Relative rest is recommended during the patients’ stay at the CCU after an acute cardiac event or after their stay at the ICU following heart surgery. Dynamic mobilisation exercises and treatment of pulmonary symptoms (if necessary) results in a faster recovery and a better physical health at discharge in CHF patients undergoing revascularisation surgery [20, 21] (level 1), valve replacement and (left) ventricular surgery, and after decompensation or other cardiac events (level 4).

Postoperative pulmonary complications (such as obstructive pulmonary diseases) are treated if necessary (as indicated by the pulmonologist or other medical specialist) at the CCU or ICU. Perioperative treatment involves teaching the patient techniques to improve ventilation and to mobilise and cough up sputum (breathing, huffing and coughing techniques) and advising the patient.

The clinical mobilisation should include functional exercises, such as exercises related to activities of daily living (ADL) and walking at an early stage of this phase. Exercise should be discontinued or intensity should be decreased if patients show signs of excessive strain/cardiac overload. The physiotherapist explains the aetiology and/or the treatment (e.g. medication, surgery), ways of coping with CHF and other complaints during daily life (i.e. how to ‘respond to the demands of life’, and how to recognise signs of excessive strain), and how to gradually increase the intensity of activities at home. Table 2 lists the referral information provided before the mobilisation starts, signs of excessive strain/ cardiac overload and outcome criteria.

At the start of the outpatient CR phase, all eligible patients should be referred for an intake procedure, carried out by a member of the CR team, in many cases the CR coordinator/nurse, preferably by using a clinical algorithm for patient needs in CR (Fig. 1) [22].

Based on the results of the assessment procedure, the CR coordinator/nurse, in consultation with the patient, decides what type of care or what interventions are indicated. The patient then goes through a specific assessment for each of the relevant disciplines, after which they start one or more CR programs (Fig. 1.).

If the patient has no contraindications for physical training (Table 3), an additional assessment should be performed by the physiotherapist to define the content of the training program.

The aim of the physiotherapist’s assessment is to assess the nature and severity of patients’ health problems in relation to their physical functioning (in terms of movements) and to assess the extent to which this can be modified. Fig. 2 shows a flowchart of the assessment procedure.

The assessment focuses on identifying impairments of bodily functions, limitations of activities, restrictions of participation and health problems that may influence the choice of exercise activities to be included in the training program. Limitations of activities may regard their nature, duration and/or quality. The physiotherapist analyses the performance of problematic activities that were identified using the patient-specific complaints instrument. [23] The physiotherapist assesses the quality of the patient’s aspects of physical performance (including endurance, strength, speed, agility and coordination) and the degree to which the patient is able to use them. The physical performance during activities perceived as problematical can be scored in terms of duration and intensity, perceived fatigue (Borg Rating of Perceived Exertion (RPE) scale 6–20) [24] and in terms of anxiety, chest pain and dyspnoea (Borg 1–10). If requested by the patient’s physician, the physiotherapist can monitor the patient’s heart rate and blood pressure during these activities. The modified Shuttle Walk Test (SWT) [25‐27] is used to determine patients’ functional exercise capacity. The MET method and the Specific Activity Scale (SAS) [28] can be used to estimate whether any discrepancy between the actual performance level and the target level can be eliminated with a suitable training program. The physiotherapist measures patients’ maximum inspiratory pressure (Pimax) using a Pimax meter. Based on the results of the assessment procedure, rehabilitation goals will be defined.

The treatment during the outpatient CR phase comprises three modalities: information/advice, a tailored training program and a relaxation program (Fig. 3). The physiotherapist systematically evaluates the rehabilitation goals, during and at the end of the treatment. Typically, the treatment phase should last for a period 8 to 12 weeks in order to obtain the optimal treatment result.

Aerobic endurance or interval training increases the exercise capacity and QoL in patients with CHF (NYHA Classes II-III) and is therefore recommended. The mechanisms underlying these beneficial effects involve improvement of patients’ muscle perfusion, muscle metabolism, breathing efficiency, neurohormonal regulation and cardiac pump function (Level 1) [4‐6].

It is assumed that high-intensity interval training (HIT) results in a better improvement of left ventricular function than moderate-intensity training (Level 2) [31].

HIT may result in a greater improvement of the aerobic endurance capacity than moderate-intensity training (Level 2) [32].

The research concerning the effectiveness of HIT training is conducted in relatively low-risk CHF patients; therefore the GDG advises to be cautious in patients with a high risk of cardiac overload (Level 4). If HIT is applied, the cardiologist should be informed and safety criteria (Table 3) should be closely adhered to.

Training should be individually directed and functionally geared toward personal goals. If the goal is to improve endurance capacity, aerobic exercise can be gradually increased from 50 to 80 % of VO₂ peak/ heart rate reserve, preceded by warming up and followed by cooling down. HIT can involve interval blocks of 4 times 4 min at 80–90 % of VO₂ peak / heart rate reserve, with active recovery for 3 min at 40–50 % of VO₂ peak / heart rate reserve (as determined by the maximum or symptom-limited exercise test with respiratory gas analysis). During both endurance or interval training and HIT, the program should preferably start with a 2-week introductory period in which the patient trains at an intensity of 40–50 % of VO₂ peak / heart rate reserve. Patients with a VO₂ peak >10.5 mL/kg/min, but <17.5 mL/kg/min (3–5 METs/40–80 W) appear to benefit most from 1 to 2 training sessions a day for 15 min, focusing on aerobic interval training. Patients with a VO₂ peak >17.5 mL/kg/min (≥5 METs / ≥80 W) can limit their training to 2–3 sessions a week, for 20–30 min per training session [9].

If the goal is to improve patients’ endurance capacity, training intensity should be based on the results of a maximum or symptom-limited exercise test with respiratory gas analysis (Table 4), preferably on a percentage of VO₂ peak, VO₂ reserve (the difference between the VO₂ max and the VO₂ at rest) or the ventilatory or anaerobic threshold, converted into heart rate (or work rate, Watt). If no respiratory gas analysis has been done, the maximum heart rate attained can be used to calculate the training zone. In both cases, the Karvonen formula is used to calculate the training heart rate as a percentage of the heart rate reserve, added to the resting heart rate. [33] If the patient’s heart rate does not rise sufficiently during the maximum or symptom-limited exercise test with respiratory gas analysis, the training intensity should be based on a percentage of the maximum capacity expressed in Power (Watt) or METs, and/or the Borg score (6–20).

Strength training increases muscle strength and endurance, and is recommended in preparation for, or as an adjunct to, aerobic exercise training for patients with stable CHF (Level 1) [5, 34].

This type of exercise training is particularly suitable for patients who experience strength-related limitations in activities of daily living and during social participation. The GDG advises caution with strength training in the CHF patient (research has only been conducted in relatively low-risk CHF patients), especially in patients with a left ventricular function <35 % (Level 4).

Strength training should be functional and directed toward personal goals and individual restrictions in daily life. The strength training starts with a 2-week ‘pre-training’ period, involving 2–3 series of 10 repetitions against a low resistance estimated at <30 % of 1 repetition maximum (RM). After this pre-training period, the resistance level for strength training can be estimated on the basis of 10 RM. If the goal is to improve the patient’s muscle strength, the external resistance can be gradually raised from 40 to 65 % of the 1RM. Training the large muscle groups is recommended, at a frequency of 2–3 times a week, in 10–15 repetitions of 2–3 series.

IMT increases Pimax and reduces the sensation of dyspnoea and is therefore recommended in CHF patients with a Pimax <70 %predicted (Level 2) [35‐37] or a ventilatory impairment according to the maximum or symptom-limited exercise test with respiratory gas analysis (i.e. insufficient or absent breathing reserve) (Level 4).

High-intensity IMT may produce better results than low-intensity IMT, however in practice the high load training is not suitable for patients with dyspnoea during low ADL effort (Level 4).

Low-intensity IMT should be performed against a resistance of 20–40 % of Pimax for 30 min/day or 2 times 15 min/day, on 3–4 days a week, preferably for a period of 8–12 consecutive weeks, and high-intensity IMT against a resistance of 60–70 % of Pimax for 4–5 times 5–10 min/day, 3–4 days a week, preferably 10 consecutive weeks, using a threshold device.

A relaxation program (including breathing therapy) is recommended in CHF patients. A relaxation program can lead to tranquillity (a more quiet / less stressful mind), better breathing control (more regular breathing), reduced sensation of dyspnoea and an improvement of QoL (stress reduction) (Level 2) [38‐48].

A relaxation program in combination with aerobic training is superior to training alone (Level 3) [40].

The CHF patient should attend two sessions to try out the relaxation program. If the program proves beneficial, they attend a further 6–8 sessions lasting 60–90 min each. An important goal of the relaxation program is to teach the patient to calm their mind and to breathe more slowly. In addition, the program may address cognitive themes such as understanding the value of rest, the balance between work and rest, the influence of psychological factors on physical functioning and differentiating between cardiac factors in relation to stress, anger, depression and pressure of time. Instructions for relaxation can be given during exercising (active relaxation) or at rest (passive relaxation), partly in the context of warming up and cooling down, and partly as a separate relaxation program.

In addition to a ‘continuous’ evaluation over the entire course of the training program, more comprehensive interim evaluations should be carried out at least every 4 weeks, as well as at the end of the CR program. Final evaluation criteria that may prevail are listed in Table 5.

Table 6 shows the intended outcomes for the CR goals, the relaxation program and patients’ acquired knowledge about CHF and lifestyle, as well as recommendations for assessment and evaluation.

The physiotherapist should report to the multidisciplinary CR team about the treatment process, the treatment outcomes and the recommendations (aftercare). This should happen at least at the end of the treatment, but preferably also during the treatment period. In addition, the physiotherapist informs the patient’s cardiologist, family physician and, if applicable, their rehabilitation physician or company doctor.

Patients are recommended to continue exercise, as part of an active lifestyle, for the rest of their lives after the outpatient CR period has ended, at a physiotherapy practice, at a certified exercise facility or independently (Level 1–2) [49‐51].

Monitoring by secondary care professionals to check if CHF patients maintain their exercise capacity and an active lifestyle in order to identify relapses at an early stage and intervene is advisable (Level 3) [52].

Patients with an indication to attend high-intensity maintenance training (≥60 % VO₂ peak) should be referred to a physiotherapy practice or a certified exercise facility (registered with the Dutch cardiac association), where professional supervision is available. Patients should preferably continue their training activities in a setting that participates in a local network which includes the hospital or rehabilitation centre where the CR program took place, as this implies easy access and frequent contacts. Patients requiring low- or moderate-intensity maintenance training (<60 % of VO₂ peak) can choose to do this independently, or at a certified exercise facility. If patients who are advised to attend low- to moderate-intensity maintenance training are deemed likely to soon relapse into an inactive lifestyle, they should be referred to a training program at a primary care physiotherapy practice, under professional supervision.