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Exercise and heart disease: Typical prescription
This is an excerpt from Fitness Professional's Handbook 7th Edition With HKPropel Access by Edward Howley & Dixie Thompson.
Fitness professionals who work in health clubs and other fitness settings often encounter clients who have gone through a cardiac rehabilitation program. Thus, it is important to have an understanding and appreciation of what these clients have experienced during their recovery process. In addition, many individuals with a master's degree in exercise physiology can, with the proper training, find jobs in cardiac rehabilitation. As part of a team of medical professionals that includes physicians, nurses, dietitians, physical therapists, and clinical psychologists, the fitness professional can play an important role in helping patients to resume a healthy life after a heart event (28). A fitness professional working in cardiac rehabilitation must be vigilant about monitoring the signs and symptoms of heart disease. This involves knowing how to read an ECG, take BP readings, and administer the angina rating scale (refer back to table 19.1). Fitness professionals should be trained in emergency procedures and preferably should achieve certification in ACLS.
The details of how to design and implement cardiac rehabilitation programs, from the first steps taken after patients are confined to bed to the time that they return to work and beyond, are provided in the AACVPR guidelines (2). This section briefly introduces these programs.
Cardiac rehabilitation programs are organized in progressive phases of programming to meet the needs of clients and their families. Phase I (the acute phase) begins when a patient arrives in the hospital step-down unit after leaving the intensive or coronary care unit (18). Within 1 to 3 days of the MI or revascularization procedure, the patient has already been taught the risk factors for atherosclerotic disease and has begun the rehabilitation process. Patients are exposed to orthostatic or gravitation stress by intermittently sitting and standing. Later, bedside activities and slow ambulation (i.e., walking) in the hallways are recommended (2).
Phases II and III refer to outpatient exercise programs conducted in a hospital environment. Rhythmic activities using large muscle groups are recommended for physical conditioning; these activities include treadmill exercise, cycle ergometry, combined arm and leg exercise, rowing, and stair-climbing. Light to moderate resistance training is accomplished with free weights (dumbbells) and elastic tubing. Special care must be taken when prescribing upper-body exercises to clients who have undergone CABG procedures because of limitations related to the chest incision. See chapter 13 for more details on resistance training in cardiac populations.
Recommendations for aerobic exercise programming in outpatient cardiac rehabilitation (phases II and III) are as follows, with patients progressing on an individual basis (4, 12-14):
- Frequency: 3 to 5 days per wk
- Intensity: moderate intensity equivalent to 40% to 80% of
O2max or HRR; or RPE 12-16 (on a 20-point scale) - Duration: 20 to 60 min per day of continuous or accumulated exercise; if patient is unable to exercise continuously for 30 min, use intermittent exercise bouts of 10 min, interspersed with rest or light intensity
- Type: prolonged, rhythmic, dynamic exercises using large muscle groups (e.g., treadmill, cycle ergometer, rower, elliptical, stair climber, arm ergometer, or combined arm-and-leg ergometer)
- 5 to 10 min of warm-up and cool-down exercises
Fitness professionals who work in cardiac rehabilitation must have knowledge of cardiovascular medications (for a description of these, see chapter 24). Patients who are on beta-blockers require special consideration, because the Karvonen formula for computing THR range is invalid if the client was not on beta-blockers at the time of testing. For these patients, a THR is sometimes computed by adding 20 to 30 beats · min-1 to the client's standing, resting HR. However, in view of the wide differences in physiological responses to beta-blockade, another approach is to use RPE ratings around somewhat hard, which correspond to 11 to 14 on the original Borg RPE scale (2).
In phase II, clients are monitored carefully for vital signs (HR, BP, ventilation), and the ECG is monitored at a central observation station via telemetry (radio signals). A single-channel recording of 6 to 10 patients can be monitored simultaneously on a computer screen, and in the event of arrhythmias or ST segment changes, a rhythm strip is printed out. The rate - pressure product (SBP ∙ HR) is sometimes used as an indicator of myocardial oxygen demand. After training, the rate - pressure product at a fixed work rate is reduced, allowing the cardiac patient to exercise at higher work rates before the onset of angina (28). In addition to exercise classes, patient education classes are offered, and they cover topics such as healthy eating, stress management, cardiovascular medications, and principles of behavior modification. Phase II programs typically last about 12 wk and are covered by health insurance.
Phase III programs are hospital-based programs in which outpatients are encouraged to continue their exercise regimens and are provided access to continuing health care and patient education. In these cases, the client's ECG usually is not monitored by telemetry, but clients continue to follow an individualized exercise prescription and attend patient education classes. Eventually, clients may enter the maintenance phase and move to a phase IV program in a nonhospital setting (e.g., sports medicine clinic).
For heart patients who are unable to attend a traditional cardiac rehabilitation outpatient program due to geography or finances, there are other options. Many hospitals offer rehabilitation programs following a distance-education model and can even monitor a client's ECG over the Internet. In addition, a group called Mended Hearts (http://mendedhearts.org) offers support-group meetings and online resources to help clients with heart disease and their families deal with the physical and emotional effects of heart disease.
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