Module E, Annotation D: Counsel Patient Regarding Activity Level

OBJECTIVE

Educate and reassure patient about safe activity levels.

ANNOTATION

Per the ACC/AHA AMI Guidelines (1996), patients can begin regular walk programs immediately following discharge. Sexual activity may be resumed within 7 to 10 days of discharge. Patients may resume driving a week from discharge, following an uncomplicated MI, if permitted by state laws.

Most patients with IHD, including those for whom an exercise program is contraindicated, benefit from some level of physical activity (Fletcher et al., 1997). The majority of patients who remain asymptomatic after an uncomplicated AMI can safely return to prior activities within 2 weeks, although scant data are available to guide this recommendation ( ACC/AHA AMI, 1996).

Post-CABG patients usually return to work within 6-8 weeks after surgery. It is important to individualize this decision, based upon specific job task requirements, as well as upon environmental and psychological stressors encountered in the workplace. Increased participation in domestic, occupational, and recreational activities is the goal. For more impaired patients, facilitation of functional independence is the optimal outcome (Fletcher, 1995).

Activity prescription

The physician should provide explicit advice about when to return to previous levels of physical activity, sexual activity, and employment. Daily walking should be encouraged immediately. Patients should be instructed to notify their primary care provider if cardiac symptoms occur, such as chest discomfort or angina, palpitations, dyspnea, or excessive fatigue.

Prior to performing symptom-limited stress test

Patients should be encouraged to walk and return to activities of daily living that maintain the patients within their physical limitations and below their symptomatic threshold. The primary care provider may obtain rough estimations of exercise tolerance by using the metabolic equivalents (MET) activity table (see Table 1). (METs indicate metabolic equivalents and refer to a percentage of maximum oxygen required to perform a specific task or activity). The primary care provider should also question patients about those activities that induce fatigue or cardiac symptoms.

For IHD patients who have undergone an exercise stress test

The safety and scope of activity can be determined by comparing MET-level performance on a symptom-limited exercise test with the MET level required for the desired activity (Table 1). The MET table presents energy levels, expressed in METs, required to perform a variety of common activities. The MET table can be helpful in translating a patient's performance on an exercise test into daily activities that may be undertaken with reasonable safety. All activity recommendations must be below the onset of symptoms (e.g., angina and shortness of breath) and/or ischemic ECG changes.

Resumption of sexual activity

In stable patients without complications (Class I), sexual activity with the usual partner can be resumed within 7 to 10 days; typically, when the patient can climb 2 flights of stairs or perform 5 METs of activity.

Return to driving

Most post-MI patients can return to driving within a week of hospital discharge. Post-CABG patients, with midline sternotomy, may usually return to driving within 4 to 6 weeks after surgery.

Table 1. Energy Levels Required to Perform Common Activities
<3 METs	3-5 METs	5-7 METs	7-9 METs	>9 METs
Walking (2 mph) Driving auto Standing (store clerk)	Level walking (3-4 mph) Sexual activity	Level walking (4.5-5.0 mph) Climbing stairs (slowly)	Level jogging (5 mph) Climbing stairs (moderate speed)	Walking uphill (5 mph) Running (>6 mph) Climbing stairs (quickly)
Stationary bike (with little or no tension) Very light calisthenics Golf (cart)	Level biking (6-8 mph) Light calisthenics Dancing (social) Golf (walking) Sailing Tennis (doubles) Volleyball (6 persons)	Swimming, breast stroke Badminton (competitive) Tennis (singles) Snow skiing (downhill) Light Backpacking Basketball Football Stream fishing	Bicycling (12 mph) Canoeing Mountain climbing Paddle ball Swimming (crawl stroke) Rowing machine Heavy calisthenics	Bicycling (>13 mph) Vigorous basketball Rope jumping Ski touring Handball/squash
Washing Shaving Dressing Desk work Washing dishes Light housekeeping Sitting (clerical) Typing Knitting Hand sewing	Carrying objects (15-30 lbs) Stocking shelves (light objects) Auto repair Light welding/ carpentry Cleaning windows Raking Power lawn mowing Bedmaking	Carrying objects (30-60 lbs) Easy digging in garden Level hand lawn mowing Digging vigorously Carpentry (exterior) Shoveling dirt Sawing wood Operating pneumatic tools	Carrying objects (60-90 lbs) Sawing wood Heavy shoveling Digging ditches (pick and shovel)	Carrying loads upstairs (objects >90 lbs) Shoveling heavy snow Lumber jack Heavy laborer

METs indicate metabolic equivalents and refer to a percentage of maximum oxygen required to perform a specific task or activity. MET is a unit measuring functional capacity. As functional capacity increases, the MET level increases.

DISCUSSION

In PAMI-II, a study of primary PTCA in low-risk patients with AMI (age <70, EF >0.40, one-two vessel disease, and good PTCA results), patients were encouraged to return to work at two weeks. The timing of return to work was not reported, but no adverse events occurred as a result of this strategy (Grines et al., 1998).