Phase II Cardiac Rehabilitation

I. Definition Of Phase II Cardiac Rehabilitation

Phase II is the next extension of cardiac rehabilitation. It begins a few days after discharge from the hospital. Phase II is a supervised and monitored out-patient program.

II. Goals and Purposes Of Phase II

1. Give the patient a safe, monitored environment for exercise. Monitoring consists of measuring the patient's blood pressure, HR, EKG, heart sounds, and lungs sounds. It is also important to monitor the patient's subjective symptoms - i.e. - fatigue, effort of difficulty of the exercise bout (Borg Scale), etc.
2. Increase the patient's exercise work capacity. This is one of the main goals of Phase II and must be done in an orderly progressive fashion.
3. Teach the patient to monitor himself/herself during an exercise period. It is very important that the patient have a very good understanding of how hard to exercise when they are not in your Phase II program. They need to be able to work at the appropriate heart rate and perceived exertion intensity when exercising away from all of the monitoring equipment of your out-patient facility.
4. Relieve fear and anxiety. Phase II is an opportunity to reassure the patient that they can still have a high quality of life. If they exercise properly, following the counsel they have received during the educational sessions of Phase I and Phase II, they may have reason to feel good about their future.
5. Patient Education. Patient education continues in Phase II as an extension of what was discussed in Phase I. Topics that can be discussed are : risk factor modification, stress management, dietary modifications to lower fat intake, smoking cessation, anatomy of the heart, sexual activity, cardiac medications, and what do you do when you feel symptoms ?

III. The Exercise Program

1. Mode - Mode must be determined by the patient's pathology. Usually, the mode is bicycle, treadmill, a rowing machine, a sitting bike (Nu-Step) or an upper extremity bicycle (Monarch). Mode is also determined by the level of monitoring the Phase II program uses.
2. Frequency - Frequency is usually always three days per week advancing to four days. The extra day is usually done at home away from the monitoring capabilities of the clinic.
3. Duration - Duration can usually start at 15 minutes of steady state exercise preceded by 5-10 minutes of warm up and followed by 5-10 minutes of cool down. It is important to remember to allow the patient to warm up and cool down before steady state exercise is performed. The warm up period allows a gradual increase in the temperature of exercising muscle. It also reduces the incidence of muscle pulls and strains. A warm-up period allows the heart to adjust to the demands of steady state exercise in a paced fashion. A cool down period is important because it permits the heart to gradually decelerate, it gives the body a chance to dispose of any lactic acid that may have accumulated during exercise, and it allows the body to dissipate heat. Cool-down periods also allow the body time to rid itself of circulating catecholamines. It is well understood that an inadequate cool-down period increases the chances that dysrhythmias may appear.
4. Intensity. Initially, the intensity of an exercise program in a Phase II cardiac rehab is calculated from the data that the physician gathered from the patient's graded exercise stress test at the end of Phase I cardiac rehab. The information that is important from the stress test is : resting HR, maximal exercise HR, resting BP, maximal exercise induced BP, and max METS obtained. If none of this information is available on the referring prescription, then a call to the physician's office is the next step to recover this data. If none of this data is available, the physician should be asked to perform a graded exercise test with this patient. If that cannot be done, then you are going to have to assess the patient's ability to tolerate exercise in a very conservative manner.
5. Rate of Progression. The speed at which a patient is advanced through their exercise program is determined by their cardiovascular response to graded increases in duration, frequency and intensity. The patient's response is determined by measuring HR, BP and examining the EKG for signs of ischemia.

The tools that we use to monitor the patient's response to exercise are : blood pressure, heart rate, the Borg exertional sclae, the anginal (pain) scale, the dyspneic scale (SOB) and the time honored telemetric EKG unit.

IV. A Word About Determining Exercise Intensity

Setting the intensity is one of the more difficult aspects of writing an exercise prescription. If the data from the GXT (graded exercise stress test) has been recorded on the prescription that is sent with the patient as they arrive for Phase II, then it is an easy manner to write a safe exercise program. Again, the important exercise parameters are : resting HR, maximal exercise HR, resting BP, maximal exercise BP, and maximal METs obtained. Using an adapted form of the Karvonen's formula, lets see how we can write a safe ise prescription for a patient.

The Adapted Karvonen's Formula is :

The data that we will use is for a fictitious patient, Mr. James :

Using The Heart Rate Data & Max METs Achieved

Let's plug in the data to see how best to use the GXT data.

(Max HR - rest HR) x (.4 -.8 + (Max METs/100)) + rest HR

Training Exercise Heart Rate (TEHR) = (180 - 80 ) x (.5 + 8/100) + 80

TEHR = ((100) x .58) + 80 = 138 bpm

Using The Blood Pressure Data & Max METs Achieved

Mr. James will begin his Phase II exercise program in your clinic exercising at a heart rate no greater than 138 BPM. In the formula that I used, I arbitrarily used a .58 starting activity fraction. This assures me that I am well below any heart rate that would have produced symptoms during the GXT.

If Mr. James came to your clinic with only blood pressure data from the GXT, could you still write the exercise prescription ? The answer is yes. Let's see how this can be done.

Again, let's plug in the data from the GXT.

(max Systolic BP - resting Systolic BP) x (.4 - .8 + (max METs/100)) + resting Systolic BP

Training Exercise Blood Pressure (TEBP) = [(180 - 120) x (.58)] + 120

TEBP = [(60) x (.58)] + 120 = 155 systolic BP

Mr. James will begin his Phase II exercise program in your clinic exercising at a systolic blood pressure no greater than 155 mm Hg.

Using The Max METs Achieved Data Only

If Mr. James comes to your clinic with only the Max METs achieved data available from the GXT, can you still write a safe exercise prescription ? The answer is yes. Let's see how this can be done.

(Max METs Achieved) x .5 = 4 METs

Mr. James will exercise in your clinic at an intensity no greater than 4 METs.