Ex Rx for Cardiovascular Disease (CAD, HF, HTN, PAD, post-revascularization)

Coronary Artery Disease and Post-Revascularization

For patients with coronary artery disease (CAD), a recent myocardial infarction (MI), percutaneous coronary intervention (PCI), or coronary artery bypass graft (CABG), intensity is set below the ischemic threshold — the heart rate or workload at which angina, ST-segment depression, or a drop in systolic blood pressure appeared on the GXT. A common target is roughly 10 bpm below the heart rate at which ischemic signs occurred, or an RPE of 11–13 ("fairly light" to "somewhat hard") on the 6–20 scale. Frequency is 3–5 days/week; time starts with short 5–10 minute bouts and progresses toward 20–40 minutes as tolerated. Resistance training typically begins 2–4 weeks after an uncomplicated MI or PCI, starting at low loads (RPE 11–13, roughly 30–40% 1RM) and always avoiding the Valsalva maneuver, since breath-holding against a closed glottis sharply raises rate-pressure product (RPP) and can push a patient past their ischemic threshold. Sternal precautions after CABG restrict pushing, pulling, or lifting greater than 5–10 pounds and delay upper-body resistance training for 4–6 weeks until sternal healing is confirmed; PCI patients without sternotomy generally resume upper-body activity sooner, once the vascular access site is stable.

Heart Failure (HFrEF/HFpEF)

Patients with heart failure often tolerate interval training (alternating higher- and lower-intensity bouts) better than continuous exercise because it reduces the cumulative cardiac and ventilatory demand of a session. Typical targets are frequency 3–5 days/week, intensity 40–70% VO2peak or RPE 11–14. Because beta-blockers and chronotropic incompetence blunt the heart-rate response in this population, RPE is generally the primary intensity tool, with HR monitored alongside it rather than driving the prescription alone. Daily weight monitoring is part of the safety plan: a gain of more than 2–3 pounds in 1–2 days, or new/worsening dyspnea and edema, signals possible decompensation and is a reason to hold that session and notify the care team before continuing.

Hypertension

Aerobic exercise is the primary mode for blood-pressure management: most or all days of the week, moderate intensity (40–59% HRR), at least 30 minutes/day, accumulating to 150+ minutes/week. Resistance training is a useful adjunct (2–3 days/week, moderate load) but is not the primary mode, and heavy, high-intensity, or isometric resistance work with Valsalva breathing should be avoided, particularly in patients whose hypertension is not yet controlled. A resting blood pressure ≥180/110 mmHg on the day of exercise is a reason to postpone the session and refer back to the prescribing provider rather than proceed.

Peripheral Artery Disease (PAD)

Claudication-limited patients follow an interval walking protocol: walk at a pace that provokes moderate-to-strong claudication pain (roughly a 3 out of 4 on the standard 0–4 claudication scale), stop and rest until the pain resolves, then resume walking. This work-rest cycle repeats to accumulate 30–50 minutes of total walking time per session, 3–5 days/week, progressing in duration over 3–6 months. Allowing claudication pain to build to a moderate-to-strong level (rather than stopping at the first twinge) is what drives collateral circulation adaptation — an important, counter-intuitive point for the exam.

Antithrombotic Therapy and Bleeding Precautions

Many CAD, post-PCI, and post-CABG patients are prescribed dual antiplatelet therapy or anticoagulation, which raises bleeding risk with contact activities, falls, or high-impact modes. The CEP screens for easy bruising or recent bleeding events, favors low fall-risk equipment (recumbent bike, treadmill with rails) during early sessions, and avoids contact sports or high-fall-risk activities until the prescribing physician confirms it is appropriate. Any unusual bruising, prolonged bleeding from a minor cut, or signs of internal bleeding (dark stool, unexplained abdominal pain) should be reported to the supervising provider before the next session.

Comparing the Cardiovascular Populations

Across all four groups, the CEP should confirm the patient's current medication list before every session, since beta-blockers, calcium-channel blockers, and vasodilators materially change the expected heart-rate and blood-pressure response (Chapter 5), and should reassess intensity whenever a medication or clinical status changes. New or worsening chest discomfort, unexplained fatigue, a significant weight change, or a change in medication dose is treated as a trigger to re-screen the patient — using the same preparticipation and risk-stratification tools from Domain I — before continuing the existing prescription unmodified, rather than assuming the original clearance still applies indefinitely.