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Introduction to Advanced Cardiopulmonry Rehabilitation. PED 596 Spring 2002. Review Physiological Responses to Exercise. Exercise is Homeostatic Emergency. Acute = Accommodate. Immediate response to an “Exercise Emergency” GOAL : Maintain homeostasis. Chronic = Adapt.

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review physiological responses to exercise
Review Physiological Responses to Exercise

Exercise is Homeostatic Emergency

acute accommodate
Acute = Accommodate
  • Immediate response to an “Exercise Emergency”
  • GOAL: Maintain homeostasis
chronic adapt
Chronic = Adapt
  • Repeated exposures to “Exercise Emergencies” stimulate adaptive changes
  • Training Effects
define exercise
Define “Exercise”
  • You should get more “exercise!”
    • Muscular activity (work)
    • Induces increased oxygen uptake
    • Increased cardiac output
    • Increased cellular energy metabolism
  • WORK CAPACITY and THE PHYSIOLOGICAL RESPONSE TO WORK
bottom line emergency 1 exercise demands atp supply and substrate delivery systems
Bottom Line - Emergency #1: Exercise Demands: ATP supply and substrate delivery systems
  • ATP Supply:
    • Fuel Supply: Glucose, Fatty Acids
    • Oxygen Supply
    • Metabolic Machinery: Rate Regulating Enzymes
  • Delivery System:
    • Cardiopulmonary Systems
bottom line emergency 2 exercise demands better machinery
Bottom Line - Emergency #2: Exercise Demands: Better machinery
  • Work Output is an “external” product of exercise
  • Work Capacity is in part determined by Muscle strength
  • Muscle Strength: Function of cross-section and neurological efficiency
specificity of training
Specificity of Training:
  • Peripheral Adaptations:
    • Muscle Fiber: Protein synthesis, metabolic enzymes, mitochondrial density, glycogen, triglyceride and myoglobin stores
    • Angiogenesis
  • Central Adaptations:
    • Cardiovascular: Cardiac output, peripheral resistance, blood volume, RBC, ventilatory threshold, insulin sensitivity
clinical indications for exercise testing
Clinical Indications for Exercise Testing:
  • Diagnosis: Reproduce symptoms
    • CP, SOB, Poor work tolerance
    • ECG changes?
  • Functional Testing:
    • Work Capacity, BP response to exercise, Exercise duration
  • Prognosis:
    • AHA, AACVPR, ACP: Risk Stratification, Duke’s 5-Year Mortality prognosis
diagnosis
Diagnosis:
  • Indications:
    • Confirm or rule out suspected myocardial ischemia
    • Mechanisms for syncope (LOC)
    • Suspected arrhythmias (palpitations with symptoms) during exercise
functional capacity
Functional Capacity:
  • Indications:
    • Assessing work capacity for return to work/leisure activites
    • Used in determining risk/prognostic stratification
    • Used in determining therapy choices
    • Exercise Prescription: Phase II Entrance requirements
prognostic benchmarks
Prognostic Benchmarks
  • <5 METs: poor prognosis especially under 65 years old
  • 10 METs: considered normal fitness: survival good – regardless of intervention
  • 13 METs: good prognosis even with CAD present
bike vs treadmill
Less expensive

Less space

Quieter

Less ECG artifact

Easier BP’s

Non-Weight dependent

More flexibility in protocols

More reproducible (not-patient dependent)

More accurate work determinations

Bike vs. Treadmill
specificity of testing
Specificity of Testing:
  • Patient Preference / Experience
  • Diagnostic Protocols:
    • To Elicit Symptoms
    • Often quit at ~80% predicted HR Max
critical measurements
Critical Measurements:
  • Work Loads: MET calculations
  • ECG: Clean ST-Segment changes
  • BP: Accurate work SBP/DBP
  • RPP: MVO2 eliciting CP
  • Elicited Symptoms: CP, SOB, Syncope
myocardial o2 demand mvo 2 depends on
Myocardial O2 demand (MVO2) depends on..
  • Myocardial tension (pressure x volume)
  • Inotropic State (Measure?)
  • Chronotropic state (Measure?)
  • Myocardial mass
indirect measure of mvo2
Indirect measure of MVO2
  • Rate pressure product (a.k.a. double product, tension-time index)
  • Considers 2 of the MVO2 indices:
    • HR X SBP
  • Good estimate of oxygen use by the heart.
  • Used to determine angina threshold
12 lead ecg electrode placement
12-Lead ECG: Electrode Placement
  • RA/LA:
    • On Shoulders at distal ends of clavicles: (Not over large muscle masses)
  • RL/LL:
    • Base of Torso: Just medial to the iliac crests
  • Chest Leads: V1-V6
    • Traditional precordial positioning
slide21

V1-V2: 4th intercostal space –R/L of sternum

V4: 5th intercostal space – midclavicle line

V3: Between V2 and V4

V5: At horizontal level of V4, anterior to axilla

V6: Midaxillary at horizontal level of V4

treadmill protocols
Treadmill Protocols:
  • Treadmill Speed: Individualize
  • Increment Size: Age, condition
    • Larger incremental increases for younger, more fit patients
    • Smaller incremental increases for elderly, de-conditioned
  • Test Length:
    • Between 8-12 minutes
estimating work capacity selecting protocols
Estimating Work Capacity: Selecting Protocols
  • Healthy Men >40 years old
    • 75% have 12.5 MET capacity
    • 50% ~ 10 METs
  • Healthy Women >40 years old
    • 75% have 10 MET capacity
    • 50% ~8-9 METs
  • Choose a protocol that achieves the estimated MET capacity between 8-12 minutes
commonly used clinical protocols
Commonly Used Clinical Protocols:
  • Naughton: 2.0 mph X 3.5% increases every 2 minutes
    • Max METs = 9 /16 minutes
  • Balke: 3.3 mph X 3% increases every 3 minutes
    • Max METs = 12 /18 minutes
  • McHenry: Similar to Balke but Stage I is 2.0 mph/3% grade
measurements hr bp ecg
Measurements: HR, BP, ECG
  • Pre-Test: Supine and Exercise Position
  • Exercise: HR/BP in final minute of each stage – ECG every minute and whenever irregularities appear
  • Post-Test: Immediately post exercise and every 1-2 minutes until full recovery
measurements rpe symptoms
Measurements: RPE, Symptoms
  • RPE: In the last minute of each stage
  • Symptoms: Note symptoms that occur:
    • Ask frequently, “How are you feeling?”
rating anginal symptoms
Rating Anginal Symptoms:
  • 1+: Light, barely noticeable
  • 2+: Moderate, bothersome
  • 3+: Severe, very uncomfortable
  • 4+: Most severe pain ever experienced
post exercise period
Post Exercise Period:
  • For Maximal Diagnostic Sensitivity:
    • No Cool Down
    • 10-sec ECG immediately
    • 6-8 minutes of supine monitoring* - record ECG every minute or after any irregularity

*Unless patient is severely dyspneic – then sitting preferred

testing competencies
Testing Competencies:
  • Know Absolute and Relative indications for test termination:
    • 3+ to 4+ angina
    • Suspected MI
    • Drop in SBP with increased work
    • Serious arrhythmias
    • Signs of poor perfusion
    • Patient request
exercise test endpoints
Exercise Test Endpoints:
  • Pre-determined HR achieved
  • Pre-determined Workload achieved
  • Patient c/o CP, SOB, leg pains, fatigue
  • ECG changes:
    • Significant ST changes
    • New Bundle branch or AV block
    • Increasing PVC frequency, VT or Fib
cardiovascular pharmacology

Cardiovascular Pharmacology

Exercise Implications

understanding the role of medications in exercise
Understanding the Role of Medications in Exercise:
  • What is the physiological response to exercise?
  • What is the mechanism of action of the drug?
  • Is there individual variability?
  • How are generalities best applied to exercise testing and prescription?
cardiovascular response to exercise acute chronic
Cardiovascular Response to Exercise: Acute / Chronic
  • Changes in Autonomic Nervous System
    • SNS: Acute responses
    • PSNS: Resting status in trained persons
  • Cardiovascular Changes:
    • HR, BP, myocardial contractility, venous return, vascular resistance,
therefore
Therefore:
  • Any drug that acts on the autonomic nervous system, heart, blood vessels or kidneys may impact exercise
drug classifications mechanism use
Diuretics:

ACE Inhibitors

Beta-blockers

Ca++ Channel blockers

Nitrates

Anti-hypertensive

Anti-hypertensive, CHF,

Anti-hypertensive, tachycardias

Anti-hypertensive, tachycardias

Anti-anginal

Drug Classifications: Mechanism: Use:
diuretics
Diuretics:
  • Alter renal reabsorption or secretion of H2O and/or Na+
  • Increase diuresis
  • Used for Hypertension and CHF
  • May cause electrolyte imbalances: especially K+
commonly used diuretics
Commonly Used Diuretics:
  • Thiazide Diuretics: Diuril, (Lozol)
  • Loop Diuretics: Lasix, Bumex, Edecrin
  • K+ Sparing: Aldactone, Dyazide
effects of diuretics on exercise see acsm
Effects of Diuretics on Exercise: (See ACSM)
  • Very little effect except for decreased blood pressure
  • CAUTION: May cause PVC’s or false + ischemia signs with electrolyte imbalances
ace inhibitors
ACE Inhibitors:
  • Inhibits Renin-Angiotensin Aldosterone (RAA) System:
    • Renin is released from kidneys in response to hypotension/ Na+
    • Renin increases levels of Angiotensin I (liver)
    • Angiotensin Converting Enzyme (ACE) converts Ang I to Angiotensin II (active)
what does angiotensin ii do
What Does Angiotensin II Do?

Vasoconstriction

Blood Pressure

Increase H2O and N+

Retention

Stimulate release of

ADH and Aldosterone

Net Effect:

Increase Blood Pressure

therapeutic uses of ace inhibitors
Therapeutic Uses of ACE Inhibitors:
  • Hypertension: Improved diuresis, vascular relaxation
  • CHF: The combined effect of diuresis, vascular relaxation reduces Pre/After-Loads on heart

* Affects diuresis without direct action on kidneys – can be used in patients with impaired kidney function

commonly used ace inhibitors
Commonly Used ACE Inhibitors:
  • Captopril (Capoten): Used in mild to moderate hypertension
  • Vasotec, Lotensisn: Used in all hypertensions and CHF
  • Zestril, Prinivil: Once a day dosing
effects of ace inhibitors on exercise
Effects of ACE Inhibitors on Exercise:
  • Little effect except to decrease blood pressure
  • May actually improve exercise capacity in patients with CHF
beta blockers
Beta-Blockers:
  • Beta-adrenoceptor antagonist:
    • Reduces SNS stimulation of Beta-receptors
    • Prolongs AV conduction ( HR)
    • Inhibit Phase 4 Depolarization
    • Decrease Contractility
    • Decreases MVO2
    • Contraindicated: CHF*, asthma, diabetes
therapeutic uses of beta blockers
Therapeutic Uses Of Beta-Blockers:
  • Used for treating mild to moderate hypertension
  • Treating Angina
  • Reducing tachyarrhythmias
commonly used beta blockers
Commonly Used Beta-Blockers:
  • Inderal
  • Lopressor
  • Corgard
  • Blocadren
  • Tenormim
  • Lopressor
effect of beta blockers on exercise
Effect of Beta-Blockers on Exercise:
  • Reduced resting and exercise HR/BP
  • Reduced ischemia
  • Exercise capacity equivocal: may decrease in patients without angina
calcium channel blockers
Calcium Channel Blockers:
  • Block slow calcium channels in myocardial and vascular smooth muscle cells:
    • Reduce vasoconstriction
    • Decrease cardiac contractility
    • Decrease MVO2
    • Can lead to AV-Block
therapeutic uses of calcium channel blockers
Therapeutic Uses of Calcium Channel Blockers:
  • Treatment of Hypertension
  • Tachyarrhythmias
  • Cautious use in CHF
commonly used calcium channel blockers
Commonly Used Calcium Channel Blockers:
  • Verapamil: Calan, Verelan
  • Diltiazem: Cardizem
  • Nifedipine: Procardia
  • Nicardipine: Cardene
effects of calcium channel blockers on exercise
Effects of Calcium Channel Blockers on Exercise:
  • Check ACSM Manual
  • Variable Effects on Heart Rate
  • Blood Pressure
  • Exercise Capacity
nitrates
Nitrates:
  • Dilates all blood vessels
  • Relieves symptoms of angina:
    • Vasodilation decreases cardiac pre-load and MVO2
    • Fast acting
    • Short lived effects
nitroglycerine
Nitroglycerine:
  • Generally used for immediate relief of angina
  • Sublingual: also Isordil, Sorbitrate
  • Adverse Effects:
    • Orthostatic hypotension
    • Headache, reflex tachycardia
    • Excesses can produce methemoglobin - hemolysis
exercise and nitrates
Exercise and Nitrates:
  • Increase HR
  • Decrease BP
  • Increase exercsie capacity for those with angina
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