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J.M. is a 52-year-old man with a 14-year history of hypertension and coronary artery disease. He works as a union pipe fitter employed at a shipyard. A major component of his work includes climbing on scaffolding for activities performed in the process of ship construction. Three days ago, he fell 8 ft to the ground off a platform, resulting in a compound fracture of the right femur. Relevant history includes moderate alcohol intake, 25-year history of smoking one-half pack of cigarettes per day (12.5 pack-year), and a body mass index of 32. Current daily drugs include metoprolol, hydrochlorothiazide, and quinapril for chronic treatment of hypertension, and additional medications for pain control. The patient is also prescribed sublingual nitroglycerin, as needed. Two days ago, the compound femur fracture was reduced via internal fixation with a medullary rod; surgeon-prescribed weight-bearing status is weight-bearing as tolerated. On postoperative day one (POD 1), the physical therapist observed that the patient had normal upper body strength and trunk control and that he was independent in squat pivot transfers from bed to chair. In the morning of POD 2, the therapist brings the patient to the inpatient gym in a wheelchair for initial assessment of standing and ambulation in the parallel bars. Seated, resting vitals signs are 135/88 mm Hg, 60 bpm. The patient expresses considerable apprehension about today’s therapy goals due to fear of excessive pain. The physical therapist convinces the patient to attempt to stand in the parallel bars with the use of a gait belt plus another assistant. The patient comes to a complete standing position with both hands on the parallel bars for assistance. Prior to taking his first step, the patient complains of left-sided chest pain that begins to radiate down the left arm. The patient is quickly assisted to a seated position, and the therapist records the following vitals: 145/92 mm Hg, 78 bpm. The therapist notes that the patient is pale and diaphoretic and asks the assistant to notify the nurse of the patient’s current status and position. The patient declined an afternoon physical therapy session.


A structured, individualized, and supervised exercise program is a key component of cardiac rehabilitation following a myocardial infarction, and has been shown to yield physical, psychological, and financial benefits to the patient. In addition, regular moderate exercise appears to reduce the potential for subsequent myocardial infarction, and may do so at a reduced financial cost to the patient and the healthcare system. Aerobic components of these programs are not limited to use of a treadmill, but may also utilize upper body activities or functional activities related to returning to work. Physical therapists, nurses, or exercise physiologists can safely supervise exercise programs. Healthcare professionals working with this patient population require an understanding of the potential benefits and liabilities of antianginal drug effects during periods of increased functional activity or exercise.


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