A 24-h ambulatory ECG monitoring was also performed, during which a painful ischemic episode (ST segment depression 1.5 mm) and five painless ischemic episodes (ST segment depression 1 mm) were registered, with a total ischemic burden of 70 min/24 h.

Coronary angiography showed a single-vessel coronary artery disease (75 % stenosis in the circumflex artery). The echo-Doppler examination revealed a normal systolic and diastolic ventricular function and a small, grade I, mitral regurgitation through calcification of the posterior mitral annulus. Intravascular ultrasound (IVUS), which was performed during coronarography, showed no unstable plaques; the stenotic lesion was fibrotic.

The laboratory data showed the following values: total cholesterol (TC) of 220 mg/dl, LDL cholesterol (LDL) of 135 mg/dl, HDL cholesterol (HDL) of 40 mg/dl, triglyceride (TG) of 260 mg/dl, and a fasting blood glucose level of 98 mg/dl. The body mass index (BMI) was 28 kg/m², and the waist circumference 86 cm.

Thus, the patient was diagnosed as suffering from chronic coronary artery disease and stable effort angina, CCS (Canadian Cardiovascular Society) class II, hypertension grade I with very high added risk and metabolic syndrome.

The patient was advised to follow a hypocaloric Mediterranean diet to lose weight; a drug treatment regimen consisting of aspirin 75 mg/day, bisoprolol 10 mg/day, rosuvastatin 10 mg/day, and perindopril 5 mg/day was initiated.

The blood pressure value returned to normal (130/80 mmHg), and angina pectoris attacks during daily activities disappeared.

The patient was then addressed to the ambulatory rehabilitation unit and submitted to an 8-week, five times per week, 1-h duration, physical rehabilitation program, consisting of dynamic but also resistance training. It was recommended, in the other 2 days, to perform physical exercises and walking for at least 30 min/day at home. After 8 weeks, a new maximal exercise stress test was performed, proving an increase of exercise capacity with 25 W, but with the same maximal ST depression.

After this, the patient was addressed to a community-based training program, with the recommendation to be followed for 6–12 months. After 12 months, the patient was recommended to perform a daily moderate or vigorous activity of 30–60-min duration, on an individual non-supervised basis, consisting of physical exercises, walking, games, and swimming.

The SCORE chart (Fig. 5.3) is used only in primary prevention to evaluate the risk of cardiovascular death for the next 10 years, a value more than 5 % being considered high and imposing special prevention measures [2].

The present patient already presents an ischemic heart disease as stable angina pectoris. In this case, the risk is already considered very high, imposing secondary prevention measures, and the use of SCORE chart is no longer indicated [2].

The principal feature of the metabolic syndrome is abdominal obesity. Our patient presents overweight, but according to the American Diabetes Association (ADA) criteria for abdominal obesity (>88 cm in women, >102 cm in men), she doesn’t present the metabolic syndrome [3].

In turn, according to the European criteria (abdominal circumference >80 cm in women and >94 cm in men), the patient presents the metabolic syndrome because other criteria are still present (hypertension, low HDL, and increased TG). This will increase the cardiovascular risk because of atherogenic dyslipidemia (increased TG, low HDL, small dense LDL particles) and because of increased risk of diabetes [2].

Lifestyle changes are recommended in all cardiovascular patients or with cardiovascular risk factors. For patients with metabolic syndrome, a special target will be to lose weight [2].

Drug treatment is recommended according to current guidelines: antiplatelets, beta-blockers, and statins; in some cases, but not ours, calcium channel blockers (CCBs) may be added [1]. Also, for second-line treatment, it is recommended to add long-acting nitrates, ivabradine, nicorandil, or ranolazine, according to heart rate, blood pressure, and tolerance [1, 4].

Myocardial revascularization is a good opportunity to decrease myocardial ischemia and to treat angina, but it is not recommended in this patient: the angina is not only stable, but the ischemic threshold, evaluated through double product (DP), is high (23,000) [1]. The maximum ST segment depression is less than 2 mm, and it appears at a high level of effort (100 W) and of heart rate (87 % of maximum heart rate). The patient presents a moderate single-vessel disease (Fig. 5.4a, b); revascularization is recommended for severe one or for multivessel or left main disease. In addition, IVUS confirmed a stable atherosclerotic plaque (Fig. 5.5). The total ischemic burden is more than 60 min (limit to indicate angiography and revascularization), but other criteria for revascularization are not fulfilled [1].

The treatment of risk factors (dyslipidemia, overweight, and hypertension) is indicated, but it is not specific for angina. The targets are those recommended by current guidelines [1].

Physical activity as the main component of cardiac rehabilitation is strongly recommended because it was demonstrated that physical activity and training can increase the quality of life and chances of survival for cardiovascular patients [1, 5].

There are two components of physical activity: physical training represents the organized and supervised form of physical activity [6–8]. For itself, physical training is not strongly recommended in this patient, whose exercise capacity is normal (seven METs). Still, there are at least two reasons to apply it. The first is represented by the direct and especially indirect effects on cardiovascular risk factors [9, 10]. The patient presents hypercholesterolemia, hypertriglyceridemia, and high blood pressure, which can be favorably influenced by physical training [7, 9]. Even more important, patients included in cardiac rehabilitation programs are more adherent to the secondary prevention measures, particularly in this case, when the patient presents, according to European criteria, a metabolic syndrome [2, 11–13]. The second reason is represented by the effect of physical training, beyond the increasing of exercise capacity. It was demonstrated that physical training, especially the high-intensity one, has antiatherogenic, anti-inflammatory, and antithrombotic properties, decreasing the progression of atherosclerotic plaque and its complications [12–15] (Fig. 5.6). Last but not least, to increase the patient’s quality of life, it is recommended to obtain the maximal exercise capacity permitted by the underlying disease [16, 17].

Physical counseling, to perform a daily physical activity of 30–60 min every day, 5 days, or minimum 3 days/week, is also recommended for our patient because of the abovementioned benefices [1, 9]. On the days when physical training is performed, individual physical activity is still recommended, but not compulsory [7].

As for all cardiovascular patients, the increase of exercise capacity is a very important target for cardiac rehabilitation programs [11]. It was demonstrated that after phase II rehabilitation programs, the exercise capacity VO₂ increases with 20–25 % without a significant increase of the ischemic threshold but with much less increase of MVO₂ for the same level of exercise (Fig. 5.2).

It also targeted the consequence upon cardiovascular risk factors through a direct effect, but also by increasing the adherence to the specific measures applied to control them (e.g.,, quit smoking) [12, 16–18].

The pleiotropic effects upon atherogenic mechanisms are also very important, being demonstrated during clinical studies [15, 16].

Inpatient cardiac rehabilitation is indicated only during the acute phase of the disease (phase I rehabilitation) or in complicated patients during phase II [7, 16, 19, 20].

Outpatient cardiac rehabilitation. For our patient, already asymptomatic under drug treatment, outpatient rehabilitation is the only indicated method. It is possible to be performed in a cardiac rehabilitation unit or even in a community center because the cardiovascular risk of the patient is moderate (class B), and tight medical supervision of physical training is not compulsory [7, 21–24].

Home cardiac rehabilitation can be recommended if supervised physical training is not possible [15, 25]. Because the exercise capacity of our patient is high, in this case, the physical training will consist of physical exercises, rapid walking, or domestic activities (30–60 min/day), with the recommendation to avoid the appearance of pain (effort under the ischemic threshold) [26–29].

Physical training can use three types of exercise:

Stretching exercises are used to maintain the joint mobility and flexibility. It has no effect on exercise capacity [16]. It can be used as a part of physical training program, but not to assure the training effect [30].

Aerobic training. It represents the main type of exercise, recommended in all cardiovascular patients, including stable angina patients [31–33]. It associates the abovementioned effect upon exercise capacity, mainly through peripheral but also through central mechanisms [34, 35]. In patients with stable effort angina, not only an increase of ischemic threshold (angina threshold) and a decrease in number and intensity of anginal attacks but also an increase in survival were registered [35–37]. It has the best hemodynamic cardiovascular effects (Table 5.1), and because it does not increase, but in fact decreases peripheral resistance during exercise, it increases systolic output, maximal cardiac output, and VO₂ max; at the same time, it is well tolerated even by patients with depressed LV systolic performance [38].

Resistance training. The isometric component of exercise cannot be avoided during daily life, and, consequently, resistance exercises have to be used during training sessions, especially in patients with normal LV performance, as is our patient. It was demonstrated (Table 5.1) that under survey and at an intensity of 20–30 % of MCV (maximal voluntary contraction), its hemodynamic effect is not detrimental (but at the same time not beneficial) upon LV performance, because of increasing afterload [17, 32]. In time, they can increase moderately the exercise capacity of the patients and decrease the double product, improving the quality of life and having neutral or favorable metabolic effects. The muscular strength is even more increased as during aerobic training (Table 5.1). They will be used in association with aerobic training in some of the training sessions (2–3 times per week).

The recommended training frequency in cardiovascular patients, including stable angina pectoris, was initially two to three times per week, but it was demonstrated that the best results are obtained by using five training sessions per week [16, 39]. The minimum training session to obtain a significant training effect is three times per week. It is ideal to perform seven sessions per week, however is not possible for practical reasons [2, 8]. That’s why the patients are encouraged to exercise by themselves, 30 min/day, using physical exercises and walking, in other days than those with supervised physical training [2, 8].

It is to mention that in physical training recommendations, we must consider the particularities of women. Thus, long-term exercise training sessions must be diversified; exercise must be conducted in intervals rather than continuously or in small groups.

They should also provide support for women emotionally, socially, and psychologically. There are recommended “open discussions” on secondary prevention measures (particularly weight loss, quitting smoking, and prescription of medication with cardioprotective effects) and on the role of physical training [6].

The duration of training sessions is generally recommended to be 50–60 min; lesser duration is recommended only in heart failure patients [16, 18]. For our patient, with stable coronary artery disease, the duration is maximal – 60 min [30, 31, 40].

The intensity of the performed exercise can be assessed using the Borg scale of perceived exertion. This scale can be used by the patient himself to determine optimal training intensity. From 3 to 4, it represents a moderate activity, accounting for 40–60 % of the maximum capacity (VO2 max). From 5 to 6, the activity is considered difficult, accounting for 60–85 % of the maximum exercise capacity, this level being recommended in stable ischemic heart disease, as in our case.

The intensity can be low, moderate, and high (Table 5.2).