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Case study

Case study. Mr. Wong is a 48-year old male, sales representative who travels often 170cm, 84kg , BMI 29 His brother just suffered from MI at age 40. Concerned about his health Want to do start exercise and lose weight. Evaluation. Classify client according to Risk Stratification Criteria

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Case study

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  1. Case study • Mr. Wong is a 48-year old male, sales representative who travels often • 170cm, 84kg , BMI 29 • His brother just suffered from MI at age 40. • Concerned about his health • Want to do start exercise and lose weight

  2. Evaluation • Classify client according to Risk Stratification Criteria • ACSM/ ACP/ACCVPR/ AHA • Identify Major Coronary Artery Disease Risk Factors • Identify signs or symptoms suggestive of cardiopulmonary disease • Identify secondary risk factors • Obesity, alcohol consumption, stress levels

  3. Case Study • Recently diagnosed to have type 2 DM, put on Daonil • BP 160/90 mmHg on metoprolol 50mg bd • Half pack a day smoking habit due to stress of his job • His brother just suffered from MI at age 40. • Cholesterol level: 6.2mmol/l , HDL 0.90 mmol/l, LDL 3.8mmol/l • TG: 2.4 mmol/l • No regular exercise • No signs or symptoms of cardiopulmonary disease

  4. Positive Risk Factors for CHDACSM (2006) Family History • Myocardial infarction, coronary revascularization (bypass surgery) or sudden death before : • the age of 55 years in father or other male first degree relative (i.e. brother or son) • the age of 65 years in mother or other female first degree relative (i.e. sister or daughter) Cigarette smoking • Current cigarette smoker or those who have quit in the last six months Hypertension • Client on Hypertensive medications • Resting SBP > 140 mmHg and/ or DBP > 90 mm Hg • Fasting Glucose • Fasting blood glucose of >100mg/dL 5.6mmol/L)

  5. Positive Risk Factors for CHDACSM (2006) Dyslipidemia • Total serum cholesterol > 200mg/dL (5.2 mmol/L) or • High density lipoprotein (HDL) < 40mg/dL (1.03 mmol/L) • Low density lipoprotein (LDL) > 130mg/dL (3.4mmol/L) Obesity • Body Mass Index (BMI) > 30 kg/m2 or • Waist girth >= 102 cm (M); >= 88 cm (F) or • Waist/hip ration >= 0.95 (M); >= 0.86 (F) Sedentary Lifestyle • Not participating in a regular exercise program • Accumulating less than 30 minutes moderate intensity exercise 3-5 days weekly Negative Risk Factors for CHDACSM (2006) High level of HDL • HDL cholesterol > 1.6 mmol/L (60 mg/dl)

  6. Initial Risk Stratification • Low risk • Men<45 years of age and women <55 years of age • Younger individuals who are asymptomatic and meet no more than one risk factor threshold • Moderate risk • Older individuals (men 45 years of age; women  55 years of age) or those who meet the threshold for two or more risk factors • High Risk • Individuals with one or more signs/symptoms or known cardiovascular, pulmonary, or metabolic disease

  7. What recommendations in reference to medical examination and testing prior to participation in an exercise program? • A. Medical examination and exercise testing • B. Physician Supervision of exercise test

  8. Consider the following criteria during your evaluation: • Age and gender • Moderate Vs vigorous exercise program • Physician present during testing • Submaximal or maximal graded exercise test • Type of test (treadmill, leg ergometer, step) • Absolute and relative contraindications to exercise testing

  9. ACSM Recommendations for: Pre-participation screening Algorithm

  10. ACSM Recommendations for: Pre-participation screening Algorithm cont’

  11. Cardiovascular System Assessment A graded exercise test may be helpful if a patient, about to embark on a moderate to high-intensity physical activity program, is at high risk for underlying cardiovascular disease, based on one of the following criteria: • Age >40 years , +/- CVD risk factors • Age >30 years and • Type 1 or 2 diabetes of >10 years' duration • Presence of any additional risk factor for coronary artery disease • Presence of microvascular disease (proliferative retinopathy or nephropathy, including microalbuminuria) • Peripheral vascular disease • Autonomic neuropathy

  12. Medications

  13. Metabolic Syndrome • A constellation of cardiovascular risk factors related to hypertension, abdominal obesity, dyslipidemia, and insulin resistance • Certain drugs used to treat hypertension may accelerate the appearance of new-onset diabetes. In particular, both β blockers and diuretics have been implicated in this effect.

  14. ALLHAT • In high risk hypertensive patients, the diuretic, chlorthalidone, was 43% more likely than the ACEI, lisinopril, to produce diabetes, but was also 18% more likely than the calcium channel blocker, amlodipine, to produce this adverse effect. • HOPE • The development of new diabetes was reduced by 34% (p<0.001) in the ramipril-treated group. • LIFE (Losartan Intervention For Endpoint Reduction in Hypertension) • The ARB, losartan, was associated with a 25% relative risk reduction in new-onset diabetes when compared with the β blocker, atenolol • VALUE(The Valsartan Antihypertensive Long-term Use Evaluation) • Valsartan, was associated with 23% RRR in new-onset diabetes when compared with the calcium channel blocker, amlodipine.

  15. ARB/ACEI may have positive effects on insulin action and potentially plays a meaningful role in protecting high-risk hypertensive patients from developing diabetes.

  16. Medications • Metoprolol changed to ACE inhibitors/ ARB • Metformin • Statin

  17. Exercise stress test • METS achieved: 8.5 • Peak heart rate: 165 beats per minute • Peak blood pressure of 200/88 mmHg. • No exercise induced ischemia

  18. Questions • Please write an initial exercise prescription • Any adjustments and practical tips in patients with DM and HT?

  19. Exercise prescription • Address each of the following • Aerobic endurance • Strength training • Flexibility Include each of the following in your prescription frequency times/day, days/week Intesnisy 5HRR, %VO2max, %HRmax, %1RM, %MVC, etc Duration warm-up, cool-down, exercise component, rest between sets, etc Mode of exercise types of exerciise, stretching techniques, resistance training, etc Rate of progression

  20. ACSM and CDC Recommendation • American College of Sports Medicine (ACSM) and Centers for Disease Control and Prevention (CDC), 1995 (Pate et al., 1995) • Recommendation: Every adult should engage in moderate-intensity physical activity for 30 minutes or longer on most, preferably all, days of the week. Moderate intensity is defined as 40 to 60% of maximal oxygen consumption (VO2max). The 30-minute activity can also consist of shorter exercise bouts (minimum of 10 minutes) that are accumulated throughout the day (e.g., walking to work, shopping). Finnish Medical Society Duodecim. Physical activity in the prevention, treatment and rehabilitation of diseases. 2004 Apr 20

  21. ACSM Recommendation for Hypertension • 40-70% of VO2max, i.e. 55-80% of the maximal heart rate. The lower range of intensity is sufficient for the elderly. • 3 or 4 times weekly for at least 30 minutes at a time • Various endurance exercise modes are suitable. Resistance training (preferably circuit training) should not be the only form of exercise but should be combined with endurance training. • Training at an intensity of about 50% of the maximal exercise performance (moderate-intensity) is sufficient with regard to resting blood pressure reduction (Fagard, 2001). Finnish Medical Society Duodecim. Physical activity in the prevention, treatment and rehabilitation of diseases. 2004 Apr 20

  22. Rehabilitation in Coronary Heart Disease • Mainly endurance training • at an intensity of 50 (-60) -75% of symptom-limited VO2max (or heart rate reserve, which is the difference between maximal and resting heart rate) for 30 minutes 3-4 times weekly (minimum), full benefit is obtained with 5-6 times/week • Resistance training in addition • at an intensity of 30-50% (up to 60-80%) of 1 RM (one repetition maximum), 12-15 repetitions, 1-3 sets twice weekly

  23. Recommendations for Patients With Type 2 Diabetes Exercise program: • Type: Aerobic • Intensity: 50-70% of maximum aerobic capacity • Duration: 20-60 minutes • Frequency: 3-5 times per week • Avoid complications • Warm up and cool down • Careful selection of exercise type and intensity • Patient education • Monitoring of blood glucose by patient and overall program by medical personnel Physical Activity/Exercise and Diabetes; Diabetes care, vol. 27, supplement 1, January 2004

  24. Recommendations for Patients With Type 2 Diabetes 3. Compliance: • Make exercise enjoyable • Convenient location • Positive feedback from involved medical personnel and family Physical Activity/Exercise and Diabetes; Diabetes care, vol. 27, supplement 1, January 2004

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  26. Hypertension • Monitor blood pressure before, during, and after exercise • Unusually high blood pressures (>190mmHg systolic) during low-level activity may warrant adjustment in medical therapy • Stop when there is a 10 to 15mmHg fall in BP during exercise and further evaluation should be performed • Begin pharmacological treatment prior t starting exercise program if BP > 160/100

  27. Rehabilitation in Coronary Heart Disease • Mainly endurance training • at an intensity of 50 (-60) -75% of symptom-limited VO2max (or heart rate reserve, which is the difference between maximal and resting heart rate) for 30 minutes 3-4 times weekly (minimum), full benefit is obtained with 5-6 times/week • Resistance training in addition • at an intensity of 30-50% (up to 60-80%) of 1 RM (one repetition maximum), 12-15 repetitions, 1-3 sets twice weekly

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