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The Changing Face of Cardiac Rehab

Cardiac rehabilitation is an exercise program designed to increase the strength and aerobic capacity of patients who have had cardiac episodes such as heart attacks or have developed conditions such as coronary heart disease. (About 13.5 million Americans have coronary heart disease, and this population is rapidly growing.) The primary goals of a cardiac rehab program are to help patients return to their normal everyday activities as much as possible. These programs are becoming more crucial and more involved due to shorter hospital stays after surgeries. With the rising costs of health care and the need to make room for more incoming patients, doctors are relying more on other institutions such as physical therapy clinics and health clubs to rehabilitate cardiac patients.

Some confusion can arise in long term care since a universal protocol for cardiac rehab does not currently exist. There are many exercise guidelines to go by but exactly who is in charge of overseeing cardiac patients and how long the different phases of the rehab last remains open to interpretation.

The benefits of cardiac rehab have been well documented for over 50 years. However, steps still need to be taken to decide how the programs should be run and where they should take place.

Cardiac Rehab Guidelines

After a cardiac patient leaves the hospital (Phase I), he then moves on to Phase II. This type of program is intended to increase the activities of daily living following surgery and return the patient to a normal life. The length of Phase II will vary depending on the patient’s condition and rate of recovery but lasts approximately four to eight weeks.

Exercises are low intensity (between an 11 and 13 on the Borg Scale of Perceived Exertion) and usually begin with five to 10 minutes of walking or cycling. The Borg Scale was established to give a quantitative number to how hard a person is working and how much energy he is expending. The scale ranges from 6 to 20, with 6 representing no energy expenditure and 20 representing maximal effort and energy expenditure. An 11 to 13 on the scale shows a light to moderate effort, such as walking briskly.

More physical therapists and exercise physiologists are now prescribing additional exercises such as water aerobics and beginning yoga for patients since these exercises are less strenuous than other modes. The duration of the exercise is gradually increased to 30 to 40 minutes once the patient can tolerate more exercise.

Strength training programs are also important and have undergone recent changes as they are applied to cardiac rehab patients. The protocols are now more defined and viewed as a vital component to a patient’s full recovery. Two to four weeks of aerobic training is recommended before strength training is commenced. Initially, patients should perform basic movements such as standing out of a chair. One set of 10 to 15 repetitions is usually recommended at first, depending on the patient’s condition and is increased to two to four sets as improvements are made. The tempo of the repetitions should be about two seconds on the hard part of the exercise and two to four seconds on the easier part of the exercise. Next, patients can progress to performing exercises with light dumbbells or resistance bands. Examples of appropriate exercises include arm curls, triceps extensions, standing rows and leg extensions with a band. One to two sets of five to 10 reps is a good starting point, and the weight can be increased by one or two pounds each week. Exercises should always be supervised, and ECG testing should be utilized. 

Sample Resistance Training Workout for Phase II

Warm up:

10 minutes on stationary bike (RPE 11)


    Cool down: 

10 minutes on stationary bike (RPE 11). Stretch all major muscles for 20 seconds each.

A patient moves to Phase III when he is more stable and ready to do unsupervised workouts. Strength machines and free weights can be used and two to four sets can be done. Proper form and increasing strength and range of motion should be the main objectives. Phase IV occurs at different times for patients and is the lifetime maintenance phase of cardiac rehab. Exercise heart rates should reach 50 to 80 percent of maximum, and an RPE of 12 to 14 should be strived for up to 60 minutes, as long as it is tolerated without adverse symptoms. Strength should also continue to be increased.

Sample Resistance Training Workout for Phase III/IV

Warm up:

10 minutes on treadmill (RPE 11)


Cool down:

10 minutes on treadmill (RPE 12-14).Stretch all major muscles for 20 seconds each.

Certified personal trainers have an opportunity to work with post-cardiac rehab patients once they receive a physician’s clearance. By networking with physicians, physical therapists and exercise physiologists who work with cardiac rehab patients, trainers can develop relationships that could gain them referrals for this special population.

Trainers must follow the exercise guidelines laid out by the physicians and therapists and consult them if any new conditions (such as elevated blood pressure) surface in the patients they are training. Longer warm ups and cool downs of 10 to 15 minutes should be practiced, and progressions may need to take place slower than a non-cardiac rehab client.

Contraindications to Strength Training

Under-utilization of Cardiac Programs

Despite the overwhelming need and benefits of cardiac rehab classes, many candidates do not take advantage of them due to the expense or because they are not convinced they need them. “Less than a third of heart patients participate in cardiac rehabilitation programs even though potentially all of them could benefit from the services,” said Douglas B. Kamerow, M.D., M.P.H., the director of Clinical Practice Guideline Development for the Agency for Health Policy and Research (AHCPR).

Other benefits of the classes include increased stamina and strength, lower blood pressure, a lower resting heart rate, decreased stress, a decreased risk of death and simply the accountability to exercise.

The guidelines released by the AHCPR called for a comprehensive approach for cardiac rehab programs that include exercise training to increase exercise tolerance and stamina and also include education, counseling and behavioral interventions to assist patients. Home-based programs monitored by a health care professional are also recommended for low or moderate risk patients who cannot participate in traditional group settings.

Another aspect to take into account is the social part of the classes. For some, each class may be the highlight of the day and is one of the few chances they have to socialize with friends.

The Changing of the Guard for Cardiac Rehab Overseers

Cardiac rehab used to be done primarily in hospitals and clinics. However, in the last decade, the setting has shifted more to an outpatient program. For example, cardiac rehab classes are now being conducted in health clubs and are supervised by exercise physiologists or physical therapists who practice in this type of environment. This can be advantageous to cardiac patients in many regards. In a health club, patients usually have access to a wider variety of equipment, pay a lower price with a membership contract than clinical visits and sometimes feel more independent and normal by working in a non-clinical facility. A lack of diagnostic equipment and often no specific emergency protocols for cardiac incidents are disadvantages. Phase III and phase IV patients would do best in this setting.

In 1995, a clinical exercise physiology licensure bill was passed in Louisiana that helped define who exactly can work in cardiac rehab care. Other states soon followed in an attempt to regulate the practice across the country. This affects where cardiac rehab classes can be held, who may supervise and how much medical evaluation (such as exercise prescription) is involved in the program. Exercise physiologists must now be certified by the American College of Sports Medicine. Registered nurses, physical therapists and doctors also oversee programs. These are the people personal trainers should network with if they wish to gain post cardiac rehab clients.

New HMO Wellness contracts have also helped to reimburse cardiac rehab patients, mainly in phase III and phase IV programs. This allows more cardiac patients to be able to afford this type of care.

Personal trainers who wish to be of valuable service to the post cardiac rehab patients can obtain certifications for working with these types of clients. The Exercise Specialist Certification from the American Council on Exercise is one example of this type of certification. Trainers can also research new periodicals such as the Journal of Medicine for new information on exercise guidelines for older populations, and they should always ask for guidance and approval in developing appropriate training programs from physicians, nurses, physiologists and physical therapists.


  1. Doctors' Guide to the Internet. “Cardiac Rehabilitation Beneficial but Under-Used.” 10 Oct. 1995.
  2. Durak, Eric P. M.SC. “The New Health And Human Services Cardiac Rehab Guidelines: What this means to the Exercise Profession.”
  3. Kavanaugh, Terry et al. "Cardiac Rehabilitation and Secondary Prevention for the Older Patient.”
  4. Rodgers, Ellie. “Topic: Cardiac Rehab: General exercise guidelines for phase II.”