home Auditorium 7 IBS rehabilitation. Methods of physical rehabilitation of patients with ischemic heart disease at the sanatorium stage. Here is one of the methods

IBS rehabilitation. Methods of physical rehabilitation of patients with ischemic heart disease at the sanatorium stage. Here is one of the methods

Rehabilitation for coronary artery disease is aimed at restoring the state of the cardiovascular system, strengthening the general condition of the body and preparing the body for previous physical activity.

The first period of rehabilitation for IHD is adaptation. The patient must get used to new climatic conditions, even if the previous ones were worse. Acclimatization of the patient to new climatic conditions may take about several days. During this period, a primary medical examination of the patient is carried out: doctors assess the patient’s health status, his readiness for physical activity (climbing stairs, gymnastics, therapeutic walking). Gradually, the patient's physical activity increases under the supervision of a physician. This is manifested in self-service, visits to the dining room and walks around the sanatorium.

The next stage of rehabilitation is the main stage. He milks for two to three weeks. During this period, physical activity, duration, and speed of therapeutic walking increase.

At the third and final stage of rehabilitation, a final examination of the patient is carried out. At this time, the tolerability of therapeutic exercises, dosed walking and climbing stairs is assessed.

So, as you already understand, the main thing in cardiac rehabilitation is dosed physical activity. This is due to the fact that it is physical activity that “trains” the heart muscle and prepares it for future stress during daily activity, work, etc.

In addition, it has now been reliably proven that physical activity reduces the risk of developing cardiovascular diseases. Such therapeutic exercises can serve as a prevention for both the development of heart attacks and strokes, as well as for rehabilitation treatment.

Health path is another excellent means of rehabilitation for heart diseases, incl. and IHD. A path is a walking ascent measured in distance, time and angle of inclination. Simply put, health path is a treatment method of dosed walking along specially organized routes.

The path path does not require any special equipment or tools. It would be a good slide. In addition, climbing stairs is also a path. Health path is an effective means for training the heart affected by coronary artery disease. In addition, it is impossible to overdo it with a health path, since the load has already been calculated and dosed in advance.

However, modern simulators allow you to carry out a health path without slides and stairs. Instead of climbing a mountain, a special mechanical path with a changing angle of inclination can be used, and walking on stairs can be replaced by a step machine. Such simulators allow you to more accurately regulate the load, provide immediate control, feedback and, most importantly, do not depend on the vagaries of the weather.

It is important to remember that a health path is a dosed load. And you shouldn’t try to be the first to climb a steep mountain or climb the stairs the fastest. Health path is not a sport, but physical therapy!

Some may wonder how stress on the heart and coronary artery disease can be combined? After all, it would seem that you need to spare the heart muscle in every possible way. However, this is not the case, and it is difficult to overestimate the benefits of physical exercise during rehabilitation after coronary artery disease.

First, physical activity helps reduce body weight and increase muscle strength and tone. During physical activity, the blood supply to all organs and tissues in the body improves, and the delivery of oxygen to all cells of the body is normalized.

In addition, the heart itself trains a little bit and gets used to working under a slightly higher load, but without reaching the point of exhaustion. Thus, the heart “learns” to work under the same load as it would under normal conditions, at work, at home, etc.

It is also worth noting the fact that physical activity helps relieve emotional stress and fight depression and stress. After therapeutic exercises, as a rule, anxiety and restlessness disappear. And with regular exercises, insomnia and irritability disappear. And as you know, the emotional component in IHD is an equally important factor. After all, according to experts, one of the reasons for the development of diseases of the cardiovascular system is neuro-emotional overload. And therapeutic exercises will help to cope with them.

An important point in therapeutic exercises is that not only the heart muscle is trained, but also the blood vessels of the heart (coronary arteries). At the same time, the wall of the vessels becomes stronger, and its ability to adapt to pressure drops also improves.

Depending on the condition of the body, in addition to therapeutic exercises and walking, other types of physical activity can be used, for example, running, vigorous walking, cycling or cycling, swimming, dancing, skating or skiing. But such types of exercise as tennis, volleyball, basketball, training on exercise machines are not suitable for the treatment and prevention of cardiovascular diseases; on the contrary, they are contraindicated, since long-term static loads cause increased blood pressure and heart pain.

In addition to therapeutic exercises, which is undoubtedly the leading method of rehabilitation for patients with coronary artery disease, herbal medicine and aromatherapy are also used to restore patients after this disease. Herbalists select medicinal herbal infusions for each patient. The following plants have a beneficial effect on the cardiovascular system: astragalus fluffy-flowered, Sarepta mustard, lily of the valley, carrots, peppermint, viburnum, cardamom.

In addition, today an interesting treatment method such as aromatherapy is widely used for the rehabilitation of patients after coronary artery disease. Aromatherapy is a method of preventing and treating diseases using various aromas. This positive effect of smells on humans has been known since ancient times. It is known that not a single doctor of Ancient Rome, China, Egypt or Greece could do without medicinal aromatic oils. For some time, the use of medicinal oils in medical practice was undeservedly forgotten. However, modern medicine is once again returning to the experience accumulated over thousands of years in the use of aromas in the treatment of diseases. To restore normal functioning of the cardiovascular system, lemon oil, lemon balm oil, sage oil, lavender oil, and rosemary oil are used. The sanatorium has specially equipped rooms for aromatherapy.

Work with a psychologist is carried out if it is required. If you suffer from depression or have suffered stress, then psychological rehabilitation, along with physical therapy, is undoubtedly important. Remember that stress can aggravate the course of the disease and lead to exacerbation. This is why proper psychological rehabilitation is so important.

Diet is another important aspect of rehabilitation. A proper diet is important for the prevention of atherosclerosis, the main cause of coronary artery disease. A nutritionist will develop a diet especially for you, taking into account your taste preferences. Of course, you will have to give up certain foods. Eat less salt and fat, and more vegetables and fruits. This is important, since if excess cholesterol continues to enter the body, physical therapy will be ineffective.

Rehabilitation of coronary heart disease

Rehabilitation of coronary heart disease involves sanatorium-resort treatment. However, you should avoid traveling to resorts with a contrasting climate or during the cold season (sharp weather fluctuations are possible), because Patients with coronary heart disease have increased meteosensitivity.

The approved standard for the rehabilitation of coronary heart disease is the prescription of diet therapy, various baths (contrast, dry-air, radon, mineral), therapeutic showers, manual therapy, and massage. Exposure to sinusoidal modulated currents (SMC), diademic currents, and low-intensity laser radiation is also used. Electrosleep and reflexology are used.

The beneficial effects of climate help improve the functioning of the body's cardiovascular system. Mountain resorts are most suitable for the rehabilitation of coronary heart disease, because... stay in conditions of natural hypoxia (reduced oxygen content in the air) trains the body, promotes the mobilization of protective factors, which increases the overall resistance of the body to oxygen deficiency.

But sunbathing and swimming in sea water should be strictly metered, because. contribute to the processes of thrombosis, increased blood pressure and stress on the heart.

Cardiac training can be carried out not only on specialized simulators, but also during walking along special routes (trails). The paths are designed in such a way that the effect is a combination of the length of the route, ascents, and number of stops. In addition, the surrounding nature has a beneficial effect on the body, which helps to relax and relieve psycho-emotional stress.

The use of various types of baths, exposure to currents (SMT, DDT), low-intensity laser radiation helps to excite nerve and muscle fibers, improve microcirculation in ischemic areas of the myocardium, and increase the pain threshold. In addition, treatments such as shock wave therapy and gravity therapy may be prescribed.

Rehabilitation of coronary artery disease using these methods is achieved through the growth of microvessels into the area of ischemia, the development of a wide network of collateral vessels, which improves myocardial trophism and increases its stability in conditions of insufficient oxygen supply to the body (during physical and psycho-emotional stress).

An individual rehabilitation program is developed taking into account all the individual characteristics of the patient.

Rehabilitation for coronary artery disease

The term "rehabilitation" translated from Latin means restoration of ability.

Rehabilitation is currently understood as a set of therapeutic and socio-economic measures designed to provide people with impairments of various functions that have developed as a result of illness, such a physical, mental and social state that would allow them to re-enter life and take a position in life that corresponds to their capabilities. society.

The scientific foundations for restoring the ability to work of patients with diseases of the cardiovascular system were laid in our country in the thirties by the outstanding Soviet therapist G. F. Lang. In recent years, the problem of rehabilitation of these patients has been actively developed in all countries of the world.

What determines such great interest in this problem? First of all, its great practical significance. Thanks to advances in the rehabilitative treatment of patients with coronary artery disease, including those who have suffered a myocardial infarction, the attitude of doctors and society towards them has radically changed: pessimism has been replaced by reasonable, albeit restrained optimism. Numerous examples from the experience of cardiologists indicate that thousands of patients whose lives could not be saved by medicine several years ago are now living and have every opportunity to improve their health so much that they can return to active and productive work, remaining a full-fledged member of society.

Taking into account the high social importance of rehabilitation and the experience of the country's leading medical institutions, several years ago a decision was made to organize state-based step-by-step rehabilitation of patients who had suffered a myocardial infarction. This system is currently being implemented.

It is three-stage and provides for the sequential implementation of rehabilitation measures in a hospital (mainly in the cardiology department), in the rehabilitation department of a local cardiology sanatorium and in a district clinic by a cardiology doctor or a local therapist, with the involvement of other specialists if necessary.

During the first period of rehabilitation the main tasks of treating the acute period of a heart attack are solved: to promote rapid scarring of the necrosis focus, prevent complications, increase the patient’s physical activity to a certain extent, and correct psychological disorders.

Second rehabilitation period- very responsible in the life of the patient, since he is the boundary between the time when a person is in the position of a patient, and the time when he returns to his usual life environment. The main goal is to identify the compensatory capabilities of the heart and their development. At this time, patients should engage in the fight against risk factors for coronary artery disease.

Before the third period The following tasks are set:

prevention of exacerbations of coronary artery disease through the implementation of measures for secondary prevention;
maintaining the achieved level of physical activity (for a number of patients and increasing it);
completion of psychological rehabilitation;
carrying out examinations of the ability to work and employment of patients.

The diversity of rehabilitation tasks determines its division into so-called types, or aspects: medical, psychological, socio-economic, professional. The solution to the problems of each type of rehabilitation is achieved by its own means.

Rehabilitation of patients after heart surgery is aimed at restoring the optimal functional capacity of the body, mobilizing compensatory mechanisms, eliminating the consequences of surgery, and slowing the progression of coronary heart disease.

Rehabilitation of patients with coronary artery disease after surgical treatment

The effectiveness of surgical treatment increases significantly if, after myocardial revascularization surgery, rehabilitation measures are carried out at 4 stages:

1. surgical hospital (period of clinical and hemodynamic instability);

2. specialized inpatient rehabilitation department

3. rehabilitation departments of a local cardiological sanatorium (patient stabilization period);

4. polyclinic.

The basic principles of rehabilitation of patients after surgery include early start, complexity of measures (drug therapy, diet therapy, exercise therapy, massage, physiotherapy), continuity and succession between stages.

The objectives of the first stage are to eliminate postoperative complications, achieve stabilization of hemodynamics, electrocardiographic and clinical laboratory parameters, physical activation within accessible limits, and psychological adaptation to the surgery. The length of hospital stay is determined by the severity of postoperative complications. Minimum terms - 8-10 days. At the end of the hospital stay, if there are no contraindications, a bicycle ergometer test is performed to determine exercise tolerance. Taking into account the severity of clinical symptoms and the results of VEP, all patients who underwent CABG can be divided into 4 groups:

1. Patients whose normal physical activity at the achieved level of rehabilitation (inpatient) does not cause angina, shortness of breath, or fatigue. Physical exercise tolerance 300-450 kgm/min (70 W or more).

2. Patients in whom moderate physical activity causes slight shortness of breath, angina pectoris, and fatigue. Physical exercise tolerance 200-300 kgm/min (40-65 W).

3. Patients with angina pectoris, shortness of breath, fatigue at low loads. Physical exercise tolerance 150-200 kgm/min (25-40 W).

4. Patients who have frequent attacks of angina with little exercise and at rest, complex rhythm disturbances and symptoms of circulatory failure H2A or more.

In the absence of postoperative complications and severe concomitant diseases, patients are referred to a specialized rehabilitation department, and then to the cardiology department of the sanatorium. Contraindications for transfer after CABG are: frequent and prolonged attacks of angina pectoris of exertion and rest, unstable; fresh ; circulatory failure IV f.kl. NYHA; severe rhythm disturbances; severe arterial hypertension with damage to internal organs, difficult to correct; postoperative complications; the presence of concomitant diseases accompanied by fever; residual effects of thromboembolism in the vessels of the brain.

At the stage of sanatorium rehabilitation, it is necessary to consolidate the effect of surgical and medical treatment received at the inpatient stage, to adapt the patient to the upcoming household stress, social communication, work activity.
The tasks of the sanatorium stage are as follows: development and application of optimal training programs; determination of the individual rate of activation depending on the nature, adequacy of surgical intervention and compensatory capabilities of the organism; selection and application of exercise therapy; normalization of the patient’s psycho-emotional status; secondary prevention to prevent the underlying disease and eliminate risk factors.

At the outpatient stage, the main tasks are the development of the body's compensatory capabilities in order to restore working capacity, prevent possible exacerbations of coronary artery disease, and combat risk factors. If the prognosis is unfavorable, the patient is referred to MREC. If the course is favorable, the patient is discharged to work with observation from a cardiologist once every 3 months, and from a cardiac surgeon - once a year.

Evaluation of the effectiveness of rehabilitation is based on changes in the nature of the disease (disappearance of angina attacks, their reduction; an angina attack occurs when performing a load of greater or lesser intensity); the need to take medications; changes in the level of physical performance, including tolerance to household and industrial stress (assessed based on the results of VEP, daily ECG monitoring and other functional tests.

One of the complications after CABG surgery is occlusion of autovenous shunts. Currently, there is no evidence that any drugs, including antithrombotic drugs, can prevent the development of late occlusions that occur more than 1 year after surgery. However, given the pathogenesis of late occlusions, a prophylactic effect can most likely be expected with long-term use of hypocholesterolemic drugs.

Shunt thrombosis

In shunts, in which the volumetric blood flow is 30 ml / min and thrombosis occurs less quickly. Thrombosis of venous bypasses occurs much more often than arterial bypasses. Aspirin significantly reduces the incidence of vein graft occlusions during the first year after surgery. At the same time, aspirin has practically no effect on the patency of arterial shunts.

When aspirin is prescribed later than 48 hours after surgery, it loses its effect on the patency of venous bypasses. Therefore, aspirin should be given in the early postoperative period at a dose of 100 to 325 mg (individualized) to patients with venous bypass grafts for at least one year after CABG.

Prof., MD Ostrovsky Yu.P.

3.3.

PHYSICAL REHABILITATIONFOR CORONARY HEART DISEASE

Coronary heart disease - acute or chronicdamage to the heart muscle caused by blood deficiencymyocardial supply due to pathological processes in the coronary arteries. Clinical forms of ischemic diseaseheart: atherosclerotic cardiosclerosis, angina pectoris and myocardial infarction. Among cardiovascular diseasestopics coronary heart disease is the most widespreadwandering is accompanied by a large loss of ability to work and high mortality. The occurrence of this diseaserisk factors contribute (see previous section). OsoIt is especially unfavorable to have several factors at the same timerisk factors: for example, a sedentary lifestyle and smokingThis increases the risk of disease by 2-3 times. And those-

rosclerotic changes in the coronary arteries of the heart worsen there is an influx of blood, which causes the proliferation of the jointbody tissue and a decrease in the amount of muscle, sincethe latter is very sensitive to lack of nutrition. Partial replacement of cardiac muscle tissue with connective tissue in the form ofscarring is called cardiosclerosis and causes a decrease in the contractile function of the heart, rapid fatigue during exercise physical work, shortness of breath, palpitations. Breast pain appears dina and in the left half of the chest, work performance decreases benefit.

Angina pectoris is a clinical form of ischemic disease, in which attacks of sudden chest pain occur,caught in acute cardiac circulatory failuremuscles, in most cases is a consequence of atheroscusLerosis of the coronary arteries. The pain is localized behind the sternum or to the left of it, spreads to the left arm, left shoulder blade, neck and is of a squeezing, pressing or burning nature.A distinction is made between exertional angina, when attacks of pain occur disappear during physical activity (walking, climbing stairs, carrying heavy objects), and resting angina, in which an attack occurs without connection with physical effort, for example, during sleep. There are several variants (forms) of stenocar- diy: rare attacks angina pectoris stable angina pectoris (withstupas in the same conditions), unstable angina pectoris (increased attacks that occur at less than earlier, tensions), pre-infarction state(attacks increase in frequency, intensity and duration, resting angina appears).

In the treatment of angina pectoris, regulation is importanttation of the motor mode: it is necessary to avoid physicalany loads leading to an attack, with unstable and extreme infarction angina, the regime is limited up tobedding. The diet should be limited in volume and caloric content of food. Medicines are needed to improvegentle blood circulation and eliminating emotional stresslife

Objectives of exercise therapy: stimulate neurohumoral regulatorsnew mechanisms for restoring normal vascular

reactions during muscle work and improve cardiovascular functionvascular system, activate metabolism (fight againstatherosclerotic process), improve emotionalmental state, ensure adaptation to physicalloads In conditions of inpatient treatment with instabilityangina pectoris and pre-infarction condition to exerciseexercises begin after the cessation of strongattacks on bed rest. For other optionsnocardia, the patient is on a ward basis. Heldgradual expansion of motor activity and walkingoperation of all subsequent modes. The physical therapy technique is the sameas in myocardial infarction. Transfer from mode to osu modeis implemented at an earlier date. New starting pointsexercises (sitting, standing) are included in classes immediately, without priorcareful adaptation. Walking in ward modestarts from 30-50 m and goes up to 200-300 m, in free mode - up to 1-1.5 km or more. Walking pace is slowwith breaks for rest.

At the sanatorium or outpatient stage, the restorer For any treatment, the motor regimen is prescribed depending onon the functional class to which the patient is classified. Therefore, it is advisable to consider the methodology for determining funcnational class based on an assessment of the patient’s toleranceto physical activity.

3.3.1. Determination of physical tolerance load (TFN) and functional class patient with ischemic heart disease

The study is carried out on a bicycle ergometer in the positionsitting under electrocardiographic control. The patient performs 3-5 minute step-increasing physicalloads starting from 150 kgm/min - I step, then on each II stage - 300, III stage - 450 kgm/min, etc. - until determinedreducing the maximum load tolerated by the patient.

When determining FN, clinical and electronic criteria are used.rocardiographic criteria for cessation of exercise. To the client

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nic criteria include: achieving a submaximal (75-80%) age-related heart rate, an attack of angina, a decrease in blood pressureby 20-30% or its increase to 230/130 mm Hg. Art., attacksuffocation, severe shortness of breath, severe weakness, patient refusalfrom further testing. TO electrocardiographic kim criteriainclude a decrease or increase in a segment ST electrocardiogram for1 mm or more, frequent (4:40) extrasistolas and other disorders of myocardial excitability (paroxysmalmalal tachycardia, atrial fibrillation, atrio-ventricular, or intraventricular, conduction, ressome reduction in tooth sizes R ). The test is stopped whenabsence of at least one of the above symptoms.Stopping the test at the very beginning (1-2 minutes of the firstload stage) indicates extremely low functionalitynatural reserve of coronary circulation, it is characteristic but sick IV functional class (150 kgm/min orless) Stop sample within 300-450 kgm/minalso speaks of low reserves of the coronary circulation nia - III functional class. The emergence of the termination criterionsample pressure within 600 kgm/min - II functional class, 750 kgm/min and more - Ifunctional class.

In addition to the functional class, clinical data are also important in determining the functional class.

TOI functional class includes patients with rare
attacks of angina pectoris that occur with excessive exercise
ical loads with a well-compensated condition
blood circulation and above the specified TNF; co II functionality
nomu - with rare attacks of angina pectoris (on
example, when climbing uphill, up stairs), with shortness of breath when
build up walking and TFN 450-600 kgm/min; To III - with frequent
stupas of angina pectoris that occur during normal
high loads (walking on level ground), insufficiency
blood circulation - II A degree, cardiac rhythm disorders
ma, TFN - 300-450 kgm/min; To IV - with frequent attacks
angina pectoris at rest or exertion, with circulatory insufficiency
appeals II B degree, TFN - 150 kgm/min or less. Pain
ny IV functional class are not subject to rehabilitation in
sanatorium or clinic, treatment is indicated for them And rehabilitated
tation in the hospital. «

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3.3.2. Methods of physical rehabilitation of patients IHD at the sanatorium stage

Sick I functional class are engaged intraining regime program. In therapeutic gym classesnastika, except for exercises of moderate intensity, is allowed 2-3 short-term, high-intensity loads are performed. Training in measured walking begins with walking nia 5 km , the distance gradually increases and is brought to 8-10 km at a walking speed of 4-5 km/hour. While walkingaccelerations are carried out, sections of the route may have an ascent10-17°. After patients have mastered distance learning well tion in 10 km, they can start training by joggingtsoy in alternation with walking. If there is a pool, carry outclasses in the pool, their duration gradually increasedruns from 30 to 45-60 minutes. Movable andsports games (volleyball, table tennis, etc.). Heart rate during exercise can reach 140 beats/min.

Sick II gram of gentle training regimen. In therapeutic classesGymnastics uses loads of moderate intensityty, although short-term physical activity of high intensity is allowed. Metered walking begins with a distance of 3 km and gradually increases to 5-6. Speedwalking at first 3 km/h, then 4, part of the route may haverise 5-10°. When exercising in the pool, gradually increaseThe time spent in water is determined, and the duration of the entireclasses last up to 30-45 minutes. Skiing is possibleprogress at a slow pace. Maximum heart rate shifts - up to 130 beats/min.

Sick III functional class are engaged in program of the gentle regime of the sanatorium. Workout in dosednew walking begins with a distance500 m, increase dailyis applied at 200-500 m and gradually increased to 3 kmcoming soon 2-3 km/hour. When swimming, breaststroke is used, proper breathing is taught with lengthening the exhalation into the water. Lesson duration 30 minutes. For any form classes use only low-intensity physical activity

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loads. Maximum changes in heart rate during exercise up to PO beats/min.

It should be noted that the means and methods of physical trainingphysical exercises in sanatoriums can make a significant differencemay occur due to differences in conditions, equipment, preparednessties of methodologists. Many sanatoriums currently haveI use various exercise machines, primarily bicycle ergometers, treadmills, on which it is very easy to dose loads with electrocardiographic control. The presence of a reservoir and boats allows you to successfully use dosed rowing. In winterOver time, measured skiing is an excellent means of rehabilitation.

Until recently, patients with ischemic heart diseaseIV medical classphysical education was practically not prescribed, as it was believedthat it could cause complications. However, drug success therapy and rehabilitation of patients with coronary artery disease allowed the developmentdevelop a special technique for this heavy contingentsick.

3.3.3. Physical rehabilitation of patients with coronary artery disease IV functional class

Objectives of rehabilitation of patients with coronary artery diseaseIV functionalclass are reduced to the following:

- achieve complete self-care for patients;

- real intensity (washing dishes, cooking
food, walking on level ground, carrying small
cargo, lifting one floor);

- reduce medication;

- improve mental state.

The physical exercise program should have the following features:

- physical exercises are only carried out
in a cardiology hospital;

- precise individual dosage of loads is carried out
using a bicycle ergometer with electrocardiography
chemical control;

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- apply low-intensity loads of no more than 50-
100 kgm/min;

- the load is increased not by increasing the intensity
load, and by lengthening the time of its execution
opinions;

d- classes are conducted only after the condition has stabilizedpatient, achieved by complex medicinal treatment.

The training methodology boils down to the following. At the beginning of theindividual FN is divided. Usually in patients IV function national class it does not exceed 200 kgm/min. Set the load level to 50%, i.e. in this case -100 kgm/min. This load is training, durationInitial work time - 3 min. It is carried out under the supervision of an instructor and a doctor 5 times a week. With consistently adequatereaction to this load, it lengthens by 2-3 minutes and brings for a more or less long period of up to 30 minutes in one lessontie. After 4 weeks, the FN determination is repeated.When it increases, a new 50% level is determined, abouttraining duration is up to 8 weeks. Before trainingon an exercise bike or after it, the patient exercisestraining gymnastics while sitting. The class includes exercises for small and medium muscle groups with a number of repetitions10-12 and 4-6 times respectively. Total number of exercisesniya - 13-14. Exercise on an exercise bike is stopped whenmanifestation of any of the signs of worsening coronary blood flowideas mentioned above. To securethe achieved effect of inpatient classes for patients with rectal cancerHome training in an accessible form is recommended. In personswho stopped training at home, after 1-2 months I will observethe condition deteriorates.

At the outpatient rehabilitation stage, the occupational programtraining for patients with coronary artery disease is very similar in nature to the program of outpatient exercises for patients after myocardial infarction, but with a more bold increase in volume and intensityloads So see the next section.