Nick Butchart

EXP 600
Practicum Experience 3
Final Case with Work Samples
12/5/2014

Patient Information
Medical History
The patient is a 78 year old male that has been retired from the military. In mid-2014, he
began complaining of chest pain during ball room dancing and was admitted to the hospital for a
check-up. Upon his visit to the hospital he was not experiencing any chest pain or pressure, but
the physician ordered an ECG which revealed an anterior MI as well as frequent premature atrial
contractions (PVC) and runs of ventricular tachycardia (V-Tach) and echocardiogram which
revealed a regurgitating bicuspid aortic valve. His primary diagnoses was Coronary Artery
Bypass Graft (CABG) and Aortic Valve Replacement (AVR), which he was admitted to cardiac
rehab for on 10/3/14. The patient underwent surgery on 9/8/2014. The physician placed exercise
limitations of 10 pounds of lifting following the surgery on 9/8/2014. After the surgery there was
no complaint of angina or shortness of breath (SOB) nor was there complaint of surgical pain.
His post operation ECG showed a normal sinus rhythm. The patients medical history is listed in
table 1 and 2 below.
TABLE 1. Past Medical History
Diagnosis

Date

Rheumatoid Arthritis
Dyslipidemia

2001
2003

Bicuspid Valve Regurgitation

Angina/SOB- Anterior MI

2014
2014

TABLE 2. Past surgical history.

Procedure

Date

LAD CABG

2014

Bicuspid AVR
Bicuspid valve regurgitation

2014

Special Considerations
The patient is prescribed several different medications that will aid in managing his
condition that will have different effects on exercise. Each medication have an important task
ranging from controlling water retention to limiting cholesterol levels in the blood. Each
medication as well as direction for uses, side effects, food interactions and effects on blood
pressure, heart rate, and work capacity during exercise are listed in table 3. All drug information
were received from Drug.com (2014). The patient began taking Warfarin (Coumadin) to reduce
the risk of the formation of blood clots in order to prevent stroke and heart attack. He is also
taking Metoprolol Tartrate (Lopressor), which is a beta blocker that affects the heart and
circulation. Metoprolol is used to treat angina, hypertension, and is used to prevent a heart attack.

Atorvastatin (Lipitor) is prescribed to reduce the level of low density lipoproteins (LDL) as well
as triglycerides while maintaining the level of high density lipoprotein (HDL). He was also
prescribed Amiodarone (Cordarone) to prevent arrhythmias in the rhythm of his heartbeat to
prevent PVC and runs of V-Tach. He is prescribed aspirin to reduce the pain and inflammation in
his chest from the operation as well as assist in the prevention of clot formation. The patient had
his chest opened for the surgery to take place. From this part of the surgery he has chest soreness
and his incision is tender.
Physical Exam
The results from the patients physical exam are posted in table 4. His heart rate and
blood pressure are both on the lower end of the spectrum due to the medications he is currently
taking. Values for his BMI meet the criteria for obesity. From the physical exam, the patient does
not note any palpitations, lightheadedness, dizziness, syncope, incisional pain, chest pain, or
SOB. He reports having some mild soreness in his knees, which he states is normal to feel from
his arthritis. He does not complain of any inabilities to perform daily tasks that are allowed by
his cardiologist and claims he discontinued the tasks that were prohibited until further notice
from his cardiologist. Upon examination there was little to no swelling or edema in his legs
noted.
TABLE 3. Current outpatient prescriptions.
Medicati
on

Directi
ons

HR, BP, and Side Effects

Exercise
Capacity
Effect

Drug/Fo
od
Interacti
ons

Amiodar
one 200
MG
tablet

Take 2
tablets
by
mouth
twice
daily

Cough
dizziness, lightheadedness,
or fainting
fever (slight)
numbness or tingling in the
fingers or toes

Interaction
s with
aspirin and
coumadin

Ascorbic
Acid 500
MG
tablet

Take 500
MG by
mouth
daily

Side or lower back pain

Interaction
with
Aspirin

Aspirin
325 MG
tablet

Take 325
MG by
mouth
dialy

HR: Increase
or Decrease
BP: may
decrease
Exercise
Capacity:
decrease
HR: no
change
BP: no
change
Exercise
Capacity: no
change
HR: no
change
BP: no
change
Exercise
Capacity: no
change

Minor Upper GI Symptoms

Interaction
with
Coumadin,
atorvastati
n,
multivitam
in, vitmain
E, and

amiodaron
e.

Atrovast
atin 10
MG
tablet

Take 1
tablet by
mouth
nightly

HR: may
increase
BP: may
increase
Exercise
Capacity: no
change

Cough
difficulty with swallowing
dizziness
fast heartbeat
muscle cramps, pain,
stiffness, swelling, or
weakness
skin rash
tightness in the chest

Interacts
with
metoprolol
tartrate
and aspirin

Metoprol
ol
Tartrate
50 MG
tablet

take 50
MG by
mouth
twice
daily

HR: decrease
BP: decrease
Exercise
Capacity:
increase

Blurred vision
chest pain or discomfort
confusion
dizziness, faintness, or
lightheadedness when
getting up suddenly from a
lying or sitting position
shortness of breath
slow or irregular heartbeat

Interacts
with
alcohol
and
multivitam
ins

Multivita
min
Tablet

take 1
tablet by
mouth
daily

Mild diarrhea and nausea.

Interaction
with
aspirin and
lipitor

Vitamin E
400
UNITS
Capsule

take 400
Units by
mouth
daily

HR: no
change
BP: no
change
Exercise
Capacity: no
change
HR: no
change
BP: no
change
Exercise
Capacity: no
change

diarrhea
dizziness
headache
nausea or stomach cramps

Interaction
with
aspirin

Warfarin
2.5 MG
Tablet

Take 1
tablet by
mouth
every
evening

HR: may
increase
BP: may
decrease
Exercise
Capacity: no
change

Abdominal or stomach pain

with cramping
bleeding gums
blood in the urine
bloody stools
blurred vision
burning, crawling, itching,
numbness, prickling, "pins
and needles", or tingling
feelings
chest pain or discomfort
coughing up blood
difficulty with breathing or
swallowing
dizziness, faintness, or
lightheadedness when
getting up suddenly from a
lying or sitting position
excessive bruising
headache
prolonged bleeding from
cuts
shortness of breath

Interaction
s with
aspirin,
lipitor,
atorvastati
n and
alcohol

Milligram (mg), heart rate (HR), blood pressure (BP)

Exercise History
The patient self-reports having no structured exercise outside of cardiac rehab other than
ball room dancing. He claims he works in the woods cutting down trees as well, but will wait
until spring to continue the action. He reports ball room dancing 3 nights per week on Monday,
Wednesday and Friday for 2 hours each night. He states the last time he participated in a
structured exercise program was when he was still in the army over 25 years ago. Since then ball
room dancing has been his passion and means of physical activity. The patient suffers from
arthritis in his knees, but claims it does not inhibit him from performing any task throughout his
day. It will still be watched closely during exercise to prevent exacerbation of pain.
Work History
The patient is a retired army veteran for over 25 years now. Although he is not employed
by a business or company he works on the side cutting down trees for friends and family in
return for the wood needed for his wood furnace.
TABLE 4. Physical Exam.
Examination

Result

Blood pressure

94/60 mmHg

Heart rate

44 bpm

Respiration

12 breaths per minute

Height

69 in

Weight

222.8 lb

BMI

32.9 kg/m2

General appearance

Acyanotic, normal breathing, proper posture

Skin/Integument

Clean, dry, slight rash on left hand

Head

Normocephalic

Eyes

No swelling or redness

Ears/Nose/Mouth/Throat

No external swelling or tenderness, mucous membranes moist,

no focal lesions

Neck

No jugular venous distension

Chest wall

Sternal incision healing well, no drainage, not tender to touch

Respiratory

Clear to auscultation bilaterally, no wheezes, crackles, or

respiratory distress

Cardiovascular

Symmetric chest without visibly increased activity, pulses equal

in all extremities, no radial-femoral delay, all extremities warm
to touch, no murmur, click, gallop or rub

Abdominal

Soft and non-tender

Extremities

Mild swelling in knees, no edema present

Neurological

Alert, normal tone

Millimeters of mercury (mmHg), beats per minute (bpm), inches (in), pounds (lb), body mass index (BMI), kilograms per meter squared (kg/m 2)

Cholesterol Measures: Taking Atorvastatin

Value

ACSM criteria

Patient Criteria

Total cholesterol

Total cholesterol 200 mg/dL

Total cholesterol: 162

Triglycerides

Triglycerides 150 mg/dL

Triglycerides: 110

LDL

LDL 130 mg/dL

LDL: 110

HDL

HDL < 40 mg/dL

HDL: 52

Psychosocial History
The patient arrives to his appointments with his wife and/or daughter each day. The
patient self-reports and overall feeling of happiness and the incidence has not caused any form of
depression. He states he has other hobbies that keep him occupied while he regains his ability to
go to ball room dancing and cut down trees. The patient and his wife go out to dinner two nights

a week with friends and have frequent visits from both daughter and son along with their
families. He self-reports watching TV often times will make him angry with politics and news
so he chooses to perform tasks that he enjoys that are low level activity allowed by his
cardiologist.
Risk Factor Classification
Based on the criteria set by ACSM guidelines for the results from the patients most
recent physical exam the he would be classified as high risk because he has a known heart
disease and had a myocardial infarction (MI). The patient presents with the following
cardiovascular risk factors, which are presented in Table 5 (American College of Sports
Medicine, 2014, p. 27).
TABLE 5. Risk Factor Classification
Risk Factor

Defining Criteria

Patient Information

Systolic blood pressure

140 mmHg
Hypertension

Diastolic blood pressure

90 mmHg

Patient is taking Metoprolol

Taking blood pressure

lowering medication
Males over the age of 45
Age

Dyslipidemia

Obesity

Females over the age of

55

Patient is 71 years of age

LDL > 130 mg/dL

HDL < 40 mg/dL
Taking a Cholesterol
Lowering Medication

Patient is taking atorvastatin

BMI greater than or

equal to 30kg/m2

Patient's BMI is 32.9kg/m2

Millimeters of mercury (mmHg)

To conclude, the patient had an Anterior MI and regurgitation of his bicuspid valve which
required a CABG and AVR. His physical exam shows he is showing improvement and recovery
from his procedures. Since the procedure, he does not complain of having any chest pain, SOB,
or dizziness. His appetite is normal and his weight is stable at 222-225 pounds. He states he still
experiences fatigue when performing more vigorous activity such as climbing stairs, but no
fatigue is noted during light activity and rest. After viewing the patients history it was
recommended he begin a cardiac rehab program. The program will help him progress back to his
daily activities and enjoyments such as cutting down trees and ball room dancing. In cardiac
rehab the patient will be given an exercise program that is updated regularly based on his goals

and set outcomes. He will also be given the standard education forms provided by the program
related to alternative prevention strategies. The patients insurance approves him for 36 exercise
sessions or until a plateau is reached and progression reaches steady state. No testing is done
prior to entering and graduating from the program, but exercise intensity and capacity are
compared from baseline to graduation.

Patient Interview
Prior to the patient beginning the program he needed to explain the goals he wanted to
achieve prior to leaving the program. He states he wants to increase his overall stamina so he can
perform daily tasks without becoming overly fatigued requiring him to stop. His most desired
goal is to be able to begin his ball room dancing class again with his wife 3 nights per week. He
states that is the activity they do that gives them the closest connection and he wants to return as
quickly as possible. He would also like to be able to regain the stamina required to cut down
trees in the woods for family and friends. The main reason he would like to accomplish this goal
is because his house is heated with a wood burner and he cuts as much woods as possible in the
non-winter months. It was stated by his cardiologist that would not be possible before the end of
the program and he would have to wait until at least spring prior to starting that activity again.
Finally, the patient would like to weigh 210 pounds by the end of the program meaning he would
need to lose 12 pounds in 12 weeks.
While the patient is working increase his cardiovascular endurance it is also very
important to increase his strength. Before the event the patient spent time cutting down trees,
dancing, and performing daily household tasks that he claims require lifting to complete some
tasks. After the surgery he is unable to cut down trees per cardiologist request and there is
concern he may not have the strength to run a chainsaw and load wood. He also is not allowed to
begin ballroom dancing yet per cardiologist request and there is concern he will not have the
muscular endurance to be able to dance for two consecutive hours. The patient was asked to
identify goals for returning to these activities and he stated he wanted to increase his overall
strength as well as have enough muscular endurance to return to ball room dancing and complete
the two hour classes without having to take breaks. After stating his goals he made it very clear
he did not want to participate in any type of resistance training. We asked him to explain what it
was about resistance training that did not appeal to him and he stated it caused him pain from his
arthritis, he does not like the feeling of the muscle fatigue he gets from resistance training and he
feels he is strong enough to return to cutting down trees without the need to life weights.
Throughout the program these goals will be reviewed with the patient to track progress he makes
toward his goals. Resistance training will also be reinforced throughout the program in hope he
realizes its benefits and decides he would like to begin a resistance training program once cleared
by the cardiologist. Various educational services will be offered to him to help him gain
knowledge toward his goals and for continuing exercise once he is graduated from the program.
Secondary Prevention

Given the patient underwent a recent surgical procedure it is important to inform him of
secondary prevention measures. According to ACSM guidelines, the modifiable risk factors he
presents with are hypertension, dyslipidemia and obesity. Education should be given to all
individuals that have hypertension so they may gain knowledge on lifestyle modification,
physical activity, and diet (Smith et al, 2011). By the end of the program he should be
participating in at least 30 minutes of exercise 3 days per week at a moderate intensity activity.
Since the patient is a ball room dancer, he will have no trouble accomplishing the physical
activity recommendation in place. With the patient being active in the ball room, it is important
for him to understand and follow his initial restrictions. Per cardiologist request, there has been a
10 pound lifting restriction placed on the patient as well as a no twisting recommendation to
prevent injury to his incision and to allow his operation to properly heal. When he is not in
cardiac rehab he is not to participate in physical activity that is greater than a 3-5 out of 10 on the
rate of perceived exertion (RPE) scale per cardiac rehab staff recommendation. If he follows
these restrictions it will lead to a swift recovery with little to no complications.
To conclude, the patient stated the goals he wanted to achieve prior to graduating from a
cardiac rehab program during his initial interview in cardiac rehab. He stated he would like to
increase his overall strength and stamina so he can get back to cutting down trees for friends and
family as well as return to ball room dancing with his wife. Both of these goals have a great deal
of value to the patient increasing the importance to him to work hard and reach his goals. It was
also brought up he did not enjoy resistance training and did not want to participate in anything
other than aerobic training during his time spent in rehab. The importance of resistance training
was reinforced to the patient and it was explained that his return to dancing as well as tree cutting
will be made easier if he strengthens his muscles with resistance training. Finally, secondary
prevention was reviewed with the patient. As the patient progresses toward his goals he will be
given educational information to make achieving his goals more attainable. Due to the patient
being hypertensive according to ACSM criteria, information about diet, specifically sodium
reduction, will be given to him to help make his blood pressure more manageable. He also meets
criteria for dyslipidemia and a handout on what cholesterol is as well as 7 strategies related to
lowering cholesterol was given. Finally, because he meets criteria for obesity handouts were
given to him about what BMI is and why we used it as a measure. Also, more diet tips were
given to him to help him reduce and manage his weight. These will all be discussed further in the
patient education section later on. Lastly, activity restrictions were reviewed as prescribed by the
cardiologist. In the interest of minimizing complications post-operation, the patient has a 10
pound lifting restriction and is requested to not perform any twisting movements. After the initial
interview is complete an exercise prescription was created.
Exercise Prescription Considerations
First, the patient is high risk according to ACSM risk stratification and education will
need to be given based on diet and exercise, which will be discussed later. Due to the patient
wishing to increase his cardiorespiratory endurance and muscular strength and endurance it is
important to take into consideration possible factors that could affect outcomes. Due to the
patient not having a stress test done we have no testing data to use when creating his initial
exercise prescription. The patients resting ECG shows normal sinus rhythm with no PVCs or

runs of V-Tach, which were seen pre-operation, due to him being on amiodarone. Along with
amiodarone, he is on multiple other medications related to health as well as management in the
body. It is necessary to check which medications he has and hasnt taken prior to each exercise
session. Due to the patient having arthritis in his knees, we will have to watch closely how he
responds to exercise so the pain and inflammation are not exacerbated. Although he is an older
individual, he has been active since he retired and has maintained a fitness level high enough to
perform most exercises in the gym depending on the modality. His two main goals are to
increase stamina for returning to ballroom dancing as well as increasing strength for returning to
cutting trees. The MET level of both activities will be taken into consideration as well as the
motions involved with each activity. All of these factors will be taken into consideration when
designing his exercise prescription.
Pre-Exercise Testing
The North Hills Health Center does not utilize pre-exercise testing prior to an individual
entering a program. The following are best practices for exercise testing in a cardiac rehab
program.
Aerobic Testing
According to the AACVPR a walking test rather than a treadmill test is required when
testing cardiac patients prior to beginning phase II cardiac rehab. This matches the
recommendations given by the AACVPR for aerobic exercise testing. After the client intake is
performed a six minute walk is done prior to any exercise is performed on the first day. On the
patients last day of phase II cardiac rehab the patient will perform another six minute walk prior
to exercising on his last day and his goals will be re-assessed at that time. Although it is strictly a
walking test the results of the six minute walk have been shown to be comparable to that of
multistage treadmill tests. Results from a six minute walk test have been validated to be
comparable to the results of a symptom limited exercise test run on a treadmill with multiple
stages (Gayda et al, 2004). Not only can exercise prescriptions be created from the data
collected from a six minute walk, but mortality risk can also be determined from the results.
Tests have shown scores less than 300m on the six minute walk test are an indicator of increased
mortality rate (Rasekaba et al, 2009). The six minute walk also has good test re-test reliability
making it useful for performing progress assessments as he advances through the program
(Hansen, McBurney and Taylor, 2012). After explaining the six minute walk to him and
confirming he knows. The results from the six minute walk will be used to create his initial
exercise aerobic exercise prescription.
Strength Testing
Musculoskeletal strength will be measured using a hand grip dynamometer to assess the
relative strength of his upper body. Knowing the maximal strength of an individual is necessary
when creating exercise prescriptions to determine the work load of each exercise. A study done
by Busch et al (2012) viewed the benefits of cardiac rehab on patients that had an MI and stated
a maximal isometric contraction is a reliable way to assess upper and lower body strength. A
study done by McDonald et al (2007) tested the use of the hand grip test as a reliable way to

measure physical function in cardiac rehabilitation. It was concluded that using the hand grip
strength in itself could not be considered a valid indicator of physical function meaning if a
program used this test it could not be used to determine overall fitness. The test can be used to
determine progress in upper body strength. The study states as hand grip strength increased due
to exercise overall physical function increased by an average of 4.6%. To test lower body
strength and endurance a 30 second sit to stand test will be used. According to Schurr et al.,
(2012) the sit to stand test is valid indicator of lower body muscular endurance. A separate study
by Takai et al (2009) states the sit to stand test is the most reliable indicator of lower body force
generating capacity. Once ready for resistance training results from the hand grip strength test
and 30 second sit to stand will be used to design his initial resistance training program.
Exercise Prescription
During exercise there are several items that will be measured. The first being blood
pressure. Blood pressure should rise and fall linearly with exercise intensity if the patient is not
on blood pressure medications. Taking blood pressures allows to determine if the patients body
is responding to exercise properly and also allows gives the cardiologist information for further
medication prescriptions. Rate of perceived exertion will be used to monitor the patient to
determine how they are handling exercise. This information will be used by the staff to
determine if the exercise prescription is too easy or too difficult. Their perceived exertion should
be between a 3 and 5 on the 0-10 scale during exercise. Each phase II patient will be monitored
continuously from start to finish each session. One member of the staff is responsible for
monitoring rhythms from the telemetry system to watch for any abnormalities in heart rhythms
during rest, exercise, or recovery. The telemetry system will also give us measures of heart rate
continuously as well. Prior to exercising, each patient must fill out a form which includes the
following: recent doctor visits, medication changes, any pain, home exercise participation, and
blood sugar if applicable. Staff will use these charts to make necessary changes in the patients
information as well as if the patient is able to perform exercise that given day.
Aerobic Exercise Prescription
Based on the results that would have been received from the six minute walk, an exercise
prescription would be created to match the fitness level of the participant. Due to the patient not
having completed a six minute walk we do not have information to go off of to select a specific
intensity. This program utilizes the RPE scale on the first day when selecting a workload for the
patient to exercise at. Based on a study done by Budts et al (2013), adults in cardiac rehab should
be presented with a target heart rate range as well as RPE values they should attempt to reach.
Target heart rate range was discussed with the patient during the review of his first exercise
prescription at the end of day one. The RPE scale was explained to the patient prior to beginning
his first modality of exercise. It was explained an RPE of between 3-5 should be achieved during
exercise on the first day. An RPE of 3-5 equates to moderate to hard activity according to the
Borgs RPE scale. These perceived exertions are focused for endurance based exercise required
to increase cardiovascular endurance (Scherr et al, 2012). Aerobic training will take place 3 days
per week with 2-3 days outside of cardiac rehab prescribed as home exercise for the patients
own benefit. The patient was dancing with his wife prior to his incident and would like to get

back to being able to comfortably finish an entire ballroom class with her once again. He chose
to use the NuStep the first day of exercise. His cardiologist ordered his exercise heart rate to be
no more than resting+30BPM which allows him to exercise between 44 and 74 BPM his first
day. A study done by Rogonmo et al (2009) examined the effects of moderate intensity exercise
on individuals with CAD. The results of the study were clinically significant showing very
beneficial results from constant moderate intensity exercise. Policy in this program is to have a
patient exercise at no greater than a 5 RPE depending on the scale the patient uses or they need
to decrease their intensity so they do not feel they are working so hard. According to the ACSM
an RPE of 11-14 should be achieved during exercise to be considered moderate to hard intensity
activity. This program utilizes the 0-10 scale which equates to a 3-5 RPE when compared to the
6-20 scale. As I work with this patient I will instruct him to achieve at least a 3 RPE and not to
get above a 5 or its time to slow it down slightly. He prefers to use the NuStep and UBE, and
requested that his aerobic training program consists only of him performing seated activities.
Exercising 3 days per week beginning at least 30 minutes per session will accumulate 90 minutes
of exercise each week on top of the resistance training we hope he will take part in by the end of
the program. He is also prescribed a home exercise program which will be discussed later. It
would be most beneficial to see 150 minutes of exercise per week according to the ACSM to
begin to see health benefits so we will increase his duration by one minute each session to reach
150 minutes per week. The ACSM recommends each patient exercise 40-60 minutes per session
leading us to increase by one minute per session until the patient is exercising a minimum of 40
minutes total preferably with no breaks. The patient enjoys going for long walks however he
does not enjoy exerting himself and will need to be motivated to push himself past his comfort
level. He is not opposed to exercise, but he states he has never walked faster than what was
comfortable for him and for that reason does not wish to use the treadmill for exercise. It would
be beneficial to convince him to exercise on the treadmill by the end of his program to we may
increase intensity when his body is prepared for the exercise. Studies have been done to
determine the effects of vigorous intensity exercise and moderate intensity exercise to determine
which is more beneficial. Vigorous intensity exercises are more beneficial as shown in studies,
but results from moderate intensity exercise are also clinically significant (Rognmo et al, 2012).
He has no interest in vigorous intensity exercise and vigorous intensity exercise would be too
intense for him to perform at his current fitness level. At first I was concerned with attempting to
increase his exercise intensity past an exertion of hard, but if he would like to return to ballroom
dancing a change will need to be made. According to the compendium of activities, dancing with
a 6-8 inch step is a MET level of 8-10 (Ainsworth et al, 2000). Using the NuStep and UBE will
not generate a great enough MET level for the patient to achieve a workload similar to ballroom
dancing which was explained to him. It was recommended he consider using the recumbent bike
and the treadmill as he progresses in the program. He was open to the recumbent bike due to the
modality allowing him to remain seated, but is still against using the treadmill at this time. His
aerobic exercise prescription is listed in table 6.
TABLE 6.
Exerc

Time

Aerobic Training Week 1 (M,W,Th)

Intensity
Sets Type

Progression

ise
NuSt
ep

20-25
Minut
es

Rest+30BPM, 3-5
RPE, 5 RPE max,
44-74 BPM, lvl 1-3

1
bout

Long
continuous,
60-80 steps
per minute

1 minute per
session

Aerobic Training Week 4 (M,W,F)

Exercise
Exercise
NuStep
NuStep

UBE

UBE

Time
Time
20-25
25-30
Minutes
Minutes

10-12
minutes
5-6

minutes

Aerobic
Training Week
Intensity
Sets8
Intensity
Sets
Rest+30BPM, 35 RPE, 5 RPE 3-5
1 bout
Rest+30BPM,
1
max,544-74
bout
RPE,
RPE max,
BPM, lvl
3-6lvl 6-9
44-74
BPM,
Rest+30BPM, 3Rest+30BPM, 3-5
5
RPE,
5 RPE
RPE,
5 RPE
max,
max,
44-74
44-74 BPM BPM

1 bout

bout

(M,W,F)
Type
Type
Long
continuou
Long
s, 60-80
continuous
steps per
, 60-80
minute
steps per
minute
Long
Long
continuou
continuous
s, 50RPM,
, 50RPM,
LVL
1-3
LVL 1-3

Progression
Progression
1
minuteper
per
1 minute
session
session

1 minute
minuteper
per
session
session

Resistance Training Prescription

As stated before in the resistance training section of this paper, there were no
musculoskeletal strength tests performed on this patient. This program does not utilize
musculoskeletal strength testing prior to exercise prescription. It should also be noted resistance
training is not a mandatory part of the exercise program and it is up to the patient if he or she
wishes to participate. The patient did not seem at all interested in participating in resistance
training because he claims he was already strong enough to perform his daily tasks. The main
concern for him is being able to get back into the woods to cut down trees for woods to keep his
house warm during the winter months. The average log will weigh between 2 and 10 pounds
depending on the species of woods he is choosing to cut. This allows him to stay below the
maximum lifting restriction in place, but the repetitive lifting may be too much. According to the
compendium of activities previously cited, stacking wood requires a MET level of around 5. If
he is able to achieve his MET level for ballroom dancing he will almost double the level required
for wood stacking. For this reason we will focus on reaching the MET level set for ballroom
dancing. It was explained to him the importance of having muscular endurance over muscular
strength to perform this activity and how he would be able to achieve that required endurance
through resistance training. Data suggests exercise intolerance in heart valve and CABG patients
is primarily due to decreased muscular strength and endurance following the surgery leading up
to the beginning of cardiac rehab (Sumide et al, 2009). Resistance training is an important factor
in any exercise program leading to strength and muscle increases leading to more stability and
increased exercise capacity. A study done by Helgrud et al (2010) initial resistance training in
individuals with CAD increased VO2max, ventilatory capacity, overall strength and balance. It
would be ideal for resistance training to begin at one day per week on Monday initially allowing

at least 48 hours for his muscles to recover. Exercise would begin at one set of ten repetitions
until his body adjusts to resistance training where we can decrease his repetitions and increase
resistance to increase strength in his lower body. In order for muscle hypertrophy to occur 8-15
repetitions must be performed allowing us to leave the number of upper body repetitions the
same during progression. Resistance training in cardiac rehab is most beneficial to hypertrophy
and strength when exercise is performed at 8-12 repetitions (Busch et al, 2012). Resistance
training is new to this patient and would need to be kept at a low intensity for the initial portion
of his exercise program. Intensity will be determined by the rate the patient will fatigue while
exercising. The patient will exercise until volitional fatigue due to us not having a 1RM to base
our intensities off of. Stopping 2-3 repetitions before volitional fatigue, which is 9-10 RPE, is
rated as a 5-6 on the RPE scale according to the ACSM and will take place instead of percent of
1RM. The program will be set in a push pull fashion in order to keep balance of his body
allowing him to maintain better posture and balance during his activities of daily living
especially ballroom dancing. Push pull exercises mean for every muscle that is exercised the next
exercise will work that antagonistic muscle to prevent one muscle from becoming stronger than
its antagonist. If the antagonistic muscles are too weak it will effect posture and balance in a
negative way potentially leading to other health problems in the future. Due to only beginning
resistance training one day per week each lift will target large muscle groups to increase the
effectiveness of each workout. Majority of the exercises with be multi-joint exercises utilized to
maximize the number of muscles that are used during each lift to ensure each muscle gets an
appropriate amount of exercise each session. Progression will depend on the patient and how he
handles each exercise. Progression will be determined by the ease the patient has with
performing the repetitions overtime. A study done by Wise and Patrick (2011) stated in elderly
individuals in cardiac rehab, weight should only be increased once the patient can easily perform
12-15 repetitions for 2-3 sets. If the patient can perform one set with ease we can increase the
number of sets to two we will progress his exercise prescription based on these
recommendations. Once the patient is ready to begin resistance training two days per week a
second day will be added with one day being dedicated to upper body exercises and one day
dedicated to lower body exercises allowing us to focus on larger muscles groups as well as
smaller specific muscle groups. The resistance training prescription is listed in table 7.
TABLE 7. Represents the resistance training exercise prescription. Note week 1 is the beginning
of the first week the patient is cleared for resistance training.

Exercise

Chest Press

Upper Body Resistance Training Week 1-4 (Wednesday)

Intensity
Sets Reps
Rest
2-3 reps prior to
fatigue

10

1 Minute

Mode

Machine

Seated Rows

2-3 reps prior to

fatigue

10

1 Minute

Machine

Lateral
Shoulder
Raise

2-3 reps prior to

fatigue

10

1 Minute

Dumbbells

Wall Squat

Half Squat

10

1 Minute

Body Weight, Stability Ball

Lunges

Quarter Lunge

10

1 Minute

Body Weight

Hip Abduction

N/A

10

1 Minute

Body Weight

Exercise

Upper Body Resistance Training Week 4-8 (Wednesday)

Intensity
Sets Reps
Rest

Mode

Chest Press

2-3 reps prior to

fatigue

10

1 Minute

Machine

Seated Rows

2-3 reps prior to

fatigue

10

1 Minute

Machine

Lateral
Shoulder
Raise

2-3 reps prior to

fatigue

10

1 Minute

Dumbbells

Wall Squat

Full Squat

10

1 Minute

Body Weight, Stability Ball

Lunges

Half Lunge

10

1 Minute

Body Weight

Bridges

N/A

10

1 Minute

Body Weight

Exercise

Upper Body Resistance Training Week 8-12 (Wednesday)

Intensity
Sets Reps
Rest

Mode

Dumbbell
Bench Press

2-3 reps prior to

fatigue

10

1 Minute

Dumbbell

Bent Over
Rows

2-3 reps prior to

fatigue

10

1 Minute

Dumbbell

Shoulder Press

2-3 reps prior to

fatigue

10

1 Minute

Dumbbell

Chair Squat

Full Squat

10

1 Minute

Body Weight Possible

Dumbbells

Lunges

Full Lunge

10

1 Minute

Body Weight, with chair

RDL

2-3 reps prior to

fatigue

1 Minute

Dumbbells

Flexibility
Flexibility is an important factor of any exercise program to help maintain elasticity of
muscles, especially muscles that are the focus of exercise. Flexibility training will improve range
of motion as well as decrease the severity of delayed onset of muscle soreness 48-72 hours after
exercise. Flexibility prescription is based on ACSM guidelines. According to ACSM guidelines,
flexibility training should be perform most if not all days of the week. Stretches should focus on
major muscle groups with more focus on muscles trained during exercise. Each stretch should be
held for 15-30 seconds each bout with each major muscle group receiving 60 seconds of
cumulative stretch time.
Goal Setting
Outcomes
Studies have shown great benefits to the individuals that choose to participate in a cardiac
rehab program after having an event or surgery. Patients that complete a cardiac rehab program
are linked to a 20% decrease in all-cause mortality (Scalvini et al, 2013). Cardiac rehab can
produce benefits such as increases in muscle strength and endurance, better balance, reduced risk
for falls, increased cardiorespiratory resistance, and increased work capacity. Individuals that are
in cardiac rehab do not produce these results in a short duration in cardiac rehab and goal setting
is important to show progression of patients.
Cardiac Rehab Goals
In his initial interview, the patient stated the goals he would like to accomplish prior to
graduating from cardiac rehab. These goals consisted of: increasing his overall stamina,
improving upper body strength, and he would like to lose 12 pounds in 12 weeks and achieve a
final weight of 210 pounds. There are various reasons for these specific goals made by the
patient. He wants to increase overall stamina in order to return to ballroom dancing 3 nights per
week without having to take rest breaks. Increasing upper body strength is a goal made in order
to make cutting down trees and stacking wood an easier task. Finally, the patient wants to lose 1
pound per week just as a personal goal he would like to achieve that has no specific purpose.
Post-Cardiac Rehab Testing 10/30
As it was said before, this program does not utilize exercise tests when evaluating the
progress of its patients. Instead, progress is measured by workloads completed in cardiac rehab
from day 1 to the final day of rehab. The patient only used two different types of equipment
during his time spent in cardiac rehab being the NuStep and the UBE. For the NuStep, rather
than looking at the resistance level and steps per minute we looked at the amount of WATTs the
patient was producing during exercise. WATTs are a measure of power that in individual is

producing during any type of activity. There are two ways to increase WATTs on the NuStep, 1)
increase the steps per minute performed 2) increase the level of resistance of the machine. The
other piece of equipment used, being the UBE, uses WATTs as well for a measurement. The UBE
differentiates from the NuStep by increasing revolutions per minute rather than increasing steps
per minute. The NuStep was the only modality of exercise used during the first 3 weeks of
cardiac rehab, despite attempts to convince the patient a different modality would be beneficial.
On the patients first day of exercise (10/9/14), he produced a wattage of 24W on the NuStep. He
initially began exercise at level 1 as do most patients on their first day. Throughout the program
he slowly increased his speed and resistance level to continue progression. By the end of the
program the patient was producing a wattage of 76 showing a significant increase in the amount
of work he was performing. By the end of the program, he had increased his resistance level to 6
while maintaining the prescribed steps per minute listed in the exercise prescription. The patient
did not begin use of the UBE until 3 weeks into the program meaning we do not have a WATTs
measurement on the baseline day. On his first day using the UBE (10/30/14), he produced a
Wattage of 18W. As he progressed through the program he chose not to increase his level of
resistance causing his WATTs to still be 18W showing no improvement. The patient finished the
program after only 23 of his 36 sessions covered by insurance. The reason for stopping was
personal preference by the patient because he felt he had the necessary knowledge to continue
exercise at home with his own equipment. Had the last 13 sessions been completed by the patient
progress would have been greater and there would have been the possibility of him beginning
use of other machines.
No progress is available in the musculoskeletal strength portion of the program due to the
patient not performing any resistance training. He did not wish to resistance train for the feeling
he had enough strength to perform the tasks he wished to accomplish in daily life. Without the
use of testing, there are various other factors that can be looked at when tracking progress. These
factors include: sets, repetitions, and weight of the exercises being performed. An increase in any
of these categories will result in an increase workload performed considering other factors do not
decrease.
Goal Reassessment
Over the past 8 weeks, the patient has been able to increase his fitness level through the
use of exercise, which is made apparent by his progression. During reassessment of his goals, the
patient self-reported his progress toward goals outside of cardiac rehab. The patient stated he
wanted to increase his overall stamina throughout the program. Prior to surgery, the patient
claimed he could participate in a 2 hour ballroom dance class 3 nights a week with his wife
without having to take any breaks. Initially the patient was not cleared to return to dancing in
order to let his procedure heal properly. Since he has been cleared, he states his first couple of
weeks were tough to finish full dance routines, but he took necessary rest breaks when needed.
Now, he states he can complete the full two hour class with only having to take one rest break
other than the break provided half way through the class. From an exercise stand point, the
patient only reached a maximum MET level of 2.8, which falls well below the original goal of 8
METs required for ballroom dancing. According to his self-report he is able to complete

exercises at the increased MET level of ballroom dancing and that will serve as a large amount of
his exercise after the program.
Another goal of the patient was to increase his overall strength by the end of the program.
The patient refused resistance training in the program, stating he did not enjoy the feeling he got
from it and he believed he was already strong enough. He wanted to increase his overall strength
to make the task of cutting down trees and stacking wood easier. He stated he does not plan on
returning to cutting wood until the spring allowing his procedure to health more. Given the fact
he did not participate in resistance training there are no progress results to review. For this reason
it will be considered he did not reach his goal for no assessment is available. Had he participated
in resistance training his sets, repetitions, and weight used would be reviewed to determine the
progression he had made from start to finish.
The patients final goal was to lose 12 pounds in the 12 weeks he planned on spending in
cardiac rehab. Due to the patient only spending 8 weeks in cardiac rehab the goal was modified
to lose 8 pounds to stay consistent with one pound per week. The patient ended up gaining five
pounds by the end of the program from his baseline measurement. He moved in the opposite
direction of the goal he placed and progressed negatively toward his goal. This is one of the main
reasons he felt it was time for him to be done with the program because he reached all of his
goals except weight loss. As a staff member I believe there was minimal change to his diet to go
along with his exercise intervention. This may have caused the increase in body weight from
baseline. It could be considered he increased his muscle mass with exercise, but he only
participated in aerobic training decreasing the likelihood he increased his muscle mass by 5
pounds. He had seen the dietician at the health center and was given the necessary education to
start choosing healthier foods throughout the program. It is up to him, if he is not already, to
change his diet to assist him in weight loss.
To conclude, the patient stated what his goals were during the initial interview with the
staff. His short term goals consisted of losing 12 pounds per week which was decreased to eight,
increasing his overall stamina in order to return to ballroom dancing, and increase his overall
strength to make cutting and stacking wood an easier task. He was able to reach only one of his
three goals by the end of the program, but the goal he reached was his most important goal.
Exercise has allowed him to return to ballroom dancing and he is now able to complete a full two
hour class while only having to take one rest break. He did not reach his strength goal only due
to the fact there are no results to compare because the patient did not participate in resistance
training. It is up to him to decide if he would like to begin resistance training at home to make it
possible to return to cutting and stacking wood. Finally, the patient increased his body weight by
five pounds progressing him in the opposite direction of his goal to lose eight pounds. Diet may
be a factor that played a role in his weight gain, but he claims he is eating healthier now. All of
his progression was accomplished through the use of strictly aerobic training. Had resistance
training been accepted by the patient his outcome may have been more beneficial.
Patient Education
Patient education was given to him based on what his modifiable risk factors were
including: hypertension, obesity, and dyslipidemia. Other handouts were given to the patient as

well on other risk factors such as smoking and stress management for his own reading if ever
needed.
Blood Pressure Management
The patient currently meets criteria set by the ACSM for hypertension due to him using a
blood pressure medication as a form of management. Through the use of diet and exercise he will
be able to better manage his blood pressure to the point he will no longer require the medication.
In order for that to happen, he will need to limit his sodium intake and decrease his consumption
of saturated and trans fats. A study done by Sonja et al (2014) states increasing sodium
consumption greater than 2300mg daily is a major risk factor for hypertension. A separate study
performed by Konfino et al (2013) states decreasing sodium intake by 319-387mg per day will
yield a reduction of blood pressure by .93-1.81mmHg. The AACVPR states if dietary sodium is
limited to just 2400mg of sodium daily it could reduce blood pressure by 2-8mmHg. The patient
was given a handout on how to better control his blood pressure which can be seen in Appendix
A. If the patient decides to control his sodium intake it could lead to better management of his
blood pressure possibly allowing him the chance to be taken off of his medication.
Dyslipidemia
The patient is diagnosed with dyslipidemia due to taking Atorvastatin. High cholesterol
leads to plaque buildup in the arteries, which can cause a decreased blood flow to the heart. This
decreased blood flow can cause abnormal function of the heart and can even lead to a heart
attack, which in this patients case his cholesterol may have been a factor in his MI. Cholesterol
can be controlled through the use of exercise because exercise plays a role in several enzyme
actions that reverse the cholesterol transport system (Vella, Janot, Kravitz, 2001). A 12 week
moderate intensity exercise program was enough to increase HDL levels to the same amount that
a vigorous intensity exercise program would (Spate-Douglas and Keyser, 1999). A study done
by Houmard et al shows an increase in LDL free cholesterol and an increase in HDL cholesterol
as a result of a 14 week exercise program. The patient was originally supposed to participate in
12 weeks of cardiac rehab showing these results are possibly upon graduating from the program.
Exercise can not only reverse the cholesterol transport system, but it can also reverse high blood
pressure in the body so it is important he continue his ballroom dancing as well as his exercise
now that he is done.

Obesity
Obesity is known to have negative effects on cholesterol levels in the body and can
ultimately lead to dyslipidemia. Obesity causes a reduction in LDL receptor activity causing a
decrease in LDL uptake by the liver (Klop et al, 2013). The liver is responsible for removing
70% of circulating LDL in the blood, but this is decreased due to high levels of free fatty acids in
being transported to the liver (Klop et al, 2013). This process leads to increased very low density
lipoproteins, increased circulating low density lipoproteins and a reduction in high density
lipoproteins leading to the CVD risk factor dyslipidemia. Obesity can also be a risk factor for the
development of hypertension if left untreated. Indicators of obesity such as body adiposity index

are related to the development of high blood pressure (Leal Neto et al, 2013). Decreasing body
fat and managing a normal weight will assist the patient in managing his blood pressure. In
combination with sodium reduction and exercise, managing a normal body weight will be very
beneficial to managing a healthy blood pressure without the need to take medicaitons.
Other topics such as physical activity and medication adherence were points of discussion
with the patient throughout his duration in cardiac rehab. No education past general guidelines
was given due to the patients already active participation in both topics. The patient brought in
his medication checklist to be sure he takes all of his medications at their appropriate times. He
also stated he participates in 6 hours of ballroom dancing every week with his wife exceeding the
minimum guideline for exercise by over 200 minutes per week.

References
Ainsworth, B. E., Haskell, W. L., Whitt, M. C., Irwin, M. L., Swartz, A. M., Strath, S. J., ... &
Leon, A. S. (2000). Compendium of physical activities: an update of activity codes and
MET intensities. Medicine and science in sports and exercise, 32(9; SUPP/1), S498-S504.
American Association of Cardiovascular and Pulmonary Rehabilitation. (2013). Guidelines for
cardiac rehabilitation and secondary prevention programs (5th ed.). Champaign, IL: Human
Kinetics.

American College of Sports Medicine. (2014). ACSM's guidelines for exercise testing and
prescription (9th ed.). Baltimore, MD: Lippincott, Williams & Wilkins.
Angell, S. Y., Yi, S., Eisenhower, D., Kerker, B. D., Curtis, C. J., Bartley, K., et al. (2014).
Sodium intake in a cross-sectional, representative sample of new york city adults. American
Journal of Public Health, 104(12), 2409-2416. doi:10.2105/AJPH.2013.301542
Budts, W., Brjesson, M., Chessa, M., van Buuren, F., Trigo Trindade, P., Corrado, D., . . .
Papadakis, M. (2013). Physical activity in adolescents and adults with congenital heart
defects: Individualized exercise prescription. European Heart Journal, 34(47), 3669-3674.
doi:10.1093/eurheartj/eht433
Busch, J. C., Lillou, D., Wittig, G., Bartsch, P., Willemsen, D., Oldridge, N., et al. (2012).
Resistance and balance training improves functional capacity in very old participants
attending cardiac rehabilitation after coronary bypass surgery Wiley-Blackwell.
doi:10.1111/jgs.12030
Drugs.com (2014). Drug Interactions Checker - For Drugs, Food & Alcohol. Retrieved July 20,
2014, from http://www.drugs.com/drug_interactions.
Gayda, M., Temfemo, A., Choquet, D., & Ahma di, S. (2004). Cardiorespiratory requirements
and reproducibility of the six-minute walk test in elderly patients with coronary artery
disease. Archives of Physical Medicine and Rehabilitation, 85(9), 1538-1543. Retrieved
June 2, 2014, from http://dx.doi.org/10.1016/j.apmr.2003.11
Hanson, L. C., Mcburney, H., & Taylor, N. F. (2012). The retest reliability of the six-minute walk
test in patients referred to a cardiac rehabilitation programme. Physiotherapy Research
International, 17(1), 55-61. Retrieved June 18, 2014, from
http://dx.doi.org/10.1002/pri.513
Helgerud, J., J. Kvrness, S. Ringgaard, L. Brix, H. Pedersen, A. Stylen, K. L. Hydal, W. Y.
Kim, T. Karlsen, and J. Hoff. "Interval and Strength Training in CAD Patients."
International Journal of Sports Medicine 32.01 (2011): 54-59. Science Direct. Web. 28
May 2014
Houmard, J., Bruno, N., Bruner, R., McCammon, M., Israel, R., & Barakat, H. (1994). Effects of
exercise training on the chemical composition of plasma LDL. Arterioschlerosis ,
Thrombosis, and Vascular Biology, 14, 325-330.
Konfino, J., Mekonnen, T. A., Coxson, P. G., Ferrante, D., & Bibbins-Domingo, K. (2013).
Projected impact of a sodium consumption reduction initiative in argentina: An analysis
from the CVD policy model argentina. Plos One, 8(9), 1-6.
doi:10.1371/journal.pone.0073824
Klop, B., Elte, J., & Cabezas, M. (2013). Dyslipidemia in Obesity: Mechanisms and Potential
Targets. Nutrients, 5(4), 1218-1240. from http://dx.doi.org/10.3390/nu5041218

Leal Neto, J.,de Souza, Coqueiro, R. d. S., Freitas, R. S., Fernandes, M. H., Oliveira, D. S., &
Barbosa, A. R. (2013). Anthropometric indicators of obesity as screening tools for high
blood pressure in the elderly. International Journal of Nursing Practice, 19(4), 360-367.
doi:10.1111/ijn.12085
Mroszczyk-McDonald, A., Savage, P., & Ades, P. (2007). Handgrip Strength in Cardiac
Rehabilitation: NORMATIVE VALUES, INTERACTION WITH PHYSICAL
FUNCTION, AND RESPONSE TO TRAINING. Journal of Cardiopulmonary
Rehabilitation and Prevention, 27(5), 298-302.
Rasekaba, T., Lee, A. L., Naughton, M. T., Williams, T. J., & Holland, A. E. (2009). The sixminute walk test: a useful metric for the cardiopulmonary patient. Internal Medicine
Journal, 39(8), 495-501. Retrieved June 2, 2014, from http://dx.doi.org/10.1111/j.14455994.2008.01880.x
Rognmo, O., Moholdt, T., Bakken, H., Hole, T., Molstad, P., Myhr, N. E., et al. (2012).
Cardiovascular Risk of High- Versus Moderate-Intensity Aerobic Exercise in Coronary
Heart Disease Patients. Circulation, 126(12), 1436-1440. Retrieved June 2, 2014, from
http://dx.doi.org/10.1161/CIRCULATIONAHA
Scalvini, S., Zanelli, E., Comini, L., Dalla Tomba, M., Troise, G., Febo, O., & Giordano, A.
(2013). Home-based versus in-hospital cardiac rehabilitation after cardiac surgery: A
nonrandomized controlled study. Physical Therapy, 93(8), 1073-1083.
doi:10.2522/ptj.20120212

Schurr, K., Sherrington, C., Wallbank, G., Pamphlett, P., & Olivetti, L. (2012). The minimum sitto-stand height test: Reliability, responsiveness and relationship to leg muscle strength.
Clinical Rehabilitation, 26(7), 656-663. Retrieved from
http://search.ebscohost.com.pioproxy.carrollu.edu/login.aspx?
direct=true&AuthType=cookie,ip,cpid&custid=s6222004&db=s3h&AN=76470346&site
=ehost-live&scope=site
Scherr, J., Wolfarth, B., Christle, J. W., Pressler, A., Wagenpfeil, S., & Halle, M. (2013).
Associations between Borgs rating of perceived exertion and physiological measures of
exercise intensity. European journal of applied physiology, 113(1), 147-155.
Smith, S., J., Benjamin, E. J., Bonow, R. O., Braun, L. T., Creager, M. A., Franklin, B. A., . . .
Taubert, K. A. (2011). AHA/ACCF secondary prevention and risk reduction therapy for
patients with coronary and other atherosclerotic vascular disease: 2011 update: A guideline
from the american heart association and american college of cardiology foundation.
Circulation, 124(22), 2458-2473. Retrieved from http://search.ebscohost.com/login.aspx?

direct=true&AuthType=cookie,ip,cpid&custid=s6222004&db=rzh&AN=2011379716&site=
ehost-live&scope=site
Spatedouglas, T., & Keyser, R. (1999). Exercise Intensity: Its Effect On The High-density
Lipoprotein Profile*1. Archives of Physical Medicine and Rehabilitation, 80(6), 691-695.
from http://dx.doi.org/10.1016/S0003-9993(99)90174-0
Sumide, T., Shimada, K., Ohmura, H., Onishi, T., Kawakami, K., Masaki, Y., et al. (2009).
Relationship between exercise tolerance and muscle strength following cardiac
rehabilitation: Comparison of patients after cardiac surgery and patients with myocardial
infarction. Journal of Cardiology, 54(2), 273-281.
doi:http://dx.doi.org/10.1016/j.jjcc.2009.05.016
Takai, Y., Ohta, M., Akagi, R., Kanehisa, H., Kawakami, Y., & Fukunaga, T. (2012). Sit-to-stand
Test to Evaluate Knee Extensor Muscle Size and Strength in the Elderly: A Novel
Approach. Journal Of Physiological Anthropology, 28(3), 123-128.
Vella, C, J, Janot and L Kravitz. (2001). "A Review of the Impact of Exercise on Cholesterol
Levels." Health Fitness Source. University of New Mexico, n.d. Web. 1 Dec. 2013.
<http://www.unm.edu/~lkravitz/Article%20folder/cholesterolNEW.html>.
Wise, F. M., & Patrick, J. M. (2011). Resistance exercise in cardiac rehabilitation. Clinical
Rehabilitation, 25(12), 1059-1065. doi:10.1177/0269215511423408