Cardiac rehabilitation is a comprehensive exercise, education, and behavior modification program for patients with heart disease. It is designed to improve physical and emotional condition through exercise training and lifestyle changes, with the primary goal of enabling participants to achieve optimal physical, psychological, social, and vocational functioning. Cardiac rehabilitation programs include four phases - inpatient treatment during recovery from cardiac events, supervised outpatient programs focused on exercise training and risk factor management, long-term unsupervised maintenance, and lifelong lifestyle modifications. Exercise is prescribed based on risk stratification and progresses over time from low-intensity activities to higher-intensity aerobic and resistance training.

1. CARDIAC
REHABILITATION

2. DEFINATIO
N
o The term cardiac rehabilitation refers to coordinated, multifaceted
interventions designed to optimize a cardiac patient’s physical,
psychological, and social functioning, in addition to stabilizing, slowing, or
even reversing the progression of the underlying atherosclerotic processes,
thereby reducing morbidity and mortality.
(AMERICAN HEART ASSOCIATION 2018)

3. Cardiac rehabilitation (CR) is a multi-factorial and comprehensive intervention in
secondary prevention, designed to limit the physiological and psychological effects of
cardiovascular disease, manage symptoms, and reduce the risk of future
cardiovascular events. CR is shown to reduce mortality, hospital readmissions, costs
and to improve exercise capacity, quality of life and psychological well-being and is
recommended in international guidelines for patients with a ST- elevation acute
myocardial infarction, a non ST-elevation myocardial infarction and stable coronary
artery disease.
( EUROPEAN SOCIETY OF CARDIOLOGY,2017)

4. Cardiac rehabilitation is a comprehensive exercise, education, and behavior
modification program designed to improve the physical and emotional
condition of patients with heart disease.
Prescribed to control symptoms, improve exercise tolerance, and improve
overall quality of life.
The primary goal of cardiac rehabilitation is to enable the participant to
achieve his/her optimal physical, psychological, social and vocational
functioning through exercise training andlifestyle change.
(AMERICAN ASSOCIATION OF CARDIOVASCULAR AND PULMONARY
REHABILITATION (AACVPR) 2007)

6. Who should be included in Cardiac
Rehabilitation ?
Post MI
Post
CABG
Congestive Heart
Failure Post PTCA
Heart Transplant
Pacemaker
Diagnosed with
CAD
Any other Cardiac
surgery

7. COMPONANTS OF CARDIAC REHABILITATION

8. MEMBERS OF CARDIAC
REHABILITATION
PATIEN
T &
FAMILY
PHARMACIS
T
NUR
S
E
DIETICIA
N
CARDIOLOGIS
T
PHYSIOTHERA
PI ST
SOCIAL
WORKE
R
PSYCHOLOGI
S T

9. Goal
s
Cardiac rehabilitation meets the emotional, educational and physical needs of patient and their family in
acute hospital phase, though outpatient care and long term follow up in community.
Decrease cardiac morbidity and relieve symptoms
Promote risk modification and secondary prevention
Decrease anxiety and increase knowledge and selfconfidence
Increase fitness and the ability to resume normal activities

10. Elements of Exercise Prescription in
CR
Rule out contraindications forexercise
Risk stratification and monitoring
Type, Intensity, Duration, Frequency,
Progression, Precaution
Warm up - Cool down
Stop with Signs & Symptoms of cardiovascular insufficiency or angina
Proper : Time, Place, Equipment, Clothes, Shoes

11. Risk Stratification (AACVPR, 2005)
Low Risk Moderate Risk High Risk
Uncomplicated MI , CABG, angioplasty,
or atherectomy
Functional capacity <5-6 METs 3 or more weeks
after clinical event
Severely depressed LV function (EF ≤
30%)
Functional capacity ≥6 METs 3 or more weeks
after clinical event
Mild to moderately depressed leftventricular
function (EF 31- 49%)
Complex ventricular arrhythmias at restor
appearing or increasing with exercise
No resting or exercise-induced myocardial
ischemia manifested as angina and/or ST
segment displacement
No resting or exercise-inducedcomplex
arrhythmias
Failure to comply with exercise prescription Decrease in systolic blood pressure of >15mm Hg
during exercise or failure to rise consistent with
exercise workloads
No significant left ventricular dysfunction
(EF ≥ 50%)
Exercise-induced ST-segment depression of
1-2mm or reversible ischemic defects
(echocardiography or nuclear radiography)
MI complicated by CHF, cardiogenic shock, and/
or complex-ventricular arrhythmias
Patients with severe CAD and marked (>2mm)
exercise-induced ST-segment depression

12. New York Heart Association (NYHA) Functional Classification
NYHA Class Symptoms
I
Cardiac disease, but no symptoms and no limitation in ordinary physical activity, e.g. no shortness of breath when
walking, climbing stairs etc.
II Mild symptoms (mild shortness of breath and/or angina) and slight limitation during ordinary activity.
III
Marked limitation in activity due to symptoms, even during less-than-ordinary activity, e.g. walking short distances
(20–100 m).
Comfortable only at rest.
IV Severe limitations. Experiences symptoms even while at rest. Mostly bedbound patients.

13. Phases of Cardiac Rehabilitation
PHASE I: Acute care phase / In Patient Period (average 3-5)
PHASE II: Convalescent phase / Immediate post-discharge (2-6weeks)
Phase III: Exercise training Phase / Supervised outpatient programme (6-12weeks)
Phase IV: Maintenance phase

14. PHASE I: Acute care phase / In Patient Period
(average 3-5 days)
Inpatient cardiac rehab uses a team approach based on activity progression, patient education, and
hemodynamic and ECG monitoring, together with medical and pharmacological management.
The role of the physical therapist is to monitor activity tolerance, prepare for discharge, educate the
patient to recognize adverse symptoms with activity, support risk factor modification techniques,
provide emotional support and collaborate with other teammembers.
GOAL IS EARLY MOBILISATION

15. Vital sign monitoring occurs before and after and if possible during activity.
Intensity of the activity
Borg RPE Scale - fairly light range
(OR)
1-2 METs
(OR)
↑ HR = 10-20 bpm (with or without Beta Blocker)
Duration
Intermittent training
Bouts lasting 3-5 min
Rest Periods 1-2 min (Always shorter than exercise bout)
Total duration = up to 20 min
Frequency
Early Period (1-2 days) = 3-4times/day
Late Period (from day 3 onwards) = 2 times/day

16. Inpatient Cardiac Rehabilitation Program
CCU – ESSENTIAL
BEDREST
level 1 (1-1.5 METs)
Evaluation and patient education
Arms supported for meals and ADLs
Bed exercises and dangle with feet supported (If CPK have peaked and patient has no complications)
Education
Introduction to inpatient cardiac rehab and role of physical therapy
Monitored progression of activity . .
Home exercise/activity guidelines/outpatient cardiac rehab

17. SITTING-LIMITED ROOM
AMBULATION
Level 2 (1.5-2METs)
Sitting 15-30 min, 2-4 times/day
Leg exercises
Commode privileges
Reclining upright chair
Limited ADL
Limited supervised room ambulation for small uncomplicated MI
Education
Identification of CAD riskfactors
Concept of "healing interval" and need to pace activities

18. ROOM-LIMITED HALL
AMBULATION
3 Level (2-2.5METs)
• Room or hall ambulation up to 5 min as tolerated 3-4 times/day
• Standing leg exercises optional
• Sit on side of bed or in bathroom to wash (per discretion nurse/PT)
• Bathroom privileges
• Independent or assisted ambulation in room or hall as advised by PT
Education
• Size of infarct and how it relates to the need for gradual resumption of activities
• Impact of exercise on reducing the patient'srisk factors
• Teach use of Borg's Scale for Rating of Perceived Exertion and appropriate parameters with activity

19. PROGRESSIVE HALL
AMBULATION
Level 4 (2.5-3METs)
• Hall ambulation 5-7 min as tolerated 3-4 times/day
• Standing trunk exercises optional
• Independent or assisted ambulation in hall as advised by PT
Education
• Teach pulse taking and appropriate parameters with activity
• Reinforce benefits of outpatient cardiacrehabilitation

20. PROGRESSIVE HALL
AMBULATION
Level5 ( 3-4 METs)
• Hall ambulation 8- 10 min as tolerated
• Arm exercises optional
• Standing shower
• Independent hall ambulation as advisedby PT
Education
Written home exercise/activity guidelines reviewed
Patient given written information on outpatient cardiacrehab

21. STAIR
CLIMBING
Level 6 (4-5METs)
• Progressive hall ambulation as tolerated.
• Full flight of stairs (or as required at home) up and down one step at a time
Education
• Answer patient's questions
• Check for understanding of activityguidelines

22. PATIENT
OUTCOME
• No systolic drop in BP > 1 0 mm Hg or increase > 30 mm Hg
• No HR increase > 12 if beta blocked, or no HR increase > 20 if not beta
blocked
• Nocomplaints of dizziness, lightheadedness or angina
• Perceived exertion < 13/20

23. AT THE TIME OF DISCHARGE
At the time of discharge a patient should understand about symptom recognition and appropriate activity
guidelines.
It is crucial that the patient be aware of and recognize, cardiac symptoms and understand the action to take if
they occur.
During first 4-6 weeks of post MI healing phase, physical activity involves a gradual increase in ambulation time,
with a goal of 20 to 30 minutes of ambulation 1 to 2 times per day at 4 to 6 weeks post MI.

24. PHASE II: Convalescent phase / Immediate post-discharge (2-6
weeks)
Patients commonly undergo a symptom-limited maximal stress test (ETT) at 4 to 6 weeks post-MI.
Based on the results of the tests, either positive (+) for ischemia or negative (-) for ischemia, an supervised
exercise prescription is prescribed.
Symptom limited exercise testing before exercise prescription
Low to Moderate intensity exercises
Supervised / Regularmonitoring

25. Provide patient and family education
Enhance CV function, physical work capacity, strength endurance and flexibility
Prepare patient to return to work
Improve QOL
Risk stratification
Prepare patient for long term exercise
Goals

26. Exercise
Program
Warm up
Aerobic work out
 Intensity- HR +20 /30 or at RPE of 11-
13
 Duration -10- 30 mins
 Frequency -3-5 times per
week Cool down

27. Recommended ECG
monitoring
lowest risk
Monitored-6 to 18sessions
Up to 30 dayspost-event
Moderate risk
Monitored-12 to 24 sessions
up to 60 - 90 days post-event
Highest risk
monitored -18 to 24 sessions
for 90 daysor more post-event

28. PHASE III : Exercise training Phase / Supervised
outpatient programme (6-12 weeks)
This phase concentrates in maintaining and improving both CV and
muscular endurance
Increase in exercise capacity
Ensure continuity of exercise program with transition into home
environment
Relieve anxiety and
depression Modify and control
risk factors

29. Goal
s
Appropriate patient monitoring and supervision
Return patient to pre-morbid vocational &/or recreational activities
Promote total conditioning including aerobic and resistance exercises

30. Who can participate
?
Patients completing phase 2
Patients with CAD risk factors
Healthy individuals interested in maintaining physical fitness

31. Principles of Exercise
Prescription
Exercise test before participation
An individualized exercise prescription for aerobic and resistance training should
be obtained that is based on evaluation findings, risk stratification
Exercise prescription should specify duration, intensity, frequency and modalities
Include warm up, cool down and flexibility exercise

32. Principles of Exercise
Prescription
According to FITT principle, exercise prescription will be prescribed
Frequency
Moderate intensity aerobic exercise - 5 day/week
(OR)
vigorous intensity aerobic exercise - 3 day/week

33. •
•
•
•
•
•
Typ
e
The aerobic exercise portion of the session should include rhythmic, large-muscle-
group activities.
The different types of exercise equipment may include:
Arm ergometer
Combination upper/lower extremity ergometer
Upright and recumbent cycle ergometer
Rower
Stair climber
Treadmill for walking

34. Time
(Duration)
• Warm-Up Exercises (10-15 mins)
- Low Intensity (≤ 40% HRR), ROM exercises, Stretching
• Conditioning / Aerobic / Circuit Training Exercises (20-60 mins)
- The goal for the duration of the aerobic conditioning phase is generally 20-
60 minutes per session. After a cardiac event, many patients begin with 5-10
minute sessions with a gradual progression in aerobic exercise time of 1-5
minutes per session or an increase in time per session of 10% to 20% per week.
• Cool-Down Exercises (5-10 mins)
- Stretching, Low intensity exercise, shavasana

35. Intensity
HRmax = 220-Age
According to Karvonan’s Formula:
Target HR (THR) = [(HRmax - HRrest) × 60-80% intensity] +
HRrest (OR)
Target VO₂max = VO₂max × 60-80% intensity
(OR)
Target MET = [(VO₂max)/3.5 ml/kg/min] × 60-80% intensity
(OR)
RPE = 12-15 (somewhat hard to hard )

36. Phase IV : Maintenance Phase (6month &
more)
This phase constitutes the components of long-term maintenance of lifestyle changes and professional
monitoring of clinical status.
It is when patients leave the structured Phase 3 programme and continue exercise and other lifestyle
modifications indefinitely.
This may be facilitated in the CR unit itself or in a local leisure center.
Alternatively, individuals may prefer to exercise independently and Phase 4 may involve helping them set a safe
and realistic maintenance programme.

37. Goal
s
Maintenance of achieved functionalstatus
Return to work – Return to hobbies and lifestyle modifications
Secondary preventive targets

38. Prescription of Exercises
Depends on patients functional status and prognosis
Intensity
60 - 80% ofVO2 max
70 - 85% ofHRR
RPE 12 - 15 (somewhat hard to
hard) MET
Type
Aerobic training and resisted exercises

39. Duration
Desired 30 - 60 min continuous workout
Intermittent workout
Exercises bouts of15 - 20 min
Frequency
One session/day
3 - 4 days/week

40. Progression to Maintenance
phase
Guidelines to progress to unsupervised or minimally supervised program
Functional capacity  8 METS
Appropriate hemodynamic response to exercise
Appropriate ECG response
Adequate management of risk factor intervention strategy and safe exercise participation
Demonstrated knowledge of disease process, abnormal signs and symptoms, medication
use and side effects

41. Resistance
Training
General Principles
Contraindications similar to aerobicprograms
Generally require moderate to good LV function and exercise capacity > 5 METs without Sign &
Symptoms
Not recommended for high riskpatients
After 2 - 3 weeks post MI and 4 - 6 weeks post surgery
Normally begin resistance program 2-3 weeks after initiating aerobic program

42. Exercises
Prescription
Intensity
Initially start with 1 set of 10-15 reps
Can engage in other forms like springs,
Theraband Moderate fatigue
Check rate pressure product (RPP)
RPE: 11-14

43. Exercises
Prescription
Duration
15 - 20 min per session
Progression
1 - 2 Kg/ week for upper limb
3 - 5 Kg / week for lower limb

44. Safety
precautions
Movements should be rhythmical, Performed at moderate-to-slow controlled speed, With a
normal breathing pattern while lifting
Do repetitions rather than single maximal lifts
Do unilateral rather than bilateral movements when possible
Avoid overhead lifting Rest as needed, do not rush the circuit
Avoid exertion
Adequate rest periods

45. Special
Considerations

46. Hypertensio
n
Aerobic exercise training leads to reductions in resting BP of 5 to 7 mm Hg in individuals with hypertension.
Exercise training also lowers BP at fixed submaximal exercise workloads.
Frequency: Aerobic exercise on most, preferably all days of the
week; Resistance exercise 2–3 d/week
Intensity: Moderate-intensity aerobic exercise (i.e., 40% to <60% HRR) supplemented by
resistance training at 60% to 80%1-RM
Time: 30–60 min/day of continuous or intermittent aerobic exercise. If intermittent, use a minimum of 10-minute
bouts accumulated to total 30–60 min/day of exercise. Resistance training should consist of at least one set of
8-12 repetitions.
Type: Aerobic activities such as walking, jogging, cycling, and swimming. Resistance training programs should
consist of 8 to 10 different exercises targeting the major muscle groups.

47. Patients with a Sternotomy
For 5 to 8 weeks after cardiothoracic surgery, lifting with the upper extremities should be restricted to 5-8
pounds (2.27–3.63 kg).
Range of motion (ROM) exercises and lifting 1-3 pounds (0.45–1.36 kg) with the arms is permissible if there is
no evidence of sternal instability, as detected by movement in the sternum, pain, cracking, or popping.
Patients should be advised to limit ROM within the onset of feelings of pulling on the incision or mild pain.

48. Recent Pacemaker/Implantable Cardioverter
Defibrillator Implantation
Pacemakers may improve functional capacity as a result of an improved HR response to exercise.
The upper HR limit of dual-sensor rate responsive and pacemakers should be set 10% below the ischemic
threshold (i.e., the 10% safety margin).
When an ICD is present, exercise training intensity should be maintained at least 10 beats/min below the
programmed HR threshold fordefibrillation.
To minimize the risk of lead dislocation, for 3 weeks after implantation, all pacemaker patients should avoid
activities that require raising the hands above the level of the shoulders.

49. Cardiac
Transplantation
Exercise prescription for these patients does not include use of a THR. For these patients, the clinician and
cardiac rehabilitation professional shouldconsider
A. an extended warm-up and cool-down if limited by muscular deconditioning;
B. using RPE to monitor exercise intensity;and
C. incorporation of stretching and ROM exercises. However, at 1 year after surgery, approximately one third of
patients exhibit a partially normalized HR response to exercise and may be given a THR based on results from a
graded exercise test (GXT)

50. THANK YOU