**4. Phase II—Supervised Exercise Training**

**Adam Staron, Fatmah AlAbsi, Meteb AlSulaimi, Hessa AlOtaiby, Abeer Hamza Abdulghani, Mohanned AlMarzook, Jana AlQahtani, Mishal AlHoti, Mohammed AlSubaie, Taghreed AlOtaiby, Ibrahim AlMalki and Mohammed AlShammari**

### *4.1. Initial Assessment and Risk Stratification*

### 4.1.1. General Remarks

Early assessment allows for the identification of the individual needs of patients referred to cardiac rehabilitation. Establishing personalized goals and a plan of care before the initiation of appropriate cardiac rehabilitation service is essential [1]. Cardiac risk stratification aims to identify patients at risk for a cardiac event recurrence. It includes the methodical assessment of the clinical and functional status of the patient to classify him/her as low, moderate, or high risk [2].

### 4.1.2. Initial Assessment

Entry assessment comprises a clinical evaluation (medical history and interview) and tests. The clinical evaluation includes the assessment of event diagnosis, the symptoms declared by the patient, the presence of cardiovascular risk factors, comorbidities, and the medical treatment regimen [3,4]. Furthermore, in patients with implanted cardiac electrical devices, the device characteristics, intervention modes, and thresholds should be recorded [2]. Psychological screening should be performed using a questionnaire or a scale [5]. Personalized physical examination should be performed according to the main diagnoses of the patient. Entry tests include resting 12-lead electrocardiograms, routine laboratory testing, resting transthoracic echocardiography, 24 h ECG monitoring, and functional capacity testing [2].

Resting electrocardiogram enables the determination of leading rhythm, heart rate, ischemia, or conduction abnormalities. Twenty-four-hour ECG monitoring should be performed in patients during phase I and II of cardiac rehabilitation if cardiac arrhythmias are suspected, and longer electrocardiographic monitoring should be considered if they occur rarely. If followed by pharmacotherapy modification, 24 h ECG recording should be repeated. The use of a resting transthoracic echocardiogram is recommended at the end of phase II of cardiac rehabilitation in patients after an episode of acute coronary syndrome or cardiac surgery with concomitant significant impairment of the left ventricular systolic function. Resting transthoracic echocardiography is recommended for assessment of indications for implantation of cardioverter defibrillator. In addition, an

echocardiogram is recommended in case of clinical deterioration during the exercise program. Echocardiogram is crucial for the assessment of the left ventricular systolic and diastolic performance, valvular abnormalities, the presence of pericardial effusion, or intracardiac thrombus. Recent routine biochemical tests, including complete blood count, hemoglobin, blood lipids panel, fasting blood glucose, renal and liver function, electrolytes, international normalized ratio (INR), and thyroid-stimulating hormone (TSH), should be reviewed upon entry to a cardiac rehabilitation program. Cardiac rehabilitation centers should have 24 h access to the rapid determination of cardiac troponins [2].

Exercise stress testing protocols (cardiopulmonary exercise testing preferable for patients with heart failure, with heart transplant, or with congenital heart disease) should be adapted to the patient's condition. A six-minute walk test is recommended when exercise stress testing is not feasible [6]. The evaluation of physical fitness should incorporate muscular strength testing [7,8]. Abreu et al. suggested the following practical cardiac rehabilitation entry checklist described in Table 22 [2].


**Table 22.** Cardiac rehabilitation entry checklist.


**Table 22.** *Cont*.

Abbreviations: BMI—body mass index; CCS—Canadian Cardiovascular Society; CPET—cardiopulmonary exercise test; ECG—electrocardiogram; NYHA—New York Heart Association. Source: Adapted from [2].
