PRINCIPI DI TERAPIA DELL’INSUFFICIENZA CARDIACA

2. PRINCIPI DI TERAPIA DELL’INSUFFICIENZA CARDIACA 1- Aumentare la forza di contrazione del cuore (inotropi positivi) 2- Ridurre la massa di volume da spostare (diuretici) 3- Ridurre le resistenze periferiche (vasodilatatori) 4- Ridurre il (lavoro) ritorno venoso (nitroderivati)

3. Inotropi positivi 1- Digitalici Inibizione pompa Na/K-ATPasi causa aumento concentrazione intracellulare Ca Diverse isoforme di pompa Digitale inibisce Na/K-ATPasi cardiaca e neuronale Sintomi cardiaci: effetto inotropo positivo, alterazioni conduzione cardiaca: aritmie Sintomi neuronali: attivazione vagale, effetto cronotropo negativo, attivazione peristalsi Tossicità: aloni visivi, alteraz psichiche 2- Inibitori PDE tessuto specifici

4. Diuretici Riduzione volume liquidi extracellulari e precarico; in genere non modificano la gettata Diuretici dell’ansa dosi multiple giornaliere con adeguato monitoraggio di peso e di elettroliti plasmatici -Tiazidici: potenziano efficacia d. dell’ansa quando effetto è insufficiente o pz diventa refrattario; possono essere utilizzati come terapia a lungo termine (monoterapia) in pz con modesta insuff. Cardiaca Resistenza ai diuretici: dovuta a deplezione di volume intravascolare o riduzione gettata e p.a. di origine cardiogena Vasodilatatori possono ridurre efficacia diuretici per riduzione perfusione renale ACEi e antiAT1 possono aumentare efficacia diuretici o ridurla (per eccessiva riduzione pressione di filtrazione, specie in pz con stenosi renale)

5. Vasodilatatori ACEi e vasodilatatori a vario meccanismo d’azione Unica classe (ampia) di farmaci che significativamente riduce mortalità: vero per ACEi o combinazione Idralazina-isosorbide dinitrato Principi di meccanismo d’azione: Riduzione precarico: riduzione congestione polmonare con effetti minimi su gettata Riduzione del postcarico: riduzione della pressione parietale ventricolare porta a miglioramento della funzione sistolica

6. ACEI Oltre a inibire effetti periferici di AngII, riducono formazione aldosterone e il grado di attivazione del sistema simpatico In pz con insuff cardiaca, elevata attività intrarenale di AngII: aumenta la frazione di filtrazione e quindi riassorbimento tubulare ( p. idrostatica e  p. oncotica): quindi ACEi potenziano attività diuretici, diminuiscono perdita di K e di acqua riducendo gravità di ipoNaemia tipica di insuff. cardiaca avanzata Attenzione:limitano meccanismi autoregolatori di funzione renale (soprattutto pressione di perfusione) Studies On Left Ventricular Disfunction (1991): riduzione significativa mortalità con ACEi in aggiunta a digitale e diuretici CONSENSUS: nessun vantaggio e effetti collaterali dannosi se somministrati entro poche ore da infarto complicato con insuff ventricolare sinistra Gruppo Italiano Studio Sopravvivenza nell’Infarto Miocardico: vantaggi per pz con infarto (anche senza alterazioni ventricolari sinistre) Conclusione: se somministrati a poche ore dall’infarto, monitorare attentamente le condizioni emodinamiche

7. Nitrati Isosorbide dinitrato: efficace e sicuro per ridurre pressione di riempimento ventricolare in insuff. Card. acuta e cronica A dosi terapeutiche effetto preponderante è riduzione precarico Efficacia aumentata se in combinazione con Idralazina Tolleranza ai nitrati limita efficacia a lungo termine (lasciar cadere Cp a zero per almeno 8 ore) Via di somministrazione comune: cerotto

8. ALTRI VASODILATATORI Idralazina Efficace antiipertensivo se usato in combinazione con f che oscurino le risposte compensatorie simpatiche e idrosaline In insuff cardiaca riduce postcarico (dx e sin) riducendo resistenze periferiche senza indurre risposte simpatiche Pochi effetti su vene: combinare con nitrati! Induce significativo miglioramento emodinamico in pz con insuff cardiaca avanzata e già in trattamento con diuretici, digitale e ACEi. Calcio antagonisti Utili solo per insuff da cause diastoliche (ipertens, miopatia ipertrofica idiopatica) Felodipina e amlodipina: A minore attività inotropo negativa

9. European Heart Journal , Volume 20, Number 6 , Pp. 456-464 The effect of physical training on hormonal status and exertional hormonal response in patients with chronic congestive heart failure K. Kiilavuoria,f1, H. Näveria, H. Leinonena and M. Härkönenb revised July 28, 1998; accepted July 29, 1998 The training group exercised on a bicycle ergometer for 30min three times a week for 3 months. The load corresponded to 50–60% of their peak oxygen consumption. For the next 3 months they exercised at home according to personal instructions. Results Submaximal exercise capacity increased significantly and peak oxygen consumption tended to improve by 12% in the training group. The plasma noradrenaline at rest tended to decrease by 19%.

10. Circulation. 1988;78:506–515 Exercise training in patients with severe left ventricular dysfunction. Hemodynamic and metabolic effects MJ Sullivan, MB Higginbotham and FR CobbDepartment of Medicine, Duke University Medical Center, Durham, NC 27710. 4-6 months of conditioning by exercising 4.1 +/- 0.6 hr/wk at a heart rate corresponding to 75% of peak oxygen consumption Exercise training resulted in a decrease in heart rate at rest and submaximal exercise and a 23% increase in peak oxygen consumption from 16.8 +/- 3.8 to 20.6 +/- 4.7 ml/kg/min (p less than 0.01). Peripheral adaptations that contributed to improved exercise performance: At peak exercise, systemic arteriovenous oxygen difference increased from 13.1 +/- 1.4 to 14.6 +/- 2.3 ml/dl (p less than 0.05). …………increase in peak-exercise leg blood flow from 2.5 +/- 0.7 to 3.0 +/- 0.8 l/min (p less than 0.01). Arterial and femoral venous lactate levels were markedly reduced during submaximal exercise after training, even though cardiac output and leg blood flow were unchanged at these workloads. Thus, ambulatory patients with chronic heart failure can achieve a significant training effect from long-term exercise. Peripheral adaptations, including an increase in peak blood flow to the exercising leg, played an important role in improving exercise tolerance.

11. Journal of the American College of CardiologyVolume 25, Issue 6 , May 1995, Pages 1239-1249 Physical training in patients with stable chronic heart failure: Effects on cardiorespiratory fitness and ultrastructural abnormalities of leg muscles MDRainer Hambrechta et al. Germany an ambulatory training program After 6 months, patients in the training group achieved an increase in oxygen uptake at the ventilatory threshold of 23% (from 0.86 ± 0.2 to 1.07 ± 0.2 liters/min, p < 0.01 vs. control group) and at peak exercise of 31% (from 1.49 ± 0.4 to 1.95 ± 0.4 liters/min, p < 0.01 vs. control group). There was no significant change in oxygen uptake at the ventilatory threshold and at peak exercise in the control group. ………………………. Conclusions. Regular physical training increases maximal exercise tolerance and delays anaerobic metabolism during sub-maximal exercise in patients with stable chronic heart failure. Improved functional capacity is closely linked to an exercise-induced increase in the oxidative capacity of skeletal muscle.

12. Physical Activity and a Healthy Heart As a general rule, it's better for people with heart failure to stay active. That might sound like contradictory advice, since the heart is already having trouble keeping up with the body's demands. Why make it work even harder? Moderate physical activity can help the heart get stronger. Most people find that exercise improves their symptoms, reduces stress and boosts energy levels. Regular physical activity also may lead to other important health advantages, including weight control, weight loss, better circulation and blood pressure, and lower cholesterol levels — all of which are especially important if you have heart failure. The healthcare team will work with you to develop an appropriate exercise plan. Often they'll start by giving you a stress test to measure your heart function during exercise (either walking on a treadmill or riding an exercise bike). This helps the physician know how much activity your heart can handle.

13. Physical Activity and a Healthy Heart Cardiac rehabilitation programs Many people with heart failure aren't used to regular exercise or feel nervous about starting. That's when a cardiac rehabilitation program can be helpful. A cardiac rehab program lets patients start exercising slowly in a supervised setting, either at a hospital or outpatient center. While patients exercise on a treadmill, stationary bike or indoor track a few times a week, nurses or therapists monitor them for any discomfort or changes in symptoms. Over time the tolerance for exercise is likely to increase. Also, many people find it easier to stick with a structured program — and then keep exercising when it's over. Cardiac rehab programs often provide additional classes in smoking cessation, nutrition and stress management.

14. Physical Activity and a Healthy Heart • Exercise tips • DO... • Wear comfortable clothes and flat shoes with laces or sneakers. • Start slowly. Gradually build up to at least 30 minutes of activity, five or more times per week (or whatever your doctor recommends). If you don't have a full 30 minutes, try two 15-minute sessions or three 10-minute sessions to meet your goal. • Exercise at the same time of day so it becomes a habit. For example, you might walk Monday through Friday from noon to 12:30 p.m. • Drink a cup of water before, during and after exercising (but check with the doctor, because some people need to limit their fluid intake). • Ask family and friends to join you. You'll be more likely to keep exercising. • Note your activities on a calendar or in a log book. Write down the distance or length of time of your activity and how you feel after each session. If you miss a day, plan a make-up day or add 10–15 minutes to your next session. • Use variety to keep your interest up. Walk one day, swim the next time, then go for a bike ride on the weekend. • Join an exercise group, health club or YMCA. Many churches and senior centers offer exercise programs, too. (Get your doctor's permission first.) • Look for chances to be more active during the day. Walk the mall before shopping, choose a flight of stairs over an escalator, or take 10–15 minute walking breaks while watching TV or sitting for some other activity.

15. Physical Activity and a Healthy Heart • DON'T... • Get discouraged if you stop for awhile. Get started again gradually and work up to your old pace. • Do isometric exercises that require holding your breath, bearing down or sudden bursts of energy. If you're taking part in an exercise class or physical therapy, ask the leader or therapist what these are. Also avoid lifting weights and competitive or contact sports, such as football. • Engage in any activity that causes chest pain, shortness of breath, dizziness or lightheadedness. If these happen, stop what you're doing right away. • Exercise right after meals, when it's very hot or humid, or when you just don't feel up to it. • Whether you take part in a formal exercise program, if you have heart failure, you need to make time for moderate aerobic physical activity, like walking, swimming or biking. You should always stay within your physician's recommendations and your own comfort zone. Here's a checklist of what to do and what to avoid.

16. WHAT ARE THE LIFESTYLE RECOMMENDATIONS FOR CONGESTIVE HEART FAILURE? Between 30% to 47% of patients who require hospitalization for heart failure are back in the hospital again within six months. Many people return because of lifestyle factors, such as poor diet, failure to comply with medications, and social isolation. Home Support and Rehabilitation Programs Home care: …..elderly people who had no emotional support at home had triple the risk of a heart attack after hospitalization for heart failure…. . (In women, this risk was eightfold.) …….. programs that offer intensive follow-up to ensure that the patient complies with lifestyle changes and medication regimens at home are reducing rehospitalization and costs and improving survival……….

17. WHAT ARE THE LIFESTYLE RECOMMENDATIONS FOR CONGESTIVE HEART FAILURE? Monitoring Weight Changes Heart failure patients should weigh themselves each morning and keep a record. Any changes are important: A sudden increase in weight of more than two or three pounds (1-1.5 Kg) may indicate fluid accumulation and should prompt an immediate call to the physician. Rapid wasting weight loss over a few months is a very serious sign and may indicate the need for surgical intervention.

18. WHAT ARE THE LIFESTYLE RECOMMENDATIONS FOR CONGESTIVE HEART FAILURE? Dietary Factors Mediterranean Diet. There is some evidence suggesting that the Mediterranean diet helps protect the heart and may even reduce the risk for heart failure after a first heart attack. Its emphasis on whole grains, fish, olive oil, garlic, and moderate, daily intake of wine may have many benefits for the heart. The diet recommends the following: A relatively high fat intake (about 35% to 45% of daily calories, mostly in monounsaturated and polyunsaturated fats.) The Mediterranean diet is known for its use of olive oil, but the greatest benefits found in a major study of this diet appeared to be derived from the use of canola oil, which is rich in omega-3 fatty acids. Olive oil, in fact, does not contain omega-3 fatty acids. On the other hand, olive oil, may have beneficial effects independent from those on lipids, such as improving insulin and blood glucose levels and reducing blood pressure. Daily glass or two of wine. The same protein intake as the AHA, although fish is the primary source. (It avoids high-fat dairy and meat products.) In fact, one 2001 study suggested that fish-consumption, not wine, that is the heart-protective ingredient in this diet. Lower carbohydrate intake than AHA. Emphasizes not only fresh fruits and vegetables, but also higher amounts of nuts, legumes, beans, and whole grains. Foods seasoned with garlic, onions, and herbs.

19. WHAT ARE THE LIFESTYLE RECOMMENDATIONS FOR CONGESTIVE HEART FAILURE? Dietary Factors DASH Diet. A diet known as Dietary Approaches to Stop Hypertension (DASH) is now recommended as an important step in managing blood pressure so it may be useful for many patients with heart failure. This diet is not only rich in important nutrients and fiber but also includes foods that contain two and half times the amounts of electrolytes, potassium, calcium, and magnesium as are found in the average American diet.Potassium-rich foods, which are important for patients with heart failure, include bananas, oranges, prunes, cantaloupes, carrots, spinach, celery, alfalfa, mushrooms, lima beans, potatoes, avocados and broccoli. It is important to note, however, that patients taking Aldactone, those with kidney dysfunction, and some of those taking ACF inhibitors may have to restrict their potassium intake.The diet also stresses avoiding saturated fats, as any healthy diet does, although it includes calcium-rich dairy products that are no- or low-fat. When choosing fats, it also advises monounsaturated oils, and it stresses whole grains, fresh fruits and vegetables every day.

20. WHAT ARE THE LIFESTYLE RECOMMENDATIONS FOR CONGESTIVE HEART FAILURE? Dietary Factors Salt Restriction. All heart failure patients should limit their salt intake, and in severe cases, very stringent salt restriction may be necessary. Patients should not add salt to their cooking and their meals. They should also avoid foods high in sodium; these include ham, bacon, hot dogs, lunch meats, prepared snack foods, dry cereal, cheese, canned soups, soy sauce, and condiments. Some patients may need to reduce their water intake as well. People with high cholesterol levels or diabetes require additional dietary precautions. [For more information, see Well-Connected Report #43, Heart-Healthy Diet. ]

21. Exercise Traditionally, people with heart failure were discouraged from exercising. Now, exercise, when performed under medical supervision, is proving to be extremely important for many patients with stable conditions. Studies have reported that patients with stable conditions who engage in regular moderate exercise (twice a week) experience a better quality of life and lower mortality rates than those who don't.

22. Linee guida critiche Attenzione. L’attività fisica non è consiogliabile per tutte le forme di in sufficienza cardiache Sempre avere la supervisione di un medico quando un paziente con insufficienza cardica inizia un programma di attività motoria Individui per il quali vi è prescrizione di attività fisica ma che non sono allenati devono iniziare con un progarmma di esercizi leggeri di 5-15 min ripetuti più volte. L’obiettivo è di costruire gradualmente un impegno di 45 min 3-5 volte la settimana di cammino, nuoto, esercizio aerobico. Accontentarsi di meno se ciò non è possibile

23. Benefici da specifici esercizi Allenamento progressivo alla forza Utile perché ricostruisce massa muscolare Con pesi leggeri, macchine (anche solo per gambe) Even simply performing daily handgrip exercises can improve blood flow through the arteries. Treadmill o ciclette Aumentano resistenza allo sforzo

24. Warnings on Alternative and So-Called Natural Remedies It should be strongly noted that alternative or natural remedies are not regulated and their quality is not publicly controlled. In addition, any substance that can affect the body's chemistry can, like any drug, produce side effects that may be harmful. Even if studies report positive benefits from herbal remedies, the compounds used in such studies are, in most cases, not what are being marketed to the public.There have been a number of reported cases of serious and even lethal side effects from herbal products. In addition, some so-called natural remedies were found to contain standard prescription medication. Most problems reported occur in herbal remedies imported from Asia, with one study reporting a significant percentage

25. IPERTENSIONE ESSENZIALE • L’ipertensione è la causa principale di ictus, di alterazioni coronariche che sfociano nell’infarto. E’ la maggior causa di insufficienza cardiaca, renale e di aneurisma dissecante dell’aorta • Definita come condizione di p.a > 140/90 ; in realtà la probabilità di insorgenza delle malattie di cui sopra è molto inferiore con p.a max <120 e p.a. <80 • P.A. : equilibrio tra gettata cardiaca e resistenze periferiche : Diversi livelli di intervento • Riduzione gettata cardiaca : • inibizione contrattilità miocardica • riduzione pressione di riempimento ventricolare via tono venoso o volume (effetti renali) • Riduzione resistenze periferiche • inibizione contrattilità vasi di resistenza • inibizione sistemi che regolano resistenze periferiche (es. simpatico) • Interventi farmacologici da condurre su siti diversi (vedi tavola): inutile contemporanea somministrazione di farmaci dotati dello stesso meccanismo d’azione

26. LIVELLI DI INTERVENTO Non farmacologici Esercizio fisico : esercizio costante isotonoco riduce p.a di 10 mmHg ( ?riduzione vol ematico, catecol, e aumento atrial natriuretic factor ?) Restrizione dietetica : riduzione assunzione sali a 5 g/die (equivale a 2 mg/die di sodio) abbassa p.a. max fino a 12 mm e p.a. min fino a 6 mmHg. Più sensibili soggetti >40a e soggetti con alta p.a. Riduzione peso. Alto tono simpatico ; insulina media riassorbimento di Na Alcool : ridurre a < 30 ml/die Rilassamento e biofeed-back : no dati statistici Dieta potassica : efficace perché riduce aldosterone ? Utile in pz con modesta ipertensione, in genere associata con dieta iposodica ; no in pz con ACEi

27. Trattamenti farmacologici Terapia multifarmacologica Bassi dosaggi Attenzione alla tossicità Sequenza Strumenti non farmacologici ACEi o losartani Diuretici Beta-bloccanti, Ca-antagonisti (DHP) a lento rilascio Alfa2-agonisti Idralazina Farmaci delle emergenze: alfa-bloccanti, nitroprussiato, minoxidil

28. Johns Hopkins Bayview Medical Center's exercise and hypertension slide presentationhttp://www.jhbmc.jhu.edu/cardiology/Rehab/ExerciseHTN/index.htm

29. Johns Hopkins Bayview Medical Center's exercise and hypertension slide presentationhttp://www.jhbmc.jhu.edu/cardiology/Rehab/ExerciseHTN/index.htm • Exaggerated BP Responses to Exercise • Excess SBP may predict future hypertension • Among normotensive men who had an exercise test between 1971-1982, those who developed hypertension in 1986 were 2.4 times more likely to have had an exaggerated BP response to exercise • Exaggerated BP response increased future hypertension risk by 300% after adjusting for all other risk factors • Exaggerated BP was change from rest in SBP>60 mm Hg at 6 METS; SBP> 70 mm Hg at 8 METS; DBP> 10 mm Hg at any workload J Clin Epidemiol 51(1): 1998 • Subjects in CARDIA study with exaggerated exercise BP response at baseline were 1.70 times more likely to develop hypertension 5 years later

30. Johns Hopkins Bayview Medical Center's exercise and hypertension slide presentationhttp://www.jhbmc.jhu.edu/cardiology/Rehab/ExerciseHTN/index.htm • Lifestyle Management of Hypertension • Lose weight if overweight • Limit alcohol intake • Exercise • Reduce sodium intake to < 2.3 grams/day • Maintain adequate dietary potassium, calcium, and magnesium intake • Stop smoking • Reduce dietary fat and cholesterol

31. Johns Hopkins Bayview Medical Center's exercise and hypertension slide presentationhttp://www.jhbmc.jhu.edu/cardiology/Rehab/ExerciseHTN/index.htm • Medical Therapy and Implications for Exercise Training • Pharmacologic and nonpharmocologic treatment can greatly reduce mortality • Because hypertension clusters with hyperlipidemia, hyperinsulinemia, glucose intolerance, and obesity, treatment must consider the total risk burden • Some antihypertensive agents have side-effects and some worsen other risk factors • Exercise and diet often improve multiple risk factors with virtually no side-effects

32. Johns Hopkins Bayview Medical Center's exercise and hypertension slide presentationhttp://www.jhbmc.jhu.edu/cardiology/Rehab/ExerciseHTN/index.htm Exercise and Hypertension JNC (1997) and ACSM (1993) recommend exercise to lower BP JNC treatment guideline High normal BP Lifestyle modification Stage 1 Lifestyle for 3-6 months before starting medications Stage 2 Lifestyle including exercise for 3-6 months before starting medications if BP only risk factor Stage 3 and 4 Medication to control BP before vigorous exercise is undertaken

33. Johns Hopkins Bayview Medical Center's exercise and hypertension slide presentationhttp://www.jhbmc.jhu.edu/cardiology/Rehab/ExerciseHTN/index.htm • Risk Stratification • Risk Group A • No risk factors; no target organ disease (TOD)/clinical cardiovascular disease (CCD) • Risk Group B • At least 1 risk factor not including diabetes; no TOD/CCD • Risk Group C • TOD/CCD and/or diabetes, with or without other risk factors

34. Johns Hopkins Bayview Medical Center's exercise and hypertension slide presentationhttp://www.jhbmc.jhu.edu/cardiology/Rehab/ExerciseHTN/index.htm Lifestyle Changes for Hypertension and Cardiovascular Risk Reduce excess body weight by caloric restriction and exercise Reduce dietary sodium to  2.4 g Maintain adequate dietary intake of potassium, calcium, and magnesium Limit daily alcohol consumption to < 2 oz of whiskey, 10 oz wine, 24 oz beer Exercise moderately each day Engage in relaxation techniques Cessation of smoking

35. Johns Hopkins Bayview Medical Center's exercise and hypertension slide presentationhttp://www.jhbmc.jhu.edu/cardiology/Rehab/ExerciseHTN/index.htm • Possible Mechanisms of BP Reduction with Exercise Training • Lower cardiac output and peripheral vascular resistance at rest and at any given submaximal level of work • Decreased HR • Decreased sympathetic and increased parasympathetic tone • Reduction in blood catecholamine levels and plasma renin activity • Reduction in central fat independent of changes in body weight or body mass index • Altered renal function to increase elimination of sodium leading to reduce fluid volume

36. Johns Hopkins Bayview Medical Center's exercise and hypertension slide presentationhttp://www.jhbmc.jhu.edu/cardiology/Rehab/ExerciseHTN/index.htm • NIH Consensus Development Conference on Physical Activity and Cardiovascular Health (1995) • Review of 47 studies of endurance training and hypertension • 70% of exercise groups decreased SBP by an average of 10.5 mm Hg from 154 mm Hg • 78% decreased DBP by an average of 8.6 mm Hg from 98 mm Hg • Only one study showed increased BP with exercise • Beneficial responses are 80 times more frequent than negative responses and 3 times more frequent as equivocal responses

37. Johns Hopkins Bayview Medical Center's exercise and hypertension slide presentationhttp://www.jhbmc.jhu.edu/cardiology/Rehab/ExerciseHTN/index.htm • Exercise Guidelines • No special guidelines for mild to moderate hypertension • ACSM recommends endurance training for mild hypertension • 3-5 days/week • 20-60 minutes • 50-85% of maximal oxygen uptake • ACSM also says that lower intensities may be required until BP control is achieved although no specific guidelines exist

38. Johns Hopkins Bayview Medical Center's exercise and hypertension slide presentationhttp://www.jhbmc.jhu.edu/cardiology/Rehab/ExerciseHTN/index.htm • Resistive Training • Resistive exercise produces the most striking increases in BP • Because resistive exercise also results in less of a HR increase compared with aerobic exercise the total myocardial burden may be less than aerobic exercise • Combined training (weight and aerobic exercise) has been shown to reduce both SBP and DBP by as much as 13 mm Hg each • Combined Aerobic and Resistive Training and Mild Hypertension • Kelemen, Effron, Valenti, Stewart: JAMA 1990:263:2766-2771

39. Johns Hopkins Bayview Medical Center's exercise and hypertension slide presentationhttp://www.jhbmc.jhu.edu/cardiology/Rehab/ExerciseHTN/index.htm • Screening and Testing • BP should measured regularly in all persons > 3 years (Guide to Clinical Preventive Services) • Current opinion is that normotensive persons should be screened every 2 years • ACSM does not recommend mass exercise testing to determine future hypertension risk • Exercise testing before participation in moderate to vigorous exercise should follow usual risk stratification guidelines • Because hypertension clusters with other risk factors, many hypertensive individuals are likely candidates for exercise testing

40. Johns Hopkins Bayview Medical Center's exercise and hypertension slide presentationhttp://www.jhbmc.jhu.edu/cardiology/Rehab/ExerciseHTN/index.htm Exercise and Hypertension Summary Hypertension is a major risk factor for CVD. Exercise is a key component in the prevention and treatment of hypertension. Exercise training can be expected to reduce SBP and DBP by 7-10 mm Hg. Some studies show that even greater benefits are possible. Exercise also has a favorable effect on other CVD risk factors like lipids and diabetes. Medical screening for exercise participation to predict hypertension is not necessary. Persons with known hypertension should follow usual risk stratification guidelines for exercise testing.

41. Exercise Guidance in Hypertension Kerry J. Stewart, EdD THE PHYSICIAN AND SPORTSMEDICINE - VOL 28 - NO. 10 - OCTOBER 2000 Exercise Guidelines Aerobic exercise. For mild hypertension, the American College of Sports Medicine (ACSM) (6) recommends 20 to 60 minutes of aerobic exercise 3 to 5 days per week, at 50% to 85% of maximal oxygen uptake. For patients with stage 2 or stage 3 hypertension, exercise should be at 40% to 70% of maximal oxygen uptake after patients begin pharmacologic therapy. Resistance exercise. One concern about resistance training has been that it produces exaggerated BP responses. While an acute bout of resistance exercise does result in greater increases in BP compared with aerobic exercise, heart rate does not increase as much. As such, the rate-pressure product, which represents myocardial oxygen demand, may be lower with resistance versus aerobic exercise (7,8). A recent position paper of the American Heart Association (9) recommends mild-to-moderate resistance exercise, at 30% to 60% of maximal effort, for improving muscle strength and endurance, preventing and managing diverse chronic medical conditions, modifying coronary risk factors including hypertension, and enhancing psychological well-being.

42. Exercise Guidance in Hypertension Kerry J. Stewart, EdD THE PHYSICIAN AND SPORTSMEDICINE - VOL 28 - NO. 10 - OCTOBER 2000 Screening and exercise testing. The ACSM does not recommend exercise testing specifically to determine BP responses (6). However, if an exercise test is done for other purposes--for example, as part of a physical exam--BP responses to exercise provide an indication of risk stratification. Because hypertension often clusters with hyperlipidemia, hyperinsulinemia, and obesity, many hypertensive individuals will be candidates for exercise testing based on risk stratification guidelines. Antihypertensive drugs and exercise. Medical management of hypertension is often complicated by concomitant hyperlipidemia, a sedentary lifestyle, hyperinsulinemia, glucose intolerance, reduced arterial compliance, sympathetic overactivity, and obesity. Unfortunately, some antihypertensive agents adversely affect other risk factors, and adherence to medication is often a problem. On the other hand, lifestyle changes improve multiple risk factors without any side effects. In some patients, exercise can reduce or eliminate the need for antihypertensive medication (8).

43. EXERCISE MAY NOT BE GOOD ENOUGH TO REDUCE MILD HYPERTENSION IN OLDER PEOPLE, HOPKINS EXPERTS SAYReductions in fat and increases in muscle key indicators of who will benefit most Moderate levels of exercise may not be enough to control mild hypertension in men and women over age 55, the age group most at risk of later developing potentially fatal heart failure, a new four-year study reports………. ….. Current guidelines from the American College of Sports Medicine recommend 30- to 45-minute periods of combined aerobic exercise and moderate weightlifting, three to five times per week, with an expected reduction in blood pressure of 8 millimeters to 10 millimeters of mercury (mm/Hg)…….. ………. Previous studies, says Stewart, who led the new study, examined mostly younger men in whom high blood pressure has different characteristics and causes than are the case in older people.  Hypertension in younger adults is often due to a high cardiac output when at rest and during exercise, where the heart beats faster than it has to, he adds. However, hypertension in mature adults results from changes in the walls of the large arteries that carry blood throughout the body.  These blood vessels become less elastic or flexible, a condition known as arterial stiffening, and this causes blood pressure to rise

44. EXERCISE MAY NOT BE GOOD ENOUGH TO REDUCE MILD HYPERTENSION IN OLDER PEOPLE, HOPKINS EXPERTS SAYReductions in fat and increases in muscle key indicators of who will benefit most ……….Upon closer examination, the Johns Hopkins team found that people most likely to decrease both systolic and diastolic blood pressure also were those who lost the most body fat, particularly abdominal fat, and gained the most muscle. These changes in body composition were more closely related to reductions in blood pressure than improvements in fitness. Overall, results for both improvements in fitness and body composition were nearly identical for men and women……. ……."Older people should still be encouraged to exercise because it produces numerous health benefits, but their expectations need to be modified about how much good the exercise alone will do for reducing systolic blood pressure.  They may also need to understand it could take much more time for them to reach blood pressure goals, and it may require more intensive exercise programs.  Although participants followed the prescribed program according to guidelines without fail, it does not seem to be enough for full blood pressure control in older people…………….