10 RISK STRATIFICATION, EXERCISE TESTING,

EXERCISE PRESCRIPTION, AND PROGRAM

SAFETY

PROF. DR. NABILA NAJAM

Director
IPM&R, DUHS
What is coronary artery disease ?

• Coronary artery disease is a chronic inflammatory disease that

demands process driven vascular vigilance to ensure the levels of
vascular protection required to prevent initial or reduce recurrent
acute coronary events.
Key Points
• In both primary and secondary prevention of cardiovascular disease events, it
is important to know the individual’s risk of subsequent adverse events, to
know the treatment targets required to prevent or mitigate those risks, and to
know the behavioral and pharmacological interventions required to achieve
those treatment targets.

• The principal determinant of cardiovascular health and disease outcomes is

an individual’s cardiometabolic fitness.

• The safe, successful, and resource appropriate delivery of cardiac

rehabilitation services demands the determination of cardiometabolic fitness
and risk stratification of patients on program entry and at regular intervals
thereafter.
Key points
• It is recommended that all cardiac rehabilitation programs perform
symptom-limited exercise stress tests, or request the same, as part of
their initial and on-going patient risk stratification and individualized
exercise prescription process.

• Most patients with cardiac disease may safely undergo resistance

training.

• The role of continuous cardiac telemetry monitoring, in the promotion

and assurance of patient safety within cardiac rehabilitation programs,
remains to be scientifically evaluated and validated.
Risk Stratification in Cardiovascular Disease

KEY POINTS
• Most current clinical event risk predication or stratification models
were developed primarily to predict events in pre symptomatic patients
i.e., those without documented coronary artery disease.

• Risk stratification for the prediction of cardiac prognosis in patients

with chronic stable coronary artery disease is dependent on variables
such as functional capacity, ischemic burden, ventricular function, the
presence or absence of dysrhythmias, and the cardiovascular disease
risk factor burden.
Key Points
• A combination of a prognostic prediction model (based on
functional capacity) and an atherosclerotic clinical event risk
prediction model (based on vascular risk factors + biomarkers) is
likely the best way to risk stratify persons with chronic stable
coronary artery disease and objectively document their
cardiometabolic fitness.

• Individualized patient risk stratification and the documentation of

cardiometabolic fitness is essential for the most efficient, effective
and appropriate utilization of cardiac rehabilitation resources.
Chemical or Biochemical CVD Risk Markers Determinants
Chemical or Biochemical CVD Reference
Risk Markers
• Biochemical markers Arroyo-Espliguero et al. 2008; Chen et al, 2009, Daniels & Maisel 2007. Dragu et al.,
2008, Musunuru et al., 2008. Niccoli et al., 2008; Ridker et al., 2004, 2007, 2008,
Romero-Corral et al., 2008; Wild et al., 2008; Wilson, 2008b

• Coronary artery calcium scoring Budoff et al., 2008, 2009; Derano et al., 2008; Folsom et al., 2008; Lakoski et al., 2007;
Nair et al., 2007, 2008; Nasir et al., 2007; Schiele & Moneveau. 2009

• Ankle-brachial index Ankle Brachial Index 2008; Espinola-Klein et al., 2008

• Vascular endothelial function Kitta et al., 2009
• Baroreflex sensitivity de Ferrari et al., 2007
• Exercise test abnormalities Aijaz et al., 2008; Aktas et al., 2004; Balady et al., 2004; Ghayoumi et al., 2002; Laver et
al., 2007
• Systemic autonomic tone Exner et al., 2007
The Reynolds Risk Score

• Neither the FHS nor SCORE Canada contain information on emerging

risk factors such as C-reactive protein (CRP) or emerging risk
syndromes such as the metabolic syndrome.

• However, recent data has confirmed that both high sensitivity CRP
(hs-CRP) and the metabolic syndrome are independent, although
perhaps not terribly strong risk predictors for CVD events (Tall, 2004;
Rutter et al., 2004).

• This has prompted some authorities to suggest that both should be

added to clinical event production models (Ridker et al., 2004, 2007,
2008).
Variables in the Reynolds Risk Score
Variable Response

• Gender Male
Female
• Age Years (Maximum 80)
• Current Smoker Yes/no
• Systolic blood pressure mm/Hg

• Total cholesterol mg/dl or mmol/L

• Hs-CRP mg/dL

• Did your mother of father Yes/no

have a heart attack before age 60?
The Process of Risk Stratification and Recurrent
Event Prediction :
Key Points
• The principle components in the risk stratification process leading
to the determination of cardiometabolic fitness are:

1. Initial patient intake and assessment

2. Determination of the patients cardio fitness

3. Determination of the patients metabolic fitness

4. Calculation of the patients cardiometabolic fitness score

The previous editions of these Guidelines emphasized three
principles in the process of CVD/CAD risk stratification.

• The need to match the degree of intervention to the degree of risk;

• The concept that risk factor burden, by promoting vascular oxidative

stress, and in turn vascular inflammation, will drive the atherosclerotic
process and increase the likelihood of atherosclerotic progression;

• That a patients prognosis, and the likelihood of suffering an exercise-

associated adverse event, is directly related to a composite function
that includes the individuals current ischemic burden, left ventricular
function, the presence or absence of significant dysrhythmias, and their
functional capacity.
 Components of the Medical History
Component Description
• Background CCS Class NYHA Nature of referral event, specifically whether substrate for residual ischemia exists and
Class presence or absence of absolute or relative contraindications for exercise testing or training.
• Symptoms Angina, dyspnoea, presyncope, syncope, claudication, palpitations, CCS classification,
NYHA classification.
• Past history Recent illness, hospitalization or surgical procedures.
• CVD risk factors Determine traditional CVD risk, factors for atherosclerotic disease progression hypertension,
diabetes, obesity, dyslipidemia, and smoking.
• Medications Medication dose and schedule, drug allergies.
• Health behaviours Adverse and potentially adverse behaviours; caffeine, alcohol, and tobacco utilization;
recreational (illicit) drug use.
• Family history Cardiac disease or sudden cardiac death, pulmonary disease, metabolic disease, stroke.

• Exercise history Determine habitual level of activity, type of exercise, frequency, duration and intensity.

• Work/Vocational history Emphasis on current physical and mental demands, nothing upper and lower extremily
requirements, estimated time to return to work.
• Musculoskeletal history Musculoskeletal problems or limitations – arthritis, joint swelling, back problems.

• Psychosocial history Living situation, martial and family status, transporation needs, family needs, domestic and
emotional problems, depression, anxiety or other psychological disorders.
Components of the Physical Examination
Component Description
• Vital Signs Resting heart rate and rhythm, blood pressure (as per Canadian) Hypertension Society
recommendations) respiratory rate + temperature and/or oxygen saturation level.

• Anthropometrical Determine body weight, height, MBl, waist to hip ratio, waist circumstance at the level of the
umbilicus, absence or presence of xanthoma or xantholasma.

• Cardiovascular Complete cardiovascular examination, with special attention to murmurs, gallops, clicks and
rubs, and the presence or absence of heart failure.
Palpation and auscultation of carotid, abdominal and femoral arteries.

• Respiratory Auscultation of the lungs.

• Musculoskeletal Examination related to orthopedic, neurological or other medical conditions that might limit
exercise testing and training Diagonal ear lobe creases (Franks Sign – Glavic et al 2008)

• Procedure-related issues Examination of chest and leg wounds and vascular access areas in patients after coronary
bypass surgery or percutaneous coronary revascularization.

• Lower extremities Palpation and inspection of lower extremities for oedema or presence of arterial pulses and
skin integrity (particularly in those with diabetes)
Calculation of the Cardio Fitness Score
The calculation of the cardio fitness risk score involves a two step process

• Determination of the Duke Treadmill Score

Exercise treadmill testing should be performed according to the Bruce Protocol (ACSM, 2000; Arena et
al., 2007, Ehrman et al., 2009; Thompson et al., 2009b). Once this is performed, the Duke Treadmill
Score (DTS) is calculated according to the following formula (Mark et al., 1991):

DTS = exercise time – (5 x maximal ST depression) – (4 x angina index)

Where:

• Exercise time = minutes on the Bruce protocol

• ST depression = maximal recorded ST depression
• Treadmill angina index:
• 0 = no angina.
• 1 = non-limiting angina.
• 2 = limiting angina
For patients with resting EKG ST segment
abnormalities..
• Correction should be made for this with the protocol suggested by
kwok and colleagues (1999).

• The degree of resting ST segment deviation, horizontal or

downsloping, should be measured 80 msec after the J point.

• Maximal exercise-associated ST segment depression, either

during or in recovery, should then be subtracted from the resting
level of ST segment depression (in mm’s), in the leads with the
greatest Change from baseline.
For patients with resting EKG ST segment
abnormalities..

• The value obtained then becomes the level of ST segment

depression then inserted into the Duke Treadmill Score.

• Cardiac rehabilitation programs not using the Bruce protocol can

convert their exercise times to METs and determine the Bruce
Protocol exercise time based on MET equivalents (Thompson et
al., 2009c)
 Total annualized percent mortality derived mean annualized
mortality rate, and Duke Treadmill Score (DTS) equivalent

Total Kwok et Ghayoumi Kavanagh Villella Derived Approximate

Mortality at., 1999 et et et Mean DTS Equivalent
Per year (%) at., 2002 al., 2002 at., 2003 Mortality
Rate (%)

Low 0.4 2.0 0.8 1.2 <1 >5

Intermediate 1.1 4 2.1 3.4 1=3 < + 4 to > = 10

High 3.4 7.0 3.5 6.8 >3 > = 11

The risk cut-points for recurrent adverse CVD events
(cardiac death, myocardial infarction, stroke or
cerebrovascular death) are:

• Low risk - < 2.5% per year adverse event rate

• Intermediate risk – 2.5% = 5% per year adverse event rate

• High risk = > 5% per year adverse event rate.

Absolute and relative contraindications exercise stress testing
 Acute myocardial infarction (within 2 days)
 High-risk unstable angina
 Uncontrolled cardiac dysrhythmias causing symptoms or hemodynamic compromise
symptomatic (usually severe to critical) valvular stenosis
 Uncontrolled heart failure
Absolute  Acute pulmonary embolism or infarction
 Acute non-cardiac co-morbidities (fever, systemic infection/sepsis, thyrotoxicosis)
 Acute myocarditis or pericarditis
 Acute aortic dissection
 Physical inability or impediment preventing safe test conduct or adequate/diagnostic test
performance.
 Inability to obtain informed consent or obtain patient co-operation during the test.

Relative • Left main coronary stenosis or equivalent

• Moderate slenotic valvular heart disease
• Electrolyte abnormalities
• Poorly or uncontrolled atrial fibrillation
• Uncontrolled diabetes mellitus (blood glucose > 22 mmol/L)
• Severe resting arterial hypertension (> 180/110 mmHg)
• Tachydysrhythmias or bradydysrhythmias
• Hypertrophic cardiomyopathy or other forms of outflow tract obstruction
• High degree atrioventricular block
The Exercise Prescription
• Key Points

• Risk stratification is the key to safe and effective exercise prescriptions.

• Exercise prescription should be established by those with appropriate

training (including national certification), experience, and expertise.

• Aerobic and resistance exercise prescriptions should be in accordance

with the FITT (frequency, intensity, time and type) formula for exercise
training.
• Stretching exercise is most effective when the muscles are warm. In recognition of this
principle, stretching should be undertaken immediately before or after the conditioning phase.

• Stretching following exercise may be preferable for sports for which muscular strength, power
and endurance are important for performance.

• Stretching does not necessarily prevent injury.

• Stretching exercise should involve the major muscle tendon groups of the body with > 4
repetitions per muscle group.

• Static, dynamic or ballistic, proprioceptive neuromuscular facilitation, and dynamic range of

motion techniques may improve flexibility.

• Static stretches should be held for 15 to 60 seconds.

• Dynamic or ballistic stretching may be considered particularly for persons whose sports
activities include ballistic movements.

• For partner-assisted (e.g. proprioceptive) neuromuscular facilitation techniques. A 6-second

contraction followed by a 10 to 30 second assisted stretch is recommended.
 Necessary components of an exercise training session
• Warm-up
A minimum of 5-10 minutes of cardiovascular and / or muscular endurance
type activities at a target heart rate of approximately 20-35% of HRR.

• Frequency
3 to 5 times per week

• Intensity
40% to 85% of HRR

• Conditioning
• Time
20 to 40 minutes

• Type
Aerobic and resistance training activities

• Cool- down
A minimum of 5-10 minutes of cardiovascular and / or muscular endurance type activities at a target heart rate of 60% of
maximum heart rate.
 Rate of Exercise Program Progression

• Consistence with the manner in which the intensity of a session is gradually

increased over several weeks to months of training, the exercise time (e.g.
target of 60 minutes daily) can begin with as little as two to six, 5 minute
exercise bouts, with rest periods between each bout, for those with very low
levels of cardio respiratory fitness.

• For patients in a CR program, exercise duration should be made as the

individual adapts to training and in the absence of symptoms suggestive of
undue fatigue or injury.

• Within the FITT paradigm of exercise prescription, large increases (~ >20%) in

any of the FITT components should be avoided to minimize or reduce the
possibility of musculoskeletal soreness of injury (Thompson et al, 2009c,d).
Exercise Measures

• Most trials of resistance training in patients with heart disease included

those with well preserved left ventricular function who had already
trained aerobically for 3 months or more.

• Interventions were generally 12 weeks or less and utilized one to two

sets of assorted upper and lower body exercises with 10-15 repetitions
per set.

• Lifting was at 30 to 80% of the 1 RM, performed in addition to the

usual aerobic exercise prescription and carried out on two to three
occasions each week McCartney, 1998)
 Protocol for determining one maximum (1 RM) for
CR patients.
Patients should receive clear instructions regarding how each resistance exercise in performed Patients
then perform each exercise several times at very low resistance to enhance.

• Step 1 familiarization The importance of normal breathing should be emphasized. Patients

should start the lift with a very brief breath hold. 1-2 seconds, but should then continue normal
breathing in order to avoid a prolonged breath hold that could lead to a Valsalva maneuver.

• Step 2 A light warm up 5 repetitions at 40% of the patients perceived or anticipated 1RM will
then be performed.

• Step 3 after a two minutes rest with light stretching. 1 repetition at 80% of the patient’s
perceived 1 RM will then be performed. Following completion of this lift, the patient will again rest for
two minutes.
• Following the rest period, take the patient as close as possible to their perceived 1RM if the
lift is successful, a rest period of two minutes will be allowed.

• This process, will continue increasing the resistance initially at 10 Ibs for lower body
(reducing to 5 Ib increments in all subsequent attempts) and increasing the

• Step 4 resistance initially at 5 Ibs for upper body (reducing to 5 Ib increments in all
subsequent attempts) and increasing the resistance initially at 5 Ibs for upper body (reducing
to 2.5Ib increments in all subsequent attempts) until a failed attempt occurs.

• Step 5 The 1RM value will reported as the weight of the last successfully completed lift.

• Step 6 The 1RM will then be established for each of the exercises in this manner during
the same session.
• Evidence suggests…

• Increased 1 RM strength (6 to 53%) and lifting endurance,

increased functional capacity and peak oxygen uptake, increased
submaximal endurance, and reduced ratings of perceived exertion
(Borg) at power outputs above 50% of the pre-training maximum
(McCartney et al, 1991;) Ades et al. 2003; McCartney et al, 1991; ‘

• in addition evidence suggests that the combination of resistance training

(2 days per week) and aerobic training (3 days per week) may further
increase the magnitude of some training adaptations (e.g. VO2peak) in
comparison to aerobic training (5 days per week) along (Marzolini et al.
2008).
Resistance training guidelines for CR programs
• Approval of the Program Medical Director.
No evidence of conditions precluding safe exercise training

• Completion of at least one month of aerobic training without

complications.

• Patient Selection :Approval of cardiac surgeon if post sternotomy

patient

• At least 3 weeks post percutaneious coronary intervention, 5 weeks

post- MI and 8 weeks post sternotomy.
.
• General Training 30-40% of 1RM for upper body and 50-
60% for lower body.

• Recommendations Repetitions should generally be

maintained between 12-15 to avoid injur and undue discomfort.

• Somewhat hard rate perceived exertion (Borg 11-15 is a useful

subjective guide Occasional use of ECG and blood pressure
monitoring is recommended, especially in the early stages and in
high risk patients
• Specific Considerations Repeat 1 to 3 sets of 6 to 10 exercise two
to three times per week.

• Large muscle groups should be exercised before small muscle groups.

• Patients should breath normally and do not hold their breath.
• Increase resistance by -5% when patients can comfortably perform 12-
15 repetitions.
• Avoid straining and sustained tight gripping.
• Patients should Utilize controlled movements with complete extensions
Tips for reducing the possibility of adverse
hemodynamic responses during resistance training.

• Reducing Tip

• Utilize high frequency repetitions (15-20) rather than single maximum

lifts.
• Do not lift to the point of fatigue or obligatory valsalva manoeuvre
usually > 80% of 1RM.
• Utilize unilateral rather than bilateral exercise where possible.
• Avoid using overhead resistance training exercise or utilize lower
intensities and repetitions
• Rest between exercises. Try to avoid rushing the circuit.
• The overall level of exertion during resistance training should not exceed the
overall level recommended for aerobic training.

• Should be restricted to a moderator RPE level (#5 on the 0-10 Borg Scale #
15 on the 6-20 scale).

• It is important to note that the monitoring of blood pressure during

resistance training should be done in a non-exercising arm of leg while the
patient is actually lifting and lowering the weight.

• Measurements done after the lifting are not valid due to the large decrease in
pressure that takes place immediately after the final lift/ Wiecek et al. 1990)
Patient Safety and guidelines on ICD
• The major concern for all involved in the delivery of exercise
training in CR is a sudden, unexpected event without warning
signs or death due to a lethal ventricular for appropriate risk
stratification and, where appropriate, anti-arrhythmic therapy.

• Therefore, it is worthwhile considering the currently available

Canadian Guidelines on ICD therapy.
Based on the best available evidence, the Canadian Cardiovascular
Society (Prevention of Sudden Death from Ventricular Arrhythmia, CCS
Consensus Conference 1999 and the Canadian Heart Rhythm Society
have recommended that

• All adult patients surviving a cardiac arrest or symptomatic sustained

VT not within three days of acute MI and not associated with a
correctable cause, or with VF or with VT causing syncope or with
minimally symptomatic VT with LVEF < 35% or any patient with LVEF
< 30% (measured > 1 month post MI or > 3 months post coronary
revascularization) should be considred for an ICD Tange et, al, 2005.
• none of these guidelines recommend that patients in the ICD
recommended categories refrain from participating in vigorous
exercise.

• Consequently, should a potential CR patient fall into any of the ICD

recommended categories above, definitive arrhythmia treatment or
decisions regarding same should be differed to the patients attending
cardiologist / documented prior to entry into the CR program.

• As a general rule of thumb, in either GXT testing or exercise

prescription, the patient’s maximum heart rate should be kept 15 beats
below the ICD threshold for either pace termination of tachycardia or
defibrillation
 Telemetry (EKG) Guidelines
• Key points

• Exercise related adverse rates with cardiac rehabilitation programs are extremely low.

• The use of continuous telemetry monitoring in cardiac rehabilitation programs has not been shown to
reduce or prevent adverse events or sudden cardiac death.

• Patient risk, is determined by recommended risk stratification, with respect to the likelihood of
exercise related events, i.e. short term cardiac event risk, is one of the principal determinants of the
need for telemetry monitoring.

• The usage, type and length of telemetry monitoring is at the discretion of the cardiac rehabilitation
program Medical Director.

• Trained professional cardiac rehabilitation staff are required to monitor telemetry equipment.

• Despite decades of exercise training within CR Programs, both supervised and unsupervised, there is
not clear consensus regarding the use of EKG telemetry monitoring.
Summary of FITT paradigm for patients in CR (Modified form
Pollack et al 2000).

Frequency 2 to 3 days per week

Upper body: 30 to 40% 1RM

Intensity Lower body: 50 to 60% 1RM

Time 1 to 3 sets with 12 to 15 repetitions

6 to 10 exercises for both upper and lower

Type
body
Recommendations
o R-10.1. All patients entering CR programs must have a medical assessment
and undergo determination of their cardiometabolic fitness prior to the
initiation of therapy.

o R-10.2. A directly supervised GXT is recommended as part of the initial

cardiac rehabilitation assessment prior to the initiation of therapy.

o R-10.3. it is recommended that patients in cardiac rehabilitation engage in

aerobic and resistance exercise 3 to 5 times per week, at 40% to 85% of
their heart rate reserve, for 200 to 40 minutes per session. Each exercise
session should include an appropriate warm up and cool down period.
o R-10.4. Patients in cardiac rehabilitation may safely derive fitness
benefits from a supervised program of resistance training.

o R-10.5 Resistance training should be offered to all CR patients.

o R-10.6 Provision of continuous EKG monitoring should be at the

discretion of CR medical Director

o R-10.7 Patient are encouraged to wear a heart rate monitor during

physical activity exercise and follow target heart rate prescribed.