Progression of exercise intensity and heart rate

This section provides the rationale for using the recommended target heart rates summarised in Table 3.1 as a range of values. The sedentary patient is thus prescribed exercise starting at the low end of the recommended heart rate range. Over the course of the first three to six months of exercise the patient should progress the intensity to elicit heart rates in the middle of the range. In the longer term, if the patient continues to exercise regularly, they could progress to the higher end of the target heart rate zone. All of this assumes that these targets are 10 beats-min-1 below the clinically significant heart rate as described in the section on the safe heart rate. The need for later progressions in exercise intensity provides an important rationale for having qualified exercise advisors available to patients in phase IV CR. This type of exercise leader is available to discuss with the patient appropriate changes to their exercise regime in the longer term.

Exercise leaders should be aware that target heart rates can be adjusted in the future. The heart rate intensity can be used to increase the training effect. For some patients the duration may be used as the variable. It is not incorrect to assume that the progression of intensity will automatically occur if the patient exercises to the same given heart rate; the work rate for a given heart rate will increase as fitness improves. However, this assumption only reflects one of the two main training adaptations to regular aerobic exercise: an increase in VO2max. The other physiological adaptation, as shown clearly in three studies involving cardiac patients, is that with training, individuals can sustain exercise at a higher proportion (percentage) of their VO2max (Sullivan, et al., 1989; Meyer, et al., 1990; Goodman, et al., 1999). In these three studies, this phenomenon was closely allied to the amount of lactic acid produced at a given VO2, a phenomenon which has been known for many years (Edwards, et al., 1939; Ekblom, et al., 1968). The importance of this is that improvements in aerobic power (VO2max) and endurance capacity (the intensity at the lactate threshold) in cardiac patients, compared to healthy individuals, is mostly due to the adaptations of skeletal muscle and not of the myocardium (Hiatt, 1991). Because the key agent in increasing VO2max in cardiac patients is skeletal muscle, it is important to ensure that this tissue is challenged as effectively as possible. This is even more apparent in the training adaptations of the older or heart failure patient (Sullivan, et al., 1989;Ades, et al., 1996).

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