Cardiac Rehabilitation
Case Study of a Patient That Sustained a Myocardial Infarction and Subsequent Congestive Heart Failure
by John Petrizzo, DPT, SSC and Alexander Pisanello, DPT
| September 25, 2025
The subject of this case study is a 76-year-old male that sustained a
myocardial infarction and underwent a left anterior descending artery
bypass graft on January 5, 2025. As a result of the infarction and
subsequent surgical procedure, he had a left ventricular ejection
fraction of 25%.
For those who may be
unfamiliar with that term, a normal ejection fraction is roughly
50-70%. This means that in a healthy individual, 50-70% of the blood
that is in their left ventricle is ejected from the heart with each
contraction. The left ventricle of the heart is the chamber that is
responsible for pumping oxygen-rich blood to the rest of the body. An ejection fraction below 30% is
considered to be severely abnormal.
The signs and symptoms the patient presented with, including, but not
limited to, ventricular pump dysfunction, pulmonary edema, nocturnal
dyspnea (shortness of breath), bilateral pitting edema, orthopnea
(dyspnea while lying down), and dyspnea, are a clinical presentation
that is consistent with congestive heart failure, which is a
condition that arises when the heart cannot pump enough blood to meet
the body’s needs.
The patient’s
physician, who is a friend and colleague of mine, referred the
patient to me for cardiac rehabilitation. Fortunately, this physician
is well aware that I utilize resistance training in the form of
properly titrated and dosed squats, deadlifts, overhead presses, and
bench presses as a cornerstone for treatment with the patient
population that I currently serve. Similarly, I treated this patient
at my clinic, where the owner encourages the Starting Strength method
of strength training, and allows me to see patients one-on-one for a
reasonable period of time.
I feel fortunate that I
have been given the freedom to utilize barbell exercises in my
treatment programs for my patients, as I realize the negative
connotation that is still associated with these exercises by many in
the rehabilitative field.
The guidelines for
cardiac rehabilitation state specifically that this patient
population benefits from incrementally increasing progressive
strength training and aerobic conditioning. However, there are
specific criteria for the initiation, modification, and termination
of exercise when working with this patient population. Cardiac
rehabilitation is reserved for medical professionals that are
licensed, competent, and able to consistently monitor for signs and
symptoms requiring the modification and or termination of exercise.
I currently teach
Cardiac Rehabilitation at Quinnipiac University, Anderson University,
and Wheeling University, and have actively taught it at many
universities nationwide for National Physical Therapy licensing exam
purposes. I also have implemented cardiac and pulmonary
rehabilitation for a diverse patient population over the course of
the last 5 years.
I evaluated and began
treating the patient on February 12, 2025. He was taking several
medications that impact heart function at the time he began working
with me. Those medications included a beta-adrenergic antagonist, a
diuretic, and organic nitrates, to name a few. At baseline, the
patient was unable to get out of a 17-inch chair without the use of
his arms, and could only walk 350 feet without gasping for air,
requiring him to sit down. His chief complaint was that he was weak,
deconditioned, and unable to get up the stairs in his home, with the
use of a handrail and becoming short of breath. The patient’s
impairments negatively impacted the performance of instrumental
activities of daily living, recreational activities, and occupational
tasks. Physical therapy services were recommended to reduce symptoms
of dyspnea, improve exercise tolerance and aerobic capacity, enhance
strength, and optimize locomotion, the performance of instrumental
activities of daily living, and recreational activities.
I began by teaching the
patient how to squat, deadlift, and overhead press, as outlined in
Starting Strength: Basic Barbell Training 3rd edition.
However, his poor physical condition at the time of his evaluation
necessitated significant modification compared to that of a healthy
individual. At this first session, he was able to deadlift a 5-pound
kettlebell for 1 set of 5 repetitions, and his overhead press was two
3-pound dumbbells for 1 set of 5 repetitions. I taught him
appropriate squat mechanics, and he was able to do 1 set of 5
repetitions starting from a 17-inch support surface without using his
hands. We did some light intervals on the air bike for conditioning
after his resistance training.
I discharged the
patient for the first time on 03/31/25, about 6 weeks later. I was
seeing him once a week in the clinic at the time of discharge. Prior
to his discharge, he goblet squatted 30 pounds for 3 sets of 5, did a
standing dumbbell overhead press for 3 sets of 8 with 20 pounds, and
he performed a dumbbell deadlift for 3 sets of 5 with 30 pounds. I
also observed him climb 15 flights of stairs in the clinic without a
problem. His 6-minute walk test distance was over 1500 meters. While
nobody in the Starting Strength community would necessarily consider
the patient to be “strong” at the time of his initial discharge,
it was amazing to see how profoundly a modest gain in strength
impacted his overall function. It is obvious that the patient could
have gotten significantly stronger and more aerobically conditioned;
however, he was very happy with the results and requested to be
discharged at that time.
He returned for 6 more
sessions, commencing on 05/29/25 and ending on 06/20/25. When he was
discharged the second time on 06/20/25, he could high bar squat with
30 pounds below parallel for 3 sets of 5 with a box, overhead press
32.5 pounds for 3 sets of 5, and he could deadlift 95 pounds from the
floor for 1 set of 5. Once again, he was satisfied with the results
he got under the bar and decided to end physical therapy at that
time.
This case study is
evidence that when carefully monitored and properly titrated and
dosed, the basic barbell exercises can be extremely beneficial for
even the most sick and frail among us.
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