Heart, Lung and Circulation (2023) 32, 1035–1048 POSITION STATEMENT

1443-9506/23/$36.00
https://doi.org/10.1016/j.hlc.2023.06.854

A Clinical Guide for Assessment and

Prescription of Exercise and Physical
Activity in Cardiac Rehabilitation.
A CSANZ Position Statement
Christian Verdicchio, PhD a,b,1,*, Nicole Freene, PhD c,d,1,
Matthew Hollings, PhD a,1, Andrew Maiorana, PhD e,f, Tom Briffa, PhD g,
Robyn Gallagher, PhD a, Jeroen M. Hendriks, PhD b,h, Bridget Abell, PhD i,
Alex Brown, PhD j, David Colquhoun, MBBS, PhD k,l,
Erin Howden, PhD m,n, Dominique Hansen, PhD o, Stacey Reading, PhD p,
Julie Redfern, PhD a
a
Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
b
Centre for Heart Rhythm Disorders, University of Adelaide, SAHMRI and Royal Adelaide Hospital, Adelaide, SA, Australia
c
Physiotherapy, Faculty of Health, University of Canberra, Canberra, ACT, Australia
d
Health Research Institute, University of Canberra, Canberra, ACT, Australia
e
Allied Health Department, Fiona Stanley Hospital, Perth, WA, Australia
f
Curtin School of Allied Health, Curtin University, Perth, WA, Australia
g
School of Population and Global Health, University of Western Australia, Perth, WA, Australia
h
Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
i
Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work,
Queensland University of Technology, Brisbane, Qld, Australia
j
Telethon Kids Institute, Australian National University, Canberra, ACT, Australia
k
Faculty of Medicine, University of Queensland, Brisbane, Qld, Australia
l
Faculty of Medicine, Wesley Medical Centre, Brisbane, Qld, Australia
m
Baker Heart and Diabetes Institute, Melbourne, Vic, Australia
n
Baker Department of Cardiometabolic Health, University of Melbourne, Melbourne, Vic, Australia
o
UHasselt, REVAL/BIOMED (Rehabilitation Research Centre), Hasselt University, Hasselt, Belgium
p
Department of Exercise Sciences, University of Auckland, Auckland, New Zealand

Received 19 June 2023; accepted 27 June 2023; online published-ahead-of-print 27 July 2023

Patients with cardiovascular disease benefit from cardiac rehabilitation, which includes structured exercise
and physical activity as core components. This position statement provides pragmatic, evidence-based
guidance for the assessment and prescription of exercise and physical activity for cardiac rehabilitation
clinicians, recognising the latest international guidelines, scientific evidence and the increasing use of
technology and virtual delivery methods. The patient-centred assessment and prescription of aerobic ex-
ercise, resistance exercise and physical activity have been addressed, including progression and safety
considerations.
Keywords Cardiac rehabilitation  Secondary prevention  Coronary disease  Cardiovascular disease  Exercise
assessment  Exercise prescription  Physical activity  Position statement

*Corresponding author at: Dr Christian Verdicchio, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia; Centre for Heart Rhythm
Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, SA, Australia; Email: christian.verdicchio@sydney.edu.au; Twitter: @c_verdicchio
1
Co-first authors
Ó 2023 The Author(s). Published by Elsevier B.V. on behalf of Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac
Society of Australia and New Zealand (CSANZ). This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
1036 C. Verdicchio et al.

working within cardiac rehabilitation (e.g., exercise physiol-

Introduction ogists, nurses, physiotherapists) in the Australian and New
Cardiovascular disease (CVD) is the leading cause of death Zealand context. Specifically, the aim is to summarise the
and disease burden globally [1]. Improvements in diagnosis, assessment and prescription recommendations for aerobic
treatment and long-term management have improved survi- exercise, resistance exercise and physical activity for all pa-
vorship and reduced hospitalisations following a cardiac tients referred for secondary prevention of their recent car-
event, however they have also greatly increased the number of diac event or a new diagnosis. To do this, a multidisciplinary
patients requiring ongoing and lifelong CVD risk manage- writing group was convened comprising of experts from
ment [2,3]. To reduce the risk of future events, international relevant disciplines, with regional, gender and cultural rep-
guidelines recommend all eligible patients have access to, and resentation to ensure diversity. A consensus process was
participate in, secondary prevention programs, including then followed to draft, review, and refine the document. The
cardiac rehabilitation [4,5]. Cardiac rehabilitation is a position paper was then submitted to the Cardiac Society of
comprehensive, multidisciplinary intervention consisting of Australia and New Zealand, ACRA, Exercise and Sports
patient assessment and individualised risk profile manage- Science Australia, and the Australian Physiotherapy Asso-
ment, dietary advice, exercise prescription and physical ac- ciation for endorsement.
tivity counselling and psychosocial support [6]. The National
Heart Foundation of Australia, the Australian Cardiovascular
Health and Rehabilitation Association (ACRA) and the Na- Aerobic Exercise
tional Heart Foundation of New Zealand all promote cardiac
Aerobic exercise is defined as any activity that uses large
rehabilitation and have online resources that can provide re-
muscle groups that can be maintained continuously and is
ferrers with a list of local services available for their patients.
rhythmic in nature [19]. Common forms of aerobic exercise
Exercise-based cardiac rehabilitation has demonstrated effec-
include walking, jogging, cycling, rowing and swimming.
tiveness for reducing hospitalisations and myocardial infarc-
The benefits of aerobic exercise training within cardiac
tion rates, whilst improving risk profile, exercise capacity and
rehabilitation are well established [7,8]. Cardiometabolic
quality of life in patients with coronary disease [7,8]. Exercise
benefits include (but are not limited to) improved insulin
programming also benefits patients with other cardiovascular
sensitivity and glycaemic control, reduction in inflammatory
conditions such as heart failure (both reduced and preserved
markers, reduced visceral fat, improved vascular function
ejection fraction) [9,10], atrial fibrillation [11], peripheral
and blood pressure control, improved lipid metabolism,
vascular disease [12], congenital heart disease [13], valve dis-
improved skeletal muscle structure and function and modest
ease [14], pulmonary hypertention [15] and, more recently,
improvements in left ventricular function [10,20,21].
with cardio-oncology patients [16].
A graduated program of structured exercise and physical
activity is a core component of comprehensive cardiac reha-
Assessment
bilitation [17]. Recent studies have described new exercise The ACRA cardiac rehabilitation core components state that
training techniques, which have improved our understanding all patients should receive “an individualised initial assess-
of the physiological adaptations from exercise training across ment that includes physical, psychological and social pa-
diverse patient groups. Furthermore, recent data have also rameters” [17]. This assessment enables the development and
provided a greater understanding of technology and virtual implementation of an individualised exercise program based
delivery methods for the prescription of exercise and physical on the aerobic exercise or functional capacity of the patient.
activity within cardiac rehabilitation programs. A patient- An aerobic exercise assessment should be conducted to
centred approach is important, and communication with pa- assess the patient’s aerobic exercise capacity. Prior to per-
tients should be non-judgemental and respectful. Shared de- forming any exercise assessment, it is imperative that clini-
cision making, where patients and their carers are actively cians consider all relevant contraindications (Table 1). The
involved in the care process, results in personalised in- gold-standard assessment for aerobic exercise capacity is a
terventions that are more likely to improve engagement, cardiopulmonary exercise test (CPET) conducted on either a
treatment adherence, and clinical outcomes [18]. Concomi- treadmill or cycle ergometer with gas analysis. However, this
tantly, health professionals should consider evidence, guide- test is limited to predominantly tertiary centres in Australia
lines and behaviour change theories, techniques, and tools and New Zealand due to the cost and specialised equipment
when collaborating with patients, identifying their individual and staff required to conduct it. Several methods for
exercise and physical activity needs, values and preferences. assessing aerobic exercise capacity and functional exercise
Realistic short- and medium-term goal setting may be capacity, and the pros and cons of each are summarised in
considered, and follow-up should be discussed and supported Table 2.
by the entire multidisciplinary team as they are central to the
patient’s rehabilitation journey [18]. Prescribing and Progressing Aerobic
The objective of this position statement is to provide Exercise
pragmatic, evidence-based guidance for the assessment and Figure 1 summarises the recommended clinician workflow in
prescription of exercise and physical activity by all clinicians relation to assessment, prescription and progression of
Exercise in Cardiac Rehabilitation 1037

Table 1 Absolute and relative contraindications to exercise and physical activity.*

Absolute Contraindications Relative Contraindications#

ˇ
Progressive worsening of exercise tolerance or dyspnoea at 2 kg increase in body mass over previous 1–3 days
rest or on exertion
over previous 3–5 days (uncompensated heart failure)
Unstable angina Concurrent continuous or intermittent dobutamine therapy
Blood glucose ,4.0 mmol/L or .15.0 mmol/L with Decrease in systolic blood pressure with exercise
symptoms of weakness/tiredness, or with ketosis
Acute systemic illness or fever NYHA functional class IV
Recent embolism (,4 weeks) Complex ventricular arrhythmia at rest or appearing with
exertion
Thrombophlebitis Supine resting heart rate 100 bpm
Active pericarditis or myocarditis*
Severe symptomatic aortic stenosis Moderate aortic stenosis
Regurgitant valvular heart disease requiring surgery Blood pressure .180/110 mmHg (evaluated on a case-by-
case basis)
Previously undiagnosed atrial fibrillation Sternal Instability Scale grade 1–2 (minimally to partially
separated sternum)
Sternal Instability Scale grade 3 (completely separated)
Resting heart rate .120 bpm
Orthostatic blood pressure drop of .20 mmHg with
symptoms
Third-degree atrioventricular block without pacemaker

*Adapted from HeartOnline [52]; American College of Sports Medicine Guidelines for Exercise Testing and Prescription [22]; El-Ansary et al. [34].
*During recovery, limit to light to moderate intensity exercise until left ventricular dysfunction has resolved.
#
Relative contradictions are a guide only and should be combined with clinical judgement at every session. If in doubt, medical advice should be sought before
commencing an exercise or physical activity assessment or session.
ˇ
Rapid weight gain may be a red flag for heart failure.
Abbreviation: NYHA, New York Heart Association.

aerobic exercise training. Informed by a comprehensive highlight that rest or recovery within and between sessions
clinical history and exercise assessment, the fundamental should also be promoted for patients to maximise their
principles of exercise prescription should be applied: Fre- overall health status and adaptations to exercise. Table 3
quency, Intensity, Time, Type, Volume and Progression provides FITT-VP recommendations for an individually
(FITT-VP) [22]. Frequency (F) considers how often the patient tailored aerobic exercise prescription at a moderate-high in-
completes the exercise. Intensity (I) is the level of effort the tensity. Table 4 provides a summary of the definitions of
patient should be exercising at based on assessment of their light, moderate, high, and very-high intensities when
exercise capacity. Absolute intensity refers to the energy assessing or prescribing exercise or physical activity.
required to perform an activity (e.g., caloric expenditure,
absolute oxygen uptake, metabolic equivalent of task).
Whereas relative intensity refers to the energy cost of the Moderate-Intensity Continuous Training
activity relative to the individual’s maximal capacity (e.g., % Versus High-Intensity Interval Training
maximum oxygen consumption or heart rate reserve, In Australia and New Zealand, exercise prescription guide-
perceived exertion). For individualised exercise prescription, lines for cardiac rehabilitation have historically been more
a relative measure of intensity is recommended, especially conservative compared to those in Europe and America,
for deconditioned individuals [22]. Time (T) is the duration focussing on low-to-moderate intensity exercise, with less
of each exercise session. Type (T) is the mode of exercise to be technical assessment of aerobic capacity [23]. Moderate-
completed. Volume (V) is the total amount of exercise intensity continuous training (MICT) is beneficial and safe
training, a product of frequency, intensity and time. Pro- for all patients with coronary disease and is strongly rec-
gression is the commencement, advancement and progres- ommended [6,24]. More recently, high-intensity interval
sion of intensity or volume over time [15]. It is important to training (HIIT) has also been recommended and deemed safe
 1038
Table 2 Types of aerobic exercise, muscle strength and physical activity assessments.

Type of assessment Description Pros Cons

Aerobic Capacity
Cardiopulmonary Exercise Test (CPET) Incremental treadmill (Modified Bruce, Gold standard Requires supervision by an allied health
Naughton, Balke protocols [52]), or leg/ Valid and reliable professional with extensive experience
arm ergometer test (Ramp protocol) with Tailored exercise prescription and training in the ability to interpret an
concomitant expired air analysis. Investigates the physiology of exercise electrocardiogram [54]
intolerance [53] Medical Practitioner on site [55]
Assesses ventilatory responses to Generally limited to tertiary medical
exercise centres, often with specialist cardiac
Assesses ventilatory thresholds (VT1 and services
VT2) Expensive equipment required
Heart rate response to peak exercise
Blood pressure response
Peak VO2 prognostic marker
Graded Exercise Test Treadmill or leg/arm ergometer test Assessment of haemodynamic response Requires qualified supervision
following a standardised protocol (e.g., to exercise Inability to walk on slowest treadmill
Balke, Naughton or Bruce Protocols [56]). Tailored exercise prescription speed
Test may be ceased once the patient Easy to implement
reaches 85% of their age predicted HRmax Lower cost than CPET
(65% for those with beta-blockade Peak METs prognostic
therapy who are well rate controlled
during exercise), or if clinically indicated;
e.g., chest pains, dyspnoea, light-
headedness, or fatigue [22,55,56]
Functional Exercise Capacity/Field Incremental Shuttle Walk Test: Valid and reliable External audible timed signal
Tests Incremental walking test between the Externally paced More complex than 6MWT
two cones 10 m apart timed to an audio Low-cost requiring minimal equipment Unsuited for those unable to walk at least
signal (beep). Patient walks as long as Assessment of physiological indices 1.8 km/hr
possible or can no longer keep up with Tailored exercise prescription Submaximal test as patient unlikely able
the beeps [57]. Well established [17] to reach higher intensities
Six-Minute Walk Test (6MWT): Prognostic Limited tool to prescribe exercise
Low-resource test that involves walking Easy to comprehend and perform intensity targets
as far as possible in 6 minutes, along a Suitable for the less agile Sensitivity
20–30m flat track. Calculate average Assessment of physiological indices

C. Verdicchio et al.
speed (km/hr) to guide exercise Tailored exercise prescription
prescription = (6MWT distance x10)/ Minimal resources
1000. Blood pressure and heart rate monitoring
 Exercise in Cardiac Rehabilitation
Table 2. (continued).

Type of assessment Description Pros Cons

Muscle Strength
1RM assessments Defined as the maximum weight that can Good–excellent test-retest reliability Requires machine or free weights with
be lifted for one-repetition, through the regardless of age, sex, experience level or adequate available loading, which can be
full available range of motion and with muscle group [58] costly
an acceptable level of technical Safe and tolerable for cardiac Requires supervision of appropriately
proficiency rehabilitation patients [59,60] trained and experienced clinicians
Completed for any major muscle group May limit the haemodynamic excursions Risk of musculoskeletal complications
and requires either machine weights or seen in higher repetition assessments [61]
free weights Results can directly inform exercise
Test terminated when patient is unable to prescription
perform one acceptable repetition on two
consecutive attempts
Estimated 1RM assessments Uses validated prediction equations [62] Lower loads may suit equipment Some error associated when population-
to estimate 1RM based on a multiple limitations or patient/clinician hesitancy level estimation equations used to
repetition test Safe and tolerable for cardiac predict individual outcomes
Multiple repetition test = the highest rehabilitation patients [59,60] Requires machine or free weights with
weight that can be lifted for a specified Results can directly inform exercise adequate available loading, which can be
number of repetitions to failure (e.g., a 3– prescription costly
6-repetition maximum test) Requires supervision of appropriately
Higher reliability with lower repetition trained and experienced clinicians
tests (6 reps)
Same equipment, range of motion,
technical proficiency and termination
criteria as standard 1RM test
Low-resource assessments The general principle of these Easily implemented across most CR Outcome not transferrable to resistance
assessments is for patients to either: settings exercise equipment for prescription
(1) complete a specified number of Minimal equipment requirements
repetitions in the fastest possible time Repeatable, objective measurement of
(e.g., 5 sit-to-stands for fastest time), or muscular strength or endurance
(2) complete the highest number of
repetitions in a specified period of time
(e.g., maximum number of sit-to-stands
in 30 seconds)

1039
 1040
Table 2. (continued).

Type of assessment Description Pros Cons

Physical Activity
Pedometers Research vs consumer pedometers Less prone to recall error and bias [63] Unable to determine context of activity
Range in functionality and accuracy and Output (steps) is simple to understand Insensitive to non-ambulatory and water
are often found in smartphones or Consumer pedometers have reasonable activities (e.g., cycling, swimming) [63]
smartphone apps accuracy for steps [64] Output does not capture intensity
Accelerometers Research vs consumer accelerometers Provides a measure of intensity, allowing Accelerometer intensity thresholds may
Capture acceleration of movement in one an overall measure of activity volume not be appropriate for cardiac
or more planes, as well as steps (i.e., MVPA minutes/week) populations
Inclinometers Research vs consumer inclinometers Considered the most accurate measure of
Measure postural transitions, recording sedentary behaviour
time in sitting/lying, standing and
stepping
Physical activity and Sedentary Long-format International Physical More practical due to their low cost and More likely to under or over-estimate
Behaviour questionnaires Activity Questionnaire [65] (group level ease of use in the clinical setting physical activity and sedentary time due
measure) Past-day Adults’ Sedentary Time to recall bias
Active Australia Survey [66] (group level questionnaire has been validated in the Tend to show low correlations with
measure) cardiac rehabilitation setting objective measures
Physical Activity Vital Sign [67] No physical activity questionnaires have
(clinically feasible, individual level been validated in the cardiac
measure) rehabilitation setting
Past-day Adults’ Sedentary Time
questionnaire [68] (group level measure)
Activity diaries At an individual level, activity diaries Labour intensive for participants [69]
can also be used

Abbreviations: METs, metabolic equivalents; VT1, ventilatory threshold 1; VT2, ventilatory threshold 2; VO2, volume of oxygen consumption; 1RM, 1 repetition-maximum; MVPA, moderate-to-vigorous physical
activity.

C. Verdicchio et al.
Exercise in Cardiac Rehabilitation 1041

Figure 1 A practical guide for the assessment, prescription and progression of aerobic exercise, resistance exercise and
physical activity.
Abbreviations: CPET, cardiopulmonary exercise test; FITT-VP, frequency intensity time type volume progression; RPE, rate
of perceived exertion; MVPA, moderate-to-vigorous physical activity.

by international authorities for various patients with stable strength, mass and endurance [22]. Participation in structured
cardiac disease and may provide superior outcomes resistance exercise sessions, known as resistance training, also
compared to MICT [25–27]. improves functional performance and prognosis for patients
If appropriate, moderate- and high-intensity training can with heart failure [29] or coronary artery disease [30].
be prescribed interchangeably as patients progress, while Resistance training is an important aspect of an exercise
considering patients’ preferences and ability, and can be a program for the diverse and ageing cardiac rehabilitation
good combination to improve a patient’s aerobic exercise population, offering unique benefits that are not provided by
capacity [28]. MICT is recommended for those patients with aerobic exercise training. Specifically, resistance training can
low aerobic exercise capacity and, where appropriate, pa- prevent or reverse the loss of muscle mass (sarcopenia) that
tients could be progressed to high intensity sessions as their occurs after coronary artery bypass grafting and with older
aerobic exercise capacity improves. Select patients with sta- age, and can also benefit comorbid metabolic, vascular,
ble coronary disease, and a good level of aerobic exercise cognitive, frailty and mental health conditions [31]. More-
capacity, may progress to high-intensity exercise after a brief over, the addition of resistance training to aerobic exercise
period of moderate-intensity exercise training. The most programs enhances both muscular strength and aerobic ca-
commonly used HIIT model is a warm-up, followed by 4x4- pacity adaptations in patients with coronary disease [32].
min intervals at 75%–90% peak heart rate (HRpeak) with an Despite historical concerns regarding safety, resistance ex-
active recovery phase of 3-min between bouts at approxi- ercise is well tolerated by patients with cardiovascular con-
mately 60% HRpeak, followed by a cool-down [28]. However, ditions, with very few adverse cardiovascular events
a flexible approach, tailored to individual requirements is reported [32] and acute haemodynamic changes comparable
judicious in practice, such as shorter intervals and/or a lower to aerobic exercise [33].
intensity for patients who have a reduced aerobic capacity
and who may be unable to complete a full 4-min workload
[28].
Assessment
The objective assessment of muscle strength in cardiac
rehabilitation is important to determine and quantify base-
Resistance Exercise line muscle strength, guide individual prescription, and
Resistance exercise requires the contraction of one or more evaluate changes in muscular strength. It is critical that cli-
muscle groups against an external resistance (e.g., weights) nicians consider all relevant contraindications before con-
with the intention to enhance muscular adaptions such as ducting any resistance exercise testing (Table 1), including
 1042
Table 3 FITT-VP Recommendations for prescribing aerobic exercise, resistance exercise and physical activity in cardiac disease patients.

Aerobic Exercise Resistance Exercise Physical Activity

All recommendations should primarily be based on patient need and preference and individual risk assessment
Frequency 3 or more days per week [6]. For patients 2–3 sessions per week. Recommend 48 hours MVPA should be completed on most days per
completing HIIT, at least two of these sessions per between sessions, where possible, to maximise week, which includes exercise as a subset.
week are recommended to be high intensity. muscular recovery
Intensity Moderate-to-high intensity (Table 4; e.g., 55%–90% Moderate-to-high intensity (Table 4; e.g., 50%–80% MVPA is recommended to meet the physical
HRmax, RPE 12–16) based on assessment of aerobic 1RM or 5–7 RPE based on assessment of muscular activity guidelines. Patients can use the Borg RPE.
capacity (Table 2) performance. Modified RPE or the Talk Test to monitor how hard
Initial prescriptions recommended at moderate they are working (Table 4)
intensity for patients not experienced in resistance
training
Time Session duration .30 min of total aerobic exercise. Session duration: .20 min 150–300 min moderate intensity, or 75–150 min
For patients who are severely deconditioned or Duration of muscle contraction .4 second per vigorous intensity, or a combination of both, per
have symptoms at low workloads, it is repetition (.1 s concentric phase, .3 s eccentric week is the aim. This does not need to be
recommended to start with bouts of light-moderate phase) accumulated in 10-minute bouts.
continuous exercise of 5–10 min in duration with Rest between sets: 60 s [70] Additionally, break up long periods of sedentary
breaks as required, to allow full recovery and time, replacing with any intensity of physical
repeat 2–3 times, progressing towards 30 min of activity, including light intensity.
continuous activity. Once moderate intensity
activities are tolerated, patients should be
encouraged to exercise at higher intensities
Type A variety of aerobic modes of exercise are Whole body, single- or multi-joint exercises, A variety of MVPA is recommended including
recommended that use large muscle groups such as performed bilaterally where possible. May include domestic, occupational, transportation and leisure
walking, jogging, cycling, swimming, rowing, stair a range of modalities including bodyweight, free- activities.
climbing. weights, machine weights and elastic resistance Explore opportunities to increase physical activity
Arm-ergometry can also be used if there are bands. within the individual’s existing daily routines,
underlying musculoskeletal issues affecting lower Altering the type of resistance training performed encouraging activities that the individual enjoys.
limb use. can be a useful way to manipulate intensity Be aware of local physical activity referral
through changes in body position and loading, opportunities (e.g., Heart Foundation walking
particularly in low-resource settings groups, Parkrun), if appropriate.
Volume A minimum of 150 minutes of moderate-high Total session volume per major muscle group = 150 min MVPA per week; 7,500 steps/day [72]
intensity aerobic exercise, with an ideal target of 15–36 repetitions, arranged as 1–3 sets of 8–15
.210 min per week for increased cardiometabolic repetitions.
benefit [71] Initial prescriptions can consider lower volumes to

C. Verdicchio et al.
allow patient familiarisation prior to progressing
towards higher volumes
Exercise in Cardiac Rehabilitation 1043

the sternal stability of post-sternotomy patients prior to

Abbreviations: HIIT, high-intensity interval training; MICT, moderate-intensity continuous training; HRmax, Maximal heart rate; MVPA, moderate-to-vigorous physical activity; RPE, rate of perceived exertion; reps,
min of moderate intensity physical activity or 7,500
commencing upper body resistance training [34].

individuals may start with as little as 2–5 minutes

of activity, 3–4 times a day. Progress towards 30

steps on most days, noting any activity is better

Start slowly and progress gradually, increasing Muscle strength should be assessed or estimated relative to
duration before intensity. If appropriate, the 1-repetition maximum (1RM) outcome measure. Several
alternative methods for the assessment of muscle strength
are summarised in Table 2, where individual service-level
factors like equipment availability and clinician experience
may limit the accessibility of 1RM assessment. It is important
to note these alternative methods are limited in their ability
to inform exercise prescription.
Physical Activity

Prescribing and Progressing Resistance

Exercise
than none

Figure 1 summarises the recommended clinician workflow in

relation to assessment, prescription and progression of aer-
obic exercise training. Prescription of resistance training
during cardiac rehabilitation should be informed by the re-
sults of a comprehensive assessment and align with the dual
E.g., Progress repetitions before sets or intensity, up
to a maximum of 15. Once 15 reps can be completed
with ease, then intensity should be progressed to

Intensity should then be progressed towards the

principles of resistance training programming: individuali-

adaptations: volume (reps, sets), intensity, type,

4–6 on RPE scale at a new target of 8–10 reps.

highest tolerable intensity and sets progressed

Clinicians should progress at least one of the

sation and progression [26]. Individualisation refers to

frequency. Volume and intensity should be
progressed before other training variables.

tailoring the resistance exercise prescription specific to a

following to optimise resistance training

patient’s physical capacity, experience, preference and car-

towards 3 per major muscle group.

diac history. Progression is the application of the progressive

overload principle and it refers to the increases in intensity or
volume over time that is essential for promoting muscle
adaptions to exercise. Prescription recommendations for
resistance training are summarised in Table 3 and exercise
Resistance Exercise

intensities in Table 4.
An objective measurement of muscular strength (e.g., 1RM)
for each of the available equipment types or movements fa-
cilitates accurate initial exercise intensity prescription [26]. In
the absence of objective data for all movements, the most
relevant subjective measurement to inform prescription and
progression of resistance exercise is the rating of perceived
exertion (RPE) (Table 4). Scales include the Borg and Omnibus
every 1–2 weeks are typically well-tolerated within
duration to meet 30 min before increasing intensity.

Resistance Exercise Scale (OMNI-RES) for rating perceived

Start slowly and progress gradually, increasing

Increases in intensity and duration of 5%–10%

exertion that allow patients to rate their own perceived level of

exertion from 1–10 (10 is maximal) using a number or pictorial
tool that have been validated against other subjective scales for
use specifically in resistance exercise [35].
Many patients will have had limited exposure to resistance
exercise prior to cardiac rehabilitation enrolment. Thus, it is
important for patients to develop good technical proficiency
during the initial training sessions, to set the technical
foundation and allow for the safe progression of resistance
Aerobic Exercise

cardiac patients.

exercise load and volume throughout the program [26].

Clinicians are encouraged to initially provide a demonstra-
tion and then communicate with and coach the patient
throughout the exercise delivery to facilitate skill acquisition
Table 3. (continued).

and body awareness. Thus, clinicians should embed clear,

concise instructions for each exercise and simple, consistent
feedback at the conclusion of each set. Patients should also be
Progression

advised that: (1) breath-holding (Valsalva manoeuvre)

repetitions.

should be avoided during resistance exercise to limit blood

pressure excursions; (2) muscle tension during resistance
exercise is a normal sensation; and (3) muscle soreness is
1044 C. Verdicchio et al.

common in the first few days after resistance exercise but is

Very High Intensity
reduced with subsequent exposures [26]. The recommenda-
tion for preliminary sessions is to commence at lower ranges
of the recommended intensity so that patients can primarily
focus on technique without being hampered by muscular
fatigue [26].
17–19
.85
.90
.85

85
8

Abbreviations: VO2max, maximal oxygen capacity; HRmax, Maximal heart rate, HRR, heart rate reserve; 6MWT, 6-minute walk test; RPE, rate of perceived exertion; 1RM, 1 repetition maximum.
9
Unable to talk comfortably Physical Activity
High/Vigorous Intensity

Physical activity is defined as any bodily movement pro-

duced by skeletal muscles that result in energy expenditure
such as walking for transport, dancing, housework, or
gardening; with exercise as a subset [36]. Sedentary behav-
iour is any waking behaviour characterised by an energy
expenditure 1.5 metabolic equivalents (METs), while in a
70–85
75–90
70–85

14–16

70–84
7–8

6–7

sitting, reclining, or lying posture [37]. In people with coro-

100

nary disease, physical inactivity and sedentary behaviour are

risk factors for cardiovascular and all-causes of death [38,39].
Able to talk in full sentences/

Active people with coronary disease have a 50% lower risk of

mortality, compared to inactive counterparts [38]. Addi-
tionally, sufficient physical activity reduces the impact of
Moderate Intensity

coronary disease, slows its progress and improves modifi-

able risk factors for recurrent CVD and other chronic disease
unable to sing

[40]. Consequently, individuals undertaking cardiac reha-

bilitation and secondary prevention interventions are
40–69
55–74
40–69

12–13

50–69

encouraged to meet the public health physical activity

4–6
80

guidelines to improve health outcomes [17].

5

The World Health Organization physical activity guide-

lines for adults with chronic disease recommend that in-
Light Intensity
Table 4 Aerobic exercise, physical activity and resistance training intensities.

dividuals should complete 150–300 minutes of moderate

Able to sing

intensity aerobic physical activity; or 75–150 minutes of

*These intensities may be an underestimate in fitter individuals in whom the test is submaximal.

vigorous intensity aerobic physical activity or a combination

10–11
,40
,55
,40

,50
,5
2–3

of both per week [41]. Muscle strengthening should be

completed on at least two days per week and varied func-
tional balance and strength activities should be completed
6MWT average speed* [73] (%)

three days per week. In addition, long periods of sedentary

time should be avoided, replacing sedentary time with any
intensity of physical activity, including light intensity, and,
for those who find it difficult to meet guidelines, any activity
OMNI-RPE [35]
VO2max [26] (%)

is better than none [41,42].

Modified RPE
Talk test [74]
HRmax (%)

Borg RPE

Assessing Physical Activity

HRR (%)

1RM (%)

Physical activity and sedentary behaviour can be assessed

subjectively (e.g., questionnaire) or objectively (e.g., pedom-
eter, accelerometer) to determine whether an individual is
inactive (i.e., not meeting the physical activity guidelines).
Aerobic exercise/physical activity

The most common metrics used to measure physical activity

are minutes of moderate-to-vigorous physical activity
Resistance training

(MVPA) and step counts. Table 2 outlines methods for

assessing physical activity and sedentary behaviour in clin-
ical practice.

Prescribing and Progressing Physical

Activity
Figure 1 summarises the recommended clinician workflow in
relation to assessment, prescription and progression of
Exercise in Cardiac Rehabilitation 1045

physical activity. Following a comprehensive assessment of signs or symptoms necessitating further investigation. For
an individual’s physical activity levels and their safety to most asymptomatic patients, continuous ECG monitoring
increase these levels (Table 1), physical activity can be pre- can be counterproductive by exacerbating feelings of anxiety
scribed according to the FITT-VP principle. An individual’s around exercise that delays development of patient self-
goals, motivation and confidence to increase physical activity efficacy. A warm-up and cool-down should be included in
in everyday life should be reviewed as part of a compre- all exercise sessions and physical activity for 5–10 minutes,
hensive assessment, with each patient receiving an individ- gradually increasing and lowering the heart rate and blood
ually tailored physical activity program based on these pressure to limit rapid haemodynamic changes.
findings. Recommendations for physical activity prescription For resistance exercise in people with underlying muscu-
and counselling at a moderate-vigorous intensity (Table 4) loskeletal conditions, correct technique and modifying in-
are outlined in Table 3. tensity or volume are important for reducing the risk of
Clinicians (e.g., nurses, allied health professionals, medical aggravating these conditions [32]. Special consideration
doctors) are well placed to provide general physical activity should also be given to recent median sternotomies; how-
advice on the types and amount of activity appropriate for ever, evidence supports early initiation of upper body
the individual’s goals, needs, abilities, preferences, functional movements within safe limits of pain [43,44]. “Keep your
limitations, medication regimes and treatment. For more move in the tube” is a paradigm shift that promotes upper
specific physical activity advice, exercise specialists such as limb activity and exercise using short lever arms by per-
physiotherapists and exercise physiologists should be con- forming activities close to the body. This encourages clini-
sulted. A medical review is generally unnecessary prior to cians to engage patients in early active recovery by educating
beginning light-to-moderate intensity physical activity on what they can safely do, in contrast to prescribing overly
within cardiac rehabilitation and the community, unless restrictive precautions not supported by current evidence
there are known contraindications (Table 1) [41]. For [43,44]. More recently, early post-sternotomy resistance ex-
vigorous or high intensity physical activity (e.g., jogging, ercise inclusive of individualised upper limb exercise has
tennis singles), a full clinical assessment and medical review been reported as safe and resulted in significant improve-
is recommended [15]. ment in muscular strength and cognitive recovery [45].
Within the community, patients should be advised to wear
comfortable clothing and footwear, have adequate fluid
intake and avoid activity after heavy meals, if they are
Safety and Monitoring suffering from an illness, and in extreme temperatures.
Regardless of diagnosis, whether there has been an acute During unsupervised exercise and physical activity, in-
cardiac event or procedure, comorbidities or age, all in- dividuals should monitor their intensity (e.g., talk test, RPE;
dividuals should be encouraged to increase their exercise and Table 4) and symptoms (i.e., chest pain, dizziness, nausea,
physical activity levels safely, starting slowly at an appro- feeling unwell, excessive sweatiness). If patients experience
priate level and progressing gradually [6,41]. It is recom- any warning signs of a cardiac event, then they should be
mended that when conducting centre-based exercise sessions encouraged to call an ambulance immediately. To improve
there are basic safety standards and procedures in place, adherence to the exercise and physical recommendations,
such as a defibrillator, resuscitative and first-aid equipment interventions using mHealth (e.g., text messages, smart-
on-site. Prior to each supervised exercise session, it is rec- phone apps) and wearable activity trackers should be
ommended to assess the patient’s contraindications to exer- considered [46].
cise, measuring pre-exercise heart rate and blood pressure, to
ensure that they are within an acceptable range at rest
(Table 1). However, as patients progress and their cardiac
disease is stable with no symptoms, these pre-exercise mea-
Wearable Activity Trackers
surements are not necessary and may be counterproductive There is emerging evidence that the use of free-living wear-
to the patient’s feelings around exercise and physical activity able activity trackers (e.g., smartwatches, wristbands, chest
in an unsupervised state. Clinical risk may increase over time strap, clothing and shoe-embedded sensors, smartphone
due to disease progression or clinical deterioration. When in pedometers and accelerometers) leads to increased physical
doubt, seek medical advice or support before commencing activity levels and aerobic capacity in cardiac rehabilitation
the exercise session. During exercise it is recommended to participants [47]. The increasing self-initiated use of wearable
monitor the patient’s heart rate and RPE (or Borg Scale for activity trackers by patients provides an opportunity for
Dyspnoea in patients with heart failure) to ensure they are clinicians to promote physical activity using these devices.
reaching their target intensity during their aerobic bout of The use of wearable activity trackers can be successfully
exercise and responding to exercise appropriately (Figure 1). incorporated within clinical settings after reviewing some
ECG monitoring during exercise is not essential for patients device and individual factors [48]. Clinicians should consider
within the supervised setting; however, in certain circum- device availability, usability (e.g., battery life, metrics avail-
stances (e.g., atrial fibrillation, history of significant ventric- able (step count, MVPA, heart rate)), clarity of the interface
ular arrhythmias), it is beneficial to use for patients showing and management of the devices (e.g., downloading and
1046 C. Verdicchio et al.

interpreting the data). Reliability and validity of the device is Summary of Recommendations
important, as well as data security and management. At an
individual level, clinicians should determine whether pa-  A comprehensive individual assessment of aerobic exer-
tients are motivated to use a wearable activity tracker and cise capacity, muscle strength and physical activity allows
have matching levels of digital literacy. Clinicians can limiting factors to be identified, guiding the safe pre-
maximise the effectiveness of wearable activity trackers, over scription of aerobic and resistance exercise and physical
the short and long term, through encouraging, educating, activity that is personalised to the patient’s abilities, needs,
monitoring, and providing effective feedback loops to pro- preferences and goals.
mote individual engagement and autonomy beyond the  Aerobic exercise capacity, muscle strength and physical
structured, supervised cardiac rehabilitation setting. activity assessments should be conducted at enrolment
and at discharge to allow for a more detailed analysis of a
patient’s response to exercise and physical activity, which
Using Telehealth to Assess and can guide the target intensities during their program, and
Prescribe Exercise and Physical allow for measurement of program effectiveness.
 Cardiac rehabilitation should incorporate a range of exer-
Activity cise and physical activity options, with the aim to achieve
Over the past decade telehealth has emerged as an alterna- moderate-to-vigorous intensity exercise and physical ac-
tive and effective model for delivering cardiac rehabilitation, tivity to receive the optimal health benefits and prevent
with its utilisation increasing markedly during the COVID- recurrent CVD events.
19 pandemic due to widespread restrictions to face-to-face  MICT is well established as being safe and effective for
delivery [49]. Ideally, it is recommended that exercise and cardiac patients, with increasing evidence that HIIT is
physical activity assessments are done in-person to ensure a well-tolerated for selected cardiac patients and can offer
safe and standardised assessment. However, for a variety of improvements to aerobic exercise capacity exceeding those
reasons, including patient preference, this may not be resulting from MICT in some patient cohorts.
possible, in which case telehealth exercise assessments are  Making use of available resources, including wearable
recommended to allow individually tailored exercise and activity trackers and telehealth, will potentially allow
physical activity prescription. increased support for exercise and physical activity
Before assessing exercise and physical activity using tele- resulting in increased health benefits, including improve-
health, safety needs to be considered, including verifying the ment of quality of life, supporting and empowering pa-
patient’s location in case you need to call an ambulance or tients to self-monitor and manage their symptoms, and
checking whether they have an action plan and medications increasing their confidence to be active over the longer
nearby if required. Some patients may not be suitable for a term.
telehealth assessment and will need an in-person review,
including those with cognitive impairments and low digital
literacy. Before commencing the assessment, clinicians Conclusion
should determine what monitoring equipment is available
Patients with cardiovascular disease benefit from cardiac
(e.g., blood pressure or heart rate monitors) and conduct a
rehabilitation, which includes structured exercise and phys-
virtual tour to check if the space is safe for exercising. Also, a
ical activity as core components. This position statement
standard subjective history should be taken, followed by a
provides up-to-date evidence-based guidance for the
virtual exercise test. Selection of a suitable exercise test is
assessment and prescription of exercise and physical activity
dependent on the space and equipment available, ensuring
for cardiac rehabilitation clinicians within the Australian and
that the test can be repeated at the end of the program using
New Zealand context. With ongoing research in this area, it
the same methods. To assess functional exercise capacity, the
is important for clinicians to be aware of current guidelines
6-minute walk test (6MWT) [50], 1-minute sit-to-stand test
and recommendations from other global cardiac bodies.
[51] and Timed Up and Go [50] could be used. To assess
muscle strength, the 5x sit-to-stand evaluates functional
quadriceps strength [50]. Consumer pedometers, accelerom- Disclosures
eters, or questionnaires can be used to assess physical ac-
tivity (Table 2). Prescription of aerobic exercise, resistance Nil disclosures
exercise and physical activity should follow the FITT-VP
principle (Table 3). Effective virtual assessment, prescrip-
tion and progression of exercise and physical activity may be
Acknowledgements
challenging; however, the assessment and prescription of We would like to acknowledge the Cardiac Society of
exercise and physical activity via telehealth is preferrable to Australia and New Zealand (CSANZ) Quality and Safety
generic untailored programs, providing new opportunities to Committee, CSANZ Clinical and Preventative Cardiology
ensure programs can remain individually tailored when in- Council, CSANZ Allied Health, Science and Technology
person assessment is not possible. Council, Australian Cardiovascular Health and
Exercise in Cardiac Rehabilitation 1047

Rehabilitation Association, Exercise and Sports Science [14] Butchart EG, Gohlke-Barwolf C, Antunes MJ, Tornos P, De Caterina R,
Cormier B, et al. Recommendations for the management of patients after
Australia, and the Australian Physiotherapy Association.
heart valve surgery. Eur Heart J. 2005;26(22):2463–71.
The authors thank Professor Doa El-Ansary for reviewing the [15] Pelliccia A, Sharma S, Gati S, Bäck M, Börjesson M, Caselli S, et al. 2020
resistance exercise section. ESC guidelines on sports cardiology and exercise in patients with car-
diovascular disease: the task force on sports cardiology and exercise in
patients with cardiovascular disease of the European Society of Cardi-
ology (ESC). Eur Heart J. 2021;42(1):17–96.
Funding [16] Howden EJ, Bigaran A, Beaudry R, Fraser S, Selig S, Foulkes S, et al.
Exercise as a diagnostic and therapeutic tool for the prevention of car-
J.R. is funded by a NHMRC Investigator Grant diovascular dysfunction in breast cancer patients. Eur J Prev Cardiol.
(GNT1143538). M.H. is funded by the NHMRC SOLVE-CHD 2019;26(3):305–15.
Synergy Grant (GNT1182301). [17] Woodruffe S, Neubeck L, Clark RA, Gray K, Ferry C, Finan J, et al.
Australian Cardiovascular Health and Rehabilitation Association
(ACRA) core components of cardiovascular disease secondary prevention
and cardiac rehabilitation 2014. Heart Lung Circ. 2015;24(5):430–41.
References [18] Redfern J, Maiorana A, Neubeck L, Clark AM, Briffa T. Achieving coor-
dinated secondary prevention of coronary heart disease for all in need
[1] World Health Organization. Cardiovascular Disaese Factsheet 2021. (SPAN). Int J Cardiol. 2011;146(1):1–3.
Available from: https://www.who.int/news-room/fact-sheets/detail/ [19] Wahid A, Manek N, Nichols M, Kelly P, Foster C, Webster P, et al.
cardiovascular-diseases-(cvds). [accessed 18.4.23]. Quantifying the association between physical activity and cardiovascular
[2] Redfern J, Gallagher R, O’Neil A, Grace SL, Bauman A, Jennings G, et al. disease and diabetes: a systematic review and meta-analysis. J Am Heart
Historical context of cardiac rehabilitation: learning from the past to Assoc. 2016;5(9).
move to the future. Front Cardiovasc Med. 2022;9:842567. [20] Dimeo F, Pagonas N, Seibert F, Arndt R, Zidek W, Westhoff TH. Aerobic
[3] Redfern J, Figtree G, Chow C, Jennings G, Briffa T, Gallagher R, et al. Cardiac exercise reduces blood pressure in resistant hypertension. Hypertension.
rehabilitation and secondary prevention roundtable: Australian imple- 2012;60(3):653–8.
mentation and research priorities. Heart Lung Circ. 2020;29(3):319–23. [21] Haykowsky MJ, Liang Y, Pechter D, Jones LW, McAlister FA, Clark AM.
[4] Visseren FLJ, Mach F, Smulders YM, Carballo D, Koskinas KC, Back M, A meta-analysis of the effect of exercise training on left ventricular
et al. 2021 ESC Guidelines on cardiovascular disease prevention in clinical remodeling in heart failure patients: the benefit depends on the type of
practice: developed by the Task Force for cardiovascular disease pre- training performed. J Am Coll Cardiol. 2007;49(24):2329–36.
vention in clinical practice with representatives of the European Society [22] American College of Sports Medicine. In: Liguori G, editor. ACSM’s
of Cardiology and 12 medical societies with the special contribution of the Guidelines for Exercise Testing and Prescription. Eleventh Edition.
European Association of Preventive Cardiology (EAPC). Rev Esp Cardiol 1Philadelphia: Wolters Kluwer; 2021.
(Engl Ed). 2022;75(5):429. [23] Price KJ, Gordon BA, Bird SR, Benson AC. A review of guidelines for
[5] Chew DP, Scott IA, Cullen L, French JK, Briffa TG, Tideman PA, et al. cardiac rehabilitation exercise programmes: is there an international
National Heart Foundation of Australia & Cardiac Society of Australia consensus? Eur J Prev Cardiol. 2016;23(16):1715–33.
and New Zealand: Australian Clinical Guidelines for the Management of [24] Elliott AD, Rajopadhyaya K, Bentley DJ, Beltrame JF, Aromataris EC.
Acute Coronary Syndromes 2016. Heart Lung Circ. 2016;25(9):895–951. Interval training versus continuous exercise in patients with coronary
[6] Ambrosetti M, Abreu A, Corra U, Davos CH, Hansen D, Frederix I, et al. artery disease: a meta-analysis. Heart Lung Circ. 2015;24(2):149–57.
Secondary prevention through comprehensive cardiovascular rehabilita- [25] Wewege MA, Ahn D, Yu J, Liou K, Keech A. High-intensity interval
tion: From knowledge to implementation. 2020 update. A position paper training for patients with cardiovascular disease—is it safe? A systematic
from the Secondary Prevention and Rehabilitation Section of the Euro- review. J Am Heart Assoc. 2018;7(21):e009305.
pean Association of Preventive Cardiology. Eur J Prev Cardiol. 2021 May [26] Hansen D, Abreu A, Ambrosetti M, Cornelissen V, Gevaert A, Kemps H,
14;28(5):460–95. https://doi.org/10.1177/2047487320913379. et al. Exercise intensity assessment and prescription in cardiovascular
[7] Rauch B, Davos CH, Doherty P, Saure D, Metzendorf MI, Salzwedel A, rehabilitation and beyond: why and how: a position statement from
et al. The prognostic effect of cardiac rehabilitation in the era of acute the Secondary Prevention and Rehabilitation Section of the European
revascularisation and statin therapy: a systematic review and meta- Association of Preventive Cardiology. Eur J Prev Cardiol. 2022;29(1):
analysis of randomized and non-randomized studies—The Cardiac 230–45.
Rehabilitation Outcome Study (CROS). Eur J Prev Cardiol. [27] Group JCSJW. Guidelines for rehabilitation in patients with cardiovas-
2016;23(18):1914–39. cular disease (JCS 2012). Circ J. 2014;78(8):2022–93.
[8] Salzwedel A, Jensen K, Rauch B, Doherty P, Metzendorf MI, [28] Taylor JL, Bonikowske AR, Olson TP. Optimizing outcomes in cardiac
Hackbusch M, et al. Effectiveness of comprehensive cardiac rehabilitation rehabilitation: the importance of exercise intensity. Front Cardiovasc
in coronary artery disease patients treated according to contemporary Med. 2021;8:734278.
evidence based medicine: Update of the Cardiac Rehabilitation Outcome [29] Nakamura T, Kamiya K, Hamazaki N, Matsuzawa R, Nozaki K,
Study (CROS-II). Eur J Prev Cardiol. 2020;27(16):1756–74. Ichikawa T, et al. Quadriceps strength and mortality in older patients
[9] Haykowsky MJ, Timmons MP, Kruger C, McNeely M, Taylor DA, with heart failure. Can J Cardiol. 2021;37(3):476–83.
Clark AM. Meta-analysis of aerobic interval training on exercise capacity [30] Sato R, Akiyama E, Konishi M, Matsuzawa Y, Suzuki H, Kawashima C,
and systolic function in patients with heart failure and reduced ejection et al. Decreased appendicular skeletal muscle mass is associated with
fractions. Am J Cardiol. 2013;111(10):1466–9. poor outcomes after ST-segment elevation myocardial infarction.
[10] Edelmann F, Gelbrich G, Dungen HD, Frohling S, Wachter R, J Atheroscler Thromb. 2020:52282.
Stahrenberg R, et al. Exercise training improves exercise capacity and [31] Williams MA, Haskell WL, Ades PA, Amsterdam EA, Bittner V,
diastolic function in patients with heart failure with preserved ejection Franklin BA, et al. Resistance exercise in individuals with and without car-
fraction: results of the Ex-DHF (Exercise training in Diastolic Heart diovascular disease: 2007 update: a scientific statement from the American
Failure) pilot study. J Am Coll Cardiol. 2011;58(17):1780–91. Heart Association Council on Clinical Cardiology and Council on Nutrition,
[11] Elliott AD, Verdicchio CV, Mahajan R, Middeldorp ME, Gallagher C, Physical Activity, and Metabolism. Circulation. 2007;116(5):572–84.
Mishima RS, et al. An exercise and physical activity program in patients [32] Hollings M, Mavros Y, Freeston J, Fiatarone Singh M. The effect of pro-
with atrial fibrillation: the ACTIVE-AF randomized controlled trial. JACC gressive resistance training on aerobic fitness and strength in adults with
Clin Electrophysiol. 2023. coronary heart disease: a systematic review and meta-analysis of rand-
[12] Fakhry F, Spronk S, van der Laan L, Wever JJ, Teijink JA, Hoffmann WH, omised controlled trials. Eur J Prevent Cardiol. 2017;24(12):1242–59.
et al. Endovascular revascularization and supervised exercise for pe- [33] Karlsdottir AE, Foster C, Porcari JP, Palmer-McLean K, White-Kube R,
ripheral artery disease and intermittent claudication: a randomized clin- Backes RC. Hemodynamic responses during aerobic and resistance ex-
ical trial. JAMA. 2015;314(18):1936–44. ercise. J Cardiopulm Rehabil. 2002;22(3):170–7.
[13] Tran DL, Maiorana A, Davis GM, Celermajer DS, d’Udekem Y, [34] El-Ansary D, Waddington G, Denehy L, Adams R. Physical examination
Cordina R. Exercise testing and training in adults with congenital heart of the sternum following cardiac surgery: validity and reliability of a
disease: a surgical perspective. Ann Thorac Surg. 2021;112(4):1045–54. Sternal Instability Scale (SIS). Heart Lung Circ. 2015;24:S415.
1048 C. Verdicchio et al.

[35] Lagally KM, Robertson RJ. Construct validity of the OMNI resistance Med. 2022 Jun 9;bjsports-2021-105261. https://doi.org/10.1136/bjsports-
exercise scale. J Strength Cond Res. 2006;20(2):252. 2021-105261.
[36] Caspersen CJ, Powell KE, Christenson GM. Physical activity, exercise, [54] Myers J, Forman DE, Balady GJ, Franklin BA, Nelson-Worel J, Martin BJ,
and physical fitness: definitions and distinctions for health-related et al. Supervision of exercise testing by nonphysicians: a scientific statement
research. Public Health Rep. 1985;100(2):126–31. from the American Heart Association. Circulation. 2014;130(12):1014–27.
[37] Tremblay MS, Aubert S, Barnes JD, Saunders TJ, Carson V, Latimer- [55] Fletcher GF, Ades PA, Kligfield P, Arena R, Balady GJ, Bittner VA, et al.
Cheung AE, et al. Sedentary Behavior Research Network (SBRN)—Ter- Exercise standards for testing and training: a scientific statement from the
minology Consensus Project process and outcome. Int J Behav Nutr Phys American Heart Association. Circulation. 2013;128(8):873–934.
Act. 2017;14(1):75. [56] Pollock ML, Bohannon RL, Cooper KH, Ayres JJ, Ward A, White SR, et al.
[38] Gonzalez-Jaramillo N, Wilhelm M, Arango-Rivas Ana M, Gonzalez- A comparative analysis of four protocols for maximal treadmill stress
Jaramillo V, Mesa-Vieira C, Minder B, et al. Systematic review of physical testing. Am Heart J. 1976;92(1):39–46.
activity trajectories and mortality in patients with coronary artery dis- [57] Alotaibi JF, Doherty P. Evaluation of determinants of walking fitness in
ease. J Am Coll Cardiol. 2022;79(17):1690–700. patients attending cardiac rehabilitation. BMJ Open Sport Exerc Med.
[39] van der Ploeg HP, Chey T, Korda RJ, Banks E, Bauman A. Sitting time 2016;2(1):e000203.
and all-cause mortality risk in 222 497 Australian adults. Arch Intern [58] Grgic J, Lazinica B, Schoenfeld BJ, Pedisic Z. Test–retest reliability of the
Med. 2012;172(6):494–500. one-repetition maximum (1RM) strength assessment: a systematic re-
[40] Alves AJ, Viana JL, Cavalcante SL, Oliveira NL, Duarte JA, Mota J, et al. view. Sports Med Open. 2020;6(1):31.
Physical activity in primary and secondary prevention of cardiovascular [59] Barnard KL, Adams KJ, Swank AM, Mann E, Denny DM. Injuries and
disease: overview updated. World J Cardiol. 2016;8(10):575–83. muscle soreness during the one repetition maximum assessment in a
[41] Bull FC, Al-Ansari SS, Biddle S, Borodulin K, Buman MP, Cardon G, et al. cardiac rehabilitation population. J Cardiopulm Rehabil. 1999;19(1):52–8.
World Health Organization 2020 guidelines on physical activity and [60] Werber-Zion G, Goldhammer E, Shaar A, Pollock ML. Left ventricular
sedentary behaviour. Br J Sports Med. 2020;54(24):1451. function during strength testing and resistance exercise in patients with
[42] Dibben GO, Dalal HM, Taylor RS, Doherty P, Tang LH, Hillsdon M. left ventricular dysfunction. J Cardiopulm Rehabil. 2004;24(2):100–9.
Cardiac rehabilitation and physical activity: systematic review and meta- [61] Gjovaag TF, Mirtaheri P, Simon K, Berdal G, Tuchel I, Westlie T, et al.
analysis. Heart. 2018;104(17):1394–402. Hemodynamic responses to resistance exercise in patients with coronary
[43] Adams J, Lotshaw A, Exum E, Campbell M, Spranger CB, Beveridge J, artery disease. Med Sci Sports Exerc. 2016;48(4):581–8.
et al. An alternative approach to prescribing sternal precautions after [62] Wood TM, Maddalozzo GF, Harter RA. Accuracy of seven equations for
median sternotomy, “Keep Your Move in the Tube”. Proc (Bayl Univ predicting 1-RM performance of apparently healthy, sedentary older
Med Cent). 2016;29(1):97–100. adults. Meas Phys Educ Exerc Sci. 2002;6(2):67–94.
[44] El-Ansary D, LaPier TK, Adams J, Gach R, Triano S, Katijjahbe MA, et al. [63] Copeland JL, Ashe MC, Biddle SJ, Brown WJ, Buman MP, Chastin S,
An evidence-based perspective on movement and activity following et al. Sedentary time in older adults: a critical review of measurement,
median sternotomy. Phys Ther. 2019;99(12):1587–601. associations with health, and interventions. Br J Sports Med. 2017;51
[45] Pengelly J, Royse C, Williams G, Bryant A, Clarke-Errey S, Royse A, et al. (21):1539.
Effects of 12-week supervised early resistance training (SEcReT) versus [64] Fuller D, Colwell E, Low J, Orychock K, Tobin MA, Simango B, et al.
aerobic-based rehabilitation on cognitive recovery following cardiac Reliability and validity of commercially available wearable devices for
surgery via median sternotomy: a pilot randomised controlled trial. Heart measuring steps, energy expenditure, and heart rate: systematic review.
Lung Circ. 2022;31(3):395–406. JMIR Mhealth Uhealth. 2020;8(9):e18694.
[46] Patterson K, Davey R, Keegan R, Freene N. Smartphone applications for [65] Craig CL, Marshall AL, Sjöström M, Bauman AE, Booth ML,
physical activity and sedentary behaviour change in people with car- Ainsworth BE, et al. International physical activity questionnaire: 12-
diovascular disease: a systematic review and meta-analysis. PloS One. country reliability and validity. Med Sci Sports Exerc. 2003;35(8):1381–95.
2021;16(10):e0258460. [66] Australian Institute of Health and Welfare. The Active Australia survey: a
[47] Ashur C, Cascino TM, Lewis C, Townsend W, Sen A, Pekmezi D, et al. Do guide and manual for implementation, analysis and reporting. Canberra:
wearable activity trackers increase physical activity among cardiac Australian Institute of Health and Welfare; 2003.
rehabilitation participants? A systematic review and meta-analysis. [67] Lobelo F, Rohm Young D, Sallis R, Garber MD, Billinger SA, Duperly J,
J Cardiopulm Rehabil Prev. 2021;41(4):249–56. et al. routine assessment and promotion of physical activity in healthcare
[48] Bayoumy K, Gaber M, Elshafeey A, Mhaimeed O, Dineen EH, Marvel FA, settings: a scientific statement from the American Heart Association.
et al. Smart wearable devices in cardiovascular care: where we are and Circulation. 2018;137(18):e495–522.
how to move forward. Nat Rev Cardiol. 2021;18(8):581–99. [68] Freene N, McManus M, Mair T, Tan R, Clark B, Davey R. Validity of the
[49] Pecci C, Ajmal M. Cardiac rehab in the COVID-19 pandemic. Am J Med. past-day adults’ sedentary time questionnaire in a cardiac rehabilitation
2021;134(5):559–60. population. J Cardiopulm Rehabil. 2020;40(5):325–9.
[50] Hwang R, Fan T, Bowe R, Louis M, Bertram M, Morris NR, et al. Home- [69] Sternfeld B, Goldman-Rosas L. A systematic approach to selecting an
based and remote functional exercise testing in cardiac conditions, during appropriate measure of self-reported physical activity or sedentary
the COVID-19 pandemic and beyond: a systematic review. Physio- behavior. J Phys Act Health. 2012;9(Suppl 1):S19–28.
therapy. 2022;115:27–35. [70] Borde R, Hortobagyi T, Granacher U. Dose-response relationships of
[51] Bohannon RW, Crouch R. 1-Minute sit-to-stand test: systematic review of resistance training in healthy old adults: a systematic review and meta-
procedures, performance, and clinimetric properties. J Cardiopulm analysis. Sports Med. 2015;45(12):1693–720.
Rehabil Prev. 2019;39(1):2–8. [71] Wadden TA, West DS, Delahanty L, Jakicic J, Rejeski J, Williamson D,
[52] Mezzani A, Hamm LF, Jones AM, McBride PE, Moholdt T, Stone JA, et al. et al. The Look AHEAD study: a description of the lifestyle intervention
Aerobic exercise intensity assessment and prescription in cardiac reha- and the evidence supporting it. Obesity (Silver Spring). 2006;14(5):737–52.
bilitation: a joint position statement of the European Association for [72] Ayabe M, Brubaker PH, Dobrosielski D, Miller HS, Kiyonaga A,
Cardiovascular Prevention and Rehabilitation, the American Association Shindo M, et al. Target step count for the secondary prevention of car-
of Cardiovascular and Pulmonary Rehabilitation, and the Canadian As- diovascular disease. Circ J. 2008;72(2):299–303.
sociation of Cardiac Rehabilitation. J Cardiopulm Rehabil Prev. [73] Online H. Heart Education Assessment Rehabilitation Toolkit 2022.
2012;32(6):327–50. Available from: https://www.heartonline.org.au/. [accessed 18.4.23].
[53] D’Ascenzi F, Cavigli L, Pagliaro A, Focardi M, Valente S, Cameli M, et al. [74] Sørensen L, Larsen KSR, Petersen AK. Validity of the talk test as a
Clinician approach to cardiopulmonary exercise testing for exercise pre- method to estimate ventilatory threshold and guide exercise intensity in
scription in patients at risk of and with cardiovascular disease. Br J Sports cardiac patients. J Cardiopulm Rehabil. 2020;40(5):330–4.