3.1 Baseline Clinical Assessment & AACVPR Risk Stratification

AACVPR CCRP Certified Cardiac Rehab Professional Exam

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1 Chapter 1: Introduction & Cardiac Rehabilitation Foundations

1.1 AACVPR CCRP Credential, Exam Specifications & Core Competencies 1.2 Phases of Cardiac Rehabilitation & Clinical Delivery Models 1.3 Interdisciplinary Team Roles, Clinical Scope of Practice & Safety

2 Chapter 2: Cardiovascular Anatomy, Physiology & Pathology

2.1 Cardiac Anatomy, Coronary Circulation & Hemodynamics 2.2 Atherosclerosis Pathogenesis, Acute Coronary Syndromes (ACS) & Revascularization 2.3 Heart Failure (HFrEF/HFpEF), Cardiomyopathies & Valvular Heart Disease 2.4 Electrical Interventions: Cardioversion, Catheter Ablation & Post-Procedure Rehabilitation

3 Chapter 3: Diagnostic Evaluation, ECG & Clinical Testing

3.1 Baseline Clinical Assessment & AACVPR Risk Stratification 3.2 12-Lead ECG Interpretation: Ischemia, Transmural Infarction & Conduction 3.3 Cardiac Arrhythmias, Conduction Blocks & Device Rhythms (Pacemakers/ICDs) 3.4 Graded Exercise Testing (GXT), Gas Exchange & Termination Criteria

4 Chapter 4: Patient-Centered Assessment: Education, Equity & Social Context

4.1 Learning Readiness: Health Literacy, Learning Styles & Communication Barriers 4.2 Social Determinants of Health, Culture & Spirituality in Cardiac Rehab 4.3 Sex- and Race-Based Differences in Cardiovascular Presentation & Outcomes 4.4 Substance Use Screening: Alcohol, Cannabis, Stimulants & Cardiac Risk

5 Chapter 5: Exercise Prescription & Aerobic Conditioning

5.1 FITT-VP Framework & Aerobic Exercise Intensity Calculation 5.2 Exercise Progression, Environmental Factors & Telemetry Monitoring Guidelines 5.3 High-Intensity Interval Training (HIIT) vs Moderate Continuous Training (MICT) 5.4 Home Exercise Program Design, Prescription & Independent Progression

6 Chapter 6: Exercise Physiology, Monitoring & Session Design

6.1 Health-Related Physical Fitness Components & Functional Capacity Testing 6.2 Acute Cardiovascular Responses to Aerobic Exercise: METs, Rate Pressure Product & VO₂ 6.3 Chronic Training Adaptations in Cardiac Patients 6.4 Structuring the Exercise Session: Warm-Up, Conditioning & Cool-Down 6.5 ECG Telemetry Setup: Skin Preparation, Electrode Placement & Artifact Troubleshooting 6.6 Pulse Oximetry, Exertional Desaturation & Supplemental Oxygen Titration

7 Chapter 7: Resistance, Flexibility & Exercise Safety

7.1 Resistance Training Guidelines, Hemodynamics & Sternal Precautions 7.2 Flexibility, Neuromotor Training & Special CR Populations 7.3 Exercise Contraindications, Adverse Signs/Symptoms & Emergency Protocols

8 Chapter 8: Physical Activity Counseling & Behavior Change

8.1 Physical Activity Guidelines, Sedentary Physiology & NEAT 8.2 Behavioral Change Theories: Transtheoretical Model & Social Cognitive Theory 8.3 Motivational Interviewing Principles & Resolving Ambivalence 8.4 SMART Goal Setting, Activity Tracking & Relapse Prevention

9 Chapter 9: Physical Activity Assessment & Real-World Activity Counseling

9.1 Physical Activity vs Exercise: Assessment Instruments, Logs & Wearables 9.2 Metabolic Requirements of Daily Life: Occupational, Recreational & Sexual Activity 9.3 Environmental & Situational Risk: Heat, Cold, Altitude, Air Quality & High-Risk Activities 9.4 Upper- vs Lower-Body Physiologic Demands & Modality Selection

10 Chapter 10: Hypertension & Blood Pressure Regulation

10.1 2017 ACC/AHA Hypertension Classification & Cardiovascular Risk 10.2 Antihypertensive Pharmacology & Exercise Hemodynamics 10.3 Exertional Blood Pressure Dynamics, Exertional Hypotension & Crisis 10.4 Home Blood Pressure Monitoring, Sodium Restriction & Lifestyle Interventions 10.5 Blood Pressure Measurement Technique, Device Validation & Renal Protection

11 Chapter 11: Diabetes Mellitus & Metabolic Regulation

11.1 Diabetes Pathophysiology, Diagnostic Criteria & Glycemic Targets 11.2 Antidiabetic Pharmacotherapy (Insulin, Sulfonylureas, SGLT2i, GLP-1 RA) 11.3 Exercise-Induced Hypoglycemia Management (Rule of 15) & Hyperglycemia 11.4 Diabetic Complications & Exercise Adaptations (Autonomic & Peripheral Neuropathy) 11.5 Blood Glucose Self-Monitoring, CGM Interpretation & Peri-Exercise Testing 11.6 Diabetic Foot Care, Skin Integrity & Footwear Assessment

12 Chapter 12: Blood Lipid Management & Atherosclerosis Prevention

12.1 Lipid Metabolism, Atherogenic Lipoproteins & Advanced Lipid Testing 12.2 Statin Therapy, Dosing Intensity & Secondary Prevention Targets 12.3 Non-Statin Pharmacotherapies & Statin-Associated Muscle Symptoms (SAMS)

13 Chapter 13: Medical Nutrition Therapy & Dietary Patterns

13.1 Nutritional Assessment & Macronutrient Guidelines in Cardiovascular Disease 13.2 Cardioprotective Dietary Patterns: Mediterranean, DASH & Plant-Based 13.3 Dietary Lipids, Sodium, Soluble Fiber & Plant Stanols/Sterols 13.4 Clinical Scope: CR Professional Counseling Boundaries vs RD/RDN Referral

14 Chapter 14: Body Composition & Weight Management

14.1 Anthropometric Assessment: BMI, Waist Circumference & Obesity Paradox 14.2 Behavioral Weight Management, Energy Balance & Caloric Deficits 14.3 Anti-Obesity Pharmacotherapy (GLP-1/GIP) & Bariatric Surgery Considerations

15 Chapter 15: Tobacco Cessation Interventions

15.1 Cardiovascular Pathophysiology of Tobacco, Nicotine & Secondhand Smoke 15.2 Clinical Cessation Frameworks: The 5 A's & 5 R's Models 15.3 Pharmacotherapy for Nicotine Dependence: NRT, Varenicline & Bupropion 15.4 Behavioral Counseling, Coping Strategies & Relapse Prevention

16 Chapter 16: Psychosocial Health, Screening & Behavioral Support

16.1 Psychosocial Risk Factors & Prognostic Impact in Heart Disease 16.2 Validated Screening Instruments: PHQ-9, GAD-7 & Administration 16.3 Evidence-Based Interventions: Stress Management, CBT Principles & Social Support 16.4 Crisis Protocols, Suicidal Ideation & Mental Health Referral Pathways 16.5 Psychotropic Pharmacology & Cardiac Safety 16.6 Sleep Disturbance, Chronic Pain & Somatic Comorbidity in Psychosocial Management

17 Chapter 17: Regulatory Compliance, Documentation & Program Outcomes

17.1 CMS Coverage Guidelines, Qualifying Diagnoses & Practitioner Supervision 17.2 Individualized Treatment Plan (ITP) Components, 30-Day Updates & Goals 17.3 AACVPR Outcome Domains & Program Certification Performance Measures 17.4 Program Certification, Quality Improvement & Medical Emergency Preparedness

3.1 Baseline Clinical Assessment & AACVPR Risk Stratification

Key Takeaways Explain This Topic AI

AACVPR Low Risk criteria require an LVEF >= 50%, functional capacity >= 7.0 METs, absence of resting or exercise-induced complex ventricular arrhythmias, and an uncomplicated post-event clinical course.

AACVPR High Risk classification is triggered by an LVEF < 40%, functional capacity < 5.0 METs with symptoms, exertional hypotension (>10 mmHg drop in SBP with increasing workload), exercise-induced ST depression >= 2.0 mm, or a history of sudden cardiac arrest.

Orthostatic hypotension is clinically defined as a sustained drop in systolic blood pressure >= 20 mmHg or diastolic blood pressure >= 10 mmHg within 3 minutes of standing from a supine or seated position.

Continuous ECG telemetry monitoring recommendations mandate 6 to 12 sessions for Low-Risk patients, 12 to 18 sessions for Moderate-Risk patients, and 18 to 36 sessions (or continuous throughout Phase II) for High-Risk patients.

An Ankle-Brachial Index (ABI) < 0.90 confirms peripheral artery disease (PAD), identifying systemic atherosclerotic burden and necessitating claudication-limited interval exercise prescription.

Last updated: September 2026

3.1 Baseline Clinical Assessment & AACVPR Risk Stratification

Every patient entering secondary prevention cardiac rehabilitation (CR) requires a structured baseline clinical assessment before initiating exercise. This intake evaluation establishes baseline functional metrics, unmasks contraindications, informs the Individualized Treatment Plan (ITP), and assigns an evidence-based risk stratum determining telemetry monitoring duration.

Intake Clinical Assessment Components
1. Medical and Surgical History Reconciliation

Clinicians document qualifying index events: acute coronary syndromes (STEMI, NSTEMI, unstable angina), revascularization (percutaneous coronary intervention [PCI], coronary artery bypass graft [CABG]), valvular repair/replacement, heart transplantation, or left ventricular assist device (LVAD) implantation. Documentation records procedural complications, residual coronary stenoses, and left ventricular ejection fraction (LVEF) assessed by echocardiography or ventriculography. Comprehensive medication reconciliation tracks agents altering exercise hemodynamics: beta-blockers, ACE inhibitors, ARBs, diuretics, antiplatelets, anticoagulants, and antiarrhythmics.

2. Cardiovascular Risk Factor Profile

Intake profiling categorizes modifiable risk factors (hypertension, dyslipidemia, diabetes mellitus, cigarette smoking, physical inactivity, obesity) and non-modifiable factors (age, sex, family history) to guide individualized risk-reduction counseling.

3. Symptom Review & Functional Scales

Exertional symptoms are quantified using two validated functional classification tools:

Scale Class I Class II Class III Class IV

CCS Angina Angina occurs only with strenuous, rapid, or prolonged exertion; no symptoms with ordinary activity Slight limitation; angina walking >2 blocks or climbing >1 flight rapidly, in cold, or under stress Marked limitation; angina walking 1–2 blocks or climbing 1 flight at normal pace Inability to perform physical activity without discomfort; angina may occur at rest

NYHA Dyspnea Cardiac disease present without limitation; ordinary physical activity causes no undue fatigue or dyspnea Slight limitation; comfortable at rest, but ordinary activity causes fatigue, palpitations, or dyspnea Marked limitation; comfortable at rest, but less than ordinary activity causes symptoms Inability to perform any activity without discomfort; heart failure symptoms present at rest

Physical Examination in Cardiac Rehabilitation
Resting Vitals & Orthostatic Hemodynamics

Resting blood pressure must be measured bilaterally. An inter-arm systolic discrepancy >10–15 mmHg suggests subclavian steal, aortic coarctation, or peripheral vascular disease; subsequent measurements and exercise monitoring must utilize the arm with higher pressure.

Orthostatic vital signs are recorded after 5 minutes seated/supine, then at 1 and 3 minutes standing: Orthostatic Criteria: Δ SBP ≤ − 20 mmHg or Δ DBP ≤ − 10 mmHg within 3 minutes of standing \text{Orthostatic Criteria: } \Delta \text{SBP} \le -20\text{ mmHg} \quad \text{or} \quad \Delta \text{DBP} \le -10\text{ mmHg within 3 minutes of standing} Orthostatic Criteria: Δ SBP ≤ − 20 mmHg or Δ DBP ≤ − 10 mmHg within 3 minutes of standing

Postural hypotension is common due to vasodilator polypharmacy, diuretic volume contraction, and deconditioning, requiring extended warm-up/cool-down periods and gradual posture transitions.

Cardiopulmonary Auscultation

Heart Sounds ( S 1 , S 2 S_1, S_2 S 1 , S 2 ) : Normal closure of AV and semilunar valves.

S 3 S_3 S 3 Gallop : Low-pitched early diastolic sound following S 2 S_2 S 2 during rapid filling. Indicates elevated left ventricular end-diastolic pressure (LVEDP) and volume overload from systolic heart failure.

S 4 S_4 S 4 Gallop : Late diastolic sound preceding S 1 S_1 S 1 generated by atrial contraction into a stiff, non-compliant ventricle (concentric LVH from hypertension, aortic stenosis).

Murmurs : Systolic ejection murmurs (aortic stenosis radiating to carotids) and holosystolic murmurs (mitral regurgitation radiating to axilla) identify afterload sensitivity.

Pulmonary Crackles (Rales) : Bibasilar inspiratory crackles signify left ventricular volume overload and pulmonary congestion.

Peripheral Vasculature, Edema & ABI

Pitting edema is graded on a 1+ to 4+ scale:

1+ (Mild) : ≤ 2 mm \le 2\text{ mm} ≤ 2 mm depth; immediate rebound; no visible distortion.

2+ (Moderate) : 2 – 4 mm 2\text{--}4\text{ mm} 2 – 4 mm depth; rebound in 10–15 seconds; slight ankle fullness.

3+ (Deep) : 4 – 6 mm 4\text{--}6\text{ mm} 4 – 6 mm depth; persists 1–2 minutes; visibly swollen extremity.

4+ (Very Deep) : 6 – 8 mm 6\text{--}8\text{ mm} 6 – 8 mm depth; persists 2–5 minutes; gross dependent distortion.

Peripheral pulses (radial, brachial, dorsalis pedis, posterior tibial) are graded from 0 (absent) to 4+ (bounding), with 2+ normal.

The Ankle-Brachial Index (ABI) screens for peripheral artery disease (PAD): ABI = Highest Ankle SBP (Dorsalis Pedis or Posterior Tibial) Highest Brachial SBP (Right or Left Arm) \text{ABI} = \frac{\text{Highest Ankle SBP (Dorsalis Pedis or Posterior Tibial)}}{\text{Highest Brachial SBP (Right or Left Arm)}} ABI = Highest Brachial SBP (Right or Left Arm) Highest Ankle SBP (Dorsalis Pedis or Posterior Tibial)

Normal : 1.00 – 1.40 1.00\text{--}1.40 1.00 – 1.40 | Borderline : 0.91 – 0.99 0.91\text{--}0.99 0.91 – 0.99

Mild-to-Moderate PAD : 0.41 – 0.90 0.41\text{--}0.90 0.41 – 0.90 (indicates systemic atherosclerosis; requires claudication interval walking)

Severe PAD : ≤ 0.40 \le 0.40 ≤ 0.40 (critical limb ischemia; urgent surgical referral)
Non-compressible Arteries : > 1.40 > 1.40 > 1.40 (severe arterial calcification; common in diabetes/ESRD)
AACVPR Risk Stratification Framework

AACVPR stratifies patients into three risk tiers based on clinical stability, LVEF, and exertional findings:

Parameter Low Risk Moderate Risk High Risk
LVEF ≥ 50 % \ge 50\% ≥ 50% 40 % – 49 % 40\%\text{--}49\% 40% – 49% < 40 % < 40\% < 40%

Functional Capacity ≥ 7.0 METs \ge 7.0\text{ METs} ≥ 7.0 METs 5.0 – 6.9 METs 5.0\text{--}6.9\text{ METs} 5.0 – 6.9 METs < 5.0 METs < 5.0\text{ METs} < 5.0 METs (with symptoms)

Exertional Angina None at rest or exercise Moderate workloads ( 5.0 – 6.9 METs 5.0\text{--}6.9\text{ METs} 5.0 – 6.9 METs ) Low workloads ( < 5.0 METs < 5.0\text{ METs} < 5.0 METs ) or rest

ECG Ischemia No ST depression Mild/moderate silent ischemia (ST < 2.0 mm < 2.0\text{ mm} < 2.0 mm ) Severe ischemia (ST depression ≥ 2.0 mm \ge 2.0\text{ mm} ≥ 2.0 mm )

Arrhythmias No complex ventricular ectopy No complex ventricular ectopy Complex ventricular dysrhythmias (VT, couplets)

Hemodynamics Normal SBP/HR rise Normal hemodynamics Exertional hypotension ( > 10 mmHg > 10\text{ mmHg} > 10 mmHg drop) or chronotropic incompetence

Clinical Course Uncomplicated MI/CABG/PCI No active heart failure Cardiac arrest survivor; cardiogenic shock
Psychological No clinical depression Mild distress Clinically significant depression/anxiety

Important

Low-Risk classification requires meeting all low-risk criteria. Fulfilling any single high-risk criterion immediately designates the patient as High Risk.

Telemetry Monitoring Guidelines & Progression

The AACVPR establishes continuous ECG telemetry duration recommendations by risk tier:

Low Risk : Continuous telemetry for 6 to 12 sessions . May transition to intermittent monitoring or unmonitored exercise if clinically stable.

Moderate Risk : Continuous telemetry for 12 to 18 sessions , stepping down based on absence of arrhythmias and symptoms.

High Risk : Continuous telemetry for 18 to 36 sessions (or throughout Phase II). Continuous surveillance is maintained at all times.

De-escalation Criteria

Transitioning from continuous to intermittent telemetry requires: documented hemodynamic stability (SBP rise 8–12 mmHg/MET), absence of exercise-induced ischemia or complex dysrhythmias, and patient proficiency in self-monitoring heart rate and perceived exertion (Borg 11–14).