Cardiac rehabilitation

Cardiac rehabilitation is a supervised exercise program designed for individuals diagnosed with cardiac disease after a qualifying cardiac event, procedure, or diagnosis, such as myocardial infarction, coronary artery bypass graft (CABG), heart failure, stable angina, percutaneous coronary intervention (PCI), heart valve repair/replacement, or heart/lung transplantation. Angioplasty is a procedure that uses an inflated balloon to open a narrowed or blocked coronary artery and restore blood flow to the heart.

Heart rate zones for exercise

Heart rate max = $220-\text{age}$

• Aerobic exercise for cardiovascular fitness is performed at 60 to 85% of max heart rate for at least 20 minutes, plus a 5-minute warm-up and cool-down at lower intensity. Total session time is typically 30 or more minutes, 3-4 times per week.

Phases of cardiac rehabilitation

The three phases track a single continuum: as the patient recovers, exercise tolerance rises and the need for close monitoring falls. That is why the MET cap climbs across the phases (2-3 in phase 1, 5 or less in phase 2, 6 or greater in phase 3) while the setting moves from the hospital, to the outpatient clinic, to the community. Constant bedside monitoring in phase 1 gives way to intermittent monitoring that weans toward discharge in phase 2, and finally to independent self-monitoring in phase 3.

• 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: ambulation with or without an assistive device, basic house chores- sweeping, washing dishes, laundry
    • Light resistance training (elastic bands, light hand weights) is commonly added in phase 2 once the patient tolerates supervised aerobic exercise
    • Frequency:
      • 30-60 minutes at 2-3 sessions per week
  • Education:
    • Review the self-monitoring techniques taught in phase 1
    • 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, defined as the ratio of oxygen consumption during an activity to oxygen consumption at rest (1 MET ≈ 3.5 mL O2/kg/min, the resting value).

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 with vigorous effort

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

A contraindication above means the session should not proceed until the condition resolves or is cleared by the physician. A precaution - such as well-controlled diabetes or compensated heart failure - calls for added caution and closer monitoring. If signs of cardiac decompensation appear during a session, stop exercise and report to the supervising PT.

Stop exercise and notify the PT if you observe:

• Systolic blood pressure drops more than 10 mmHg as workload increases
• Blood pressure rises excessively (roughly ≥250/115 mmHg)
• New or worsening angina
• Marked dyspnea, dizziness, pallor, or cyanosis
• A new arrhythmia
• Heart rate rises above the PT-set limit (in phase 1, commonly resting heart rate +20 after MI or +30 after surgery)

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

PTA role: The PTA carries out the exercise program established by the supervising PT - monitoring heart rate, blood pressure, RPE, and symptoms during sessions - and reports abnormal responses or the need to progress the program to the PT rather than independently modifying the prescription.

Definitions

Exercise prescription

An individualized exercise plan that specifies the frequency, intensity, time (duration), and type (mode) of exercise (the FITT principle) and how it is progressed. It is set by the PT and progressed across the phases as tolerance improves.

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
  • Keep heart rate within the prescribed target range (typically 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
  • Patients taking beta-blockers or other rate-controlling medications have a blunted heart rate response to exercise, making RPE a more reliable measure of intensity for these patients

Definitions

Borg scale - RPE scale

A subjective tool used to measure how hard an individual is working to perform a physical activity, rated from 6 (no exertion) to 20 (maximal exertion).

Valsalva maneuver

Forceful exhalation against a closed glottis. It raises intrathoracic pressure, causing a blood-pressure surge, then reduced venous return and a drop in blood pressure. It can trigger arrhythmias, chest pain, and lightheadedness. Cue patients to exhale during exertion.

Rating	Description
6
7	Very, very light
8
9	Very light
10
11	Fairly light
12	60% of heart rate max
13	Somewhat hard
14
15	Hard
16	85% of heart rate max
17	Very hard
18
19	Very, very hard
20	Maximal exertion

Aerobic training generally targets Borg 12-16 (about 60-85% of heart rate max, matching the table); resistance training is kept lighter, at RPE 11-13.

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 (NYHA) functional classes

Class I - no functional limitation

• Ordinary physical activity does not cause:
  • undue fatigue
  • palpitations
  • dyspnea
  • anginal pain
• Comfortable at rest
• Typically >7 METs tolerated

Class II - mild functional limitation

• Slight limitation in physical activity
• Comfortable at rest
• Ordinary activity results in:
  • fatigue
  • palpitations
  • dyspnea
  • angina
• Approximately 5-7 METs tolerated

Class III - marked functional limitation

• Marked limitation in physical activity
• Comfortable at rest
• Less-than-ordinary activity produces symptoms
• Approximately 2-5 METs tolerated

Class IV - severe functional limitation

• Unable to perform physical activity without discomfort
• Symptoms may be present even at rest
• Any physical activity increases symptoms
• Usually <2 METs tolerated

Example: matching activity to NYHA class

A patient with NYHA Class II heart failure tolerates approximately 5-7 METs. Which is the more appropriate home activity to recommend: sweeping the floor (3.0-3.5 METs) or shoveling heavy snow (6.0-7.0 METs)?

Answer: Sweeping the floor. Shoveling heavy snow (6.0-7.0 METs) falls at the upper limit of the patient’s tolerated range and risks triggering decompensation, while sweeping (3.0-3.5 METs) sits well below that limit.

Exercise prescription for individuals with pacemakers

Pacemakers are implanted electrical devices used to regulate heart rhythm in patients with bradycardia or conduction abnormalities. They detect inadequate intrinsic cardiac activity and deliver electrical impulses to stimulate myocardial depolarization and maintain appropriate cardiac output.

Special considerations

• Rate-responsive (rate-adaptive) pacemakers adjust heart rate in response to physical activity; demand pacemakers pace only when the intrinsic heart rate falls below a preset rate.
• 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 programmed by the physician and documented in the plan of care.

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.

Arterial and venous insufficiency can look similar but call for different management, since the positioning and compression that help venous disease can worsen arterial disease. The ankle-brachial index, covered in a later chapter, helps confirm which condition is present.

Feature	Arterial insufficiency	Venous insufficiency
Positioning	Avoid elevation; legs may be kept dependent	Elevate the legs
Compression	Generally contraindicated, especially with a low ankle-brachial index	Indicated (elastic wraps, stockings)

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.