Ryan with a history of hypertension and pre-diabetes presents to Cardiac Rehab.
A 54-year-old male, Ryan with a history of hypertension and pre-diabetes presents to Cardiac
Rehab. He had open heart surgery 17 days ago and received double-bypass to the medial left
anterior descending artery. Prior to surgery he noticed shortness of breath while lifting heavy
weights at the gym. His usual routine of 4 days a week of strength training mixed with a little HIIT
training was becoming challenging. The last day he was at the gym he experienced severe chest and
excessive diaphoresis pain during exercise. An ambulance was called, and he was transported to the
hospital. Upon arrival to the hospital, Ryan’s EKG showed significant ST elevation in the precordial
leads V1-V4 and his troponin I level was 27.8 ng/mL and blood pressure was 180/96. Ryan was
transported to the cath lab where the surgeon explored his vessels. A 100% blockage was found in
his LAD, and an 80% blockage was found in the RCA, with residual disease in the left circumflex.
The decision was made for Ryan to undergo emergent open-heart surgery to bypass the blockages
in the vessels. After surgery, Ryan recovered well, with one episode of atrial fibrillation post-op that
was corrected with a bolus of amiodarone. His ejection fraction was preserved at 55-60%. See lab
values and medications below:
a. Medications:
i. Aspirin 81 mg
ii. Metoprolol 12.5 mg twice per day
iii. Lisinopril 10 mg once per day
iv. Atorvastatin 10 mg once per day
v. Amiodarone 100 mg for 30 days
vi. Clopidogrel 75 mg/day
vii. Metformin 500 mg twice per day
b. Labs:
i. LDL Cholesterol: 95 mg/dL
ii. HDL Cholesterol: 52 mg/dL
iii. Triglycerides: 165 mg/dL
iv. Hemoglobin A1c: 6.3
1) Upon arrival to Cardiac Rehab, Ryan is eager to get started with exercise. He sees the
weights at the back of the room and the elliptical in the corner and asks if he can give them a
try. He has been walking at home for 15 minutes 2x a day, reports 4/10 sternal incision
discomfort, has not been sleeping well, and gets quickly fatigued after helping with chores
around the house. Explain to Ryan what the plan for exercise will be. Consider safe exercise
progression as well as his current report of fatigue and recent surgery. Create a short
exercise plan for his first day at Cardiac Rehab. Assume the equipment available includes:
treadmills, recumbent and upright bikes, upper body cycle, elliptical and free weights. (5
pts)
2) During the session, Ryan asks a lot of questions regarding his surgery and medications.
Looking at his history, what kind of education would you want to provide to Ryan to help in
his recovery? (2 pts)
3) What guidelines would you follow to return Ryan to strength training and what do you
recommend he should do at home for exercise to supplement the 2 days/week in Cardiac
Rehab? (4 pts)
4) What is Ryan’s risk stratification for patients with CVD according to AACVPR and why?
Assume his performance on his 6-minute walk test during his intake was 2.8 METs (use for
functional capacity assessment) (2 pts)
5) Ryan expresses concerns that his resting heart rate is lower than it used to be before
surgery. He has an apple watch and would monitor his resting and exercise heart rate
closely prior to surgery. Now he notices that he can’t get near where he used to at the gym.
Explain to Ryan why this might be occurring and what the benefits are. (3 pts)
6) Before returning to work, Ryan needs to complete a stress test. What should be monitored
during
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