6.7.1. General Remarks

Heart transplantation is considered the gold-standard treatment for selected patients with end-stage heart failure despite optimal medical therapy [37]. Aerobic exercise training revokes the pathophysiological consequences related to cardiac denervation and prevents immunosuppression-induced adverse effects in heart transplant recipients [54]. Postulated exercise-induced beneficial effects include oxygen extraction, an increase in cardiac output, and reduced neurohormonal activity [55]. Numerous studies have demonstrated a significant increase in cardiorespiratory fitness following heart transplantation—e.g., in a trial of 27 cardiac transplant recipients randomized to supervised exercise training, a 4.4 mL/kg/min (49%) increase in maximal oxygen uptake was reported at 6 months, compared with the increase of 1.9 mL/kg/min (18%) seen in the control group [54,56]. Cardiac rehabilitation, however, is challenging in the early post-operative period, due to patients' physical deconditioning, muscular atrophy, and low exercise capacity. The denervation of the donor's heart results in [32]:


### 6.7.2. Exercise Prescription

In-hospital phase [37,56].

Early mobilization should be initiated as soon as possible after hemodynamic stability is achieved and after the patient has been weaned from intravenous therapy [40]. Walking progressively increasing distances is typically implemented alongside the monitoring of vital signs and perceived exertion. At discharge, patients who have undergone heart transplantation should be able to walk for a period of

40–60 min, inducing moderate fatigue, 4–5 times a week [7]. In addition, the exercise regimen should include resistance (low loads), flexibility, and respiratory training [6]. Recommendations concerning personal hygiene and the importance of reducing the risk of infection should be discussed with the patient. These include good dental hygiene, frequent hand washing, avoiding contact with potential sources of infection (i.e., persons with active infection; decaying plants, fruits, or vegetables; swimming pools). Patients should be notified about the clinical symptoms of potential acute transplant rejection—i.e., changes in blood pressure, changes in heart rate, increased body mass, or impaired fitness level [7]. Prehabilitation principles prior to cardiac surgery were described earlier in this book.

Phase II

Initial assessment should entail in particular:


Functional capacity assessment utilizing cardiopulmonary exercise test, if available, is recommended as the gold standard, with small increments of 10 Watts or modified Bruce/Naughton protocols implemented on a treadmill. Exercise tests can be performed safely four weeks after heart transplantation, as can exercise training programs for heart transplant recipients.

Exercise prescription for heart transplant recipients should comprise all components and occur at a residential cardiac rehabilitation department, in cooperation with the cardiac surgery department [57]. Aerobic training can begin in the second or third week after heart transplantation and should incorporate prolonged warm-up and cool-down phases with relation to the pathophysiological consequences of the denervation of the heart. An initial exercise intensity of 10% below the anaerobic threshold in the case of CPET or below 50% of the maximal workload attained during the exercise test is recommended; however, due to the denervation of the heart rate, the patient's perceived level of exertion and respiratory rate should guide exercise rather than their specific heart rate [8]. Resistance training is essential to reverse muscular atrophy and should include 2–3 sets of exercises with 10–15 repetitions per set at 50% of one repetition maximum, with breaks of at least 1–2 min occurring between the sets. Training progression should be conducted to 70% of 1-RM.

The AACVPR exercise prescription for heart transplant recipients is presented in Table 46 [6].


**Table 46.** AACVPR exercise prescription after heart transplant.

Abbreviations: AACVPR—American Association of Cardiovascular and Pulmonary Rehabilitation; RPE—rating of perceived exertion. Source: Reprinted from [6].

### *6..8. The Elderly*

### 6.8.1. Rationale

Ageing leads to a growing number of elderly patients with cardiac disease and increased rates of comorbidities, cognitive impairment, and frailty [58]. Although the reduced exercise capacity and risk profile of the elderly indicate their need for cardiac rehabilitation, they are often excluded from large meta-analyses and subsequently are insufficiently represented in cardiac rehabilitation programs [3]. In observational studies, cardiac rehabilitation has been found to improve functional capacity, the cardiovascular risk factor profile, and patients' quality of life. Other registries have demonstrated the reduced rates of mortality and hospitalization in the elderly, but the observational nature of these studies may be associated with selection bias [59]. The main aims of cardiac rehabilitation in the elderly are the maintenance of mobility and independence and the prevention of frailty.

### 6.8.2. Initial Assessment

Elderly patients typically present with a low functional capacity and reduced muscle power, which make them prone to falls. Other frequently observed comorbidities and problems related to ageing include the presence of osteoarthritis; chronic obstructive pulmonary disease; dementia; problems with sight, hearing, and balance; and urine incompetence [60]. Entry assessment should include, particularly in patients over 75 years of age, multidimensional geriatric evaluation (MGA) to exclude the possibility of disability, frailty, and cognitive problems [61]. MGA has been incorporated in programs to determine the presence of medical, psychosocial, functional, and environmental problems in elderly patients. Specific measures of MGA include:


The Fullerton test, or Senior Fitness Test, is frequently utilized to assess the strength, flexibility, coordination, speed, balance, and endurance of elderly patients [62]. It includes the 30 s chair stand test, arm curl test, chair sit-and-reach test, back scratch test, eight-foot and go test, and six-minute walk test (or two-minute step test).

**The 30 s chair stand test** is suitable for the assessment of lower body strength and reflects daily activities such as climbing stairs or getting out of a chair. The number of full stands completed in 30 s with arms folded across the chest is counted. The norm is eight or more unassisted stands for both men and women.

**The arm curl test** is suitable for the assessment of upper body strength and reflects daily tasks such as lifting and carrying things. The number of biceps curls completed in 30 s is counted (with hand weights of 5 lbs. (2.2 kg) for women and 8 lbs. (3.6 kg) for men). The norm is 11 or more.

**The chair sit-and-reach test** is utilized for the assessment of the lower body flexibility. From a sitting position at the front of the chair with one leg extended and hands reaching toward the toes, the distance between the fingers and the tips of the toes is measured. The norm is less than 4 inches (10 cm) for men and less than 2 inches (5 cm) for women.

**The back scratch test** is used for the assessment of upper body flexibility, aiming to reflect daily activities such as combing one's hair or reaching for a seat belt. With one hand reaching over the shoulder and the other up in the middle of the back, the number of inches between the extended middle fingers of both hands are counted. The norm is less than 4 inches (10 cm) for men and less than 2 inches (5 cm) for women.

**The eight-foot and go test** assesses agility and dynamic balance. The number of seconds required to get up from a seated position, walk 8 feet (2.44 m), turn back, and return to a seated position is counted. The norm is less than 9 s for both men and women.

**The six-minute walk test and the two-minute step test** principle were described earlier in this book, with norms of >320 m and 65 steps or more, respectively.

## 6.8.3. Exercise Prescription

If frailty and cognitive problems can be excluded, an exercise program with an individually tailored intensity and based on an aerobic component associated with resistance, flexibility, and balance training is executed. Aerobic training following the "start low and go slow" formula is recommended, with the duration of the first few sessions being as short as 15 min [16]. Training should include adequate durations of warm-up and cool-down phases. Low-intensity exercises are safe and reduce injury risk, but older patients can also benefit from moderate-intensity training. The initial workload can be increased after a few weeks of conditioning to moderate intensity, if tolerated. Due to age-related chronotropic incompetence, heart-rate-lowering drugs, and sedentary lifestyles, the maximal heart rate of elderly patients is typically lower than that of younger patients; therefore, what can be considered light exercise for younger patients can be considered moderate exercise for elderly patients. Heart rates cannot be utilized to determine workload in the case of atrial fibrillation, and the Borg scale is utilized with the goal of 11–13 [63]. A session duration of 30 min, 3–4 times a week, with a total program duration of 12 weeks is recommended. Resistance training on alternate days of aerobic session utilizing a multi-weight machine is recommended to stabilize body position when lifting weights [64]. A very low load should be used initially and increased, if tolerated, to a moderate intensity, with 8–12 repetitions. The set can be repeated once or twice, with a 10 min break between the two. If the patient has not attended several consecutive sessions, resistance training should be resumed at 50% of the previous load. A light to moderate intensity (30–70 and 1-RM) is recommended. Patients should avoid rapid postural changes so as not

to evoke orthostatic hypotension. Flexibility and neuromotor exercises are integral parts of exercise programs for the elderly—e.g., tai chi, which incorporates both components, can be performed twice a week for 10–15 min.

### 6.8.4. Frailty

Frailty is a geriatric syndrome characterized by impairment in physical, psychological, and social abilities. Frailty has been demonstrated as a strong predictor of mortality, morbidity, and hospitalization [65]. Several models for frailty screening have been proposed, with MGA, the phenotypic Freid model, and the deficit accumulation model being widely adapted [66]. The Freid phenotype model includes nutritional status (non-intentional weight loss of at least 4.5 kg in the previous year), self-reported physical exhaustion, low energy expenditure (kcal expended per week), mobility level (gait speed for a few meters of walking), and muscular strength (assessed by handgrip). Each component is scored as 1 if present, with a total of 1–2 points for a pre-frail state and frailty recognized in those who score 3 or more points. The true incidence of frailty in cardiac rehabilitation is unknown; however, cardiac rehabilitation is recommended for frail patients with a resistance component in addition to endurance, balance, and flexibility components to improve their physical capacity and muscular strength, reduce their risk of falls, and preserve their independence [67]. Exercise sessions should be individually tailored to the patient's level of functional impairment. Patients with frailty usually cannot perform baseline exercise stress tests or cardiopulmonary tests; therefore, the intensity of aerobic training, performed on alternate days of resistance exercise, should be set at a heart rate slightly lower than that attained during the 6-min walk test. For patients who are unable to perform the 6 MWT, bed mobilization and walking with support remain training targets [68].

Resistance exercise improves muscular strength and reduces the risk of falls in patients with frailty. The strength program protocol proposed by Vigorito et al. is summarized in Table 47 [69].


**Table 47.** Resistance training recommendations for frail patients [69].

Source: Adapted from [69].
