Which cardiovascular conditions benefit from physical therapist-supervised exercises, such as coronary artery disease (CAD), heart failure (HF), and peripheral artery disease (PAD)?

Cardiovascular Conditions Benefiting from Physical Therapist-Supervised Exercise

Physical therapist-supervised exercise programs provide substantial morbidity and mortality benefits for three primary cardiovascular conditions: coronary artery disease (including post-revascularization), heart failure with reduced ejection fraction, and peripheral artery disease with claudication. 1

Coronary Artery Disease (CAD)

Supervised exercise training should be offered to all patients with stable CAD, including those post-revascularization, as it reduces cardiac events by 29% and hospital readmissions by more than half. 1

Clinical Benefits in CAD:

• Cardiac event reduction: Exercise-trained CAD patients experienced 11.9% cardiac events versus 32.2% in usual care over 337 months of follow-up 1
• Hospitalization reduction: 18.6% readmission rate in trained patients versus 46% in controls 1
• Functional improvement: Peak VO2 increases by 26% with 6 months of supervised training 1
• Quality of life: Significant improvements in QOL parameters across multiple trials 1

Mechanism of Benefit:

The improvements stem from reduced abnormal coronary vasoconstrictive responses and improved endothelial function, not just peripheral adaptations. 1 Exercise training alters coronary vasomotor response specifically during exercise, explaining improved myocardial perfusion without changes in baseline coronary diameter. 1, 2

Post-Revascularization Patients:

Supervised exercise is particularly valuable after coronary bypass surgery or percutaneous interventions, with the ETICA trial demonstrating 30% reduction in residual coronary stenosis in trained subjects. 1 Despite underutilization (only 31% of post-bypass patients receive cardiac rehabilitation), nearly all diagnosed heart disease patients can benefit from individualized exercise training. 1

Heart Failure with Reduced Ejection Fraction (HFrEF)

Supervised exercise training receives a Class I, Level A recommendation from the American Heart Association for HFrEF patients to improve functional capacity, reduce hospitalizations, and enhance quality of life. 3

Clinical Benefits in HFrEF:

• Exercise capacity: Mean peak VO2 increase of 20.5% across 15 randomized controlled trials involving 426 HF patients, with individual trials showing 12-31% improvements 1
• Hospitalization reduction: At least one trial demonstrated reduced hospitalizations and improved 1-year survival 1
• Cardiac output: Improved at maximal workloads 1
• Quality of life: Demonstrated improvements in both men and women with moderate, chronic HF 1

Physiological Adaptations:

Exercise training in HF produces multiple beneficial adaptations: improved mitochondrial size and density, increased skeletal muscle oxidative enzymes, reduced endothelial dysfunction, and decreased circulating catecholamines. 1 These peripheral adaptations are the primary mechanism, as cardiac adaptation is variable. 4

Safety Profile:

Exercise testing and training in HF patients appear safe when properly screened, with contraindications including acute exacerbation of symptoms and clinical instability. 1, 3 The risk is approximately 1 cardiac arrest per 115,000 patient-hours and 1 death per 750,000 patient-hours in supervised cardiac rehabilitation. 1

Supervision Requirements for Severe HFrEF:

For patients with severely reduced ejection fraction (≤20%), initial exercise should be conducted in a supervised setting with cardiac monitoring. 3 Start with low intensity (40-50% of peak oxygen consumption), short sessions (5-10 minutes), and gradually progress to 30-40 minutes at 3-5 sessions per week. 3 After initial supervised training, transition to home-based exercise may be considered with proper education. 3

Peripheral Artery Disease (PAD) with Claudication

Supervised exercise training is the single most effective treatment for improving walking distance in PAD patients with claudication, surpassing pharmacological agents and showing comparable or superior results to revascularization alone. 1

Clinical Benefits in PAD:

• Walking distance to pain onset: Increased 179% (225 meters) in meta-analysis of 21 exercise programs 1
• Maximal walking distance: Increased 122% (397 meters) 1
• Superiority over medications: Walking improvements exceed those from pentoxifylline and cilostazol 1
• Comparable to revascularization: The CLEVER trial showed supervised exercise and stent revascularization had comparable benefits at 6 and 18 months, both superior to optimal medical care alone 1

Optimal Exercise Prescription for PAD:

The 2024 ESC guidelines provide the most current recommendations (Class I, Level A): 1

• Frequency: At least 3 times per week 1
• Duration: At least 30 minutes per session 1
• Program length: Minimum 12 weeks 1
• Intensity: Vigorous intensity (77-95% maximal heart rate or 14-17 on Borg scale) produces best results 1
• Pain level: Training to moderate-severe claudication pain may be considered, though improvements also occur with lesser pain severities 1
• Modality: Walking is first-line, but alternative modes (strength training, arm cranking, cycling) are effective when walking is not feasible 1

Supervised vs. Home-Based Exercise:

Supervised exercise should be discussed as a treatment option before revascularization (Class I, Level B-R recommendation). 1 When supervised exercise is unavailable, structured and monitored home-based exercise with calls, logbooks, or connected devices should be considered (Class IIa, Level A). 1

Combined Therapy Approach:

For patients undergoing endovascular revascularization, supervised exercise is recommended as adjuvant therapy (Class I, Level A), as combined treatment produces greater benefits than either therapy alone. 1 The ERASE study demonstrated that revascularization plus supervised exercise yielded superior improvements in walking distances and quality of life compared to supervised exercise alone. 1

Heart Failure with Preserved Ejection Fraction (HFpEF)

While supervised exercise training improves exercise capacity and quality of life in HFpEF patients with effect sizes similar to or greater than HFrEF, Medicare coverage was specifically excluded due to insufficient evidence at the time of the 2023 scientific statement. 1 However, considerable evidence now supports the safety and efficacy of supervised exercise for chronic, stable HFpEF. 1

The exercise prescription for HFpEF follows similar principles to HFrEF: at least 3 sessions per week of aerobic exercise (walking, cycling) with 36 supervised visits typically prescribed over 12 weeks. 1

Common Pitfalls and Contraindications

Absolute Contraindications:

• Acute exacerbation of heart failure symptoms 3
• Exercise-limiting cardiovascular disease 1
• Clinical instability on medical therapy 3
• Amputation or wheelchair confinement (for PAD programs) 1

Risk Stratification:

Patients with LV ejection fraction <50%, exercise-induced ischemia or complex ventricular arrhythmias, or hemodynamically significant residual coronary stenoses require supervised exercise training with immediate physician availability. 1 For moderate-to-high-risk patients (Class C), a physician should be immediately available, though a properly trained nurse or exercise physiologist can directly supervise if the physician is not in the exercise area. 1

Underutilization Problem:

Despite strong evidence, supervised exercise programs remain severely underutilized, with only 14% of post-MI patients and 31% of post-bypass patients referred to cardiac rehabilitation. 1 Barriers include provider factors (lack of training in exercise therapeutics), system factors (poor hospital-to-outpatient transition), and patient factors (depression, travel time, insurance coverage). 1

Exercise Training Principles Across All Conditions

Effective training requires exercise at 70-85% of predicted maximal heart rate for 15-20 minutes or more, at least 3 times per week, with prescriptions based on individual exercise electrocardiogram testing. 4 The primary mechanism is increased efficiency of peripheral musculature and circulation, with variable cardiac adaptation. 4

Training reduces mortality by 25-35%, reduces clinical manifestations and complications (rhythm problems, thrombosis), and improves physical capacity, reintegration, and quality of life across cardiovascular diseases. 5 The effects link to improved metabolic performance of muscles, reduced endothelial dysfunction, insulin resistance, and neurohormonal abnormalities. 5