|Home | About | Journals | Submit | Contact Us | Français|
A 39-year-old male police officer with coronary artery disease enrolled in our cardiac rehabilitation (CR) program after coronary artery bypass grafting. He wanted to return not only to his job but also to playing ice hockey and outdoor soccer, and his responses to a self-assessment scale confirmed that he identified strongly as an athlete. On the basis of this unique profile, the CR staff designed an occupation- and sport-specific exercise program that was symptom limited and enabled the patient to train safely, but earlier and at a higher intensity than is typically allowed in conventional CR programs. The exercises were selected to replicate the various combinations of muscular strength, agility, and cardiovascular endurance required by the patient's police work and two competitive team sports. He completed the high-intensity training with no clinically significant adverse symptoms.
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, 2).
Our CR program has helped athletes (3, 4) 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).
During all 18 exercise training sessions, the patient's blood pressure was measured before and after exercise, and he performed warm-up and cool-down routines. His heart rate and rhythm were continuously monitored by telemetry, and peak blood pressure measurements were taken while he performed various training exercises. A physician was present in the rehabilitation room at all times. The first two sessions consisted of supervised endurance training (treadmill walking and recumbent biking), during which the nurse on duty confirmed that the patient's vital signs were responding appropriately to exercise and that he had no adverse physiological symptoms that would require cessation of training.
The remaining 16 sessions consisted of gradually increasing high-intensity exercise that was specifically designed to simulate the tasks and MET requirements of the patient's police work and two strenuous sports, as summarized below:
The 75-minute sessions were designed so that the patient moved from one exercise to another, ensuring that he trained each day to meet the physical demands of all three goal activities.
Peak heart rates during conventional CR training are commonly restricted, either by a fixed value (typically 150 beats/min ) or by a calculated limit such as the percent maximal heart rate, defined as 64% to 94% of age-predicted heart rate (10). In part because the patient in this case was taking a beta-blocking agent, which slows the heart rate, we used symptom-limited training, meaning that no heart rate limit was used to restrict exercise intensity. Using this approach allowed our staff to train him at higher intensities than would normally be used in conventional CR.
During high-intensity exercise training, the patient's blood pressure and chronotropic responses (means, 112/62 to 147/58 mm Hg and 79 to 141 beats/min, respectively) were within safe ranges and likely blunted by beta-blocking medications. Peak blood pressure measurements were well below 240/110 mm Hg, the recommended maximum (9). In addition to monitoring the patient's heart rate and blood pressure, the CR staff watched for unusual arrhythmias, ST depression, angina, dizziness, pain, dyspnea, and perceived exertion. The patient had no adverse events that required the discontinuation of any exercise session.
The 39-year-old police officer–athlete began high-intensity training 15 days after cardiac surgery and after only two sessions of supervised endurance training—far sooner than the 4 weeks of supervised endurance training recommended by the American College of Sports Medicine (5). With only 16 sessions available for this patient's high-intensity training, it was essential for our staff to have a well-planned and carefully executed exercise prescription to adequately prepare him for a safe return to work and sports (Figure).
One purpose of CR is to return patients to a normal and productive life after a cardiac event, and rebuilding their self-confidence is an integral part of that process. After coronary artery bypass grafting, patients may fear the intensity of physical training that would be required for their return to strenuous activities. One of this patient's most important goals was to regain confidence that a fellow officer could depend on him in perilous situations. By testing his reaction to heavy exertion in a safe and monitored CR setting, he demonstrated that he could perform capably and reliably on the job. After training at high physical intensities in our CR program, he not only returned to work as a police officer but also resumed playing ice hockey 6 weeks after surgery. He resumed playing outdoor soccer during the next scheduled season.
Although many cardiac patients reach their goals by participating in conventional CR exercise training, others may want to return to more physically demanding sports and jobs. The patient in this report was the first police officer–athlete to undergo combined occupation- and sport-specific training in our CR program; indeed, we believe his case is the first of its kind to be described. He performed high-intensity exercises that are not usually attempted by CR patients, particularly after sternotomy. More than a year after graduating from the program, he is still on the job and playing competitive team sports with no negative cardiovascular symptoms.
Grant support was provided by the Harry S. Moss Heart Trust and the Baylor Health Care System Foundation, Dallas, Texas, through the Cardiovascular Research Review Committee and in cooperation with the Baylor Heart and Vascular Institute. The authors thank the Cardiovascular Research Review Committee for their continued support of cardiovascular rehabilitation research projects. They also thank the patient for graciously allowing his story and photographs to be published. Beverly Peters, MA, ELS, a freelance medical editor, assisted with manuscript development and preparation.