Cardiac rehabilitation is a supervised exercise program designed for individuals diagnosed with cardiac disease who specifically require hospitalization and/or surgical intervention, such as myocardial infarction, coronary artery bypass graft (CABG), heart failure, unstable angina, percutaneous coronary intervention (PCI), heart valve repair/replacement, or heart/lung transplantation.

Heart rates for exercise

Karvonen formula: 220-Age= heart rate max

• Submaximal aerobic exercise for the goal of fitness, weight loss, or blood sugar management is performed around 115 beats/min for 30-60 minutes 5 or more times a week. This is analogous to a steady brisk walk. With no warm up or cool down required.

• Aerobic exercise for cardio vascular fitness is performed at 60 to 85% of max target heart rate for 20 min. This does not include a required warm up and cool down of 5 minutes at submaximal levels. Total time of 30 or more minutes is required 3-4x week on non consecutive days.

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 the previous functional status, pending no medical complications
    • Decrease 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 in understanding the 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 conservation and avoidance of fatigue
    • Home exercise program (HEP) for discharge

• Phase 2:

  • Setting:
    • Patient has been discharged home but is completing rehabilitation in an outpatient setting
    • Outpatient setting provides availability to monitor heart rate, blood pressure, electrocardiogram readings (EKG), and pulse oximetry with progressive exercise
  • Goals:
    • Return to all activities such as ADLs, occupational, and recreational activities
    • Provide further education on lifestyle modification (modifiable risk factors)
    • Continue teaching of the energy conservation techniques and activity pacing
  • Exercise guidelines:
    • Monitoring of heart rate, blood pressure, electrocardiogram readings (EKG), and pulse oximetry is done initially, with weaning occurring closer to discharge from the 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 an 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 conservation and avoidance of fatigue
    • Update home exercise program (HEP) for current functional status

• Phase 3:

  • Setting:
    • Community — patient has been discharged from the outpatient-phase 2 cardiac rehab
  • Goals:
  • Continue improving functional activity tolerance and/or maintain current functional activity tolerance
  • Encourage continued self-monitoring and adherence to lifestyle modifications
  • Exercise guidelines:
    • Join community-based centers to assist with a continued exercise program and HEP
    • Able to exercise at 6 METs or greater
      • Which include resistance training (light weights and/or elastic bands)
    • Frequency:
      • 45 minutes or more at 3-4 times per week

Definitions

Metabolic equivalents (METs)

Unit of measurement used to assess how much energy is expended to perform a functional activity- further defined as the ratio of oxygen necessary to complete an activity vs the ratio of oxygen consumption at rest.

Activities of daily living (ADLs)

•1.0 METs: Sitting quietly

• 1.3-1.5 METs: Grooming and eating

• 1.5-2.0 METs: Light housework, brushing hair and teeth, making the bed

• 2.0-3.0 METs: Showering (seated), dressing

Instrumental Activities of Daily Living (IADLs) • 1.3-1.5 METs: Repairing clothing, wrapping presents (seated)

• 3.0-3.5 METs: Sweeping or vacuuming, light gardening, preparing meals

• 4.0-5.0 METs: Raking leaves, light carpentry

• 6.0-7.0 METs: Shoveling heavy snow, scrubbing bathrooms

METS for exercise equipment treadmill and stationary bike

• 3-4 METS = walk 3 mph and bike 4 mph
• 4-5 METS = walk 3.5 mph and bike 8 mph
• 5-6 METS - walk 4 mph and bike 10 mph
• 6-7 METS = walk 5 mph and bike 11 mph
• 7-8 METS = walk 5.5 mph and bike 12 mph
• 8-9 METs = walk 6 mph and bike 13 mph

Contraindication to cardiac rehabilitation

• Unstable angina
• Resting systolic blood pressure >/= 200 mmHg or diastolic blood pressure >/= 110 mmHg
• Critical aortic stenosis
• Acute systemic illness or fever
• Uncontrolled sinus tachycardia
• Uncompensated congestive heart failure
• Third-degree heart block without a pacemaker
• Recent embolism
• Uncontrolled diabetes mellitus
• Resting ST-segment depression or elevation >2 mm

Effects of cardiac rehabilitation

• Decrease in resting heart rate
• Increased stroke volume
• Increased myocardial contraction
• Reduced adipose tissue
• Improved glucose tolerance
• Increased participation in exercise activities
• Improve oxygenation of the myocardium and the peripheral system
• Decreased cholesterol and triglyceride levels

Exercise prescription for cardiac patients

Definitions

Exercise prescription

Exercise prescription for any individual with cardiac disease that does not require surgical intervention or that is status post 6 weeks of surgical intervention

Prescription of resistance training

• Progression:
  • Start with low resistance at one set of 10-15 repetitions
  • Progress as tolerated and slowly
• Types of resistance activity:
  • Elastic bands
  • Cuff weights
  • Wall pulleys
  • Hand weights
• Intensity:
  • Maintain RPE scale of 11-13 (light to somewhat hard)
  • Hemodynamically stable
  • Not to exceed 50-85% of heart rate max
• Special considerations:
  • Avoid the Valsalva maneuver
  • Heart rate is the best predictor of exercise tolerance, but if unable to utilize the heart rate, then utilize the RPE scale

Definitions

Borg scale- RPE scale

Subjective tool used to measure how hard an individual is working to perform a physical activity

6

7- very, very light

8

9 - very light

10

11 - fairly light

12 - (indicates work at 60% of heart rate max)

13 - somewhat hard

14

15 - hard

16- indicates work at 85% of heart rate max

17 - very hard

18

19 - very, very hard

20

Modified Borg - modified RPE scale

0 Rest No exertion at all.

1 Very easy. You can sing or easily hold a conversation.

2 Easy

3 Moderate Breathing is heavier, but you can still hold a conversation.

4 Somewhat hard

5 Hard

6

7 Very hard Breathing is heavy, and it is difficult to talk.

8

9

10 Maximum exertion: All-out, maximal effort.

The goal of each would be to be in the aerobic zone- Borg 12-14 and Modified 4-7.

Valsalva maneuver

Forceful attempt through exhalation through closed airways (closed mouth), which can cause decreased blood pressure, heart arrhythmias, chest pain, lightheadedness

Exercise prescription for individuals with heart failure

• Criteria for inclusion:
  • Compensated (controlled) or chronic heart failure
• Considerations for monitoring during session:
  • Assess for cardiac decompensation
    • Shortness of breath
    • Abdominal swelling
    • Increased pain or fatigue
    • Spasmodic cough
    • Sudden weight gain
    • Increased lower extremity edema
  • Avoid the Valsalva maneuver
  • Utilize caution when positioning in supine or prone due to orthopnea
• Prescription based on New York Heart Association stages
  • Class I — mild heart failure
    • 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 at 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 at 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, overstretching, 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 the 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.