Prior to each exercise session, any changes in the patient’s clinical state since the last training session should be noted, including signs or symptoms of reduced exercise tolerance such as:

• Worsening dyspnoea
• Dizziness
• Angina at lower workloads
• Increased fatigue

Prior to each supervised exercise session, the following should also be measured:

Body weight – Rapid weight gain (Eg., increase by >2 kg over 48 hours) is a contraindication to exercise as often indicates fluid retention and possible decompensation in those with HF. As this is often associated with worsening symptoms, exercise should be avoided in these patients until review by the patient's supervising physician or cardiac nurse. If these individuals are unavailable, the patient should present to their GP or emergency department. 

Conversely, a sudden loss of weight may also be of concern, as this may be suggestive of dehydration.

Blood pressure (BP) – If resting systolic BP is > 180 mmHg or resting diastolic blood pressure is > 110 mmHg, the exercise session should not commence. Symptomatic hypotension may also preclude exercise.

Heart rate (HR) – The exercise session should not commence if resting HR is >100 beats per minute (bpm) or in cases of significant bradycardia. Changes in cardiac rhythm can be determined by palpating the pulse manually. An irregular pulse in someone with a previously regular rhythm requires further investigation as this may represent a new arrhythmia. Exercise training should be avoided until this has been further investigated.

Oxygen saturation (SpO₂) – If available, oxygen saturation is a useful measure to assist appropriate exercise prescription and to identify the need for supplemental oxygen during the exercise session. In the absence of respiratory disease, patients with HF usually present with a normal SpO2. A reduction in SpO2 in these patients may represent decompensated HF. 

Where possible or relevant, the following assessments may be required:

ECG – An ECG may be warranted to monitor for tachyarrhythmias and bradyarrhythmias and myocardial ischaemia, particularly in symptomatic individuals or those with new objective findings

Blood glucose – Blood glucose levels should be measured before and after exercise in individuals with diabetes. For some individuals, hypoglycaemia may be addressed, for example, by carbohydrate intake prior to commencing exercise. New and significant changes in blood glucose levels may represent infection, effects of medication or other causes,  and should thus be investigated further.

Physiological monitoring during exercise may be warranted for those:

• with complicated disease
• who are symptomatic with exercise
• who have poor understanding of their condition

Self-monitoring

All patients should be educated and encouraged to self-monitor their exercise intensity progress and response, in order to promote self-confidence in undertaking exercise or activity outside of a clinical environment. The rating of perceived exertion (RPE) is commonly used to monitor exercise intensity and patients should be encouraged to rate the RPE for each exercise during their exercise session. For more information see Borg's rating of perceived exertion.  Physiological monitoring may be weaned as the individual nears completion of the program.

Data from exercise assessments should be recorded on an exercise monitoring form. Only parameters relevant to the individual should be recorded.

Examples of parameters that may need monitoring include:

• Blood pressure and heart rate assessment – in those who are:
  • Symptomatic during exercise or those with BP concerns prior to the exercise session
  • At high risk of an exercise-related cardiac event (see Safety considerations)

• Oxygen saturation monitoring – in those with excessive breathlessness during exercise or those with marginal SpO2 prior to the exercise session

• Blood glucose level – in diabetics who are symptomatic during exercise

ECG telemetry monitoring

In cardiac rehabilitation, ECG telemetry monitoring does not reduce adverse events or prevent sudden death, but can be useful for several sessions to document a patient’s exercise response and to identify rhythm abnormalities if the HR is irregular on palpation, linking symptoms with arrhythmias. However, long-term reliance on ECG monitoring can be detrimental to a patient exercising confidently away from a monitored environment.

TIP: If using a HR monitor, it is still valuable to palpate the pulse manually to determine regularity and to confirm the accuracy of the monitor. HR monitors are less accurate for irregular pulses such as occurs with AF or those with frequent ectopics.

Individuals should be observed for at least 10 minutes following the exercise session to ensure safety, prior to leaving the facility.

All patients should be assessed following the exercise session to determine their individual response. For some, this may be a simple subjective review of symptoms whilst for others a more detailed assessment may be warranted. For example, blood glucose should be reassessed for diabetics, whilst for others, BP, HR or SpO₂ may be appropriate.