**3. Phase I—Early Mobilization**

**Adam Staron, Abdulrahman AlMoghairi, Jadwiga Wolszakiewicz, Mohanned AlMarzook, Ali AlDawsari, Mohammed AlSubaie and Mohammed AlHindi**

### *3.1. Idea of Early Mobilization*

Bed rest and immobility have been the recommended standard of care following acute cardiac events for many decades [1]. The implementation of early mobilization was gradual, from chair therapy in the 1940s, to several minutes of walks after four weeks of rest in the 1950s and mobilizing patients after 12 days of rest in the 1960s [2]. A study conducted by Saltin in 1968 revealed the problem of the vicious cycle of prolonged hospital bed rest [3]. Prolonged hospital bed rest contributes to decreased cardiac output; secondary complications such as deep venous thrombosis, pneumonia, pressure sores, a rapid loss of skeletal muscle mass, reduced strength, and a decline in aerobic capacity [4,5]. Early mobilization means the initiation of mobilization activities as soon as clinical stability is achieved, typically with 1–2 days of admission, and has significant effects on the length of hospital stay and the readmission rate [6,7].

Goals of early mobilization include [8,9]:


## *3.2. Early Mobilization after Myocardial Infarction*

Cardiac rehabilitation should start immediately after clinical stabilization, usually at a coronary care unit, after 12–48 h [8]. The progression of the mobilization depends on the clinical course and the potential complications. All patients with myocardial infarction should be monitored for at least 24 h after an acute event and longer in cases wherein there is a high risk of arrhythmia, hemodynamic instability, severe impairment of left ventricular systolic function, unsuccessful reperfusion, or multivessel coronary disease [10].

The patient is considered appropriate for daily ambulation and mobilization if [11]:


• No new, significant abnormal rhythm or ECG ischemic changes have occurred during the previous 8 h period.

Absolute contraindications for mobilization are:


Mobilization should be stopped in the case of:


Exercises are recommended to be performed twice a day, optimally on every day of the week. Blood pressure and heart rate should be checked before, during, and after exercises [10]. The key elements of the early mobilization period remain supervision during training, the regular evaluation of training response and progress, the management of clinical symptoms of hypotension, the assessment of fluid status, heart rate control, and pharmacological treatment modification. The importance of early mobilization following myocardial infarction has been well established, and a growing body of evidence suggests the improvement of the inflammatory response and impact on the ventricular remodeling process [12,13]. However, some discrepancy between the recommendations and clinical practice exists with regard to bed rest time following myocardial infarction. According to the study conducted by Cortez, mobilization in the coronary care unit takes place late, nearly 50 h after the onset of myocardial infarct, and patients spend up to 70% of their time on bed rest [14,15].

The authors of this book want to present an adapted model of early mobilization utilized widely in Poland described in Tables 16–18 (A1, A2, and B pathways):


**Table 16.** Suggested first stage of early mobilization after myocardial infarction.

**Table 17.** Suggested second stage of early mobilization after myocardial infarction.


Source: Table by authors.

**Table 18.** Suggested third stage of early mobilization after myocardial infarction.


Source: Table by authors.

A model

The A1 model applies to the following groups of patients:


The A2 model is dedicated to patients:


The B model applies to:


In all presented models, mobilization comprises three stages (Tables 16–18).
