Cardiac rehabilitation is a supervised exercise program designed for individuals diagnosed with cardiac disease that specifically required hospitalization and/or surgical intervention such myocardial infarction, coronary artery bypass graft (CABG), heart failure, unstable angina, percutaneous coronary intervention (PCI), heart valve repair/replacement, or heart/lung transplantation
Phases of cardiac rehabilitation
Phase 1
Setting:
In hospital for approximately 2-5 days after cardiac surgical intervention
Constant monitoring of vitals such as heart rate, blood pressure, electrocardiogram readings (EKG), pulse oximetry
Goals:
Initiate return to previous functional status pending no medical complications
Decreased the risk of contracture development, weakness due to immobility, deep vein thrombus development, and orthostatic hypotension
Provide patient and family education
Exercise guidelines:
Performance of activities of daily living (ADL), early ambulation, therapeutic exercise of arms and legs while maintaining all precautions as appropriate
Activities should be maintained between 2-3 metabolic equivalents (METs)
Activities include toileting, showering while seated, short distances of ambulation, and hygiene
Frequency:
20-30 minutes at 1-2 times per day
Education:
Assist understanding patient’s cardiac disease
Teach self-monitoring techniques such as heart rate (HR), rate of perceived exertion scale (RPE), signs of dyspnea, signs of anginal pain, dizziness, and palpitations
Teach concepts of energy conversation and avoidance of fatigue
Home exercise program (HEP) for discharge
Phase 2:
Setting:
Patient has discharged home but is completing rehabilitation in outpatient setting
Outpatient setting proves availability to monitor heart rate, blood pressure, electrocardiogram readings (EKG), and pulse oximetry with progressive exercising
Goals:
Return to all activities such as ADLs, occupational, and recreational activities
Provide further education on lifestyle modification (modifiable risk factors)
Continue teaching of energy conservation techniques and activity pacing
Exercise guidelines:
Monitoring of heart rate, blood pressure, electrocardiogram readings (EKG), and pulse oximetry are done initially with weaning occurring closer to discharge from outpatient setting
Goal is to progress to self-monitoring of exercise tolerance
Activities should be maintained at 5 METs or less
Activities include: graded exercise testing, ambulation with or without assistive device, basic house chores- sweeping, washing dishes, laundry
Frequency:
30-60 minutes at 2-3 sessions per week
Education:
Review of self-monitoring techniques such as heart rate (HR), rate of perceived exertion scale (RPE), signs of dyspnea, signs of anginal pain, dizziness, and palpitations
Continue reviewing concepts of energy conversation and avoidance of fatigue
Update home exercise program (HEP) for current functional status
Phase 3:
Setting:
Community- patient has been discharged from outpatient-phase 2 cardiac rehab
No limitation in physical activity (up to 6.5 METs); comfortable at rest, ordinary activity does not cause undue fatigue, palpitations, dyspnea, or anginal pain
Class II- slight heart failure
Slight limitation in physical activity (up to 4.5 METs); comfortable rest; ordinary activities cause fatigue, palpitations, dyspnea, or anginal pain
Class III- marked heart failure
Marked limitation in physical activity (up to 3.0 METs); comfortable rest; less than ordinary activities cause fatigue, palpitations, dyspnea, or anginal pain
Class IV- severe heart failure
Unable to perform any physical activities (1.5 METs) without discomfort; symptoms of ischemia, dyspnea, anginal pain at rest that increases with exercise
Exercise prescription for individuals with pacemakers
Pacemakers are used to help regulate the heart rate when a cardiac condition prevents appropriate intrinsic rate control. They restore rhythm by delivering electrical impulses to the heart when the rate falls outside programmed limits or when arrhythmias are detected.
Special considerations:
Demand pacemakers adjust heart rate in response to physical activity.
Fixed-rate pacemakers maintain a preset heart rate and do not respond to increased activity levels.
Post-implantation care: Avoid upper extremity aerobic or strengthening exercises for the first 6 weeks to allow for proper lead stabilization.
Exercise intensity: Maintain heart rate at least 10 beats per minute below the pacemaker’s upper limit, as identified by the evaluating therapist.
Exercise prescription for individuals with arterial insufficiency
Precautions:
Protect the limb from excessive stress, over-stretching, and extreme temperatures.
Exercise guidelines:
Exercise enhances both functional capacity and peripheral circulation.
Interval walking with frequent rest breaks is recommended.
Encourage walking to the point of moderate pain, followed by rest and repetition.
Track pain intensity, duration, and location during and after activity.
Ensure proper footwear to reduce pressure and risk of skin breakdown.
Use an active cool-down to facilitate improved blood return.
Perform regular skin assessments to monitor for signs of ischemia or breakdown.
Exercise prescription for individuals with venous Insufficiency
Deep vein thrombosis (DVT)- rehabilitation considerations:
Resume activity only after medical clearance post-DVT diagnosis.
Gradually progress aerobic activity as tolerated.
Provide education on recurrence prevention, including use of graded compression garments.
Prophylactic measures:
Encourage early ambulation after surgery or immobilization.
Support adherence to anticoagulation therapy.
Teach recognition of DVT signs/symptoms (e.g., calf pain, warmth, swelling).
Chronic venous insufficiency
Edema management:
Encourage leg elevation and minimize time spent in dependent positions.
Implement compression therapy using elastic wraps, paste bandages, or graduated compression stockings.
Exercise recommendations:
Promote regular ambulation, use of a stationary cycle, and active ankle pumping exercises.
Include education on skin care to prevent ulcers and infections.
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