Exercise in Heart Disease and Cardiac Rehabilitation

Cardiac rehabilitation is delivered by a multidisciplinary team and is built around several core components: a supervised, individually prescribed exercise programme, education about the heart condition and its risk factors, support with smoking cessation, diet and weight, medicines optimisation, and attention to mood and anxiety. It is commonly described in phases. Phase 1 begins in hospital immediately after the event, with early mobilisation, assessment and reassurance, and rehabilitation is initiated before discharge, with formal assessment normally within about ten days. Phase 2 covers the early weeks after discharge at home. Phase 3 is the structured, supervised exercise and education programme, which begins promptly after assessment and is typically run as group sessions once or twice a week over about six to twelve weeks. Phase 4 is long-term maintenance in the community, often through exercise instructors with British Association for Cardiovascular Prevention and Rehabilitation (BACPR) qualifications. Programmes are offered as a priority after acute coronary syndrome, coronary revascularisation and in chronic heart failure, with stable angina an additional group where service capacity allows, yet uptake across the country remains patchy, so actively encouraging referral is part of the SEM clinician's role.

The exercise component follows familiar principles, applied with cardiac-specific caution. Sessions include a thorough warm-up, an aerobic conditioning component, resistance work for the major muscle groups, and a gradual cool-down, which matters more here because abruptly stopping can drop blood pressure and provoke arrhythmia. Aerobic intensity is usually set at a moderate level, around 40 to 70 percent of heart rate reserve, corresponding to a rating of perceived exertion (RPE) of about 12 to 14 on the 6 to 20 Borg scale, at which a person is working but can still hold a conversation. An important practical point is that many cardiac patients take beta-blockers, which blunt the heart rate response, so age-predicted heart rate targets are unreliable; an individualised heart rate target based on a measured exercise test may still be useful, and perceived exertion, symptoms and the talk test add valuable guidance. Functional capacity is assessed with submaximal tests such as the incremental shuttle walk test or the six-minute walk test, and the programme is progressed gradually as fitness improves. The long-term goal is to build towards the general recommendation of at least 150 minutes of moderate activity a week, reached in stages.

Cardiac rehabilitation has an excellent safety record when patients are screened and supervised, but some situations call for caution or delay. Exercise should not go ahead in a given session, and the person should be reviewed, if they have unstable or worsening symptoms such as rest or crescendo angina, decompensated heart failure with breathlessness at rest or rapid weight gain from fluid, uncontrolled arrhythmia, a very high resting blood pressure, or a fever or acute illness. During exercise, the warning signs to stop and seek assessment include new or worsening chest pain or tightness, undue breathlessness out of proportion to effort, dizziness, palpitations or an irregular pulse, and cold sweats or nausea. Patients should carry their glyceryl trinitrate (GTN) spray if it has been prescribed and know how to use it, and if chest tightness persists they should follow their plan for escalation to emergency care. After bypass surgery, gentle, comfortable arm movement is encouraged and individual surgical and rehabilitation advice is followed, with heavier lifting, pushing and pulling restricted during sternal healing, commonly for about six to twelve weeks. With sensible screening, gradual progression and clear advice on symptoms, the benefits of cardiac rehabilitation comfortably outweigh the small risks.

• •Cardiac rehabilitation combines supervised exercise with education, risk-factor management and psychological support, and reduces mortality and readmission, with strongest evidence after a heart attack.
• •Offer it as a priority after acute coronary syndrome, revascularisation and in chronic heart failure, with stable angina where capacity allows; encourage referral.
• •Prescribe moderate aerobic exercise at about 40 to 70 percent of heart rate reserve, or a rating of perceived exertion of 12 to 14.
• •Beta-blockers blunt the heart rate, so avoid age-predicted targets; use a measured individualised target if available, with perceived exertion and the talk test.
• •Warning signs to stop include chest pain, undue breathlessness, dizziness, palpitations or an irregular pulse.
• •Defer exercise with unstable angina, decompensated heart failure, uncontrolled arrhythmia or acute illness, and restrict heavier lifting during sternal healing, commonly about six to twelve weeks.