Cardiac rehabilitation is a broad term. It includes physical activities for cardiac patients as well as risk stratification, management of risk factors, occupational rehabilitation and patient education and counselling. This presentation deals with the prescription of physical activity and exercise for patients with acute coronary syndrome, chronic coronary syndrome, heart failure etc.

1. Cardiac Rehabilitation
Physical Activities for
Cardiac Patients
Dr. Noshin Tabassum
MD (Cardiology) Final Part
Department of Cardiology
Sir Salimullah Medical College Mitford Hospital

2. What is Cardiac Rehabilitation (CR)?
•It is a guideline-recommended, multidisciplinary program of
exercise training, risk factor management, and
psychosocial counseling for people with cardiovascular
disease
•Beneficial but underused
•Substantial disparities in referral, access, and participation
https://doi.org/10.1161/CIRCULATIONAHA.122.061046Circulation. 2023;147:254–266

3. https://iris.who.int/bitstream/handle/10665/336656/9789240015128-eng.pdf?sequence=1&isAllowed=y
Physical Activity (PA):
Any bodily movement produced by
skeletal muscles that requires energy
expenditure
Physical Exercise:
A subcategory of physical
activity that is planned,
structured, repetitive, and
purposeful with the objective of
improvement or maintenance of
one or more components of
physical fitness

4. Components of Physical Fitness

5. Effects of PA on CV Risk Factors

6. Expected Outcomes
Physical Activity
• Increased participation in domestic, occupational, and recreational
activities
• Improved psychosocial well-being
• Reduced stress
• Facilitation of functional independence
• Prevention of disability
• Enhancement of independent self-care
• Improved aerobic fitness and body composition
• Lower coronary risk factors (particularly for sedentary patient
adopting regular PA)

7. Expected outcomes cont.
Exercise Training
• Patient understands safety issues during exercise, including warning
signs/symptoms
• Achieves increased cardiorespiratory fitness and enhanced flexibility,
muscular endurance, and strength
• Achieves reduced symptoms, attenuated physiologic responses to
physical challenges, and improved psychosocial well-being
• Achieves reduced global cardiovascular risk and mortality resulting from
an overall program of CR/secondary prevention that includes exercise
training

8. Patient Selection
Whether CR may
benefit requires
further study
• Heart failure with
preserved or
intermediate
ejection fraction
• Atrial fibrillation
• Cancer
CR is Beneficial
 Acute myocardial infarction
 Percutaneous coronary
intervention
 Coronary artery bypass surgery
 Heart valve repair or
replacement
 Heart transplant
 Chronic stable angina
 Systolic heart failure
Supervised
Exercise Therapy
is recommended
in AHA/ACC
guidelines
• Lower extremity
peripheral
vascular disease
Acute myocardial infarction
Percutaneous coronary
intervention
Chronic stable angina
Systolic heart failure

9. Higher levels of physical
activity and fitness lowers
• All-cause mortality
• Rates of CVD
• Prevalence of several
malignancies
• Intense exercise may paradoxically
trigger life-threatening exercise-
related MACE (SCA, SCD, ACS, TIA,
CVA, and SVTs)
• Sudden cardiac death is the leading
cause of sports and exercise-related
mortality in athletes
PHYSICAL ACTIVITY

10. Contraindications for CR
•Unstable angina
•Uncontrolled hypertension (resting SBP >180 mmHg and/or
resting DBP >110 mmHg)
•Orthostatic BP drop of >20 mmHg with symptoms
•Significant aortic stenosis (aortic valve area <1.0 cm2)
•Uncontrolled atrial or ventricular arrhythmias
•Uncontrolled sinus tachycardia (>120 beats/min)
•Decompensated heart failure

11. Contraindications for CR cont.
• Third degree AV block without pacemaker
• Active pericarditis or myocarditis
• Recent embolism
• Acute thrombophlebitis
• Acute systemic illness or fever
• Uncontrolled diabetes mellitus
• Severe orthopedic conditions that would prohibit exercise
• Other metabolic conditions: acute thyroiditis, hypokalemia,
hyperkalemia, or hypovolemia (until adequately treated)

13. Characteristics of Exercise
Frequency Intensity Time Type

14. Definitions
Metabolic Equivalent (MET):
The rate of energy expenditure of an adult while sitting at rest
• 1 MET = amount of O2 consumed by a resting, awake individual
= 3.5 ml O2/kg of body weight/minute
Exercise intensity:
The amount of energy required for the performance of the physical
activity per unit of time
• Measurement methods:
- Respiratory gas analysis to quantify O2 uptake during exercise
- Estimated using standard regression models to estimate energy
expenditure per a given workrate of exercise
- Also expressed in terms of METs

15. Definitions cont.
Absolute intensity does not take account of individual factors
such as body weight, sex and fitness level
• An older person exercising at the vigorous intensity of 6METS
may be exercising at their maximum intensity, while a young
person working at the same absolute intensity may be exercising
moderately
Relative intensity:
It is the level of effort required to perform an activity
• Determined in relation to an individual's level of cardio-
respiratory fitness (VO2 max)
• Or as a percentage of a persons measured or estimated heart
rate (HR) (%max HR)

16. Definitions cont.
Sedentary Behavior:
Implies activities performed at an intensity of 1-1.5 METs
• Sitting, reclining/ lying, watching television
Light Intensity PA:
Implies activities performed at an intensity of 1.6-2.9 METs
• Slow-walking, cooking, light housework
Moderate Intensity PA:
Implies activities performed at an intensity of 3-5.9 METs
• Brisk-walking (2.4-4 mph), biking (5-9 mph), ballroom dancing, active
yoga, recreational swimming
Vigorous Intensity PA:
Implies activities performed at an intensity of ≥ 6 METs
• Jogging, biking (≥ 10 mph), single tennis, active yoga, swimming

17. Aerobic Physical Activity:
•Activity in which the body’s large
muscles move in a rhythmic
manner for a sustained period of
time
•Also called endurance activity
•Improves cardiorespiratory
fitness
•Examples include walking,
running, swimming, and bicycling
Anaerobic Physical Activity:
•Anaerobic physical activity
consists of brief intense bursts of
exercise where oxygen demand
surpasses oxygen supply
•Such as weightlifting and sprints
https://doi.org/10.1093/eurheartj/ehaa605

18. Definitions cont.
Dynamic exercise (isotonic):
There is movement of the limbs
• Dynamic aerobic exercise
cause volume load on heart
• Increases heart rate
• Arm circle, arm swings, high
stepping, heel to toe walk
• Further classified as
1. Concentric exercise
2. Eccentric exercise
Static exercise (isometric):
Not principally associated with
movement of the limbs
• Causes pressure overload
• Increases blood pressure
• Examples:
Hamstring stretch
Low squat
Biceps Stretch
Static lunges

19. Definitions cont.
Concentric Exercise:
Associated with shortening of muscle fiber
Eccentric Exercise:
Associated with lengthening of muscle fiber

20. Definitions cont.
Maximum HR (max HR) = (220-age) bpm
Maximal oxygen consumption (VO2 max):
The maximum amount of oxygen that an individual can utilize
during intense or maximal exercise
• Generally considered the best indicator of cardiovascular fitness
and aerobic endurance

22. https://www.escardio.org/Councils/Council-for-Cardiology-Practice-(CCP)/Cardiopractice/physical-activity-for-cardiovascular-prevention

23. Patient with
Cardiovascular Disease
Low risk CVD patients
• No exercise restrictions
High risk CVD patients
Additional:
• Echocardiography
• Exercise stress test
• Advance imaging
High risk/ positive result
• Individualized exercise plan
Low risk/ negative result
• No exercise restrictions
Evaluate
• Clinical history • Physical examination • ECG
https://www.escardio.org/Councils/Council-for-Cardiology-Practice-(CCP)/Cardiopractice/physical-activity-for-cardiovascular-prevention

24. History
•Current and prior cardiovascular medical and surgical diagnoses
and procedures (including assessment of LV EF)
•Comorbidities (including peripheral arterial disease,
cerebrovascular disease, pulmonary disease, kidney disease,
diabetes mellitus, musculoskeletal and neuromuscular disorders,
depression, and other pertinent diseases)
•Symptoms of cardiovascular disease
•Medications (including dose, frequency, and compliance)
•Date of most recent influenza vaccination
•Cardiovascular risk profile
•Educational barriers and preferences

25. Physical Examination
•Cardiopulmonary systems
- Pulse rate and regularity
- Blood pressure
- Auscultation of heart and lungs
•Inspection and palpation of lower extremities
- Edema
- Arterial pulses
•Post-cardiovascular procedure wound sites
•Orthopedic and neuromuscular status
•Cognitive function

26. Phase I (Acute
Phase)
In-Hospital monitoring
period
Phase II (Subacute)
Post-Discharge Outpatient
Pre-Exercise Conditioning
period
Phase III
(Training Phase)
Exercise & Education
Programme
Phase IV
(Maintenance)
Prevention programme
Cardiac
Rehabilitation

27. Phase I (Acute Phase)
•Early mobilization
•Counteract immobilization
•Teaching activities of daily living
•Start patient education
• Starts after 24 hours
Or
• Whenever patient is safe & stable for 24 hours
Strength training
±
• ADLs
• Seated arm & leg
exercises
Cardiac training
• Low
• 2-3 METs
Discharge
• 5 METs

28. Phase I (Acute Phase) cont.
Post MI
• Limited to 70% max HR (5 METs) for 6 weeks
Sternal precautions
• 8 - 10 weeks
Discharge
• 5 METs

29. Phase II (Subacute Phase)
•Increase capacity & endurance
•Progress to full ADLs
•Ensure exercise programme continuity & accountability
•Assess response to increasing workloads
•Self-monitoring
•Lifestyle changes

30. Phase II (Subacute Phase) cont.
Strength training
• General: after 3 weeks
• Post MI: after 5 weeks
• Post-CABG: after 8 weeks
• Start light (bands or 1-3 lb weights)
• Progress to moderate loads (12-15 lbs)
Cardiac training
• Initially 40-50% max HR
• Progressively increase target HR 10bpm each week
Discharge
• 9 METs

31. Phase II (Subacute Phase) cont.
Post MI
• Limited to 70% max HR (5 METs) for 6 weeks
Sternal precautions
• 8 - 10 weeks
Always requires warm up and cool down

32. Phase III (Training Phase)
•Continued conditioning
•Long term reduction in
risk factors
•Ongoing education
Strength training
• Moderate intensity & loads
Cardiac training
• 70-85% max HR
• 3-4 times/ week
• Depends on intensity & duration
-20 to 30 min moderate intensity
-40 to 60 min low intensity
Discharge
• 9 METs

33. ESC 2020 Guideline
Recommendations

34. Potential Risks for Elderly during Exercise
• Arrhythmias
• Increased blood pressure
• Myocardial ischaemia
• Musculoskeletal injuries and fracture
• Muscle soreness
• Swollen joints
• Increased risk of falls and subsequent injuries

35. Type & Intensity of
Exercise for Older People

36. Clinical Evaluation for
Patients with Established CAD
nical evaluation & recommendations for sport
on in individuals with established coronary art

37. High-risk Features for Exercise-induced Adverse
Cardiac Events in Patients with Atherosclerotic CAD

38. Return to Exercise after ACS

39. Exercise in CCS

40. Exercise in CCS cont.

41. Optimal Exercise Training for
Patients with Chronic HF

42. Exercise in HFrEF/ HFmrEF

43. Exercise in HFrEF/ HFmrEF cont.

44. Sports in Heart Failure

45. Sports in Heart Failure cont.

46. Special Situations

47. Myocarditis

48. Myocarditis cont.

49. Pericarditis

50. Atrial Fibrillation

51. Atrial Fibrillation cont.

52. Atrial Fibrillation cont.

53. Pregnancy

54. Pregnancy cont.

55. Pregnancy cont.

56. Chronic Kidney Disease (CKD):
Contraindications of Exercise
•Temporary contraindications for sports participation

57. CKD cont.

58. CKD cont.

59. Counselling Tools
1.Do you understand the benefits of physical activity
for your health and well being?
2.How would you classify your current lifestyle?
3.How many minutes per week do you want to
participate in PA?
4.Are you afraid to participate in PA? Or is your
partner afraid for you?
5.Do you see any obstacles regarding performing PA?
6.Do you need any help regarding PA from the health
care system or from your physician?

60. Physical Activity
Evaluation
Assess current physical activity level (eg, questionnaire,
pedometer) and determine domestic, occupational, and
recreational needs
Evaluate activities relevant to age, gender, and daily life, such as
driving, sexual activity, sports, gardening, and household tasks
Assess readiness to change behavior, self-confidence, barriers to
increased physical activity, and social support in making positive
changes

61. Physical Activity cont.
Interventions
• Provide advice, support, and counseling about PA needs
• Target exercise program to meet individual needs
• Provide educational materials
• Consider exercise tolerance/ simulated work testing for patients with heavy labor jobs
• Encourage 30-60 min/day of moderate-intensity PA on ≥5 (preferably most) days of week
• Explore daily schedules to suggest how to incorporate increased activity into usual routine
(eg, parking farther away from entrances, walking ≥2 flights of stairs, walking during
lunch break)
• Advise low-impact aerobic activity to minimize risk of musculoskeletal injury
• Recommend gradual increases in the volume of physical activity over time
• Caution to avoid unaccustomed vigorous physical activity (eg, racquet sports and manual
labor)
• Reassess the patient's ability to perform such activities

62. Exercise Training
Evaluation
• Symptom-limited exercise testing prior to participation in an
exercise-based CR program is strongly recommended
• Evaluation may be repeated as changes in clinical condition
warrant
• Test parameters should include assessment of heart rate and
rhythm, signs, symptoms, ST-segment changes,
hemodynamics, perceived exertion, and exercise capacity.
• Risk-stratification of the patient to determine the level of
supervision and monitoring required during exercise training

63. Exercise Training cont.
Interventions
• Develop individualized exercise prescription for aerobic and
resistance training based on evaluation findings, risk
stratification, comorbidities (eg, peripheral arterial disease and
musculoskeletal conditions), and patient and program goals
• Exercise prescription should specify frequency (F), intensity (I),
duration (D), modalities (M), and progression (P)
• Include warm-up, cool-down, and flexibility exercises in each
exercise session

64. Exercise Training cont.
Interventions cont.
Aerobic exercise:
• F= 3-5 days/wk
• I = 50-80% of exercise capacity
• D= 20-60 min
• M= walking, treadmill, cycling, rowing, stair climbing, arm/leg ergometry,
and others using continuous or interval training as appropriate
Resistance exercise:
• F= 2-3 days/wk
• I = 10-15 repetitions/ set to moderate fatigue
• D= 1-3 sets of 8-10 different upper and lower body exercises
• M= calisthenics, elastic bands, cuff/hand weights, dumbbells, free
weights, wall pulleys, or weight machines

65. Excellent Online Resource
for Exercise
Please check out the NHS Fitness Studio’s videos on different
exercises:
•https://www.nhs.uk/conditions/nhs-fitness-studio/

66. Any activity is better
than no activity...
As long as you think
of safety first!