Cardiac Rehabilitation for exercise professionals part 2

Cardiac Rehabilitation for exercise professionals part 2

When and how to start exercise for a new client in cardiac rehab

Hi, I’m Steve Selig, founder of fit.test in Part 2 of this series on cardiac rehabilitation for exercise professionals, I’m going to present some of the information on when to start exercise after an acute cardiovascular event (e.g. “heart attack” or cardiac arrest) or an intervention (e.g. bypass surgery, valve surgery, a stent or implantable device). In other words, what to do at the entry of a cardiac rehabilitation program. I will talk about aerobic training, resistance training and stretching. And finally I’ll discuss a case study that is relevant to this topic. 

Cardiac Rehab for different client types

Open chest surgery

  • Aerobic: in general, you can introduce gentle aerobic exercise early at about Week 2
  • Stretching and range of movement:
    • with some provisos, especially around range of movement, can generally be introduced at around week 4
    • Unloaded doorway stretches are often safe and easier to control the range of movement and are a good place to start
    • passive PEC stretches can be introduced at about weeks 6 – 12
  • Resistance exercise: 
    • lower limb exercises can be introduced soon after surgery
    • upper limb exercises above the shoulder can be commenced a little later at about week six 
  • Obviously use gradual progressions for all of these through the rehab program. 
  • Following open chest surgery (e.g. bypass, some valve surgeries), it is essential that sternal stability be protected at all times: this healing takes 4 – 6 weeks:
    • You MUST monitor sternal stability or sternal pain and adjust the plan to stay SAFE
    • STOP and MODIFY if your client is feeling that an unusual or overstretching, chest pain / discomfort / pressure and any other adverse signs or symptoms
  • Remember that the client will be probably severely deconditioned after surgery, including periods of bed rest and recovery from the surgery, and the patient may be elderly as well
    • Follow any guidelines provided by the interventionalist, cardiologist or cardiac surgeon  
    • Understand and make allowances for any co-morbidities
    • Monitor, record and if necessary report on any adverse signs or symptoms
    • Avoid Valsalva effect, such as breath holding or forcing breath out under closed mouth or nose, as these can engender arrhythmias which make exercise potentially unsafe. Ask your clients to count out loud for sets of resistance exercise or stretching; avoid isometric exercise for two or three months; after that isometric exercise can be quite effective in helping to regain strength

Percutaneous procedures (e.g. angiograms, stents, percutaneous valve implantations, interventions for arrhythmias, especially ablations)

  • Aerobic: in general, you can introduce gentle aerobic exercise early at about Week 2
  • Resistance exercise: can start a bit later and again, gradual progressions for both
  • Follow the other general advice above

Implantable devices: (e.g. permanent pacemakers PPM, automated implantable cardioverter defibrillators AICD)

  • Aerobic: in general, you can introduce gentle aerobic exercise early at about Week 2
  • Above shoulder exercise can commence from weeks 4 – 6, but follow any guidelines provided by the interventionalist, cardiologist or cardiac surgeon:
    • One objective of the guidelines is to prevent lead displacement and allow the lead to fully grow into where it was implanted
    • Comply with upper limits of heart rates for both pacing and defibrillation settings: stay at least 10 bpm under the thresholds for both

Ongoing stable angina

  • Follow the other general advice above
  • Monitor and adjust your program for any onset of chest pain
  • Stay safely under any symptom thresholds such as chest pain
  • If unexpected chest pain arises, then
    • STOP exercise and continuously monitor the client
    • support the client to self-administer short acting anti-anginal medication if they have been prescribed this: NOTE: clients who have been prescribed a  short acting anti-anginal medication (usually a spray for under the tongue) MUST bring the medication to all exercise sessions; failure to this should result in the exercise professional denying the service to the client
    • report any adverse signs or symptoms, whether or not they are associated with exercise, to the client’s primary care medical practitioner
  • Medications for stable angina:
    • Short acting and long acting anti-anginals (especially nitrates) provide a safety net for exercise, but exercise professionals still need to be vigilant with respect to adverse signs or symptoms
    • Anti-anginal medications:
      • Nitrates (anginine) = nitroglycerin or glyceryl trinitrate (rapid onset and short duration of action)
      • Isosorbide mononitrate = preventive long acting anti-anginals such as Imdur
      • and Monodur (slow onset and long duration of action = 24/7 protection)
    • Other drug classes that are anti-anginal include
      • Beta blockers
      • Ca++ channel blockers
      • “funny channel” blockers (e.g. Ivabradine)
      • Nicorandil (Ikorel; potassium channel opener = arterial relaxant)

Case Study

The client has longstanding T1DM, hypercholesterolemia and diffuse coronary artery disease. In 2019, two of the focal lesions were stented. However, the client is having ongoing angina pain, including at night that impairs her sleep quality, and this is due to the remaining diffuse disease. 

She was being managed conservatively because diffuse disease cannot be stented. She was prescribed a number of anti-diabetic, anti-hyperlipidemia and anti-anginal medications.

She developed some chest pain during a submaximal sign, symptom and fatigue-limited incremental exercise test and so we stopped at the threshold of chest pain, and were able to prescribe exercise safely at levels below her symptom threshold. Just because someone develops exercise-induced symptoms is NOT a reason to avoid exercise, but care needs to be taken. But do NOT use heart rates to prescribe exercise as so many of these types of clients are on heart rate modulating medications and/or have some form of chronotropic incompetence.

Reference: Revised Guidelines for Cardiac Rehab by the National Heart Foundation of Australia (2019)