Cardiac Rehabilitation

Case Study of a Patient That Sustained a Myocardial Infarction and Subsequent Congestive Heart Failure

by Alexander Pisanello, DPT | September 25, 2025

The subject of this case study is a 76-year-old male that sustained a myocardial infarction and underwent a left anterior descending artery bypass graft on January 5, 2025. As a result of the infarction and subsequent surgical procedure, he had a left ventricular ejection fraction of 25%.

For those who may be unfamiliar with that term, a normal ejection fraction is roughly 50-70%. This means that in a healthy individual, 50-70% of the blood that is in their left ventricle is ejected from the heart with each contraction. The left ventricle of the heart is the chamber that is responsible for pumping oxygen-rich blood to the rest of the body. An ejection fraction below 30% is considered to be severely abnormal.

The signs and symptoms the patient presented with, including, but not limited to, ventricular pump dysfunction, pulmonary edema, nocturnal dyspnea (shortness of breath), bilateral pitting edema, orthopnea (dyspnea while lying down), and dyspnea, are a clinical presentation that is consistent with congestive heart failure, which is a condition that arises when the heart cannot pump enough blood to meet the body’s needs.

The patient’s physician, who is a friend and colleague of mine, referred the patient to me for cardiac rehabilitation. Fortunately, this physician is well aware that I utilize resistance training in the form of properly titrated and dosed squats, deadlifts, overhead presses, and bench presses as a cornerstone for treatment with the patient population that I currently serve. Similarly, I treated this patient at my clinic, where the owner encourages the Starting Strength method of strength training, and allows me to see patients one-on-one for a reasonable period of time.

I feel fortunate that I have been given the freedom to utilize barbell exercises in my treatment programs for my patients, as I realize the negative connotation that is still associated with these exercises by many in the rehabilitative field.

The guidelines for cardiac rehabilitation state specifically that this patient population benefits from incrementally increasing progressive strength training and aerobic conditioning. However, there are specific criteria for the initiation, modification, and termination of exercise when working with this patient population. Cardiac rehabilitation is reserved for medical professionals that are licensed, competent, and able to consistently monitor for signs and symptoms requiring the modification and or termination of exercise.

I currently teach Cardiac Rehabilitation at Quinnipiac University, Anderson University, and Wheeling University, and have actively taught it at many universities nationwide for National Physical Therapy licensing exam purposes. I also have implemented cardiac and pulmonary rehabilitation for a diverse patient population over the course of the last 5 years.

I evaluated and began treating the patient on February 12, 2025. He was taking several medications that impact heart function at the time he began working with me. Those medications included a beta-adrenergic antagonist, a diuretic, and organic nitrates, to name a few. At baseline, the patient was unable to get out of a 17-inch chair without the use of his arms, and could only walk 350 feet without gasping for air, requiring him to sit down. His chief complaint was that he was weak, deconditioned, and unable to get up the stairs in his home, with the use of a handrail and becoming short of breath. The patient’s impairments negatively impacted the performance of instrumental activities of daily living, recreational activities, and occupational tasks. Physical therapy services were recommended to reduce symptoms of dyspnea, improve exercise tolerance and aerobic capacity, enhance strength, and optimize locomotion, the performance of instrumental activities of daily living, and recreational activities.

I began by teaching the patient how to squat, deadlift, and overhead press, as outlined in Starting Strength: Basic Barbell Training 3rd edition. However, his poor physical condition at the time of his evaluation necessitated significant modification compared to that of a healthy individual. At this first session, he was able to deadlift a 5-pound kettlebell for 1 set of 5 repetitions, and his overhead press was two 3-pound dumbbells for 1 set of 5 repetitions. I taught him appropriate squat mechanics, and he was able to do 1 set of 5 repetitions starting from a 17-inch support surface without using his hands. We did some light intervals on the air bike for conditioning after his resistance training.

I discharged the patient for the first time on 03/31/25, about 6 weeks later. I was seeing him once a week in the clinic at the time of discharge. Prior to his discharge, he goblet squatted 30 pounds for 3 sets of 5, did a standing dumbbell overhead press for 3 sets of 8 with 20 pounds, and he performed a dumbbell deadlift for 3 sets of 5 with 30 pounds. I also observed him climb 15 flights of stairs in the clinic without a problem. His 6-minute walk test distance was over 1500 meters. While nobody in the Starting Strength community would necessarily consider the patient to be “strong” at the time of his initial discharge, it was amazing to see how profoundly a modest gain in strength impacted his overall function. It is obvious that the patient could have gotten significantly stronger and more aerobically conditioned; however, he was very happy with the results and requested to be discharged at that time.

He returned for 6 more sessions, commencing on 05/29/25 and ending on 06/20/25. When he was discharged the second time on 06/20/25, he could high bar squat with 30 pounds below parallel for 3 sets of 5 with a box, overhead press 32.5 pounds for 3 sets of 5, and he could deadlift 95 pounds from the floor for 1 set of 5. Once again, he was satisfied with the results he got under the bar and decided to end physical therapy at that time.

This case study is evidence that when carefully monitored and properly titrated and dosed, the basic barbell exercises can be extremely beneficial for even the most sick and frail among us.