What are the guidelines for target heart rate and recommended exercises for patients undergoing cardiac rehabilitation?

Guidelines for Target Heart Rate and Recommended Exercises in Cardiac Rehabilitation

For patients undergoing cardiac rehabilitation, the target heart rate should be 60-75% of maximum predicted heart rate for unsupervised exercise and 70-85% of maximum predicted heart rate for supervised training, with aerobic exercise beginning 1-2 weeks after discharge and resistance training introduced 2-4 weeks after aerobic training. 1

Target Heart Rate Guidelines

Determining Exercise Intensity

• For supervised cardiac rehabilitation, target heart rate should be 70-85% of age-predicted maximum heart rate 1
• For unsupervised exercise, target heart rate should be 60-75% of maximum predicted heart rate 1
• Exercise intensity can also be determined using the Rating of Perceived Exertion (RPE) scale, with recommended values of 12-13 (somewhat hard/moderate) on the 6-20 scale 1
• Heart rate can be calculated using heart rate reserve formula: [(maximal heart rate minus resting heart rate) × (40% to 60%)] + resting heart rate for initial prescription, increasing to 85% if tolerated 1

Timing of Exercise Initiation

• Exercise training can generally begin within 1-2 weeks after acute coronary syndrome treated with PCI or CABG 1
• Additional restrictions apply when residual ischemia is present 1

Recommended Exercise Types and Prescription

Aerobic Exercise

• Frequency: 3-5 days per week 1
• Duration: 30-60 minutes per day, which can be spread over 2-3 segments during the day 1
• Modalities: Walking, treadmill, cycling, rowing, stair climbing, arm/leg ergometry 1
• Progression: Begin with lower intensity and gradually increase duration first, then intensity as tolerance improves 1

Resistance Training

• Can be added 2-4 weeks after beginning aerobic training 1
• Frequency: 2-3 days per week 1
• Intensity: 1-3 sets of 8-12 repetitions to moderate fatigue 1
• Include 8-10 different exercises involving major muscle groups 1
• Use calisthenics, elastic bands, light weights, or weight machines 1

Special Considerations

Exercise Prescription Without Exercise Testing

• If exercise test is unavailable, activity questionnaires or nomograms can guide exercise prescription 1
• Using resting heart rate plus 30 beats per minute (RHR+30) is more effective than RHR+20 for achieving recommended exercise intensities and improving functional capacity 2, 3

Safety Precautions

• Patients should be risk-stratified to determine the level of supervision and monitoring required during exercise training 1
• Exercise is contraindicated in patients with refractory/unstable angina and other high-risk cardiovascular conditions 1
• Patients should be educated about warning signs/symptoms during exercise 1
• All exercise sessions should include warm-up, cool-down, and flexibility exercises 1

Patient Education and Activity Guidelines

• Provide specific instructions on permissible and restricted activities (heavy lifting, climbing stairs, yard work, household activities) 1
• Address resumption of driving, return to work, and sexual activity 1
• Encourage daily walking immediately after discharge 1
• Advise low-impact aerobic activity to minimize risk of musculoskeletal injury 1
• Caution patients to avoid unaccustomed vigorous physical activity 1

Comprehensive Cardiac Rehabilitation Programs

• All eligible patients should be referred to a comprehensive cardiovascular rehabilitation program either before hospital discharge or during the first outpatient visit 1
• Programs should include medical evaluation, prescribed exercise, cardiac risk factor modification, education, and counseling 1
• Home-based cardiac rehabilitation with or without telemonitoring may increase participation and can be as effective as center-based cardiac rehabilitation 1
• Regular follow-up and monitoring help ensure adherence and appropriate progression of exercise prescription 1