Exercise for Patients with Coronary Artery Disease

February 19, 2010

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Before beginning an exercise program, patients with coronary artery disease require a complete medical history, physical examination, and a graded exercise test.[4,11] The initial evaluation is directed at the patient's cardiovascular as well as general medical and orthopedic status. Further evaluation, if clinically indicated, is directed at defining any pathophysiological abnormalities, including left ventricular dysfunction, myocardial ischemia, or cardiac arrhythmias. Abnormalities identified may then be managed medically or surgically prior to beginning the exercise program.

Patients identified as high risk for cardiovascular complications during exercise include patients with unstable angina, severe aortic stenosis, uncontrolled cardiac arrhythmias, decompensated congestive heart failure, or other medical conditions that could be aggravated by exercise (e.g., acute myocarditis or infectious disease).[11] These patients should defer exercise training until the above problems are controlled.

Patients at increased risk who may be able to exercise under direct medical supervision include those with:[2,11,17] i) Severely depressed left ventricular function; ii) resting complex ventricular arrhythmias; iii) ventricular arrhythmias appearing or increasing with exercise; iv) decrease in systolic blood pressure with exercise; v) survivors of sudden cardiac arrest; vi) recent myocardial infarction complicated by congestive heart failure; and vii) marked exercise-induced ischemia. It should be noted; however, that the risk to benefit ratio of exercise training for such patients is not defined.

The exercise prescription, especially in terms of exercise intensity and degree of monitoring and supervision, is also based on the initial clinical and exercise evaluation.

Reevaluation should be performed regularly and as clinically indicated, generally 2-3 months after starting a program, and then at least yearly thereafter.[11] It is important to assess the physiologic changes resulting from an exercise program as well as the possibility of disease progression.

Exercise Prescription

Exercise for patients with coronary artery disease includes activities performed in formal supervised exercise programs, as well as everyday physical activities. Therefore, general daily activity is encouraged in addition to formal exercise sessions.

The exercise program for the patient with coronary artery disease is based on the traditional prescription for developing a training effect in healthy persons.[3] It is, however, modified as indicated by the patient's cardiovascular and general medical status. It involves an individually appropriate program of exercise with respect to mode, frequency, duration, intensity, and progression of exercise.[3,4,11]

Mode. Large muscle group, continuous exercise, such as walking, jogging, bicycling, swimming, group aerobics, and rowing, is appropriate for cardiovascular endurance conditioning. Upper extremity exercises performed with arm ergometers may also be utilized for those who cannot tolerate lower extremity activity for orthopedic or other reasons, and for patients whose occupational or recreational activities are dominated by arm work. Strength training is also beneficial for selected patients.[13] Resistance exercises generally are performed with a circuit training approach, up to 10-12 exercises using 10-12 repetitions of resistances that can be performed comfortably.[22] Cross-training may also help to reduce musculoskeletal problems and increase compliance.

Frequency. Minimum frequency is three nonconsecutive days per week. Some patients prefer to exercise daily. However with increased frequency of exercise, the risk of musculoskeletal injury increases.[33]

Duration. Warm-up and cool-down periods of at least 10 min, including stretching and flexibility exercises, should precede and follow 20-40 min of cardiovascular exercise performed either continuously or through interval training. The latter may be especially useful for patients with peripheral vascular disease and intermittent claudication.

Intensity. Exercise in supervised programs is performed at a moderate, comfortable intensity, generally 40-85% of maximal functional capacity (V·O2max), which correlates with 40-85% of maximal heart rate reserve ([maximal heart rate - resting heart rate] X 40-85% + resting heart rate), or 55-90% of maximal heart rate. Ratings of perceived exertion (RPE) may also be used to monitor exercise intensity, with the goal of keeping the intensity at a moderate level. The exercise intensity should be below a level that provokes myocardial ischemia, significant arrhythmias, or symptoms of exercise intolerance as judged clinically or by exercise testing.

The recommended intensity of exercise training varies with the degree of supervision available and the patient's level of risk. Lower exercise intensities are indicated for higher risk patients (defined above) especially when exercising outside of supervised programs or without continuous ECG monitoring.

Progression. Any exercise program for patients with coronary artery disease should involve an initial slow, gradual progression of the exercise duration and intensity.

Supervision and Monitoring

Patient supervision involves both direct patient observation and monitoring of heart rate and rhythm. Blood pressure measurement is generally performed when clinically indicated. The nature and degree of supervision and monitoring depends upon the patient's risk for exercise complications and the intensity of exercise. Supervision and monitoring should be performed most extensively when dealing with high-risk patients (defined above). Patients exercising without medical supervision and monitoring should do so at lower exercise intensities.

Risks of Exercise. Major cardiovascular complications during exercise in patients with coronary artery disease are acute myocardial infarction, cardiac arrest, and sudden death. The estimated incidence of cardiovascular complications in supervised cardiac rehabilitation programs are: 1 myocardial infarction per 294,000 patient hours, 1 cardiac arrest per 112,000 patient hours, and 1 death per 784,000 patient hours.[41] Over 80% of patients who have been reported to suffer a cardiac arrest (primarily due to ventricular fibrillation or ventricular tachycardia) in supervised cardiac rehabilitation programs have been successfully resuscitated with prompt defibrillation.[41]


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