Rehabilitation for

Patients with
Cardiovascular Disease

Asistent universitar
Ala Soroceanu

Background
18 ~ 65 years old healthy adults need
1. Moderate-intensity activity at least 30
minutes on 5 days per week
Or

Vigorous-intensity aerobic activity at least 20

minutes on 3 days per week
2. Resistance training involving the major
muscle groups at least 2 days per week

Exercise is also recommended for the

elderly or people with illness

Cardiac Rehabilitation
1. Introduction of Cardiac Rehabilitation
2. Disease-Specific Effects on Physiologic Responses
and Fitness
3. Scientific and Physiologic Rationale for Exercise
Therapy in Patients with Heart Disease
4. Morbidity, Mortality, and Safety of Cardiac
Rehabilitation
5. Exercise Prescription and Programming

Definition
Cardiac Rehabilitation, and
secondary prevention
Cardiac rehabilitation can be defined as the effort
toward cardiovascular risk factor reduction designed
to lessen the chance of a subsequent event, to slow,
and perhaps stop the progression of cardiovascular
disease process. Multifactorial and multidisciplinary
approach is imperative to meet such challenges.
Long term comprehensive cardiac care program
involves a close follow up, risk factor modification,
patient education, and psychological guidance

Indication of Cardiac Rehabilitation

Cardiac rehabilitation programs are indicated for
patients recovering from recent MI, following
coronary bypass, valve surgery or coronary
angioplasty, cardiac transplantation, patients
with stable angina or patient with compensated
chronic heart failure. traditionally, cardiac
rehabilitation has been provided to some what
lower risk patient who could exercise without
getting into trouble.

Contraindication of Cardiac
Rehabilitation
cardiac rehabilitation services are
contraindicated in patients with severe
residual angina, uncompensated heart
failure, uncontrolled arrhythmias, poor
left ventricular out flow tract, and
unstable concomitant medical problems

Goals
Restore patients to their optimal medical, physical,
psycological, social, emotional, sexual, vocational,
and economic status compatible with the severity
of their heart disease
Prevention of heart disease
Primary screen healthy people to identify and treat
risk factors
Secondary to improve heart disease risk factors and
limit further morbidity and mortality

Cardiac Rehabilitation
1. Introduction of Cardiac Rehabilitation

2. Disease-Specific Effects on
Physiologic Responses and Fitness
3. Scientific and Physiologic Rationale for Exercise
Therapy in Patients with Heart Disease
4. Morbidity, Mortality, and Safety of Cardiac
Rehabilitation
5. Exercise Prescription and Programming

Cardiovascular Response during Exercise

Heart Rate
Normal
Achieving HR within 2 standards deviations
of an age-predicted maximum value
Decreasing HR to baseline fairly quickly
during recovery

Cardiovascular Response during Exercise

Heart Rate
Abnormal
Chronotropic Incompetence

Failure to achieve 85% predicted maximum HR

(without medication effect)
Predict CAD and associated with increased risk
of Mortality/Morbidity

Abnormal HR recovery

alking: decrease in HR < 12 bpm / 1 minute

Supine: decrease in HR < 22 bpm / 2 minutes
Predict future cardiac mortality

Cardiovascular Response during Exercise

Blood Pressure
Normal
DBP: Constant or slightly decrease
SBP: Increase progressively about 8~12
mmHg/MET, with a plateau at peak exercise

Abnormal
In patients with CAD, SBP during exercise may
respond normally or may disproportionately
increase or inappropriately decrease

Cardiovascular Response during Exercise

Blood Pressure
Abnormal
Exertional hypertension: SBP > 250 mmHg or
DBP > 115 mmHg
Exertional hypotension:
Compare to resting BP, SBP decrease 10mmHg
Exertional systolic hypertension/hypotension would
increase cardiac event risk
Increase DBP 10mmHg
Often a marker for future hypertension

Cardiovascular Response during Exercise

Cardiac Output and Oxygen uptake
Normal Peak VO2: 30~45 ml/kg/min
CAD patient Peak VO2 reduction 20%
Due to Cardiac Output
Cardiac Output = Heart Rate x Strove volume
Heart Rate Chronotropic incompetence
Strove Volume Left ventricular dysfunction

With Exercise Training VO215~30%

Oxygen Consumption
1 MET (Metabolic
Equivalent)
= Oxygen consumption at
resting
= Basal metabolic rate
At rest, 70kg man O2
consumption
= 3.5ml oxygen/ minute/ Kg
of BW

Relationship between oxygen

consumption and intensity of
work being performed.
Braddom Figure 34-1

Cardiac Rehabilitation
1.
2.

Introduction of Cardiac Rehabilitation

Disease-Specific Effects on Physiologic Responses and
Fitness

3. Scientific and Physiologic Rationale for

Exercise Therapy in Patients with Heart
Disease
4.
5.

Morbidity, Mortality, and Safety of Cardiac Rehabilitation

Exercise Prescription and Programming

Ischemic cascade
The temporal sequence of cellular, hemodynamic,
electrocardiographic, and symptomatic
expressions occurring during ischemia:
Imbalance between Myocardial oxygen supply and demand
Ischemic event
Abnormalities in Diastolic function
Abnormalities in Systolic function
EKG changes, such as ST-segment depression
Patient may or may not experience Angina

Ischemic cascade
After the myocardial oxygen supply and
demand imbalance is corrected at the
cellular level, the process is reversed:
Angina resolves
EKG changes
Improvement in Systolic function
Normalization of Diastolic function

Ischemic cascade
Patients with CAD studied during ischemia
Hemodynamic abnormalities nearly all
Radionuclide evidence of global or regional wall motion
abnormalities 80%
EKG 50%
Symptomatic evidence of ischemia 30%

Some patients, such as DM or undergone cardiac

transplant, experience ST-segment depression without
angina (i.e., silent angina), whereas others may experience
angina without ST-segment depression.
Berger HJ, Reduto LA, Johnstone DE, et al. Global and
regional left ventricular response to cycle exercise in
coronary artery disease: assessment byquantitative
radionuclide angiocardiography, Am J Med. 1979; 66: 13-21

Myocardial Oxygen Demand

Increase myocardial oxygen demand increasing HR,
increasing left ventricular preload, and increasing
myocardial contractility

Myocardial oxygen consumption can be reliably

estimated by
RatePressure Product = HR x Systolic BP
(Double product)
The normal maximal exercise response results in a rate
pressure product of 25,000 or higher

Myocardial Oxygen Supply

Four factors affect myocardial O2 supply
1.
2.
3.
4.

Coronary artery stenosis with endothelial dysfunction

Microvascular dysfunction
Abnormalities of the autonomic nervous system
Abnormalities of coagulation and fibrinolytic systems

Endothelial dysfunction Paradoxical vasoconstriction is

observed in patients with CAD or chronic heart failure,
maybe due to decreased production of nitric oxide

ACSMs TABLE 35-2. Pathophysiologic Effects of Exercise and Exercise Training

Pathophysiologic Variable

Acute Exercise

Chronic Exercise Training

Vascular stenosis

Partial regression (>2200 kcalwk -1)

Coronary collaterals

Endothelial dysfunction

Capillary flow

Parasympathetic

Sympathetic

Fibrinogen

Factor VII

Platelet aggregation

Fibrinolysis

Viscosity

Vascular

Autonomic nervous symptoms

Hemostatic

<1000 kcal per week experienced the greatest amount of disease progression
>1400 kcal per week showed improved cardiopulmonary fitness
>1500 kcal per week demonstrated the slowest rate of disease progression
>2200 kcal per week showed regression of CAD

Cardiac Rehabilitation
1. Introduction of Cardiac Rehabilitation
2. Disease-Specific Effects on Physiologic Responses
and Fitness
3. Scientific and Physiologic Rationale for Exercise
Therapy in Patients with Heart Disease

4. Morbidity, Mortality, and Safety of

Cardiac Rehabilitation
5. Exercise Prescription and Programming

Morbidity, Mortality, and Safety of Cardiac

Rehabilitation
Total cardiovascular mortality are reduced in
patients following myocardial infarction who
participate in cardiac rehabilitation exercise
training
The 1995 Agency for Heath Care Policy and Research (AHCPR)
Clinical Practice Guidelines for Cardiac Rehabilitation

Cardiac rehabilitation reduced all-cause mortality

by approximately 25%
Taylor RS, Brown A, Ebrahim S, et al. Exercise-based
rehabilitation for patients with coronary heart disease: systematic
review and meta-analysis of randomized controlled trials. Am J
Med. 2004;116:682692.

Classification of Cardiac Rehabilitation

Inpatient phase
Minimize the de-conditioning time
Education about risk factors and lifestyle modification

Early outpatient phase

Maintenance phase
Follow-up phase
Differing based on extent of supervision and
monitoring, subject independence, and time from the
event
Improve exercise performance and modify cardiac risk
factors

Phase I of Cardiac Rehabilitation

Phase I of CRP begins when the patient is
admitted to the hospital and ends on
discharge .The goals of exercise in this phase are
to avoid the deleterious effect of bed rest by
making a gradual transition from passive rang of
motion to active range of motion with low
intensity, short duration exercise and ambulation

Phase II of Cardiac Rehabilitation

The patient, who has completed hospitalization, has to undergo
through a pre discharge exercise tolerance test to determine his
functional capacity, before he can begin phase II of CRP, where
the physician and cardiac rehabilitation staff members formulate
the level of exercise to meet an individual patient's needs, based
on the result of exercise test. An exercise training usually are
scheduled at a rehabilitation facility with a constant medical
supervision including exercise electrocardiograms .In addition to
exercise, counseling, and education about stress management,
smoking cessation, nutrition, and weight loss also incorporated
in this phase which may last three to six months

The main goals of phase II CRP are to improve functional

capacity, progress toward full resumption of habitual and
occupational activities and to promote positive life style
changes .Exercise training in phase II is generally
administered three to four times per week. Duration range
from as low as 10 to 15 minutes per session, and gradually
increasing up to 30 to 60 minutes per session as the level
of fitness improve. Programs may offer a single mode of
training or a circuit mode of training in which the patient
spends a prescribed amount of time at one exercise station
before moving into the next (e.g. treadmill, cycle ergo
meter ,arm ergo meter, weight.)

Cardiovascular response to work

during training session is
monitored by number of factors,
including heart rate, blood
pressure, rhythm disturbance,
rate of perceived exertion and
sign of exertional intolerance

After performing another stress or cardiopulmonary

exercise test, Phase III CRP (maintenance phase) is
usually initiated for individual who participated in phase
I and phase II (typically 6 to 12 weeks after
discharge) .This phase is designed to continue for
patient's life time, aiming for maintaing patient function,
promoting life long commitment to physical fitness and
physical health management. In this phase, individuals
are expected to progress from supervision to self
regulation of their programs and the activities consist of
the type of exercise that the patient enjoys such as
walking bicycling or jogging. Regular medical follow up
and periodic graded exercise test are required every 3
to 6 months or annually

Cardiac Test
Rest/ Exercise cardiac test should be
performed before prescription
Cardiac Testing Resting EKG, CXR, 2Decho, Holter exam, Coronary angiography,
Cardiac exercise stress test
Cardiac exercise stress test is generally safe, and adverse
outcomes are infrequent

Cardiac Exercise Stress Test

Modality
Treadmill, Bicycle, Arm ergometers
Dipyridamole, Adenosine

End point
Normal EST = 85% age/gender predicted HRmax
Symptom-limited maximum EST
Low-level submaximal EST
HR = 120
70% HRmax
Peak MET = 5

Braddom Box 34-6 Contraindications to exercise stress testing

Absolute
Acute myocardial infarction (within 2 days)
High-risk unstable angina
Uncontrolled cardiac arrhythmias causing symptoms of hemodynamic compromise
Symptomatic severe aortic stenosis
Uncontrolled symptomatic congestive heart failure
Acute pulmonary embolus or pulmonary infarction
Acute myocarditis or pericarditis
Acute aortic dissection
Relative
Left main coronary artery disease
Moderate stenotic valvular heart disease
Electrolyte abnormalities A
Severe arterial hypertension (> 200 mmHg systolic blood pressure and/or 110
mmHg diastolic blood pressure)
Tachyarrhythmias or bradyarrhythmias
Hypertrophic cardiomyopathy and other forms of left ventricular outflow tract
obstruction
Mental or physical impairment leading to inability to exercise adequately
High-degree atrioventricular block

Contraindications to Exercise
Unstable angina
Resting ST depression > 2mm
Uncontrolled arrhythmias
Critical aortic stenosis
Uncompensated congestive heart failure
Resting SBP > 200mmHg or DBP >110mmHg
Fall in SBP > 10mmHg with exercise
Symptomatic orthostatic SBP drop 10-20 mmHg

Comorbidities Impacting the Safety of Exercise

Diabetes

Hypoglycemia

Anticoagulation

Progressive bruise or INR > 5.0

Visual and Cognitive

Impairment

Need close supervision

Wound and Skin Integrity

Sacral pressure sores require pressure

relief

Rheumatologic, Neurologic, Warrant close attention

Orthopedic, or Balance
disorders

Cardiac Rehabilitation
1. Introduction of Cardiac Rehabilitation
2. Disease-Specific Effects on Physiologic Responses
and Fitness
3. Scientific and Physiologic Rationale for Exercise
Therapy in Patients with Heart Disease
4. Morbidity, Mortality, and Safety of Cardiac
Rehabilitation

5. Exercise Prescription and Programming

Braddom Box 34-4 Adaptations noted with aerobic training

Functional
Higher peak work rate
Reduced disturbance of body function
Enhanced rate of recovery after exercise
Cardiovascular and pulmonary
Increased stroke volume and peak CO
Increased respiratory muscle strength, maximal voluntary ventilation
Reduced dyspnea
Musculoskeletal
Increased flexibility
Increased muscle, tendon, and cartilage strength
Increased bone density
Increased lean muscle mass
Reduced body fat percentage
Biochemical
Increased aerobic enzyme concentration
Endocrine
Reduced stress hormone release
Psychologic
Improved depression and anxiety

Exercise Pattern Resistance Exercise

Moderate-intensity dynamic resistance exercise (defined as
50%60% of one repetition maximum [1RM]) results in
improved muscle strength and endurance
A small reduction of 3 and 4 mm Hg for resting systolic
blood pressure and diastolic blood pressure, respectively
A commonly recommended resistance-training program
involves performing one set of eight to 10 regional
exercises, performed 2 to 3 days per week
Isometric exercises are not recommended because of a
potential significant rise in systolic and diastolic blood
pressure

Exercise Pattern Resistance Exercise

Time to Start Resistance Exercise
Catheterization with or without PCI 3 weeks later
Recover from an uncomplicated MI 5 weeks later
CABG surgery or valve surgery involving a
sternotomy avoid upper-limb resistance training
until sternal healing has occurred), generally 6 to 12
weeks after surgery

ACSMs Table 35-4 Summary of Unique Exercise Prescription

Issues among Patients with Cardiovascular Disease
Illness

Intensity

Comments

Coronary artery
disease

40/50%-85% of HRR

To affect mortality, frequency,

duration, and intensity of training
should sum to yield a weekly
energy expenditure .1,500
kcalwk-1.a,b

Angina or
equivalent

40/50%-85% of HRR with

necessary adjustment to
keep upper HRR limit to no
more than 10 beats below
ischemic threshold

Consider a prophylactic
nitroglycerin 15 min before
anticipated exertion if symptoms
limit routine ADLs or ability to
exercise.

Myocardial
infarction

40/50%-85% of HRR

Achieve 1,500-2,000 kcal of energy

expenditure through physical
activity each week.a,b

PTCA with or
without stent

40/50%-85% of HRR

Achieve 1,500-2,000 kcal of energy

expenditure through physical
activity each week.a,b

ACSMs Table 35-4 Summary of Unique Exercise Prescription

Issues among Patients with Cardiovascular Disease
Illness
CABG or
valve
surgery

Intensity
40/50%-85% of
HRR

Comments
Restrict upper-body movement
until sternum is healed (6-12
wk).

Heart failure

40/50%-70% of
HRR

If needed, initially guide exercise

intensity at 60% of HRR and
adjust duration to three bouts
of 10 min each, progressing to
30-40 min.

Cardiac
transplant

RPE 11-14

Restrict upper-body resistance

exercises until sternum is
healed (6-12 wk).

Pacemaker,
ICD,
biventricul
ar, RCT

10% below
activation
threshold

Avoid activities that stretch the

arms. After 8 wk, nonballistic
activities may be resumed, and
ballistic activities may be
resumed after 12 wk.

Coronary Artery Disease

Intensity 40/50%-85% of HRR
To affect mortality, frequency, duration, and
intensity of training should sum to yield a weekly
energy expenditure 1500 kcal/ week
Total energy expenditure is more important than
duration or type of activity

Braddom Box 34-1 Risk Factors for Coronary

Artery Disease
Modifiable
Physical inactivity
Hypertension
Smoking
Dyslipidemia
Overweight or obesity
Diabetes
Metabolic syndrome
Non-modifiable
Increasing age
Gender: male > female
Prior history: cardiac, peripheral vascular, or cerebrovascular
disease
Family history: genetics
Cultural or socioeconomic

ACSMs Table 35-3 Summary of Effects of Cardiorespiratory

Exercise Training on Selected Cardiovascular Risk Factors
Risk Factor

Effect

Smoking

By itself: little or no effect

Exercise should be part of a comprehensive smoking
cessation program

Lipid
abnormalities
Cholesterol

Little or no effect

LDL cholesterol

Little or no effect

HDL cholesterol

Mild to moderate increase

Hypertension

Reduces incidence (especially among white men)

Systolic

Reduced: average, 6 mm Hg

Diastolic

Reduced: average, 5 mm Hg

Obesity

Exercise alone: mild effect

Exercise should be part of a comprehensive weightmanagement program

Angina
Exercise, lifestyle behavior changes, and medical compliance
40/50%-85% of HRR
Patients with evidence of exercise-induced ischemia (i.e.,
angina, ECG changes), the upper HR for exercise training
should be set 10 or more beats below the HR or RPP
Goal for patients with angina
To perform routine daily activities at a lower RPP, thus
reducing the amount of angina/ fatigue they experience
To increase the amount of work, home activity, or
exercise they can perform at a given RPP

Angina
Patients need to recognize and understand their
symptoms first
Patients regularly experience angina at relatively
low workloads (e.g., 2 METs) to take one
sublingual nitroglycerin about 15 minutes before
starting their warm-up.
Exercise in a pain-free manner and at slightly higher
workloads

A longer warm-up (10 min) to minimize or avoid

ischemia

Myocardial Infarction
Start at the lower end of their training intensity
(40%60% of HR reserve method)
Three nonconsecutive days of cardiac
rehabilitation per week, with each exercise session
consisting of a 5- to 10-minute warm-up and cooldown period
Progressively increase exercise intensity and
duration up to 85% of HR reserve method and 20
to 60 minutes
Encouraged to adopt an active life style, including
exercise and daily activities, so that they expend
>1500 kcal each week

Revascularization (Coronary Artery Bypass Graft

and Percutaneous Coronary Intervention)
Signs of ischemia during exercise are often
eliminated after revascularization
Patients undergoing PCI
Recommendations for exercise programming for
patients after PCI are generally the same as for other
patients with CAD
Because patients undergoing PCI frequently do not
experience myocardial damage or extensive surgery,
they can sometimes begin cardiac rehabilitation, return
to work, and resume ADLs much sooner
Cardiac rehabilitation can begin within 48 hours after
PCI

Revascularization (Coronary Artery Bypass Graft and

Percutaneous Coronary Intervention)

Patients undergoing CABG surgery

Begin rehabilitation as early as 2 weeks after surgery,
with the initial focus on aerobic-type exercises
All upper-body exercise should be limited to ROM and
light repetitive activities until 4 to 8 weeks after surgery
Following the initial wound healing, patients should be
able to exercise up to 85% of HR reserve method, 3 to
4 days per week, for 20 to 60 minutes
After the sternum is healed at 6 to 12 weeks, patients
can then begin a resistance-training program similar to
other patients with cardiovascular disease

Valve Dysfunction/Repair/Replacement
Heart valve abnormalities
Increase the work the heart due to reducing effective
cardiac output
Myocardial hypertrophy
Mild diastolic dysfunction or a decrease in ventricular
distensibility
Exercise will not improve or change the function of the
valves, but it will help to improve the efficiency of oxygen
extraction by the skeletal muscles and improve the work
capacity of the individual

Valve Dysfunction/Repair/Replacement
The majority of valve abnormalities can be
corrected with surgical procedures.
Patients follow the same guidelines as CABG
patients following surgery
Patients on warfarin for mechanical valves or
atrial fibrillation should avoid contact sports

Heart Failure
Exercise intolerance Peak exercise capacity
reduced 30% to 40% in patients with heart failure
Several mechanisms to explain the exercise
intolerance

A reduction in peak cardiac output (~40%)

Chronotropic incompetence
Reduced stroke volume
The ability to increase blood flow to the more metabolically active
skeletal muscles during exercise is attenuated
Abnormalities in the skeletal muscle, such as a reduction in
myosin heavy chain I isoforms, reduced activity of the enzymes
associated aerobic metabolism, and a reduction in fiber size

Heart Failure
Moderate exercise is generally safe and results in
improvements in many aspects
Exercise training increases ejection fraction and
decreases LV end-diastolic volume
Patients with decompensated heart failure should
not be involved in an exercise program
More opportunity for rest, then progressively
increase to 30 minutes or more.
The upper end of exercise intensity at 60% of HR
reserve method, based on patient's condition
ECG monitoring or not

Cardiac Transplant
Cardiac transplant recipients continue to
experience exercise intolerance after
transplantation
This exercise intolerance is believed to be
primarily attributable to the absence of efferent
sympathetic innervation of the myocardium,
affecting heart rate and contractility responses,
residual skeletal muscle abnormalities developed
before transplantation because of heart failure, and
decreased skeletal muscle strength

Cardiac Transplant
After transplantation, many differences

Elevated resting HR (often >90 bpm)

Elevated systolic and diastolic BPs at rest
Attenuated increase in HR during submaximal work
Lower peak HR and peak stroke volume
Greater increase in plasma norepinephrine during
exercise
Delayed slowing of HR in recovery
Elevated systolic and diastolic BPs at rest, partly attributable to

increased plasma norepinephrine and the immunosuppressive

medications (i.e., cyclosporine and prednisone)

Delayed HR in recovery is thought to be attributable to increased

levels of plasma norepinephrine, exerting its positive chronotropic
effect in the absence of vagal efferent innervation

Cardiac Transplant
In the first year after surgery, it is best to simply disregard all
HR-based methods because of the abnormal HR control in these
patients
Cardiac transplant patients undergo exercise training

Exercise capacity increases by about 15% to 40%

Resting HR is unchanged or decreases slightly
Peak HR increases
Little change in peak stroke volume or cardiac dimensions
Quality of life is favorably altered

A progressive resistance training program started 6 to 12 weeks

after transplant surgery and performed twice per week

DeLisa Table 83-2 Borg Scales for Rating Perceived Exertion

15-Grade scale

10-Grade Scale

6 No exertion at all
7 Extremely light
8
9 Very light

0 Nothing

0.5

10
11 Light

Very, very light (just

noticeable)

1 Very light

12
13 Somewhat hard

2 Light (weak)

14

3 Moderate

15 Hard (heavy)

16

5 Heavy (strong)

17 Very hard

18

7 Very heavy

19 Extremely hard

20 Maximal exertion

Pacemakers, Implantable Cardiac Defibrillators,

and Arrhythmias
In general, the exercise training prescription is unaltered
for patients with these devices.
Exercise intensity in patients with an ICD should be set at
least 10 beats below the programmed firing threshold
Avoid activities that stretch the arms. After 8 wk,
nonballistic activities may be resumed, and ballistic
activities may be resumed after 12 wk.

Summary
The inclusion of exercise in the treatment of
these patients is beneficial because of its
favorable effects on risk factors, symptoms,
functional capacity, physiology, and quality
of life.
All patients with cardiovascular disease
should be encouraged to participate in
exercise because of its real or likely positive
impact on mortality and morbidity.

Thanks for your attention