For patients with cardiovascular disease, exercise is a critically important intervention and should be prioritized to slow the progression of disease and prevent or reverse physical deconditioning.

1. Exercise Training Recommendation for
Individual with Chronic Stable Angina and
Coronary Artery Bypass Graft Surgery
Nihal Ashraf
MPT 3rd Sem.
Jamia Millia Islamia

2. Introduction
• For patients with cardiovascular disease, exercise is a critically
important intervention and should be prioritized to slow the
progression of disease and prevent or reverse physical
deconditioning.
• Along with other therapeutics prescribed to patients with
cardiovascular disease, exercise training should be viewed as
medicinal.
• As is the case with all medicines, it is critically important that
the optimal “dose” of exercise is recommended to patients.

3. Angina Pectoris
• Ischemic heart disease is a major public health problem. It is
estimated that 1 in 3 adults (about 81 million people) in the
United States has some form of ischemic heart disease,
including nearly 10 million people with angina pectoris.
• Common symptoms associated with heart disease are angina,
dyspnea at rest or at low levels of exertion, orthopnea,
peripheral edema, palpitations, dizziness, and syncope.
• Angina is defined as chest pain, pressure, discomfort, or
fullness that is the manifestation of diminished blood flow
resulting in inadequate oxygen delivery to the myocardium.
• Angina is not a disease but rather the symptom of an
underlying heart problem.

4. • Management of symptoms is of paramount importance in the
treatment of patients with heart disease and is important reason
for referral to CR.
• A typical presentation of stable angina occurs following the
initiation of physical activity.
• Generally, symptoms at rest are nonexistent. The anginal
symptoms generally resolve with a cessation of activity, a
decrease in physical activity intensity, or administration of
vasodilator medication.
• Education and counseling are important when developing an
exercise training program for an individual who experiences
chronic, stable angina.

5. Coronary Artery Bypass Graft Surgery
• There are different methods of coronary revascularization that
vary significantly regarding the level of invasiveness and the
time required for convalescence.
• CABGS is the most durable and complete treatment for
coronary heart disease.
• Nearly 400,000 CABGSs are performed each year in the
United States.
• Although CABGS results in revascularization, it should not be
viewed as a permanent fix.

6. • Patients who have undergone CABGS remain at risk for the
progression of coronary artery disease of the native arteries or
the development of vein graft atherosclerosis.
• Exercise is a critically important component of the secondary
prevention strategy for patients after CABGS.
• minimally invasive surgeries allow for a more speeding
recovery than surgery involving a sternotomy.
• Recovery times after minimally invasive operations are from 2
to 4 weeks.

7. • For a patient undergoing sternotomy, Upper body weight
restrictions are often put in place for up to 8–12 weeks from
the date of surgery.
• A patient needs not to wait until 12 weeks to start with an
exercise program, however.
• Patients undergoing CABGS can start with lower intensity
exercise as early as 2 weeks post-surgery with an initial focus
on lower body, aerobic activity.

8. Exercise Testing Considerations
• As part of the baseline evaluation, it is highly preferred for a
patient to perform a symptom-limited exercise tolerance test
(e.g., exercise stress test).
• Information obtained from an exercise test is necessary for
developing an individualized, safe, and appropriate exercise
prescription and is useful for guiding a patient’s return to work
or home/leisure activities.
• Because some medications affect HR, BP, and exercise
tolerance, a patient should be instructed to take medications as
prescribed on the day of the stress test.

9. Exercise Prescription and Progression
Considerations
• 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 detailed.
Based on the FITT Recommendations present in ACSM’s Guidelines for Exercise
Testing and Prescription.

10.  Frequecy
• Minimal 3 days per week.
• preferably 5 days per week.
 Intensity
• With an exercise test, use 40%– 80% of exercise capacity,
using HRR, O2R, or O2peak .
• Without an exercise test, use seated or standing HRrest + 20–
30 bpm or an RPE of 12–16 on a 6–20 scale.

11.  Time
• 20–60 min
 Intervention
• Arm ergometer,
• upper and lower (dual action) extremity ergometer,
• upright and recumbent cycles,
• recumbent stepper, rower, elliptical, stair climber, or treadmill.

13. Resistance Training
• Resistance training should be encouraged in this population for
muscle strength and endurance, both of which are important
for the safe return to ADL along with occupational and
avocational pursuits.
• 2–3 days per week. (nonconsecutive) at 40%–60% 1- RM or
RPE ~11–13 (6–20 scale).
• 10–15 repetitions Without fatigue,
• 1–3 sets per exercise 8–10 different muscle groups Select
equipment that is safe for the patient to use.

14. Flexibility Training
• 2–3 days per week with daily being most effective Stretch to
the point of feeling tightness or slight discomfort.
• 15 second hold for static stretching.
• >4 repetitions of each exercise Static and dynamic stretching
focused on major muscle groups of the limbs and lower back.
• consider PNF stretching.

15. 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
weeks from the date of surgery.
• Encourage patients with CABGS to start to exercise prior to 12
wk.

16. • Typically, an exercise session consists of a 5- to 10-minute
warm-up and cool-down period in addition to the aerobic
training phase.
• The warm-up and cool-down phases should include range of
motion, stretching, and low intensity aerobic activities.
• For patients with chronic stable angina, a lower intensity and
prolonged warm-up might help avoid the development of
symptoms, ECG changes, arrhythmias, and cardiac
dysfunction.

17. • Exercise training programs for individuals with coronary
artery disease have traditionally targeted a light-to- moderate
intensity for exercise training.
• The vast majority of studies reporting outcomes in cardiac
patients have used a training regimen of moderate-intensity
exercise. These studies have provided overwhelming evidence
that moderate-intensity exercise is both beneficial and
safe.(Anderson et al.,2016).
• More recently, however, a number of studies utilizing higher
intensity interval training have demonstrated significantly
greater improvements in cardiorespiratory fitness.(Elliott et al.,
2015).

18. References
• Elliott, A. D., Rajopadhyaya, K., Bentley, D. J., Beltrame, J. F., & Aromataris, E. C. (2015). Interval
training versus continuous exercise in patients with coronary artery disease: a meta-analysis. Heart,
Lung and Circulation, 24(2), 149-157.
• ANDERsONL, O. L. D. R. I. D. G. E. N. (2016). Exerciser based cardiac rehabilitation forcoronary
heartdisease: cochrane systematicreviewandmetaranalysis. JAmcollcardiol, 67(1), 1r12.
• American Association of Cardiovascular & Pulmonary Rehabilitation. (2004). Guidelines for
cardiac rehabilitation and secondary prevention programs. Human Kinetics.
• Riebe, D., Ehrman, J. K., Liguori, G., Magal, M., & American College of Sports Medicine (Eds.).
(2018). ACSM's guidelines for exercise testing and prescription. Wolters Kluwer.
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(2012). 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and
management of patients with stable ischemic heart disease: executive summary: a report of the
American College of Cardiology Foundation/American Heart Association task force on practice
guidelines, and the American College of Physicians, American Association for Thoracic Surgery,
Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and
Interventions, and Society of Thoracic Surgeons. Journal of the American College of
Cardiology, 60(24), 2564-2603.
• Kulik, A., Ruel, M., Jneid, H., Ferguson, T. B., Hiratzka, L. F., Ikonomidis, J. S., ... & Sellke, F. W.
(2015). American Heart Association Council on Cardiovascular Surgery and Anesthesia. Secondary
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20. Thank you