National Strength and Conditioning Association
Volume 29, Number 1, pages 1823
Keywords: cardiac rehabilitation; rehab; resistance training;
strength; self-efficacy; confidence
Resistance Training in Outpatient
Cardiac Rehabilitation
Jeremy L. Spencer, MS, CSCS
Hopedale Wellness Center, Hopedale, Illinois
summary
Many phase II cardiac rehabilitation
patients suffer from general muscu-
loskeletal weakness and atrophy
caused by inactivity associated with
recovery, sedentary lifestyle, or old
age. As a result, patients often lack
the capacity or the confidence to
perform everyday living tasks, and
so their psychological and emotion-
al well-being frequently suffers. The
addition of resistance training to
usual-care, cardiovascular-only pro-
grams offers solutions to these
problems, problems that are not ef-
fectively addressed by usual-care
programs alone.
he primary concern of phase II
T cardiac rehabilitation is the re-
conditioning of the heart muscle
18
after a cardiac event such as a coronary
artery bypass graft (CABG), myocardial
infarction (MI), pacemaker, or angio-
plasty. Additionally, rehab programs en-
deavor to aid in the improvement of
coronary artery disease (CAD) risk fac-
tor profile, improve functional capacity,
increase productivity and indepen-
dence, alleviate or lessen activity-in-
duced symptoms, and assist in the re-
sumption of daily occupational and
recreational activities (13).
Many phase II cardiac rehabilitation pa-
tients suffer from general musculoskele-
tal weakness and atrophy caused by in-
activity associated with recovery,
sedentary lifestyle, or old age. As a re-
sult, patients often lack the capacity or
the confidence to perform everyday liv-
ing tasks, and so their psychological and
emotional well-being frequently suffers.
The addition of resistance training (RT)
to usual-care, cardiovascular-only pro-
grams offers solutions to these problems
that are not effectively addressed by
usual-care programs alone.
When compared with cardiovascular ex-
ercise, RT tends to produce fewer is-
chemic responses and arrhythmias; has
no apparent adverse effects on the left
ventricle; produces higher diastolic
February 2007 Strength and Conditioning Journal
blood pressure, which may facilitate
coronary perfusion; and lowers heart
rates (7, 14, 15). In addition, resistance
training programs improve balance, en-
durance, coordination, range of motion
(ROM), flexibility, hypertension, hy-
perlipidemia, glucose tolerance, insulin
sensitivity, body composition, the pain
associated with peripheral artery dis-
ease, and physical capacity over a wide
range of household physical activities
(1, 8, 10, 11, 14, 15). These differences
and benefits, along with numerous oth-
ers, have been well documented in the
literature.
Haennel et al. (9) found that a 12-week
RT program lowered heart rate, systolic
blood pressure, and rate of perceived ex-
ertion (RPE) during 3 activities of daily
living, whereas no such changes were
found in a control group participating
in a walk-jog-cycle program. RT, in par-
ticular circuit weight training (CWT),
also improves various measures of aero-
bic capacity among cardiac rehab pa-
tients, with total time and perceived ef-
fort being the most affected (9, 15).
Stewart et al. (13, 14) performed 2 stud-
ies in which usual-care programs were
compared with programs that included
CWT. Both studies showed that the
CWT groups experienced no sustained
arrhythmias or ischemic episodes and
increased V O2max, maximal cycle time,
and leg and arm strength. The usual care
groups saw less improvement, with no
increase in V O2max and arm strength in
1 study and significantly less improve-
ment in all measures in the second study
(13, 14, 16). Moreover, the benefits of
RT for the cardiac patient extend be-
yond strength-related activities and
physical measures to improvements in
patients psychological well-being and
self-efficacy (1, 16).
As stated earlier, one of the main goals of
phase II rehab is to develop a greater
sense of self-confidence to perform vo-
cational and recreational activities
where strength is required (3). Ades et
al. (1) found that activities that involve
flexibility and coordination such as
pouring milk, putting on a jacket, floor
scrubbing, vacuuming, and laundry
loading and unloading were made easier
by resistance training. The same study
noted that offering positive reinforce-
ment regarding the significance of the
patients strength gains on everyday
functioning may go a long way in en-
couraging, understandably apprehen-
sive patients to utilize their increased
strength to perform a greater range of
physical activities in the home (1).
Many everyday activities that require
some measure of strength resemble resis-
tance exercises, or, if necessary, exercises
can be modified to resemble everyday
tasks such as shoveling snow or carrying
luggage. It is important to counsel pa-
tients on the pertinence and practical
application of their strength training.
Correlating the overhead press with
putting a box of cereal in a high cup-
board, for example, will help patients
understand the why of RT and translate
into increased confidence and ease of
living. It is also important to make the
goals of RT clear to each patient: (a) im-
provements in absolute strength, (b) in-
creased cardiovascular endurance, and
(c) a greater sense of self-confidence to
perform vocational and recreational ac-
tivities where strength is required (16).
February 2007 Strength and Conditioning Journal
Patients should also be encouraged to set
some of their own goals. These personal
goals should be discussed with the pa-
tient and changes made in exercise selec-
tion and progression, if necessary, in
order to help facilitate progress toward
their personal goals.
The benefits of RT reinforce the impor-
tance of a carefully examined and proper-
ly implemented RT program. In concur-
rence with the traditional cardiovascular
exercises, RT is a necessary addition to the
traditional aerobic conditioning pro-
grams for low-to-moderate risk cardiac
patients. The addition of an RT compo-
nent offers patients the most effective,
well-rounded, and comprehensive reha-
bilitation experience (16). However, im-
plementation should only be undertaken
after thorough screening of each patient
for contraindications and appropriate-
ness. Screenings should be conducted by a
registered nurse and an exercise specialist.
Screening
In screening patients for appropriate-
ness, strength and conditioning profes-
sionals should be mindful of contraindi-
cations to RT for cardiac patients. These
contraindications include the following
items:
Unstable angina
Resting systolic blood pressure >200
mm Hg, or resting diastolic blood
pressure >100
Uncontrolled hypertension (>160/
100 mm Hg)
Abnormal hemodynamic response or
significant ischemic electrocardio-
gram (EKG) changes with graded ex-
ercise test
Poor left ventricular function (ejec-
tion fraction <30%)
Uncontrolled arrhythmias
Severe aortic stenosis or coronary
artery disease
Aerobic capacity <6 metabolic equi-
valent (METs)
Clinically limiting orthopedic or
cardiovascular symptomology
Acute systemic illness or fever
Uncontrolled atrial or ventricular
dysrhythmias
Uncontrolled sinus tachycardia (>120
bpm)
Uncontrolled congestive heart failure
Third-degree atrio-ventricular (A-V)
heart block
Active pericarditis or myocarditis
Resting ST displacement (>3 mm)
Uncontrolled diabetes
Orthopedic problems that would
prohibit exercise
Hypertrophic cardiomyopathy
The presence of any of these contraindi-
cations would generally disqualify a pa-
tient from RT participation (3, 4, 7).
We also consider the following RT in-
clusion criteria and application guide-
lines from The American College of
Sports Medicine (ACSM) and the Amer-
ican Association of Cardiovascular and
Pulmonary Rehabilitation (AACVPR),
respectively.
ACSM Inclusion Criteria
46 weeks post-MI or CABG
12 weeks following percutaneous
transluminal coronary angiography
or other revascularization procedure,
except CABG, without MI
Following 46 weeks in a supervised
cardiovascular endurance program
or completion of phase II
Resting diastolic blood pressure
below 105 mm Hg
Peak exercise capacity of 5 METs
Not compromised by coronary heart
failure, unstable symptoms, or ar-
rhythmias (3)
AACVPR Application Guidelines
Limit resistance training to patients
who are asymptomatic or only mild-
ly symptomatic.
Initiate resistance training after a min-
imum of 12 weeks of aerobic training.
To prevent soreness and minimize
the risk of injury, the initial load
should allow 1215 repetitions com-
fortably. If a 1 repetition maximum
(RM) test is used, this load would be
19
 approximately 3040% 1RM for the
upper body and 5060% for hips
and legs. Low-risk-stratified, well-
trained patients may progress to
higher relative loads depending on
program goals.
Use single limb (instead of double
limb) in patients who have an exag-
gerated rise in blood pressure (BP)
and/or rate pressure product (sys-
tolic BP heart rate) during resis-
tance training.
One set of 68 exercises (multijoint)
23 days per week
RPE (620 RPE scale) should not ex-
ceed fairly light (RPE 14) to some-
what hard (RPE 15) during resistance
training. Patients should not strain.
Avoid breath holding. Breathe nor-
mally at all times.
Increase resistance by 2.55 lb when
1215 repetitions can be comfort-
ably accomplished.
Exercise muscles generally in a large-
muscle to small-muscle order, 23
times per week. Include exercises for
both upper and lower extremities.
Avoid excessive static contraction
and hand gripping (e.g., free weight
bars, dumbbells, and machine han-
dles) if possible; high level static
contraction may evoke excessive
blood pressure response.
Discontinue exercise in the event of
any contraindicative warning signs or
symptoms, especially dizziness, ab-
normal heart rhythm, unusual short-
ness of breath, and/or chest pain (2).
Only after it has been determined that
the patient is free from any contraindi-
cations and the inclusion criteria have
been considered does he/she begin the
RT component of the phase II program.
The Program
General Overview
The RT component of our rehabilita-
tion program generally begins during
the second month of the 3-month phase
II program. This is equivalent to the
13th session. As stated earlier, however,
implementation depends on the condi-
20
Table 1
Daily Warm-Up
Exercise Sets Reps
Slow walking (2 laps on 100-m track) 1
Neck movements 1 10
Shoulder shrugs 1 10
Shoulder stretch 1 30 seconds each
Side stretch 1 30 seconds each
Standing hip abduction 1 10
Standing knee extensions 1 10
Ankle rotations 1 10
Wrist and hand movements 1 10
Standing calf stretch 1 30 seconds each
Seated hamstring stretch 1 30 seconds each
Table 2
Introductory Band Training (Month 2)
Exercise Sets Reps
Band rows 13 12
Band punch twists 13 12
Band overhead press 13 12
Bench sits (squats) 13 12
Band curls 13 12
Band tricep pulldowns 13 12
Band front raises 13 12
tion of the individual patient and the terns and avoidance of breath holding.
severity of their disease. Occasionally The Valsalva maneuver can greatly de-
patients will be started earlier, later, or crease blood volume returning to the
not at all depending on the presence of heart, thereby decreasing what is often
any of the above-mentioned contraindi- already greatly lowered cardiac output
cations. among rehab patients. Exercise choices
during this phase serve 2 main purposes.
Typically, initial RT includes the use of The first is to gently introduce individu-
light free weights, resistance bands, and als to the ideas and concepts of RT and
bodyweight exercises. Resistance is kept to help them grow accustomed to the
low, and emphasis is placed on correct movements and sensations associated
body position, correct exercise tech- with this type of exercise. The second is
nique, proper speed and range of move- to equip the patients with the tools,
ment of each exercise, correct breath pat- knowledge, and confidence to continue
February 2007 Strength and Conditioning Journal

Table 3
Introductory D-Bell Training (Month 3)
Exercise
D-bell rows
Band punch twists
D-bell overhead press
Bench sits with D-bells (squats)
D-bell curls
Tricep kickbacks
D-bell front raise
D-bell carry
D-bell farmer carry
D-bell = dumbbell.
to exercise at home or on their own
should they choose not to continue as
members of our facility. At the beginning
of the third, and final, month of phase II,
Nautilus machines are introduced.
At the end of the phase II program, pa-
tients are given the option to continue
in the phase III program, free of charge,
for 1 month. The vast majority of our
patients choose to continue to exercise.
During phase III, cardiovascular exer-
cise is continued, minus EKG monitor-
ing except when deemed appropriate,
and resistance training progresses to in-
clude the full circuit of Nautilus ma-
chines in addition to the established
band and body weight program. At the
end of the free month patients then have
the option of becoming members of our
facility, at which time they will enter
phase III. Patients continue in the phase
III program for 6 months or until they
cancel their membership. These pa-
tient/members are no longer EKG mon-
itored on a regular basis, but RPE, blood
pressure, SpO2, etc., are monitored and
recorded. The goal of this phase of the
program is to help the patient become
self-sufficient in their exercise. A nurse,
exercise specialist, and a fitness atten-
dant are available during phase III class-
February 2007 Strength and Conditioning Journal
Sets Reps
13 12
13 12
13 12
13 12
13 12
13 12
13 12
13 12
13 12
es. Upon completion of the phase III
program patients are reevaluated and
tested. After evaluation and testing pa-
tients are either deemed ready to move
on to full unrestricted membership or
placed in a medically supervised exercise
program.
Phase II Program Design
Warm-Up
Each exercise session is started with a
light warm-up emphasizing range of
motion and gentle stretching (Table 1).
The warm-up generally lasts 57 min-
utes. Each exercise is performed for 1 set
with little or no rest between sets. All
stretches are held for 30 seconds. Range
of motion exercises are performed for
1012 repetitions and are performed bi-
laterally as well. The first 3 minutes of
the cardiovascular session are also in-
cluded in the warm-up.
Frequency
Cardiac rehab patients should practice
RT a minimum of 2 days per week, with
3 days being optimal. Patients should
never do RT on consecutive days. Phase
II programs usually occur 3 days per
week. Our program has patients doing
both resistance and cardiovascular exer-
cise on all 3 days. The warm-up and aer-
obic portion of each session comprises
the first 3540 minutes of each hour-
long phase II session. The RT and cool-
down portion of each session takes the
balance of the time.
Mode and Volume
Beginning at week 5, initial resistance
exercises consist of light resistance band
and body weight training (Table 2).
Basic dumbbell exercises are also gradu-
ally introduced over the course of weeks
6 through 8 (Table 3). Each exercise is
performed for 1 set of 10 repetitions
with <30 seconds rest between exercises
and gradually increased to 2 sets of 12
repetitions.
At week 9, 3 to 5 multijoint Nautilus
machines are introduced (Table 4). Rest
periods for the Nautilus circuit are also
relatively short (no more than 1 minute
or the time it takes to make seat and re-
sistance adjustments), between both in-
dividual exercises and sets of exercises,
to maximize muscular endurance and
aerobic training benefits. Patients are in-
structed to perform at least 2 sets and no
more than 3 sets of 10 repetitions for
each of the exercises. If time allows pa-
tients are encouraged to do a selection of
single joint, band, and dumbbell exer-
cises as well, usually dumbbell curls,
bench sits, or body weight squats, tri-
ceps kickbacks, and bent-arm lateral
raise.
Intensity
We use the acclimatization method to
determine starting resistance levels (2,
7). This saves time, which is essential
with a small staff. 1RM testing has been
shown to be safe, however, among low-
risk cardiac patients, if this method is
preferred or if time and staffing allows
(5). In using the acclimatization
method, we start with very light
weights and monitor patient responses
for 1215 reps or until the RPE is no
greater than 13 (somewhat hard) on the
Borg scale. If the patient is well below
the target heart rate pressure product, is
asymptomatic, and tolerates the weight
21

Table 4
Introductory Phase III Nautilus Training
Exercise
Leg press*
Chest press*
Lat pulldown*
Lower back*
Abdominal*
Leg curl*
Leg extension
Hip abduction
Hip adduction
Deltoid fly
Overhead press
Tricep dips
Bicep curls
* Initial multijoint exercises.The remaining exercises are added as appropriate.
well, we will generally increase the re-
sistance to the next level, usually a 5-lb
increase on the Nautilus machines,
until an RPE no greater than 1314 is
reached for the prescribed number of
repetitions, 1215 (7). These increases
may occur from session to session or on
subsequent sets during the same session
depending on the situation. When
using bands, the lightest resistance is
selected, and changes are made accord-
ingly.
Patient intensity and condition are care-
fully monitored by the exercise specialist
during training. All patients are also
asked to monitor RPE and symptoms
following each exercise or set of exercis-
es. The session is terminated if any of the
following ACSM criteria are experi-
enced:
Fatigue
Failure of monitoring equipment
Lightheadedness, confusion, ataxia,
22
Patients should not strain and are in-
structed to exhale during exertion, con-
trolling the lift, performing the exercise
Sets Reps through a full range of motion, exercis-
ing large muscle groups before smaller
13 12
muscles, and to avoid isometric contrac-
13 12 tions such as the sustained gripping of
the machine handles, which can lead to
13 12 excessive blood pressure response (7,
13 12 15).
13 12 Conclusion
While the main goal of phase II cardiac
13 12
rehab programs is the reconditioning
13 12 of the heart muscle, patients self-effi-
cacy and ability to perform everyday
13 12 living tasks are important in determin-
13 12 ing their psychological outlooks. Most
patients enter rehab programs a least a
13 12 little apprehensively. Their recent ex-
13 12
perience, often a very near brush with
death and their own mortality, fre-
13 12 quently leaves them doubtful of their
abilities to recover and to live vibrant
13 12
lives in the future. While the quantita-
tive improvements and benefits of RT
are apparent, with improvements in
absolute strength, increased cardiovas-
pallor, cyanosis, dyspnea, nausea, or cular endurance, improved balance,
any peripheral circulatory insuffi- coordination, ROM, flexibility, hyper-
ciency tension, hyperlipidemia, glucose toler-
Onset of angina with exercise ance, insulin sensitivity, body compo-
Symptomatic supraventricular tachy- sition, the pain associated with
cardia peripheral artery disease, as well as
ST displacement (3 mm) horizontal physical capacity over a wide range of
or downsloping from rest household physical activities (1, 8, 10,
Ventricular tachycardia (3 or more 11, 1416), it is more difficult, but
consecutive pulmonary ventricular just as vital, to gauge RTs impact on
contractions [PVCs]) the psyche. Anecdotally, RT seems to
Exercise-induced left bundle branch empower our patients to a much
block greater extent than cardiovascular exer-
Onset of second and/or third-degree cise. Possibly because for many of them
AV block RT is wholly new. It may offer them an
R-wave or T-wave PVCs opportunity not only to feel stronger
Frequent multifocal PVCs (30% of and more confident physically, but also
complexes) the opportunity to master new skills.
Exercise hypotension (20 mm Hg Many of our patients are truly sur-
drop in systolic BP during exercise) prised at the difference resistance
Excessive blood pressure rise (systolic training makes in how they feel both
220 or diastolic 110 mm Hg) mentally and physically. Considering
Inappropriate brachycardia (drop in these facts, even if the physiological
heart rate greater than 10 bpm) with benefits were not as significant as they
increase or no change in workload (3). are, it would be difficult to overstate
February 2007 Strength and Conditioning Journal
the importance of RT in the cardiac re-
habilitation process.
References
1. ADES, A.A., P.D. SAVAGE, M.E. CRESS,
M. B ROCHU , N.M. L EE , AND E.T.
P OEHLMAN . Resistance training on
physical performance in disabled older
female cardiac patients. Med. Sci.
Sports Exerc. 35:12651270. 2003.
2. AMERICAN ASSOCIATION OF CARDIO-
VASCULAR AND PULMONARY REHABILI-
TATION. Guidelines for Cardiac Reha-
bilitation and Secondary Prevention
Programs (4th ed.). Champaign, IL:
Human Kinetics, 2004.
3. AMERICAN COLLEGE OF SPORTS MED-
ICINE . ACSMs Resource Manual for
Guidelines for Exercise Testing and Pre-
scription. (5th ed.). Philadelphia: Lip-
pincott Williams & Wilkins, 2006.
4. AMERICAN COLLEGE OF SPORTS MED-
ICINE POSITION STAND. Exercise for
patients with coronary artery disease.
Med. Sci. Sports Exerc. 26:iv. 1994.
5. B ARNARD K.L., K.J. A DAMS , A.M.
S WANK , E.M. D ENNY , AND D.M.
DENNY. Injuries and muscle soreness
during one repetition maximum as-
sessment in a cardiac rehabilitation
population. J. Cardiopulm. Rehabil.
19:5258. 1999.
6. D E G ROOT , D.W., T.J. Q UINN , R.
KERTZER, N.B. VROMAN, AND W.B.
OLNEY. Circuit weight training in car-
diac patients: Determining optimal
workloads for safety and energy expen-
diture. J. Cardiopulm. Rehabil. 18:
145152. 1998.
7. DROUGHT, J.H. Resistance exercise in
cardiac rehabilitation. Strength Cond. J.
17(2):5664. 1995.
8. EBBEN, W.P., AND D.H. LEIGH. The ef-
fects of resistance training on cardio-
vascular patients. Streng. Cond. J.
28(2):5458. 2006.
9. H AENNEL , R.G., K. S VEDAHL , N.
HABIB, V. GEBHART, AND R. HUDEC.
Effects of strength training on cardio-
vascular response to activities of daily
living (adl) in post-myocardial infarc-
tion (mi) patients. Med. Sci. Sports
Exerc. 26(Suppl.):185. 1994.
February 2007 Strength and Conditioning Journal
10. M C C ARTNEY , N. Role of resistance
training in heart disease. Med. Sci.
Sports Exerc. 30:S396S402. 1998.
11. M C G UIGAN , M.R.M., AND R.
BRONKS. Resistance training for pa-
tients with peripheral arterial disease:
A model of exercises rehabilitation.
Strength Cond. J. 23(3):2632. 2001.
12. MEYER K., R. STEINER, P. LASTAYO, K.
LIPPUNER, Y. ALLENMANN, F. EBERELI,
J. SCHMID, H. SANER, AND H. HOP-
PELER. Eccentric exercise in coronary
patients: Central hemodynamic and
metabolic responses. Med. Sci. Sports
Exerc. 35:10761082. 2003.
13. S TEWART , K.J., L.D. M C F ARLAND ,
AND J.J. WEINOFFER. Weight training
soon after myocardial infarction.
Med. Sci. Sports Exerc. 26(Suppl.):32.
1994.
14. STEWART, K.J., L.D. MCFARLAND, J.J.
W EINOFFER , E. C OTTRELL , C.S.
BROWN, AND E.P. SHAPIRO. Safety and
efficacy of weight training soon after
acute myocardial infarction. J. Car-
diopulm. Rehabil. 18:3744. 1998.
15. VERRILL, D.E., AND P.M. RIBISIL. Re-
sistive exercise training in cardiac reha-
bilitation. Sports Med. 21:347383.
1996.
16. VESCOVI, J., AND B. FERNHALL. Car-
diac rehabilitation and resistance train-
ing: Are they compatible? J. Strength
Cond. Res. 14:350358. 2000.
Jeremy Spencer is the Fitness Coordina-
tor and an exercise specialist at the Hope-
dale Wellness Center in Hopedale, Illinois.
23