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

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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  1. EXERCISEPRESCRIPTIONINPATIENTSWITH CARDIOVASCULARDISEASE LEANDRO C. BONGOSIA, MD, FPCP, FPCC, FACC

  2. 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

  3. 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

  4. 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

  5. Exercise training and myocardial oxygen consumption Pre-training Rate-pressure product Post-training Work rate Ades PA, et al. Circulation 2006;113:2706-2712

  6. 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.

  7. 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

  8. Theoretical relation between health and fitness benefits and the amount or intensity of exercise: Health Fitness Quantity of exercise Benefits

  9. 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

  10. The Process of Developing an Exercise Prescription Assessment Interpretation Prescription Mode Progression Precautions Frequency Duration Intensity

  11. Components of Exercise Prescription: A. Mode B. Intensity C. Duration D. Frequency E. Progression

  12. 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

  13. 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

  14. 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”

  15. Components of Exercise Prescription B. Intensity (cont.) 1. Establishing a training/target HR 2. Using MET method 3. Rate of Perceived Exertion

  16. 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

  17. 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

  18. 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.

  19. 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

  20. Components of Exercise Prescription D. Frequency 3 – 5 days/week 3 days/week ---- 60% – 80% HRR ACSM

  21. 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.

  22. 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.

  23. 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.

  24. 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

  25. 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

  26. 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.

  27. 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

  28. 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

  29. Restrictions of Resistance Training • Unstable angina • Uncontrolled HPN ( BP > 160/100) • Uncontrolled arrhythmias • Recent CHF • Severe Valvular Heart disease or hypertrophic cardiomyopathy

  30. Restrictions of Resistance Training • Poor left ventricular function • Inadequate functional capacity, less than or equal to 5 METS (not an absolute contraindication)

  31. 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

  32. 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

  33. 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

  34. 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

  35. 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

  36. 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

  37. 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

  38. 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 with increase in duration first

  39. Thank You

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