Skip Navigation LinksHome > February 2010 - Volume 4 - Issue 1 > You've Graduated From Cardiac Rehab. Now What?
HEART Insight:
doi: 10.1097/01.HEARTI.0000368505.48160.16
Features: Fit & Happy

You've Graduated From Cardiac Rehab. Now What?

Prentice, Kathleen

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How To Avoid The “Meet Market” And Find A Serious Gym That's Right For You

I was getting ready to graduate from cardiac rehabilitation after a heart attack two years ago, and wasn't sure what my next step would be. A nurse told me that walking my 13 year old golden retriever, my pre-heart attack exercise, was fine for fun and toning but wouldn't suffice as a cardiovascular workout — so Plan A went out the window.

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“When people finish a cardiac rehab program after angioplasty, bypass or heart attack, they need to realize that cardiac rehab is not something like a diploma with long-lasting benefits. If you go home and do nothing, you will lose fitness in a couple of weeks,” says Barry Franklin, Ph.D., Director of Beaumont Hospital's Cardiac Rehabilitation and Exercise Laboratories Program in Royal Oak, MI.

While some patients opt to continue going to their cardiac rehab program on an unmonitored, private pay basis and others join short- term, specialized transitional programs — options that can be limited by availability and cost — many of us are faced with gym shopping.

There are over 30,000 private and public gyms in the U.S. that run the gamut from certified medical fitness centers to state of the art complexes complete with indoor tracks and pools to franchise cookie cutter centers. The first gym I joined was a small, independent fitness center in my neighborhood that was recommended by the cardiac rehab staff. I did take a look around the facility before handing over my credit card, but missed asking some essential questions. I should have found out about staff qualifications and emergency procedures, but the reality is that I didn't know enough to ask.

I recently found myself gym shopping again when the fitness center closed. This time I started with the Yellow Pages and was armed with a checklist. One place I visited sounded great over the phone — certified staff, intake questionnaire, one week free trial — but when I got there, I saw lots of muscular people in spandex working out on strength machines, and found that the few cardio machines available were relegated to a small, windowless room down the hall. I passed.

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In choosing a post-rehab gym, three essentials to look for are the right equipment, a well-trained staff and emergency preparedness, advises Cary Wing, Ed.D., Executive Director of the Medical Fitness Association, based in Richmond, VA.

There should be a variety of cardio machines, such as treadmills, ellipticals, recumbent bikes and rowers. Also look for strength-training equipment — free weights and weight machines that work different parts of the body. The equipment should look clean and well maintained.

Fitness personnel who work directly with clients need at least a bachelor's degree in exercise science and certification, which should be from organizations like the American College of Sports Medicine (ACSM), National Strength and Conditioning Association (NSCA) and Medical Fitness Association (MFA), says Murray Low, Ed.D., Program Director of Cardiac Rehab at Stamford Hospital, Burke Rehabilitation Hospital in White Plains, NY.

William Kraus, M.D., Professor of Medicine and Director of Cardiac Rehab at Duke University recommends looking for gym staff who are certified as ACSM fitness specialists. Before you visit a gym, check its Website for staff bios, which will list credentials. You can also check the Websites of certifying organizations, which often list approved trainers and facilities. Your cardiac rehab program could also be a resource of information on specific organizations and credentials for trainers.

Also, specialized classes — say weight management, yoga or Pilates — should be taught by personnel who have appropriate credentials and certifications, notes Wing. As a rule, nutrition guidance should be provided by a registered dietician (RD).

Yoga instructors should know, and be able to recommend, disciplines that are not too strenuous or extreme for someone who has risk factors for cardiovascular disease or is recovering from a heart attack. For instance, Bikram — which is both demanding and requires an overheated room — is not a good idea. Attend a session on a trial basis before signing up for a class and let the instructor know about your cardiac issues, recommends Deb Riggs, M.Ed., General Manager of Cincinnati-based TriHealth Fitness & Health Pavilion. Check for teacher certifications for gentle yoga with Yoga Alliance (

For a stamp of approval on Pilates programs check with the Pilates Method Alliance (

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It's also a good idea to ask about the staff's experience with your medical diagnosis — as well as accommodations for multiple medical issues (what doctors call “comorbidities”), such as diabetes or arthritic knees and hips. Your new exercise routine should mirror your cardiac rehab activities, taking into account all of your medical needs, Kraus says. For example, arthritic clients may get their aerobic workout in a pool instead of on a treadmill.

“A lot of kids graduate with degrees and have experience with a healthy population so you want to ask ‘Have you worked with older adults, with diabetics, people with high blood pressure, and for how many years?,’” suggests Riggs.

Perhaps most important, the staff needs to be trained and certified in cardiopulmonary resuscitation (CPR). That means trainers as well as those who work the front desk. An automated external defibrillator (AED) should also be on hand, and every staff member should know how to operate it. Defibrillators are now required in many states, but compliance can be spotty.

The American Heart Association and ACSM recommend that gyms have written emergency policies and procedures that are reviewed and practiced regularly. Don't be embarrassed about asking specific questions about the policies and if all staff participate in emergency drills.

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When you complete your cardiac rehab sessions, your cardiologist and the rehab staff should provide an exercise prescription outlining intensity, duration and frequency guidelines tailored to your diagnosis and current condition, the machines you've used for your rehab workout and a list of the medications you are taking. If you don't get this information, ask for it before you start checking out gyms.

It's important that you “know your heart rate range, how to monitor it and how to recognize when you need to seek help,” says Kraus. “The goal of cardiac rehab is to make you independent, to exercise on your own and monitor yourself.”

With this crucial information in hand, you should be able to use any of the equipment, Wing says.

“Just because you had a heart attack you need not say ‘no’ to Pilates or spinning. In terms of your cardio workout, it doesn't matter as long as you exercise within your (heart rate) guidelines.”

In addition to reviewing your exercise prescription, the gym staff should also give you a health risk assessment that ranges from a simple health history to an in-depth questionnaire that includes family history. At a minimum, the gym will use the baseline Physical Activity Readiness Questionnaire (PAR-Q), says Curt Meyer, FACHE, of Health Integration Partners. The PAR-Q is a brief, seven question tool to screen for cardiovascular, bone and joint problems. It was developed by the British Columbia Ministry of Health.

When I joined my first post-cardiac rehab gym, I filled out a medical history form and made an appointment with a gym manger for an introductory training session. A red flag went up when he led me to the wall of weight machines and I asked him about starting with a warm-up session, reminding him that I just finished cardiac rehab after a heart attack. He casually replied, “Sure, whatever you want.”

One afternoon, noticing the guy on the next treadmill huffing and puffing, I started wondering about emergency preparedness and tracked down the manager to ask about CPR and defibrillator training. I was told they were “working on it.” Another red flag. I wish I had asked before paying a year's membership in advance.

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The best time to start looking for a place to work out is before you finish cardiac rehab. If you wait, even a few months, your exercise prescription will no longer fit your condition. Down the road, your cardiologist may also readjust your training plan if your medications change, says Kraus.

Transitioning from cardiac rehab to a gym means moving from group to solo exercise. It also means that you are responsible for following your exercise prescription, and monitoring your heart rate.

Always warm up and always cool down, Kraus emphasizes. Warming up is to prevent muscular skeletal injuries, but cooling down protects your cardiovascular system by maintaining blood flow as you gradually decrease your activity.

Franklin adds: “Be aware of warning signs and symptoms when you're exercising and stop if you feel lightheaded or dizzy during your workout. Stop if you feel pain or pressure anywhere from the belly button up that comes and goes. Be aware of heart rhythm irregularities, irregular pulse or rapid pulse.”

A sports heart monitor is useful in alerting you when you've reached your target range. I wear one with the strap under my T-shirt and a wristband that looks like a watch. Some people find them distracting, but I like knowing that I'm working to capacity, but not overdoing it.

Kraus also recommends having your nitroglycerin with you when you exercise and wearing a medical alert tag tucked under your workout clothes. “The health tag should be specific to your condition — for example, if you have a pacemaker or an electronic device like an implantable defibrillator.” Of course, you should also include that information on your initial intake assessment or PAR-Q.

Another adjustment I had to make when I left rehab was losing my built-in support group of fellow heart patients. But there is a simple solution: “Go at a time when people your age are there so you can relate and make friends,” suggests Riggs.

But on the plus side, I like the flexibility of working my gym time into my day rather than building my day around a scheduled rehab class. I also like feeling that I am just another middle-aged woman on the elliptical, rather than a heart attack survivor. HI

© 2010 American Heart Association, Inc.