CARDIAC
REHABILITATION
Exercise capacity
• calculated by the following equations:
• (i) Men:
Predicted METs = 14.7 − 0.11 × age
• (ii) Women:
• Classify
Predicted METs = 14.7 – 0.13 × age
functional capacity below normal if lower than
85% of the predicted value
Functional Classification of Heart Disease
Functional Classification, Exercise Tolerance, Description Approximate
 I (6 –10 METs) Patient without any resulting limitations of physical
activity; ordinary physical activity does not cause undue fatigue,
palpitations, dyspnea, or anginal pain.
 II (4–6 METs) Slight limitations of physical activity; comfortable at rest,
but ordinary physical activity results in fatigue, palpitations, dyspnea, or
anginal pain
 III (2–3 METs) Marked limitation of physical activity; comfortable at
rest, but less than ordinary physical activity causes symptoms, as above.
 IV (<2 METs) Unable to carry out any physical activity without
discomfort; symptoms of cardiac insufficiency or of angina may be
present even at rest.
COMPONENTS OF AN EXERCISE TRAINING SESSION
• To maximize safety and effectiveness, the format of each exercise
session should include
1.
Warm-up
2.
conditioning
3.
Cool-down
• A comprehensive exercise program includes both aerobic and
resistance training, flexibility exercises, and guidance about
recreational activities.
Warm-Up
•
period of 5 to 10 minutes
•
low-intensity large muscle activity, such as low-intensity callisthenic-type exercise
or aerobic activity and gentle stretching,
1.
facilitates the transition from rest to exercise, increasing heart rate (HR),
2.
augmenting blood flow, increasing oxygen uptake,
3.
reduce the risk of musculoskeletal injury by increasing connective tissue
distensibility,
4.
improving joint range of motion and function, and
5.
•
enhancing muscular performance.
patients with heart disease may exhibit delayed adaptive circulatory responses to the
onset of exercise, and thus may require longer warm-up periods.
Conditioning
• The conditioning phase includes endurance, resistance, and
flexibility exercises, parts of which may be performed on
different days.
Classification of Activities
Activities
are classified as light, moderate, or heavy according to the
energy expended or the oxygen consumed while accomplishing them.
Light
work for the average male (65 kg) requires 2.0 to 4.9 kcal/min, or
6.1 to 15.2 mL O2/kg per minute, or 1.6 to 3.9 METs.
Strolling
1.6 km/hr, or 1.0 mph, is considered light work.
Heavy
work for the average male (65 kg) requires 7.5 to 9.9 kcal/min, or
23.0 to 30.6 mL O2/kg per minute, or 6.0 to 7.9 METs.

Jogging 8.0 km/hr, or 5.0 mph, requires 25 to 28 mL O2/kg per minute
and is considered heavy work.
Methods of Aerobic Exercise
• There are four methods of training that challenge the aerobic
system:
1)
Continuous.
2)
Interval (work relief).
3)
Circuit.
4)
Circuit interval.
Cooldown
•
period of 5 to 10 minutes provides for
1.
gradual physiological recovery after aerobic exercise, which
2.
allows HR and BP to return to near-resting values,
3.
maintains adequate venous return, f
4.
acilitates the dissipation of body heat and removal of lactic acid, and
5.
attenuates the post-exercise rise in plasma catecholamines (which may induce
ventricular arrhythmias).
•
Cooldown is critical for exercise safety for both healthy individuals and those
with disease, as it reduces the risk of postexercise hypotension and myocardial
ischemia.
•
Low-intensity exercise (e.g., slow walking or cycling) and stretching are typical
modes of cooldown exercise.
VO2 max
• Units
• liters/minute
or ml/minute (absolute)
• ml/kg/min (relative to body weight)
• ml/kg of FFM/min (relative to FFM)
• Range
15 (sedentary with disease) to 75 (young
endurance runner) ml/kg/min
• Women
about 10-20% lower than men
Methods of Determining VO2 max
•Submaximally
•Maximally
•Graded Exercise Testing - GXT
(incremental increases in workload)
General Guidelines
• Measure
the subject’s HR and BP and RPE at regular intervals
(near the end of each stage [HR, BP, RPE] or every minute [HR])
• If HR does not reach steady state during the stage extend stage 1
minute
• All testing begins with a 2-3 min warm-up
• Cool- down at a low intensity for at least 4 minutes - continue
measuring HR, BP and RPE
• increase intensity in 0.5 -2 MET increments
• closely observe subject for contraindications
Submaximal Protocols
• Oxygen consumption for
any given Work Load does not
vary between subjects
• The
slope of the line is about the same for any two given
subjects
• The
rate of increase in O2 consumption with increasing
Work Load does not vary between subjects
Bruce Treadmill Protocol
Stage 1
• Increase grade to 10%
• 3 minutes long
• Measure HR at end of each minute and BP at end of
each stage
Bruce Treadmill Protocol
• The
objective is to reach a steady state HR between 115 and 155
bpm (usually occurs during the first 6 minutes of exercise or by the
end of the 2nd stage)
• Once
subject reaches proper HR terminate the test at the end of that
stage
• Reduce
treadmill speed to 1.7mph and 5% grade and cool-down for
4 minutes.
• VO2
is estimated from the last minute of a fully completed stage
Treadmill Protocol
Calculate VO2 from the gender specific equations
• Males
VO2=SMVO2 [(HRmax-61)/(HRSM-61)]
• Females
VO2=SMVO2[(HRmax-72)/(HRSM-72)]
SMVO2 = submaximal VO2 from table or ACSM equations
HRSM = submax HR from test
Modified Bruce Protocol
• Start
at 1.7 mph, 0% grade or at 1.7 mph and 5% grade
(used on diseased and elderly populations)
Treadmill Protocol
• Protocols
• Test
should be individualized
time should ideally be 8-12min
• Increments
of 10-15 W/min or 1-3%/min grade can be
used for the elderly
Advantages of Submaximal Testing
1. Safer
6.
2. Controlled pace
(motivation not a factor)
7. Can do mass testing
3. Not population specific (no
pacing advantage)
4. Quick assessment
5. Cost effective
Don’t need highly trained
personnel
8. No physician supervision
required (if symptom and
disease free)
Disadvantages of Submaximal Testing
1. VO2 max is error rate of (10-20%)
2. Don’t get a measure of true maximal HR
• estimates
of max HR using 220-age can vary by +15
bpm for individuals not directly measured (of the same
age).
Advantages and Disadvantages
of a Maximal Test
Advantages
1. More accurate
Disadvantages
1. Motivation is a factor
2. More risk involved
3. Time
4. Cost of equipment (if using metabolic cart)