Heart, Lung and Circulation (2023) -, -–-
1443-9506/23/$36.00
https://doi.org/10.1016/j.hlc.2023.06.854
POSITION STATEMENT
A Clinical Guide for Assessment and
Prescription of Exercise and
A CSAN
Christian Verdicchio,
Matthew Hollings
Alex Brown, PhD , David Colquhoun, MBBS, PhD ,
exercise
rehabilitation
use of
of aerobic ex-
and safety
C15 Exercise
for Heart Rhythm
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Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, SA, Australia; Email: christian.verdicchio@sydney.edu.au; Twitter: @c_verdicchio
1
Co-?rst authors
C211 2023 The Author(s). Published by Elsevier B.V. on behalf of Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac
Society of Australia and New Zealand (CSANZ). This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
Julie Redfern, PhD
a
a
Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
b
Centre for Heart Rhythm Disorders, University of Adelaide, SAHMRI and Royal Adelaide Hospital, Adelaide, SA, Australia
c
Physiotherapy, Faculty of Health, University of Canberra, Canberra, ACT, Australia
d
Health Research Institute, University of Canberra, Canberra, ACT, Australia
e
Allied Health Department, Fiona Stanley Hospital, Perth, WA, Australia
f
Curtin School of Allied Health, Curtin University, Perth, WA, Australia
g
School of Population and Global Health, University of Western Australia, Perth, WA, Australia
h
Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
i
Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work,
Queensland University of Technology, Brisbane, Qld, Australia
j
Telethon Kids Institute, Australian National University, Canberra, ACT, Australia
k
Faculty of Medicine, University of Queensland, Brisbane, Qld, Australia
l
Faculty of Medicine, Wesley Medical Centre, Brisbane, Qld, Australia
m
Baker Heart and Diabetes Institute, Melbourne, Vic, Australia
n
Baker Department of Cardiometabolic Health, University of Melbourne, Melbourne, Vic, Australia
o
UHasselt, REVAL/BIOMED (Rehabilitation Research Centre), Hasselt University, Hasselt, Belgium
p
Department of Exercise Sciences, University of Auckland, Auckland, New Zealand
Received 19 June 2023; accepted 27 June 2023; online published-ahead-of-print xxx
Patients with cardiovascular disease bene?t from cardiac rehabilitation, which includes structured
and physical activity as core components. This position statement provides pragmatic, evidence-based
guidance for the assessment and prescription of exercise and physical activity for cardiac
clinicians, recognising the latest international guidelines, scienti?c evidence and the increasing
technology and virtual delivery methods. The patient-centred assessment and prescription
ercise, resistance exercise and physical activity have been addressed, including progression
considerations.
Keywords Cardiac rehabilitation C15 Secondary prevention C15 Coronary disease C15 Cardiovascular disease
assessment C15 Exercise prescription C15 Physical activity C15 Position statement
Corresponding author at: Dr Christian Verdicchio, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia; Centre
Erin Howden, PhD
m,n
, Dominique Hansen, PhD
o
, Stacey Reading, PhD
p
,
Robyn Gallagher,
Please cite this article
Activity in Cardiac
10.1016/j.hlc.2023.06.854
Z Position Statement
PhD
a,b,1,
, Nicole Freene, PhD
c,d,1
,
, PhD
a,1
, Andrew Maiorana, PhD
e,f
, Tom Briffa, PhD
g
,
PhD
a
, Jeroen M. Hendriks, PhD
b,h
, Bridget Abell, PhD
i
,
j k,l
Activity in Cardiac Rehabilitation.
in press as: Verdicchio C, et al. A Clinical Guide
Rehabilitation. A CSANZ Position Statement.
Physical
for Assessment and Prescription of Exercise and Physical
Heart, Lung and Circulation (2023), https://doi.org/
assess the patient’s aerobic exercise capacity. Prior to per-
2 C. Verdicchio et al.
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Introduction
Cardiovascular disease (CVD) is the leading cause of death
and disease burden globally [1]. Improvements in diagnosis,
treatment and long-term management have improved survi-
vorship and reduced hospitalisations following a cardiac
event,howevertheyhavealsogreatlyincreasedthenumberof
patients requiring ongoing and lifelong CVD risk manage-
ment [2,3]. To reduce the risk of future events, international
guidelinesrecommendalleligiblepatientshaveaccessto,and
participate in, secondary prevention programs, including
cardiac rehabilitation [4,5]. Cardiac rehabilitation is a
comprehensive, multidisciplinary intervention consisting of
patient assessment and individualised risk pro?le manage-
ment, dietary advice, exercise prescription and physical ac-
tivity counselling and psychosocial support [6]. The National
HeartFoundationofAustralia,theAustralianCardiovascular
Health and Rehabilitation Association (ACRA) and the Na-
tional Heart Foundation of New Zealand all promote cardiac
rehabilitation and have online resources that can provide re-
ferrers with a list of local services available for their patients.
Exercise-based cardiac rehabilitation has demonstrated effec-
tiveness for reducing hospitalisations and myocardial infarc-
tion rates, whilst improving risk pro?le, exercise capacity and
quality of life in patients with coronary disease [7,8]. Exercise
programmingalsobene?tspatientswithothercardiovascular
conditions such as heart failure (both reduced and preserved
ejection fraction) [9,10], atrial ?brillation [11], peripheral
vascular disease [12], congenital heart disease [13], valve dis-
ease [14], pulmonary hypertention [15] and, more recently,
with cardio-oncology patients [16].
A graduated program of structured exercise and physical
activity is a core component of comprehensive cardiac reha-
bilitation [17]. Recent studies have described new exercise
trainingtechniques,whichhaveimprovedourunderstanding
of the physiological adaptations from exercise training across
diverse patient groups. Furthermore, recent data have also
provided a greater understanding of technology and virtual
delivery methods for the prescription of exercise and physical
activity within cardiac rehabilitation programs. A patient-
centred approach is important, and communication with pa-
tients should be non-judgemental and respectful. Shared de-
cision making, where patients and their carers are actively
involved in the care process, results in personalised in-
terventions that are more likely to improve engagement,
treatment adherence, and clinical outcomes [18]. Concomi-
tantly, health professionals should consider evidence, guide-
lines and behaviour change theories, techniques, and tools
when collaborating with patients, identifying their individual
exercise and physical activity needs, values and preferences.
Realistic short- and medium-term goal setting may be
considered,andfollow-upshouldbediscussedandsupported
by the entire multidisciplinary team as they are central to the
patient’s rehabilitation journey [18].
The objective of this position statement is to provide
pragmatic, evidence-based guidance for the assessment and
prescription of exercise and physical activity by all clinicians
Please cite this article in press as: Verdicchio C, et al. A Clinical Guide
Activity in Cardiac Rehabilitation. A CSANZ Position Statement.
10.1016/j.hlc.2023.06.854
forming any exercise assessment, it is imperative that clini-
cians consider all relevant contraindications (Table 1). The
gold-standard assessment for aerobic exercise capacity is a
cardiopulmonary exercise test (CPET) conducted on either a
treadmill or cycle ergometer with gas analysis. However, this
test is limited to predominantly tertiary centres in Australia
and New Zealand due to the cost and specialised equipment
and staff required to conduct it. Several methods for
assessing aerobic exercise capacity and functional exercise
capacity, and the pros and cons of each are summarised in
Table 2.
Prescribing and Progressing Aerobic
Exercise
Figure 1 summarises the recommended clinician work?ow in
working within cardiac rehabilitation (e.g., exercise physiol-
ogists, nurses, physiotherapists) in the Australian and New
Zealand context. Speci?cally, the aim is to summarise the
assessment and prescription recommendations for aerobic
exercise, resistance exercise and physical activity for all pa-
tients referred for secondary prevention of their recent car-
diac event or a new diagnosis. To do this, a multidisciplinary
writing group was convened comprising of experts from
relevant disciplines, with regional, gender and cultural rep-
resentation to ensure diversity. A consensus process was
then followed to draft, review, and re?ne the document. The
position paper was then submitted to the Cardiac Society of
Australia and New Zealand, ACRA, Exercise and Sports
Science Australia, and the Australian Physiotherapy Asso-
ciation for endorsement.
Aerobic Exercise
Aerobic exercise is de?ned as any activity that uses large
muscle groups that can be maintained continuously and is
rhythmic in nature [19]. Common forms of aerobic exercise
include walking, jogging, cycling, rowing and swimming.
The bene?ts of aerobic exercise training within cardiac
rehabilitation are well established [7,8]. Cardiometabolic
bene?ts include (but are not limited to) improved insulin
sensitivity and glycaemic control, reduction in in?ammatory
markers, reduced visceral fat, improved vascular function
and blood pressure control, improved lipid metabolism,
improved skeletal muscle structure and function and modest
improvements in left ventricular function [10,20,21].
Assessment
The ACRA cardiac rehabilitation core components state that
all patients should receive “an individualised initial assess-
ment that includes physical, psychological and social pa-
rameters” [17]. This assessment enables the development and
implementation of an individualised exercise program based
on the aerobic exercise or functional capacity of the patient.
An aerobic exercise assessment should be conducted to
relation to assessment, prescription and progression of
for Assessment and Prescription of Exercise and Physical
Heart, Lung and Circulation (2023), https://doi.org/
and
Relative
2 kg
Concurren
Decrease
NYHA
Complex ventricular arrhythmia at rest or appearing with
exertion
Supine
Moderate
Blood
case
Sternal
separate
Exercise in Cardiac Rehabilitation 3
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Table 1 Absolute and relative contraindications to exercise
Absolute Contraindications
Progressive worsening of exercise tolerance or dyspnoea at
rest or on exertion
over previous 3–5 days (uncompensated heart failure)
Unstable angina
Blood glucose ,4.0mmol/L or .15.0mmol/L with
symptoms of weakness/tiredness, or with ketosis
Acute systemic illness or fever
Recent embolism (,4 weeks)
Thrombophlebitis
Active pericarditis or myocarditis
Severe symptomatic aortic stenosis
Regurgitant valvular heart disease requiring surgery
Previously undiagnosed atrial ?brillation
Sternal Instability Scale grade 3 (completely separated)
Resting heart rate .120 bpm
aerobic exercise training. Informed by a comprehensive
clinical history and exercise assessment, the fundamental
principles of exercise prescription should be applied: Fre-
quency, Intensity, Time, Type, Volume and Progression
(FITT-VP) [22]. Frequency (F) considers how often the patient
completes the exercise. Intensity (I) is the level of effort the
patient should be exercising at based on assessment of their
exercise capacity. Absolute intensity refers to the energy
required to perform an activity (e.g., caloric expenditure,
absolute oxygen uptake, metabolic equivalent of task).
Whereas relative intensity refers to the energy cost of the
activity relative to the individual’s maximal capacity (e.g., %
maximum oxygen consumption or heart rate reserve,
perceived exertion). For individualised exercise prescription,
a relative measure of intensity is recommended, especially
for deconditioned individuals [22]. Time (T) is the duration
of each exercise session. Type (T) is the mode of exercise to be
completed. Volume (V) is the total amount of exercise
training, a product of frequency, intensity and time. Pro-
gression is the commencement, advancement and progres-
sion of intensity or volume over time [15]. It is important to
highlight that rest or recovery within and between sessions
should also be promoted for patients to maximise their
overall health status and adaptations to exercise. Table 3
provides FITT-VP recommendations for an individually
tailored aerobic exercise prescription at a moderate-high in-
tensity. Table 4 provides a summary of the de?nitions of
light, moderate, high, and very-high intensities when
assessing or prescribing exercise or physical activity.
Moderate-Intensity Continuous Training
Versus High-Intensity Interval Training
In Australia and New Zealand, exercise prescription guide-
lines for cardiac rehabilitation have historically been more
conservative compared to those in Europe and America,
focussing on low-to-moderate intensity exercise, with less
technical assessment of aerobic capacity [23]. Moderate-
intensity continuous training (MICT) is bene?cial and safe
for all patients with coronary disease and is strongly rec-
ommended [6,24]. More recently, high-intensity interval
Orthostatic blood pressure drop of .20 mmHg with
symptoms
Third-degree atrioventricular block without pacemaker
Adapted from HeartOnline [52]; American College of Sports Medicine Guidelines for Exercise Testing and Prescription [22]; El-Ansary et al. [34].
During recovery, limit to light to moderate intensity exercise until left ventricular dysfunction has resolved.
#
Relative contradictions are a guide only and should be combined with clinical judgement at every session. If in doubt, medical advice should be sought before
commencing an exercise or physical activity assessment or session.
ˇ
Rapid weight gain may be a red ?ag for heart failure.
Abbreviation: NYHA, New York Heart Association.
Please cite this article in press as: Verdicchio C, et al. A Clinical Guide for Assessment and Prescription of Exercise and Physical
Activity in Cardiac Rehabilitation. A CSANZ Position Statement. Heart, Lung and Circulation (2023), https://doi.org/
10.1016/j.hlc.2023.06.854
resting heart rate C21100 bpm
aortic stenosis
pressure .180/110 mmHg (evaluated on a case-by-
basis)
Instability Scale grade 1–2 (minimally to partially
d sternum)
physical activity.
Contraindications
#
increase in body mass over previous 1–3 days
ˇ
t continuous or intermittent dobutamine therapy
in systolic blood pressure with exercise
functional class IV
Table 2 Types of aerobic exercise, muscle strength and physical activity assessments.
Type of assessment Description Pros Cons
Aerobic Capacity
Cardiopulmonary Exercise Test (CPET) Incremental treadmill (Modi?ed Bruce,
Naughton, Balke protocols [52]), or leg/
arm ergometer test (Ramp protocol) with
concomitant expired air analysis.
Gold standard
Valid and reliable
Tailored exercise prescription
Investigates the physiology of exercise
intolerance [53]
Assesses ventilatory responses to
exercise
Assesses ventilatory thresholds (VT1 and
VT2)
Heart rate response to peak exercise
Blood pressure response
Peak VO
2
prognostic marker
Requires supervision by an allied health
professional with extensive experience
and training in the ability to interpret an
electrocardiogram [54]
Medical Practitioner on site [55]
Generally limited to tertiary medical
centres, often with specialist cardiac
services
Expensive equipment required
Graded Exercise Test Treadmill or leg/arm ergometer test
following a standardised protocol (e.g.,
Balke, Naughton or Bruce Protocols [56]).
Test may be ceased once the patient
reaches 85% of their age predicted HR
max
(65% for those with beta-blockade
therapy who are well rate controlled
during exercise), or if clinically indicated;
e.g., chest pains, dyspnoea, light-
headedness, or fatigue [22,55,56]
Assessment of haemodynamic response
to exercise
Tailored exercise prescription
Easy to implement
Lower cost than CPET
Peak METs prognostic
Requires quali?ed supervision
Inability to walk on slowest treadmill
speed
Functional Exercise Capacity/Field
Tests
Incremental Shuttle Walk Test:
Incremental walking test between the
two cones 10 m apart timed to an audio
signal (beep). Patient walks as long as
possible or can no longer keep up with
the beeps [57].
Six-Minute Walk Test (6MWT):
Low-resource test that involves walking
as far as possible in 6 minutes, along a
20–30m ?at track. Calculate average
speed (km/hr) to guide exercise
prescription = (6MWT distance x10)/
1000.
Valid and reliable
Externally paced
Low-cost requiring minimal equipment
Assessment of physiological indices
Tailored exercise prescription
Well established [17]
Prognostic
Easy to comprehend and perform
Suitable for the less agile
Assessment of physiological indices
Tailored exercise prescription
Minimal resources
Blood pressure and heart rate monitoring
External audible timed signal
More complex than 6MWT
Unsuited for those unable to walk at least
1.8 km/hr
Submaximal test as patient unlikely able
to reach higher intensities
Limited tool to prescribe exercise
intensity targets
Sensitivity
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A
Clinical
Guide
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Assessment
and
Prescription
of
Exercise
and
Physical
Activity
in
Cardiac
Rehabilitation.
A
CSANZ
Position
Statement.
Heart,
Lung
and
Circulation
(2023),
https://doi.org/
10.1016/j.hlc.2023.06.854
Table 2. (continued).
Type of assessment Description Pros Cons
Muscle Strength
1RM assessments De?ned as the maximum weight that can
be lifted for one-repetition, through the
full available range of motion and with
an acceptable level of technical
pro?ciency
Completed for any major muscle group
and requires either machine weights or
free weights
Test terminated when patient is unable to
perform one acceptable repetition on two
consecutive attempts
Good–excellent test-retest reliability
regardless of age, sex, experience level or
muscle group [58]
Safe and tolerable for cardiac
rehabilitation patients [59,60]
May limit the haemodynamic excursions
seen in higher repetition assessments [61]
Results can directly inform exercise
prescription
Requires machine or free weights with
adequate available loading, which can be
costly
Requires supervision of appropriately
trained and experienced clinicians
Risk of musculoskeletal complications
Estimated 1RM assessments Uses validated prediction equations [62]
to estimate 1RM based on a multiple
repetition test
Multiple repetition test = the highest
weight that can be lifted for a speci?ed
number of repetitions to failure (e.g., a 3–
6-repetition maximum test)
Higher reliability with lower repetition
tests (C206 reps)
Same equipment, range of motion,
technical pro?ciency and termination
criteria as standard 1RM test
Lower loads may suit equipment
limitations or patient/clinician hesitancy
Safe and tolerable for cardiac
rehabilitation patients [59,60]
Results can directly inform exercise
prescription
Some error associated when population-
level estimation equations used to
predict individual outcomes
Requires machine or free weights with
adequate available loading, which can be
costly
Requires supervision of appropriately
trained and experienced clinicians
Low-resource assessments The general principle of these
assessments is for patients to either:
(1) complete a speci?ed number of
repetitions in the fastest possible time
(e.g., 5 sit-to-stands for fastest time), or
(2) complete the highest number of
repetitions in a speci?ed period of time
(e.g., maximum number of sit-to-stands
in 30 seconds)
Easily implemented across most CR
settings
Minimal equipment requirements
Repeatable, objective measurement of
muscular strength or endurance
Outcome not transferrable to resistance
exercise equipment for prescription
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C,
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A
Clinical
Guide
for
Assessment
and
Prescription
of
Exercise
and
Physical
Activity
in
Cardiac
Rehabilitation.
A
CSANZ
Position
Statement.
Heart,
Lung
and
Circulation
(2023),
https://doi.org/
10.1016/j.hlc.2023.06.854
Table 2. (continued).
Type of assessment Description Pros Cons
Physical Activity
Pedometers Research vs consumer pedometers
Range in functionality and accuracy and
are often found in smartphones or
smartphone apps
Less prone to recall error and bias [63]
Output (steps) is simple to understand
Consumer pedometers have reasonable
accuracy for steps [64]
Unable to determine context of activity
Insensitive to non-ambulatory and water
activities (e.g., cycling, swimming) [63]
Output does not capture intensity
Accelerometers Research vs consumer accelerometers
Capture acceleration of movement in one
or more planes, as well as steps
Provides a measure of intensity, allowing
an overall measure of activity volume
(i.e., MVPA minutes/week)
Accelerometer intensity thresholds may
not be appropriate for cardiac
populations
Inclinometers Research vs consumer inclinometers
Measure postural transitions, recording
time in sitting/lying, standing and
stepping
Considered the most accurate measure of
sedentary behaviour
Physical activity and Sedentary
Behaviour questionnaires
Long-format International Physical
Activity Questionnaire [65] (group level
measure)
Active Australia Survey [66] (group level
measure)
Physical Activity Vital Sign [67]
(clinically feasible, individual level
measure)
Past-day Adults’ Sedentary Time
questionnaire [68] (group level measure)
More practical due to their low cost and
ease of use in the clinical setting
Past-day Adults’ Sedentary Time
questionnaire has been validated in the
cardiac rehabilitation setting
More likely to under or over-estimate
physical activity and sedentary time due
to recall bias
Tend to show low correlations with
objective measures
No physical activity questionnaires have
been validated in the cardiac
rehabilitation setting
Activity diaries At an individual level, activity diaries
can also be used
Labour intensive for participants [69]
Abbreviations: METs, metabolic equivalents; VT1, ventilatory threshold 1; VT2, ventilatory threshold 2; VO
2
, volume of oxygen consumption; 1RM, 1 repetition-maximum; MVPA, moderate-to-vigorous physical
activity.
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C,
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A
Clinical
Guide
for
Assessment
and
Prescription
of
Exercise
and
Physical
Activity
in
Cardiac
Rehabilitation.
A
CSANZ
Position
Statement.
Heart,
Lung
and
Circulation
(2023),
https://doi.org/
10.1016/j.hlc.2023.06.854
and
frequency
activity.
Exercise in Cardiac Rehabilitation 7
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training (HIIT) has also been recommended and deemed safe
by international authorities for various patients with stable
cardiac disease and may provide superior outcomes
Figure 1 A practical guide for the assessment, prescription
physical activity.
Abbreviations: CPET, cardiopulmonary exercise test; FITT-VP,
of perceived exertion; MVPA, moderate-to-vigorous physical
compared to MICT [25–27].
If appropriate, moderate- and high-intensity training can
be prescribed interchangeably as patients progress, while
considering patients’ preferences and ability, and can be a
good combination to improve a patient’s aerobic exercise
capacity [28]. MICT is recommended for those patients with
low aerobic exercise capacity and, where appropriate, pa-
tients could be progressed to high intensity sessions as their
aerobic exercise capacity improves. Select patients with sta-
ble coronary disease, and a good level of aerobic exercise
capacity, may progress to high-intensity exercise after a brief
period of moderate-intensity exercise training. The most
commonly used HIIT model is a warm-up, followed by 4x4-
min intervals at 75%–90% peak heart rate (HR
peak
) with an
active recovery phase of 3-min between bouts at approxi-
mately 60% HR
peak
, followed by a cool-down [28]. However,
a ?exible approach, tailored to individual requirements is
judicious in practice, such as shorter intervals and/or a lower
intensity for patients who have a reduced aerobic capacity
and who may be unable to complete a full 4-min workload
[28].
Resistance Exercise
Resistance exercise requires the contraction of one or more
muscle groups against an external resistance (e.g., weights)
Please cite this article in press as: Verdicchio C, et al. A Clinical Guide
Activity in Cardiac Rehabilitation. A CSANZ Position Statement.
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with the intention to enhance muscular adaptions such as
strength,massandendurance[22].Participationinstructured
resistance exercisesessions,knownasresistance training,also
progression of aerobic exercise, resistance exercise and
intensity time type volume progression; RPE, rate
improves functional performance and prognosis for patients
with heart failure [29] or coronary artery disease [30].
Resistance training is an important aspect of an exercise
program for the diverse and ageing cardiac rehabilitation
population, offering unique bene?ts that are not provided by
aerobic exercise training. Speci?cally, resistance training can
prevent or reverse the loss of muscle mass (sarcopenia) that
occurs after coronary artery bypass grafting and with older
age, and can also bene?t comorbid metabolic, vascular,
cognitive, frailty and mental health conditions [31]. More-
over, the addition of resistance training to aerobic exercise
programs enhances both muscular strength and aerobic ca-
pacity adaptations in patients with coronary disease [32].
Despite historical concerns regarding safety, resistance ex-
ercise is well tolerated by patients with cardiovascular con-
ditions, with very few adverse cardiovascular events
reported [32] and acute haemodynamic changes comparable
to aerobic exercise [33].
Assessment
The objective assessment of muscle strength in cardiac
rehabilitation is important to determine and quantify base-
line muscle strength, guide individual prescription, and
evaluate changes in muscular strength. It is critical that cli-
nicians consider all relevant contraindications before con-
ducting any resistance exercise testing (Table 1), including
for Assessment and Prescription of Exercise and Physical
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Table 3 FITT-VP Recommendations for prescribing aerobic exercise, resistance exercise and physical activity in cardiac disease patients.
Aerobic Exercise Resistance Exercise Physical Activity
All recommendations should primarily be based on patient need and preference and individual risk assessment
Frequency 3 or more days per week [6]. For patients
completing HIIT, at least two of these sessions per
week are recommended to be high intensity.
2–3 sessions per week. Recommend 48 hours
between sessions, where possible, to maximise
muscular recovery
MVPA should be completed on most days per
week, which includes exercise as a subset.
Intensity Moderate-to-high intensity (Table 4; e.g., 55%–90%
HRmax, RPE 12–16) based on assessment of aerobic
capacity (Table 2)
Moderate-to-high intensity (Table 4; e.g., 50%–80%
1RM or 5–7 RPE based on assessment of muscular
performance.
Initial prescriptions recommended at moderate
intensity for patients not experienced in resistance
training
MVPA is recommended to meet the physical
activity guidelines. Patients can use the Borg RPE.
Modi?ed RPE or the Talk Test to monitor how hard
they are working (Table 4)
Time Session duration .30 min of total aerobic exercise.
For patients who are severely deconditioned or
have symptoms at low workloads, it is
recommended to start with bouts of light-moderate
continuous exercise of 5–10 min in duration with
breaks as required, to allow full recovery and
repeat 2–3 times, progressing towards 30 min of
continuous activity. Once moderate intensity
activities are tolerated, patients should be
encouraged to exercise at higher intensities
Session duration: .20 min
Duration of muscle contraction .4 second per
repetition (.1 s concentric phase, .3 s eccentric
phase)
Rest between sets: 60 s [70]
150–300 min moderate intensity, or 75–150 min
vigorous intensity, or a combination of both, per
week is the aim. This does not need to be
accumulated in 10-minute bouts.
Additionally, break up long periods of sedentary
time, replacing with any intensity of physical
activity, including light intensity.
Type A variety of aerobic modes of exercise are
recommended that use large muscle groups such as
walking, jogging, cycling, swimming, rowing, stair
climbing.
Arm-ergometry can also be used if there are
underlying musculoskeletal issues affecting lower
limb use.
Whole body, single- or multi-joint exercises,
performed bilaterally where possible. May include
a range of modalities including bodyweight, free-
weights, machine weights and elastic resistance
bands.
Altering the type of resistance training performed
can be a useful way to manipulate intensity
through changes in body position and loading,
particularly in low-resource settings
A variety of MVPA is recommended including
domestic, occupational, transportation and leisure
activities.
Explore opportunities to increase physical activity
within the individual’s existing daily routines,
encouraging activities that the individual enjoys.
Be aware of local physical activity referral
opportunities (e.g., Heart Foundation walking
groups, Parkrun), if appropriate.
Volume A minimum of 150 minutes of moderate-high
intensity aerobic exercise, with an ideal target of
.210 min per week for increased cardiometabolic
bene?t[71]
Total session volume per major muscle group =
15–36 repetitions, arranged as 1–3 sets of 8–15
repetitions.
Initial prescriptions can consider lower volumes to
allow patient familiarisation prior to progressing
towards higher volumes
C21150 min MVPA per week; C217,500 steps/day [72]
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press
as:
Verdicchio
C,
et
al.
A
Clinical
Guide
for
Assessment
and
Prescription
of
Exercise
and
Physical
Activity
in
Cardiac
Rehabilitation.
A
CSANZ
Position
Statement.
Heart,
Lung
and
Circulation
(2023),
https://doi.org/
10.1016/j.hlc.2023.06.854
Table
3.
(continued).
Aero
bic
Exerc
ise
Resistance
Ex
ercise
Physica
l
Act
ivity
Progres
sion
Star
t
slow
ly
and
progre
ss
gra
dually
,
increas
ing
durat
ion
to
meet
30
min
befo
re
increasing
intensity.
Incr
eases
in
intensity
and
duration
of
5%
–
10%
ever
y
1
–
2
weeks
are
typically
well
-tolerated
within
cardi
ac
patients.
Clinic
ians
shoul
d
progress
a
t
leas
t
one
of
the
followi
ng
to
optimise
resistance
training
adapt
ations:
volum
e
(reps,
sets
),
intensity,
type,
freq
uency.
Volu
me
and
intensity
should
be
progre
ssed
befo
re
other
training
vari
ables.
E.g.,
Prog
ress
repetitions
befo
re
sets
or
in
tensity,
up
to
a
m
aximu
m
o
f
15.
Once
15
reps
can
be
comp
leted
with
ease,
then
in
tensity
sh
ould
be
progressed
to
4
–
6
o
n
RPE
scale
at
a
new
targe
t
o
f
8
–
10
reps.
Inten
sity
should
then
be
progre
ssed
towar
ds
the
highe
st
tolerable
in
tensity
and
sets
progressed
towar
ds
3
per
m
ajor
m
uscle
grou
p.
Start
slowly
and
prog
ress
grad
ually,
increasing
duration
befo
re
intensity.
If
appropriate,
indivi
duals
m
a
y
start
w
ith
as
little
as
2
–
5
m
inutes
of
activi
ty,
3
–
4
times
a
day.
Progre
ss
toward
s
3
0
min
o
f
m
oderate
in
tensity
ph
ysical
activity
or
7,50
0
steps
on
most
days,
noting
any
activity
is
bette
r
than
non
e
Abbreviations:
HIIT,
high-intensity
interval
training;
MICT,
moderate-intensity
continuous
training;
HR
max,
Maximal
heart
rate;
MVPA,
moderate-to-vigorous
physical
activity;
RPE,
rate
of
perceived
exertion;
reps,
repetitions.
Exercise in Cardiac Rehabilitation 9
HLC3932_proof ■ 24 July 2023 ■ 9/14
Please cite this article in press as: Verdicchio C, et al. A Clinical Guide
Activity in Cardiac Rehabilitation. A CSANZ Position Statement.
10.1016/j.hlc.2023.06.854
the sternal stability of post-sternotomy patients prior to
commencing upper body resistance training [34].
Muscle strength should be assessed or estimated relative to
the 1-repetition maximum (1RM) outcome measure. Several
alternative methods for the assessment of muscle strength
are summarised in Table 2, where individual service-level
factors like equipment availability and clinician experience
may limit the accessibility of 1RM assessment. It is important
to note these alternative methods are limited in their ability
to inform exercise prescription.
Prescribing and Progressing Resistance
Exercise
Figure 1 summarises the recommended clinician work?ow in
relation to assessment, prescription and progression of aer-
obic exercise training. Prescription of resistance training
during cardiac rehabilitation should be informed by the re-
sults of a comprehensive assessment and align with the dual
principles of resistance training programming: individuali-
sation and progression [26]. Individualisation refers to
tailoring the resistance exercise prescription speci?ctoa
patient’s physical capacity, experience, preference and car-
diac history. Progression is the application of the progressive
overload principle and it refers to the increases in intensity or
volume over time that is essential for promoting muscle
adaptions to exercise. Prescription recommendations for
resistance training are summarised in Table 3 and exercise
intensities in Table 4.
Anobjectivemeasurementofmuscularstrength(e.g.,1RM)
for each of the available equipment types or movements fa-
cilitates accurate initial exercise intensity prescription [26]. In
the absence of objective data for all movements, the most
relevant subjective measurement to inform prescription and
progression of resistance exercise is the rating of perceived
exertion(RPE)(Table4).ScalesincludetheBorgandOmnibus
Resistance Exercise Scale (OMNI-RES) for rating perceived
exertionthatallowpatientstoratetheirownperceivedlevelof
exertionfrom1–10(10ismaximal)usinganumberorpictorial
toolthathavebeenvalidatedagainstothersubjectivescalesfor
use speci?cally in resistance exercise [35].
Many patients will have had limited exposure to resistance
exercise prior to cardiac rehabilitation enrolment. Thus, it is
important for patients to develop good technical pro?ciency
during the initial training sessions, to set the technical
foundation and allow for the safe progression of resistance
exercise load and volume throughout the program [26].
Clinicians are encouraged to initially provide a demonstra-
tion and then communicate with and coach the patient
throughout the exercise delivery to facilitate skill acquisition
and body awareness. Thus, clinicians should embed clear,
concise instructions for each exercise and simple, consistent
feedback at the conclusion of each set. Patients should also be
advised that: (1) breath-holding (Valsalva manoeuvre)
should be avoided during resistance exercise to limit blood
pressure excursions; (2) muscle tension during resistance
exercise is a normal sensation; and (3) muscle soreness is
for Assessment and Prescription of Exercise and Physical
Heart, Lung and Circulation (2023), https://doi.org/
(MVPA) and step counts. Table 2 outlines methods for
Table
4
Aerobic
exercise,
physical
activity
and
resistance
training
intensities.
Light
Intens
ity
Mo
derat
e
I
n
tensity
Hi
gh/Vigo
rous
Intens
ity
Very
High
Intensity
Aerob
ic
exercise/p
hysica
l
activ
ity
VO
2max
[
26
]
(%)
,
40
40
–
69
70
–
85
.
85
HR
max
(%)
,
55
55
–
74
75
–
90
.
90
HRR
(%)
,
40
40
–
69
70
–
85
.
85
6MW
T
averag
e
spee
d
[
73
]
(%)
80
100
Bo
rg
RPE
10
–
11
12
–
13
14
–
16
17
–
19
Mo
di
?
ed
RPE
2
–
34
–
67
–
89
Ta
lk
tes
t
[
74
]
Able
to
sing
Abl
e
t
o
talk
in
full
sentence
s/
un
able
to
sing
Una
ble
to
talk
comf
ortably
R
esistan
ce
trainin
g
1
R
M
(%)
,
50
50
–
69
70
–
84
C21
85
OM
NI-RP
E
[
35
]
,
55
6
–
7
C21
8
These
intensities
may
be
an
underestimate
in
?
tter
individuals
in
whom
the
test
is
submaximal.
Abbreviations:
VO
2max,
maximal
oxygen
capacity;
HR
max,
Maximal
heart
rate,
HRR,
heart
rate
reserve;
6MWT,
6-minute
walk
test;
RPE,
rate
of
perceived
exertion;
1RM,
1
repetition
maximum.
10 C. Verdicchio et al.
HLC3932_proof ■ 24 July 2023 ■ 10/14
Please cite this article in press as: Verdicchio C, et al. A Clinical Guide
Activity in Cardiac Rehabilitation. A CSANZ Position Statement.
10.1016/j.hlc.2023.06.854
assessing physical activity and sedentary behaviour in clin-
ical practice.
Prescribing and Progressing Physical
Activity
Figure 1 summarises the recommended clinician work?ow in
common in the ?rst few days after resistance exercise but is
reduced with subsequent exposures [26]. The recommenda-
tion for preliminary sessions is to commence at lower ranges
of the recommended intensity so that patients can primarily
focus on technique without being hampered by muscular
fatigue [26].
Physical Activity
Physical activity is de?ned as any bodily movement pro-
duced by skeletal muscles that result in energy expenditure
such as walking for transport, dancing, housework, or
gardening; with exercise as a subset [36]. Sedentary behav-
iour is any waking behaviour characterised by an energy
expenditure C201.5 metabolic equivalents (METs), while in a
sitting, reclining, or lying posture [37]. In people with coro-
nary disease, physical inactivity and sedentary behaviour are
risk factors for cardiovascular and all-causes of death [38,39].
Active people with coronary disease have a 50% lower risk of
mortality, compared to inactive counterparts [38]. Addi-
tionally, suf?cient physical activity reduces the impact of
coronary disease, slows its progress and improves modi?-
able risk factors for recurrent CVD and other chronic disease
[40]. Consequently, individuals undertaking cardiac reha-
bilitation and secondary prevention interventions are
encouraged to meet the public health physical activity
guidelines to improve health outcomes [17].
The World Health Organization physical activity guide-
lines for adults with chronic disease recommend that in-
dividuals should complete 150–300 minutes of moderate
intensity aerobic physical activity; or 75–150 minutes of
vigorous intensity aerobic physical activity or a combination
of both per week [41]. Muscle strengthening should be
completed on at least two days per week and varied func-
tional balance and strength activities should be completed
three days per week. In addition, long periods of sedentary
time should be avoided, replacing sedentary time with any
intensity of physical activity, including light intensity, and,
for those who ?nd it dif?cult to meet guidelines, any activity
is better than none [41,42].
Assessing Physical Activity
Physical activity and sedentary behaviour can be assessed
subjectively (e.g., questionnaire) or objectively (e.g., pedom-
eter, accelerometer) to determine whether an individual is
inactive (i.e., not meeting the physical activity guidelines).
The most common metrics used to measure physical activity
are minutes of moderate-to-vigorous physical activity
relation to assessment, prescription and progression of
for Assessment and Prescription of Exercise and Physical
Heart, Lung and Circulation (2023), https://doi.org/
Regardless of diagnosis, whether there has been an acute
cardiac event or procedure, comorbidities or age, all in-
move in the tube” is a paradigm shift that promotes upper
Exercise in Cardiac Rehabilitation 11
HLC3932_proof ■ 24 July 2023 ■ 11/14
dividuals should be encouraged to increase their exercise and
physical activity levels safely, starting slowly at an appro-
priate level and progressing gradually [6,41]. It is recom-
mended that when conducting centre-based exercise sessions
there are basic safety standards and procedures in place,
such as a de?brillator, resuscitative and ?rst-aid equipment
on-site. Prior to each supervised exercise session, it is rec-
ommended to assess the patient’s contraindications to exer-
cise, measuring pre-exercise heart rate and blood pressure, to
ensure that they are within an acceptable range at rest
(Table 1). However, as patients progress and their cardiac
disease is stable with no symptoms, these pre-exercise mea-
surements are not necessary and may be counterproductive
to the patient’s feelings around exercise and physical activity
in an unsupervised state. Clinical risk may increase over time
due to disease progression or clinical deterioration. When in
doubt, seek medical advice or support before commencing
the exercise session. During exercise it is recommended to
monitor the patient’s heart rate and RPE (or Borg Scale for
Dyspnoea in patients with heart failure) to ensure they are
reaching their target intensity during their aerobic bout of
exercise and responding to exercise appropriately (Figure 1).
ECG monitoring during exercise is not essential for patients
within the supervised setting; however, in certain circum-
stances (e.g., atrial ?brillation, history of signi?cant ventric-
physical activity. Following a comprehensive assessment of
an individual’s physical activity levels and their safety to
increase these levels (Table 1), physical activity can be pre-
scribed according to the FITT-VP principle. An individual’s
goals, motivation and con?dence to increase physical activity
in everyday life should be reviewed as part of a compre-
hensive assessment, with each patient receiving an individ-
ually tailored physical activity program based on these
?ndings. Recommendations for physical activity prescription
and counselling at a moderate-vigorous intensity (Table 4)
are outlined in Table 3.
Clinicians (e.g., nurses, allied health professionals, medical
doctors) are well placed to provide general physical activity
advice on the types and amount of activity appropriate for
the individual’s goals, needs, abilities, preferences, functional
limitations, medication regimes and treatment. For more
speci?c physical activity advice, exercise specialists such as
physiotherapists and exercise physiologists should be con-
sulted. A medical review is generally unnecessary prior to
beginning light-to-moderate intensity physical activity
within cardiac rehabilitation and the community, unless
there are known contraindications (Table 1)[41]. For
vigorous or high intensity physical activity (e.g., jogging,
tennis singles), a full clinical assessment and medical review
is recommended [15].
Safety and Monitoring
ular arrhythmias), it is bene?cial to use for patients showing
Please cite this article in press as: Verdicchio C, et al. A Clinical Guide
Activity in Cardiac Rehabilitation. A CSANZ Position Statement.
10.1016/j.hlc.2023.06.854
limb activity and exercise using short lever arms by per-
forming activities close to the body. This encourages clini-
cians to engage patients in early active recovery by educating
on what they can safely do, in contrast to prescribing overly
restrictive precautions not supported by current evidence
[43,44]. More recently, early post-sternotomy resistance ex-
ercise inclusive of individualised upper limb exercise has
been reported as safe and resulted in signi?cant improve-
ment in muscular strength and cognitive recovery [45].
Within the community, patients should be advised to wear
comfortable clothing and footwear, have adequate ?uid
intake and avoid activity after heavy meals, if they are
suffering from an illness, and in extreme temperatures.
During unsupervised exercise and physical activity, in-
dividuals should monitor their intensity (e.g., talk test, RPE;
Table 4) and symptoms (i.e., chest pain, dizziness, nausea,
feeling unwell, excessive sweatiness). If patients experience
any warning signs of a cardiac event, then they should be
encouraged to call an ambulance immediately. To improve
adherence to the exercise and physical recommendations,
interventions using mHealth (e.g., text messages, smart-
phone apps) and wearable activity trackers should be
considered [46].
Wearable Activity Trackers
There is emerging evidence that the use of free-living wear-
able activity trackers (e.g., smartwatches, wristbands, chest
strap, clothing and shoe-embedded sensors, smartphone
pedometers and accelerometers) leads to increased physical
activity levels and aerobic capacity in cardiac rehabilitation
participants [47]. The increasing self-initiated use of wearable
activity trackers by patients provides an opportunity for
clinicians to promote physical activity using these devices.
The use of wearable activity trackers can be successfully
incorporated within clinical settings after reviewing some
device and individual factors [48]. Clinicians should consider
device availability, usability (e.g., battery life, metrics avail-
able (step count, MVPA, heart rate)), clarity of the interface
signs or symptoms necessitating further investigation. For
most asymptomatic patients, continuous ECG monitoring
can be counterproductive by exacerbating feelings of anxiety
around exercise that delays development of patient self-
ef?cacy. A warm-up and cool-down should be included in
all exercise sessions and physical activity for 5–10 minutes,
gradually increasing and lowering the heart rate and blood
pressure to limit rapid haemodynamic changes.
For resistance exercise in people with underlying muscu-
loskeletal conditions, correct technique and modifying in-
tensity or volume are important for reducing the risk of
aggravating these conditions [32]. Special consideration
should also be given to recent median sternotomies; how-
ever, evidence supports early initiation of upper body
movements within safe limits of pain [43,44]. “Keep your
and management of the devices (e.g., downloading and
for Assessment and Prescription of Exercise and Physical
Heart, Lung and Circulation (2023), https://doi.org/
resulting from MICT in some patient cohorts.
12 C. Verdicchio et al.
HLC3932_proof ■ 24 July 2023 ■ 12/14
interpreting the data). Reliability and validity of the device is
important, as well as data security and management. At an
individual level, clinicians should determine whether pa-
tients are motivated to use a wearable activity tracker and
have matching levels of digital literacy. Clinicians can
maximise the effectiveness of wearable activity trackers, over
the short and long term, through encouraging, educating,
monitoring, and providing effective feedback loops to pro-
mote individual engagement and autonomy beyond the
structured, supervised cardiac rehabilitation setting.
Using Telehealth to Assess and
Prescribe Exercise and Physical
Activity
Over the past decade telehealth has emerged as an alterna-
tive and effective model for delivering cardiac rehabilitation,
with its utilisation increasing markedly during the COVID-
19 pandemic due to widespread restrictions to face-to-face
delivery [49]. Ideally, it is recommended that exercise and
physical activity assessments are done in-person to ensure a
safe and standardised assessment. However, for a variety of
reasons, including patient preference, this may not be
possible, in which case telehealth exercise assessments are
recommended to allow individually tailored exercise and
physical activity prescription.
Before assessing exercise and physical activity using tele-
health, safety needs to be considered, including verifying the
patient’s location in case you need to call an ambulance or
checking whether they have an action plan and medications
nearby if required. Some patients may not be suitable for a
telehealth assessment and will need an in-person review,
including those with cognitive impairments and low digital
literacy. Before commencing the assessment, clinicians
should determine what monitoring equipment is available
(e.g., blood pressure or heart rate monitors) and conduct a
virtual tour to check if the space is safe for exercising. Also, a
standard subjective history should be taken, followed by a
virtual exercise test. Selection of a suitable exercise test is
dependent on the space and equipment available, ensuring
that the test can be repeated at the end of the program using
the same methods. To assess functional exercise capacity, the
6-minute walk test (6MWT) [50], 1-minute sit-to-stand test
[51] and Timed Up and Go [50] could be used. To assess
muscle strength, the 5x sit-to-stand evaluates functional
quadriceps strength [50]. Consumer pedometers, accelerom-
eters, or questionnaires can be used to assess physical ac-
tivity (Table 2). Prescription of aerobic exercise, resistance
exercise and physical activity should follow the FITT-VP
principle (Table 3). Effective virtual assessment, prescrip-
tion and progression of exercise and physical activity may be
challenging; however, the assessment and prescription of
exercise and physical activity via telehealth is preferrable to
generic untailored programs, providing new opportunities to
ensure programs can remain individually tailored when in-
person assessment is not possible.
Please cite this article in press as: Verdicchio C, et al. A Clinical Guide
Activity in Cardiac Rehabilitation. A CSANZ Position Statement.
10.1016/j.hlc.2023.06.854
C15
Making use of available resources, including wearable
activity trackers and telehealth, will potentially allow
increased support for exercise and physical activity
resulting in increased health bene?ts, including improve-
ment of quality of life, supporting and empowering pa-
tients to self-monitor and manage their symptoms, and
increasing their con?dence to be active over the longer
term.
Conclusion
Patients with cardiovascular disease bene?t from cardiac
rehabilitation, which includes structured exercise and phys-
ical activity as core components. This position statement
provides up-to-date evidence-based guidance for the
assessment and prescription of exercise and physical activity
for cardiac rehabilitation clinicians within the Australian and
New Zealand context. With ongoing research in this area, it
is important for clinicians to be aware of current guidelines
and recommendations from other global cardiac bodies.
Disclosures
Nil disclosures
Acknowledgements
We would like to acknowledge the Cardiac Society of
Australia and New Zealand (CSANZ) Quality and Safety
Committee, CSANZ Clinical and Preventative Cardiology
Council, CSANZ Allied Health, Science and Technology
Summary of Recommendations
C15
A comprehensive individual assessment of aerobic exer-
cise capacity, muscle strength and physical activity allows
limiting factors to be identi?ed, guiding the safe pre-
scription of aerobic and resistance exercise and physical
activity that is personalised to the patient’s abilities, needs,
preferences and goals.
C15
Aerobic exercise capacity, muscle strength and physical
activity assessments should be conducted at enrolment
and at discharge to allow for a more detailed analysis of a
patient’s response to exercise and physical activity, which
can guide the target intensities during their program, and
allow for measurement of program effectiveness.
C15
Cardiac rehabilitation should incorporate a range of exer-
cise and physical activity options, with the aim to achieve
moderate-to-vigorous intensity exercise and physical ac-
tivity to receive the optimal health bene?ts and prevent
recurrent CVD events.
C15
MICT is well established as being safe and effective for
cardiac patients, with increasing evidence that HIIT is
well-tolerated for selected cardiac patients and can offer
improvements to aerobic exercise capacity exceeding those
Council, Australian Cardiovascular Health and
for Assessment and Prescription of Exercise and Physical
Heart, Lung and Circulation (2023), https://doi.org/
fractions. Am J Cardiol. 2013;111(10):1466–9.
[10] Edelmann F, Gelbrich G, Dungen HD, Frohling S, Wachter R,
Clin Electrophysiol. 2023.
[12] Fakhry F, Spronk S, van der Laan L, Wever JJ, Teijink JA, Hoffmann WH,
Exercise in Cardiac Rehabilitation 13
HLC3932_proof ■ 24 July 2023 ■ 13/14
et al. Endovascular revascularization and supervised exercise for pe-
ripheral artery disease and intermittent claudication: a randomized clin-
ical trial. JAMA. 2015;314(18):1936–44.
[13] Tran DL, Maiorana A, Davis GM, Celermajer DS, d’Udekem Y,
Cordina R. Exercise testing and training in adults with congenital heart
disease: a surgical perspective. Ann Thorac Surg. 2021;112(4):1045–54.
Stahrenberg R, et al. Exercise training improves exercise capacity and
diastolic function in patients with heart failure with preserved ejection
fraction: results of the Ex-DHF (Exercise training in Diastolic Heart
Failure) pilot study. J Am Coll Cardiol. 2011;58(17):1780–91.
[11] Elliott AD, Verdicchio CV, Mahajan R, Middeldorp ME, Gallagher C,
Mishima RS, et al. An exercise and physical activity program in patients
with atrial ?brillation: the ACTIVE-AF randomized controlled trial. JACC
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Australia, and the Australian Physiotherapy Association.
The authors thank Professor Doa El-Ansary for reviewing the
resistance exercise section.
Funding
J.R. is funded by a NHMRC Investigator Grant
(GNT1143538). M.H. is funded by the NHMRC SOLVE-CHD
Synergy Grant (GNT1182301).
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