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Exercise Physiology For Cardiovascular Diseases

Exercise Physiology For Cardiovascular Diseases. Dr.Demet Demircioğlu. Prevention of Atherosclerotic Vascular Disease by Physical Exercise. Physical activity reduces the incidence of CAD Physical inactivity is a major CAD risk factor

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Exercise Physiology For Cardiovascular Diseases

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  1. ExercisePhysiologyForCardiovascularDiseases Dr.Demet Demircioğlu

  2. Prevention of Atherosclerotic Vascular Disease by Physical Exercise • Physical activity reduces the incidence of CAD • Physical inactivity is a major CAD risk factor • The relation is strong, with the most physically active subject is generally demonstrated CAD rates half those of the most sedentary group • Independent of other risk factors • Not protective in later years without lifelong physical activity • Benefit seen in middle age and older age groups Powell KE, Thompson PD, Caspersen CJ, et al. Physical activity and the incidence of coronary heart disease. Annu Rev Public Health. 1987;8:253-287

  3. Reduction of Atherosclerotic Risk Factors • Physical activity both prevents and treats establish atherosclerotic risk factors: • Elevated blood pressure • Insulin resistance • Glucose intolerance • Elevated triglyceride concentration, low HDL-C • Obesity • Exercise + weight reduction >>>>  LDL-C and increase HDL Thompson et al, Exercise and Physical Activity in Cardiovascular Disease. Circulation June 24, 2003; 107:3109-3166

  4. Response of Blood Lipids to Exercise Training • Meta-analysis of 52 exercise training trials of >12 weeks • Include 4700 patients • Change in lipid profile • HDL-C increase 4.6% • Reduction in LDL-C by 5.0% • Reduction in TG by 3.7% Leon AS, Sanchez O. Meta-analysis of the effects of aerobic exercise training on blood lipids. Circulation. 2001;104(suppl II):II-414-415. Abstract.

  5. Response of Blood Pressure to Exercise Training • 44 randomized controlled trials include 2674 patients • Average change in blood pressure • SBP decrease by 3.4 mmHg • DBP decrease by 2.4 mmHg • Hypertensive patient • SBP decrease by 7.4 mmHg • DBP decrease by 5.8 mmHg • Normotensive patient • SBP decrease by 2.6 mmHg • DBP decrease by 1.8 mmHg BP drop is not dose related Fagard RH. Exercise characteristics and the blood pressure response to dynamic physical training. Med Sci Sports Exerc. 2001;33(6 suppl)

  6. Blood Pressure Reductions as Little as 2 mmHg Reduce the Risk of Cardiovascular Events by up to 10% Meta-analysis of 61 prospective, observational studies 1 million adults 12.7 million person-years 7% reduction in risk of ischemic heart disease mortality 2 mmHg decrease in mean systolic blood pressure 10% reduction in risk of stroke mortality Lewington S, et al. Lancet. 2002;360:1903–1913

  7. Lifestyle modification

  8. Lifestyle modification

  9. Outcome Mean Difference 95% Cl Statistically Significant? Exercise-only intervention Total mortality -27% -2% to –40% Yes Cardiac mortality -31% -6% to –49% Yes Nonfatal MI -4% -31% to +35% No Comprehensive rehabilitation Total mortality -13% -29% to +5% No Cardiac mortality -26% -4% to –43% Yes Nonfatal MI -12% -30%-+12% No Effect of Exercise-based Cardiac Rehabilitation on Cardiac Events Cl indicates confidences intervals. Cls not including zero are statistically significant. • Meta analysis include 51 randomized trials • Include 8440 patients: CABG, PTCA, MI, angina, middle-age men • Supervised exercise for 6 months, follow up 2 years later Jolliffe JA, Rees K, Taylor RS, et al. Exercise-based rehabilitation for coronary heart disease. Cochrane Database Syst Rev. 2001(1):CD001800

  10. The Exercise Training Intervention after Coronary Angioplasty • Randomised 118 patients after coronary revascularization • 6 months of exercise training vs usual care • Trained patients significant increases in peak VO2 (26%) • Quality of life parameters increases in 27% • Fewer cardiac events (11.9% vs 32.2%) • Hospital readimissions (18.6% vs 46%) • Residual coronary stenosis decrease by 30% • Recurrent cardiac event reduced by 29% BelardinelliR, Paolini I, Cianci G, et al. Exercise Training Intervention after Coronary Angioplasty: the ETICA trial. J Am Coll Cardiol., 2001;37:1891-1900

  11. Risk • Cardiac rehabitation programs • Cardiac arrest: 1 in 117000 (patient-hours of participation) • Nonfatal MI: 1: in 220000 • Death : 1: 750000

  12. Hypertension and ExercisePosition Stand (Evaluation) • Severity • Secondary cause • CV risk factors • Target organ damage (TOD) • CVD complications

  13. Exercise is a major lifestyle modification needed to prevent, treat and control hypertension

  14. Hypertension and ExercisePosition Stand (Evaluation) • Supervised exercise stress test • High intensity exercise program (VO2 R >60%) • Patients with TOD/DM or BP >180/110 before engaging in moderate-intensity exercise (VO2R 40 to 60%) • Patients with CVD (stroke, heart failure, IHD) • Avoid high intensity exercise (vigorous program best initiated at dedicated rehabilitation centre)

  15. Special Consideration • Beta-blockers and diuretics impair the ability to regulate body temperature. • S/S of heat illness • Adequate hydration • Proper clothing • Optimal times of the day • Beta blockers can alter submaximal and maximal exercise capacity • Alpha blockers, CCB, vasodilators • Provoke hypotensive episodes after abrupt cessation of activity • Extend the cool-down period • Diuretics increase the potential for dehydration

  16. Hypertension and ExercisePosition Stand • Emphasis on aerobic activity. VO2R 40 to 60%. RPE 12-13. • Avoid high-intensity resistance training (lower intensity, higher repetitions). • Clients should maintain hypertensive medications, if prescribed. • Do not exercise if resting SBP > 200 mm Hg or DBP > 115 mm Hg. Maintain BP <220/105 during exercise • Begin pharmacological treatment prior to starting exercise program if BP > 160/100

  17. Resistance training/ Valsalva maneuver • Forced expiration against a closed glottis • Increase in intrathoracic pressure leading to decreased venous return and potentially reduced cardiac output • At the release of the “strain,” venous return is dramatically increased, increasing cardiac output and elevation of BP • Symptoms of lightheadedness or dizziness may occur if cardiac output is reduced. • With relaxation, individuals may experience headache while pressure remains elevated. • In patients with heart disease, symptoms of myocardial ischemia may ensue as a result of elevated BP and increased myocardial work.

  18. Adherence • Education regarding the importance of regular exercise for BP control • Especially responsive if information comes from their personal physician • Knowledge of the immediate BP-lowering effects of exercise (up to 22 hr)

  19. Cardiac rehabilitation • Core components • Medical assessment • Nutrition counseling • Risk factor management (lipid, DM, weight, smoking) • Psychosocial management • Activity counseling and exercise training

  20. Cardiac rehabilitation • Phase I • Inpatient • Phase II • Up to 12 weeks of ECG monitored exercise • Phase III • Clinical supervision • Phase IV • No ECG, medical supervision

  21. Cardiovascular System Assessment • Patients with known coronary artery disease should undergo a supervised evaluation of the ischemic response to exercise, ischemic threshold, and the propensity to arrhythmia during exercise. • In many cases, left ventricular systolic function at rest and during its response to exercise should be assessed. Physical Activity/Exercise and Diabetes; Diabetes care, vol. 27, supplement 1, January 2004

  22. Exercise testing • Integral component of the rehab process • Establishment of appropriate specific safety precautions • Guide training intensity • Target exercise training heart rates • Initial levels of exercise training work rates • Risk stratification • Should be performed on all cardiac patients entering an exercise training program

  23. Exercise prescription for individuals with CAD (Risk Stratification) • Mildly increased risk • Preserved LV systolic function (EF > 50%) • Normal exercise tolerance for age • > 50 years old > 10METS • 50 to 59 >9METS • 60 to 60 >8METS • >70 >7METS • Absence of exercise induced ischemia • Absence of hemodynamically significant stenosis of a major coronary artery (>50%) • Successful revascularization

  24. Exercise prescription for individuals with CAD (Risk Stratification) • Substantially increased risk • Impaired LV systolic function (<50%) • Evidence of exercise-induced myocardial ischemia • Hemodynamically significant stenosis of a major coronary artery (>50%)

  25. Medically Supervised Exercise • Moderate to High risk subjects • Medical supervision required until safety established • ECG and BP monitoring (usually > 12 sessions) • Low risk subjects • Benefit from medically supervised programs • Safe • Group dynamics • ECG monitoring (useful during the early phase, 6 – to 12 sessions)

  26. Rehabilitation in Coronary Heart Disease • Mainly endurance training • at an intensity of 50 (-60) -75% of symptom-limited VO2max (or heart rate reserve) 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

  27. Outpatients exercise program • Setting a safe upper limit for Intensity • Moderate intensity exercise (40 to 60% VO2max) • Brisk walking, treadmill, cycle, stair-climbing, rowing machine • Initial intensity • 40 to 60% of heart rate reserve • Can be increased to 85% (high intensity) if tolerated • RPE (algılanan zorluk derecesi) • 11 to 13 (between fairly light to somewhat hard) • Duration may be increased as appropriate after safe activity levels established • Intensity may be increased as heart rate response to exercise decreases with conditioning

  28. Exercise prescription without exercise test • Initial exercise intensity • 2 to 3 METs • 1 to 2 mph, 0% grade on treadmill • 100 to 300 kg.m.min-1 (12.5- 50W) on cycle ergometer • RPE: 11-13 • Gradual increments of 0.5 to 1.0 METs as tolerated • Target heart rate • 20 beats/min above standing rest • Frequency • 30 – 45 minutes per day 5 d/wk,

  29. Exercise prescription in the presence of ischemia • Inappropriate for those with angina < 3METS • Aim to increase anginal threshold • Prolonged warm up and cool • Upper body exercises may precipitate angina more readily • Heart rate and work rate below the identified threshold of ischemia • Should be a minimum of 10 beats/min below the heart rate at which the abnormality occurs • Intermittent, shorter duration-type on a more frequent basis

  30. Home exercise rehabilitation • Lower cost • Convenience • Promote independence • Comparable safey and efficacy • Good communication between patients and staff required

  31. Heart Failure • Benefits of exercise • Functional capacity, improved leg blood flow and oxidative capacity, neurohormones, autonomic tone • Initiated at a low to moderate level (25 to 60% of VO2max) • VO2max determined by direct gas exchange measurements • Careful supervision and monitoring • Brief training session • Lengthened warm up and cool down • RPE: 11 to 14 • Safety and efficacy of resistance training not well established

  32. After cardiac procedure • CABG • Avoid upper body exercise for 3 months • PCI • Resume exercise no sooner than 5 to 7 days • Catheterization access sites should be healed

  33. Pacemakers and implantable cardioverter defrillators • Type and settings of pacemaker should be noted • Avoid high intensity resistance exercise • Fixed-rate pacemakers • Activity intensity must be gauged by other methods • RPE • ICD • Limit target heart rate at least 10 to 15 beats/min lower than the threshold discharge rate

  34. AHA Scientific Statement: Recommendations for the Acceptability of Recreational (Noncompetitive) Sports Activities and Exercise in Patients With Genetic CVD • GCVD • HCM, LQTS, Marfan syndrome, ARVC, Brugada syndrome • Recreational sports are categorized with regard to high, moderate and low levels of exercise • Graded on relative scale (from 0 to 5) for eligibility • 0 to 1: indicating generally not advised or strongly discouraged • 4 to 5: indicating probably permitted • 2 to 3: indicating intermediate and to be assessed clinically in an individual basis

  35. Intensity Level HCM LQTS Marfan Syndrome ARVC Brugada Symdrome High Basketball 0 0 2 1 2 Full court 0 0 2 1 2 Half court 1 1 0 1 1 Body building 0 0 1 0 0 Ice hockey 0 2 2 0 2 Racquetball/squash 1 1 1 1 1 Rock climbing 0 0 2 0 2 Running (downhill) 2 2 2 1 1 Skiing (cross-country) 2 3 2 1 4 Soccer 0 0 2 0 2 Tennis (singles) 0 0 3 0 2 Touch (flag) football 1 1 3 1 3 Windsurfing 1 0 1 1 1 AHA Scientific Statement: Recommendations for the Acceptability of Recreational (Noncompetitive) Sports Activities and Exercise in Patients With GCVDs Recommendations for Physical Activity and Recreational Sports Participation for Young Patients with Genetic Cardiovascular Diseases, Circulation. 2004; 109:2807-2816)

  36. Intensity Level HCM LQTS Marfan Syndrome ARVC Brugada Symdrome Moderate Baseball/softball 2 2 2 2 4 Biking 4 4 3 2 5 Modest hiking 4 5 5 2 4 Motocycling 3 1 2 2 2 Jogging 3 3 3 2 5 Sailing 3 3 2 2 4 Surfing 2 0 1 1 1 Swimming (lap) 5 0 3 3 4 Tennis (doubles) 4 4 4 3 4 Treadmill/stationary bicycle 5 5 4 3 5 Weightlifting (free weights) 1 1 0 1 1 Hiking 3 3 3 2 4 AHA Scientific Statement: Recommendations for the Acceptability of Recreational (Noncompetitive) Sports Activities and Exercise in Patients With GCVDs Recommendations for Physical Activity and Recreational Sports Participation for Young Patients with Genetic Cardiovascular Diseases, Circulation. 2004; 109:2807-2816)

  37. Intensity Level HCM LQTS Marfan Syndrome ARVC Brugada Symdrome Low Bowling 5 5 5 4 5 Golf 5 5 5 4 5 Horseback riding 3 3 3 3 3 Scuba diving 0 0 0 0 0 Skating 5 5 5 4 5 Snorkeling 5 0 5 4 4 Weights (non-free weights) 4 4 0 4 4 Brisk walking 5 5 5 5 5 AHA Scientific Statement: Recommendations for the Acceptability of Recreational (Noncompetitive) Sports Activities and Exercise in Patients With GCVDs Recommendations for Physical Activity and Recreational Sports Participation for Young Patients with Genetic Cardiovascular Diseases, Circulation. 2004; 109:2807-2816)

  38. Case study • BP 150/90 mmHg • Medications: atenolol 50mg daily, lisinopril 10mg daily • Resting HR: 60/min • 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

  39. 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

  40. 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

  41. Hypertension and ExercisePosition Stand (Evaluation) • Supervised exercise stress test • High intensity exercise program (VO2 R >60%) • Patients with TOD/DM or BP >180/110 before engaging in moderate-intensity exercise (VO2R 40 to 60%) • Patients with CVD (stroke, heart failure, IHD) • Avoid high intensity exercise (vigorous program best initiated at dedicated rehabilitation centre)

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