Exercise Prescription for
Cardiac Rehabilitation
Azran Ahmad
Exercise Physiologist
Your Heart…Our Passion
Objectives
• To understand the process of assessment & exs
prescription pts for CRP
• To define risk of progression & stratification
• To understand the exs prescription process for
CRP
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Fancy to do this?
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Are they at risk?
Can you prescribe them an exercise ?
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Assessment & Risk Stratification
• Clinical examination :
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The site & size infarct & operation details
Current cardiac status
Any complications
Current medication
Progress since D/C
Current exs level – including the recent results
Any symptoms, ex: chest pain, s.o.b, dizziness
GTN
Relevant past medical history
Risk factor for CHD
Weight/ BMI
Psychological status/ mood
Orthopedic limitations
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Risk Stratification
Process of assessing the risk of pts having a
further event.
The main risk factors is :
•Extensive cardiac damage
•Residual ischaemia
•Ventricular arrhythmias on exs
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Risk Stratification
1. History of :
- more than one previous infarct
- an anterior rather than inferior infarct
- ↑ cardiac enzyme levels @ the time of infarct
- complications ie: LV failure/ CS
2. Symptoms severe exertional breathlessness &
orthopnea.
3. Finding of large heart/ Pulmonary venous congestion & ↓
EF.
4. A low capacity on the ex. Test with significant ECG
changes/ poor HR/BP response.
5. Current angina
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Risk Stratification
sample
sample
Note: Pts with extensive cardiac damage &
associated cardiological complications may not be
able to join the formal exercise session& may be
limited to a significantly modified home exs till their
recovery has been stabilized & complete
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Risk Stratification Criteria for Cardiac Patients
(AACVPR)
Low Risk
Moderate Risk
High Risk
Uncomplicated MI.CABG,
angioplasty
FC less than 5-6 Mets 3 or more
wks after event
Severely depressed LVF
(≤30%).
Complex ventricular arrhythmias
@ rest/ appearing/ increasing
with exs.
FC equal or greater than 6METs
3 or more wks after event
Mild – moderately depressed
LVF (EF 31to 49%)
↓ SBP of › 15mmHg during exs
or failure to rise consistent with
exs workloads
No resting/ exs induced
myocardial ischaemia
manifested as angina & or ST
seg displacement
Failure to comply with Exercise
Prescription
MI complicated by CHF,
cardiogenic shock & or complex
ventricular arrhythmias
No resting/ exs induced
complex arrhythmias
Exercise induced ST-seg
depression of 1-2mm/ reversible
ischaemic defects (echo/ nuc
radio)
Pt with severe CAD & marked
(›2mm) exs induced STsegment depression
No significant LV dysfunction
(EF = / ↑ than 50%)
Survivor of cardiac arrest
AACVPR, 2005
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Exercise Test
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Risk Assessment Form
sample
sample
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ECG Stress Test
Objective:
- Assess the pt response to
exercise
- Enable risk risk stratification for
future events
- Determine medical & rehab mgmt
Info from the result:
- Duration & rate of work achieved
- HR & BP response via exercise
- HR, BP & exercise level @ peak/
changes
- Medication during test
- RPE (rate perceive exertion)
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6 Minutes Walk Test (FC)
• Strongest indication
measuring the response
to medical interventions
in patients with moderate
to severe heart or lung
disease
• Used as a one-time
measure of functional
status of patients, as well
as predictor of morbidity
and mortality
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2D ECHO
• stress echo sign of
viability is a stress
induced improvement of
function in a region that is
abnormal at rest
• Stress echocardiography
can detect CAD with an
accuracy that is similar to
that of stress myocardial
perfusion imaging and
superior to exercise ECG
alone
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Exercise Monitoring
Standard monitoring
Additional Monitoring Techniques
1. RPE (Borg Scale)
1. BP
2. Talk Test
2. HR
3. Self Monitoring
3. Telemetry ECG
4. Symptoms
4. METs
5. General Observation
5. Pulse Oxymeter
BACR,2005
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Heart Rate
Karvonen Formula
THR = ((HRmax − HRrest) × % intensity) + HRrest
Example for someone with a HRmax of 180 and a HRrest of 70:
50% Intensity: ((180 − 70) × 0.50) + 70 = 125 bpm
85% Intensity: ((180 − 70) × 0.85) + 70 = 163 bpm
Predicted maximal HR
e.g. if patient is 40 years of age and is required to work at 60% - 75% of MHR
220 – Age =
220 – 40 = 180 (MHR)
180 x 60% = 108
180 x 75% = 135
Therefore the THR is (108 -135)
Note: Remember that Beta Blockers reduces the heart rate @ rest & during exercise. Please take off 20- 30 BPM
(Adapted from ACSM/ AACVPR)
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Borg Scale
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RPE is well established tool for approximations
of max FC (VO2max)
Only can be use for those who can reliably use
RPE
Useful in changes of medication
when cannot assess HR accurately (AF)
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Gunnar Borg, 1998
Borg RPE Scale
Vo2
Max
RPE Chart
11-14 Frequently used for
moderate exercise
SING
30%
TALK
49%
50-74%
GASP
12 - 16
75%
84%
> 85%
12 -16 are consistent with
improvements in exs tolerance.
Corresponding to exs @ 75% 84% Vo2 Max
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Gunnar Borg, 1998
Metabolic Equivalent (METs)
energy cost
Activity
METs (min)
METs (Max)
Skipping 120-140 min
‹ 80/min
11
8
11
9
Cycling 13mph
10mph
5 mph
8
5
2
9
6
3
Swimming (freestyle)
(breast st)
9
8
10
9
Dancing (aerobic)
(ballroom)
6
4
9
5
Tennis
4
9
5
3.5
3
2
1
6
4
3.5
3
2
Walking 4 mph
3.5 mph
3 mph
2 mph
1 mph
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BACR, 2005
Exercise
Programme
Exercise programme for CRP
Planned
Structured
Goals/ aims
• Periodization
• Fun & enjoyable
• Suit pts needs
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i.e 4-12 weeks
Posed by a leader
Has a clear purposed & objective
Well facilitated
• Create exs habits
• Achieved an improvement in exs capacity
• Return pts to their pre morbid activity level
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Exercise Program Card
SAMPLE 1
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SAMPLE 2
Exercise Program Card
Patients Name
HOSPITAL ABC
Contact no.
Vital Signs
Diagnosis
Medications
Pre- Ass Body
Composition
HR pre & post
Comments
Program review &
staff in charge
signature
Reason for non
completion
Post- Ass Body
Composition
Completing METs/
6MWT Distance/
Shuttle Walk Test
Staff Name, signature,
stamp & date
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FITT Principles
F
FREQUENCY
2 – 3 WEEKLY
(2 REHABILITATION CLASSES & 1 HOME CURCUIT)
OTHER DAYS WALK/ LEISURE ACTIVITIES
I
INTENSITY
60% - 75% OF MAXIMAL HEART RATE
12 – 13 RPE (BORG SCALE)
40% - 60 % OF VO2 PEAK OR HRR
T
TIME / DURATION
20 – 30 MINUTES CONDITIONING PERIOD
(not inclusive of w/up or cool down)
T
TYPE/ MODE
AEROBIC, ENDURANCE TRAINING
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AACPVR 2005
Exercise Recommendation
(ACSM & AACPVR Guidelines)
Modes
Aerobics
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Large muscle activities
(arm/leg ergometry)
Goals
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Increase aerobic
capacity
Decreased BP & HR
response to sub max
exercise
Intensity
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Strength
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Circuit training
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Increase ability to
perform leisure,
occupational & daily
living activities
Increased muscular
strength
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Flexibility
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Upper & lower body
ROM
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Decreased risk of injury
Improved ROM in post
sternotomy
Time to Goal
Borg RPE 12- 14
40-85 VO2max/ HRR
Intensity to be kept
below ischaemic
threshold
3-7 days a week
20-60 mins continuous
exs
5-10 mins warm
up/down
• 4-6 months
40-50% maximal
voluntary contraction
(avoid vasalva)
2-3 days/ week
1-3 sets, 10-15
repetitions
Resistance should be
gradually increased
over time (1-2 lbs)
• 4-6 months
2-3 days/ week
• 4-6 months
Note: more attention should be paid to upper extremity of ROM & pts can resume normal activities (light – mod) 24-48 hrs after
PTCA
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Other consideration/ minimum
standard to run CR
• Exs session must be led
& supervised by qualified
staff
• Staff - pts ratio, depend
upon the composition of
the group (1 vs 5)
• Room size
• Temperature & humidity
• Induction/ programme
orientation
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Exercise Programme
Pts should not take part if they present with:
• Fever & acute systemic illness
• Unresolved unstable angina
• Resting BP systolic > 200mmHg, diastolic >
110mmHg
• Significant unexplained drop in BP
• New/ recurrent symptoms of SOB, palpitations,
dizziness or lethargy
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Prescription Considerations
1.
2.
3.
4.
Component of fitness
Warm- up / cooling down
Stretching
Mode of activity/ Method of training
(continuous, cumulative or interval)
5. Functional capacity
6. CV conditioning
7. Muscular conditioning
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Circuit Training for Group Exercise CRP
Resistive
Exercise
Tubing
Recumbent
Bicycle
Squat with
Gym Ball
Rowing
Machine
Warm-up/ Cool
Down &
Stretching
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Dumbbell
Exercise
Step Board
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Group Exercise vs One 2 One
Group Exercise
One to One
Advantages:
• Standardized & comprehensive
screening & risk stratification
• Individualization of prescription
• Social support from one to another
• Special variation in format
Advantages:
• Allows complete individualization of
screening & exercise prescription
• Enables flexibility of choices as to
training modes/ venues/ times
Disadvantages:
• May perpetuate the ‘sick people’
image
• Restricts availability & choice of
classes
• Male predominance may
discourage participation by women
Disadvantages:
• Less effective in terms of fostering
independence
• Lack of social support
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Termination Criteria from
Exercise
• Any angina symptoms
or feeling too
breathless to continue
• Feeling dizzy or faint
• Leg pain limiting
further exercise
• Exceeds level of
perceived exertion >
15 (Borg Scale)
• Increased Heart Rate
> 85% as of THR.
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Contraindication for Exercise
• Unstable or unresolved
angina.
• Fever and acute systemic
illness.
• Patient in severe pain.
• Resting blood pressure: SBP>
180mmHg, DBP> 100mmHg
• Significantly unexplained drop
in blood pressure.
• Tachycardia > 100bpm.
• New or recurrent symptoms of
breathlessness, palpitation,
dizziness.
• Significant lethargy.
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10 Rules for Exercise Patients
1. Choose a form of exs that suits pts
2. Always build up gradually
3. If pts have a break for whatever reason, build up
gradually again
4. Always warm up & cool down
5. Do not allow pts to exs if they are ill
6. Stop exs if pts c/o of pain/ feel dizzy/ uncomfortable/
palpitation/ irregular
7. Pts should be able to talk & exs @ the same time
8. Do not exs pts immediately after a meal
9. Make sure pts wear suitable clothing & good footwear
10. If in doubt consult a health professional
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General Considerations
• Content must be simple &
adaptable
• Adopt educational
approach
• Monitor type A behavior
• Ensure that goals are
agreed upon rather than
imposed & readily
achievable
• Exercise prescription
must reflect individual
differences,pts will differ
greatly in most other
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respects
Thank You
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References
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ACSM`s Recourse Manual (2001). Guideline for Exercise Testing and Prescription. (4TH ED)
Lippincott Williams & Williams : London
ACSM`s Exercise Management for Persons with Chronic Disease and Disabilities. (1997) Human
Kinetics: Leeds
Braith, R. W. (1998) Exercise training in Patient with CHF and heart transplant recipients.
Medicine and Science in Sports and Exercise,30. S367-S378
Cerny, F.J & Burton, H.W (2001). Exercise physiology for Health Care Professional, Human
Kinetics : London
Frownfelter, D. & Dean, E. Cardiovascular and Pulmonary Physical Therapy Evidence and
Practice. 4th edn. Missouri: Mosby Elsevier
Fardy, P.S, Frankin , B.A ,Porcari, J.P, & Vernil,D.E (1998). Training Techniques in Cardiac
Rehabilitation Human Kinetics : Leeds
Squires, R.W (1998) : Exercise Prescription for the High – Risk Cardiac Patient
American College of Sport Medicine (ACSM) (1991) Guidelines for Exercise testing and
Prescription (4th edn), Philadelphia; Lea and Febiger
American College of Sport Medicine (ACSM) (1995) guidelines for Exercise testing and
Prescription (5th edn) , Baltimore : Williams and Wilkins
American College of Sport (ACSM) (1994) ` Position stand Exercise for Patient with Coronary
Artery Disease` Medicine in Science & Sport Exercise,26:4, pp-I-V
British Heart Foundation (1998) British Heart Foundation CHD Statistics British Heart Foundation
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References
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British Heart Foundation (2002) British Heart Foundation CHD Statistics
British Heart Foundation
Campble, N.C , Grimshaw, J.M , Ritchie, L.D and Rawles ,JN ( 1996)
`Outpatient` Cardiac Rehabilitation ; are the potential benefits being
realised?’ Journal of the Royale College of Physicians,30, pp.514-19
Ewart , C.K , Taylor , C.B, Reese, L.B and de busk , R.F (1983) ` Effects of
Early post-myocardial infraction exercise testing on self-perception and
subsequent Physical Activity’ American journal Cardiology ,51, pp.1076-80
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