A 39-year-old male police officer had been playing outdoor soccer and felt unusually dyspneic while running during the game. A few days later, he presented to a cardiologist with class II typical angina pectoris. Following a stress echocardiogram showing multiple left ventricular wall motion abnormalities, coronary angiography revealed multivessel coronary artery disease. The patient ultimately underwent coronary artery bypass grafting and was referred to cardiac rehabilitation (CR) at our institution 7 days later.
At initial presentation, his total cholesterol was 178; high-density lipoprotein cholesterol, 53; low-density lipoprotein cholesterol, 116; and triglycerides, 43 mg/dL. He had never smoked. His father had a fatal myocardial infarction at age 51. The patient's body mass index was 23 kg/m2, and his waist circumference, 35 inches. Medications at CR enrollment included aspirin, clopidogrel, lisinopril, metoprolol, ezetimibe, rosuvastatin, nitroglycerin spray, naproxen, and hydrocodone.
After being referred to our CR program, the patient attended the first session, an orientation that allows an exercise physiologist to evaluate each patient's medical history and current physical condition. When asked about the goals he wanted to reach during CR, the patient said that he wanted to return not only to his work as a police officer but also to active participation in outdoor soccer and ice hockey. His score of 1480 on the Athletic Identity Measurement Scale–Plus confirmed that participating in sports was important to him; a score of 1467 to 2200 indicates a strong athletic identity (1
Our CR program has helped athletes (3
) and manual labor workers return to their desired activities, but this patient's request posed a unique challenge. Instead of wanting to resume a physically demanding job or
a strenuous sport, he wanted to resume a physically demanding job and
two strenuous sports that required different combinations of muscular strength, agility, and cardiovascular endurance. Providing the necessary training would have been problematic within the limitations of conventional CR. Using our facility's occupation- and sports-oriented equipment, we designed and implemented a comprehensive high-intensity exercise regimen that was symptom limited and specific for the patient's needs.
Exercise intensity is commonly quantified as metabolic equivalents (METs), a value that is often used as a goal for exercise training (5
); vigorous physical activity is classified as >6 METs (6
). By referring to tables that list the MET levels for a wide range of occupational and recreational tasks, the exercise physiologist developed an exercise prescription that matched the patient's athletic and work goals and greatly exceeded the conventional CR graduation goal of 6 to 8 METs (7