What exercise recommendations are suitable for a patient with coronary vascular disease?

Exercise Recommendations for Coronary Vascular Disease

Patients with coronary vascular disease should perform 30-60 minutes of moderate-intensity aerobic activity (such as brisk walking) at least 5 days per week, preferably 7 days per week, supplemented by resistance training at least 2 days per week. 1

Mandatory Pre-Exercise Assessment

Before initiating any exercise program, perform risk stratification through:

• Physical activity history and/or exercise stress testing to guide prognosis and prescription 1
• Counsel patients to report and be evaluated for any exercise-related symptoms 1

This assessment is critical because it identifies high-risk patients who require medically supervised programs and establishes safe heart rate parameters for unsupervised exercise. 1

Aerobic Exercise Prescription (Primary Component)

Frequency and Duration

• Minimum 5 days per week, preferably 7 days per week 1
• 30-60 minutes per session 1
• The 2024 European Society of Cardiology guidelines recommend at least 3 days per week, preferably 6-7 days per week 1

Intensity

• Moderate-intensity continuous training (40-70% of heart rate reserve or VO2 max) 1
• Examples include brisk walking, jogging, cycling, or swimming 1
• For unsupervised exercise, target 60-75% of maximum predicted heart rate 2

High-Intensity Interval Training Considerations

The 2024 ESC guidelines note that high-intensity interval training (HIIT) can be prescribed in selected patients for specific targets such as increasing VO2 peak, though there is insufficient evidence to promote it over moderate-intensity continuous training. 1 Research demonstrates that HIIT is superior to moderate-intensity exercise for increasing aerobic capacity (17.9% vs 7.9% improvement in VO2 peak), 3 and shows a relatively low rate of major adverse cardiovascular events (1 per 17,083 training sessions) when applied in cardiac rehabilitation settings. 4

However, exercise intensity should not exceed 18 hours of strenuous exercise per week, as intensive training beyond this threshold increases mortality risk in coronary artery disease patients. 2

Resistance Training (Complementary Component)

• At least 2 days per week 1
• One to three sets of 8-12 repetitions at 60-80% of one-repetition maximum 1
• Use 8-10 different exercises involving each major muscle group 1
• For cardiac patients, use 10-15 repetitions at lower relative resistance (40-60% of 1-RM) to prevent injury 2
• Resistance training should only be initiated after 2-4 weeks of established aerobic training 2

The evidence shows that resistance exercise combined with aerobic training is associated with lower risks of total cardiovascular events and all-cause mortality. 1

Lifestyle Activity Supplementation

Increase daily lifestyle activities beyond structured exercise sessions, including:

• Walking breaks at work
• Gardening
• Household work 1

This approach moves patients out of the least fit, least active high-risk cohort (bottom 20%) and optimizes total energy expenditure. 1

Cardiac Rehabilitation Programs

Medically supervised programs are strongly recommended for high-risk patients, including those with:

• Recent acute coronary syndrome
• Recent revascularization
• Heart failure 1

Exercise training in the context of multidisciplinary, exercise-based cardiac rehabilitation leads to reduction in hospitalizations, adverse cardiovascular events, and mortality rates. 1 Home-based cardiac rehabilitation with or without telemonitoring may increase participation and be as effective as center-based programs. 1

Absolute Contraindications to Exercise

Exercise is contraindicated in patients with:

• Refractory or unstable angina
• High-grade arrhythmias
• Decompensated heart failure
• Severe aortic dilatation
• Active thromboembolic disease
• Active infection, uncontrolled diabetes, end-stage cancer, or COPD exacerbation 1

Critical Pitfalls to Avoid

Do not restrict all exercise based on coronary disease diagnosis alone. Over 50% of coronary disease patients fail to meet minimum physical activity guidelines due to the belief they cannot exercise, which worsens outcomes. 2 Physical inactivity confers greater lifetime cardiovascular event risk than moderate exercise itself. 2

Avoid high-intensity activities including basketball, ice hockey, sprinting, squash, soccer, and singles tennis in patients with coronary microvascular dysfunction or unstable disease. 2

Do not assume patients are protected from exercise-related events. The combination of increased myocardial oxygen demand and impaired coronary supply creates an arrhythmogenic substrate, particularly during excessive sympathetic activation. 2

Adherence Strategies

Maintenance of the prescribed exercise regimen is crucial. The largest reductions in total and cardiovascular mortality are seen in patients with the highest adherence rates. 1 Strategies to improve adherence include:

• Personalized prescription based on patient preferences and abilities (age, concomitant diseases, leisure and working habits, logistical restraints) 1
• Smartphone applications and wearable activity trackers to assist in long-term adherence 1
• Continuation of Phase III cardiac rehabilitation to maintain functional capacity, quality of life, and physical activity levels 1