What is cardiac rehabilitation?
Cardiac rehabilitation (rehab) teaches you how to be more active and make lifestyle changes that can lead to a stronger heart and better health. Cardiac rehab can help you feel better and reduce your risk of future heart problems.
In cardiac rehab, you work with a team of health professionals. Often the team includes a doctor, a nurse specialist, a dietitian, an exercise therapist, and a physical therapist. The team designs a program just for you, based on your health and goals. Then they give you support to help you succeed.
If you have had a heart attack, you may be afraid to exercise. Or if you have never exercised, you may not know how to get started. Your cardiac rehab team will help you start slowly and work up to a level that is good for your heart.
Many hospitals and rehab centers offer cardiac rehab programs. You may be part of a cardiac rehab group, but each person will follow his or her own plan.
Who should take part in cardiac rehab?
Doctors often prescribe cardiac rehab for people who have had a heart attack or bypass surgery. But people with many types of heart or blood vessel disease can benefit from cardiac rehab. Rehab might help you if you have:

• Heart failure.
• Peripheral artery disease (PAD).
• Had or plan to have a heart transplant.
• Had angioplasty to open a coronary artery.
• Had another type of heart surgery, such as valve replacement.

What happens in cardiac rehab?
In cardiac rehab, you will learn how to:

• Manage your heart disease and problems such as high blood pressure and high cholesterol.
• Exercise safely.
• Eat a heart-healthy diet.
• Break bad habits, like smoking.
• Reduce stress and depression.
• Get back to work sooner and safely.

Exercise is a big part of cardiac rehab. So before you get started, you will have a full checkup, which may include tests such as an electrocardiogram (EKG or ECG) and a “stress test” (exercise electrocardiogram). These tests show how well your heart is working. They will help your team design an exercise program that is safe for you.
At first your rehab team will keep a close watch on how exercise affects your heart. As you get stronger, you will learn how to check your own heart rate when you exercise. By the end of rehab, you will be ready to continue an exercise program on your own.
What are the benefits of cardiac rehab?
Starting cardiac rehab after a heart attack can lower your chance of dying from a heart attack and can help you stay out of the hospital. It may reduce your need for medicine.
Cardiac rehab may also help you to:

• Have better overall health.
• Lose weight or keep weight off.
• Feel less depressed and more hopeful.
• Have more energy and feel better about yourself.

Changing old habits is hard. But in cardiac rehab, you get the support of experts who can help you make new healthy habits. And meeting other people who are in cardiac rehab can help you know that you're not alone.
Phases of Cardiac Rehab
Cardiac rehab is a program designed specifically for you and your medical needs. It includes exercise, lifestyle changes, education, and emotional support. It can help improve your health and enable you to live a more active life after you have had a heart attack or heart surgery or if you have a long-term heart problem such as heart failure. Cardiac rehab can also help you return to work safely and in a timely manner.

You may start a cardiac rehab program while you are still in the hospital after having treatment for a heart attack or other heart problem, soon after leaving the hospital, or at any other time to help prevent future heart problems, improve the quality of your life, and make you healthier.

Your doctor will give you an exercise prescription that gives you and your cardiac rehab team guidelines for the frequency, duration, and intensity of exercise. The prescription will be based on your medical condition and your fitness level.
How fast you recover depends on your age, your health, and whether you have other health conditions that may slow your recovery. A younger person without other health problems may improve more quickly than an older person who is in poor health. Depending on your condition and how you respond to rehab, you may stay in a particular phase or move back and forth among the various phases. There is no set length of time that you must stay in a specific phase.
If any of the following symptoms last for more than a few minutes before, during, or after your exercise session, stop exercising and seek medical help:

• Any unusual discomfort, such as chest pain or angina
• Nausea
• Extremely heavy breathing
• Severe fatigue
• Extreme sweating
• Abnormal changes in heart rate, including either of the following:
• Unexplained low heart rate, or
• Dramatically higher heart rate than your target heart rate
• Abnormal blood pressure, including any of the following:
• Drop in systolic blood pressure
• Failure of systolic blood pressure to rise
• Excessive blood pressure (over 240/100 millimeters of mercury, or mm Hg)
• Blood sugar below 80 milligrams per deciliter (mg/dL) or above 250 mg/dL

Cardiac rehab has four phases. Your doctor will determine which phase is best for you to start your program.
Phase I: Inpatient program
Phase I takes place in the hospital after you have experienced a heart attack or other major heart problem. Phase I of cardiac rehab usually includes:

• Determining how well you can care for yourself (bathing, dressing, and grooming) after your heart attack or surgery.
• Measuring your ability to exercise. Your doctor will probably want you to have an exercise test before you begin your cardiac rehab exercise program. This test will show what types of exercise are safe for you and how soon you can begin to exercise.
• Identifying which daily activities, such as lifting, you can safely do.
• Providing patient and family education about the lifestyle changes you need to make, such as eating healthy foods and stopping cigarette smoking. Changes in your diet may be difficult to make, but even small changes can help lower cholesterol levels and improve your health. For ideas that can help you get started, see:
• Doing light exercise, such as walking short distances several times a day and possibly beginning a weight-training program.

Home program, phase II, and phase III: Outpatient programs

The remaining three phases of your cardiac rehab take place outside the hospital. At first, your rehab team will keep a close watch on how exercise affects your heart and how you are progressing, before gradually releasing you from supervision to continue cardiac rehab on your own. The healthier lifestyle you've learned—including eating a balanced diet, exercising regularly, and not smoking—can then become a way of life for you.
During this time you may also see your doctor regularly to treat other medical conditions, including high cholesterol and high blood pressure.
Cardiac rehab during home program, phase II, and phase III usually includes:

• Close monitoring and supervision during the early part of your exercise program.
• Preparing you to return to work and the recreational activities you enjoyed before your heart problems. Your work or leisure activities may need to be modified.

Providing education and counseling for you and your family to help you maintain a lifestyle of healthy habits that will lower your risk of having further heartproblems. Depression is common in people with heart problems. Counseling and medicines for depression, if necessary, may be another important part of cardiac rehab.

Making a plan to help you start a safe home exercise program and participate in other unsupervised activities. For tips on walking as exercise, see:

Cardiac rehab: Examples of phase I exercises after a heart attack
As your strength gradually increases, your recovery team (nurses and physical therapists) will encourage you to progress from basic postural exercises in your bed to walking in the halls and down stairs. An example of daily activity following a heart attack is shown below.

Initial inpatient daily activity Step 1 Rest in bed until stable. Sit up in bed with assistance. Stand at bedside with assistance. Perform self-care activities while seated. Step 2 Sit up in bed independently. Walk in room and to bathroom. Perform self-care activities in bathroom. Step 3 Sit and stand independently. Walk in hall with assistance; 5 to 10 minutes, 2 to 3 times a day. Step 4 Walk in hall; 5 to 10 minutes, 3 to 4 times a day. Walk down flight of stairs with assistance.

As you become stronger, walking in the halls should become an important part of your recovery. An example of a progressive program that may be used is shown below:

Increase in daily activity
Mode	Walking in hospital hall
Frequency	Early mobile (days 1 to 3) 1 to 2 times a day (always warm up and cool down) Later mobile (begin on day 4) online casino games 3 to 4 times a day
Intensity	Heart rate greater than 120 bpm (beats per minute), or 20 bpm above resting heart rate (RHR) Rating of perceived exertion (RPE) greater than 13 Stop when you get tired.
Cardiac rehab: General exercise guidelines for phase II The following exercise guidelines for phase II cardiac rehab may vary depending on your medical history, clinical status, symptoms, and whether you have had heart surgery. These are just guidelines: Discuss any additional physical limitations or medical issues with your doctor before beginning any exercise program. Your rate of recovery depends on age, gender, and other health conditions. Depending on your condition and how you respond to rehab, you may stay in a particular phase or move back and forth among the various phases. There is no set length of time that you must stay in a specific phase. Phase II cardiac rehab program Phase II is the initial outpatient cardiac rehab program. A phase II program has many parts, including supervised exercise and a variety of measurements and assessments. For example, you may wear a portable heart monitor for all exercises in phase II. In addition to restoring your physical function, the focus of phase II is on reducing your risk of future heart conditions. You will receive information and tools to change certain aspects of your lifestyle, such as smoking, nutrition, stress, and taking your medicines. You may also receive vocational rehabilitation so you can return to work safely and in a timely manner. Your progress will be monitored by several rehab staff members. The frequency and duration of phase II rehab sessions per week will vary depending upon the structure of your particular program. Phase II exercise program Your exercise program will include stretching, aerobic exercise, and an introduction to strength training. Approximate length: 8 to 12 weeks (6 to 8 weeks following discharge) Physical goals: Increasing aerobic capacity and overall strength, self-monitoring of heart rate (HR) and rating of perceived exertion (RPE), introduction to stretching, and strength exercises Flexibility exercises Make stretching part of your warm-up and cooldown every time you exercise. The benefits associated with an increase of flexibility are numerous, and as part of your lifetime physical maintenance program, stretching will help increase the length of time that you can continue to be active. Enjoy the feeling of relaxation as you stretch. As you perform each exercise in a slow and controlled manner, focus on your breathing and become more aware of your body's range of motion and positioning. Continue to follow the recommended guidelines carefully. General guidelines for flexibility exercises Frequency: At least 3 days per week Intensity: Stretch to a position of mild discomfort. Duration: 10 to 30 seconds for each stretch Repetition: 3 to 5 for each stretch Type: Control and hold without resistance, emphasis on lower back and legs Aerobic exercise Phase II rehab includes a carefully monitored aerobic program that involves one or more types of exercise. Choose an exercise that you enjoy and record how hard you exercise. Use your target heart rate (THR) and rating of perceived exertion (RPE). Sometimes, exercise may cause angina. It is important to know when you reach an exercise intensity that causes angina and to exercise below that threshold. Therefore, note your heart rate intensity at any signs of chest discomfort or pain, and tell your doctor and the staff who is supervising your exercise. It is suggested that you use heart rate monitors to accurately record your heart rate and exercise 10 to 15 beats per minute (bpm) below the known threshold.   Aerobic exercise Mode Aerobic (walking, swimming, biking) Intensity RPE: 11 to 13 Heart rate: within your target heart rate range 30 bpm above resting heart rate (RHR) Duration 15 to 60 minutes Frequency Minimum of 3 to 5 times a week Progression Increase HR Change mode Increase duration and endurance (gradually)     Strength training Strength training has been shown to be very effective with cardiac patients for improving muscular strength and endurance as well as help in improving coronary risk factors. It also decreases the cardiac demands of daily activities such as lifting and increases your endurance capacity for other activities. You should not start a strength-training program without discussing it with your doctor. When strength training, it is important that you follow guidelines regarding correct technique, breathing, and appropriate intensity. Below is an introductory program and guidelines to use to begin improving your muscular strength and endurance. Introductory program to increase strength Mode Strength training (hand weights, machines) Intensity RPE: 11 to 13 No straining No pain 1 to 10 pounds Duration 10 to 12 reps 1 to 2 sets per exercise Frequency 2 to 3 days a week Add following aerobic exercise Progression Increase resistance. Reduce rest period between sets. Add more exercises. General guidelines for strength training Avoid holding your breath; try to exhale upon effort. Be sure to warm up and cool down to prevent injury and soreness. Complete a smooth, controlled, and full range of motion with each activity. Balance your exercise between complementary muscle groups: Biceps and triceps Quadriceps and hamstrings Chest and upper back Always include exercises that strengthen your trunk (lower back and abdomen). Avoid gripping the weight handles tightly to prevent an excessive blood pressure response to lifting. Typically, weight training is done after aerobic exercise and/or on alternate days. Begin with exercises for major muscle groups: work large muscles, such as chest and back, before smaller muscles, such as biceps and triceps. Delayed onset of muscular soreness may occur, so progress slowly and allow for recovery time. Do not do strength training every day because your muscle groups need at least one day to recover.	Intermittent bouts, 3 to 5 min. Rest periods at your discretion, 1 to 2 min. shorter than exercise bout To progress, initially increase to 10 to 15 min., then increase intensity. Include stair climbing when your doctor says it’s okay.

Cardiac rehab: Examples of phase II exercises after open-heart surgery

Your chest, shoulder, and upper back muscles tend to become tight after open-heart surgery. The following exercises are designed to help flexibility and prevent stiffness in these muscles.
These are just guidelines. Discuss additional physical limitations or medical issues with your doctor before beginning any exercise program.
Start with the easy exercises, and add others as you are able to do them comfortably.

Phase II exercises after open-heart surgery
Time	Position	Description
Start right after discharge, or within 1 week after surgery	Lying on your back on the bed or floor	Keep your arms flat on the bed or floor. Place your arms at 90º angles to your body. Keep your elbows slightly bent. Move your hands over your head as far as you comfortably can but keep your arms flat on the bed or floor. Hold this position for 10 seconds. Clasp your hands behind your head, then bring your elbows in so they are above your ears. Then flatten your elbows so that they rest against the bed or floor. Hold this position for 10 seconds.
	Sitting	Shoulder roll: Shrug your shoulders toward your ears, then roll them back. Move slowly and gently. Repeat 5 times. Stretch your arms forward and back: Reach your arms forward, keeping your elbows straight so your shoulder blades move away from your spinal column. Bring your elbows back so you are pinching your shoulder blades together. Hold this position for 10 seconds.
Start 2 weeks after discharge, or 3 weeks after surgery	Standing or sitting	Put your arms down in front with a broomstick or cane in both hands. Lift the stick over your head, and then gently down behind your head. Lift the stick overhead and return to starting position. Repeat 5 times. Put the broomstick or cane behind your lower back and lift it slowly up your back by bending your elbows until you feel tightness. Slowly lower the stick to the starting position. Repeat 5 times. Bring the stick up to shoulder level and then move your arms gently from side to side.
Start 4 weeks after discharge, or 5 to 6 weeks after surgery	Standing	Wall push-ups: Stand an arm's length away from the wall, your arms shoulder-width apart and palms against the wall. Slowly lean towards the wall, elbows out, and then gently push away from the wall so your arms are straight. Repeat 5 times.

General guidelines for exercise right after discharge

• Do the exercises twice a day for the first 3 weeks and then once a day for the next 3 weeks. Your exercise program will become more strenuous, so you will not exercise as often as you did at the beginning of your program.
• Gradually build up to 5 repetitions on each exercise.
• You may space exercises out throughout the day to avoid fatigue.
• If any exercise causes excessive discomfort, skip it and try it again in a week or two.
• Extend until it feels tight, and hold the position for 10 to 15 seconds. Relax and repeat.
• Do exercises slowly, avoid fast or jerky movements, and do not stretch to the point of pain.

Cardiac rehab: General exercise guidelines for phase III
The following exercise guidelines for phase III cardiac rehab may vary depending on your medical history, clinical status, and symptoms and whether you have had heart problems or heart surgery
Your rate of recovery depends on age, gender, and other health conditions. Depending upon your condition and how you respond to rehab, you may stay in a particular phase or move back and forth among the various phases. There is no set length of time that you must stay in a specific phase.
Phase III cardiac rehab program
Phase III is often referred to as the maintenance phase of cardiac rehab because it emphasizes long-term lifestyle issues. The program will help you practice and keep healthy behaviors and habits to continue to improve your existing heart condition or to keep your risk of heart disease low. Regularly communicate with your rehab staff and doctors for periodic reviews and assessments.

 

Phase III exercise program
Your exercise program will include stretching, aerobic exercise, and strength training. A daily exercise routine is encouraged.

• Length: Lifetime
• Physical goals: Maintain your aerobic capacity, overall strength, and flexibility.

Flexibility exercises
Stretching should be a part of your warm-up and cooldown every time you exercise. There are many benefits associated with an increase of flexibility, including an increase in the length of time that you can continue to be active.
General guidelines for flexibility exercises

• Frequency: Do stretching exercises at least 3 days a week.
• Intensity: Stretch to a position of mild discomfort.
• Duration:Hold each stretch for 10 to 30 seconds.
• Repetition: Do each stretch 3 to 5 times.
• Type: Control and hold without resistance, with emphasis on the lower back and legs.

Aerobic exercise
Aerobic exercise in phase III rehab is a program designed for a lifetime of commitment. Make it enjoyable by choosing activities that you like. It is still important that you use your target heart rate and rating of perceived exertion (RPE) and modify your intensity as you improve or encounter difficulties

Aerobic exercise
Mode	Intensity	Frequency	Duration	Progression
Aerobic (walking, swimming, biking, rowing, jogging)	Within target heart rate range An RPE of 12 to 14 Until tolerance if no symptoms	Minimum of 3 to 4 times a week Minimum of 5 days each week for weight loss	15 to 60 minutes Minimum of 45 to 60 minutes for weight loss	Increase heart rate. Change type of activity. Increase duration (gradually).

Strength training
Strength training continues to be an important part of your overall physical rehabilitation and conditioning. Gradually progress as you feel comfortable, but more important, combine it with your aerobic training. Be sure to monitor your progress toward your goals.
Continue to follow your doctor's guidelines about correct technique, breathing, and intensity to improve and/or keep your muscular strength and endurance
Cardiac rehab: When to stop exercising and call your doctor
Exercise is safe and beneficial in your cardiac rehabilitation program. Exercise helps you return to your normal life. But there is a small risk of complications.1 When you exercise, it is important that you are aware of signs and symptoms that mean that you should stop exercising and contact your doctor.
If any of the following symptoms last for more than a few minutes before, during, or after your exercise session, stop exercising and seek medical help.

• Any unusual discomfort, such as chest pain or angina
• Nausea
• Extremely heavy breathing
• Severe fatigue
• Extreme sweating
• Abnormal changes in heart rate, including either of the following:
• Unexplained low heart rate, or
• Dramatically higher heart rate than your target heart rate
• Abnormal blood pressure, including any of the following:
• Drop in systolic blood pressure
• Failure of systolic blood pressure to rise
• Excessive blood pressure (over 240/100 millimeters of mercury, or mm Hg)
• Blood sugar below 80 milligrams per deciliter (mg/dL) or above 250 mg/dL

Your ability to identify how your body is responding to exercise and what physical conditions are normal is necessary for your rehabilitation. It is important that you monitor specific physical information to be aware not only of your improvement but also of possible complications. If you are experiencing any other physical or medical concerns such as the flu, backache, or knee pain, it is best that you put off exercising until the problem passes. You should seek medical advice if it does not.
 Exams and Tests
Before starting a cardiac rehab program, a thorough risk assessment will be done to determine your heart health and the types of exercises you can safely do. Testing may be done before and during cardiac rehab to help your doctor decide whether you can safely take part in a program and to monitor your progress.
Tests to determine your ability to exercise that may be done before you start cardiac rehab include:

• Resting electrocardiogram (EKG or ECG), a test that measures the electrical signals that control the rhythm of your heartbeat. The graph that shows the results is called an electrocardiogram. A resting ECG will sometimes show if more extensive testing is needed before you start an exercise program.
• Exercise electrocardiogram (ECG), a test that records the electrical activity of the heart. An exercise electrocardiogram (sometimes called a stress or treadmill test) is done during exercise to evaluate how the heart responds to exercise. Your doctor can use the test results to prescribe a safe amount of exercise for you.
• Echocardiogram (echo), a type of ultrasound test that uses high-pitched sound waves to produce an image of the heart. The sound waves are sent through a device called a transducer and are reflected off the various structures of the heart. This test shows how well your heart is pumping blood and how well your heart valves are working. Sometimes it is combined with an exercise stress test.
• Thallium scanning, a test to estimate the amount of blood reaching the heart muscle during rest and exercise. It is typically done to find out the cause of unexplained chest pain or to find out the location and amount of injured heart muscle after a heart attack.
• Ambulatory electrocardiogram (Holter monitoring test), which monitors the electrical activity of your heart while you go about your usual daily activities. Many heart problems occur only during certain activities, such as exercise, eating, sex, emotional stress, bowel movements, or even sleeping. A continuous 24-hour recording is much more likely to detect any abnormal heartbeats that occur during these activities.

Other testing can help monitor your progress during cardiac rehab. Additional monitoring may include blood pressure, cholesterol, weight, blood sugar levels, and exercise ECGs.
You will be monitored closely when you first begin your cardiac rehab program. But after your exercise program is well established, you probably won't need continuous supervision. But if your doctor determines that you have special needs, he or she may want you to wear a monitoring device at home.
Risks
After having a heart attack or surgery or discovering you have heart disease, you may be afraid to exercise or be active. You may worry that exercise will cause another heart attack or that you aren't strong enough for a cardiac rehab program. It may ease your fears to know that as you begin your rehab, your doctor will monitor your activity closely and health professionals will be on hand to deal with any problems you may have. Your rehab team will tailor all of your exercises specifically for you, based on your medical condition and overall health. All cardiac rehab begins slowly at a comfortable pace and may be as gentle as walking on a treadmill.
If you are worried or afraid to be active again, talk to your doctor. Exercise and activity can greatly improve the quality of your life.
But exercise may not be safe for some people. You may not be able to participate in the exercise portion of cardiac rehab if you have:

• Unstable angina.
• Uncontrolled high blood pressure or low blood pressure.
• Heart rhythm problems or heart failure that is not under control.
• Uncontrolled diabetes.
• Experienced problems during exercise in your cardiac rehab program, such as chest pain (angina). Exercise causes the heart to work harder. As the heart works harder, the heart muscle needs more oxygen. If the narrowed heart vessels cannot provide enough blood (and oxygen) to the heart, you will have chest pain.

Even if you can't exercise or be active, you will benefit from other parts of a cardiac rehab program. For example, you can get help with quitting smoking and reducing stress, and you can get advice on how to eat a heart-healthy diet. This type of education can lower the risk of heart-related death.
Medicines may also affect your ability to participate in cardiac rehab. Some prescribed medicines can change your heart rate, blood pressure, and overall ability to exercise. For example, antidepressants may increase your heart rate and decrease your blood pressure at rest and during exercise. Tell your doctor and other health professionals on your rehab team about all of the medicines you are taking, especially if they cause any side effects during exercise.
How Well It Works
Clinical research has confirmed many benefits of cardiac rehab, including:

• A reduced risk of major heart problems and death after a heart attack for those who participate in a cardiac rehab program that includes exercise.
• Decreased severity of angina and decreased need for medicines to control angina.
• Reduced need for hospital stays because of heart problems. Costs for doctor visits and hospital stays are reduced for those who participate in cardiac rehab. Visits to the emergency room are also reduced.
• Decreased blood pressure.
• Reduced shortness of breath and less fatigue in people with heart failure.
• Ability to exercise longer.
• Lower cholesterol and triglyceride levels.
• Reduced emotional stress, depression, and anxiety.

Cardiac rehab can increase the quality of your life by improving your health overall; helping you lose weight, if necessary; reducing depression, stress, and anxiety; and helping to increase your self-esteem.
What to Expect
The goal of cardiac rehab is to help you re-establish and maintain a healthy, active lifestyle after a major heart problem, such as a heart attack or heart surgery, or if you have a long-term heart condition. Most likely, as you progress through cardiac rehab, you'll be concerned about returning to work, resuming recreational and other activities, and resuming a normal sex life.
To maintain the benefits of cardiac rehab, you will have to continue to exercise and follow the healthy lifestyle changes you've learned. Research shows that many people who start a rehab program stop after only a few months, often after the end of phase II, when the close monitoring ends.
Exercise and lifestyle changes. Although exercise, especially weight training, is a significant part of cardiac rehab, lifestyle changes combined with exercise may be more important than exercise alone in keeping your heart healthy. Staying with your program can give you the support you need to make these changes a permanent part of your life and may help reduce the risk of further serious heart problems.
Getting back to work. After you have a heart problem, you may worry about going back to work. Most people can return to work. How quickly you can return to work depends on how bad your heart problem is and how much physical activity your job requires. Some people go back to work part-time in 2 to 3 weeks. Others may require a longer recovery.
If you have a very serious heart problem or your job involves heavy lifting or a great deal of stress, you may want to see a job or vocational counselor. A job counselor can help you return to your current job or help you find training to start a new job.
Resuming a sex life. You or your partner may be worried that you will have symptoms such as chest pain or will not have enough energy for sex. Sharing your concerns and fears about having sex is important for both partners. Both partners need to feel ready to restart an active sex life. Discuss your concerns with a health professional from your rehab program, who can help you and your partner decide if your concerns are warranted and give you suggestions for resuming your sex life. In general, it is safe to resume your sex life about 6 weeks after an uncomplicated heart attack.
Managing stress. Stress management may lower the risk of serious heart problems, such as heart attacks. People who do not deal well with anger and frustration may have a higher risk of coronary artery disease. Learning to manage stress is often part of programs to help you make positive changes in your lifestyle.
Seeking treatment for depression.Depression is often overlooked, especially in older adults, but commonly occurs after a serious heart problem. Depression can make it difficult for you to have the energy to perform some of the cardiac rehab programs. If you feel you suffer from symptoms of depression, make sure you seek help.