EXERCISE & CARDIAC REHABILITATION

individual will spend at a station is relat- ed to their medical condition and general physical fitness level - these times will vary widely but timings are discussed in the circuit training section. To enable pro- gression and monitoring of the client’s medical condition, all exercise prescrip- tions should be reviewed regularly.

Exercise benefits The benefits of exercise depend on type, frequency, duration and intensity as well as the fitness levels of the individual when commencing the exercise programme.

Benefits of endurance training in Phase IV (2,3,4,5&8) ● Improved survival rate ● Reduced heart rate for a given amount of work

● Reduced arrhythmias (irregular heart beat patterns)

● Lowered blood pressure ● Improved lipid profiles (ratios of LDL to HDL)

● More efficient use of oxygen in work- ing muscles

● Delayed onset of angina ● Reduced body fat ● Improved confidence and self-esteem ● Decreased anxiety and depression

Joining a Phase IV class Prior to entering the Phase IV programme, clients have to fulfil particular criteria. As the patient moves through the cardiac rehabilitation process, there is an increas- ing emphasis on the importance and ben- efits of exercise.

At Phase III, and prior to any patient undertaking exercise, patients should have an electrocardiogram exercise test (ECG). Upon the successful completion of Phase III, the result of this test together with details of the patient’s medical sta- tus and progress through Phase III are passed to the Phase IV instructor.

This information enables the client to be risk-stratified according to their potential for future cardiac events and for the Phase IV instructor to plan and prescribe an appropriate exercise regime. BACR Phase IV instructors are not allowed to accept individuals onto a Phase IV programme who have not successfully completed Phase III within the past five years and/or have had a further cardiac event without returning to Phase III.

Criteria for exercising at

Phase IV ● The individual’s medical condition is controlled and stable ● Able to sustain activities equivalent to a minimum of 5 METS (see section on Exercise Intensity for more details) ● Able to monitor and regulate the intensity of prescribed exercise during their exercise period through the use of heart rate and/or the rate of perceived exertion ● The individual recognises an exercise level beyond which they should not work ● Able to acknowledge the importance of and demonstrate a commitment to modi- fying risk related behaviour by changing lifestyle habits (including cessation of smoking, improved diet etc.)

Risk stratification Rather than focusing on one aspect of the client’s progress, it is the overall picture of the client that enables the instructor to make their assessment. For example a family history of heart disease by itself would result in a relatively low stratifica- tion profile but if this was accompanied by a personal history of more than one myocardial infarction the risk stratifica- tion would be considered high. A high-risk stratification would result in a client undertaking a less intense exercise pre- scription with slower rates of progression. If the client fails to fulfil the entry crite- ria onto a Phase IV programme they will be referred back to the Phase III team.

When undertaking risk stratification at Phase IV, the instructor will be looking at a number of factors, which include: - ● Previous cardiac event history ● Current cardiac status ● Family history ● Modifiable risk factors for coronary heart disease ie.smoking, stress, inactivi- ty, overweight, high fat diet, excessive alcohol intake ● Compliance with exercise prescription ● Ability to monitor exercise intensity

Phase III to IV transfer Since the success of the cardiac rehabili- tation process can depend on the transfer of the patient between Phase III and Phase IV, the development of mutually agreed protocols and criteria regarding the movement of clients onto a Phase IV programme are essential. Access to patient medical information and knowl-

edge of the transfer documentation, including patient information sheets and paths of communication, are essential in the initial stages of developing a Phase IV programme.

Information exchanged between Phase III and IV 1. Current cardiac status 2. Current medication 3. Past medical history 4. Compliance with lifestyle modifications 5. Details of prescription through Phase III including exercise prescription 6. Pending medical treatment

Condition deterioration Over time clients can develop symptoms that indicate a worsening of their med- ical condition. If this occurs, Phase IV instructors should refer clients to their GP before they are allowed to continue on a Phase IV exercise programme.

Symptoms requiring referral to a GP ● Deteriorating functional capacity despite apparent compliance with the prescribed exercise regime

● Worsening of angina or the develop- ment of unstable angina

● Worsening of other symptoms eg. suspected arrhythmias, excessive breathlessness

● Any further cardiac event ● Uncontrolled tachycardia ● A resting systolic blood pressure higher than 180 mmHg

EXERCISE PRESCRIPTION

AT PHASE IV As stated earlier, cardiac rehabilitation is an active process with clients taking responsibility for their own health and lifestyle. To enable the individual to fulfil this role, Phase IV continues to support and reinforce the good practice of the pre- vious stages in the rehabilitation process.

These include maintaining risk factor lifestyle changes such as diet improve- ments, reduction or cessation of smoking and increases in physical activity levels; educating the client about exercise; dis- cussing and mutually agreeing goals; pro- viding the opportunity for supervised exercise and giving guidance for indepen- dent exercise outside the classes.

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