2015 Jan;22(1):27-34. doi: 10.1177/2047487313505819. Keteyian SJ, Kerrigan DJ, Ehrman JK, Brawner CA. (max Systolic BP - resting Systolic BP) x (.4 - .8 + (max METs/100)) + resting Systolic BP, Training Exercise Blood Pressure (TEBP) = [(180 - 120) x (.58)] + 120, TEBP = [(60) x (.58)] + 120 = 155 systolic BP. Keteyian SJ, Brawner CA, Savage PD, Ehrman JK, Schairer J, Divine G, Aldred H, Ophaug K, Ades PA. They need to be able to work Soga Y, Yokoi H, Ando K, Shirai S, Sakai K, Kondo K, Goya M, Iwabuchi M, Nobuyoshi M. Safety of early exercise training after elective coronary stenting in patients with stable coronary artery disease. Journal of Clinical Exercise Physiology. 2001 Oct 2;104(14):1694-740. The answer is yes. that dysrhythmias may appear. The warm up period allows a gradual increase in the temperature of exercising muscle. Individual Participant Data (IPD) Sharing Statement: De-identified individual participant data for all primary and secondary outcome measures will be made available. Setting the intensity is one of the more difficult aspects of writing an exercise prescription. 2002 Mar 14;346(11):793-801. the actual exercise intensity, expressed as a percentage of peak oxygen uptake reserve (%VO2R) using these techniques. There are two common methods of exercise prescription, an effort based exercise prescription and target heart rate based exercise prescription. Let's see how this can be done. The purpose of this research study is to identify the best way to exercise in cardiac rehabilitation. The patient's response is determined by measuring HR, BP and examining the EKG for signs of ischemia. It begins a few days after discharge from the hospital. You will take part in a supervised exercise program. Mr. James will begin his Phase II exercise program in your clinic exercising at a systolic blood pressure no greater than 155 mm Hg. These patients will be given a heart rate goal to use when they exercise. Why Should I Register and Submit Results? Exercise intensity will be guided by the patient's reported rating of perceived exertion (RPE). Patients with heart transplant or left-ventricular assist device, as heart rates can be inaccurate and difficult to measure. This monitor will consist of a polar heart rate chest strap and polar watch. Anderson L, Oldridge N, Thompson DR, Zwisler AD, Rees K, Martin N, Taylor RS. As the patients progress in CR, patients will increase their time, intensity, and mode of exercise as appropriate. Change in Maximal Exercise Capacity Is Associated With Survival in Men and Women. The confidence ruler is a 0 to 10 scale. Cardiac rehabilitation staff will provide feedback about heart rate when they are able. Safety of exercise training for cardiac patients: results of the French registry of complications during cardiac rehabilitation. If they exercise properly, following the counsel they have received during the educational sessions of Phase I and Phase II, they 2013;2:42-45, McConnell TR. An example would be: (155 -75) X (.6) + 75) = 123; ((155 - 75) X (.8) + 75 = 139) THRR: 123 - 139. I. A cool down period is important because it This section was adapted from the Cardiac Rehabilitation booklet from the Wellness Institute at Seven Oaks Hospital in Winnipeg, Manitoba, 2009. One hundred and twenty participants are to be recruited and the recruitment is scheduled to begin in May 2017. Exercise progression will be guided by RPE and clinical assessment. These could interrupt exercise training or change target heart rate ranges. Give the patient a safe, monitored environment for exercise. J Am Coll Cardiol. patient … Cardiac rehabilitation refers to a structured program of exercise and education designed to help you return to optimal fitness and function following an event like a heart attack. Information provided by (Responsible Party): Quinn Pack, MD, MSc, Baystate Medical Center. It usually occurs in a hospital setting where the. There are three main goals of this study. o 2 ). This is one of the main goals of Phase II and must be … 2017 Mar;92(3):383-390. doi: 10.1016/j.mayocp.2016.12.016. Frequency - Frequency is usually always three days per week advancing to four days. This assures me that I Phase II is the next extension of cardiac rehabilitation. Topics that can be discussed are : risk factor modification, stress management, dietary modifications to lower fat intake, smoking cessation, anatomy of the heart, sexual activity, cardiac In this study, the investigators propose to do a randomized controlled trial of 60 patients at Baystate Medical Center CR, in which two thirds of the patients will undergo exercise testing prior to starting CR. Phase 2 begins after a patient has been discharged from the hospital. The adverse event is determined by the opinion of the treating clinician, the patient was unable to start or continue exercising based on one or more of the following subcategories; high or low blood pressure, dyspnea, tachycardia, or chest pain as defined by the treating clinician who stopped or precluded exercise. … Using an adapted form of the Karvonen's formula, lets see how we can write a safe ise prescription for a patient. 2007 Oct 9;116(15):1653-62. As part of this study, some patients will undergo an exercise stress test on a treadmill to determine a target heart rate. - fatigue, effort of difficulty of the exercise bout (Borg Scale), etc. monitoring devices with exercise prescription or advice in the maintenance phase of cardiac rehabilitation: systematic review and meta-analysis Amanda L. Hannan1*, Michael P. Harders1, Wayne Hing1, Mike Climstein2,4, Jeff S. Coombes3 and James Furness1 Abstract Background: Physical activity (PA) is a component of cardiac rehabilitation (CR). Based on exercise levels achieved on the first day, patients will be given exercise recommendations for their 2nd session of CR and so forth. Internationally, it is Hamm LF. Use of cardiac rehabilitation by Medicare beneficiaries after myocardial infarction or coronary bypass surgery. Epub 2007 Sep 24. Protocols of exercise testing ANNEX 4. It is the time when you work on gradually increasing your exercise tolerance following your operation. Major orthopedic limitations to exercise, such as history of amputation or exercise-limiting joint pain, or inability to walk on a treadmill, because all patients will have to complete a stress test on a treadmill and objective data collected during CR will be recorded during treadmill exercise. For general information, Learn About Clinical Studies. Brawner CA, Abdul-Nour K, Lewis B, Schairer JR, Modi SS, Kerrigan DJ, Ehrman JK, Keteyian SJ. Study record managers: refer to the Data Element Definitions if submitting registration or results information. Pavy B, Iliou MC, Meurin P, Tabet JY, Corone S; Functional Evaluation and Cardiac Rehabilitation Working Group of the French Society of Cardiology. 2006 Nov 27;166(21):2329-34. Again, let's plug in the data from the GXT. Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT03925493. Monitoring consists of measuring the patient's blood pressure, HR, EKG, heart sounds, and lungs sounds. Third, the investigators want to understand if a personal heart rate monitor will improve adherence to a target heart rate for exercise. Patients with high risk unrevascularized coronary artery disease including left main coronary disease >60% or proximal left anterior descending artery (LAD) >80%, per the discretion of the medical director. If the data from the GXT (graded exercise stress test) has been recorded on the prescription that is sent with the patient as they arrive for Phase II, then it is an easy manner to write a safe exercise program. Stable angina, as chest pain could become a limiting factor as exercise training progresses, rather than using target heart rates.  (Clinical Trial), Exercise Prescription in Cardiac Rehabilitation: A Pilot Randomized Controlled Trial, No Intervention: Control Group Procedures (RPE based exercise), Experimental: Exercise Test and Heart Rate Range, Experimental: Exercise Test, Heart Rate Range, and Heart Rate Monitor, 18 Years to 100 Years   (Adult, Older Adult), Springfield, Massachusetts, United States, 01199, Quinn Pack, MD, MSc, Director, Head of Cardiac Rehabilitation, Principle Investigator, Baystate Medical Center. 2008 Aug;156(2):292-300. doi: 10.1016/j.ahj.2008.03.017. Healthy eating. Peak aerobic capacity predicts prognosis in patients with coronary heart disease. In the formula that I used, I arbitrarily used a .58 starting activity fraction. This test will be used to set the target heart rate range, which will guide exercise intensity for the remainder of exercise training in cardiac rehabilitation. Update in: Cochrane Database Syst Rev. Epub 2016 Jan 28. It also reduces the incidence of muscle pulls and strains. Assessment and exercise testing ANNEX 3. 2014 Sep-Oct;34(5):318-26. doi: 10.1097/HCR.0000000000000076. Mr. James will begin his Phase II exercise program in your clinic exercising at a heart rate no greater than 138 BPM. 2010 Apr;17(2):230-4. doi: 10.1097/HJR.0b013e3283359c4e. Talk with your doctor and family members or friends about deciding to join a study. Pack QR, Squires RW, Lopez-Jimenez F, Lichtman SW, Rodriguez-Escudero JP, Zysek VN, Thomas RJ. Circ J. If Mr. James came to your clinic with only blood pressure data from the GXT, could you still write the exercise prescription ? Please remove one or more studies before adding more. 2016 Jan 5;67(1):1-12. doi: 10.1016/j.jacc.2015.10.044. Read our, ClinicalTrials.gov Identifier: NCT03925493, Interventional At the beginning of your cardiac rehabilitation program, we asked you to tell us which results you are hoping to reach. Keywords Cardiac rehabilitation, cardiovascular disease, guidelines, exercise therapy, exercise test, exercise Received 15 December 2015; accepted 11 June 2016 Introduction Cardiovascular disease (CVD) is a leading contributor to global mortality and morbidity. Epub 2012 Oct 10. and max METS obtained. Try to walk in flat areas for at least the first six weeks, avoiding hills and gradients where possible. Phase 1: Education Day The Education Day provides you with the tools needed to begin your Cardiac Rehabilitation journey. It is also important to monitor the patient's subjective symptoms - i.e. A lower score on the anxiety scale indicates less anxiety or fear. COVID-19 is an emerging, rapidly evolving situation. This is one of the main goals of Phase II and must be done in an orderly progressive fashion. 2002 Oct;66(10):930-6. Circulation. Exercise capacity and mortality among men referred for exercise testing. Studies a U.S. FDA-regulated Drug Product: Studies a U.S. FDA-regulated Device Product: Recruit 60 patients [ Time Frame: One year ], Retain patients for at least 12 exercise sessions of cardiac rehab [ Time Frame: within 3 months of recruitment ], Peak exercise capacity at the completion of cardiac rehabilitation [ Time Frame: Within 6 months of study enrollment ], Change in functional exercise capacity from baseline to end of cardiac rehab [ Time Frame: Within 6 months of study enrollment ], Adherence to Cardiac Rehabilitation (CR) [ Time Frame: Within 6 months of enrollment ], Change in Patient Exercise Confidence [ Time Frame: Within 6 months of enrollment ], The number of patients with at least one or more adverse events in CR [ Time Frame: Within 6 months of enrollment ]. Eur J Cardiovasc Prev Rehabil. doi: 10.1002/14651858.CD001800.pub2. Patients who plan to attend fewer than 12 sessions of CR, for reasons that might include need to return to work, high copays, transportation, lack of insurance, or lack of interest in the program. Cost J Cardiopulm Rehabil Prev. A higher score on the confidence survey, indicates a greater level of confidence. The percentage of patients that have an adverse clinical event that precludes or stops exercise during cardiac rehabilitation. The answer is yes. Some patients will be given a personal heart rate monitor to improve adherence. Epub 2013 Sep 20. Additionally, half of the patients undergoing a stress test will receive a personal heart rate monitor to help improve adherence to the exercise prescription and THRR. The modified Borg scale will be used by the patients to determine their RPE. Patients who plan to undergo a clinically indicated stress test in the next 3 months as this would potentially interfere with the exercise prescription in the control group. Methods: For this study, 11 new referrals to a phase 2 cardiac rehabilitation program voluntarily underwent a symptom-limited exercise test and a field test that consisted of self-paced over-the-ground walking for 10 minutes at levels corresponding to RPE 11-13 and RHR+20. 2011 Jul 6;(7):CD001800. Exercise Prescription C.6. The extra day is usually done at home away from the monitoring capabilities of the clinic. Relationship Between Exercise Workload During Cardiac Rehabilitation and Outcomes in Patients With Coronary Heart Disease. Eur J Prev Cardiol. Baduanjin exercise for patients with ischemic heart failure in phase-II cardiac rehabilitation (BEAR) trial is a single-center, parallel-design, prospective RCT, and will be conducted at Fuwai Hospital, Chinese Academy of Medical Sciences, China. Any other condition in which exercise training or exercise testing would be contraindicated such as severe uncontrolled hypertension, diabetes, arrhythmia, or severe valvular disease, as determined by the Medical Director of Cardiac Rehabilitation. Keteyian SJ, Leifer ES, Houston-Miller N, Kraus WE, Brawner CA, O'Connor CM, Whellan DJ, Cooper LS, Fleg JL, Kitzman DW, Cohen-Solal A, Blumenthal JA, Rendall DS, Piña IL; HF-ACTION Investigators. Phase II is a supervised and monitored out-patient program. Twelve of 20 cardiac arrests (60%) occurred during the exercise session, 6 (30%) occurred during the immediate recovery period, and 2 (10%) occurred 30 to 60 minutes after the exercise session. Today’s patients may not even get 12 hours before they’re out of bed, a far cry from Eisenhower’s 12 weeks of bedrest. Am J Cardiol. Cardiac Rehabilitation (CR) is an effective exercise-based lifestyle therapy for patients with cardiac disease. Fear and Anxiety will be measured using an anxiety questionnaire. If none of this data is available, the physician should be asked to perform a graded exercise test with this patient. Heran BS, Chen JM, Ebrahim S, Moxham T, Oldridge N, Rees K, Thompson DR, Taylor RS. The primary outcome is to determine feasibility, protocol fidelity, and effect sizes in preparation for a fully powered subsequent trial that will measure the impact of stress testing and a target heart rage range exercise prescription on exercise gain during CR. If that cannot be done, then you are going to have to The researchers will obtain the patients peak heart rate from this stress test. The tools that we use to monitor the patient's response to exercise are : blood pressure, heart rate, the Borg exertional sclae, the anginal (pain) scale, the dyspneic scale (SOB) and the time honored telemetric EKG unit. Mode - Mode must be determined by the patient's pathology. Cardiac Rehab Phase II is an outpatient program of exercise and education. ... Table 2. Second, the investigators want to understand what type of exercises should be recommend to patients. Heart rate monitors (HRM) will be given to half of the patients randomly assigned to exercise stress testing group. The investigators are using the heart rate monitors because cardiac rehab staff are not always able to adjust exercise intensity for all patients, and telemetry is not always used. Monitoring consists of measuring the patient's blood pressure, HR, EKG, heart sounds, and lungs sounds. assess the patient's ability to tolerate exercise in a very conservative manner. During both tests, gas exchange data were obtained via the Cosmed K4b and heart rate via the Polar monitor. Any elective hospitalization or revascularization procedure (such as PCI or CABG) that are planned to occur in the next 3 months. Programming Considerations for Including Patients With Heart Failure Into Phase 2 Cardiac Rehabilitation Robert Berry, MS, ACSM-RCEP Address for correspondence: Robert Berry, MS, Cardiovascular Rehabilitation, 759 Chestnut St., Springfield, MA 01199; (413) 794-7171; e-mail: robert.berry@baystatehealth.org . - fatigue, effort of difficulty of the exercise bout (Borg Scale), etc. Am Heart J. Patients with pacemakers, as the polar heart rate monitor interferes with pacing lines on the telemetry system. Let's plug in the data to see how best to use the GXT data. 2018 Jul;38(4):208-214. doi: 10.1097/HCR.0000000000000358. Review. Data access requests will be reviewed by an external independent review panel. IV. Again, the important exercise parameters are : Phase II (Outpatient) Cardiac Rehabilitation (CR) Phase II CR is described by the U.S. Public Health Service as consisting of “comprehensive, long term programs involving medical evaluation, prescribed exercise, cardiac risk factor modification, education, and counseling.” medications, and what do you do when you feel symptoms ? In chronic heart failure from left ventricular dysfunction, training intensities should be equal to 50–85% peak heart rate (40–80% peak V . It's usually provided by a team of specialists in various settings; these healthcare professionals work together to help you improve your functional mobility, decrease risk factors related to your cardiac injury, and help you and your family manage the psychosocial effects that may influence your recovery after a heart attack. Cardiac Rehabilitation (CR) is an effective exercise-based lifestyle therapy for patients with cardiac disease that reduces cardiovascular morbidity and mortality, increases quality of life, and is cost-effective. Fletcher GF, Balady GJ, Amsterdam EA, Chaitman B, Eckel R, Fleg J, Froelicher VF, Leon AS, Piña IL, Rodney R, Simons-Morton DA, Williams MA, Bazzarre T. Exercise standards for testing and training: a statement for healthcare professionals from the American Heart Association. The exercise test will determine the initial target heart rate range (THRR) and will also influence subsequent exercise progression. J Cardiopulm Rehabil Prev. There are two common methods of exercise prescription, an effort based exercise prescription and target heart rate based exercise prescription. Requestors will be required to sign a data access agreement. 2001 Sep 20;345(12):892-902. Review. Review. To learn more about this study, you or your doctor may contact the study research staff using the contacts provided below. Epub 2005 Jan 19. Patients who need cardiac strengthening are referred by their physician, and ... our program, a health history and the results of an exercise stress test are needed to develop a personal exercise prescription. Patient education continues in Phase II as an extension of what was discussed in Phase I. The data that we will use is for a fictitious patient, Mr. James : Using The Heart Rate Data & Max METs Achieved. However, it is unclear which methods maximize exercise gains in CR. The cost-effectiveness of cardiac rehabilitation in 1995 dollars was $4900 per year life saved Compares favorably with other preventive therapies used in the post-myocardial infarction setting, such as pharmacologic lipid lowering, beta- adrenergic blocking medications, and thrombolysis Exercise rehabilitation studies from the United To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor. Training Techniques in Cardiac Rehabilitation Human Kinetics : Leeds • Squires, R.W (1998) : Exercise Prescription for the High – Risk Cardiac Patient • American College of Sport Medicine (ACSM) (1991) Guidelines for Exercise testing and Prescription (4th edn), Philadelphia; Lea and Febiger Mayo Clin Proc. Increase the patient's exercise work capacity. Suaya JA, Shepard DS, Normand SL, Ades PA, Prottas J, Stason WB. First, the investigators want to know if an exercise test should be done near the beginning of cardiac rehabilitation. MBA. Aerobic exercises for heart cardiac may rehab include: Walking can burn more calories than cycling or swimming, making it a great exercise for cardiac rehab patients who are looking to lose weight in order to decrease their risk of a repeat heart attack. C.5. Usually, the mode is bicycle, treadmill, a rowing machine, a sitting bike (Nu-Step) or an upper extremity bicycle (Monarch). Cardiology. Cochrane Database Syst Rev. There are three main goals of this study. Point: High quality or just average - the need for exercise testing before cardiac rehabilitation. Ades PA. Cardiac rehabilitation and secondary prevention of coronary heart disease. 2005;103(3):113-7. The Outpatient program called Cardiac Rehabilitation Phase II is designed to meet the needs of the patient once the patient has left the hospital. Teach the patient to monitor himself/herself during an exercise period. Cool-down periods also allow the body time to rid itself of circulating catecholamines. J Am Coll Cardiol. MET Values ANNEX 6. am well below any heart rate that would have produced symptoms during the GXT. This program is one part, or phase, of your cardiac rehab. The goal is to lower your risk of future heart problems. 2017 Jul;37(4):257-261. doi: 10.1097/HCR.0000000000000210. Patients who join the Baystate CR program after having completed more than 3 sessions of CR at a different CR program. Trial oversight. Obtaining an accurate peak heart rate will allow for the calculation of a target heart rate range (THRR) using the Karvonen formula. may have reason to feel good about their future. Patients who are referred with an eligible diagnosis to CR. (Max HR - rest HR) x (.4 -.8 + (Max METs/100)) + rest HR, Training Exercise Heart Rate (TEHR) = (180 - 80 ) x (.5 + 8/100) + 80, Using The Blood Pressure Data & Max METs Achieved. Exercise prescription based on the intensity of the ventilatory threshold, measured during maximal cardiopulmonary exercise test, is also often used for CHD patients, especially those receiving beta-blockers, and corresponds to 50% to 60% V ˙ O 2 p e a k (initial moderate-zone intensity). Review. Cardiac rehabilitation (CR) is a comprehensive model of care for the secondary prevention and control of CVD, including blood pressure (BP) assessment and delivery of interventions for hypertension management. Heart rate is used for exercise intensity assessment and prescription based on its linear relationship with both V. o 2 and work load during incremental exercise in cardiac disease . Goto Y, Sumida H, Ueshima K, Adachi H, Nohara R, Itoh H. Safety and implementation of exercise testing and training after coronary stenting in patients with acute myocardial infarction. You will receive information and tools to make lifestyle changes, such as: Not smoking. Definition Of Phase II Cardiac Rehabilitation. Mode is also determined by the level of monitoring the Phase II program uses. The Exercise Component. Based upon the Karvonen formula, the THRR will be between 60-80% of the patient's heart rate reserve. Any other condition that would prohibit adherence to study protocols, such as active drug use, or untreated mental health conditions that would interfere with following instructions. Let's see how this can be done. Relation between volume of exercise and clinical outcomes in patients with heart failure. Relieve fear and anxiety. Scheinowitz M, Harpaz D. Safety of cardiac rehabilitation in a medically supervised, community-based program. Phase II helps you develop a regular heart-strengthening exercise routine. The program includes: A personalized evaluation and exercise prescription; A comprehensive focus on exercise, education and lifestyle change; Telemetry-monitored exercise sessions; resting HR, maximal exercise HR, resting BP, maximal exercise BP, and maximal METs obtained. Featuring Min Naruki-van Velzen, MSc, Cardiac Rehabilitation Specialist, Athletic Therapist Duration: 1 minute, 26 seconds Phase II, phase III cardiac rehab is generally done as an outpatient, meaning you'll come into a hospital to participate in structured exercise classes one to three times per week and you'll be supervised by a multi-disciplinary team of healthcare professionals. As you know, heart disease is a condition that requires long-term care. Cardiac Rehabilitation Phase II Our 12-week program is tailored to each participant's specific needs. Example of Detailed protocol for Cardiac Rehabilitation: Phase 1-4. 2012 Nov 6;60(19):1899-905. doi: 10.1016/j.jacc.2012.08.958. In phase II of cardiac rehabilitation, aerobic endurance training on a cycle ergometer is recommended as standard procedure. Duration - Duration can usually start at 15 minutes of steady state exercise preceded by 5-10 minutes of warm up and followed by 5-10 minutes of cool down. 2016 Apr 15;117(8):1236-41. doi: 10.1016/j.amjcard.2016.01.018. 2016;1:CD001800. The Karvonen formula can be calculated as follows ((peak heart rate - resting heart rate) X % intensity (0.6 or 0.8) + resting heart rate)). Patients with myocardial infarction, percutaneous coronary intervention, or bypass surgery. Counterpoint: All patients do no need an exercise test before starting cardiac rehabilitation. Cardiac Rehab, also known as Phase 2 Rehab, is a Nurse monitored, low-pace exercise program in which heart care patients wear wireless heart monitoring devices with constant nurse supervision. The advantages of this training form are that it is non-weight bearing and enables the exercise load to be precisely dosed, independent of the patient’s body weight. subjective symptoms - i.e. It begins after discharge from the hospital. N Engl J Med. Patients will then adjust their exercise intensity to match this target heart rate range for the duration of their time in cardiac rehabilitation. Exercise-based cardiac rehabilitation for coronary heart disease. moderate intensity), per current program standards. The purpose of this research study is to identify the best way to exercise in cardiac rehabilitation. It is important to remember to allow the patient to warm up and cool down before steady state exercise is performed. permits the heart to gradually decelerate, it gives the body a chance to dispose of any lactic acid that may have accumulated during exercise, and it allows the body to dissipate heat. It is well understood that an inadequate cool-down period increases the chances Each question has a scale from 1 to 5 indicting very little fear to very fearful. Circulation. Data will be available within 12 months of study completion. Journal of Clinical Exercise Physiology. Exercise prescription • 10 min callisthenic warm‐up • 20‐60 min conditioning : continuous or intermittent Initially, the intensity of an exercise program in a Phase II cardiac rehab is calculated from the data that the physician gathered from the patient's graded exercise stress test at the end of Phase I cardiac rehab. Write a safe, monitored environment for exercise that dysrhythmias may appear in II...: you have reached the maximum number of saved studies ( 100 ) personal decision own intensity! Keteyian SJ, Kerrigan DJ, Ehrman JK, brawner CA, Abdul-Nour K, N! 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Tools needed to begin your cardiac rehabilitation and secondary outcome Measures will be completed in Baystate Medical.... Is also important to monitor himself/herself during an exercise period progression will be to in. Exercise-Based lifestyle therapy for patients with cardiac disease please remove one or more phase 2 cardiac rehab exercise prescription before adding more tests gas... ( Borg scale ) phase 2 cardiac rehab exercise prescription etc 15 ):1653-62 has left the hospital mode exercise... Ii program uses to meet the needs of the patient 's blood pressure, HR EKG. Well below any heart rate data & Max METs Achieved Squires RW, Lopez-Jimenez,.