Exercise Training after Cardiac Surgery

Sri Wahyudati

Department of Physical Medicine and Rehabilitation, Dr. Kariadi General Hospital,

Faculty of Medicine, Universityof Diponegoro, Semarang, Indonesia

Keywords: Exercise Training, Cardiac Rehabilitation

Abstract: Exercise training is one important part of cardiac rehabilitation after cardiac surgery. This training is

aimed at improving exercise capacity and optimizing daily physical functioning concerning individual

physical activity limitations and participation restrictions. Exercise training should be started as early as

possible after cardiac surgery, which must be prescribed and supervised under medical guidance. In the

case of rehabilitation after cardiac surgery exercise training should be individually tailored according to

the clinical condition. Exercise training for patients after cardiac surgery has benefits in improving

exercise capacity, increasing muscular strength, improving graft patency and recovery of cardiac function

after surgery. Exercise training is a major component in cardiac rehabilitation programs has been proven

to be safe and effective in improving cardiac surgery patients' outcomes. Each cardiac rehabilitation

programs are tailored individually according to the clinical condition.

1 INTRODUCTION

Exercise training is one important part of Cardiac

Rehabilitation after Cardiac Surgery. This training

is aimed at improving exercise capacity and

optimizing daily physical functioning concerning

individual physical activity limitations and

participation restrictions and also can induce

inactive patients to develop and maintain an active

lifestyle, and consequently lower their future

cardiovascular risk. (Lavie CJ et.al, 2009; Taylor et

al, 2004) Cardiac rehabilitation (CR) itself usually

beginning during hospitalization (phase I,

inpatient), followed by a supervised outpatient

program lasting 3-6 months (phase II), and

continuing in a lifetime maintenance stage in

minimally supervised or unsupervised setting

(phase III). Physical activity counseling and

individually prescribed and supervised exercise

training are core components of a comprehensive

cardiac rehabilitation program, compromising 30–

50% (up to >70%) of all cardiac rehabilitation

activities. This applies to phase II as well as to

phase III cardiac rehabilitation for patients post-

acute coronary syndrome (ACS) and post-primary

coronary angioplasty (PCI), post-cardiac surgery

(coronary artery bypass, valve heart surgery, cardiac

transplantation), as well as in chronic heart failure

patients. Within large meta-analysis of the

Cochrane database, exercise training interventions

have been shown to reduce overall mortality rate of

patients with coronary artery disease by 27% (risk

reduction 0.73; con dence interval 0.54–0.98) and

mortality rate due to cardiovascular disease by 31%

(risk reduction 0.87, con dence interval 0.71–1.05).

(Jolliffe JA et al, 2001; Taylor RS et al, 2004)

Figure.1: Effectiveness of exercise only or exercise as

part of a comprehensive cardiac rehabilitation program on

all-cause mortality and cardiac mortality (according to

Jolliffe et al).

Wahyudati, S.

Exercise Training after Cardiac Surgery.

DOI: 10.5220/0009062800760081

In Proceedings of the 11th National Congress and the 18th Annual Scientiﬁc Meeting of Indonesian Physical Medicine and Rehabilitation Association (KONAS XI and PIT XVIII PERDOSRI

2019), pages 76-81

ISBN: 978-989-758-409-1

There are some benefits of exercise training for

patients after cardiac surgery. They improve exercise

capacity, increase muscular strength, improves

ventilatory efficiency, and also can improve graft

patency and recovery of cardiac function. For

example, inpatient after CABG, exercise training

can improve exercise capacity, without significant

complications or other adverse effects. Kavanagh et

al reported exercise test data for 12,169 male

rehabilitation candidates and found the most

powerful predictor of cardiac and all-cause mortality

was VO2peak. Values of <15, 15 to 22, and >22

mL·kg-1·min-1 yielded respective hazard ratios of

1.00, 0.62, and 0.39 for cardiac deaths and 1.00,

0.66, and 0.45 for all-cause deaths. Additionally, the

mortality rate might decrease by 9% for each 1

mL·kg-1·min-1 increase of VO2peak. (Kavanagh T

et al, 2002)

Furthermore, exercise training also improves

cardiac function after surgery. Nakai et al. reported

the effects of exercise training on the recovery of

cardiac function and graft patency in 115 patients

after CABG. The patients were divided into Group I

(n = 60) and Group II (n = 55) without a CR

program. The rate of graft patency was 98% in

Group I and 80% in Group II. After training, the

exercise stroke index increased significantly in

Group I, but not in Group II. The result suggested

that physical exercise training should be started as

early as possible after CABG to improve graft

patency and recovery of cardiac function. Study by

Brügemann et al.also showed physical training

improves quality of life of patients, by comparing

two types of cardiac rehabilitation: physical training

plus information ('Fit' program) during 6 weeks or

comprehensive CR which, on top of the Fit-program,

included weekly psycho-education sessions and

relaxation therapy ('Fit-Plus' program) for 8 weeks.

The results showed that quality of life improved in

both treatment groups with time up to 9 months after

training, and there was no difference between the

two types of CR. (Brugemann J et al., 2007) Based

on many studies in multicentre of cardiology,

cardiac rehabilitation programs have evolved to be

an integral part of the standard of care in modern

cardiology. (Brugemann J et al., 2007; Eagle KA et

al., 2004)

2 DISCUSSION

Based on recommendation EACPR Committee

2010, in post-cardiac surgery, cardiac rehabilitation

in patients after coronary artery and valve heart

surgery should be consist of: (recommendation class

I, level evidence C)(Eagle KA et al., 2004; Vahanian

A et al., 2007; Butchart EG et al., 2005)

 Physical activity counseling:

o Assess exercise capacity to guide exercise

prescription.

o Submaximal exercise stress test as soon as

after surgery. A maximal exercise test after

surgical wound stabilization.

o Recommended physical activity counseling

according to wound healing and exercise

capacity.

 Exercise training recommendation

o Exercise training can be started early in-

hospital.

o Programs should last 2 – 4 weeks for in-

patient or up to 12 weeks for out-patient

settings.

o Upper-body training can begin when the

sternal wound is stable.

o Exercise training should be individually

tailored according to the clinical condition,

baseline exercise capacity, ventricular

function, and different valve surgery (after

mitral valve replacement exercise tolerance is

much lower than that after aortic valve

replacement, particularly if there is residual

pulmonary hypertension).

The following points are established/general

agreed on issues in exercise training applicable to all

clinical conditions : (Piepoli MF et al., 2010)

 Assess exercise capacity by symptom-limited

stress testing, either on bicycle ergometer or on

a treadmill. In the routine clinical setting, this

is not always applicable, particularly in the

presence of left ventricular dysfunction

(ejection fraction 40%) or after recent surgical

intervention (because of the surgical wounds)

and therefore sub-maximal exercise evaluation

and/ or 6 min walk test should be considered.



Advise individualized exercise training after

careful clinical evaluation, including risk

stratification.

 Recommend as general advice sub-maximal

endurance aerobic.

 Educate on the recognition of symptoms

induced by effort. Appropriate behavior and re-

definition of exercise training target should be

discussed for the individual patient.

 Expected outcomes: increased

cardiorespiratory fitness and enhanced

flexibility, muscular endurance, and strength;

reduction of symptoms, attenuated physiologic

Exercise Training after Cardiac Surgery

responses to physical challenges, and improved

psychosocial well-being.

 Program settings. During the initial phases

supervised in-patient or hospital-based exercise

training programs may be recommended in

high-risk cardiovascular patients, i.e. those

with impaired systolic left ventricular function,

those with severe co-morbidities, leading to

significant disability, and in those with recent

(1 week) clinical destabilization. This will

verify individual responses and tolerability in a

safe clinical setting and will promptly identify

signs and symptoms indicating to modify or

terminate the program. The supervision should

include physical examination, assessment of

exercise-related symptoms or arrhythmias, and

monitoring of heart rate and blood pressure

before, during, and after exercise training. The

supervised period should be prolonged in

patients with new symptoms, clinical signs of

decompensation, blood pressure abnormalities,

and increased supraventricular or ventricular

arrhythmia during exercise.

There are a recommendation of exercise training

that generally applicable for secondary prevention in

patients with heart disease: (Piepoli MF et al., 2010)

 Mode: Continuous endurance: walking,

jogging, cycling, swimming, rowing, stair

climbing, elliptical trainers, and aerobic

dancing.

 Duration: At least 20–30 min (preferably 45–

60 min).

 Most days (at least 3 days/week and preferably

6 – 7 days/ week.

 Intensity: 50–80% of peak oxygen

consumption (close to the anaerobic threshold)

or peak heart rate or 40 – 60% of heart rate

reserve; 10/20–14/20 of the Borg Rating of

Perceived Exertion.

There are some differences in prescription in

patients after cardiac surgery. The following general

criteria should be considered in planning exercise

testing modality for exercise prescription in patients

after cardiac surgery: (Piepoli MF et al., 2010)

 Safety

 Co-morbidities: hemoglobin concentration

(Hb) values; muscular-skeletal discomfort,

healing issues at the incision sites

 Associated factors: deconditioning due to

prolonged hospitalization, sedentary habits,

orthopedic limitations, occupational and

recreational needs.

 Incomplete revascularization after CABG

surgery.

2.1 Exercise Prescription in Patients

After CABG.

Exercise prescription methodology is generally the

same as that used with CAD patients. Initially, some

patients may need lower-intensity or modified

exercise because of musculoskeletal discomfort or

healing issues at their incision sites, including not

only the chest but possibly also legs and arms.

Specifically, patients should completely refrain from

upper-extremity aerobic exercise training, for

example, arm ergometry and resistance training, for

4–6 weeks post-surgery to ensure the stability of the

sternum and sternal wound healing. The exception is

appropriate upper and lower body stretching and

flexibility exercises to promote mobility. In patients

with previous CABG, several aerobic training

intensities have proven effective the choice of which

will depend on both the level of exercise-related risk

and the patient's clinical condition. In this regard, it

must be borne in mind that, among patients entering

a rehabilitation program after a recent acute cardiac

event, those with recent CABG have been found to

have the lowest peak VO2. (Ades PA et al., 2006)

Because of the possibility of graft closure,

program staff should be alert for new patient

complaints of angina pectoris or angina-equivalent

symptoms or signs, such as exercise intolerance or

new ECG signs of myocardial ischemia. Patients

should also be educated regarding these possibilities.

Recognizing whether the revascularization was

complete or incomplete is valuable in this regard as

the latter may increase the likelihood of postsurgical

signs and symptoms of residual myocardial ischemia

during exercise, which may significantly affect the

results of the rehabilitation process.

2.2 Exercise Prescription in Patients

After Valve Repair/ Replacement

The exercise prescription and training of patients

with recent valve replacement or repair is very

similar to that used with CABG surgery patients.

However, the physical activity of some valvular

heart disease patients may have been very restricted

for an extended period before the surgical

intervention. Consequently, the resulting low

functional capacity may require these patients to

KONAS XI and PIT XVIII PERDOSRI 2019 - The 11th National Congress and The 18th Annual Scientiﬁc Meeting of Indonesian Physical

Medicine and Rehabilitation Association

initiate, and proceed with, an exercise in a

conservative fashion, especially during the early

stages of the exercise training program. Exercise

intensities in the light to moderate and moderate to

high domains have been used in patients with recent

heart valve replacement or repair and balloon

valvuloplasty, demonstrating significant effects on

exercise capacity and quality of life. Preliminary

data also indicate a possible reverse left ventricular

remodeling effect of prolonged aerobic training in

patients with previous aortic valve replacement.

Anticoagulation therapy is very common in patients

who have undergone valve surgery; consequently,

this necessitates caution for exercise-related injuries

and subsequent bleeding. Staff should frequently

remind patients undergoing exercise training of the

increased risk of such events.

2.3 How to Define Exercise Intensity

Training intensity can be defined based on the

results of an exercise stress test. This should yield

maximal heart rate, maximal exercise load in watts,

possible ischemic threshold, and blood pressure

response to exercise. These data will form the basis

for determining the individual training load and

training heart rate. A complete cardiovascular

examination or more specific therapy has to take

place if cardiac complaints and/or symptoms arise

during the exercise stress test.

If complaints or symptom limitations persist,

despite maximal therapeutic efforts, it is crucial to

keep the exercise load at a level free of symptoms

and ischemia. It is generally recommended that the

training intensity should be clearly below the

ischemic threshold

The heart rate is an objective, easily determined

parameter used to regulate and control exercise load

in cardiac rehabilitation. The maximal heart rate

(HRmax) is the highest heart rate achieved before

the termination of an incremental exercise tolerance

test due to subjective exhaustion or objective

indications. In cardiac rehabilitation, a training heart

rate of 60–75% HFmax (maximal heart rate) is

recommended. It is important to keep in mind that

only the heart rate response to an exercise stress test

performed under the patient’s actual medication can

be used for exercise prescription. This applies

especially to the use of ß-receptor blockers The

training heart rate can also be determined

mathematically by using the Karvonen formula, in

which the heart rate reserve (HRR) is calculated. In

cardiac patients, training heart rate of 40–60% of

heart rate reserve is recommended. The heart rate

reserve method should especially be used in patients

with chronotropic incompetence. The training heart

rate should always be determined clearly below the

ischemic threshold (i.e., 10 beats/min).

Maximal exercise capacity measured in watt is a

reliable and reproducible parameter to regulate

exercise training performed on a bicycle ergometer.

In cardiac rehabilitation, exercise intensity at 40–

60% (if tolerated up to 70–80%) of maximal load

(watt) achieved in a symptom-limited exercise test is

recommended. In patients with very low exercise

tolerance, very low heart rate reserve as well as with

the inability of the sinus node to react adequately to

exercise stress by increasing heart rate (patients with

chronotropic incompetence, atrial fibrillation,

pacemakers, and post-heart transplant) training

intensity should be controlled according to exercise

load in watts and by using the Borg scale.

Figure 2: How to determine the target heart rate for

exercise training in cardiac rehabilitation using the

Karvonen formula.

The Borg Scale (rate of perceived exertion, RPE)

is used to subjectively assess how the individual

perceives the intensity of the performed exercise on

a scale from 6 to 20. It is not advisable, however, to

solely rely on the Borg scale to regulate training load

as it contains too many influencing factors from the

patient’s perspective (i.e., unfamiliar method, poor

body awareness, over motivation, and peer

pressure). The Borg scale can be used as a

supplement to other training regulation options, as

well as to facilitate developing body awareness to

Exercise Training after Cardiac Surgery

the exercise load. Target values are RPE 11–14,

comparable to light to moderate exercise intensity.

Figure 3: The Borg- Scale

Maximal oxygen consumption (VO2peak)

reached during an exercise stress test and the oxygen

consumption at the anaerobic threshold (VO2-AT)

are meaningful parameters in regulating exercise

load during training. The latter can also be

determined during submaximal exercise testing,

independent of the individual's motivation level. If a

cardiopulmonary exercise test is used to determine

aerobic training intensity, then 40–70% of VO2peak

(up to 80% if tolerated) should be targeted, close to

the individual's anaerobic threshold.

Before doing exercise training in cardiac

patients, there are some contraindications for aerobic

endurance training that should be aware of some

conditions listed in table 1.

Table 1: Exercise Contraindication in Cardiac Patients.

Acute coronary syndrome (ACS)

Malignant hypertension with systolic blood

pressure >190 mmHg during exercise training

despite exhaustive antihypertensive medication

therapy

Drop-in systolic blood pressure by 320 mmHg

during exercise, in particular in patients with

coronary heart disease (CHD)

Severe secondary mitral valve insufficiency or

more specifically moderate mitral valve

insufficiency with evidence of increased

regurgitation during exercise

Heart failure NYHA IV

Supraventricular and ventricular arrhythmias

causing symptoms or hemodynamic compromise,

continual ventricular tachycardia

Frequent ventricular extra-systoles, known

continual ventricular tachycardia in advanced left

ventricular dysfunction or more specifically after

myocardial infarct as well as in response to

exercise or during the post-exercise regeneration

phase

Cardiovascular diseases that have not been risk

evaluated according to 4.1.3, and that have not

been treated according to guideline requirements in

terms of best possible prognosis outcome (i.e.,

Beta-blocker in patients with CHD, angiotensin-

converting enzyme-inhibitor in patients with heart

failure), or more specifically, hemodynamic

control (i.e., maximal medication therapy for blood

pressure regulation in severe arterial hypertension).

Patients with contraindications to exercise training

due to malignant arrhythmias, on the other hand,

can be introduced to a training program after

antiarrhythmic measures have been taken (i.e.,

implantable cardio de brillator (ICD), proven

efficacy of medication therapy)

3 CONCLUSION

Based on many studies, the clinical effect of

exercise training for patients after cardiac surgery

has benefits in improving exercise capacity,

increasing muscular strength, improving graft

patency and recovery of cardiac function after

surgery. Thus cardiac rehabilitation programs must

be given in advanced to patients who underwent

cardiac surgery. The programs are generally

exercised based and prescribed individually

according to the patient's special condition which

varies one another. According to that the cardiac

rehabilitation programs exercise’s prescription

which determined by exercise testing particularly is

safe.

Cardiac rehabilitation programs have become an

integral part of the standard of care in modern

cardiology. Their scope has shifted from the

emphasis on exercise therapy to a comprehensive

exercise measured approach that has many benefits

in supporting cardiac surgery patient outcomes. Each

cardiac rehabilitation programs are tailored

individually according to the clinical condition. In

most current guidelines of cardiovascular societies

worldwide cardiac rehabilitation is a class I

recommendation.

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Exercise Training after Cardiac Surgery