Physical activity and exercise training is central in cardiac rehabilitation. Cardiorespiratory fitness is a strong predictor of cardiac mortality in women with IHD referred for cardiac rehabilitation. For each 1 mL/kg/min increase in initial peak oxygen uptake (VO₂peak) cardiac mortality decreased by 10% [11]. Women have low levels of physical activity which are lower than men. In the EUROASPIRE trial only 31% of women with IHD reported vigorous physical activity for 20 min once or more than once a week while this applied for 43% of men [12]. Physical inactivity is more strongly associated with risk of ACS in women than in men [13]. In order to improve cardiorespiratory fitness aerobic endurance training is recommended [14–15].

Patients referred to cardiac rehabilitation vary considerably with respect to age, co-morbidity, symptoms, readiness to change behaviour, prior training habits and cardiorespiratory fitness as exemplified in the clinical cases. Thus, exercise programmes should be tailored for each participant [10, 14, 15, 16]. Both American and European guidelines stress the importance of an individual risk assessment in patients referred to cardiac rehabilitation based on medical and physical activity history, clinical examination and, if possible, an exercise test to assess exercise capacity and symptoms or arrhythmias related to physical activity [10, 15–16]. Patients with preserved exercise capacity, who are accustomed to physical activity and have no symptoms, can resume every day physical activity and aerobic exercise training at moderate intensity for 30–60 min/day. Otherwise, physical activity should be started at <50% of maximal exercise capacity and gradually increased as widely as possible respecting the patients physical ability as outlined in Fig. 11.2 [10, 14–16]. Resistance training, adapted to the individual patient, can supplement the aerobic exercise training [14, 15].

An assessment of relative intensity can be used to facilitate individualized exercise programmes, by taking into account the patients physical capacity, and to monitor an exercise session [14]. Percentage of maximal heart rate or VO₂peak determined using a cardiopulmonary exercise test is widely used. However, in patients treated with beta-blockers, suffering from chronotropic incompetence or atrial fibrillation, or with a pacemaker heart rate driven exercise may be difficult. In these cases rate of perceived exertion (RPE, Borg Scale [17]) [14].

Obesity is a modifiable, independent risk factor for CVD [18] and abdominal obesity and visceral adipose tissue in particular, is a predictor of mortality in IHD even at normal range BMI [19]. Premenopausal women tend to accumulate adipose tissue in the hip region and have less visceral adipose tissue than men; however, this differences is diminished after menopause [20]. Weight loss has been demonstrated to improve cardiovascular risk factors such as hypertension, dyslipidemia and insulin resistance. [15] Weight loss or weight maintenance is recommended as secondary prevention in both American and European guidelines and should be obtained by diet, exercise and behaviour modifications aiming at a body mass index between 20 and 25 kg/m² and waist circumference <80 cm in women [16, 21].

The beneficial effects of weight loss in secondary prevention of CVD have been debated in relation to the so-called “obesity paradox” suggesting a protective effect of overweight in patients with CVD [22]. However, abdominal obesity and cardiorespiratory fitness may influence the relation between adiposity and prognosis in the obesity paradox [19, 23]. A recent review and meta-analysis [24] distinguishing between intentional weight loss associated with lifestyle changes and observational weight loss with a less well-defined aetiology described in epidemiological studies showed that observational weight loss was associated with more adverse cardiovascular events while intentional weight loss was associated with fewer events.

The dietary patterns recommended in the European guidelines of CVD prevention resemble the Mediterranean diet. The recommendations are a daily intake of 30–45 g of fibre, preferably from whole grain, 30 g of unsalted nuts, ≥200 g of fruit and ≥200 g of vegetables. In addition, fish 1–2 times/week one of which to be oily fish. Saturated fatty acids should account for <10% of total energy intake and trans unsaturated fatty acids should be avoided. Sugar-sweetened soft drinks should be avoided and alcoholic beverages should be ≤1 glass/day. Women in general are more likely to adhere to a heart-healthy diet than men.

Women with IHD seem to struggle more with depression and anxiety and experience lower quality of life and social support than men [25]. Lifetime risk of depression is as high as 20% with twice the risk in women compared to men. Among patients with established IHD the prevalence of depression is high although with considerable variation across studies and women again have twice the risk of men of developing depression [26]. IHD patients who develop or have persistent depression or depressive symptoms have poorer outcomes. Meta-analyses indicate a hazard ratio of 1.49 for depressive symptoms and 2.69 for clinical depression [27]. This has been corroborated in registry studies following patients with a diagnosis of depression [26]. The subsequent morbidity and mortality risk associated with depression is similar in men and women but due to the higher prevalence, depression has more impact on female prognosis. Medical treatment of depression has not been shown to improve cardiovascular prognosis perhaps because of the limited effect of the medication and spontaneous recovery. Conversely, the association may partly be explained by lack of lifestyle changes: A study indicated that the excess risk in patients scoring high on depression scales could largely be explained by lack of physical activity [28] and randomized trials have indicated that exercise is efficient treatment of depression while [29] also addressing cardiovascular risk directly. Both the European Society of Cardiology and the American Heart Association guidelines recommend screening and addressing depression in patients with IHD [30].