E xercise p rescription i n p atients w ith c ardiovascular d isease
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E XERCISE P RESCRIPTION I N P ATIENTS W ITH C ARDIOVASCULAR D ISEASE. L EANDRO C. B ONGOSIA , MD, FPCP, FPCC, FACC. Definition of terms. Physical Activity – any bodily movement produced by contraction of the skeletal muscle that results in energy expenditure

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E XERCISE P RESCRIPTION I N P ATIENTS W ITH C ARDIOVASCULAR D ISEASE

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E xercise p rescription i n p atients w ith c ardiovascular d isease

EXERCISEPRESCRIPTIONINPATIENTSWITH CARDIOVASCULARDISEASE

LEANDRO C. BONGOSIA, MD, FPCP, FPCC, FACC


Definition of terms

Definition of terms

Physical Activity – any bodily movement produced by contraction of the skeletal muscle that results in energy expenditure

Exercise – planned, structured, and repetitive bodily movement done to improve or maintain one or more components of physical fitness


Definition of terms1

Definition of terms

Physical Fitness – an attained set of attributes that relate to the ability to perform physical activity. This includes cardiorespiratory endurance, muscle power, balance, flexibility and body composition.

Singh, J Gerontology 2002

Dionne, Elsevier 2003


Why the need to exercise

Why the need to exercise?

  • Regular exercise performed at low to moderate intensity is associated with improvements in risk factors.

  • Improvement in functional class and increased feeling of independence leading toa higher quality of life

  • Improvements in physical function have been seen after short term exercises of 3 to 4 months with interventions that include both aerobic and resistance.

Mazzeo, J Sports Med 2001

Hessert, J of Fam Med 2005

Dionne, Elsevier 2003


E xercise p rescription i n p atients w ith c ardiovascular d isease

Exercise training and myocardial oxygen

consumption

Pre-training

Rate-pressure product

Post-training

Work rate

Ades PA, et al. Circulation 2006;113:2706-2712


Exercise prescription

Exercise prescription

  • The exercise prescription is ideally based on the results of a maximal incremental exercise test.

  • However, because of the muscular specificity of exercise testing and training, the mode of the exercise test should be tailored.


Purpose of exercise prescription

Purpose of Exercise Prescription

  • To provide a safe and effective program

  • To define individual patient guidelines by describing frequency, intensity , duration and mode of exercise


Theoretical relation between health and fitness benefits and the amount or intensity of exercise

Theoretical relation between health and fitness benefits and the amount or intensity of exercise:

Health

Fitness

Quantity of exercise

Benefits


Guidelines for exercise prescription

Guidelines for Exercise Prescription

  • ACSM and CDC recommends 30 minutes of moderate intensity physical activity on most days of the week.

  • Priority should be given to exercises that enhance everyday movements and an individual’s ability to function independently.

    Mazzeo, J Sports Med 2001

Hessert, J of Fam Med 2005


E xercise p rescription i n p atients w ith c ardiovascular d isease

The Process of Developing an Exercise

Prescription

Assessment

Interpretation

Prescription

Mode

Progression

Precautions

Frequency

Duration

Intensity


Components of exercise prescription

Components of Exercise Prescription:

A. Mode

B. Intensity

C. Duration

D. Frequency

E. Progression


Components of exercise prescription1

Components of Exercise Prescription

A. Mode

  • Endurance exercise - uses large muscle groups over prolonged periods on activities that are rhythmic and aerobic in nature

  • Should avoid high impact activities particularly early on in the exercise program


E xercise p rescription i n p atients w ith c ardiovascular d isease

Components of Exercise Prescription

Mode(cont.)

Resistance Training:

- Does little to increase VO2 max

- Effective method for muscle strength and endurance

- Prevents and manages a variety of chronic medical conditions

- Enhance independence in elderly patients

- Attenuates rate - pressure product when lifting any

given load


Components of exercise prescription2

Components of Exercise Prescription

B. Intensity

For Cardiac Patients: 40% - 60% VO2max

“Above a minimal level required to induce a training effect but below the metabolic rate that evokes abnormal signs or symptoms”


E xercise p rescription i n p atients w ith c ardiovascular d isease

Components of Exercise Prescription

B. Intensity (cont.)

1. Establishing a training/target HR

2. Using MET method

3. Rate of Perceived Exertion


Training target hr method

Training/Target HR Method

Percent (%) maximal HR

  • Calculates a fixed % of measured or estimated heart rate (220-age)

  • Examples: 1. HRmax = 120/min

    60 % of 120 = 72/min

    2. HRmax (estimated)

    Age = 60 yrs.

    220 – 60 =160

    60% of 160 = 96


Training target hr method1

Training / Target HR Method

Heart Rate Reserve (Karvonen)

HRR = HRmax - HR rest

Karvonen Method = defines a HRR, multiplied by % desired and adjusting for the resting HR

= (HRmax - HR rest) 40-80% + HR rest

Example: HRmax = 150

HR rest = 70

HRR=150-70 = 80

If target is 60%, 80 x 0.6 = 48

HRR = 48 + 70 = 118


Components of exercise prescription3

Components of Exercise Prescription

B. Intensity(cont.)

MET Method

- prescribes intensity by workload or activities associated with MET values

Rate of Perceived Exertion

- particularly useful in patients where HR response is blunted ( beta blocker tx or cardiac transplant), AF, pacemakers with fixed rate.


Components of exercise prescription4

Components of Exercise Prescription

C. Duration

20 to 60 minutes of continuous or intermittent (minimum of 10-min bouts) aerobic activity accumulated throughout the day

ACSM


Components of exercise prescription5

Components of Exercise Prescription

D. Frequency

3 – 5 days/week

3 days/week ---- 60% – 80% HRR

ACSM


Components of exercise prescription6

Components of Exercise Prescription

E. Progression

General Principle:

Increase in exercise every 1 to 3 weeks achieving 20 to 30 minutes of continuous exercise before prescribing additional increase in intensity.


Five interacting elements of exercise prescription

Five interacting elements of exercise prescription

Warm up

- important for older adults prone

to musculoskeletal injuries and

cardiac events

- light movements simulating the

actual exercise activities.


Five interacting elements of exercise prescription1

Five interacting elements of exercise prescription

Exercise Intensity

- low to moderate intensity initially

to improve emerging risk factors.

- later on moderate intensity exercises

should be emphasized.


E xercise p rescription i n p atients w ith c ardiovascular d isease

MODERATE INTENSITY IS DEFINED AS FOLLOWS:

  • 55 to 70% of HR max (220 – age)

  • 40 to 60% of HRR

  • 40 to 60% of 208 – (0.7 x age)

  • Rate of Perceived Exertion at 12 to 13


Caloric cost of exercise

Caloric Cost of Exercise

(METS x 3.5 x body weight in Kg/200=kcal/min

Example: Mr A. weighing 85 kg exercising at 8 mets on treadmill. How much calories shall he expend for 30 min?

8 x 3.5 x 85/200 = 11.9 or 12 kcal/min x 30

Caloric cost per 30 min of exercise = 360 kcal

Balady GJ, Cardiology Clinics, Vol 19, No.3 Aug 2001


Five interacting elements of exercise prescription2

Five interacting elements of exercise prescription

Duration

- this should be increased first prior

to increasing intensity

- 30 minutes per day

Frequency

- most or all days of the week

- if vigorous exercise is done,

should be done only 3x a week.


Five interacting elements of exercise prescription3

Five interacting elements of exercise prescription

Type / Mode

- based on the fitness level

- exercises which can be incorporated into

everyday life instead of a structured activity

- enjoyable and minimal potential for injury

- results to better compliance

Mazzeo, J Sports Med 2001


Why the need to include resistance training

Why the need to include resistance training?

Sedentary individuals lose 20 to 40% of muscle mass over the course of adult life. Muscle mass cannot usually be maintained into old age even with regular aerobic activities. Appropriate progressive resistance training of 3 to 6 months was shown to increase muscle strength by 40 to 150% and mass by 1 to 3 kg.

Singh, J Gerontology 2002


Restrictions of resistance training

Restrictions of Resistance Training

  • Unstable angina

  • Uncontrolled HPN ( BP > 160/100)

  • Uncontrolled arrhythmias

  • Recent CHF

  • Severe Valvular Heart disease or hypertrophic cardiomyopathy


Restrictions of resistance training1

Restrictions of Resistance Training

  • Poor left ventricular function

  • Inadequate functional capacity, less than or equal to 5 METS (not an absolute contraindication)


Division of an exercise program

Division of an exercise program

  • Warm up

  • Pre-stretching

  • Dexterity

  • Resistance / wt. bearing

  • Endurance

  • Balance

  • Cool Down

5 to 10 minutes

5 to 10 minutes

10 minutes

15 minutes

20 to 30 minutes

5 to 10 minutes

5 to 10 minutes

Hessert, J of Fam Med 2005


S ummary of exercise prescription among patients with cvd

Summary of Exercise Prescription among Patients with CVD

CVD Intensity Comments

Angina or

equivalent

40 - 50% of HRR

with necessary adjustment to keep

upper HRR limit to

no more than 10

beats below ischemic threshold

Consider prophylactic

NTG 15 min before

anticipated exertion

if symptoms limit

routine ADL’s or

ability to exercise

Shuler G, et al. Circulation 1992;86:1-11


Summary of exercise prescription among patients with cvd

Summary of Exercise Prescription among Patients with CVD

CVD Intensity Comments

Myocardial 40 – 85% of HRR

Infarction

PCI

CABG or 40-85% of HRR

Valve surgery

Achieve 1,500-2,000 kcal

of energy expenditure

thru activity each week

Restrict upper body

movement until sternum

is healed (6 - 12 weeks)

Shuler G, et al. Circulation 1992;86:1-11


Summary of exercise prescription among patients with cvd1

Summary of Exercise Prescription among Patients with CVD

CVD Intensity Comments

Heart failure 40(50)-70% of HRR

If needed, initially guide

exercise intensity at 60%

of HRR and adjust duration

to 3 bouts of 10 min each

progressing to 30 - 40 min.

As patient progresses,

maintain upper rate below

ventilatory threshold


Summary of exercise prescription among patients with cvd2

Summary of Exercise Prescription among Patients with CVD

CVD Intensity Comments

Pacemaker,

ICD, CRT

10% below

activation

threshold

Avoid activities that stretch

the arms. After 8 weeks

nonballistic activities may

be resumed and ballistic

activities may be resumed

after 12 weeks

Shuler G, et al. Circulation 1992;86:1-11


Summary of exercise prescription among patients with cvd3

Summary of Exercise Prescription among Patients with CVD

CVD Intensity Comments

CAD 40-85% of HRR

To affect mortality, frequency, duration and intensity of training should sum to yield a weekly energy expenditure of > 1,500 kcal/week

Shuler G, et al. Circulation 1992;86:1-11


Summary of exercise prescription among patients with cvd4

Summary of Exercise Prescription among Patients with CVD

Hypertension

- If BP is uncontrolled, avoid weight lifting

- Borderline HPN under medications: may use light weights and avoid Valsalva

- 3 sets of 8 to 15 repetitions using major muscle groups 3 to 4x a week

- Those on dialysis should have light weights to promote the anabolic effects


Guidelines for exercise rx for cardiac patients acsm

Guidelines for Exercise Rx for Cardiac Patients (ACSM)

Summary and Conclusion:

  • Mode:Select rhythmical aerobic activities that can

    be maintained continuously involving large muscle

    muscle groups

  • Intensity: Prescribe between 40 - 85% VO2max

  • Duration:Schedule 20 to 60 minutes of continuous or intermittent activity

  • Frequency: Schedule exercise 3 to 5 days a week

  • Progression: Progress every 1 to 3 weeks as tolerated withincrease in duration first


E xercise p rescription i n p atients w ith c ardiovascular d isease

Thank You


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