Exercise Prescription in Cardiac Rehabilitation

According to the World Health Organization definition, cardiac rehabilitation is “the sum of activities required to influence, favorably, the underlying cause of the disease, as well as to provide the best possible physical, mental, and social conditions, so that patients may, by their own efforts, preserve or resume optimal functioning in their community and through improved health behavior, slow or reverse the progression of a disease”. The objectives of exercise-based cardiac rehabilitation are to increase functional capacity level, reduce anginal symptoms and disability, improve quality of life, modify coronary risk factors, and reduce morbidity and mortality rates.

Exercise stress tests determine cardiovascular system response during exertion. Historically, exercise testing has been performed to provoke myocardial ischemia; however, indications have evolved over time. Exercise capacity assessment delivers crucial information for exercise prescription guidance in cardiac rehabilitation programs, and cardiopulmonary exercise testing should ideally be executed. Exercise tests are typically performed on a treadmill or stationary bike; incremental exercise tests are the gold standard.

Bed rest and immobility have been the recommended standard of care following acute cardiac events for many decades. The implementation of early mobilization was gradual, from chair therapy in the 1940s, to several minutes of walks after four weeks of rest in the 1950s and mobilizing patients after 12 days of rest in the 1960s. A study conducted by Saltin in 1968 revealed the problem of the vicious cycle of prolonged hospital bed rest. Prolonged hospital bed rest contributes to decreased cardiac output; secondary complications such as deep venous thrombosis, pneumonia, pressure sores, a rapid loss of skeletal muscle mass, reduced strength, and a decline in aerobic capacity. Early mobilization means the initiation of mobilization activities as soon as clinical stability is achieved, typically with 1–2 days of admission, and has significant effects on the length of hospital stay and the readmission rate.

Early assessment allows for the identification of the individual needs of patients referred to cardiac rehabilitation. Establishing personalized goals and a plan of care before the initiation of appropriate cardiac rehabilitation service is essential. Cardiac risk stratification aims to identify patients at risk for a cardiac event recurrence. It includes the methodical assessment of the clinical and functional status of the patient to classify him/her as low, moderate, or high risk.

Phase III, or the maintenance phase, contains a program that typically starts within the cardiac rehabilitation center and is continued at the local fitness center, gym, or the patient’s home. The objective of phase III is to provide guidance and support for a continuous lifestyle change. Phase III involves more independence and self-monitoring, shifting a center-based program into a home-based environment. Therefore, the transition between structured phase II and long-term phase III can be a vulnerable point due to the risk for non-adherence to recommended pharmacological treatment and lifestyle modifications, including physical activity.

The principles of exercise were described in detail in this book in a chapter
dedicated to exercise prescription

The successful delivery of cardiac rehabilitation service requires amultidisciplinary team of professionals with appropriate qualifications andexperience. The staff included will depend on local recommendations, staff availability, or the phase of cardiac rehabilitation. It is essential to assign specific duties to all staff members regarding staff competencies.

Cardiovascular disease accounts for more than 45% of total mortality in the Arabian Peninsula. The rate of physical inactivity in this region remains very high. In the Kingdom of Saudi Arabia, the central country of the region, the prevalence of physical inactivity has reached a rate of 69%.  The two main barriers to physical exercise in the Middle East region are the hot environment and sociocultural factors. Some obstacles relate to women specifically, as traditionally women are not expected to perform physical activity in public. Thus, it is important to develop adequate strategies to improve the physical activity rate in the Middle East region.