CVR Physiotherapy › Technique cards › Rehabilitation programmes
Cardiac rehabilitation: definition, indications, contraindications, phases and outcome measures
Cardiac rehab is part of the most common long answer in this paper (16 IHD and CABG cases in 2016–2026) and of several 7-mark questions (Phase I, Phase II after PTCA, rehab after valve replacement, risk stratification). This page is the programme itself for any heart condition; the day-by-day doses after MI and CABG are on the IHD page.
- Syllabus
- Ch 7 Cardiac rehabilitation (AHA/ACSM guidelines): definition, indications, contraindications, phases I–IV, outcome measures
- Priority
- High yield. Inside the most-asked long answer, plus 7-mark questions in W16, W17, S21, W21 and W24.
- Asked as
- 16 IHD long cases 7m W16W17S21W21W24 3m S20W25
- Usual split
- 7-mark phases or programme; 15-mark IHD and CABG cases
- Checked against
- AHA/AACVPR core components (2024 update); ACSM guidelines (indications and contraindications); WHO definition; Cochrane review update (2026). Full list under Sources.
- Content checked
- 19 October 2026. Next review due October 2027.
- My revision
-
1Definition and aims
Cardiac rehabilitation is a coordinated, multi-part programme that helps people with heart disease recover their physical, psychological and social function, and that slows the underlying disease through exercise, education and risk-factor control (AHA/AACVPR). The WHO describes it as all the activities needed so that patients, by their own efforts, regain as normal a place as possible in the community.
- Aims: safe return to daily activities, work and leisure; better exercise capacity; control of risk factors; fewer future heart attacks and admissions; better quality of life and mood; self-management for life.
2Indications (who should be referred)
- Myocardial infarction or acute coronary syndrome.
- After coronary artery bypass grafting (CABG) or angioplasty with stent (PCI).
- Stable angina.
- Stable heart failure with reduced ejection fraction (and increasingly other heart failure).
- After heart valve repair or replacement (including transcatheter valves).
- Heart or heart–lung transplant.
- Others who benefit: pacemaker or ICD, cardiomyopathy, congenital heart disease in adults, after cardiac surgery of any kind, peripheral arterial disease (supervised walking programme), people at high risk of coronary disease (diabetes, metabolic syndrome).
Older age, a low ejection fraction in stable heart failure, an ICD and diabetes are not reasons to exclude; they are reasons to stratify risk and supervise more closely.
3Contraindications to exercise in cardiac rehab (ACSM)
- Unstable angina
- Resting systolic BP above 180 or diastolic above 110 mmHg (decide case by case)
- BP falls more than 20 mmHg on standing, with symptoms
- Significant aortic stenosis
- Uncontrolled atrial or ventricular arrhythmias; uncontrolled sinus tachycardia above 120
- Uncompensated (decompensated) heart failure
- Third-degree heart block without a pacemaker
- Active pericarditis or myocarditis
- Recent embolism (pulmonary or systemic); acute thrombophlebitis; aortic dissection
- Acute illness or fever
- Uncontrolled diabetes; other uncorrected metabolic problems (for example abnormal potassium)
- Severe orthopaedic or psychological problems that prevent exercise
Stop criteria during sessions are on the IHD page and the exercise testing card.
4Core components (AHA/AACVPR, 2024 update)
| Component | What it includes |
|---|---|
| Patient assessment | History, examination, ECG, exercise test or 6MWT, risk stratification, goals |
| Nutritional counselling | Heart-healthy diet, salt below 5 g a day, less fried food and sugar |
| Weight management and body composition | Waist and BMI targets (Indian cut-offs), diet plus activity |
| Cardiovascular risk-factor management | BP, lipids, diabetes, tobacco cessation, medicines and adherence |
| Psychosocial management | Screening for depression and anxiety, stress management, family support, return to work |
| Aerobic exercise training | FITT-VP prescription, monitored and progressed |
| Strength training | Major muscle groups, 2–3 days a week |
| Physical activity counselling | At least 150 minutes a week of moderate activity for life; less sitting |
| Programme quality improvement | Measuring outcomes and improving the service |
5Phases I–IV
| Phase | When and where | Aims and content | Intensity |
|---|---|---|---|
| I: inpatient | From the first stable day to discharge (days) | Prevent bed-rest effects; breathing exercises (after surgery); graded self-care and walking; stairs before discharge; education, warning signs, GTN use; home plan; referral to Phase II | Up to about 3 METs; RPE below 13; HR within rest + 20 (MI) or rest + 30 (surgery) |
| II: early outpatient (supervised) | Starts within a few weeks of discharge; about 8–12 weeks; hospital, centre, home or hybrid | Exercise test, risk stratification, monitored aerobic and strength training, risk-factor control, psychological support, return to work, driving and sexual activity | 40–80% heart-rate reserve or RPE 11–16, starting low; 3–5 days a week; resistance 2–3 days |
| III: community | After Phase II, for several months | Less supervision; keep and build fitness; self-monitoring with pulse and RPE | As in Phase II, progressed |
| IV: lifelong maintenance | For life | Independent exercise and healthy lifestyle; periodic review | At least 150 min a week moderate activity plus 2 days of strength work |
Detailed Phase I progression, Phase II FITT-VP, Karvonen examples and sternal precautions: IHD page, section 12. Rehab after PCI for sport (W24) and after valve replacement (W21): IHD page and valve page.
6Exercise across heart conditions
| Condition | Key adjustment |
|---|---|
| After MI or CABG | Phase I limits; sternal precautions for 6–8 weeks after CABG; legs first in resistance training |
| After PCI | No sternal precautions; protect the radial or femoral puncture site for about a week; can progress faster |
| Heart failure | Start low (RPE 11–13), interval training, longer warm-up and cool-down; watch weight gain and breathlessness (fluid); inspiratory muscle training if weak |
| Valve surgery | Sternal precautions; atrial fibrillation is common; anticoagulation (bleeding, falls) |
| Pacemaker or ICD | Device-side arm below shoulder height for 4–6 weeks; keep heart rate at least 10 beats below the ICD detection rate |
| Heart transplant | The heart has no nerve supply, so heart rate rises slowly and late: use RPE, long warm-up and cool-down |
| Atrial fibrillation, beta-blockers | Heart rate is unreliable: use RPE and the talk test |
| Peripheral arterial disease | Supervised walking to moderate claudication pain, rest, repeat (see the PAD page) |
7Risk stratification
Before Phase II, patients are grouped as low, moderate or high risk for events during exercise (AACVPR), using ejection fraction, exercise-test results (functional capacity in METs, ischaemia, arrhythmias), symptoms, complications in hospital and depression. Risk sets the amount of ECG monitoring and supervision and how fast to progress. The full table (asked as 7 marks in S21) is on the IHD page.
EF 50 / 40, METs 7 / 5
Low risk: EF 50% or more and capacity 7 METs or more. High risk: EF below 40%, or symptoms below 5 METs, or complex arrhythmias, or a complicated course.
8Outcome measures (syllabus 7d)
| Domain | Measures |
|---|---|
| Exercise capacity | Exercise test (METs, peak oxygen uptake), 6-minute walk test, incremental shuttle walk test, sit-to-stand test |
| Risk factors | BP, lipid profile, HbA1c, weight, BMI, waist, smoking status |
| Symptoms | Angina frequency (CCS grade), breathlessness (NYHA, Borg), fatigue |
| Quality of life | MacNew heart disease questionnaire, Seattle Angina Questionnaire, MLHFQ or KCCQ in heart failure, SF-36, EQ-5D |
| Mood | Hospital Anxiety and Depression Scale (HADS), PHQ-9 |
| Physical activity and behaviour | Step count, activity questionnaires, medicine adherence, return to work |
| Events | Readmissions, repeat heart attacks, revascularisation |
9Evidence and ways of delivering it
- Benefit: compared with no programme, exercise-based cardiac rehab reduces heart attacks by about 28% and hospital admissions by about 35%, probably reduces deaths, and improves quality of life (Cochrane review update, 2026: 107 trials, 26,886 people).
- Settings: home-based and digitally supported programmes are about as effective as centre-based ones, and suit patients who live far away or work.
- Yoga-based rehab: the Indian Yoga-CaRe trial improved self-rated health and return to activities, but did not significantly reduce major events (see the yoga card).
- The gap: few eligible patients join, especially in India and among women. Physiotherapists can refer at discharge, start Phase I early and offer home programmes.
10Exam corner
Past questions (MUHS, 2016–2026)
- Long answers16 IHD, MI and CABG cases ask for cardiac rehab phases with doses; S26 Q4(a) asked the phases with their aims, inpatient care, convalescence to 6 weeks and rehab after 3 months (see the IHD exam corner).
- 7-mark questionsPhase I cardiac rehabilitation after MI (W16, W17). Risk assessment and stratification for CAD (S21). Phase 1 and 2 after valve replacement (W21). Phase 2 after PTCA to the LAD for a patient who wants to play sport (W24).
- 3-mark questionsPhase I of cardiac rehabilitation (S20). Karvonen's formula in cardiac rehabilitation (W25).
Answer skeleton: "cardiac rehabilitation", 7 marks
- [1] Definition and aims.
- [1] Indications.
- [1] Contraindications (any six).
- [3] Phases I–IV table with timing, content and intensity.
- [1] Outcome measures and benefits.
Test yourself
3 mList six indications for cardiac rehabilitation.
MI or acute coronary syndrome; after CABG; after PCI; stable angina; stable heart failure with reduced EF; after valve surgery; heart transplant; pacemaker or ICD (any six).
3 mName three outcome measures used in cardiac rehabilitation.
6-minute walk test or exercise test (METs); MacNew or Seattle Angina Questionnaire; HADS; risk factors such as BP, lipids and HbA1c (any three).
MCQWhich is a contraindication to starting exercise training?A. Age 75B. Stable heart failure with EF 35%C. Unstable anginaD. An ICD
C. The others need risk stratification and closer supervision, not exclusion.
MCQAfter heart transplant, exercise intensity is best set by:A. Heart rateB. RPEC. Blood sugarD. Respiratory rate alone
B. The transplanted heart has no nerve supply, so heart rate responds slowly.
Sources
- MUHS BPTh syllabus (2012) and MUHS IV BPTh question papers 2016–2026 (muhsonline.com, unofficial archive; Dhole Patil College of Physiotherapy past-paper page).
- Brown TM, et al. Core components of cardiac rehabilitation programs: 2024 update. A scientific statement from the AHA and AACVPR. Circulation 2024;150:e328–47.
- American College of Sports Medicine. ACSM's Guidelines for Exercise Testing and Prescription (indications and contraindications for inpatient and outpatient cardiac rehabilitation).
- World Health Organization. Rehabilitation after cardiovascular diseases, with special emphasis on developing countries. Technical Report Series 831, 1993.
- Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Review CD001800, update 2026. Cochrane news summary.
- Prabhakaran D, et al. Effect of yoga-based cardiac rehabilitation on health outcomes (Yoga-CaRe). J Am Coll Cardiol 2020.
- Structure and classical content: Hillegass (2022); AACVPR Guidelines for Cardiac Rehabilitation Programs.
Educational notes for exam preparation. Not medical advice.
Version 1. Content checked 19 October 2026. Next review October 2027.