Indications of Patient Instability and Treatment should be withheld

Acute rehab or Inpatient cardiac rehab (regular PT)

Orthostatic BP drop > 20 mmHg with symptoms
Resting SBP > 200 mmHg or resting DBP > 110 mmHg
2nd or 3rd degree Heart blocks
> 10 PVC per minute, multifocal PVCs
ECG changes associated w/ischemia (ST segment depression OR elevation > 2mm)
New onset (<24hrs) of A-fib
Chest pain w/ new ST changes on ECG
MI or extension of MI w/in previous 2 days
Acute aortic dissection/stenosis
Uncontrolled metabolic diseases
Psychosis or other unstable psychologic condition

Contraindications for STARTING Inpatient or Outpatient Cardiac Rehab

ABSOULTE
Acute MI (w/in 2 days)
Unstable angina not stabilized by meds
Uncontrolled cardiac arrhythmias causing
s/s or hemodynamic compromise
Acute PE or pulmonary infarction
Acute myocarditis or pericarditis
Acute aortic dissection
RELATIVE
Left Main coronary stenosis
Moderate stenotic valvular heart disease
Electrolyte abnormalities
Severe arterial hypertension
Tachyarrhythmias or bradyarrhythmia
Hypertrophic cardiomyopathy, outflow obstructions
Mental or physical impairment- unable to exercise
High degree AV block

INDICATIONS TO STOP EXERCISE:

Cardiac Rehab Phase I
ABSOULTE
HR > 130 BPM or > 30 BPM above RHR
DBP ≥ 110 mm Hg SBP ≥ 200
Decrease in SBP > 10 mmHg
Significant ventricular or atrial dysrhythmias
2nd or 3rd degree heart block
s/s including angina, marked dyspnea, and ECG changes
 Cardiac Rehab Phase II
ABSOULTE
Plateau or decrease in HR or SBP w/increase in work
SBP > 250 mmHg or DBP > 115 mmHg
ST depression > 1mm
2nd or 3rd degree heart block
Ventricular dysrhythmias
Angina or other s/s of cardiovascular insufficiency

Normal/Exercise testing/(not in cardiac rehab)

ABSOULTE RELATIVE
SBP Drop ≥ 10 mmHg w/ increased work ST or QRS changes or marked axial shift
Angina mod-severe (3/4) Arrhythmias other than VT (e.g. multifocal PVC)
Increasing nervous system s/s: ataxia, Fatigue, SOB, wheezing, leg pain, claudication
dizziness, near syncope
s/s of poor perfusion/ischemia Bundle branch block-can’t be distinguished from VT
Technical difficulties in monitoring ECG or BP Increased chest pain
Subject’s desire to stop Hypertensive response: >250 SBP or > 115 DBP
Sustained VT > 2 mm ST segment depression
ST elevation ≥ 1.0 mm

◦ References = acute care handbook, scorebuilders, o’sullivan

EXERCISE PRESCRIPTION GUIDELINES:
NORMAL (not cardiac rehab):
Aerobic Exercise
*NOTE*
Dynamic arm exercise (UBE) = smaller muscle mass and lower VO2 max than bicycling
 HR will be higher
 SV lower
 SBP and DBP higher

1. Intensity
a. 40-85% of max on exercise tolerance test
b. Heart Rate % Calculation:
i. Lower THR = HRmax x 55%
ii. Upper THR = HRmax x 90%
iii. HRmax = 220- age
c. Heart Rate Reserve (HRR) or Karvonen formula:
i. Lower THR = [(HRmax -HRrest )x 40%] + HRrest
ii. Upper THR = [(HRmax-HRrest) x 85%] + HRrest
d. RPE (6-20 scale)
i. 13-14 = ~ 70% of HRmax (somewhat hard)
e. METs
i. 40-85% of METmax
ii. Can use Karvonen formula
1. [(METmax- 1) x (40-85%)] + 1
2. Duration
a. 20-60 minutes of continuous or intermittent activity (minimum of 10 minute bouts
of intermittent)
b. Lower intensity exercise > 30 minutes
c.
3. Frequency
a. 3-5 days/week
CARDIAC REHAB PHASE I: INPATIENT
When to begin Active Exercise:
 Post-CABG = 24 hours
o Avoid lifting, pushing, pullin for 4-6 weeks post-sx.
 Post- MI = 2 days
General Exercise Guidelines:
 Begin with activities of low intensity (2-3 METs) sitting- standing- level walking
Aerobic Exercise:
1. Mode:
a. level walking (2-3 METs)
b. Walking up/down steps and TM walking (3-4 METs)
2. Intensity:
a. RPE < 13 (6-20 scale)
i. Between 11-13
3. Duration:
a. Intermittent bouts of 3-5 minutes to start
b. Progress to 10-15 minutes continuous activity
4. Frequency
a. Days 1-3: 3-4 x a day
b. Days 3 to Discharge: 2-3x a day
5. Progression Guidelines:
a. Adequate increase in HR
b. Adequate rise in SBP (10-40mmHg w/work)
c. No new dysrhythmias or ST changes
d. No cardiac symptoms
Special Considerations:
 Post- MI
o HR < 120 BPM or < 20 BPM above RHR
o Limited 70% HR max and/or 5 METs until 6 weeks post-MI
 Post- Surgery.
o HR < 130 BPM or < 30 above RHR
Goals for Discharge (graduate to Phase II)
1. ≥ 5 METs tolerated
2. Walk 5-10 minutes continuously, or 1000 feet, 4x daily
3. Walk up/down 1 flight of stairs independently
4. Know HR and RPE limits, s/s of intolerance to activity, prepared for return home
CARDIAC REHAB PHASE II: OUTPATIENT
General Guidelines:
 Exercise test and ECG recommended prior to
 Low risk pt. w/stable CAD: 6-12 sessions of ECG and BP monitoring and medical
supervision recommended
 Moderate-High risk pt.: continuous ECG and BP monitoring and medical supervision
recommended until safety is established ≥12 sessions
Aerobic Exercise:
1. Intensity
a. Heart Rate
i. Without exercise test = Standing RHR + 20 BPM
ii. % of Max HR
1. Karvonen Formula [(HRmax-RHR0+ (40-85%)] + RHR
2. HRmax x (55-90%)
iii. METs
1. [(METmax-1+ (40-85%)] + 1
iv. RPE
1. Initial phases = 11-13 (“fairly light” to “somewhat hard”)
2. Middle phase =12-16 = “somewhat hard” to “hard”
a. Corresponds to 40 -85% of Max capacity
3. Higher intensity training = 14-16
2. Duration
a. Month 1: 15-20 minutes of continuous or intermittent exercise
i. 3-5 minute intervals with equal rest periods for intermittent
b. Months 3-4: 25-30 minutes
c. Month 6 on: greater than 40 minutes
3. Frequency:
a. 3-5 days/week
Goals for Discharge:
 9 MET functional capacity
o 8-12 MET is average norm
 ≥ 40 minutes of exercise
 50-85% exercise capacity toleration
 Able to self-monitor safely
RESISTANCE TRAINING:
 Strength training can be initiated after 3 weeks in cardiac rehab:
o Begin with elastic bands and light (1-3lb) weights
o Progress to moderate loads (12-15 reps)
o RPE: 11-13
o RPP (HR x BP) shouldn’t exceed prescribed (if indicated)
Special Considerations:
 Post MI: strength training after 5 weeks
o Remain under 70% HRmax or 5 METs post- MI
 Post- CABG: strength training after 6-8 weeks (UE)
o Lower extremity resistance training ok as soon as medically cleared
 PTCA: Strength training 3 weeks post-op

PULMONARY REHAB:
Aerobic Exercise:
1. Intensity:
a. [(HRmax-RHR+ (40-85%)] + RHR
b. ≥ 50% peak O2 consumption
c. Sub-max dyspnea rating

d. 60-80% max exercise tolerance

e. RPE 4-6 on (0-10 scale) or 12-16 on (6-20 scale)
f. O2 Saturation > 90%
2. Duration
a. Minimum 30 minutes accumulated exercise
b. Interval training (30 seconds – 3minutes w/equal rest time)
3. Frequency
a. 3-5 days/week