4.6.3. Training Protocols in Practice

Cardiac rehabilitation is commonly divided into either three or four phases, with the content of these phases varying across different countries [68]. The recommended exercise intensity varies significantly between countries, from light-to-moderate intensity (e.g., in Australia) to moderate intensity (in the United Kingdom). The European Association of Preventive Cardiology endorsed the exercise prescription principle in relation to the patient's risk [2]:

A. Low-risk patients.

Low-risk patients encompass patients who have undergone elective percutaneous coronary intervention, have an uncomplicated course of acute coronary syndrome, have primary PCI, have undergone coronary artery bypass grafting, or have undergone valve surgery.

Characteristics of low-risk patients [2]


Cardiac rehabilitation programs can be provided in the form of early outpatient or home-based programs or as a combination of both approaches. Prior to commencing exercise training, a symptom-limited exercise test should be performed. If the low-risk characteristics of the patient are obvious, no cardiopulmonary test is necessary. The testing modality should preferably match the exercise modality. Thus, bicycle exercise testing should be used for patients with walking problems and if exercise training on a bicycle is planned. A ramp protocol starting at 20–50 watts with an increase of 10–20 watts per min is recommended [9]. Treadmill testing is suitable for obese patients with sitting problems in the case of patients with rate-adaptive cardiac pacemakers and when treadmill exercise training is planned. Aerobic training modalities for low-risk patients include walking, walking with a stick (known as Nordic walking), or training on a stationary bicycle. Exercise regimens for deconditioned patients start with 10 min of very-light-/light-intensity training, whereas patients with good functional capacity can begin with 20 min of light-to-moderate-intensity sessions. Continuous-mode training is suitable for very-light-, light-, and moderate-intensity training, whereas high-intensity training should be performed in interval mode [69]. Moderate-intensity continuous exercise (MICE) is typically recommended for low-risk patients, and the intensity can be enhanced with the toleration of the training load—i.e., with a lower heart rate and/or rate of perceived exertion for the same load. Further transition to a high-intensity interval protocol can be implemented for selected patients [2].
