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Question 5#

Whilst you are working in your local cardiology ward, one of the nursing staff approaches you and asks, in general, which patients are very high risk and will need specialist assessment prior to referral for the exercise component of your local cardiac rehabilitation (CR) programme. 

Which one of the following statements is correct?

A) Patients with cyanotic congenital heart disease or those who have received an implantable cardiac defibrillator should never be referred for cardiac rehabilitation
B) Patients with decompensated heart failure should be encouraged to exercise if it is part of a cardiac rehabilitation programme
C) Patients with severe valvular stenoses can take part in exercise programmes whilst awaiting valve replacement surgery
D) Patients who undergo exercise testing and develop angina at <5 METs are safe to participate in community-based exercise programmes
E) Patients with angina or breathlessness occurring at a low level of exercise (e.g. inability to complete the first 4 minutes of the shuttle walking test) should participate in exercise sessions based in a safe environment with access to a defibrillator and staff trained in advanced life support

Correct Answer is E

Comment:

CR should be offered to all patients following an acute MI and those undergoing a CABG or angioplasty. CR should also be offered to patients with chronic heart failure and unstable angina with disabling symptoms. Increasingly there is also evidence to support the benefit for other patient groups including those with congenital heart disease, post cardiac transplantation, and those with implantable cardiac defibrillators. High-risk patients should participate in exercise sessions based in a safe environment with access to a defibrillator and staff trained in advanced life support. High-risk patients include those with:

  1. a myocardial infarction complicated by heart failure, cardiogenic shock, and/or complex ventricular arrhythmias
  2. angina or breathlessness occurring at a low level of exercise (inability to complete the first 4 minutes of the shuttle walking test)
  3. ST segment depression ≥ mm on resting ECG

exercise testing with marked ST depression ≥2 mm or angina at <5 METs (3 minutes of a Bruce protocol).

Patients unsuitable for exercise training include those with:

  1. decompensated heart failure
  2. severe valvular stenosis or regurgitation
  3. refractory arrhythmias
  4. other clinical conditions which worsen with exertion.