Community Classes, Mainstream Exercise Classes

• SWT <level 7 with cardiac symptoms;

• unable to reach workload of 5METs/level 7 of SWT with non cardiac limitation;

• ETT ?5METs with cardiac symptoms/2mm ST depression/silent

ischaemia;

• poor LV function ;

• diagnosis of heart failure;

• post transplant;

• post ICD insertion;

• refractory angina;

• awaiting CABG;

• awaiting angiogram or PTCA;

• SBP >180mm hg at rest;

• DBP >100mm hg at rest.

Phase IV exercise leaders The BACR has also, in recent years, established an accredited quali?cation for community instructors providing exercise to cardiac rehabilitation phase III graduates.This has allowed CR professionals to consider more safely referral for patients who, in the past, would not have had the phase IV option and who would bene?t from supervision at that level.There remains a debate as to whether there should be specialist classes for cardiac patients or whether they should be integrated into mainstream exercise classes. Phase III cardiac classes are likely to be male dominated whereas mainstream community classes are more likely to be female dominated.Risk strati?cation should play the pivotal role in the type of class and supervision the exercise professional recommends to each patient, while taking into account their exercise preferences in order to encourage long term adherence to exercise.

However, even with a trained phase IV exercise leader the patients with complex cardiac histories, complex co morbidity or high risk features may require ongoing clinical supervision at a level that is unlikely to be achieved in a community phase IV environment. There is a clear and vital role for the highly skilled exercise professional providing phase III to provide suitable long term maintenance options for those patients least suited to exercise in the community .Risk Strati?cation and Health Screening for Exercise PRACTICE ISSUES Staf?ng Although CR is delivered by a multidisciplinary team of health professionals, the exercise component should be delivered by suitably trained exercise professionals, i.e. exercise physiologists, physiotherapists or phase IV BACR exercise professional. Current international guidelines vary in their recommendations for staf?ng levels, but all agree that the level of staf?ng required should be driven by the risk strati?cation of the CR participant within the exercise group. Staff to patient ratio is covered in Chapter 6.