Mrs. Case Study-HF

Mrs. Case Study-HF is a 54-year-old woman weighing 67.7 kg (149 lb) with a height of 163 cm (64 in). She has a history of anteroseptal myocardial infarction (MI) treated with a percutaneous transluminal coronary angioplasty (PTCA) and stent placement. Risk factors for the subject included a family history of heart disease as both her mother and father died of MIs. She works as a United Parcel Service package handler at a large midwestern airport, and her primary goal for an exercise program is to facilitate her return to work. She is married and attributes high stress to both her job and marriage. She had been a smoker for most of her life; however, on the night of her MI, she quit cold turkey and has been smoke-free ever since. Her medications at discharge from her MI included metoprolol (a β-blocker), 25 mg; lisinopril (angiotensin-converting enzyme [ACE] inhibitor), 10 mg; baby aspirin, 81 mg; and simvastatin (anti-lipidemic), 10 mg. Her blood pressure (BP) levels have been below 120/80 mm Hg since medical management. She then performed 24 weeks of exercise: 12 weeks in cardiac rehabilitation and 12 weeks at her neighborhood fitness facility.

She was asymptomatic for 4 years and at that time began to notice episodes of chest discomfort and dyspnea during walking and cutting the grass. Chest pains were random, with pain present during an activity on one occasion but not the next. She scheduled an appointment with her cardiologist and informed him of her symptoms. He suggested she either have a treadmill test or undergo a cardiac catheterization to evaluate possible progression of disease. She opted for the cardiac catheterization procedure. Results of the catheterization procedure showed akinesis of anterolateral, anteroapical, and inferoapical walls, with anterobasal hypokinesis and an ejection fraction of 30%. Coronary artery analysis demonstrated 10% ostial left main coronary artery disease and 60%–70% in-stent restenosis of the mid-left anterior descending artery. Because of these findings, she was admitted to the hospital for a myocardial viability study that was negative. Because of the negative myocardial viability study, medical management was continued and her dosage of lisinopril was increased to 20 mg. Since then, she has not complained of any chest discomfort. Two years later, her physician again increased her lisinopril to 40 mg daily to achieve maximum benefit with ACE-inhibitor therapy. She continues to do well with medical management. Recently, a graded exercise test was performed to evaluate the patient’s appropriateness for a supervised exercise program (Table 12.1).

During the graded exercise test, the patient stopped at the end of the second minute of stage IV due to fatigue and mild dyspnea. Muscle strength was measured by the one repetition maximum (1-RM) method according to accepted standards for leg press, horizontal squat, shoulder press, leg extension, latissimus dorsi pull-down, and biceps curl exercises.

Mrs. Case Study-HF performed the following exercise prescription/progression for 12 weeks at cardiac rehabilitation and then for an additional 12 weeks at her fitness club in her neighborhood. Her exercise training program consisted of cardiovascular training 3 days a week and resistance training 2 days a week for 24 weeks (12 wk in cardiac rehabilitation and 12 wk at her fitness club). She trained 15 minutes on both the treadmill and Schwinn Airdyne bike at 60%–80% of her heart rate reserve (HRR) following a 5-minute warm-up at 50% of HRR. Exercise intensity was increased 0.5 metabolic equivalents (METs) per week consistent with patient tolerance. During the first 12 weeks of training at cardiac rehabilitation, heart rate (HR) and rhythm were monitored continuously using a Nihon-Kohden WEP-9430 Cardiac Telemetry System. The following exercises were used for resistance training: leg press, shoulder press, leg extension, lateral pull-down, cable biceps curl, and horizontal squat starting at 50% of her 1-RM and progressing to 80%. During weeks 1 and 2, she worked at 50% and 60% of her 1-RM, respectively. During week 3, she worked at 70% of her 1-RM. For weeks 4–12, she trained at 80% of her 1-RM as outlined in Table 12.2.

Table 12.3 presents the exercise program recommended for Mrs. Case Study-HF that transitioned her from cardiac rehabilitation to her fitness center and was accomplished with the help of a personal trainer with experience in resistance training for individuals with HF. At week 13, dumbbell lunges, dumbbell shoulder press, and dumbbell curl were substituted for the leg extension, the machine shoulder press, and cable biceps curl, respectively. The addition of the dynamic free weight program at week 13 is beneficial for several reasons:

  First, the neuromuscular system will likely be optimally challenged by activities that affect activities of daily living (ADL) so crucial to the quality of life for individuals with HF.

  Second, the free weight program is reproducible outside of the clinic and thus provides the subjects with resistance training techniques that can be performed independently after completion of supervised exercise.

  Lastly, the dynamic free weight program mimics the balance and strength requirements of activities such as walking and climbing stairs, facilitating the transfer of muscular strength gains to activities of daily life. This aggressive resistance training program was designed to facilitate return to work and was accomplished safely and effectively.