Exercise for Controlled Cardiovascular, Pulmonary & Metabolic Disease

Cardiovascular Disease: Post-MI, Revascularization & Hypertension

Clients with medically-controlled cardiovascular disease arrive with physician clearance from the screening algorithm (Chapter 4); the EP-C's job is translating the diagnosis into safe FITT modifications.

Post-MI and Revascularization

Exercise prescription for clients recovering from myocardial infarction (MI), percutaneous coronary intervention (PCI), or coronary artery bypass graft (CABG) follows a cardiac-rehabilitation progression: begin at low intensity (roughly 40-60% HRR, or RPE 11-13 on the 6-20 Borg scale) with short bouts (10-15 min), progress duration before intensity, and monitor HR, BP, RPE, and signs/symptoms (chest pain, undue dyspnea, dizziness) throughout every session. Avoid the Valsalva maneuver (breath-holding against a closed glottis) during resistance work — it spikes intrathoracic pressure and blood pressure and can provoke arrhythmia; clients should exhale on exertion. Resistance training typically begins only after adequate healing (commonly 4-6 weeks post-event, per physician clearance) and starts with light loads (RPE ≤13, or roughly 30-40% 1-RM) before progressing.

Hypertension

Aerobic exercise is the first-line modality for blood pressure control: regular aerobic training lowers resting systolic and diastolic BP by roughly 5-7 mmHg in clients with hypertension, and lower-to-moderate intensities (40-70% VO2max) lower BP as effectively as higher intensities. Dynamic resistance training is a useful adjunct but should avoid heavy loads and sustained isometric holds, which produce disproportionate BP spikes; as with cardiac clients, hypertensive clients must avoid the Valsalva maneuver. A resting BP ≥180/110 mmHg should prompt referral back to the physician for better control before starting or continuing an exercise program.

Peripheral Artery Disease (PAD)

Clients with PAD experience intermittent claudication — reproducible, ischemic leg pain during walking that resolves with rest — from atherosclerotic narrowing of the limb arteries. The prescription of choice is intermittent walking: walk to a moderate level of claudication pain, rest until it subsides, then repeat, accumulating a target total walking time per session. This interval approach improves pain-free and maximal walking distance over time by promoting collateral circulation, even though individual walking bouts stay short.

Pulmonary Disease: COPD & Asthma/EIB

COPD

Chronic obstructive pulmonary disease clients are limited by ventilatory capacity, not cardiac output, so intensity is best guided by dyspnea rather than HR alone. Use a standardized dyspnea scale — the modified Borg CR-10 (0 = none, 10 = maximum) or the mMRC scale (0-4) — and target a dyspnea rating of "somewhat severe" rather than a fixed %HRR. Pursed-lip breathing — inhale through the nose, then exhale slowly through pursed lips for roughly twice the inhalation time — increases airway pressure during exhalation, splints the airways open, and reduces air trapping and dyspnea; teach it during both rest and exertion. Interval training (short work bouts with rest) is often better tolerated than continuous exercise because it limits sustained ventilatory demand; supplemental oxygen is used per physician order if prescribed.

Asthma & Exercise-Induced Bronchoconstriction (EIB)

For clients with asthma or EIB, a short-acting beta2-agonist (SABA) used roughly 15 minutes before exercise, per physician direction, is standard prophylaxis. A gradual, extended warm-up can induce a refractory period that blunts the bronchospastic response. Cold, dry air is the strongest environmental trigger, so warm, humid environments (e.g., swimming) are typically better tolerated than cold-weather activities; clients should always carry rescue medication.

Metabolic Disease: Type 2 Diabetes & Obesity

Dyslipidemia & Metabolic Syndrome

Metabolic syndrome is diagnosed from a cluster of risk factors — abdominal obesity, elevated triglycerides, low HDL-C, elevated blood pressure, and elevated fasting glucose — and regular aerobic exercise combined with weight management improves nearly every component of that cluster. For dyslipidemia, aerobic exercise training reliably raises HDL-C and lowers triglycerides, with a more modest and less consistent effect on LDL-C; exercise is prescribed alongside dietary modification rather than as a substitute for it.

Type 2 Diabetes

Both aerobic and resistance training improve glycemic control, and combined training outperforms either mode alone; clients should not go more than 2 consecutive days without activity, since insulin-sensitivity gains fade within 24-72 hours. Two blood-glucose safety rules are non-negotiable:

Time sessions to avoid peak insulin action, and clients on insulin or sulfonylureas should always carry a rapid-acting carbohydrate source. Peripheral neuropathy raises injury risk with high-impact or weight-bearing activity, so well-fitted footwear and daily foot checks are part of the prescription.

Obesity

Obesity is classified as a metabolic disease in the screening algorithm; FITT emphasizes a sustainable caloric deficit through both diet and activity (detailed in Chapter 9), longer accumulated duration at moderate intensity, and non-weight-bearing or low-impact modes (cycling, water exercise) when joint loading limits tolerance.

Absolute vs. Relative Indications to Terminate a Session

• Absolute (stop immediately): new or worsening chest pain/angina; signs of poor perfusion (pallor, cyanosis, cold clammy skin); a sustained drop in systolic BP with increasing workload; SBP >250 mmHg or DBP >115 mmHg; moderate-to-severe CNS symptoms (ataxia, confusion, dizziness); or inability to monitor the client adequately.
• Relative (evaluate, may continue at reduced intensity with close monitoring): dyspnea out of proportion to workload; leg cramping or claudication; unusual fatigue; a hypertensive or hypotensive BP response that does not meet an absolute threshold; or a new arrhythmia that is not clearly serious.