Exercise & Medicine

Exercise & Medicine Dr. Wong Bun Lap Bernard Specialist in Cardiology HKMA Council Member

Genius is one percent inspiration,Ninety-nine percent perspiration ~ Thomas Alva Edison 1847-1931

Interesting Definitions Exercise • Physical activity that is planned, structured, repetitive, and purposeful, usually aimed at a improving or maintaining physical fitness. Physical activities • Any body movement produced by skeletal muscles that results in energy expenditure beyond resting expenditure. ~ Richard C Pasternak, Braunwald’s Heart Disease, A textbook of cardiovascular medicine, 7th Edition 2005’

Heart DiseaseA very common disease 2nd Killer • 5,390 deaths in 2003’ (14.8/day) Public resources demanding • More than 60,000 hospital admissions per year • Only for ischemic heart diseases • 17,523 (48/day) admissions & 1,780 deaths per year ~ Statistical Report 2003/2004, Hospital Authority ~ Census & Statistic Department, Department of Health

Heart DiseaseA very common disease A coronary artery disease community survey in HK 95-96’ • Prevalences 2.4% • 164,523 in 6,855,125 HK population1 A projection from US data • Prevalences 6.80%2 • Estimated 466,148 in 6,855,125 HK population • we are seeing the “tip of iceberg” only • Janus et al, 1997. Hong Kong cardiovascular risk factor prevalence study 1995-1996. • US Census Bureau 2004’

The Benefits of ExercisePrimary Prevention • Brisk walking, 30mins/day, 5 times/week • 30% ↓vascular events in 3.5 years follow-up1 • 3 hours of brisk walking/week = 1.5 hours of vigorous exercise per week2 • Resistance exercise and weight training were also beneficial3 1. Manson JE, Greenland P, LaCroix AZ, et al: Walking compared with vigorous exercise for the prevention of cardiovascular events in women N Eng J. Med 347;716, 2002 2. Manson JE, Hu FB, Rich Edward JW , et al: a prospective study of walking as compared with vigouous exercise in the prevention of coronary artery disease in women. N Eng J. Med 341:650, 1999 3. Tanasescu M, Leitzmann MF, Rimm EB, et al: Exercise type and intensity in relation to coronary heart disease in men. JAMA 288:1994, 2002

The Benefits of ExercisePrimary Prevention • “ No pain, no gain” approach is out!1 • Centers for Disease Control and Prevention and the American College of Sports Medicine 1995’ • Every person should accumulate at least 30minutes of moderate-intensity physical activity daily • Lee IM, Rexrode KM, Cook NR, et al: Physical activity and coronary heart disease is “No pain,no gain “ passe? JAMA 285:1447, 2001

The Benefits of ExerciseSecondary Prevention Physical activity with 1000kcal/wk • 20-30% ↓ all cause mortality1 For patients without revascularization • Exercise training improves SBP, angina symptoms and exercise tolerance2 For patients with revascularization • Improvement in QoL, exercise tolerance • ↓29% cardiac events • ↓re-admissions (18.6 vs 46%)3 • Lee I-M, Skerett PJ: Physical activity and all-cause mortality—What is the dose response relation? Med. Sci Sports exerc33(6Suppl):S459,2001 • Hambrecht R. Wolf A, Gielen S, et al: Effects of exercise on coronary endoothelial function in patients wwith coronary artery disease. Am J Cadriol 90:124, 2002 • Belardinelli R, Paolini I, Cianci G, et al: Exercise training intervention after coronary angioplasty: The ETICA trial. J Am Coll Cardiol 37:1891, 2001

Safety of Exercise Exercise without medical advice: • Sudden Cardiac Arrest: 1 per 60,000 pt. hours1 Supervised Programs: • Cardiac events: 8.9 per 1,000,000 pt. hours • Myocardial Infarction: 3.4 per 1,000,000 pt. hours • Mortality: 1.3 per 1,000,000 pt. hours2 • Fletcher GF, Balady GJ, Amsterdam EA, et al: Exercise standards for testing and training: A statement for healthcarecare professionals from the American eart Association. Circulation 104:1694, 2001 • Ades PA: Cardiac rehabilitation and secondary prevention of coronary heart disease. N Eng J Med 345:892, 2001

Principles of Exercise Avoid: • Unstable angina • SBP ≥ 180mmHg or DBP ≥ 100mmHg • Symptomatic orthostatic BP drop > 20mmHg • Critical aortic stenosis • Acute systemic illness or fever • Uncontrolled arrhythmia • Uncompensated CHF • 3rd degree AV Block (complete heart block) • Acute pericarditis & myocarditis • Recent embolism • Thrombophlebitis • Resting ST displacement ≥ 2mm • Uncontrolled DM • Electrolyte disturbance • hypovolemia

Principles of Exercise Prescription • Treadmill exercise stress test initial assessment • Cardiovascular status assessment • Exercise induced arrhythmia • Execise induced ischemia • Trend of Blood pressure during exercise • Trend of SaO2 during exercise

Principles of Exercise Prescription • Treadmill exercise stress test initial assessment • Functional capacity assessment • Activity of daily living: • Lying quietly 1.0METS • Sitting: light activity 1.5METS • Walking from house to car/bus 2.5METS • Watering plants 2.5METS • Taking out trash 3.0METS • Walking the dog 3.0METS • Household tasks, moderate effort 3.5METS • Vacuuming 3.5METS

Principles of Exercise Prescription • Treadmill exercise stress test initial assessment • Functional capacity assessment • Leisure activities • Playing piano 2.3METS • Golf (with cart) 2.5METS • Walking (2mph) 2.5METS • Ballroom Dancing 2.9METS • Walking (3mph) 3.3METS • Cycling (Leisurely) 3.5METS • Golf (without cart) 4.4METS • Swimming (slow) 4.5METS • Walking (4mph) 4.5METS • Tennis (doubles) 5.0METS • Ballroom Dancing (fast) 5.5METS • Cycling (mod) 5.7METS • Hiking (no load) 6.9METS • Swimming 7.0METS • Walking (5mph) 8.0METS • Jogging (10min/mile) 10.2METS • Rope skipping 12.0METS • Squash 12.1METS

Principles of Exercise Regular treadmill exercise stress test reassessment • Ascess the impact of medical and exercise management • Provide feedback to patient • Plan of future management

Tips on DM patients Pre- exercise treadmill Stress test was indicated: 1. Age > 40 2. Age > 30 with • DM > 10 yrs • HT • Smoking • Hyperlipidemia • Retinopathy • Nephropathy (microalbuminuria) 3. Coronary Artery Disease 4. CVA 5. Peripheral vascular disease 6. Autonomic neuropathy 7. Renal Failure

Tips on DM patients • Postpone exercise if • Hstix > 16.5mmol/L • Hstix >13mmol/L with ketones in urine • Monitor Hstix before, (during) and after exercise • Ideal pre-exercise 6.7 – 10mmol/L • Ingest Carbohydrate : Hstix 4.4-5.5mmol/L2

Tips on DM patients • prevent injury • peripheral neuropathy • Lower extremity care • Swimming/cycling/rowing better than walking/jogging • Autonomic neuropathy • Blunted BP/P response • Postural hypotension • Heat stroke

Tips on DM patients • Silent myocardial ischemia • Proliferative retinopathy • Consult opthalmologist • Low-impact exercise • Adequate hydration • DM identification card3,4 • Ronald J Signal, Geln P Kenny, David H. Wasswerman, carmen Castaneda-Sceppa et al. (Oct 2004) Physic al Activity, exercise and Type 2 Diabetes Care, 27(10), 2518-2539 • Barry A. Franklin, Mitchell H. Whaley, & Edward T. Howley, et al. (2000). American College of Sports Medicine’s Guidelines for exercise testing and presciption, 6th ed. Baltimore: Lippincott Williams & Wilkins • Birrer, Richard B., Sedaghat, & Vahid-David et al. (May 2003). Exercise and Diabetes Mellitus, Physician & Sports Medicine, 31(5). • American Diabetes Association. (January2004). Physical activity/Exercise and Diabetes, Diabetes Care, 27, Supplement 1.

After Doctors’ Consultation Just Do It !

DIY !

DIY!

Exercise & Medicine