What is the optimal rehabilitation plan for an elderly patient with a history of coronary artery disease (CAD), cardiomyopathy, hypertension (HTN), and new-onset atrial fibrillation (A-fib) following a recent hospitalization for worsening dyspnea and pulmonary edema?

Key Questions and Monitoring Priorities During Rehabilitation

For this elderly patient with multiple cardiac comorbidities and new-onset atrial fibrillation following acute decompensation, rehabilitation assessment must focus on cardiac rehabilitation eligibility, fall risk stratification, anticoagulation safety, and rate control adequacy during physical activity. 1

Cardiac Rehabilitation Assessment

This patient should be referred to a comprehensive cardiac rehabilitation program immediately, as this is a Class I recommendation for patients post-cardiac surgery (AVR, MVR, CABG) and with heart failure. 1 The rehabilitation team must evaluate:

• Exercise capacity baseline using a pre-discharge exercise test or 6-minute walk distance to establish safe training parameters and provide prognostic information 1, 2
• Rate control adequacy during exertion, as resting heart rate assessment is insufficient in atrial fibrillation—exercise testing reveals inadequate rate control not apparent at rest 3
• Cardiorespiratory reserve and functional status to guide progressive mobilization intensity 2
• Presence of exercise-induced symptoms including dyspnea, chest pain, dizziness, or palpitations that may indicate inadequate rate control or ischemia 3

Fall Risk and Musculoskeletal Safety

Given the recent multiple rib fractures (5th-8th ribs) and reported dizziness, critical assessments include:

• Orthostatic vital signs to evaluate for postural hypotension, particularly given midodrine use and recent diuretic optimization 2
• Gait stability and balance testing to quantify fall risk before initiating ambulation exercises 2
• Pain control adequacy from rib fractures, as inadequate analgesia will limit respiratory effort and exercise participation 2
• Medication-related dizziness, specifically evaluating whether metoprolol, enalapril, or midodrine dosing requires adjustment 3

Anticoagulation Safety Monitoring

With new-onset atrial fibrillation on Eliquis (apixaban):

• Bleeding risk assessment during physical activities, particularly given recent rib fractures and fall history 1
• INR or anti-Xa levels if applicable to ensure therapeutic anticoagulation without excessive bleeding risk 1
• Signs of occult bleeding including hemoglobin trends, melena, hematuria, or excessive bruising during rehabilitation activities 1
• Fall prevention strategies must be intensified given the 5-fold increased mortality risk associated with major bleeding in anticoagulated patients 4

Rate Control Evaluation During Activity

Exercise testing is specifically indicated to assess rate control adequacy in permanent atrial fibrillation, as this cannot be reliably determined at rest. 3 Monitor:

• Heart rate response during graded exercise, maintaining physiological range and avoiding excessive tachycardia 3
• Symptoms of inadequate rate control including dyspnea, fatigue, or chest discomfort during activity 3
• Need for medication adjustment if heart rate exceeds target during exercise—beta-blockers are first-line for exercise-induced tachycardia in patients with preserved ejection fraction 3
• Alternative intensity monitoring methods such as Rating of Perceived Exertion (RPE) or systolic blood pressure, since pulse counting is unreliable in atrial fibrillation 3

Heart Failure Status and Volume Management

Given recent pulmonary edema and pleural effusion:

• Daily weights and fluid balance to detect early decompensation during increased activity 1
• Respiratory symptoms including dyspnea on exertion, orthopnea, or cough suggesting recurrent pulmonary congestion 1
• Diuretic response adequacy and whether furosemide dosing remains appropriate for current activity level 1
• Signs of overdiuresis including hypotension, dizziness, or electrolyte abnormalities that may contribute to falls 2

Exercise Prescription Specifics

Begin with low-intensity supervised exercise, progressing based on tolerance, with specific attention to this patient's multiple limiting factors. 2 The program should include:

• Aerobic training at 40-70% heart rate reserve, 3-7 days per week, 20-60 minutes per session, adjusted for atrial fibrillation and deconditioning 2
• Resistance training using circuit training or weight machines, 1-3 sets of 10-15 repetitions of 8-10 exercises, once clinically stable 2
• Stretching exercises 2-3 days per week, holding each stretch 10-30 seconds to prevent contractures from prolonged hospitalization 2
• Gradual progression based on tolerance, with vital sign monitoring during each session to ensure safety 2

Psychosocial and Cognitive Assessment

Psychological interventions are recommended to improve depression symptoms and health-related quality of life in coronary artery disease patients. 1 Evaluate:

• Depression screening, as sertraline is listed in current medications suggesting prior or current mood disorder 1
• Anxiety about cardiac symptoms or fear of recurrent decompensation that may limit rehabilitation participation 1
• Cognitive function to ensure ability to follow complex medication regimens and rehabilitation instructions 5
• Social support availability for home exercise program adherence and medication management 1

Medication Reconciliation and Optimization

Critical medication-related questions include:

• Why lisinopril is discontinued while enalapril is continued—ACE inhibitors are Class I recommendation for heart failure with reduced LVEF <40% 1
• Pravastatin discontinuation rationale—statins are Class I recommendation for all post-ACS and CAD patients with LDL-C goal <55 mg/dL 1
• Midodrine indication and whether it remains necessary, as it may contribute to supine hypertension or complicate rate control 3
• Polypharmacy review given extensive medication list including multiple PRN laxatives and bowel regimen agents 1

Specific Rehabilitation Contraindications to Monitor

Early mobilization should begin as soon as medically stable, but specific contraindications must be ruled out. 2 Watch for:

• Hemodynamic instability including hypotension, uncontrolled hypertension, or symptomatic arrhythmias during activity 2
• Active ischemia or anginal symptoms requiring immediate cessation of exercise 3
• Acute decompensated heart failure signs including worsening dyspnea, edema, or weight gain 1
• Uncontrolled atrial fibrillation with rapid ventricular response during exertion requiring medication adjustment before exercise progression 3

Long-Term Adherence Strategies

Continued physician encouragement and support improve long-term adherence to rehabilitation programs. 1 Plan for:

• Transition from supervised to home-based exercise with clear prescriptions and regular follow-up 1
• Lifestyle modification counseling including diet, weight management, and physical activity maintenance 1
• Regular cardiology follow-up to monitor heart failure status, atrial fibrillation management, and medication optimization 1
• Repeat rehabilitation sessions if functional decline occurs, as maintenance of benefits requires ongoing activity 2