REVIEW/REVISÃO

PHYSICAL EXERCISE AFTER MYOCARDIAL INFARCTION:

SAFETY DURING EXERCISE
EXERCÍCIO FÍSICO APÓS INFARTO AGUDO DO MIOCÁRDIO: SEGURANÇA
Daniel Godoy Martinez1
Leonardo Barbosa de
Almeida1
Patrícia Fernandes Trevizan1
Lilian Pinto da Silva1
Mateus Camaroti Laterza1
1. Unit of Cardiovascular Research
and Exercise Physiology (InCFEx),
Federal University of Juiz de Fora
(UFJF), MG, Brazil.
Correspondence:
Daniel Godoy Martinez
Faculty of Physical Education and
Sports, Federal University
of Juiz de Fora. Rua José Lourenço
Kelmer, s/n. University Campus
Juiz de Fora, MG 36036-900, Brazil
danielgmartinez@yahoo.com.br
DURANTE O EXERCÍCIO
ABSTRACT
The long-term benefits of exercise-based cardiac rehabilitation for MI patients are now
indisputable. However, physical exercise sessions markedly increase the risk of cardiovascu-
lar events through cardiac, autonomic, inflammatory and vascular mechanisms. Therefore,
it is important to recognize the aspects related to the pathophysiology, exercise physiology,
evaluation, exercise prescription and monitoring of post-MI patients, as recommended by
the main guidelines for the treatment of the disease. Among the ways to reduce the risks
during physical exercise, we highlight risk stratification of the patient through anamnesis and
the physical exercise test. Prescription of adequate physical exercise during the different
phases of cardiac rehabilitation is also indicated, progressively increasing the intensity and
volume according to the clinical evolution of the patient. It is also important to monitor the
vital signs, perceived exertion, and possible cardiac ischemias and arrhythmias, depending
on the phase of cardiac rehabilitation. With these measures, the numbers of fatal and
nonfatal cardiac events indicate that exercise-based cardiac rehabilitation is considered
safe, provided the relative and absolute indications and contraindications to the practice
of physical exercise in post-MI patients are followed.

Keywords: Exercise; Rehabilitation; Myocardial Infarction.

336 Received on 06/06/2018,
Accepted on 08/03/2018

RESUMO
Atualmente, os benefícios da reabilitação cardíaca baseada em exercícios para pacientes
após IAM são indiscutíveis a longo prazo. Porém, as sessões de exercício físico aumentam
acentuadamente o risco de eventos cardiovasculares através dos mecanismos cardíacos,
autonômicos, inflamatórios e vasculares. Portanto, conhecer os aspectos relacionados à
fisiopatologia, fisiologia do exercício, avaliação, prescrição do exercício e monitorização
dos pacientes pós-IAM, recomendados pelas principais diretrizes de tratamento da doença,
é de suma importância. Entre as maneiras de reduzir os riscos durante o exercício físico,
destaca-se a estratificação de risco do paciente através da anamnese e teste de esforço
físico. Além disso, é indicada a prescrição de exercício físico adequada durante as diferentes
fases de reabilitação cardíaca, aumentando a intensidade e volume progressivamente com
a evolução clínica do paciente. Também é importante a monitorização dos sinais vitais, da
percepção de esforço, de possíveis arritmias e isquemias cardíacas, dependendo da fase
da reabilitação cardíaca. Com essas medidas, os números de eventos cardíacos fatais e
não-fatais indicam que a reabilitação cardíaca baseada em exercícios é considerada segura,
desde que sejam seguidas as indicações e contraindicações relativas e absolutas para a
prática de exercício físico em indivíduos pós-IAM.

Descritores: Exercício; Reabilitação; Infarto do Miocárdio.

INTRODUCTION
Five decades prior, bed rest was recommended for patients
recovering from acute myocardial infarction (MI) to improve
myocardial healing.1 However, reduced cardiac function, loss
of skeletal muscle mass, impaired functional capacity, and in-
creased anxiety and depression symptoms were observed after
these patients were discharged from the hospital. Therefore,
since the 1960s, several studies have analyzed the effect of
early physical exercise on MI patients, and cardiac rehabilita-
tion based on physical exercise was instituted to prevent the
deleterious effects of prolonged bed rest.2
Performing physical exercise as an integral part of cardiac
rehabilitation is extremely relevant for the clinical evolution of
patients after MI. Several guidelines for cardiac rehabilitation

http://dx.doi.org/10.29381/0103-8559/20182803336-41 Rev Soc Cardiol Estado de São Paulo - Supl - 2019;28(3):336-41

 PHYSICAL EXERCISE AFTER MYOCARDIAL INFARCTION: SAFETY DURING EXERCISE
or treatment of MI recommend performing physical exercise
after hospital discharge3-16 because there is an improvement
in morbidity and a decrease in mortality of patients performing
the physical training program.17,18
Currently, the long-term benefits of a physical training
program are undeniable, such as cardiovascular protection
and improved prognosis. However, physical exercise sessions
increase the risk of acute cardiovascular events. Moreover,
the increased risk of cardiovascular adverse events seems
to be directly related to the intensity of the proposed physical
exercise. However, if an individual routinely practices physical
exercise, the relative risk of cardiovascular events during
physical exercise decreases considerably.19
Based on these findings, it is relevant to consider the
pathophysiology of MI and the principles of physical training
to minimize the risks and maximize the benefits, and thus pro-
mote an adequate and safe care practice for these individuals.
CLINICAL PHYSIOLOGY OF PHYSICAL
EXERCISE AND CARDIOVASCULAR RISK
Atherosclerotic disease is associated with >80% and
>95% of cases of sudden cardiac death related to physical
exercise in individuals older than 35 and 40 years, respec-
tively.19 Therefore, the practice of physical exercise after MI
should be performed safely, and it is crucial to understand
the factors that contribute to the cardiovascular risk induced
by physical exercise during and after its practice.
During physical exercise, sodium or potassium imbalances
can occur depending on factors such as intensity, duration,
and local temperature. In combination with increased levels
of circulating catecholamines, such imbalances can increase
myocardial irritability.20
It is well known that patients with acute coronary syndro-
me, with or without subsequent MI, have increased levels
of inflammatory markers. Moreira et al.21 showed increased
inflammatory marker levels, such as high-sensitivity C-reactive
protein, interleukin-6, and lipoprotein-associated phospho-
lipase A2, in patients with acute coronary syndrome during
the acute phase.
Moreover, during physical exercise, increases in prothrom-
botic activity and inflammatory factor levels can destabilize
the remaining atherosclerotic plaques, leading to decreased
coronary perfusion and myocardial ischemia. In addition to
the impairment caused by ischemia in cardiac myocytes,
cardiac electrical conduction can also be impaired, leading
to changes in both depolarization and repolarization, which
can increase ventricular ectopic activity and can evolve to
more significant and severe cardiac arrhythmias.20
During physical exercise, the sympathetic nerve activity
increases, and the parasympathetic (vagal) nerve activity
decreases. This leads to increased heart rate and blood
pressure level, culminating in increased myocardial oxygen
consumption. In patients with coronary artery disease (CAD),
this can lead to increased risk for myocardial ischemia, which
can reinforce changes in depolarization and repolarization, as
well as alter cardiac conduction velocity, resulting in increased
ventricular ectopic activity.20 Compared with healthy individuals,
patients have increased levels of muscle sympathetic nerve
activity (MSNA) both at rest and during isometric handgrip
exercise even approximately 30 days after an acute MI.
Rev Soc Cardiol Estado de São Paulo - Supl - 2019;28(3):336-41
Moreover, during physical exercise, these patients also did
not present the expected muscle vasodilator response.22 This
result can be associated with increased MSNA, endothelial
dysfunction, or both. Taken together, these factors can explain,
at least in part, the lower tolerance to physical exercise and
worse prognosis in these patients.
The recovery period after physical exercise is extremely
important considering the hemodynamic and autonomic
changes observed during its practice. Traditionally, performing
the so-called cool down after the physical exercise session is
recommended because abrupt cessation of physical exercise
can lead to decreases in venous return due to lack of muscle
contraction, which is known to aid in the pumping of blood
from the muscles (called the peripheral heart) back to the
heart. In association with the lack of muscle contraction,
excessive arterial vasodilatation of the active muscles can
also contribute to the decrease in venous return, which would
lead to a decrease in cardiac output, blood pressure, and
coronary perfusion, and, ultimately, to myocardial ischemia.20
Given the physiology of physical exercise and patho-
physiology of CAD, consideration of the patient’s safety is
important when prescribing and supervising physical exer-
cise, particularly in patients after MI. Based on this, several
guidelines worldwide indicate when to begin cardiac reha-
bilitation through the practice of physical exercise after MI.
Subsequently, the main guidelines on cardiac rehabilitation
with physical exercises after MI will be addressed.
Physical exercise-based post-MI cardiac
rehabilitation
337
Cardiac rehabilitation, which includes physical exercise,
is defined by the World Health Organization as a continuous
action for the development and maintenance of suitable
mechanisms to ensure that the patient has the best physical,
mental, and social conditions to return to and/or maintain his
social and professional activities in an independent manner.3
Cardiac rehabilitation is multidisciplinary and aims at increa-
sing adherence to health care and promoting the adoption of
healthy lifestyle habits.4 The main national and international
guidelines for the treatment of patients after MI or myocardial
revascularization indicate physical exercise-based cardiac
rehabilitation as a strategy to increase functional capacity,
relieve ischemic symptoms, promote the return to social
and professional activities, and, most importantly, reduce
cardiovascular mortality.3-11
A recent systematic review with a meta-analysis that in-
cluded 63 randomized controlled trials (RCTs) with a sample
of 14,486 participants, predominantly post-MI and post-
-revascularization, showed that physical exercise reduced
cardiovascular mortality (relative risk ratio [RR], 0.75; 95%
confidence interval [CI], 0.64–0.86) and reduced the risk of
hospital readmission (RR, 0.82; 95% CI, 0.70–0.96).17
Normalization of MSNA and baroreflex sensitivity are
among the possible mechanisms to improve the prognosis
of patients after cardiac rehabilitation.23 The increase in MSNA
is known to be associated with a worse prognosis, at least
in patients with heart failure.24 Furthermore, the decrease
in baroreflex sensitivity observed in patients after MI is also
associated with a worse prognosis.25 In contrast, the practice
of aerobic physical exercise for 6 months in patients after MI
 has been shown to decrease and normalize the MSNA and
baroreflex sensitivity. These changes were not observed in
patients with MI who were sedentary during the study.23 Thus,
the authors propose the practice of physical exercise as an
important non-pharmacological approach for the long-term
treatment of patients, which positively influences the patho-
physiology of MI.
Another aspect to consider is the cost-effectiveness of
physical exercise-based cardiac rehabilitation. Based on
this, Anderson et al.17 performed a systematic meta-analysis
of 4 RCTs that evaluated the economic impact of physical
exercise. Physical exercise-based cardiac rehabilitation has
been shown to be potentially cost-effective for increasing the
quality of life adjusted for the years of the study.
Despite the indication of post-MI physical exercise by the
world’s leading cardiology societies, only 5%–30% of the eli-
gible patients have been estimated to participate in a cardiac
rehabilitation program, regardless of adherence rates to this
type of non-pharmacological treatment.8 Thus, the guidelines
indicate that integration with primary health care, promoting the
practice of physical exercise in the community and at home,
considering the age, pre-MI physical activity level, and physical
limitations, in addition to the indication of specialized centers,
is relevant to increase the number of patients participating in
rehabilitation programs after hospital discharge.8-11
POST-MI AND/OR POST-MYOCARDIAL RE-
VASCULARIZATION PHYSICAL EXERCISE
Risk stratification
338 After hospital discharge due to acute MI or myocardial
revascularization, the guidelines indicate with a strong degree
of evidence that patients should be encouraged to practice
regular physical exercise for secondary prevention. Thus,
the Brazilian and South American cardiac rehabilitation
guidelines4,8 and the European and American cardiology
societies advocate stratification of the cardiovascular risk
through anamnesis and a physical exercise test (Table 1).5-7,9-11
Initially, information on the patient’s clinical history, existen-
ce of cardiovascular risk factors, ischemic symptoms, and
osteomioarticular alterations that may limit the practice of
physical exercise should be collected. In addition, a physical
exercise test should ideally be performed using an ergometric
test or a cardiopulmonary exercise test to identify the onset
of myocardial ischemia induced by exertion and to obtain
information on ventricular function and existence of cardiac
arrhythmias and cardiac conduction abnormalities. It is also
possible to determine the heart rate (HR) using these tests
and oxygen consumption (VO2) and ventilatory thresholds for
the prescription of physical training through the evaluation of
expired gases (cardiopulmonary exercise test).
The guidelines indicate that the physical exercise test
should be performed to guide the prognosis and prescription
of physical training. Thus, evidence suggests that the ergo-
metric test, for example, should be performed early in the
hospital and through special protocols of low intensity and
energy expenditure.4,5,8,12 The South American Cardiovascular
Rehabilitation Guidelines more specifically indicates that the
stress test should be performed after hospital discharge and in
the first 4-7 weeks of physical training to adjust the prescription.
Table 1. Cardiac risk stratification.14
Low risk
No significant left ventricular dysfunction (ejection fraction >50%)
No complex at rest or exercise-induced arrhythmias
Acute MI; myocardial revascularization surgery; percutaneous
transluminal coronary angioplasty (uncomplicated)
Absence of congestive heart failure or signs/symptoms of post-
event ischemia
Asymptomatic, including absence of angina with exertion or
during the recovery period
Functional capacity ≥7 METs (in ergometric test)
Moderate risk
Moderate left ventricular dysfunction (ejection fraction, 40– 49%)
Signs/symptoms, including angina in moderate-intensity
exercises (5–6.9 METs) or during the recovery period
High risk
Severe left ventricular dysfunction (ejection fraction <40%)
Survivors of cardiac arrest or sudden death
Complex ventricular arrhythmias at rest and/or during exercise
AMI or complicated cardiac surgery with cardiogenic shock; heart
failure
Post-procedure signs/symptoms of myocardial ischemia
Abnormal hemodynamics with exercise (especially SBP drop or
chronotropic incompetence)
Functional capacity <5 METs
Signs/symptoms of angina at low-intensity exercises (<5 METs)
or during recovery
Ischemic ST-segment depression during exercise (>2 mm)
MI, acute myocardial infarction; MET, unit/metabolic equivalent; SBP, systolic blood pressure.
Cardiac risk stratification according to the American Association of Cardiovascular and
Pulmonary Rehabilitation – AACVPR14.
After risk stratification, annual reevaluations are indicated for
patients classified as low risk and biannual reevaluations for
patients classified as having moderate and high risk and/or
with emerging symptoms.4,8,13
Before starting the physical training, the patient’s functional
capacity should be assessed by the Six-Minute Walk Test to
determine the current state of the patient and as a periodic
measurement within the rehabilitation program.8
Post-hospital discharge physical exercise or Phase 2
After risk stratification, the main treatment guidelines for
MI and myocardial revascularization recommend aerobic
exercise as the main non-pharmacological approach.4-11 The
American Heart Association (AHA) established that supervised
physical exercise should be initiated at hospital discharge or
until the first return visit is scheduled, that is, approximately 1–2
weeks.5 Approximately 2–3 months after hospital discharge,
cardiac rehabilitation is designated as Phase 2 or the conva-
lescence phase.4 During this period, it is recommended that
all symptoms arising during and/or after physical exercise
are reported to the attending physician.5 Low to moderate
intensity aerobic physical exercises are generally prescribed
in Phase 2 cardiac rehabilitation, with no physical impact in
the first few weeks, lasting at least 30 min with a frequency
of at least thrice weekly. However, physical exercise should
be ideally practiced for 30–60 min, 7 days a week, and at
moderate intensity.4-9 However, because most post-MI patients
are sedentary and physically unconditioned, initiating aerobic
Rev Soc Cardiol Estado de São Paulo - Supl - 2019;28(3):336-41
 PHYSICAL EXERCISE AFTER MYOCARDIAL INFARCTION: SAFETY DURING EXERCISE
physical exercises lasting 10 min, with gradual increases in
duration, should be sufficient, to prevent muscle injuries,
fatigue, and overtraining.14
The South American Cardiovascular Rehabilitation Gui-
delines recommend practicing aerobic physical exercise
with an intensity of 60% to 80% of the maximum HR reached
in the ergonometric test or 50% to 70% of the HR reserve8:
HRtraining = [((HRmax- HRrest) x Intensity) + HRrest]
In contrast, the AHA indicates the prescription of moderate-
-intensity aerobic exercise of 60% to 75% of the maximum HR
reached in the exercise stress test.6 If the cardiopulmonary test
has been performed, the intensity should not exceed the anae-
robic threshold.8 Moreover, the prescribed aerobic physical
exercise should not exceed the ischemic threshold presented
in the exercise stress test, and prescribing an intensity 10 bpm
below the ischemic threshold is recommended.15 For the first
sessions, prescribing an intensity within the lower limits with
a progressive increase of intensity in subsequent weeks or
according to the patient’s adaptation is recommended. The
intensity of physical exercise can also be assessed using
the Borg subjective scale of perceived exertion. This scale
is graded from 6 to 20, and the exercise is stratified as low
(<12), moderate (12–14), and high (>14).8 In addition, the
Cardiac Society of Australia & New Zealand indicates that
low-to-moderate physical exercise can be monitored by the
individual’s ability to talk despite increased respiratory rate
during physical exercise.9 In addition to structured aerobic
exercise, an increase in physical activity level is recommended
by performing walks and household activities.5
According to the European Society guidelines on primary
cardiovascular prevention in healthy individuals, replacing
continuous moderate-intensity aerobic exercise by high/vi-
gorous-intensity exercise is possible. In this case, aerobic
exercise is prescribed at intensities exceeding 80% of the
maximum HR reached in the exercise stress test, for 15 min
per session, five times a week, with a total minimum volume
of 75 min per week. Concerning primary prevention, high-in-
tensity interval physical training has not been recommended
until safety and efficacy studies are available.14 Specifically
after MI, no guidelines have indicated high-intensity physical
exercise for secondary prevention and improvement of clinical
outcomes, although recent studies have shown positive effects
with this type of training.26,27
In addition to aerobic exercise, all guidelines indicate the
concomitant use of resistance exercises. According to AHA6,
resistance training should be considered after MI and started
2–4 weeks after starting the aerobic physical exercise. Based on
the Brazilian Guidelines on Cardiac Rehabilitation, the isometric
component of resistance exercises increases blood pressure
(BP), particularly diastolic BP (DBP). Increases in DBP lead to
increased coronary perfusion and reduced ischemic process.
In addition, resistance training improves trophism, mass and
skeletal muscle oxidative capacity, thereby increasing oxygen
consumption.4 The European and American cardiology societies
indicate resistance exercises at least twice weekly after MI.5,7 In
Phase 2 of cardiac rehabilitation, resistance exercises should
be started with a light load and gradually progressed to allow
adaptation and execution of the exercises with a correct posture.
Resistance training should be performed 2 to 3 times a week
Rev Soc Cardiol Estado de São Paulo - Supl - 2019;28(3):336-41
with 6 to 15 repetitions per muscle group involved and intervals
of 30 s to 1 min between exercises.8
Flexibility exercises should also be part of the cardiac
rehabilitation program. After MI, it is recommended to start
with light flexibility exercises and to progressively increase
the intensity, without discomfort, and perform them at the
beginning and, more importantly, at the end of the session.8
In Phase 2 of the cardiac rehabilitation, considering the
severity of cardiac event and the risk stratification, monito-
ring the patient throughout the physical exercise session;
measuring the HR, BP, oxygen saturation, and subjective
perceived exertion; and in patients with cardiac arrhythmias,
electrocardiographic monitoring, are recommended.4,8,15
Physical exercise in Phase 3
Normally, the patient can perform the physical exercise
in Phase 3 after 3 months of physical exercise in Phase 2 of
cardiac rehabilitation. For this, the patients must be asymp-
tomatic and without signs of myocardial ischemia and left
ventricular dysfunction.4,8,15 If the patient had a cardiac event
and was not referred immediately after hospital discharge to a
physical exercise program in 1 year, the patient is considered
to start physical exercise in Phase 3.4,5
At that moment, it is recommended to perform a new
exercise stress test using protocols of greater intensity and
energy expenditure to determine the cardiac risk associated
with physical exercise, and the parameters that will assist in
the prescription of physical training.4,8,15
The American, European, and South American cardiology
societies recommend performing aerobic physical exercise at
least 3 to 5 times a week, lasting between 30 and 60 min, with 339
moderate intensity (50% to 80% of the HR reserve or 70% to
90% of the maximum HR reached in the exercise stress test
or Borg score of 12–14).4-6 Similar to Phase 2, the intensity of
aerobic physical exercise should be prescribed 10 bpm below
the ischemic threshold.15 Electrocardiographic monitoring is
recommended in the first 6 to 12 sessions to determine the
relationship between the intensity of the physical exercise
and cardiac arrhythmias.8
Resistance physical exercise should be introduced during
this phase, with progressive loads, sufficient to cause fatigue
in the last 3 repetitions but without causing movement failure.
Resistance exercise should be prescribed at least thrice
weekly, with 8 to 15 repetitions per muscle group. One possible
alternative to resistance exercise is the Pilates method, which,
in addition to resistance exercise, also includes flexibility and
breathing exercises. Similar to Phase 2, flexibility exercises
can be performed at the beginning and, more importantly,
at the end of the physical exercise session. Yoga and Tai Chi
Chuan are among the alternatives for this type of exercise.
Elderly individuals can also benefit from neuromotor exercises,
with the aim of improving balance and motor coordination,
although the prescription for these exercises is unknown.8
Phase 3 of cardiac rehabilitation lasts between 3 and 12
months, and after this period, the patient will participate in
Phase 4 of cardiac rehabilitation, which is the maintenance
phase. At that moment, the individual will perform physical
activity in an unsupervised manner, and the intensity of the
prescribed physical exercise is limited by the functional ca-
pacity. In Phase 4, the individual should be knowledgeable
 about the disease, should have a controlled BP and HR at
rest and during the exercise stress test, and should be able to
monitor the physical exercise session.4 For the patient to follow
in an independent and effective manner in this phase, health
education must be a constant goal in the previous phases.
The physical exercise session in Phases 2, 3, and 4 should
comprise warm-up, aerobic exercise, and localized muscular
resistance, followed by relaxation and cool down.4,8,15
Safety and contraindications
Patients enrolled in a physical exercise-based cardiac
rehabilitation program are at risk of developing arrhythmias,
MI, and cardiorespiratory arrest. However, according to the
Society of Cardiology of Australia & New Zealand, the risk
of a patient developing a non-fatal and a fatal cardiac event
is 1:115,000 and 1:75,000 patients/h of physical exercise,
respectively.9 The South American Guidelines present similar
data. The incidence of cardiac events, MI, and mortality during
physical exercise is estimated to be 1:112,000, 1:300,000,
and 1:790,000 patients/h, respectively.8
To make physical exercise safe for patients who had an MI
or who have been revascularized, accurate initial assessment,
risk stratification, and adequate monitoring during the sessions
are important. Moreover, for greater safety during the physical
exercise session, a specialist physician or trained staff should
be present to adequately manage potential emergency com-
plications. Therefore, the team involved in the rehabilitation
process should be trained and updated on basic life support
techniques such as manual cardiopulmonary resuscitation
and/or handling an automated external defibrillator.
340 In addition, there are relative and absolute contraindica-
tions to physical exercise in this population (Table 2). Therefore,
physical exercise-based cardiac rehabilitation program is
considered safe by the world’s leading cardiology societies.4-11
Table 2. Absolute contraindications for the practice of physical exercise
in cardiovascular rehabilitation programs.
Very recent acute myocardial infarction (<72 h)
Unstable angina (<72 h of stabilization)
Severe symptomatic valve disease with surgical indication
Uncontrolled arterial hypertension (SBP>190 mmHg and/or
DBP>120 mmHg)
Decompensated heart failure
Severe ventricular arrhythmias
Suspected left coronary artery trunk lesion (unstable/severe)
Infective endocarditis; myocarditis; pericarditis
Severe symptomatic congenital cardiomyopathies
Pulmonary thromboembolism and acute thrombophlebitis
Aortic dissection (type A or B in the acute phase)
Severe symptomatic left ventricular outflow tract obstruction
with low induced exertion
Uncontrolled diabetes mellitus
Acute systemic infectious disease
SBP, systolic blood pressure; DBP, diastolic blood pressure. Absolute contraindications
for the practice of physical exercise in cardiovascular rehabilitation programs outside the
hospital (Phases 2, 3, and 4) according to the South American Cardiovascular Prevention
and Rehabilitation Guidelines.8
AUTHORS’ CONTRIBUTIONS: DMG, LBA, PFT, LPS, and MCL actively participated in the discussion of the results and in the review and
approval of the final version of the article.
Special situations
In revascularized patients, special attention should be
given to the exercises because a surgical scar is frequently
seen in the initial phase in the thorax and lower limbs.16
The return to sports activities will depend on the clinical
assessment and complementary tests, in addition to the risk
stratification. For low-risk patients, mild- and low-intensity
competitive sports, such as boccia and golf, can be prescribed
after hospital discharge. For moderate- and high-risk patients,
competitive sports should be avoided initially.16
The return to professional activities is a strong indicator of
health recovery, indicating that prolonged medical leave is not
beneficial.11 The decision to return to professional activities is
based on ventricular function, the revascularization procedure
performed, and the type of professional activity. Therefore, after
hospital discharge, even patients with moderate ventricular
dysfunction and mild ischemia in the exercise stress test
can return to office work for a maximum of 8 h because they
will remain seated and static most of the time. Patients with
severe ventricular dysfunction and/or moderate myocardial
ischemia can return to office work if their exercise capacity
is >5 METs without presenting with symptoms. Otherwise,
they should not return to professional activities. In contrast,
patients with jobs that require manual activities or moderate
physical activity should not exceed 50% of the maximum
functional capacity and should work for a maximum of 4 h in
the first month, with monthly increments of 2 h, depending
on their tolerance.8
Sexual activity can be resumed early if it is adjusted to
the ability to perform physical exercise.11
For patients with compensated MI and revascularized
patients, the clinical condition and anxiety level should be
assessed for release for travel. The risk is low in patients
with an ejection fraction of >40%, and the patients can
safely travel after the third day of hospital discharge. In
contrast, revascularized patients with heart failure, with an
ejection fraction of <40%, residual ischemia and cardiac
arrhythmias should be advised to postpone travel until
adequate clinical stability.11
FINAL CONSIDERATIONS
The integration of knowledge regarding the physiopathol-
ogy of myocardial infarction, physiology of physical exercise,
risk stratification, relative and absolute contraindications to
physical exercise, and adequate prescription and monitoring
of physical exercise based on various cardiac rehabilitation
guidelines can avoid and/or minimize the risk of undesirable
events. Following these advices, an adequate and safe care
practice will be performed improving the prognosis and
quality of life of the individuals.
CONFLICTS OF INTEREST
The authors declare that they have no conflicts of
interest in conducting this study.
Rev Soc Cardiol Estado de São Paulo - Supl - 2019;28(3):336-41
 PHYSICAL EXERCISE AFTER MYOCARDIAL INFARCTION: SAFETY DURING EXERCISE
REFERENCES
1. Piegas LS, Feitosa G, Mattos LA, Nicolau JC, Rossi Neto JM, Ti-
merman A, et al. IV Diretriz da Sociedade Brasileira de Cardiologia
sobre Tratamento do Infarto Agudo do Miocárdio com Suprades-
nível do Segmento ST. Arq Bras Cardiol. 2009;93(6):179-264.
2. Muela HCS, Bassan R, Serra SM. Avaliação dos benefícios funcio-
nais de um programa de reabilitação cardíaca. Arq Bras Cardiol.
2011;24(4):241-50.
3. Jneid H. Cardiac rehabilitation after myocardial infarction. JAMA
Cardiol. 2016;1(9):978-79.
4. Diretriz de Reabilitação Cardíaca. Arq Bras Cardiol. 2005;84(5):431-40.
5. Smith SC, Benjamin EJ, Bonow RO, Braun LT, Creager MA, Franklin
BA, et al. AHA/ACCF Secondary Prevention and Risk Reduction
Therapy for Patients with Coronary and other Atherosclerotic
Vascular Disease: 2011 update: a guideline from the American
Heart Association and American College of Cardiology Foundation.
Circulation. 2011;124(22):2458-73.
6. Amsterdan EA, Wenger NK, Brindis RG, Casey DE, Ganiats TG, Holmes
DR, et al. 2014 AHA/ACC Guideline for the Management of Patients
with Non-ST-Elevation Acute Coronary Syndromes: a report of the
American College of Cardiology/American Heart Association Task Force
on Practice Guidelines. J Am CollCardiol. 2014;64(24):e139-e228.
7. Windecker S, Kolh P, Alfonso F, Collet JP, Cremer K, Falk V, et al.
2014 ESC/EACTS Guidelines on myocardial revascularization:
The Task Force on Myocardial Revascularization of the European
Society of Cardiology (ESC) and the European Association for
Cardio-Thoracic Surgery (EACTS)Developed with the special
contribution of the European Association of Percutaneous Cardio-
vascular Interventions (EAPCI). Eur Heart J. 2014;35(37):2541-619.
8. Herdy AH, López-Jiménez F, Terzic CP, Milani M, Stein R, Carva-
lho T, et al. Diretriz Sul-Americana de Prevenção e Reabilitação
Cardiovascular. Arq Bras Cardiol. 2014;103(2):supl 1.
9. Chew DP, Scott IA, Cullen L, Franch JK, Briffa TG, Tideman PA, et al.
National Heart Foundation of Australia & Cardiac Society of Australia
and New Zealand: Australian Clinical Guidelines for the Management of
Acute Coronary Syndromes 2016. Heart Lung Circ. 2016;25(9):895-951.
10. Jneid H, Addison D, Bhatt DL, Fonarow GC, Gokak S, Grady KL,
et al. 2017 AHA/ACC Clinical Performance and Quality Measures
for Adults With ST-Elevation and Non-ST-Elevation Myocardial
Infarction: A Report of the American College of Cardiology/Ame-
rican Heart Association Task Force on Performance Measures. J
Am Coll Cardiol. 2017;70(16):2048-90.
11. Ibanez B, James S, Agewall S, Antunes MJ, Bucciarelli-Ducci
C, Bueno H. et al. 2017 ESC Guidelines for the management of
acute myocardial infarction in patients presenting with ST-segment
elevation: The Task Force for the management of acute myocardial
infarction in patients presenting with ST-segment elevation of the Eu-
ropean Society of Cardiology (ESC). Eur Heart J. 2018;29(2):119-77.
12. Fletcher GF, Froelicher VF, Hartley LH, Haskell WL, Pollock ML.
Exercise standards: A statement for health professionals from
the American Heart Association. Circulation. 1990;82:2286-322.
Rev Soc Cardiol Estado de São Paulo - Supl - 2019;28(3):336-41
13. AACVPR. Guidelines for Cardiac Rehabilitation and Secondary
Prevention Programs. 4th ed. Champaign, IL: Human Kinetics
Publishers, Inc; 2004.
14. Piepoli MF, Hoes AW, Agewall S, Albus C, Brotons C, Catapano
AL, et al. 2016 European Guidelines on cardiovascular disease
prevention in clinical practice. Eur Heart J. 2016;37:2315-81.
15. ACSM’s guidelines for exercise testing and prescription, 7th ed.
Philadelphia, PA: Lippincott Williams & Wilkins; 2006.
16. Gil CA, Brito FS, Castro I, Ribeiro JP, Mastrocola LE, Ghorayeb
N, et al. Reabilitação após Infarto Agudo do Miocárdio. Arq Bras
Cardiol. 1995;64(3):289-96.
17. Anderson L, Thompson DR, Oldridge N, Zwisler AD, Rees K, Martin
N, et al. Exercise-based cardiac rehabilitation for coronary heart
disease. Cochrane Database Syst Rev. 2016;5(1):CD001800.
18. Stewart RAH, Held C, Hadziosmanovic N, Armstrong PW, Cannon CP,
Granger CB, et al. Physical activity and mortality in patients with stable
coronary heart disease. J Am Coll Cardiol.  2017;70(14):1689-700.
19. Thompson PD, Franklin BA, Balady GJ, Blair SN, Corrado D, Estes
NA, et al. Exercise and acute cardiovascular events: placing risks into
perspective: a scientifc statement from the American Heart Associa-
tion Council on Nutrition, Physical Activity, and Metabolism and the
Council on Clinical Cardiology. Circulation. 2007;115(17):2358-68.
20. Goodman J, Thomas S, Burr JF. Physical activity series: cardio-
vascular risks of physical activity in apparently healthy individuals:
risk evaluation for exercise clearance and prescription. Can Farm
Physician. 2013;59(1):46-9, e6-e10..
21. Moreira HG, Lage RL, Martinez DG, Ferreira-Santos L, Rondon
MUPB, Negrão CE, et al. Sympathetic nervous activity in patients
with acute coronary syndrome: a comparative study of inflamma-
tory biomarkers. Clin Sci. 2017;131(9):883-95.
22. Martinez DG, Nicolau JC, Lage RL, Trombetta IC, de Matos LD, La-
terza MC et al. Abnormal muscle vascular responses during exercise
in myocardial infarction patients. Int J Cardiol. 2013;165(1):210-2.
23. Martinez DG, Nicolau JC, Lage RL, Toschi-Dias E, de Ma-
tos LD, Alves MJ et al. Effects of long-term exercise train-
ing on autonomic control in myocardial infarction patients.
341
Hypertension. 2011;58(6):1049-56.
24. Barreto AC, Santos AC, Munhoz R, Rondon MU, Franco FG, Trom-
betta IC et al. Increased muscle sympathetic nerve activity predicts
mortality in heart failure patients. Int J Cardiol. 2009;135(3):302-7.
25. La Rovere MT, Bigger JT, Marcus FI, Mortara A. Schwartz PJ. Baroreflex
sensitivity and heart-rate variability in prediction of total cardiac mortal-
ity after myocardial infarction. ATRAMI (Autonomic Tone and Reflexes
After Myocardial Infarction) Invertigators. Lancet. 1998;351:478-84.
26. Choi HY, Han HJ, Choi JW, Jung HY, Joa KL. Superior Effects of
High-Intensity Interval Training Compared to Conventional Therapy
on Cardiovascular and Psychological Aspects in Myocardial
Infarction. Ann Rehabil Med. 2018;42(1):145-53.
27. Bartels MN, Bourne GW, Dwyer JH. High-intensity exercise for
patients in cardiac rehabilitation after myocardial infarction. PM
R. 2010;2(2):151-5.