12.1 Ischaemic Heart Disease and Myocardial Infarction

Quick Answer: Treat ACS red flags (new/prolonged rest chest pain, equivalents with autonomic features, haemodynamic change) as stop and escalate—never “walk it off.” After MI/PCI/CABG, prioritise medical stability, graded mobilisation, sternal precautions, and cardiac rehab referral. Progress by symptoms + HR/BP/SpO2/RPE + protocol, not day-number bravado.

Ischaemic heart disease (IHD) and myocardial infarction (MI) are high-yield cardiorespiratory topics on the APC Written Assessment. You are not expected to interpret a 12-lead ECG for reperfusion decisions or prescribe antiplatelet regimens. You are expected to recognise acute coronary syndrome (ACS) red flags, stop unsafe exercise, mobilise and progress activity after MI within medical limits, support cardiac rehabilitation pathways, and apply sternal precautions after open cardiac surgery in Australian public, private, and community settings.

Ischaemic Heart Disease: Working Map for Physiotherapists

Ischaemic heart disease (also called coronary artery disease or coronary heart disease) reflects imbalance between myocardial oxygen supply and demand, usually from atherosclerotic coronary stenosis, plaque rupture, or coronary thrombosis. Stable patterns may present as exertional angina that is predictable, relieved by rest or prescribed nitrate use under medical plans, and without prolonged rest pain. Unstable patterns belong to the ACS spectrum and change physiotherapy behaviour immediately.

Common risk factors appear constantly in vignettes: older age, male sex or post-menopausal status, smoking, hypertension, dyslipidaemia, diabetes, obesity, sedentary lifestyle, family history, and chronic kidney disease. Physiotherapy’s long-game contribution is secondary prevention through safe physical activity, risk-factor education within scope, and adherence support—never as a substitute for medical therapy.

Angina equivalents matter. Not every ischaemic presentation is classic left-sided crushing chest pain. Older adults, women, and people with diabetes may present with dyspnoea, nausea, diaphoresis, epigastric discomfort, profound fatigue, jaw/neck/arm pain, or unexplained syncope. Exam traps often hide ACS behind “musculoskeletal chest wall pain” after a gym session. If symptoms are new, severe, prolonged, occurring at rest, or associated with autonomic features, escalate—do not dry-needle the pectoralis and hope.

ACS Recognition: Red Flags That Stop Physiotherapy Loading

Acute coronary syndromes include unstable angina, non–ST-elevation MI (NSTEMI), and ST-elevation MI (STEMI). From a physiotherapy decision lens, treat the following as stop and escalate cues:

• Chest pain/pressure/tightness at rest or with minimal effort that is new, worsening, or prolonged (minutes, not fleeting musculoskeletal twinges)
• Pain radiating to arms, jaw, neck, or back with cardiac suspicion
• Associated dyspnoea, diaphoresis, nausea/vomiting, dizziness, syncope, profound anxiety or sense of impending doom
• Haemodynamic instability: hypotension, marked hypertension with symptoms, new arrhythmia symptoms, cool clammy skin, acute pulmonary oedema signs
• Post-procedure chest pain after recent PCI/stent with new quality different from expected wound discomfort

Immediate actions (setting-adjusted):

1. Stop exercise/activity and seat or lie the person safely.
2. Call emergency services (community/private) or activate the hospital medical emergency/MET pathway.
3. Monitor consciousness, breathing, and pulse; support ABCs within scope and training (BLS if arrest).
4. Do not continue graded walking “to see if it settles” when ACS is plausible.
5. Document time of onset, symptom description, vitals if obtained, and handover clearly.

Nitroglycerin self-administration may be part of a known angina plan for some patients; that does not replace emergency activation when pain is severe, unrelieved, or first-presentation ACS is suspected. Stay within local protocol and medical orders. In Australian private practice and community home visits, the practical pathway is often 000 / emergency department, not “finish the session and call the GP tomorrow.”

Post-MI Precautions and Early Physiotherapy Role

After confirmed MI (with or without reperfusion—PCI, thrombolysis where used, or medical management), myocardium is healing. Early goals are prevent deconditioning and complications while avoiding excessive myocardial demand and haemodynamic stress.

Typical physiotherapy contributions in Australian acute settings:

• Assessment: mobility baseline, respiratory status, sternal/wound status if surgery, lines/monitors, pain, anxiety, orthostatic tolerance
• Education: activity pacing, symptom recognition, when to stop and seek help, risk-factor basics, importance of medications and follow-up
• Graded mobilisation: bed exercises → sitting → standing → short walks, dose by response
• Respiratory care as indicated (atelectasis prevention, supported cough if needed post-surgery)
• Discharge planning: stairs, home setup, referral to outpatient cardiac rehab

Post-MI precautions (conceptual—always follow unit protocol and cardiology advice):

• Avoid isometric straining, heavy resistance, and Valsalva early, especially with uncontrolled BP or incomplete revascularisation concerns
• Keep sessions short and frequent if fatigue or low reserve
• Respect bed-rest or sheath-site restrictions after femoral access PCI for the protocol window
• Watch for recurrent ischaemia, arrhythmia symptoms, heart-failure signs, and bleeding at access sites
• Progress using symptoms + objective response, not pride or family pressure to “walk the whole ward today”

Beta-blockers, rate-limiting drugs, and delayed chronotropic response mean heart rate alone can under-read effort; use RPE, symptoms, and BP alongside HR. Many APC stems plant a beta-blocker in the medication list specifically to trap candidates who force age-predicted max HR targets.

Cardiac Rehabilitation Phases: Exam-Level Framework

Cardiac rehab is a structured secondary-prevention model combining supervised exercise, education, psychosocial support, and risk-factor management. Exact local labels vary, but a useful APC-level map is:

Phase 1 details: early assessment and safe mobilisation; education on disease, medication adherence themes, wound care coordination, and warning symptoms; plan for outpatient referral and home activity guidance.

Phase 2 details: typically weeks of supervised aerobic and resistance training (when cleared), education modules, and monitoring; individualised intensity using HR zones if prescribed, RPE, talk test, and symptom limits; multidisciplinary input (nursing, exercise physiology, physiotherapy, dietetics, psychology as available).

Phase 3 details: transition to independent or community-based exercise with periodic review; lifelong secondary prevention: walking programs, gyms, heart-failure exercise groups, self-monitoring skills.

You do not need to memorise every Australian program’s exact week counts. You do need to know that supervised rehab after cardiac events is evidence-aligned, that referral is a core physiotherapy action, and that unsupervised high-intensity return to sport or heavy labour without medical clearance is a common wrong answer. Psychosocial recovery (anxiety after “the heart attack,” fear of exercise, return-to-work stress) is part of secondary prevention—not a soft optional extra.

Sternal Precautions After Cardiac Surgery

Coronary artery bypass grafting (CABG) and valve surgery often use median sternotomy. Sternal bone healing takes weeks; excessive stress can contribute to dehiscence or instability (uncommon but serious). Precaution protocols differ by surgeon and centre—some use traditional bilateral loading limits, others use more movement-permissive “keep your move in the tube” style guidance. Entry-level principles that survive protocol variation:

• Clarify duration and content of sternal precautions with the team (often in the order of ~6–8 weeks, but follow the written protocol)
• Avoid unilateral heavy lifting, pushing/pulling that loads one side asymmetrically, and forced end-range shoulder work that stresses the closure early
• Teach log-roll bed mobility, use of arms carefully for sit-to-stand (often pushing equally or minimising arm force depending on protocol), and hugging a pillow for cough/sneeze to support the sternum
• Progress upper-limb range and light activity as protocol allows; do not impose lifelong unnecessary restriction that causes frozen shoulder
• Escalate sternal click, instability, wound drainage, fever, or severe wound pain

Exam trap: choosing heavy free-weight upper-body gym work at week 2 post-CABG because “exercise is always good.” Another trap: refusing all shoulder movement forever and causing avoidable stiffness. Minimally invasive or off-pump approaches may have different restrictions—read the protocol in the stem.

Activity Progression After MI and Cardiac Surgery

Use a criteria-based ladder:

1. Medical stability: no active ischaemia at rest, controlled rhythm for planned intensity, adequate haemoglobin/oxygenation context, cleared restrictions
2. Low-level functional tasks: sitting balance, stand, transfer, short indoor walk
3. Endurance building: progressive walking time/distance, interval rest as needed
4. Light resistance when protocol and wound/sternal status allow (functional lower-limb first often)
5. Role-specific return: stairs, work simulation, sport—only with appropriate medical and program clearance

Monitor before, during, and after activity: symptoms (chest pain, undue dyspnoea, dizziness, palpitations, claudication), HR, BP, SpO2 when relevant, RPE, and recovery. Stop criteria concepts (detailed in section 12.3) apply from day one. Stair practice before discharge is high-yield in Australian public hospitals when the home has stairs—still dose by response, not by “must climb three floors day 1.”

Return-to-driving, sexual activity, and heavy occupational lifting have medical timeframes that vary; physiotherapy supports graded capacity but does not invent legal clearance. When a vignette is about work hardening after CABG, answer with protocol + progressive capacity + medical liaison, not macho loading.

APC Case Patterns and Competency Links

Common item stems:

• Outpatient develops crushing chest pain mid-session → stop, emergency pathway
• Day-1 post-MI wants to walk 500 m corridor → graded short distance with monitoring
• Week-3 post-sternotomy wants unilateral suitcase lift training → respect sternal precautions / modify
• Discharge after PCI without rehab mention → educate + refer to cardiac rehab
• Beta-blocked patient “not hitting HR zone” → use RPE/symptoms, do not force max HR

Map to Thresholds: assessment and planning (safe parameters), collaborative practice (cardiology, nursing, cardiac rehab services), professional judgment (know when not to treat), and risk management. Cultural safety still matters: explain ACS stop decisions in plain language, use interpreters when needed, and avoid shaming smoking or lifestyle history while still supporting secondary prevention.

Closing Exam Anchor

Recognise ACS and stop; after MI, progress under medical limits with monitoring; use cardiac rehab phases as the pathway; protect the sternum after surgery; progress by response and protocol, not bravado.