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Summary table

Exercises

Stages

Response

Heart rate

Blood pressure

RPE

Chester step test;

Details: 8-inch step 2-minute increments

Stage 1

82 bpm;

150/ 90

10 to 11

Chester step test;

Details: 8-inch step 2-minute increments

Stage 2

94 bpm;

160/90

12

Chester step test;

Details: 8-inch step 2-minute increments

Stage 3

105 bpm;

170/90

14 to 15

Cardiac risk stratification can be considered as a critical assessment technique for the medical practitioners in terms of detecting those patients who are high health risk. Cardiovascular disease has been recognised as one of the leading factors underlying substantial mortality as well as morbidity rate around the globe. Evidences suggest that Individuals who are at a higher risk of developing cardiovascular disorders should be diagnosed at an early phase so that it might become easier for the medical professionals to make preventive efforts (Singh & Zeltser, 2018).  

There are several cardiovascular risk factors which are often categorised as modifiable and non- modifiable risk factors. According to the given case study, the 52 years old male patient has been diagnosed with Anterior/lateral STEMI for which he had to undergo coronary artery bypass graft. The patient is a full- time worker and has been diagnosed with medical health issues mainly high blood pressure as well as diabetes mellitus (type 2).

Age, gender, and most importantly family history are three risk variables that cannot be changed. These risk factors, in general, are irreversible, and nothing can be done to mitigate an existing risk. Several studies have found that the prevalence of CVD rises with age, with a substantial increase in the prevalence of any vascular disease for every decade of life after the age of 40 (Brunner et al., 2019). Across various diverse populations, males have been demonstrated to have a higher risk than females. Multiple studies have found that family history, especially paternal family history, is an independent risk factor for CVD or future myocardial infarction.  Any 1st-degree relative who died or had CVD prior the age of 55 in case of males or 65 in case of females might be considered to have a positive CVD family history. In the given case study, no, data regarding the family history of the patient had been mentioned, hence risk stratification based on this category remain inconclusive however other two factors which include age above 40 year and male gender remark that the 52 years old male patient is at higher risk of experiencing cardiovascular problem in future as well.

Other risk factors which include medical history of the patient which may include type 2 diabetes mellitus and hypertension can also be correlated with high risk of cardiovascular problems in the patient. There is substantial number of evidences which directs that hypertension is one of the most potential risk factors that increases the risk of coronary artery disease among individuals (Fuchs & Whelton, 2020). Coronary artery disease (CAD), previous heart failure, diabetes mellitus and renal failure are independent clinical indicators which can be considered as risk predictors for cardiovascular ailments in major studies. Each of these indicators entails a relative risk of severe cardiac problems ranging from 2.0 to 5.0. From the anthropometric data of the patient, it is evident that he is overweight and having a BMI of 29.4 kg/m2. Hence it can be assessed that the risk of developing cardiovascular illnesses is high for the patient. In the context of modifiable risk factors, it has also been reported that the patient is having anxiety disorders as measured through Hospital Anxiety and Depression Scale (HADS). According to growing body of clinical evidences it has been indicated that people with anxiety issues are more susceptible to encounter negative cardiovascular outcome.

Risk-stratification

The protective factors that might be mentioned while stratifying the risk of cardiac issues in the patient include swimming, playing badminton occasionally and overall am active lifestyle. However, the Exercise test results indicated that the blood pressure and heart beat have increased due to performance of exercise. However, in this regard, it has to be taken under consideration that exertion might lead to cardiovascular complications as well and thus might impact the current condition of the patient.

Hence, it can be concluded that the 52 years old male patient is at high risk of disease progression as well as exertion. As a preventive measure the patient must perform light to moderate physical activity to control both the blood sugar and hypertension. Walking is a form of cardiovascular exercise that elevates the heart rate. Blood flow is improved, and blood pressure is reduced (McDermott et al., 2021). According to studies, there was a higher change in Functional Capacity at that time cycling was employed as the primary type of exercises in cardiac rehabilitation compared to treadmill exercise. Furthermore, when cycling could be considered as  the major mode of exercise in CR, CAD patients had better increases in FC, but CHF patients saw greater benefits from treadmill-based exercise programmes.

Brisk walking (As warm up)

20 Minutes per day

Treadmill

15 minutes +/- 5 minutes

Cycle ergometer

10 minutes +/- 2 minutes

Concept II rowing machine

12 minutes +/- 2 minutes

Early detection of vulnerable population would facilitate risk factor modification therapy to be implemented, thereby lowering the risk of co- morbidity and mortality status. Evidence-based cardiovascular risk assessment should be emphasised by the interprofessional team members since their involvement in coordinating treatment is highly necessary to accurately identify cardiovascular risk and enhance patient outcomes (Ambrosetti et al., 2021). In this regard it is important for the medical professionals to evaluate different clinical parameters so that they might plan effective strategies to ensure positive health outcomes throughout the cardiac rehabilitation period and later on. There are ample number of evidences which indicate that for individuals with coronary heart disease, exercise training can be referred as an essential element for cardiac rehabilitation regimens. It lowers cardiovascular mortality and aids in the recovery of decreased myocardial contractile function following myocardial infarction, as seen by an increase in left ventricular ejection fraction (LVEF) (Peretti et al., 2020). It also boosts cardiorespiratory fitness and helps with a variety of chronic conditions. Cardiac rehabilitation has also been proved to lessen the financial burden of cardiovascular disease as per many researchers which have conducted recently. In this report different important aspects including metabolic equivalent (also known as MET), percentage of heart rate reserve (also referred as HRR) and ratings of perceived exertion will be critically appraised. Implications and clinical significance of these aspects in monitoring assessing and guide exercise intensity during the cardiac rehabilitation programme for individuals will also be highlighted throughout the paper.

Metabolic equivalents are the difference between an active person's calorie expenditure and their resting basal metabolic rate. They are utilised as a functional capacity estimate during EST. A metabolic equivalent (or, MET) is a measurement of oxygen uptake measured in millilitres per kilogramme of body weight per minute (mL kg1 min1) (Gois et al., 2022). Age, gender, lifestyle patterns, heredity, and cardiovascular functional state all might influence Vo2 max. The threshold (ventilatory) is another measure of relative labour effort; it is the point at which, despite linear rise in oxygen work rate as well as intake, ventilation tends to rise abruptly (Weatherwax et al., 2019). The ventilatory criterion is highly reproducible in the great majority of cases, albeit it may not be achieved or readily detected in certain people, especially those with very poor exercise capacity. According to the research conducted by Franklin et al. (2018) it has been indicated that metabolic equivalents, or METs, can be routinely incorporated in the medical care plan as a guide in order to evaluate exercise training and also for activity prescription so that cardiorespiratory fitness (CRF) can be categorized. However, there are certain limitations associated with the concept, along with misapplications of the parameter as well. CRF or cardiorespiratory fitness and the person’s capability to perform physical activity are frequently exaggerated and underestimated. Furthermore, fitness thresholds linked to the greatest and lowest death rates may be deceptive, as they are impacted by a variety of factors, which may include gender and age of the person. Numerous studies have called into question the common assumption that 1 MET = 3.5 mL O2 per kg per min, indicating a considerable overestimation of actual resting energy expenditure in specific populations, such as people with cardiovascular problems, morbidly obese people, and people using beta-blockers. These findings have ramifications for categorising relative energy consumption during submaximal and maximum activity. The "personal activity intelligence" or PAI score may be estimated using heart rate to approximate activity METs, resulting in a potential new fitness metric. Despite its flaws, the MET idea is a valuable tool for quantifying CRF and defining a repertoire of safe and therapeutic physical activities. Finally, moderate-to-vigorous physical exercise, equivalent to 3 METs, may raise MET capacity and lower the risk of future cardiac events in previously sedentary persons. As per the study conducted by Duggal et al. (2021) it has been demonstrated that men who participate in cardiac rehabilitation programmes at a higher rate than women, according to most research. Given the underrepresentation of women in these studies, it's impossible to say if any variations in peak MET levels reported are a real reflection of sex differences in peak MET levels. Despite this, the statistically significant improvement in METs in both sexes implies that CR has therapeutic benefits for women and that more women should be sent to CR programmes.

Exercise plan for everyday must include:

The gap between your resting and maximum heart rates is known as heart rate reserve (HRR). It is primarily used to determine heart rate zones and the amount of cushion in heartbeats available for activity during exercise. Eliminating the resting from the highest heart rate is the way to get the HRR. The RPE scale is used to determine how intense your workout is. On a scale of one to ten, the RPE scale spans from 0 to 10. The numbers below correlate to words patients use to rate how easy or how difficult a task is for them. According to the research conducted by Khushhal et al. (2019) it was indicated that the percentage range strategy for personalised prescription of exercise has come under fire in recent years, and we were worried that sub-optimal exercise dosage (particularly intensity) might be contributing to the heterogeneity in the success of cardiac rehabilitation (or the CR) programs in the United Kingdom. The goal of this study was to track and measure intensity of the exercise training in order to determine the validity of a structured Phase III CR programme. The average exercise training intensity was lower than the minimum training intensity guidelines for the Phase III CR programme. Previous papers noting the substantial heterogeneity in efficacy of UK CR services, as well as low CRF improvements found in various past trials, may have been influenced by these findings. As per the study conducted by Pymer et al. (2020) it has been indicated that in cardiac rehabilitation programmes exercise intensity is recommended from a predetermined percentage range (percent heart rate reserve (percent HRR)). We wanted to see how reliable this method was by comparing it to an objective, threshold-based method that included an exact calculation of the ventilatory anaerobic threshold (VAT). The researchers have included almost 112 referred patients. The findings also indicated that current exercise intensity guidelines in the United Kingdom are based on a defined % range. According to the findings of this study, a high percentage of patients undergoing cardiac rehabilitation may be misdiagnosed using this method.

According to the study conducted by Heber et al. (2019) it has been indicated that with increased power output, the heart rate (HR) rises, but in most healthy people, the HR slope flattens off as the intensity rises. The heart rate performance curve (HRPC) might be deflected downward in this case. In individuals who have had a myocardial infarction, on the other hand, an upward HRPC deflection is common, especially in those who have a low left ventricular ejection fraction. Suggestions for goal heart rates should instead be based on extensive workout testing. Exercise tests should also be done on a frequent basis, as HRPCs fluctuate over time, and patients should be instructed to report any changes in perceived effort at a particular heart rate right away. Given the technological possibility, prescribing watts (or speed for treadmill walking/jogging) is another option to address the problem of changed HRPC deflection.

As per the research conducted by Ciampi et al. (2021) it has been demonstrated that heart rate reserve (also abbreviated as HRR) along with exercise testing can be used to assess sympathetic dysfunction. The researchers' goal was to see how useful HRR was in predicting the fate of hypertrophic cardiomyopathy patients (HCM). The authors enlisted 917 HCM patients in this study in order to obtain reliable results. HRR predicts HCM outcome independently of other known indicators like age and maximum wall thickness. HRR surpassed left ventricular outflow tract gradient (LVOTG) and hypotension induced by exercises in terms of survival prediction, and it was both independent and additive to regional wall motion abnormalities (RWMA). Reduced sympathetic reserve, which causes autonomic system imbalance and life-threatening sensitivity to electrical instability, is the most plausible pathophysiological substrate of a muted HRR.

Critically appraisal

The rate of perceived exertion (RPE) can be defined as a metric for determining the amount of effort an individual experiences at the time of exercising. RPE can be regarded as an effective tool for those individuals who are willing to control the intensity of their physical activity (Shea et al., 2019). The Borg Rating of Perceived Exertion Scale is commonly used for reporting RPE. In cardiac rehabilitation program REP is considered one of the most essential tools in order to monitor and assess the cardiovascular functioning of a patient who has recently encountered an injury or operation. As per the research conducted by Foster et al. (2021) it has been demonstrated that the session rating of perceived exertion (sRPE) approach was created 25 years ago as a variation on the Borg idea of rating of perceived exertion (RPE), It was designed in a way so that the training session intensity can be accessed as a whole. It appears to be widely used as a measure of internal training load. sRPE was originally meant to be obtained 30 minutes post the training bout to avoid the terminal features of an exercise session from disproportionately affecting the rating, but it has been demonstrated to be temporally resilient spanning durations ranging from 1 minute to 14 days after an exercise session. The researchers have concluded with the opinion that the sRPE has the benefit of being extremely simple to use as a training monitor. While it isn't perfect for meticulously recording the details of the external training load, it offers significant advantages for measuring the internal training load.

According to the research conducted by Morishita et al. (2019) it has been indicated that RPE scales can be used at home or in nursing homes to measure the intensity of resistance training for older people who do not have access to resistance training machines. RPE is a simple and effective tool that can help with skeletal muscle strength and other health concerns. Similarly, according to the research conducted by Compagnat et al. (2018) it has been indicated that the Borg Scale for the rating of perceived exertion (RPE) is suggested for measuring the intensity of physical activity during stroke rehabilitation at home and in the hospital, but its validity in activities of daily living has to be investigated further in future research. As discussed by Nichols et al. (2021) when calculating exercise intensity using ratings of perceived exertion (RPE), the impact of baseline cardiorespiratory fitness must be taken into account. In low-, moderate-, and higher-fit people, RPE values of 10 to 14 correlates to the ventilatory anaerobic threshold. Initial exercise intensity prescription should take into account each person's cardiorespiratory fitness level. According to the study conducted by Peñailillo, Mackay and Abbiss (2018) it was explained that Despite distinct physiological stress, perceived exertion was higher during concentric cycling compared to eccentric cycling. However, effort was equivalent across the two circumstances. These findings have ramifications for understanding how such perceptions emerge during exercise. According to the study conducted by Zinoubi et al. (2018) it has been indicated that HR and RPE values were greater after alternated-intensity activities with the same average power outputs or APO than during constant-intensity exercises. When the exercise times in alternated-intensity regimens were longer, the impact was more evident. The associations between HR and RPE between continuous and alternated-intensity procedures, on the other hand, were not substantially different. RPE may be used to prescribe training for both continuous and alternated-intensity activities based on an individual's RPE score.

Hence it can be concluded that exercise training is an important component of cardiac rehabilitation regimens for people with coronary heart disease, according to a large body of research. It reduces cardiovascular mortality and helps myocardial contractile function recover after a heart attack, as evidenced by a rise in left ventricular ejection fraction (LVEF). The difference between an active person's calorie expenditure and their resting basal metabolic rate is measured in metabolic equivalents. During EST, they are used as a functional capacity estimate. A metabolic equivalent (or MET) is a measurement of oxygen uptake in millilitres per kilogramme of body weight per minute that should be taken into account while evaluating a patient's cardiovascular condition during cardiac rehabilitation of CR. HRR or Heart rate reserve is the difference between your resting and maximal heart rates (HRR). It's mostly used to figure out heart rate zones and how much cushion there is between heartbeats during exercise. The rates of perceived exertion (RPE) is a statistic that measures how much effort a person feels when they exercise. RPE might be considered a helpful technique for those who want to manage the intensity of their physical activities. RPE is frequently measured using the Borg Rating of Perceived Exertion Scale. All of these are beneficial in terms of monitoring, assessing, and implementing an appropriate exercise programme during cardiovascular rehabilitation.

References

Ambrosetti, M., Abreu, A., Corrà, U., Davos, C. H., Hansen, D., Frederix, I., ... & Zwisler, A. D. O. (2021). Secondary prevention through comprehensive cardiovascular rehabilitation: From knowledge to implementation. 2020 update. A position paper from the Secondary Prevention and Rehabilitation Section of the European Association of Preventive Cardiology. European journal of preventive cardiology, 28(5), 460-495. https://academic.oup.com/eurjpc/article-abstract/28/5/460/6145619

Brunner, F. J., Waldeyer, C., Ojeda, F., Salomaa, V., Kee, F., Sans, S., ... & Koenig, W. (2019). Application of non-HDL cholesterol for population-based cardiovascular risk stratification: results from the Multinational Cardiovascular Risk Consortium. The Lancet, 394(10215), 2173-2183. https://www.sciencedirect.com/science/article/pii/S014067361932519X

Ciampi, Q., Olivotto, I., Peteiro, J., D’Alfonso, M. G., Mori, F., Tassetti, L., ... & Stress Echo 2020 Study Group on behalf of the Italian Society of Echocardiography and Cardiovascular Imaging (SIECVI). (2021). Prognostic value of reduced heart rate reserve during exercise in hypertrophic cardiomyopathy. Journal of Clinical Medicine, 10(7), 1347. https://www.mdpi.com/2077-0383/10/7/1347

Compagnat, M., Salle, J. Y., Mandigout, S., Lacroix, J., Vuillerme, N., & Daviet, J. C. (2018). Rating of perceived exertion with Borg scale in stroke over two common activities of the daily living. Topics in Stroke Rehabilitation, 25(2), 145-149. https://www.tandfonline.com/doi/abs/10.1080/10749357.2017.1399229

Duggal, N. A., Scalzitti, D. A., Watkins, S., Hecht, O., & Johnson, S. J. (2021). Sex-Based Differences in Metabolic Equivalents (METs) After Cardiac Rehabilitation: A Systematic Review. J Card Pulm Rehabil, 5(143), 2. https://www.researchgate.net/profile/David-Scalzitti/publication/354076743_Sex-based_differences_in_metabolic_equivalents_METs_after_cardiac_rehabilitation_a_systematic_review/links/6123ec3e169a1a01031fe459/Sex-based-differences-in-metabolic-equivalents-METs-after-cardiac-rehabilitation-a-systematic-review.pdf

Foster, C., Boullosa, D., McGuigan, M., Fusco, A., Cortis, C., Arney, B. E., ... & Porcari, J. P. (2021). 25 years of session rating of perceived exertion: historical perspective and development. International journal of sports physiology and performance, 16(5), 612-621. https://journals.humankinetics.com/view/journals/ijspp/16/5/article-p612.xml

Franklin, B. A., Brinks, J., Berra, K., Lavie, C. J., Gordon, N. F., & Sperling, L. S. (2018). Using metabolic equivalents in clinical practice. The American journal of cardiology, 121(3), 382-387. https://doi.org/10.1016/j.amjcard.2017.10.033

Fuchs, F. D., & Whelton, P. K. (2020). High blood pressure and cardiovascular disease. Hypertension, 75(2), 285-292. https://www.ahajournals.org/doi/abs/10.1161/HYPERTENSIONAHA.119.14240

Gerlach, S., Mermier, C., Kravitz, L., Degnan, J., Dalleck, L., & Zuhl, M. (2020). Comparison of treadmill and cycle ergometer exercise during cardiac rehabilitation: a meta-analysis. Archives of Physical Medicine and Rehabilitation, 101(4), 690-699. https://doi.org/10.1016/j.apmr.2019.10.184

Gois, C. O., Conceição, L. S. R., & Carvalho, V. O. (2022). Comment on:“Resting Oxygen Uptake Value of 1 Metabolic Equivalent of Task in Older Adults: A Systematic Review and Descriptive Analysis.”. Sports Medicine, 1-3. https://link.springer.com/article/10.1007/s40279-021-01617-4

Heber, S., Sallaberger?Lehner, M., Hausharter, M., Volf, I., Ocenasek, H., Gabriel, H., & Pokan, R. (2019). Exercise?based cardiac rehabilitation is associated with a normalization of the heart rate performance curve deflection. Scandinavian journal of medicine & science in sports, 29(9), 1364-1374. https://onlinelibrary.wiley.com/doi/abs/10.1111/sms.13462

Khushhal, A., Nichols, S., Carroll, S., Abt, G., & Ingle, L. (2019). Insufficient exercise intensity for clinical benefit? Monitoring and quantification of a community-based Phase III cardiac rehabilitation programme: A United Kingdom perspective. PLoS One, 14(6), e0217654. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0217654

McDermott, M. M., Dayanidhi, S., Kosmac, K., Saini, S., Slysz, J., Leeuwenburgh, C., ... & Ferrucci, L. (2021). Walking exercise therapy effects on lower extremity skeletal muscle in peripheral artery disease. Circulation research, 128(12), 1851-1867. https://www.ahajournals.org/doi/abs/10.1161/CIRCRESAHA.121.318242

Morishita, S., Tsubaki, A., Nakamura, M., Nashimoto, S., Fu, J. B., & Onishi, H. (2019). Rating of perceived exertion on resistance training in elderly subjects. Expert review of cardiovascular therapy, 17(2), 135-142. https://www.tandfonline.com/doi/abs/10.1080/14779072.2019.1561278

Nichols, S., Engin, B., Carroll, S., Buckley, J., & Ingle, L. (2021). Ratings of perceived exertion at the ventilatory anaerobic threshold in people with coronary heart disease: A CARE CR study. Annals of Physical and Rehabilitation Medicine, 64(6), 101462. https://doi.org/10.1016/j.rehab.2020.101462

Peñailillo, L., Mackay, K., & Abbiss, C. R. (2018). Rating of perceived exertion during concentric and eccentric cycling: are we measuring effort or exertion?. International journal of sports physiology and performance, 13(4), 517-523. https://journals.humankinetics.com/view/journals/ijspp/13/4/article-p517.xml

Peretti, A., Maloberti, A., Garatti, L., Palazzini, M., Triglione, N., Occhi, L., ... & Riccobono, S. (2020). Functional improvement after outpatient cardiac rehabilitation in acute coronary syndrome patients is not related to improvement in left ventricular ejection fraction. High Blood Pressure & Cardiovascular Prevention, 27(3), 225-230. https://link.springer.com/article/10.1007/s40292-020-00374-1

Pymer, S., Nichols, S., Prosser, J., Birkett, S., Carroll, S., & Ingle, L. (2020). Does exercise prescription based on estimated heart rate training zones exceed the ventilatory anaerobic threshold in patients with coronary heart disease undergoing usual-care cardiovascular rehabilitation? A United Kingdom perspective. European journal of preventive cardiology, 27(6), 579-589. https://academic.oup.com/eurjpc/article-abstract/27/6/579/5924766

Shea, M. G., Headley, S., Mullin, E. M., Brawner, C. A., Schilling, P., & Pack, Q. R. (2022). Comparison of Ratings of Perceived Exertion and Target Heart Rate–Based Exercise Prescription in Cardiac Rehabilitation: A RANDOMIZED CONTROLLED PILOT STUDY. Journal of Cardiopulmonary Rehabilitation and Prevention, 10-1097. https://journals.lww.com/jcrjournal/Fulltext/9900/Comparison_of_Ratings_of_Perceived_Exertion_and.1.aspx

Singh, S., & Zeltser, R. (2018). Cardiac risk stratification. https://www.ncbi.nlm.nih.gov/books/NBK507785/

Weatherwax, R. M., Harris, N. K., Kilding, A. E., & Dalleck, L. C. (2019). Incidence of VO2max responders to personalized versus standardized exercise prescription. Med Sci Sports Exerc, 51(4), 681-91. https://paulogentil.com/pdf/Incidence%20of%20VO2max%20Responders%20to%20Personalized%20versus%20Standardized%20Exercise%20Prescription.pdf

Zinoubi, B., Zbidi, S., Vandewalle, H., Chamari, K., & Driss, T. (2018). Relationships between rating of perceived exertion, heart rate and blood lactate during continuous and alternated-intensity cycling exercises. Biology of sport, 35(1), 29. https://dx.doi.org/10.5114%2Fbiolsport.2018.70749

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