1. CARDIAC REHABILITATION

2. Exercise capacity calculated by the following equations: (i) Men: Predicted METs = 14.7 − 0.11 × age (ii) Women: Predicted METs = 14.7 – 0.13 × age Classify functional capacity below normal if lower than 85% of the predicted value

3. 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.

4. 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.

5. 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.

6. Conditioning The conditioning phase includes endurance, resistance, and flexibility exercises, parts of which may be performed on different days.

7. 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.

8. 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.

9. 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.

10. VO 2 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

11. Methods of Determining VO 2 max Submaximally Maximally Graded Exercise Testing - GXT (incremental increases in workload)

12. 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

13. 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

14. 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

15. 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

16. Treadmill Protocol Calculate VO 2 from the gender specific equations Males VO 2 =SM VO2 [(HR max -61)/(HR SM -61)] Females VO 2 =SM VO2 [(HR max -72)/(HR SM -72)] SM VO2 = submaximal VO 2 from table or ACSM equations HR SM = submax HR from test

17. Modified Bruce Protocol Start at 1.7 mph, 0% grade or at 1.7 mph and 5% grade (used on diseased and elderly populations)

18. Treadmill Protocol Protocols should be individualized Test time should ideally be 8-12min Increments of 10-15 W/min or 1-3%/min grade can be used for the elderly

19. Advantages of Submaximal Testing 1. Safer 2. Controlled pace (motivation not a factor) 3. Not population specific (no pacing advantage) 4. Quick assessment 5. Cost effective 6. Don’t need highly trained personnel 7. Can do mass testing 8. No physician supervision required (if symptom and disease free)

20. Disadvantages of Submaximal Testing 1. VO 2 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).

21. 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)