This document provides guidelines for exercise prescription for patients who have experienced an acute coronary syndrome (ACS). It discusses that exercise training can improve outcomes for ACS patients by enhancing exercise tolerance, quality of life, and reducing cardiovascular risk factors. The guidelines recommend that ACS patients complete cardiac rehabilitation, including both aerobic and resistance training exercises. Aerobic exercise should be 3-5 days per week at a moderate intensity based on heart rate, and resistance training 2-3 days per week focusing on major muscle groups. Exercise prescriptions must ensure the ischemic threshold is not exceeded to prevent anginal symptoms.

1. Exercise prescription for patients with
Acute Coronary Syndrome
Hiba Anis
MPT 3rd Sem
Jamia Millia Islamia

2. Acute coronary syndrome (ACS)
• Coronary artery disease (CAD) remains the first cause of mortality worldwide
• Among all types of coronary artery diseases, acute coronary syndrome (ACS) is
the most serious one
• Acute coronary syndrome (ACS, formerly called ischemic heart disease) refers to
a large spectrum of clinical conditions which is caused by a sudden onset of
cardiac tissue ischemia secondary to impaired blood flow.
• The precipitating event is blockage in the coronary arteries or a mismatch between
the demand and supply of blood to cardiac tissue

3. • There is dysfunction of cardiac muscle due to decreased blood flow in the coronary
arteries.
• The resulting tissue ischemia can cause symptoms such as substernal chest pressure;
radiation of pain to the left arm, shoulder, or jaw; and changes on an
electrocardiogram (ECG).
• It clinically manifests as an acute condition, but is actually an acute onset of chronic
systemic vascular disease (atherosclerosis) that has been progressing slowly over a
long period
• ACS is usually divided into three categories:
1. ST elevation myocardial infarction (STEMI, 30%),
2. Non ST elevation myocardial infarction (NSTEMI, 25%), or
3. Unstable angina (38%)

4. Pathophysiology
• characterized by the formation of an atherosclerotic plaque following a long-term
and complex process.
• Most of the time patients would remain asymptomatic if the plaque is stable.
• Once ruptures, it can cause partial or complete occlusion of a coronary artery.
• The rupture of plaque exposes the collagen underneath the endothelial, which may
result in cascade of platelets activation, leading to thrombus formation.
• Several factors may make plaque prone to rupture, like systemic inflammatory
reactions, local shear stress, platelet hyperactivity, prothrombotic states caused by
smoking, dehydration, infection, cocaine, malignancy and so on
• The reduction of blood flow results in these typical angina symptoms

5. • Patients with complete occlusion generally present with ST Elevated Myocardial
infarction (STEMI) .
• If the occlusion is unresolved in a timely manner, it may result in transmural
infarction. This provides the rationale for early reperfusion with either
pharmacological or catheter-based approaches.
• Patients with partially occluded coronary arteries usually presented with other ST-T
changes on EKG.
• These presentations are grouped as Unstable Angina (UA) or Non ST Elevated
Myocardial Infarction (NSTEMI), depending on whether the troponin is elevated
or not.

7. Exercise and ACS
• Exercise training has been demonstrated to improve exercise tolerance, quality of
life, functional capacities and job-related physical tasks, as well as decrease
cardiovascular risk factors and cardiac mortality.
• exercise is a critically important intervention and should be prioritized to slow the
progression of disease and prevent or reverse physical deconditioning

8. Cardiac rehabilitation
• Cardiac rehabilitation (CR) is a long-term program that involves prescribed
exercise, education, and counseling to limit physiological and psychological
effects of cardiac disease and to enhance the psychosocial and vocational status of
selected patients. (Thomas R et al. 2007)
• Recent studies on the effects of CR found that the exercise component of CR
improves ACS individual’s QOL, regardless of the type of coronary syndrome and
type and setting of CR
• US guidelines recommend CR for all patients after CABG, with the referral
ideally performed early postoperatively during the surgical hospital stay (AHA
2015) and all eligible patients with ACS, or those whose status is immediate post
CAB surgery or post PCI should be referred to a comprehensive outpatient CR
program either prior to hospital discharge or during the first follow-up office visit
(AHA 2011)

9. Preparticipation health screening
• After experiencing a cardiac event and prior to starting an exercise training
program, medical clearance is recommended
• Baseline evaluation/ Assessment review
• Medical and surgical history
• most recent cardiovascular event,
• comorbidities, and
• other pertinent medical history
• Current medications
• Dose,
• means by which the drug is administered,
• frequency

10. • Cardiovascular risk factors should be identified
• Physical examination
• Cardiopulmonary system
• musculoskeletal systems
• The baseline physical examination should be performed by a physician or other
appropriate health care provider under the direction of a physician who is actively
involved in the care of patients
• Identification of contraindications for exercise training have been developed and
should be considered prior to having an individual with coronary artery disease
initiate an exercise training program

11. Exercise Testing Considerations
• Symptom-limited cardiopulmonary exercise test
• Symptom-limited cardiopulmonary exercise testing is currently accepted as a standard
in CR programs for patients after ACS
• Assessing the risk of participation in exercise-induced CR programs based on changes
in HRs, abnormal ECGs, changes in BP, and the onset of symptoms as a result of
increasing exercise load can be used to develop safe and effective exercise
prescriptions
• Submaximal exercise test (6-minute walk test)
• Where maximal exercise testing is difficult, a submaximal exercise test, such as a 6-
minute walk test, is commonly recommended
• a 6-minute walk distance is used to set exercise intensity and evaluate the
effectiveness of CR

12. • For all patients, regardless of whether an exercise tolerance test is
administered, RPE should be used as a tool to guide and adjust
exercise intensity while maintaining patients within their physical
limitations and below their symptomatic threshold

13. Exercise prescription
• Early CR is usually recommended if PCI is performed for ACS. In cases of
CABG, CR may be delayed due to concerns about general deconditioning and the
recovery of the sutured site after sternotomy
• Prescriptive techniques for determining exercise dosage or the frequency,
intensity, time, and type (FITT) of an exercise prescription for chronic stable
angina and coronary artery bypass surgery patients are followed

14. Aerobic exercise
• Frequency : Minimal 3 d/wk ; preferably 5 d/wk
• Intensity: With an exercise test, use 40%– 80% of exercise capacity, using HRR,
VO2peak . Without an exercise test, use seated or standing HRrest + 20– 30 bpm
or an RPE of 12–16 on a 6–20 scale
• Time : 20-60 mins
• Type: Arm ergometer, upper and lower (dual action) extremity ergometer, upright
and recumbent cycles, recumbent stepper. activities that employ large muscle
groups through rhythmic activities such as walking, jogging, cycling, elliptical,
stair climbing, and rowing.

15. Resistance training
• the American Heart Association (AHA) (2011) reports that resistance exercise
improves muscle strength, endurance, fitness, independence, and QOL, regardless
of the presence of CVD.
• One limitation of these studies on the reported effects of resistance training,
however, was that they were generally small-scale studies involving low-risk
groups for exercise-related adverse CV events. Thus, the AHA (2011) presents the
absolute and relative contraindications of resistance exercise

16. • Absolute
• Unstable coronary heart disease
• Decompensated heart failure
• Uncontrolled arrhythmias
• Severe pulmonary hypertension (mean pulmonary arterial pressure>55 mmHg)
• Severe and symptomatic aortic stenosis
• Acute myocarditis, endocarditis, or pericarditis
• Uncontrolled hypertension (>180/110 mmHg)
• Aortic dissection
• Marfan syndrome
• High-intensity RT (80–100% of 1-RM) in patients with active proliferative
retinopathy or moderate or worse non-proliferative diabetic retinopathy

17. • Relative (should consult a physician before participation)
• Major risk factors for coronary heart disease
• Diabetes at any age
• Uncontrolled hypertension (>160/100 mmHg)
• Low functional capacity (<4 Metabolic equivalents of task)
• Musculoskeletal limitations
• Individuals with implanted pacemakers or defibrillators
(Kim, C., Sung, J., Lee, J. H., Kim, W. S., Lee, G. J., Jee, S., Jung, I. Y., Rah, U. W., Kim, B. O., Choi, K. H., Kwon, B. S., Yoo, S. D., Bang,
H. J., Shin, H. I., Kim, Y. W., Jung, H., Kim, E. J., Lee, J. H., Jung, I. H., Jung, J. S., … Kim, S. (2019). Clinical Practice Guideline for
Cardiac Rehabilitation in Korea: Recommendations for Cardiac Rehabilitation and Secondary Prevention after Acute Coronary
Syndrome. Korean circulation journal, 49(11), 1066–1111. https://doi.org/10.4070/kcj.2019.0194)

18. • Resistance training results in improved muscle strength and endurance, both of which
are important for the safe return to ADL along with occupational and avocational
pursuits
• Frequency : 2–3 d/wk −1 (nonconsecutive) at 40%–60% 1RM or RPE ~11–13 (6–
20 scale)
• Volume: 10–15 repetitions. Without fatigue,1–3 sets per exercise for 8–10
different muscle groups
• Type: Select equipment that is safe for the patient to use.
• Proper form should be maintained through the entirety of the range of motion and
individuals should be counseled to refrain from holding their breath during resistance
training
• Patients should be instructed to exhale during the concentric phase of the exercise and
to inhale during the eccentric contraction.

19. • Patients undergoing a catheterization with or without percutaneous intervention
and those who experienced an uncomplicated myocardial infarction may begin
resistance training program as early as 3 and 5 weeks from the date of the event,
respectively
• It is generally recommended that for patients undergoing CABGS involving
sternotomy, upper body resistance training should be avoided for 8–12 weeks from
the date of surgery or until sternal healing has fully occurred.
• Initiating lightweight resistance training prior to when the weight restrictions are
removed, however, is useful to promote range of motion and to minimize muscle
atrophy

20. Special considerations
• Special considerations for those with angina to stay below the ischemic threshold;
• medications such as βblockers, nitrates, and calcium channel blockers may
influence the ischemic threshold.
• Patients with CABGS with sternotomy need to ensure that the sternum is fully
healed and stable.
• Significant restrictions for upper body activities for up to 8–12 wk from the date
of surgery.
• Encourage patients with CABGS to start to exercise prior to 12 wk
• Any increase or change in anginal symptoms should be recorded and receive
immediate medical attention as it may reflect a change in coronary status.

21. • The exercise session should include a prolonged warm-up and cool down (~10
minutes), both of which may have an antianginal effect, and consist of range of
motion, stretching, and low-level aerobic activities. The goal of the warm-up is to
gradually raise the heat rate response within 10 to 20 bpm of the lower limit
prescribed for endurance training.
• Because symptomatic or silent ischemia may be arrhythmogenic, the THR for
endurance exercise should be set safely below (~10bpm) the ischemic ECG or
anginal threshold. Alternatively, the upper heart level can be set as the highest
"nonischemic" workload from the GXT.

22. • If anginal symptoms are not relieved by termination of exercise or by the use of
three sublingual nitroglycerin tablets (one taken every 5 minutes), the patient
should be transported to the nearest hospital emergency center.

23. Thank you!