FEATURED REVIEW ARTICLE

c e ................................................................................................................................................................................

Resistance Training for Individuals

With Cardiovascular Disease
Kevin R. Vincent, MD, PhD; Heather K. Vincent, PhD

.................................................................................................................................................................................................................

INTRODUCTION individual.7Y9 Resistance exercise increases the muscle

............................................................................................................. fiber cross-sectional areas and shifts the muscle fiber
Cardiovascular rehabilitation is a well-established means composition favorably from that of type IIB to type
of improving the functional capacity and psychologic IIAB.10 Some data show increased capillarity to the
well-being in persons diagnosed with cardiovascular trained muscles accompanies this muscle fiber shift,
disease (CVD).1Y3 The foundation of both cardiac suggesting improvement in blood delivery to the mus-
rehabilitation and exercise prescription for patients with culature.10 Bone mineral density (BMD) increases by up
CVD has traditionally been aerobic endurance exercise, to 3% at the sites of mechanical loading following RT
such as treadmill or outdoor walking. Despite concerns training in older men and women.11,12 Bone mineral
regarding orthopedic and hemodynamic safety, resis- density improvements occur even in the frailest of the
tance training (RT) has emerged as a safe component of frail populations, such as those who have corticosteroid-
cardiac rehabilitation. To reflect the acceptability of RT in induced bone loss following heart transplant surgery.13
cardiac patients, the American Heart Association (AHA), Heart transplant patients demonstrate preservation of
the American College of Sports Medicine (ACSM), and lumbar spine bone density with regular RT, indicating
the American Academy of Cardiovascular and Pulmonary exercise protection at skeletal sites prone to fracture.
rehabilitation (AACVPR) have included RT in their
current guidelines for this population.3Y5 This article will
Endurance and Physical Function
briefly present the collective physiologic adaptations,
safety, efficacy, and appropriate prescription of RT for Increases in muscle strength also correspond to im-
patients with CVD. provements in cardiorespiratory endurance. Following
RT, treadmill time to exhaustion increases, showing that
intensive activities can be sustained for longer com-
HEALTH BENEFITS OF pared with the pretraining period. Resistance training
RESISTANCE EXERCISE improves performance of activities of daily living and
............................................................................................................. decreases overall disability.14Y17 Given that many activi-
Evidence is mounting that RT improves health and ties of daily living, such as climbing stairs, carrying
comorbidities associated with CVD (Table 1). Improved groceries, and rising from a chair, require muscular
musculoskeletal fitness has recently been associated with strength to perform, RT optimizes performance of daily
decreased rates of mortality; death rates decreased from tasks. Resistance training offers an exercise option for
30 to 12 per 10,000 person-years when muscular fitness is debilitated or deconditioned persons who may not be
increased from ‘‘low’’ to ‘‘high’’ status.6 The demonstrated
health benefits associated with improvements in strength From the Department of Physical Medicine and Rehabilitation
are briefly discussed in the following sections. (Dr K. Vincent and Dr H. Vincent) and Center for the Study of
Complementary and Alternative Therapies (Dr H. Vincent),
University of Virginia, Charlottesville.
Musculoskeletal Benefits The authors have no conflict of interest.
Address correspondence to: Kevin R. Vincent, MD, PhD,
Gains in muscle strength with chronic RT range from Department of Physical Medicine and Rehabilitation, University
17% to 170% in both older men and women, depending of Virginia, PO Box 801004, Charlottesville, VA 22908-1004
on the muscle group and the baseline status of the (e-mail: kv8p@virginia.edu).

Resistance Exercise for Cardiac Patients / 207

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.............................................................................................................
metabolic rates and daily energy expenditure.37Y39 It
Table 1 & RESISTANCE AND AEROBIC
also decreases abdominal adiposity and reduces the
EXERCISE TRAINING EFFECTS ON
waist-to-hip ratio even when other changes in total body
HEALTH AND DISEASE RISK MEASURES
fat and weight are small.21,40,42Y44 Both abdominal
Aerobic Resistance adiposity and elevated waist-to-hip ratio are correlated
Measure Exercise Exercise
to the development of CVD, and reductions in these
Strength18Y20 6 jjj parameters lower the risk for future disease. Resistance
Glucose metabolism21Y25 training reduces the risk of developing the metabolic
Insulin response to glucose ,, ,, syndrome, a powerful risk for cardiovascular complica-
challenge tions and disease.42
Basal insulin levels , ,
Insulin sensitivity jj jj
Cardiovascular Disease Risk Factors
GLUT-4 transporter number jj j
Serum lipids22,23,26Y28 Resistance training has been shown to attenuate several
HDL jj j6 risk factors of CVD.29,42,45,46 The existing studies regarding
LDL ,, ,6 the influence of RT on blood lipids are equivocal, with some
Homocysteine29 j6 ,
showing a positive effect on lowering total cholesterol
and triglycerides, low-density lipoproteins (LDL-C), and
Lipid peroxidation30 ,, ,,
30
elevations in high-density lipoproteins (HDL-C).22,23,26Y28
Antioxidant enzyme activity jj j
One report indicated an RT-induced shift of the total cho-
Systemic inflammation31Y34 , ,
lesterol/HDL ratio by 1.1 points, indicating a 25% reduc-
(TNF-", CRP, IL-6)
tion in cardiovascular risk.28 Other studies do not show
Resting heart rate18 ,, 6
any RT-induced changes with any cholesterol subfraction
Stroke volume18 jj 6 or triglycerides.29,42 Resistance training positively affects
Blood pressure at rest18 newly identified and emerging risk factors for atheroscle-
Systolic ,, 6 rotic disease and CVD such as hemoglobin A1c (HbA1c),
Diastolic ,, ,6 homocysteine, and plasma lipid peroxidation.21,29,30,47
Blood pressure during exertion35,36
Aerobic ,, ,,
Inflammation and Immunity
Anaerobic , ,,
VO2max14 jjj j Systemic inflammation is considered an emerging risk
Endurance time 14
jjj jj
factor for atherosclerotic disease.47 Chronic RT lowers sys-
temic inflammation, as shown by reductions in plasma
Physical function15Y17 jj jjj
levels of cytokines such as tumor necrosis factor-",
Basal metabolism37Y39 j jj
18,19
interleukin-6, and C-reactive protein.31,32 Initial findings
Body composition
suggest that RT reduces the levels of soluble tumor ne-
% fat ,, , crosis factor receptors proportionate to the gains in mus-
LBM 6 jj cle strength.33 Recent evidence suggests that RT promotes
Abdominal adipose tissue21,40 natural cell-mediated cytotoxicity, especially during the
Visceral ,, , postexercise period.34 This has important implications
Subcutaneous ,, , for the management of postsurgical heart transplant pa-
Intra-abdominal ,, ,, tients who are pharmacologically immunosuppressed.
Bone mineral density11Y13 j jj
% fat indicates percent body fat; LBM, lean body mass; HDL, high-density Glucose Metabolism and Insulin Resistance
lipoprotein; LDL, low-density lipoprotein; VO2max, maximum oxygen
consumption. Resistance training ameliorates insulin insensitivity and
Adapted with permission from Pollock and Vincent, 1996.18
several dysfunctional pathways associated with diabetes.
able to perform aerobic exercise, and might be useful in It also decreases fasting glucose and insulin levels in
the transition from bed to ambulation recovery situa- persons who are obese-diabetic, and lowers HbA1c
tions (eg, postsurgery).41 levels, showing improvements in long-term glycemic
control.21Y25 The effect on HbA1c appears to be time-
dependent, with longer training protocols resulting in
Body Composition, Metabolism, and Obesity
greater reductions in HbA1c.21 Studies using an insulin
Resistance training often develops muscle mass and shifts clamp method show that RT improves the overall
body composition to an improved ratio of fat free/fat glucose disposal rate by as much as 48% from pretraining
mass. Resistance training increases the basal and resting level.48,49 When added to aerobic exercise programs,

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RT improves glucose clearance rates and insulin sensi- development of muscular endurance is best accom-
tivity in patients with diabetes; these data suggest that plished with lighter loads and more repetitions (912
compared with aerobic exercise alone, RT can enhance repetitions). A moderate repetition range (È8 to 12
the accrual of glucose metabolism benefits within a repetitions) with moderate loads may optimize strength
program time frame.43 At the muscle level, RT increases and power. A clinically relevant finding is that when
the muscle content of GLUT-4 receptors and insulin exercise volume is controlled, high-intensity (6 to 8
receptors in persons with diabetes, indicating that RT repetitions) and low-intensity (È12 to 15 repetitions)
increases insulin action.50 yield similar strength and health adaptations in older
men and women.8,12,14,29,30,35
The term repetition maximum (RM) refers to the
Depression and Self-efficacy
maximal number of times a load can be lifted before
In patients with CVD, depressive symptoms are common, fatigue using appropriate form and technique. For
and depression is associated with increased cardiac risk. example, 1 RM refers to the maximum load or weight
Resistance exercise improves self-efficacy and decreases that can be lifted once with proper form. The term
depression and fatigue.51 Recently, older adults with ‘‘intensity’’ in RT is defined as the percentage of 1 RM that
major or minor depression completed 8 weeks of either is used to perform the repetitions of a given exercise. The
high-intensity or low-intensity RT training; a 50% reduc- percent of 1 RM used roughly correlates to a given
tion in depression scores was attained in 61% of the high- number of repetitions, but this is variable.20 Monitoring
intensity RT and 29% of the low-intensity RT, compared intensity during an RT program can be achieved by 2
with 21% of the nonexercise group. Strength gain was methods: (1) frequent reassessment of the 1 RM for each
directly associated with reduction in depressive symp- exercise and readjustment of the training loads, or (2) the
toms and improvement in vitality.52 High-intensity RT rating of perceived exertion (RPE) scale for each
may be more effective than low-intensity RT for the exercise.55 It has been recommended that the initial
treatment of depression in older patients. resistance should allow the participant to complete the
desired number of repetitions with correct form reaching
an RPE of 13 to 15 (‘‘Somewhat Hard to Hard’’).3 The RPE
Blood Pressure and Hemodynamics
scale has been successfully used for monitoring the
The data regarding the effect of RT on hemodynamic difficulty and progression of RT in young adults, older
variables and resting blood pressure (BP) are equivo- adults, and cardiac patients.8,15,56Y58 A compelling reason
cal.18 Recently, chronic RT was shown to attenuate the to use the RPE scale to monitor the difficulty of exertion
BP response to acute maximal exercise and to improve during RT is that the percent of 1 RM does not correlate
heart rate (HR) recovery following aerobic exercise.35 to the same level of difficulty for each muscle group.
Resistance training decreases the HR and BP response to Hoeger et al59 examined how many repetitions could be
the same absolute workload during RT.36 This is performed during leg press, leg curl, bench press, and
important cardioprotection because the rate of increase arm curl exercises at 40%, 60%, and 80% of 1 RM. The
in BP and HR may precipitate cardiovascular events. The results of this study demonstrated that at 60% of 1 RM,
implications of these data are that the patient will not the participants could perform 34, 11, 20, and 15 repeti-
experience the same magnitude and rate of increase in tions for the leg press, leg curl, bench press, and arm curl
hemodynamic measures during physical stress as exercises, respectively.59 Although each exercise was
observed prior to training. Activities such as snow performed at the same relative difficulty (% of 1 RM), the
shoveling and lawn mowing elicit similar elevations in actual level of difficulty was vastly different between
hemodynamic responses as an aerobic maximal graded muscle groups as shown by the different numbers of
exercise test (GXT).53,54 The aerobic stress of those repetitions achieved by each muscle group. Using the
activities was approximately half of what was obtained RPE scale for progression would more accurately allow
during the GXT. Resistance training may potentially each exercise to be performed at the same level of
enable performance of these stressful activities by difficulty. This is important when working with clini-
attenuating elevations in BP and HR. cal populations where intensity is an important safety
issue.

RESISTANCE EXERCISE Number of Sets

PRESCRIPTION COMPONENTS
............................................................................................................. Several studies have compared the effects of single-set
and multiple-set RT programs.60 Current guidelines from
Repetitions
the ACSM, AHA, and AACVPR recommend 1 set per
Muscular strength is best developed by using greater exercise with 8 to 10 exercises incorporating all major
loads with fewer repetitions (G8 repetitions), whereas muscle groups. People desiring greater gains in strength

Resistance Exercise for Cardiac Patients / 209

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and muscle cross-sectional areas may derive greater is currently experiencing pain and/or receiving medical
benefit from multiple sets or periodized programs.61 treatment without the express direction from a medical
When comparing regimens with 2, 3, and 4 sets in older professional; (3) Patients should be instructed and
adults, Harris et al62 reported similar strength gains for all monitored for appropriate performance of each exercise;
groups. Single-set regimens performed to failure have (4) The initial exercise intensity should be low and
been shown to provide significant cardiovascular and progressed conservatively with close supervision.
functional benefits.8,12 Performing a single set of a series In such cases where prior injury does exist, the
of 8 to 10 exercises takes 20 to 25 minutes, depending on exercise should be performed with the lightest possible
the length of rest periods. This allows for the patient to resistance and progression should be very slow, once
perform other activities, such as stretching and aerobic clearance has been obtained. 1-RM testing involving an
exercise, in a time-efficient manner which has been injured joint should be avoided.
shown to improve compliance.63
Cardiovascular Safety
Frequency of Training
Cardiac rehabilitation programs initially did not include
The frequency of training refers to the number of RT an RT component because of concerns of possible
sessions performed per week. The rest period between excessive elevations in BP and of secondary unfavorable
sessions must be sufficient to allow for tissue repair and ventricular wall remodeling. These concerns arose from
development and to prevent overtraining, and must not prior studies that used isometric contractions.3,68Y72
be too long that the exercise effect wanes. Present During isometric contractions, a pressor response is
guidelines suggest a frequency of 2 to 3 sessions per elicited which involves simultaneous elevations of HR,
week with a 48-hour rest period between sessions.3,5,61 peripheral resistance, and mean arterial pressure. The
Session frequencies of 2 d/wk can produce 75% of the magnitude of the pressor response is directly propor-
improvements made with frequencies of 3 d/wk.64 tional to the intensity (% of 1 RM) of the contraction.
Recent evidence indicates that even 1 intensive session Further complicating this issue were the results from
per week yielded similar improvements in muscle cross- MacDougall et al73 which demonstrated BP responses of
sectional areas, strength, and hemodynamic responses up to 480/350 mm Hg in adult males performing leg
during exercise.65 It is unclear whether improvements in press exercises. These results convinced many within the
CVD risk factors and comorbidities can be obtained with field of cardiac rehabilitation that resistance exercise
only 1 session per week. would be inappropriate for CVD patients. However, this
study was conducted in young males performing an
exercise involving a large amount of muscle mass using
SAFETY ISSUES WITH loads of 80% to 100% of 1 RM. In contrast, cardiac
RESISTANCE EXERCISE rehabilitation programs typically use loads that are 40%
............................................................................................................. to 60% of the patient’s 1 RM, which elicit much lower BP
responses.
Musculoskeletal Risks
Numerous investigations have examined the cardio-
The available literature indicates that injury rates sec- vascular responses to resistance exercise testing and
ondary to RT or 1-RM testing are similar, if not lower in training in CVD patients since the study of MacDougall
older adults and CVD patients compared with younger et al.3,73,74 Haslam et al75 used a continuous intrabrachial
participants. The reduced rate of injury may be due to artery recording technique to measure the BP responses
the close supervision and more conservative weight during leg press and biceps curl exercise at 20%, 40%,
adjustments made in these populations compared with 60%, and 80% of 1 RM. The results showed that the rate
their younger counterparts. Injury rates reported in the pressure product (RPP) of only the 80% of 1-RM
literature for elderly subjects participating in RT testing condition for each exercise was similar to the rate
and training (12 to 26 weeks) is approximately 2% to pressure product obtained during a maximal cycle
8%.66 In studies that have reported orthopedic injuries, ergometer test. Also, none of the conditions were
the preponderance of injuries occurred in participants associated with angina or arrhythmias. Similar results
with a previous history of injury to the joint being have been reported in patients with left ventricular
exercised.67 The possibility of sustaining a musculo- dysfunction, CVD, congestive heart failure (mean left
skeletal injury can be minimized if these guidelines are ventricular ejection fraction [LVEF] 27%), and orthotopic
followed: (1) Patients should be carefully screened for heart transplant recipients performing leg and arm
current or past history of musculoskeletal injuries. Any resistance exercise at 50% to 70% of 1 RM.76Y78 In each
injuries should receive evaluation, limitation parameters, study, RT elicited cardiovascular responses similar to
and clearance from the patient’s physician; (2) Exercises those observed with submaximal endurance exercise and
should not be performed that involve a joint or tissue that lower than the responses recorded during a maximal

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symptom-limited GXT on either a cycle ergometer or a endurance (299%), 6-minute walk distance (13%), type I
treadmill. fiber area (9.5%), and citrate synthase activity (35%) after
Resistance training and 1-RM testing are associated 10 weeks of RT at 80% of 1 RM. Conraads et al85 reported
with fewer wall motion abnormalities as detected by decreased indices of left ventricular wall stress, ventricu-
echocardiography than a GXT. When compared with lar remodeling, and reduced left ventricular end-systolic
endurance exercise, acute RT causes similar changes in diameter after RT in congestive heart failure patients
systolic BP, a lower HR, and increased diastolic BP. (LVEF G35%). Other investigations have shown that RT
Collectively, these factors would prolong coronary increases muscular strength, endurance, and bone min-
perfusion time at a greater perfusion pressure and reduce eral density in orthotopic heart transplant recipients.13,89
myocardial oxygen demand.74 Increased peak oxygen consumption during graded
exercise testing has been shown to correlate to decreased
rates of morbidity and mortality.90 Resistance training
Appropriate Technique to Reduce Risk for Injury
improves muscular exercise time to exhaustion with
Prior to initiation of RT, the patient should participate either treadmill or cycle ergometry.91,92 Investigations
in several orientation sessions which would allow for using RT alone in CVD patients have not reported an
demonstration of appropriate form, determination of increase in maximal oxygen consumption (VO2max).81
each joint’s range of motion, determination of appropri- However, when RT was added to CAD patients already
ate resistance loads, and appropriate breathing tech- performing aerobic exercise, VO2max increased more
niques. During the exercise, patients should be careful to compared with those that continued with aerobic
avoid excessive hand gripping or holding their breath exercise alone.83 It has been postulated that in debilitated
(Valsalva maneuver) during each repetition due to rapid patients, such as those with CVD, skeletal muscle weak-
rises in BP. Patients should inhale during the eccentric ness and leg muscle atrophy may be a primary limiting
phase and exhale during the concentric phase. The factor in VO2max and cardiorespiratory endurance.66
concentric phase should take 2 to 4 seconds, whereas the Braith et al93 reported that quadriceps strength was
eccentric component should be completed in 4 seconds. highly correlated to VO2max in heart transplant recipients
Patients should avoid static or isometric exercises due to (r = 0.91). Meuleman et al41 demonstrated that in very
concerns of cardiovascular safety.3 Although both free debilitated geriatric patients, initial exercise with RT
weights and exercise machines are acceptable modes of improved function and leg strength, thus enabling
exercise, RT machines may be more appropriate for CVD subsequent participation in ambulatory activities. For
patients because: (1) machines allow easier titration of debilitated patients, preparticipation in RT prior to
workload in smaller increments; (2) resistance is applied aerobic exercise might allow the patient to increase the
evenly through the joint’s full range of motion; (3) efficiency in gains of cardiorespiratory endurance.
machines may be ‘‘double pinned’’ to restrict the range These physiologic adaptations translate into improved
of motion due to orthopedic limitations; (4) the patient performance of activities of daily living. In a group of
does not need to balance the weight which may reduce female cardiac patients, Brochu et al58 compared 6
the risk of injury; and (5) routines with machines are months of RT progressing from 50% to 80% of 1 RM
typically more time efficient. to a control (CON) group that met 3 times per week
to perform stretching, yoga, calisthenics, and relaxation
exercises. In addition to expected improvements in
EFFICACY OF RESISTANCE EXERCISE FOR strength, endurance, balance and coordination, and
THE CARDIAC PATIENT 6-minute walk distance, RT-trained patients performed
............................................................................................................. better on the Continuous Scale Functional Performance
Numerous investigations have examined the efficacy of (CS-PFP) test, which evaluates 15 practical activities
RT for patients with CVD, post-coronary artery bypass such as carrying groceries, climbing stairs, lifting heavy
grafting (CABG), and post-myocardial infarction pots, bed making, unloading a washing machine and
(MI).15,37,79Y83 These studies show that participation in dryer, and vacuuming. The CON group did not demon-
RT with loads ranging from 40% to 80% of 1 RM is a safe strate improvement with the CS-PFP. Similarly, Ades
and effective means of improving muscular strength and et al15 reported that 6 months of RT improved the ability
endurance in cardiac patients. to perform household activities in female CVD patients.
Several favorable adaptations have been reported in The incorporation of RT in a well-rounded cardiac
stable congestive heart failure and heart transplant rehabilitation program has more than physiologic rami-
patients.13,84Y89 Congestive heart failure is characterized fications. Patients with CVD, particularly those post-MI,
by skeletal muscle myopathy with loss of type I fibers, have an increased risk of developing depression and
decreased oxidative enzymes and mitochondrial reduced self-efficacy. Depression has been shown to
enzymes, and earlier activation of glycolytic pathways. increase the risk of future cardiac events.94Y97 Beniamini
Pu et al88 reported increased strength (43%), muscular et al51 examined the effects of 12 weeks of RT on

Resistance Exercise for Cardiac Patients / 211

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 .............................................................................................................
quality-of-life measures including depression and self-
Table 3 & ABSOLUTE AND RELATIVE
efficacy. The participants were patients with diagnoses
CONTRAINDICATIONS FOR
of either angina, post-MI, post-CABG, or post-coronary
PARTICIPATION IN RESISTANCE
angioplasty divided into RT or flexibility groups. The RT
EXERCISE
group showed greater improvements in mood, depres-
sion, fatigue, self-efficacy, and emotional health com- 1. Resting SBP 9200 mm Hg or DBP 9110 mm Hg
pared with the flexibility group. 2. Orthostatic blood pressure drop of 920 mm Hg with symptoms
3. Exertional hypotension (915 mm Hg)
4. Unstable angina
RESISTANCE EXERCISE PRESCRIPTION 5. Uncontrolled arrhythmias
GUIDELINES FOR THE CARDIAC PATIENT 6. Critical or symptomatic aortic stenosis
.............................................................................................................
7. Acute illness or fever
Eligibility for RT is typically established by evaluating the 8. Resting heart rate exceeding 120 beats/min
patient based on level of risk as well as established in- 9. Uncompensated heart failure
clusion and exclusion criteria (Tables 2 and 3).3,5,72,98,99
10. Third-degree AV block without a pacemaker
Identification of the risk of the cardiovascular patient
11. Active pericarditis or myocarditis
is the first step in determining the nature of the RT
12. Recent pulmonary embolism or pulmonary infarction
program. Those patients who fall into ‘‘moderate’’ or
13. Resting ST segment depression of 92 mm
............................................................................................................. 14. Severe orthopedic problems that would prohibit RT
Table 2 & IDENTIFICATION OF LOW-RISK,
15. Hypertrophic cardiomyopathy
MODERATE-RISK, AND HIGH-RISK
16. Recent CABG (G4 weeks)
PATIENTS IN CARDIAC REHABILITATION
17. LVEF G30%
Low Moderate High
Risk Risk Risk* 18. Advanced or complicated pregnancy

Ability to monitor own exercise Yes Yes No SBP indicates systolic blood pressure; DBP, diastolic blood pressure; AV,
atrioventricular; RT, resistance training; CABG, coronary artery bypass graft;
intensity LVEF, left ventricular ejection fraction.
Exercise ability of 97 METs Yes Yes No Adapted from AACVPR, 20045 Verrill and Ribisl, 199672 and ACSM, 2000.98
Signs of ischemia at rest or during No No Yes
an exercise test of G5 METs or
‘‘high’’ risk categories require additional monitoring
during recovery
during the RT by trained personnel in a supervised
Signs of ischemia at rest or during No Yes No
setting. All patients should be evaluated and cleared by
an exercise test of 95 METs or
a physician prior to participation in RT.
during recovery
LVEF 950% Yes No No
LVEF 40Y49% No Yes No Initiation of RT
LVEF G40% No No Yes Low-level RT is typically introduced in Phase II of
ST segment depression of Q4 mm No No Yes cardiac rehabilitation (2 to 3 weeks post-MI). During
or angina in exercise this phase, the patient uses light dumbbells (1 to 5 lbs) to
Abnormal hemodynamics with No No Yes perform 10 to 15 repetitions for 8 to 10 exercises using
exercise (flat or decrease in BP all major muscle groups of the upper and lower
or chronographic incompetence
extremities. The difficulty of exercise should not exceed
with exercise)
12 to 13 on the RPE scale. Patients may progress in
Ventricular arrhythmia at rest or No No Yes
increments of 1 to 3 lb/wk depending on exercise
during exercise
tolerance. Typically, cardiac patients are discharged from
Two or more previous MIs No No Yes
the hospital with a restriction not to lift more than 10 lbs
Previous cardiac arrest No No Yes for 6 weeks post-MI or CABG. There is evidence to
Cardiac surgery complicated by No No Yes indicate that this may be an unnecessarily restrictive
cardiogenic shock, MI, or recommendation. Dressendorfer et al100 examined the
ischemia
hemodynamic responses in 119 patients an average of 10
Corticosteroid treatments No No Yes days post-MI to a submaximal treadmill test (4 METs),
Clinically significant depression No No Yes maximal handgrip strength (MHS) measured by a
LVEF indicates left ventricular ejection fraction; METs, metabolic equivalents; dynamometer, constant load holding (50% MHS) for
MI, myocardial infarction; BP, blood pressure. 1 minute, and load carrying (20% MHS) while walking
Adapted in part from Fletcher et al, 199599 and AACVPR, 2004.5
*High-risk is assumed with the presence of any one of the descriptors in for 3 minutes. The results indicated that the load for
this category. constant holding was 41 lbs, whereas the dynamic load

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was 16.5 lbs. Both of the load-holding conditions were the program will depend on factors such as previous
associated with lower hemodynamic responses, fewer musculoskeletal injuries, level of left ventricular dysfunc-
ST-segment changes, and less ventricular ectopy when tion, neurologic limitations, pulmonary status, and time
compared with the treadmill testing. The authors con- availability. Further care should be taken to monitor the
cluded that assessing MHS prior to hospital discharge in patient’s physiologic responses particularly in the early
patients after an uncomplicated MI who have mildly stages of the program for unacceptable elevations in BP
impaired left ventricular function may allow for more
appropriate and less restrictive load-carrying restrictions. .............................................................................................................
This would allow the patient to more fully participate in Table 4 & SYNOPSIS OF GUIDELINES
routine activities of daily living. FOR TESTING AND RESISTANCE
TRAINING PRESCRIPTION IN PATIENTS
WITH CARDIOVASCULAR DISEASE
Progression
Low-Risk Patient High-Risk Patient
Prior to progressing to more advanced RT equipment PHASE I (1 to 2 weeks) PHASE I (1 to 2 weeks)
and regimens, the patient should successfully perform a Initial health assessment Initial health assessment
symptom-limited GXT to establish their level of fitness. It Begin mild aerobic activity Begin mild aerobic activity
has been suggested that patients participate in 2 weeks of PHASE II (2 to 3 weeks) PHASE II (2 to 3 weeks)
a traditional aerobic exercise cardiac rehabilitation pro-
SL-GXT assessment SL-GXT assessment
gram in a supervised setting prior to progressing with
Continue aerobic activity Continue aerobic activity
RT.3 Patients may progress to utilizing free weights or RT
Begin low-level RT activity Begin low-level RT activity
machines 4 to 6 weeks post-MI.3 Circuit-type RT at 40%
of 1 RM has been safely initiated 4 weeks post-MI in low- RPE 12Y13 RPE 12Y13
risk patients.83 The period prior to progressing to more 1Y5 lb dumbbells 1Y5 lb dumbbells
advanced routines is extended to 6 weeks for patients 8Y10 exercises 8Y10 exercises
post-CABG. These patients should be cleared from 10Y15 reps/set 10Y15 reps/set
sternal precautions by their healthcare provider before Handgrip test, set lifting limits Handgrip test, set lifting limits
progressing with more advanced RT. RT exercises that PHASE III/IV (4 weeks) PHASE III/IV (4 weeks)
cause pulling or stretching on the sternum should be Begin free weights and/or Check sternal precautions
avoided for 8 to 12 weeks post-CABG, unless otherwise weight circuits at Clearance required from
instructed by the patient’s healthcare professional. If the 40% 1YRM lifts physician to start
patient experiences clicking or grinding in the sternum or RPE 13 RT program
anterior chest, they should discontinue RT and be 40Y50% 1 RM Avoid exercises that pull or
referred to their healthcare professional for evaluation. 8Y10 exercises, stretch sternum for 8Y12
Once the appropriate clearance and adaptation period 10Y15 reps/set weeks
has been completed, patients with CVD should start with Begin free weights and/or
1 set of 10 to 15 repetitions for 8 to 10 exercises weight circuits
encompassing all major muscle groups 2 to 3 d/wk. RPE 13
Suggested exercises include chest press, shoulder press, 40Y50% 1 RM
triceps extension, biceps curl, pull-down, lower back 8Y10 exercises, 10Y15 reps/set
extension, abdominal crunch, leg press, leg curls, and (10Y12 weeks) (12Y14 weeks)
calf raises.3 Patients that are classified as ‘‘low risk’’
Progress RT to volitional fatigue Progress RT to volitional fatigue
(Table 2) should start with an initial RPE of È13 (40% to
RPE 17Y20* RPE 15
50% of 1 RM) and after a 4- to 6-week adaptation period
8Y10 exercises, 8Y10 exercises,
may progress to volitional fatigue (RPE 17 to 20, Table 4).3
10Y15 reps/set 10Y15 reps/set
‘‘Moderate risk’’ patients should also start with a similar
Increase resistance loads by Increase resistance loads by 2Y5
regimen but use a goal of 15 on the RPE scale after the
2Y5 lbs/wk for upper body lbs/wk for upper body and
4- to 6-week adaptation period has been completed.
and 5Y10 lbs/wk for the 5Y10 lbs/wk for the lower
As the patient’s strength improves, the resistance can lower body, or as tolerated body, or as tolerated
be increased 2 to 5 lb/wk for the upper body and 5 to
Maintain other aerobic activities Periodically check for sternal
10 lb/wk for the lower body. and stretching grinding or clicking
Maintain other aerobic activities
Special Considerations stretching

When prescribing an exercise regimen, the overall health SL-GXT indicates symptom-limited graded exercise test; RT, resistance
training; RPE, rating of perceived exertion; 1 RM, = 1 repetition maximum.
and level of disability of the patient needs to be con- *For moderate-risk patients, start with similar regimen but use RPE of
sidered. The intensity, frequency, or exercises chosen for 15 during Phase IV.

Resistance Exercise for Cardiac Patients / 213

Copyr ight © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
or HR, chest pain, shortness of breath, dizziness, changes
on an electrocardiogram, and sternal grinding or clicking
if the patient is post-CABG.
Medications can also influence exercise tolerance
and prescription. For example, beta-blockers will blunt
the hemodynamic responses to exercises in that HR
and BP will always be lower at a given workload in
patients using these drugs compared with those who
do not. This response would limit the utility of using
HR as a method for exercise intensity prescription.
Under these circumstances, using the RPE scale would
allow for a more sensitive means of monitoring
intensity.
SUMMARY
.............................................................................................................
Resistance training elicits multiple health benefits for
primary and secondary prevention of disease, increases
quality of life, and helps with maintaining functional in-
dependence. Resistance training is a safe, well-tolerated
modality of exercise for patients with CVD and can even
be performed soon after invasive cardiovascular pro-
cedures provided specific guidelines are followed. The
practitioner should consider RT prescription for appro-
priate candidates in all ranges of cardiovascular health
as long as safety precautions are followed and pro-
grams are adapted to meet the needs of each individual
patient.
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