Exercise Prescriptions: Cardiac Rehab and Frail Adults. Brian K. Unwin, M.D. Colonel, Medical Corps, USA Uniformed Services University. Cardiac Rehab. Only 15-25% of eligible patients participate!. The Evidence Fewer events, reduced all cause mortality 20-34%.
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Brian K. Unwin, M.D.
Colonel, Medical Corps, USA
Uniformed Services University
Only 15-25% of eligible patients
Am Heart J 2006; 152:835-841
Fewer events, reduced
all cause mortality
Am Heart J. Nov. 2006. 152(5):835-41
Heart 2007; 93: 862-864
Heart, Lung and Circulation 2007; 16: S83-S87
American Association of Cardiovascular Rehabilitation (AACVPR) (Card Clin 2001; 19: 415-431)
American Heart Association (Circulation 2001; 104:1694-1740)
Class DRisk Stratification
AHA Guidelines include activity
guidelines and supervision requirements
Non-exercise variables are important
Gradual exposure to outdoor exercise program
See ACSM Guide Appendix E
ACSM Guide to Exercise Rx 7th Edition
For stable cardiac patients progress to expenditure of 1000kcal/week over 3-6 months
Higher level than this is associated with atherosclerotic regression (1500-2200kcal/week) (15-20 miles per week)
Typical cardiac program is <300kcal per session and <200 on non-program days
19-43% of patients in rehab programs reach these levels
Traditional exercise rx falls short of this goal!
Goal: increase anginal and ischemic threshold
Prolonged warm-up & cool down (gradual rise)
Target HR below ischmic level (± 10 bpm)
Caution with exertion in the cold
Upper body exercise may precipitate symptoms due to higher pressor response
Monitor blood pressures before and after exercise (or NTG use)
Alternative exercise: frequent, short, intermittent sessions
Must be on stable medical therapy
Monitor hypokalemia and hemodynamic response
THR 40-70% VO2max 3-7days per week, 20-40 minutes per session
Long warm-up and cool down
Interval exercise training
RPE may be used
Aerobic and resistance after access site healed
May progress rapidly if no myocardial damage
People live longer with chronic diseases.
10% of nondisabled adults 75 years+ lose independence in 1 or more ADL’s each year.
Exercise and physical activity can improve health, functional capacity, QOL, and independence.
Aging, high burden of chronic disease, malnutrition and extreme lack of activity.
Muscle weakness and low muscle mass (sarcopenia), low bone density, cardiovascular deconditioning, poor balance and gait.
Inactivity with low energy intake, weight loss or low BMI.
Lunney et al. JAMA; 289:2387-92, 2003
Sarcopenia = decreased quality of muscle
Strength decline: diminished walking speed and balance difficulties as a result
Grip strength: inversely related to IADL deficits
Spinal mobility: affects many functional tasks
Established Populations for Epidemiologic Studies of the Elderly (EPESE) . J Gerontology, 1994;49(3):M109-15
Dementia and depression
Impaired balance and falls
Stressful life events
AM J Med. 2007. 120(9):748-753
If identified as Frail:
27% reported ADL
46% had co-morbid
22% had ADL disability
and com-morbid illness
27% had neither disability
Overall: 2,762 subjects with comorbidity and/or disability and/or frailty
Genetic Factors, atherosclerosis,
Low level of exercise,
Lancet. 2007. 369: 1328-29
Predictor of death within 3 yrs (6x mortality)
3x mortality at 7years
Increased falls, decreased mobility, injury and ADL disability
Pre-frail had 2x the risk of progression to being frail
From the Cardiovascular Health Study, three or more of the following:
>10 pounds (or 5%) of body weight in prior year
Lowest 20% adjusted for gender and BMI
Self report of exhaustion
Correlates with VO2 max and cardiovascular disease
Slowest 20% based on time to walk 15 feet, gender and standing height adjusted
Low physical activity level
Weighted score of kcals expended per week, lowest 20% adjusted to gender
Fried. J Gerontol. 2001. 56A(3): M146-156
3 or more criteria met
1-2 criteria met
Fried, Tangen, et al. Frailty in Older Adults: Evidence for a Phenotype. J of Gerontology. 2001: 56A(3): M146-M156.
Time to walk 15 feet:
159# person walking at 5kph
The aged person with unintended weight loss
Self-report of exhaustion
Regular physical activity reduces age-related loss of muscle mass.
Resistance training increases muscle mass, counteracts sarcopenia, and improves function.
Chronic disease and syndromes respond favorably to exercise.
Small improvements in physiological capacity = substantial effect on functional performance.
Cochrane Collaboration: falls reduction
Fiatarone et al: increased muscle strength = increased daily function
FICSIT Trials: balance exercises lowered falls
FAST trial: diminished pain and disability in OA patients
NEJM Oct 2002: 45% reduction in disability
Health ABC Study: exercise = better function
Improve ADL and IADL function
Enhance: flexibility, balance/postural stability, endurance, coordination, movement speed, strength, and bone health
Prevent/decrease the burden of disease
Improve patient education
What is the patient’s lifelong pattern of activities and interests?
Patient’s investment in plan
What has been the patient’s activity level in the past 2-3 months?
Determines current baseline
What are the patient’s concerns and perceived barriers regarding exercise?
Opportunity for education
Physical Performance Test (PPT)
Timed Get Up and Go (TUG)
Vulnerable Elders Survey (VES-13)
Functional Status Questionnaire (FSQ)
EPESE study: Physical performance measures
Others: LLFDI, PF-10 and LHS
Frailty or extreme age is not!
Caution: acute illness; unstable CP; uncontrolled DM, HTN, asthma, CHF; musculoskeletal pain, weight loss and falling
Not during treatment: hernias, cataracts, retinal bleeding or joint injuries
Stop!: enlarging AAA, end stage CHF, malignant ventricular arrhythmias, severe AS
Main risk = musculoskeletal injury
Higher: vigorous exercise, higher volume, obesity
Lower: higher fitness, supervision, protective gear and well designed exercise environment
Risk of exercise related MI and sudden death: greatest in least active elders
OA: aquatic; flexibility training; isometric exercises
Osteoporosis: weight bearing; improve balance
Obesity: rotation to minimize orthopedic injury
HTN: aerobic activity, large muscle groups
COPD: walking; PRT of shoulder girdle, inspiratory and UE muscles. Bronchodilators reduce dyspnea
CHF: aerobic and resistance training; improves VO2 max, dyspnea, work capacity and LV function; muscle strength and muscle endurance
The “MD FITT” Prescription (AACVPR)
(for the older adult)
Saliba et al. JAGS ; 49: 1691-99, 2001
Patient sits in a straight-backed high-seat chair
Instructions for patient:
Get up (without using the armrests)
Stand still momentarily
Walk forward (10 ft or 3 m)
Turn around and walk back to chair
Turn and be seated
>15 seconds higher risk for fall
Reuben DB, Siu AL. JAGS; 38(10): 1105-12, 1990
Exercise: A Guide from the NIA http://www.nia.nih.gov/HealthInformation/Publications/ExerciseGuide
ACSM Fit Society Page http://www.acsm.org
CDC Physical Activity for Everyone http://www.cdc.gov/nccdphp/dnpa/physical/index.htm