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INDICATIONS: An 82-year-old man entering the cardiac rehabilitation program 6 weeks after a porcine aortic valve replacement and single-vessel coronary bypass graft procedure. The patient has had a complicated postoperative course with rapid atrial fibrillation, pleural effusions, anemia and thrombocytopenia. He is currently stabilized and improving in strength. He is living in Nantucket with his daughter Debra Anderson while he recuperates and completes the cardiac rehabilitation program. He has a few other significant medical problems.

MEDICATIONS:
1. Toprol-XL 25 mg daily.
2. Simvastatin 80 mg daily.
3. Aspirin 81 mg daily.
4. Synthroid 0.5 mg daily.
5. Warfarin 1.5 mg daily.

PHYSICAL EXAMINATION: The patient appears pale and fragile. He is comfortable at rest. His resting heart rate is 80. His resting blood pressure is 112/70. His conjunctivae are pale. His lungs have decreased breath sounds throughout and dullness at the bases bilaterally. Heart exam reveals a distant S1 and S2. There is a short 2/6 systolic ejection murmur. The extremities are normal without clubbing, cyanosis or edema.

The resting echocardiogram showed a sinus rhythm at 70 beats per minute. There is poor R wave progression across the pericardium and Q waves inferiorly.

DESCRIPTION: The patient exercised according to the modified Bruce protocol stopping at 3 minutes and 20 seconds with fatigue and shortness of breath. He did not experience chest pain with exercise. He did achieve a maximal heart rate of 100, which is 72% of his maximal predicted heart rate. His maximal blood pressure was 190/70 resulting in a double product of 19,000 and achieving 2.3 METS. As noted, the resting electrocardiogram had inferior Q waves and poor R wave progression. There were no significant ST segment changes with exercise. There were only rare ventricular premature beats with exercise.

CONCLUSION:
1. Poor exercise capacity 6 weeks following an aortic valve replacement and single-vessel bypass procedure.
2. No chest pain with exercise.
3. No significant ECG changes with exercise.
4. The patient is considered stable to enter our cardiac rehabilitation program. I recommend the patient have a complete blood count, basic metabolic profile, and TSH obtained prior to entering the rehab program.

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