1. Exercise Prescription for Aerobic Training in the Cardiac Population
Teresa Eber Lee, EdD, RCEP, CCRP, Wellcoach
Program Director
Clinical Exercise Science
Winona State University

2. Are there people who should not exercise?
Unstable angina
Uncontrolled HTN (180/110 mm Hg), dysrhythmias, or DM
Uncompensated heart failure
Severe aortic stenosis
Active pericarditis or myocarditis
Acute thrombophlebitis or recent PE
2nd or 3rd degree heart block without a pacemaker
Electrolyte abnormalities (hypo/hyperkalemia)

3. Aerobic Exercise Prescription

4. What are your goals when prescribing exercise?
Prescribe a program that:
Promotes positive physiological changes
Is safe and avoids injuries
Fosters exercise adherence

6. Principals of Exercise Prescription
FITT-VP Principle

7. Frequency Minimally 3 day/week Preferably >5 days/week
3 supervised sessions
2 or more sessions on their own
“most days of the week”

8. Time / Duration 20 - 60 minutes of continuous activity
shoot for 30 – 40 minutes
reduces boredom
less chance for injury

9. “walk often and walk far”
Ades et al., Circulation: 2009
Standard Cardiac Rehabilitation
3 days week
25-40 minutes/session
65-75% peak VO2
goal of kcal/week
High Caloric Exercise for Cardiac Patients
5-7 days week
45-60 minutes/session
50-60% peak VO2
goal of 3,000-3,500 kcal/week

10. Results – 5 months High Caloric Standard CR Kcal/day 615 269
Kcal/wk
Weight Loss (kg)
Waist Loss (cm)
MET Syndrome (%)

11. Give them homework!

12. Type or Modality
Any large muscle, sustainable activity is acceptable (rhythmic)
Modes with an upper body component may have some advantages:
increased upper body muscular endurance
sharing of workload, so can do more work at same perceived effort (RPE); burn more calories
may facilitate glucose metabolism

15. So Which Aerobic Exercise Is the Best?

16. Changes in aerobic capacity following 12 weeks of stationary cycling,
treadmill walking, stepping, or simulated cross-country skiing
VO2max
(ml/kg/min)
Control
Bike
Tmill
Stepper
Skier

17. Changes in body weight and % fat following 12 weeks of stationary
cycling, treadmill walking, stepping, or simulated cross-country skiing.
Control
Bike
Tmill
Stepper
Skier
Change

18. Multi-station vs single mode?

19. SPECIFICITY
SAID PRINCIPLE
Specific
Adaptation to
Imposed
Demands

20. Intensity If you have an maximal effort graded exercise test (GXT):
% of VO2peak or Heart Rate Reserve (Karvonen)

21. Divide VO2 (ml/kg/min) by 3.5 = METs
HR/VO2 Relationship
40-80%
Divide VO2 (ml/kg/min) by 3.5 = METs

22. Exercise Prescription by METs 40-80% of VO2max or max METs
1 MET = 3.5 ml/kg/min = amount of oxygen the average person consumes at rest.
Someone with a maximal capacity of 10 METs has a capacity that is 10 times greater than their resting level.
If I want someone to work at 40-60% of maximal METs:
10 METs X .40 = 4 METs
10 METs X .60 = 6 METs

23. 40-80% of Heart Rate Reserve (aka: Karvonen Method)
Target HR = [(max HR - rest HR) X desired % + rest HR]
Lower Limit Upper Limit
Maximal heart rate
Resting heart rate
Heart rate reserve
Desired % X X .60
Resting heart rate

24. Intensity Violators

25. Signs and Symptoms Below Which an Upper Limit for Exercise Intensity Should be Set
Angina
Drop in SBP
Significant ST depression on previous GXT
Increased frequency of ventricular ectopy
Onset of heart blocks (e.g., BBBs, 2º or 3º AV block)
Other signs/symptoms of intolerance to exercise (e.g., extreme SOB)
**Exercise heart rate should be set at least 10 bpm below the HR associated with any of the above criteria

27. ST depression at HR of 125 bpm

28. RPE Method (Borg Scales)
Scale Scale
7 Very, very light Extremely weak
Very weak
9 Very light Weak
Moderate
11 Fairly light 4
Strong
13 Somewhat hard 6
Very strong
15 Hard 8
17 Very hard Very, very strong 18
19 Very, very hard 20

29. What about the Cardiac Meds?19 17
No BB 13 10 8 BB
RPE 13
No BB: 135/155 = 87%
On BB: 115/130 = 87%

30. Exercise Prescription with or without a GXT
Frequency: same
Time / duration: same
Modalities: same
The only difference is how you prescribe exercise intensity!

31. Intensity ACSM AACVPR If you do not have an exercise test: 2 - 4 METs
RPE
ACSM
Rest +20bpm to + 30 bpm (arbitrary upper limit)
RPE
To tolerance if asymptomatic
<10 beat below ischemic and angina threshold

32. That allows you to recognize deviations from that, which may indicate:
If you use RPE only…you still record the exercise HRs on each modality to get an idea of what they are
That allows you to recognize deviations from that, which may indicate:
some sort of dysrhythmia
heart block
forgot to take their meds

33. Can you exceed 20-30 bpm above rest in some patients?

34. Yes…Yes…Yes ACSM AACVPR 20-30 bpm are “arbitrary upper limits”
RPE on a 6-20 scale
“to tolerance if asymptomatic”
AACVPR
“Over time, stable patients typically progress to exercise plans similar to those presented in Table 8.6.”
RPE of (which corresponds to 40-80% of HR reserve)

35. Titrate workloads based on:
Signs and symptoms
EKG and BP responses
RPE
Talk Test
Staff comfort
Sound clinical judgment

36. Talk Test Exercise at an intensity where
you can still carry on a “normal”
conversation!

37. In subjects who had exertional ischemia, 18/19 subjects were below the ischemic threshold when they could still pass the Talk Test. Ischemia did not occur until after they could no longer speak comfortably.

38. Tim McConnell Data Geisinger Medical Center
Week 1 Week 12
Exercise HR
GXT
No GXT
Exercise METs
GXT
No GXT
**No difference in complication rates during training between groups and all problems were minor (e.g., dysrhythmias, hypotension)

39. Progression Depends upon: 1. Functional capacity - lower go slower
2. Age - older takes longer
3. Health status – co-morbidities may
affect how fast you can progress
4. Goal - what do they want to do?
As a general rule, increase duration first and then alter intensity.

41. End of Cardiac Rehab Cardiovascular Stress Test (CVST)
Non-diagnostic, functional capacity test
Guidelines for home exercise program.

42. EXERCISE PRESCRIPTION
EXERCISE PRESCRIPTION
for
MODE: Aerobic Exercise: walk, bike, etc.
Strength Training: weights or therabands
Stretching
FREQUENCY: Aerobic Exercise: 5-7 days a week
Stretching: after each workout
Strength training: 2-3 days a week -
DURATION: minutes of continuous aerobic exercise
Warm-up for 5 minutes at a slow pace
Cool-down for 5 minutes at a slower pace
INTENSITY: Rate of Perceived Exertion: (RPE) 11-15
“Fairly Light to Hard”
Heart Rate Range: beats per minute
11-12 Beats in a 10 second count
Remember to adjust your workload to meet your prescribed exertion.
Stop exercise if at any time you feel chest pain, excessive shortness of breath, dizziness,
light-headedness, excessive sweating, frequently skipped beats or blurred vision.
______________ , congratulations on making healthy lifestyle change! Remember, consistent exercise is the
key to maintaining good health. Continue to exercise, eat healthy, and be good to yourself. If you have any
questions or need anything, please call us or stop by the Exercise Center

43. CASE STUDIES

44. Home Program
No insurance coverage
Co-pay
Back to work
Driving issues

45. Home Program
Review cardiovascular exercise that can be done at home with minimal equipment.
5-7 days per week
RPE or target heart rate if applicable
30-60 minutes daily
Progression
Stretches following exercise.
Exercise log given to track progress.

46. Follow-up Every 1-2 weeks Introduce strength training
2-3 days per week using therabands.
1-2 sets, 8-12 reps

47. Case Studies Patient History:
55 year old male.
S/P MI and Stent to LAD
BMI 34
GXT Bruce Protocol:
8 METS
HRrest 62 bpm
HRmax 136 bpm
No Ischemia or Angina
What goal would you recommend for rehabilitation?
What is his HR reserved?
What mode of exercise do you recommend?
What is an appropriate THR?

48. Case Studies Patient Hx:
62 y/old Female
Stable Angina
GXT Naughton Protocol
4.8 Mets
HRrest 74 bpm
HRmax 115 bpm
Angina and 1mm ST
HR of 108 bpm
BP of 146/74
Is this patient Safe to exercise in a CR program?
What was the Rate Pressure Produce at the time of ischemia?
What intensity would you use for the ExRx?

49. Case Studies Patient History:
67 year old male.
S/P CABG (1 month ago)
No GXT:
HRrest 58bpm
BP 118/66
No angina
No physical limitations?
What intensity would you start this patient?
How would you progress?