshold has been determined for the patient. The presence of classic angina pectoris that is induced with exercise and relieved with rest or nitroglycerin is sufficient evidence for the presence of myocardial ischemia
- For the purposes of the Ex Rx, it is preferable for individuals to take their prescribed medications at their usual time as recommended by their health care providers. Individuals on a β-adrenergic blocking agent (i.e., β-blocker) may have an attenuated HR response to exercise and an increased or decreased maximal exercise capacity. For patients whose β-blocker dose was altered after an exercise test or during the course of rehabilitation, a new graded exercise test may be helpful, particularly in patients who have not undergone a coronary revascularization procedure or who have been incompletely revascularized (i.e., residual obstructive coronary lesions are present) or who have rhythm disturbances. However, another exercise test may not be medically necessary in patients who have undergone complete coronary revascularization, or when it is logistically impractical.
-When patients whose β-blocker dose has been altered exercise without a new exercise test, signs and symptoms should be monitored, and RPE and HR responses should be recorded at previously performed workloads. These new HRs may serve as the patient's new exercise target HR (THR) range. Patients on diuretic therapy may become volume depleted, have hypokalemia, or demonstrate orthostatic hypotension particularly after bouts of exercise. For these patients, the BP response to exercise, symptoms of dizziness or light- headedness, and arrhythmias should be monitored while providing education regarding proper hydration (3). See Appendix A for other medications that may influence the hemodynamic response during and after exercise.
3. Time: Warm-up and cool-down activities of 5-10 min, including static stretching, ROM, and light intensity (i.e., <40% VO2R, <64% peak heart rate [HRpeak], or <11 RPE) aerobic activities, should be a component of each exercise session and precede and follow the conditioning phase. The goal for the duration of the aerobic conditioning phase is generally 20-60 min per session. After a cardiac-related event, patients may begin with as little as 5-10 min of aerobic conditioning with a gradual increase in aerobic exercise time of 1-5 min per session or an increase in time per session of 10%-20% per week.
4. Type: The aerobic exercise portion of the session should include rhythmic, large muscle group activities with an emphasis on increased caloric expenditure for maintenance of a healthy body weight and its many other associated health benefits (see Chapters 1, 7, and 10). To promote whole body physical fitness, conditioning that includes the upper and lower extremities and multiple forms of aerobic activities and exercise equipment should be incorporated into the exercise program. The different types of exercise equipment may include the following:
-Combination of upper or lower (dual action) extremity cycle ergometer
-Upright and recumbent cycle ergometer
-Treadmill for walking
5. Type (cont.): Aerobic interval training (AIT) involves alternating 3-4 min periods of exercise at high intensity (90%-95% HRpeak) with exercise at moderate intensity (60%-70% HRpeak). Such training for approximately 40 min, three times per week has been shown to yield a greater improvement in VO2peak in patients with heart failure (44) and greater long-term improvements in VO2peak in patients after CABG (27) compared to standard continuous, moderate intensity exercise. Although AIT has routinely been used in athletes, its use in patients with CVD appears to have potential but cannot yet be universally recommended until further data regarding safety and efficacy are available.
Progression: There is no standard format for the rate of progression in exercise session duration. Thus, progression should be individualized to patient tolerance. Factors to consider in this regard include initial physical fitness level, patient motivation and goals, symptoms, and musculoskeletal limitations. Exercise sessions may include continuous or intermittent exercise depending on the capability of the patient. Table 9.1 provides a sample progression using intermittent exercise.
-In addition to formal exercise sessions, patients should be encouraged to gradually return to general ADL.
-Participation in competitive sports should be guided by the recommendations of the ACC Bethesda Conference.
-Relatively inexpensive pedometers can be useful to monitor physical activity and may enhance adherence with walking programs. Walking for 30 min · d−1 equates to 3,000-4,000 steps, whereas a 1-mi (1.6 km) walk equates to ~2,000 steps. To meet current recommendations for physical activity, adding ~2,000 · d to reach a daily step count 5,400-7,000 steps · is beneficial.
-Pedometers are most effective in increasing physical activity when accompanied by a goal for achieving specific daily step count, such as goal of 10,000 steps · d (see Chapter 7).
1. Frequency: Weight-bearing aerobic exercise 3-5 d ∙ wk−1; resistance exercise at least 2 d ∙ wk−1.
Intensity: Moderate intensity (i.e., 40%-<60% VO2R) that allows the patient to walk until he or she reaches a pain score of 3 (i.e., intense pain) on the 4-point pain scale (45). Between bouts of activity, individuals should be given time to allow ischemic pain to subside before resuming exercise (19,45).
2. Time: 30-60 min ∙ d−1, but initially, some patients may need to start with 10 min bouts and exercise intermittently to accumulate a total of 30-60 min ∙ d−1 Many patients may need to begin the program by accumulating only 15 min ∙ d−1, gradually increasing time by 5 min ∙ d−1 biweekly.
3. Type: Weight-bearing aerobic exercise, such as walking, and non-weight-bearing exercise, such as arm and leg ergometry. Cycling may be used as a warm-up but should not be the primary type of activity. Resistance training is recommended to enhance and maintain muscular strength and endurance (see Chapter 7).
-Cardiac pacemakers are used to restore an optimal HR and to synchronize atrial and ventricular filling and contraction in the setting of abnormal rhythms. Specific indications for pacemakers include sick sinus syndrome with symptomatic bradycardia, acquired atrioventricular (AV) block, and persistent advanced AV block after MI.
-Cardiac resynchronization pacemakers, sometimes called biventricular pacemakers, are used in patients with left ventricular systolic dysfunction who demonstrate ventricular dyssynchrony during contraction of the left and right ventricles.
-The different types of pacemakers are the following:
1. Rate-responsive pacemakers that are programmed to increase or decrease HR to match the level of physical activity (e.g., sitting rest or walking)
2. Single-chambered pacemakers that have only one lead placed into the right atrium or the right ventricle
3. Dual-chambered pacemakers that have two leads; one placed in the right atrium and one in the right ventricle
4. Cardiac resynchronization therapy pacemakers that have three leads; one in right atrium, one in right ventricle, and one in coronary sinus or, less commonly, the left ventricular myocardium via an external surgical approach.
-The type of pacemaker is identified by a four-letter code as indicated in the following section:
1. The first letter of the code describes the chamber paced (e.g., atria [A], ventricle [V], or dual [D]).
2. The second letter of the code describes the chamber sensed.
3. The third letter of the code describes the pacemaker's response to a sensed event.
4. The fourth letter of the code describes the rate response capabilities of the pacemaker, (e.g., inhibited [I] or rate responsive [R])
-Ex Rx considerations for those with pacemakers are as follows:
1. Programmed pacemaker modes, HR limits, and ICD rhythm detection algorithms should be obtained from the patient's cardiologist prior to exercise testing or training.
2. Exercise testing should be used to evaluate HR and rhythm responses prior to beginning an exercise program.
3. When an ICD is present, the HRpeak during the exercise test and the exercise training program should be maintained at least 10 beats ∙ min−1 below the programmed HR threshold for antitachycardia pacing and defibrillation.
4. After the first 24 h following the device implantation, mild upper extremity ROM activities can be performed and may be useful to avoid subsequent joint complications.
5. To maintain device and incision integrity, for 3-4 wk after implant, vigorous upper extremity activities such as swimming, bowling, lifting weights, elliptical machines, and golfing should be avoided. However, lower extremity activities are allowable.
1. Equipment (Type):
-Cuff and hand weights
-Machines (dependent on weight of lever arms and range of motion)
2. Proper techniques:
-Raise and lower weights with slow, controlled movements to full extension.
-Maintain regular breathing pattern and avoid breath holding.
-Avoid sustained, tight gripping, which may evoke an excessive blood pressure (BP) response.
-A rating of perceived exertion (RPE) of 11-14 ("light" to "somewhat hard") on a scale of 6-20 may be used as a subjective guide to effort.
-Terminate exercise if warning signs or symptoms occur including dizziness
-Initial load should allow 10-15 repetitions that can be lifted without straining (~30%-40% one repetition maximum [1-RM] for the upper body; ~50%-60% for the lower body). 1-RM is the maximum load that can be lifted one time. When determination of 1-RM is deemed inappropriately, multiple trials using progressively higher loads can be performed until the patient can perform no more than 10 repetitions without straining. That load can then be used for training.
-Exercise dosage can be progressed by increasing the resistance, increasing the number of repetitions, or decreasing the rest period between sets or exercises.
Increase loads by 5% increments when the patient can comfortably achieve the upper limit of the prescribed repetition range (e.g., 12-15 repetitions).
-Low-risk patients may progress to 8-12 repetitions with a resistance of ~60%-80% 1-RM.
-Because of the potential for an elevated BP response, the rate pressure product (RPP) should not exceed that during prescribed endurance exercise as determined from the exercise test.
-Each major muscle group (i.e., chest, shoulders, arms, abdomen, back, hips, and legs) should be trained initially with one set; multiple set regimens may be introduced later as tolerated.
-Sets may be of the same exercise or from different exercises affecting the same muscle group.
-Perform 8-10 exercises of the major muscle groups.
-Exercise large muscle groups before small muscle groups.
-Include multijoint exercises or "compound" exercises that affect more than one muscle group.
1. Frequency: 2-3 d ∙ wk−1 with at least 48 h separating training sessions for the same muscle group. All muscle groups to be trained may be done in the same session, that is, whole body or each session may "split" the body into selected muscle groups so that only a few are trained in any one session. Resistance training should be performed after the aerobic component of the exercise session to allow for adequate warm-up.
2. Progression: Increase slowly as the patient adapts to the program (~2-5 lb ∙ wk−1 [0.91-2.27 kg] for upper body and 5-10 lb ∙ wk−1 for lower body [0.91-4.5 kg]).
-Assessment of patient's work demands and environment
-Nature of work
-Muscle groups used at work
-Work demands that primarily involve muscular strength and endurance
-Primary movements performed during work
-Periods of high metabolic demands vs. periods of low metabolic demands
-Environmental factors including temperature, humidity, and altitude
-Emphasize exercise modalities that use muscle groups involved in work tasks.
-If possible, use exercises that mimic movement patterns used during work tasks.
-Balance resistance vs. aerobic training relative to work tasks.
-If environmental stress occurs at work, educate the patient about appropriate precautions including avoidance if need be, and, if possible, expose them to similar environmental conditions while performing activities similar to work tasks (see the American College of Sports Medicine Position Stands [1,2,10] and Chapter 8 for additional information on environmental precautions).
-If possible, monitor the physiologic responses to a simulated work environment.
-Following a documented physician referral, patients hospitalized after a cardiac-related event or procedure associated with CAD, cardiac valve replacement, or MI should be provided with a program consisting of early assessment and mobilization, identification of and education regarding CVD risk factors, assessment of the patient's level of readiness for physical activity, and comprehensive discharge planning.
-Inpatients should be educated and encouraged to investigate outpatient exercise program options and be provided with information regarding the use of home exercise equipment. All patients, especially moderate- to high-risk patients with CVD, should be strongly encouraged to participate in a clinically supervised outpatient cardiac rehabilitation program.
-Exercise training is safe and effective for most patients with CVD; however, all patients should be classified according to future risk for occurrence of cardiac-related events during exercise training.
-In addition to formal outpatient exercise sessions, patients should be encouraged to gradually return to general ADL such as household chores, yard work, shopping, and hobbies as evaluated and appropriately modified by the rehabilitation staff.
-It is important that outpatients eventually transition from a medically supervised program to an independent (i.e., self-monitored and unsupervised) home exercise program. The optimal number of weeks of attendance at a supervised program before entering an independent program is unknown and is likely patient specific.
-PAD is a common disorder with increasing prevalence in older adults. Conservative management of patients with asymptomatic PAD and patients with intermittent claudication is recommended to modify risk factors and improve ambulatory ability, whereas patients with more severe PAD typically require revascularization of the lower extremities. Exercise rehabilitation is a highly effective, conservative treatment to improve ambulation in patients with intermittent claudication.
-Resistance training is now a standard part of the overall exercise training program for most, if not all, patients with CVD (see Chapter 7).
-Standard stroke care during the initial 3-6 mo postevent period focuses on basic mobility function and recovery of ADL. Exercise interventions that go beyond the early subacute period are needed to optimize functional capacity for the long term.