Heart Disease

Cardiovascular rehabilitation can benefit some elderly patients who have angina or severe heart failure, who have had a myocardial infarction, or who have undergone bypass surgery or angioplasty. The goal of rehabilitation is to help these patients maintain or regain independence, based on their physical capability. For those in poor physical condition because of cardiac disease or physical inactivity, the heart's maximum working capacity (cardiac reserve) may be greatly reduced. Restoration of cardiac reserve through cardiac rehabilitation enables most patients to eventually resume their previous level of physical activity.

Rehabilitation programs typically begin with light activity and gradually progress to moderate activity under the supervision of a trained attendant. However, because patients respond differently to the stress of severe heart disease, rehabilitation programs must be individualized. For some patients (eg, those with heart failure, arrhythmias, or valvular disease), even light activity may increase risk. Patients with unstable angina should not exercise at all. High-risk patients should exercise only in a well-equipped cardiovascular rehabilitation facility under the supervision of a trained attendant.

Physical activity is measured in metabolic equivalents (METs), which are multiples of the resting rate of oxygen consumption; 1 MET (the resting rate) equals about 3.5 mL/kg/minute of oxygen. Normal working and living activities (excluding recreational activities) rarely exceed 6 METs. Light to moderate housework is about 2 to 4 METs; heavy housework or yard work is about 5 to 6 METs. (see Table 31-4)

Maximum allowable workloads, established by the New York Heart Association, are based on the patient's functional classification (see Table 29-1). For hospitalized patients, physical activity should be controlled so that heart rate remains < 60% of maximum for that age (eg, about 160 beats/minute for persons aged 60); for patients recovering at home, heart rate should remain < 70% of maximum.

For patients who have had an uncomplicated myocardial infarction, a 2-MET exercise test may be performed to evaluate responses as soon as the patient is stable. A 4- to 5-MET exercise test performed before discharge helps guide physical activity at home. Patients who can tolerate a 5-MET exercise test for 6 minutes can safely perform low-intensity (sedentary) activities (eg, light housework) after discharge if they rest sufficiently between each activity.

Unnecessary restriction of activity is detrimental to recovery. The physician and other members of the rehabilitation team can therefore provide psychologic support and explain which activities can be undertaken and which cannot. When discharged, patients can be given a detailed home activity program. Most elderly persons can be encouraged to resume sexual activity, but they will need to stop and rest as necessary to avoid overexertion. Young couples expend 5 to 6 METs during intercourse; whether elderly couples expend more or less is unknown.