Frequently Asked Questions
Is access to a defibrillator required for all cardiovascular prevention and rehabilitation exercise sessions?
As outlined in the 2018 joint statement by the Resuscitation Council (UK) and BACPR, all venues in which cardiovascular prevention and rehabilitation are held must have a defibrillator immediately available on site, with staff trained and competent in its use. In community venues, an AED will be the appropriate choice of defibrillator. For further information on funding for defibrillators, BACPR recommends approaching British Heart Foundation (Welcome to British Heart Foundation - BHF) or Arrhythmia Alliance (arrhythmiaalliance.org.uk).
What temperature and humidity is safe to exercise individuals with cardiovascular disease?
The 2023 Association of Chartered Physiotherapists in Cardiovascular Rehabilitation (ACPICR) Standards for Physical Activity and Exercise in the Cardiovascular Population (Healthcare Professionals - ACPICR) recommend a temperature maintained between 18-23°C and humidity below 65%. These recommendations are not mandatory, but have been specified to ensure the safety and comfort of those participating in exercise. BACPR recommend service providers develop an individual local policy suited to their own circumstances. For example, where temperatures are above these recommendations, ensuring drinking water is easily accessible, opening windows and doors, use of fans, and adjusting exercise intensity can all be used to allow participants to exercise more comfortably.
What considerations should be taken when exercising individuals with diabetes?
Up to 25% of those attending cardiovascular rehabilitation will have diabetes (with >90% being type 2 diabetic). For cardiovascular rehabilitation participants with diabetes, the value of regular physical activity is of even greater value than for those participants without diabetes, as it has significant influences on these two key independent and interdependent morbidities. Unfortunately, uptake, adherence and completion of a CR programme has been found to be poorer in CR participants with diabetes versus those without.
Participants with diabetes on insulin therapy are typically more fearful of glucose exertion related events (both during or for several hours after the exercise session has ended) and therefore need greater individualised attention, support and guidance to optimise management. Good glycaemic management not only helps to mitigate the risk of acute glycaemic events during exercising, it also important to enabling adherence and self-efficacy. Thorough assessment of any complications of diabetes such as autonomic and peripheral neuropathy will also be important to ensure adaptations to exercise are made appropriately.
To ensure safe and effective exercise participation, there are some extra considerations for diabetics that healthcare and exercise professionals should be familiar with. These are all found in the consensus statement linked below:
Diabetes UK: Diabetes UK - Know diabetes. Fight diabetes. | Diabetes UK
Which risk stratification tool should be used for individuals attending cardiovascular rehabilitation?
The American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) risk stratification tool (2021) uses exercise test and non-exercise test findings to stratify risk for cardiac events during exercise participation. The BACPR risk stratification tool (2022) also provides a useful criteria checklist for risk stratifying individuals with CVD prior to exercise.
What should the instructor/client ratio for long term exercise/Phase IV be?
For group long term exercise /Phase IV sessions there is no recommended instructor/client ratio as this depends largely upon the profile of the group members and will depend on their risk stratification (i.e. cardiac status) and the level of supervision required (cardiac status and / or co-pathologies e.g. orthopaedic limitations).
The ratio really depends on the profile of the group e.g. those at higher cardiac risk and those presenting with multiple comorbidities will require more supervision plus the size of the venue and current policies. This needs to be discussed between local scheme coordinators/venues and instructors, along with the procedure for emergencies, so that they can agree on a ratio that those leading the sessions are comfortable and confident with, and that is viable for the scheme/centre.
How soon can an individual participate in the exercise component of core (early) cardiovascular rehabilitation following a cardiovascular event?
The BACPR Standard’s and Core Components (2023) emphasises the earliest commencement of all components of rehabilitation, including physical activity and exercise training. The average start time for cardiovascular rehabilitation (CR) for patients in the UK has been no earlier than 6-weeks (Buckley et al, 2020). However, there is a growing evidence-base supporting early commencement of CR. This section is designed to give support to CR programmes (CRPs) in developing their own local policies for waiting times.
Post Myocardial Infarction (MI) – Due to advances in medicine, the average length of hospital stay for patients post-MI is short (approximately 5 days). In stable post-MI patients, research has shown that CR started within one-week of discharge from hospital and lasting twelve weeks can positively impact on ventricular remodelling (Haykowsky et al., 2011). Exercise intensity in this study was set a >60% VO2 peak, which is in line with BACPR intensity guidance. This study also estimated that for every one-week delay in starting CR an extra four weeks of exercise training would be required to obtain similar LV remodelling benefits.
Post elective angioplasty – Following elective angioplasty (with or without stenting), there is a requirement to allow for adequate healing of the insertion site of the catheter. Individual healing times will need to be considered, but most sites should be healed within two weeks. There is less risk of reopening the insertion site when the radial artery at the wrist is used, so this might be lowered to one week. Although now less commonly used, the femoral artery insertion site might require a more cautious approach due to friction and pressure applied to the area during lower body exercise.
CR practitioners should consider the risk of post-angioplasty interventions (e.g., in-stent restenosis or thrombosis, arterial ‘stretch pain’), however, research has shown that early commencement of CR does not increase the risk and improves the chances of detecting these complications, therefore reducing rehospitalisation rates (Buckley et al, 2020). This further supports the case for early commencement of supervised exercise.
Post CABG – Historically, the guidance for people starting cardiac rehab after coronary artery bypass graft (CABG) surgery was 6 weeks post-surgery due to concerns regarding the sternotomy. However, this guidance was not based on evidence (Ennis et al, 2022). There was also a restriction on upper body exercise (e.g., ergometry or resistance training) for up to 12 weeks post-surgery. Data from the SCAR randomised control trial has shown that starting exercise two weeks after CABG surgery was safe and effective for patients (Ennis et al., 2022). It is worth noting that patients had individual exercise prescription starting with light shoulder and chest mobility over the initial 2-3 weeks of their CR programme. This was progressed to usual CR guidance following this period, as tolerated.
Monitoring of patient’s heart rate (HR) during exercise may have to be performed manually if CR is started early, as the chest wound may still be healing, and HR monitors requiring a chest strap introduce an infection risk.
General Considerations:
The above evidence supports the early commencement of CR in stable cardiac patients. However, CR practitioners must ensure that a full assessment of patients is completed (including pre-activity screening, exercise testing, and risk stratification) to ensure that the patient in front of them is stable. Shorter waiting times for commencing CR may result in patients beginning exercise whilst their pharmacotherapy is still being optimising. This should be taken into consideration and pre-exercise checks be routinely made. A benefit of this is that outcomes measures such as HR and blood pressure can be feedback to the patient’s specialist.
References and further reading:
Buckley, J., Grove, T., Turner, S., and Breen, S. (2020). Physical Activity and Exercise. In Jones J. Buckley J. Furze G. & Sheppard G., (Eds) Cardiovascular prevention and rehabilitation in practice (2nd Ed). Wiley Blackwell.
Ennis, S., Lobley, G., Worrall, S., Evans, B., Kimani, P. K., Khan, A., Powell, R., Banerjee, P., Barker, T., & McGregor, G. (2022). Effectiveness and Safety of Early Initiation of Poststernotomy Cardiac Rehabilitation Exercise Training: The SCAR Randomized Clinical Trial. JAMA cardiology, 7(8), 817–824. https://doi.org/10.1001/jamacardio.2022.1651
Haykowsky, M., Scott, J., Esch, B., Schopflocher, D., Myers, J., Paterson, I., Warburton, D., Jones, L., & Clark, A. M. (2011). A meta-analysis of the effects of exercise training on left ventricular remodeling following myocardial infarction: start early and go longer for greatest exercise benefits on remodeling. Trials, 12, 92. https://doi.org/10.1186/1745-6215-12-92
What are the blood pressure limits considered safe for exercise for individuals with cardiovascular disease?
The American College of Sports Medicine (ACSM) guidelines consider resting hypertension with a systolic blood pressure >200mmHg or diastolic >110mmHg a relative contraindication to symptom-limited maximal exercise testing (ACSM 2021). In UK cardiovascular rehabilitation settings where exercise testing and training is submaximal, the 2023 Association of Chartered Physiotherapists in Cardiovascular Rehabilitation (ACPICR) Standards for Physical Activity and Exercise in the Cardiovascular Population (Healthcare Professionals - ACPICR) suggest that in the presence of such relative contraindications, exercise professionals should use clinical judgement to give individualised advice about physical activity at an appropriate intensity. This judgement may be informed by knowing the recent trends for an individual’s blood pressure, their symptoms, their general well-being, recent changes to medications, compliance with medication and the individual’s psychological state. For example, those working in early (core) cardiovascular rehabilitation settings may allow an individual to complete a graduated warm up and then re-test prior to proceeding to moderate-intensity aerobic exercise. In long-term maintenance settings where staffing ratios are lower, resting blood pressure may not be tested routinely but should be available if symptoms indicate or medications have changed. In these settings, upper blood pressure limits are more conservative (systolic blood pressure >180mmHg or diastolic >100mmHg). The Valsava manoeuvre can result in extremely high blood pressure responses and therefore should always be avoided e.g. when performing resistance exercise (ACPICR 2023). Procedures for measuring blood pressure and potential sources of error in blood pressure assessment are described in detail elsewhere (ACSM 2021; NICE 2023 Hypertension in adults: diagnosis and management (nice.org.uk)).
There are no specified lower blood pressure limits for exercise training in the published literature. In the presence of hypotension (systolic blood pressure <90mmHg, diastolic <60mmHg), exercise professionals should use clinical judgement to give individualised advice about physical activity. For example if symptoms are brought on through sudden changes of position, avoid exercises that use such movements (e.g. repeated sit-to-stand) or consider seated exercise. Where there is an orthostatic blood pressure drop of >20mmHg from sitting to standing postures, it may be advisable to delay exercise training until a medication review has taken place (ACPICR 2023). Antihypertensive medications may also lead to sudden excessive reductions in post-exercise blood pressure. An extended cool down of ten minutes with careful monitoring until blood pressure (and heart rate) have returned to near-resting levels is therefore recommended (ACPICR 2023).
How often should an individual’s blood pressure be checked whilst attending a cardiovascular rehabilitation programme?
There is no published guidance available regarding frequency of blood pressure testing whilst attending a cardiovascular rehabilitation programme. However, based on expert consensus, if blood pressure is within normal ranges i.e. systolic blood pressure 90-140mmHg and diastolic 60-90mmHg (NICE 2023; Goldie and Brady 2023) at initial assessment, and the individual arrives at their exercise session feeling well and having had no changes to their medication, there would no indication to check it before or after each individual exercise session. However, if an individual arrives feeling unwell or reports changes to medication that may alter their blood pressure, it would be indicated to check their blood pressure before commencing exercise. If an individual presents with any symptoms of concern during an exercise session, a blood pressure check may also be indicated. In early (core) cardiovascular rehabilitation settings, where an individual’s blood pressure is outside of the normal ranges specified above, clinical judgement will be required to determine the frequency of subsequent blood pressure testing depending on the individual’s circumstances, for example to assess the impact of a medication change or to assess the impact of regular aerobic exercise training on resting hypertension.
References:
American College of Sports Medicine (ACSM). ACSM’s Guidelines for Exercise Testing and Prescription. 11th Edition. William and Wilkins: Baltimore; 2021
Association of Chartered Physiotherapists in Cardiovascular Rehabilitation (ACPICR). ACPICR Standards for Physical Activity and Exercise in the Cardiovascular Population. 4th Edition. London: ACPICR; 2023: Available from: ACPICR2023StandardsReaderlayout.pdf [accessed 8 January 2024]
Goldie FC and Brady AJB. New National Institute for Health and Care Excellence guidance for hypertension: a review and comparison with the US and European guidelines. Heart 2023;0:1-3; doi: 10.1136/heartjnl-2022-322118 [accessed 9 January 2024]
National Institute for Health and Care Excellence (NICE). Hypertension in adults: diagnosis and management [NG136]. London: NICE; 2023: Available from: Hypertension in adults: diagnosis and management (nice.org.uk) [accessed 8 January 2024]