Individualized exercise prescription and cardiac rehabilitation following a spontaneous coronary artery dissection or aortic dissection

Abstract

Importance Prescribed aerobic-based exercise training is a low risk fundamental component of cardiac rehabilitation (CR). Secondary prevention therapeutic strategies following a spontaneous coronary artery dissection (SCAD) or aortic dissection (AD) should include CR. Current exercise guidance for post-dissection patients recommends fundamental training components including target heart rate zones are not warranted. Omitting fundamental elements from exercise prescriptions risks safety and makes it challenging for both clinicians and patients to understand and implement recommendations in real-world practice. We review the principles of exercise prescription for CR, focusing on translating guidelines and evidence from well-studied high-risk CR populations to support the recommendation that exercise testing and individualized exercise prescription are important for patients following a dissection. Discussion When patients self-perceive exercise intensity there is a tendency to underestimate intensities within metabolic domains that should be strictly avoided during routine exercise training following a dissection. However, exercise testing associated with CR enrollment has gained support and not been linked to adverse events in optimally medicated post-dissection patients. Graded heart rate and blood pressure responses recorded throughout exercise testing provide key information for developing an exercise prescription. An exercise prescription that is reflective of medical history, medications, and cardiorespiratory fitness optimizes patient safety and yields improvements in blood pressure control and cardiorespiratory fitness, among other benefits. Conclusion This clinical practice and education article demonstrates how to develop and manage a CR exercise prescription for post-acute dissection patients that can be safe and effective for maintaining blood pressure control and improving cardiorespiratory fitness pre-post CR.

Exercise prescription for the prevention and treatment of arterial hypertension: targeting blood pressure is not necessarily the goal

“…In certain high-risk populations where blood pressure control is critical for reasons beyond ASCVD risk reduction (eg, spontaneous coronary dissection and aortic dissection),8 10 11 it is even more important that comprehensive discussions on exercise prescriptions for blood pressure management underscore potential safety concerns relating to specific exercise modalities. For instance, non-aerobic-based exercise and muscle-strengthening activities that may be generalised as highly effective for lowering blood pressure may portend serious health risks for select individuals, including a higher chance of death 2 8…”

“…This risk factor milieu has resulted in the need for multidisciplinary interventions that directly account for the multifactorial nature of ASCVD risk and its prognostic correlates. The inclusion of aerobic-based exercise prescription as a core lifestyle therapy for both the primary and secondary prevention of ASCVD is not only effective for benefitting blood pressure control but also known to directly elicit favourable effects on CRF to yield clinically relevant reductions in cardiovascular-related morbidity and mortality risk over the short, middle and long term 1–8. Evidence for an alternative exercise training paradigm specifically aimed at lowering blood pressure has been equivocal and lacks clear clinical relevance beyond evaluating the change in blood pressure measurement itself 2.…”

Exercise-Based Cardiac Rehabilitation: Analyzing Clinical Effectiveness

“…Taking into account age, baseline physical fitness, state of health and specific rehabilitation goals is essential to achieve optimal results. Personalised training also ensures that patients are more 9 motivated to participate in rehabilitation programmes on a regular basis, which translates into better health outcomes [30].…”

Sex and Gender Differences in Cardiovascular Disease: A Review of Spontaneous Coronary Artery Dissection

“…6 During cardio-aerobic exercise, a heart rate up to 75% of the patient's calculated maximum heart rate has been previously shown to be safe. 51 Additionally, all patients should be referred to cardiac rehabilitation, which may be SCAD-specific, on discharge. 6 Cardiac rehabilitation along with other aerobic physical activity can improve exercise capacity and mental health, and reduce chest pain.…”