What exercises are recommended for a patient after a myocardial infarction (MI)?

Exercise After Myocardial Infarction

Begin daily walking immediately upon hospital discharge, progressing to 30-60 minutes of moderate aerobic activity (such as brisk walking) 5-7 days per week, with enrollment in a supervised cardiac rehabilitation program strongly recommended for safe progression to higher-intensity activities. 1, 2

Immediate Post-Discharge Phase (Days 1-14)

Start walking the day after discharge in uncomplicated, stable post-MI patients. 2 This can begin immediately without waiting for formal exercise testing in low-risk patients. 1

• Target 30-60 minutes total daily activity, which can be divided into 2-3 segments throughout the day 1
• Maintain heart rate at 60-75% of maximum predicted for unsupervised exercise 1, 2
• Supplement with increased daily lifestyle activities such as walking breaks at work, gardening, and light household work 1

Critical safety note: The incidence of major cardiovascular complications during outpatient cardiac exercise is approximately 1 in 60,000 participant-hours, with lowest rates occurring during controlled activities like walking and cycling. 1

Weeks 2-6: Structured Exercise Training

Formal exercise training can begin within 1-2 weeks after MI treated with PCI or CABG to relieve ischemia. 1

• Enroll in cardiac rehabilitation programs, particularly for moderate-to-high-risk patients or those with multiple modifiable risk factors 1, 2
• Supervised training allows for higher intensity targets (70-85% of maximum predicted heart rate) compared to unsupervised exercise (60-75%) 1, 2
• Low-intensity exercise training starting at 14 days post-MI is safe and effective, though research shows similar outcomes whether starting at 2 weeks versus 6 weeks 3

Exercise modalities with lowest risk: Walking, cycling, and treadmill exercise cause minimal stress on joints and have the lowest incidence of sudden cardiac arrest. 1

Weeks 6-12: Progression and Resistance Training

Add mild-to-moderate resistance training 2-4 weeks after aerobic training has begun, performed 2 days per week. 1, 2

• Start with 30-40% of 1-repetition maximum for upper body exercises 4
• Research demonstrates that low-to-moderate intensity strength training (20-60% of 1-RM) starting 6-16 weeks post-MI increases strength by 10-14% without cardiovascular complications 4
• Resistance training may actually have lower rates of cardiovascular problems than aerobic exercise in selected patients 4

Avoid high-impact activities (running, aerobic dancing) that cause repeated impact on joints. 1

Return to Running: Specific Algorithm

Running should only be considered after meeting ALL of the following criteria: 2

1. Completion of 2-4 weeks of moderate-intensity aerobic training
2. Exercise capacity of 3-5 times per week without symptoms
3. Absence of residual ischemia on stress testing
4. Adequate left ventricular function documented

Phased progression to running: 2

• Weeks 1-2: Daily walking only
• Weeks 2-6: Walking 3-5 times per week at moderate intensity
• Weeks 6-12: Consider interval training if above criteria met
• Strict monitoring for symptoms required throughout

Special Considerations for Left Ventricular Dysfunction

Patients with moderate-to-severe LV dysfunction (EF <45%) benefit equally from exercise training without deteriorating LV remodeling. 5

• Research shows similar improvements in exercise capacity (15-18% increase in peak VO2) regardless of baseline LVEF 5
• Two randomized controlled trials demonstrate no adverse effects on regional wall motion, LV systolic function, or chamber dimensions after months of moderate-to-high-intensity exercise 1
• Even patients with EF <35% can safely participate in moderate-intensity exercise (50-60% of heart rate reserve) starting early after MI 5

Activities to Avoid and Restrictions

Specific restrictions for strenuous activities: 1

• Heavy lifting (>30 pounds for upper body)
• Climbing multiple flights of stairs initially
• Strenuous yard work
• High-impact household activities

For post-CABG patients specifically: Avoid traditional upper-body resistance training for 8-12 weeks to allow sternal healing. 6

Low-Risk Patients: Accelerated Return

Highly selected low-risk patients may return to full normal activities, including work, at 2 weeks post-MI if they meet ALL criteria: 7

• No angina
• LVEF >40%
• Negative symptom-limited exercise stress test at 1 week (<2 mm ST depression)
• Achieved >7 METs on testing
• No inducible ventricular tachycardia (if LVEF <40%)

Research demonstrates this accelerated approach is safe with no deaths, heart failure, or increased reinfarction rates at 6 months. 7

Monitoring and Safety Parameters

Exercise testing should be performed before discharge or early post-discharge to guide exercise prescription and assess risk. 1

• Submaximal protocols target peak heart rate of 120 bpm or 70% predicted maximum 1
• Symptom-limited protocols continue until abnormal signs/symptoms occur 1
• Exercise testing after MI has a fatal cardiac event rate of only 0.03% 1

Warning signs requiring immediate cessation: 1

• Angina or chest discomfort
• ST segment depression or elevation
• Chronotropic incompetence
• Decrease in systolic blood pressure
• Excessive dyspnea or fatigue

Long-Term Benefits and Goals

Each single-stage increase in physical work capacity reduces all-cause mortality by 8-14% in post-MI patients. 2

• Exercise rehabilitation reduces mortality and improves collateral circulation, exercise capacity, and quality of life 2
• Target frequency of 3-5 times per week for meaningful functional improvement 2
• Comprehensive cardiac rehabilitation includes medical evaluation, prescribed exercise, risk factor modification, education, and counseling 1

Common pitfall: Patients who undergo revascularization (PCI or CABG) may mistakenly believe this obviates the need for significant lifestyle changes and exercise—aggressive counseling is essential. 1