CLINICAL PRACTICE GUIDELINES Using guidelines for exercise in cardiac patients Shirley M. Moore, RN, PhD, FAAN (Professor and Associate Dean for Research), Yaewon Seo, RN (Doctoral Student), & Laura Rosenthal, RN, BSN, CCRN (Acute Care Nurse Practitioner Student) Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio Column Editor: Mary Jo Goolsby, EdD, MSN, NP-C, FAANP Correspondence: Shirley M. Moore, RN, PhD, FAAN, Frances Payne Bolton School of Nursing, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH 44106-4904. Tel: 216-368-5978; Fax: 216-368-3542; E-mail: smm8@case.edu doi:10.1111/j.1745-7599.2006.00176.x Introduction Despite treatment recommendations prior to the 1960s that cardiac patients refrain from exercise or activities requiring exertion, guidelines for exercise as a treatment for chronic illness were first developed for the cardiac population. Today, exercise guidelines exist for both the prevention and the treatment of cardiovascular disease and many of its risk factors. Guidelines for exercise refer to both physical activity and exercise. Physical activity is defined as any bodily movement produced by skeletal muscles that result in energy expenditure. Exercise is a subset of physical activity and involves planned, struc- tured, repetitive, and purposeful activity seeking to improve or maintain physical fitness (Thompson et al., 2003). Exercise guidelines typically describe a common set of features, including the rationale for exercise in that population, features of the exercise prescription (type, frequency, amount, intensity of exercise), and safety con- siderations. Published guidelines often include the strength of the evidence on which the guidelines were developed as well. Nurse practitioners in the primary care arena are treating a considerable number of cardiac patients and need a readily available summary of the exercise guidelines specific to particular cardiac subpopu- lations. This report summarizes the current guidelines for exercise in patients with cardiovascular disease, includ- ing indications and recommendations for exercise, adher- ence to exercise recommendations, interventions to improve exercise adherence, and safety considerations (see Table 1). Exercise and prevention of coronary artery disease A clear causal relationship has been found between physical activity and the development of coronary artery disease (Lee, Paffenbarger, & Hennekens, 1997; Powell, Thompson, Caspersen, & Kendrick, 1987), with increasing rates of activity associated with decreased incidence of developing coronary artery disease (Blair & Jackson, 2001). Regular exercise also reduces the risk of cardiovas- cular disease and its complications in patients with type 2 diabetes (Stewart, 2002); improves blood pressure control (Fagard, 2001), weight control (Wing & Hill, 2001), and lipid levels (Leon et al., 2000; Stefanick et al., 1998); and retards the progression and promotes the reversal of ath- erosclerosis (Ornish et al., 1990). In response to this evidence, the American Heart Association has published the guideline, ‘‘Exercise and Physical Activity in the Pre- vention and Treatment of Atherosclerotic Cardiovascular Disease’’ (Thompson et al., 2003). The guideline recom- mends that individuals should engage in 30 min or more of moderate-level activity on most, preferably all, days of the week to reduce the risk of the development of coronary artery disease. Moderate-level activities are those per- formed at a relative intensity of 40%–60% of VO 2 max (comparable to an absolute intensity of 4–6 metabolic equivalents [METS]) (Taylor et al., 2004). All individuals beginning a moderate-intensity exercise program do not require an exercise stress test prior to starting the exercise regimen. Because the usefulness and efficacy of exercise stress testing before initiation of vigorous exercise Journal of the American Academy of Nurse Practitioners 18 (2006) 559–565 ª 2006 The Author(s) Journal compilation ª 2006 American Academy of Nurse Practitioners 559