By Serena Agusto-Cox | News & Views

Cardiac devices can transform patients’ lives. Yet when these patients enter cardiac rehabilitation, some clinicians may feel uncertain about how to safely guide them through exercise programs. With targeted education, clinicians can gain the knowledge and confidence they need to support these patients effectively. Tammy Laplace, MSN, RN, Cath/Ep lab and device clinic nurse manager at Mayo Clinic, recognized the need to fill this gap, which she and co-presenter Dean Engle, BSN, RN, tackled in a recent AACVPR webinar: “Advancements in Pacemaker/ICD: Exploring the Role of Cardiac Devices in Rhythm Management and Exercise.”

“My inspiration came from wanting to bridge that gap—bringing translational knowledge to the rehab setting so clinicians feel empowered and patients feel secure,” she says. “Exercise is medicine, and for individuals with devices, tailoring that medicine requires confidence and understanding.”

Engle adds, “With my previous career in adult fitness and exercise science, I believe that patients with cardiac devices who have sinus node dysfunction are often underserved and are not properly managed due to a lack of understanding regarding appropriate heart rate with exercise. Some professionals need to learn how to optimally program the right response features in these cardiac devices.”

Understand Each Device’s Function and Programming

For clinicians, the first step in safely engaging patients with cardiac devices is understanding what each device does and how it’s programmed. Each type of device interacts with exercise differently:

• Cardiac Resynchronization Therapy (CRT) devices resynchronize ventricular contraction to improve cardiac output in heart failure patients.
• An implantable cardioverter-defibrillator (ICD) provides life-saving therapy for tachyarrhythmias, including shocks or antitachycardia pacing.
• Pacemakers primarily support bradyarrhythmias by maintaining adequate heart rates.

According to Laplace, these distinctions matter. Some device responses during exercise could impact exercise tolerance and heart rate responses or influence arrhythmia risk. “For example, a patient with CRT may fatigue differently than one with just a pacemaker, and ICD patients may have thresholds for therapy delivery that exercise could trigger if not accounted for,” she explains. “Recognizing these nuances ensures exercise prescriptions are safe, effective, and individualized.” According to Engle, “If a person has sinus node dysfunction, whether it be organic or medication-induced, they need specific tailored programming to their device.”

Allay Patient’s Fears and Address Misconceptions

Patients with these devices often have certain concerns, such as “Will I be able to exercise again?” or “Can I use my arm normally?”  It is common for patients to be concerned about physical activity after device implantation. “They don’t want to dislodge the lead (wires) and have to redo the implant procedure again,” Engle explains.

Laplace adds, “Too often, patients believe they have to avoid most physical activity or limit their arm movement permanently.” However, once healing has taken place, most patients can return to their previous activities with some guidance.

Patients also believe the misconception that their device is fragile. “These are robust systems designed to support an active lifestyle,” she says. Clinicians are there to not only address these concerns but also to encourage safe movement within realistic boundaries. For instance, during early recovery, patients should avoid high-contact sports or movements that result in extreme upper-body strain.

“Patients with ICDs often fear getting shocked during exercise,” explains Laplace. “But these devices are smart and have algorithms that distinguish between a normal rhythm during exercise and a rhythm that would require device intervention.”

Adapt Exercise Programs to the Device and Individual

Rate-responsive pacing and programmed heart rate limits are key considerations for patients with an implanted device, according to Laplace. With CRT patients, the device is programmed to optimize synchrony, and clinicians who understand this can establish patient guidelines for energy levels and endurance. ICDs also have programmed detection zones that clinicians can use to tailor exercise programs and avoid triggering inappropriate therapy during exercise.

According to Engle, for most people and most devices, just a general rate response feature with a traditional accelerometer (or movement sensor) is appropriate. “For patients who have a more structured or advanced exercise routine and greater heart rate response and needs, these devices have a smart and automated auto-adjusted sensor response to make things easier for the cardiac device practitioner and patient,” he explains. “For patients who do specific activities, such as riding a stationary bike, which don’t provide a type of feedback to the device, these patients will need specific features like minute ventilation (breathing) or CLS (ventricular contractility), which provide unique and specific hemodynamic feedback to the device without requiring significant vibration or movement.”

Laplace recommends that exercise programs adopt strategies that involve:

• Using perceived exertion (RPE) in addition to heart rate monitoring
• Gradually progressing intensity to avoid surpassing ICD therapy thresholds
• Incorporating interval-based training, when appropriate, to build endurance safely
• Reviewing device settings that impact exercise capacity and using  a “phone a friend” approach to discuss any questions with a colleague

Clinicians who have a clear understanding of the differences between CRTs, ICDs, and pacemakers and knowledge of patient-reported exertion will be better equipped to safely prescribe exercise. This knowledge will enable them to adapt patients’ exercise programs through pacing that leads to optimal responsiveness. By dispelling misconceptions and modifying exercise to individual needs, clinicians can help patients with cardiac devices not only heal but thrive. “I’m hopeful that this helps them feel more confident when talking to their patients who have these cardiac devices about their physical activity goals and any barriers they may have,” says Engle.

Laplace advises clinicians to embrace curiosity. “Never underestimate the impact of patient education,” she adds. “Devices are complex, but patients don’t need complexity. They need reassurance, clarity, and encouragement.” Knowledgeable clinicians empower patients with devices to confidently participate in rehab and reclaim their lives.