Presentation on theme: "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."— Presentation transcript:
1 Case studyMr. Wong is a 48-year old male, sales representative who travels often170cm, 84kg , BMI 29His brother just suffered from MI at age 40.Concerned about his healthWant to do start exercise and lose weight
2 Evaluation Classify client according to Risk Stratification Criteria ACSM/ ACP/ACCVPR/ AHAIdentify Major Coronary Artery Disease Risk FactorsIdentify signs or symptoms suggestive of cardiopulmonary diseaseIdentify secondary risk factorsObesity, alcohol consumption, stress levels
3 Case Study Recently diagnosed to have type 2 DM, put on Daonil BP 160/90 mmHg on metoprolol 50mg bdHalf pack a day smoking habit due to stress of his jobHis brother just suffered from MI at age 40.Cholesterol level: 6.2mmol/l , HDL 0.90 mmol/l, LDL 3.8mmol/lTG: 2.4 mmol/lNo regular exerciseNo signs or symptoms of cardiopulmonary disease
4 Positive Risk Factors for CHD ACSM (2006) Family HistoryMyocardial 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 smokingCurrent cigarette smoker or those who have quit in the last six monthsHypertensionClient on Hypertensive medicationsResting SBP > 140 mmHg and/ or DBP > 90 mm HgFasting GlucoseFasting blood glucose of >100mg/dL 5.6mmol/L)
5 Positive Risk Factors for CHD ACSM (2006) DyslipidemiaTotal serum cholesterol > 200mg/dL (5.2 mmol/L) orHigh density lipoprotein (HDL) < 40mg/dL (1.03 mmol/L)Low density lipoprotein (LDL) > 130mg/dL (3.4mmol/L)ObesityBody Mass Index (BMI) > 30 kg/m2 orWaist girth >= 102 cm (M); >= 88 cm (F) orWaist/hip ration >= 0.95 (M); >= 0.86 (F)Sedentary LifestyleNot participating in a regular exercise programAccumulating less than 30 minutes moderate intensity exercise 3-5 days weeklyNegative Risk Factors for CHD ACSM (2006)High level of HDLHDL cholesterol > 1.6 mmol/L (60 mg/dl)
6 Initial Risk Stratification Low riskMen<45 years of age and women <55 years of ageYounger individuals who are asymptomatic and meet no more than one risk factor thresholdModerate riskOlder individuals (men 45 years of age; women 55 years of age) or those who meet the threshold for two or more risk factorsHigh RiskIndividuals 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 testingB. Physician Supervision of exercise test
8 Consider the following criteria during your evaluation: Age and genderModerate Vs vigorous exercise programPhysician present during testingSubmaximal or maximal graded exercise testType of test (treadmill, leg ergometer, step)Absolute and relative contraindications to exercise testing
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 factorsAge >30 years andType 1 or 2 diabetes of >10 years' durationPresence of any additional risk factor for coronary artery diseasePresence of microvascular disease (proliferative retinopathy or nephropathy, including microalbuminuria)Peripheral vascular diseaseAutonomic neuropathy
13 Metabolic SyndromeA constellation of cardiovascular risk factors related to hypertension, abdominal obesity, dyslipidemia, and insulin resistanceCertain 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 ALLHATIn 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.HOPEThe 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, atenololVALUE (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 MedicationsMetoprolol changed to ACE inhibitors/ ARBMetforminStatin
17 Exercise stress test METS achieved: 8.5 Peak heart rate: 165 beats per minutePeak 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 followingAerobic enduranceStrength trainingFlexibilityInclude each of the following in your prescriptionfrequencytimes/day, days/weekIntesnisy5HRR, %VO2max, %HRmax, %1RM, %MVC, etcDurationwarm-up, cool-down, exercise component, rest between sets, etcMode of exercisetypes of exerciise, stretching techniques, resistance training, etcRate 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 Apr 20
21 ACSM Recommendation for Hypertension 40-70% of VO2max, i.e % 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 timeVarious 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 Apr 20
22 Rehabilitation in Coronary Heart Disease Mainly endurance trainingat 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/weekResistance training in additionat an intensity of 30-50% (up to 60-80%) of 1 RM (one repetition maximum), repetitions, 1-3 sets twice weekly
23 Recommendations for Patients With Type 2 Diabetes Exercise program:Type: AerobicIntensity: 50-70% of maximum aerobic capacityDuration: minutesFrequency: 3-5 times per weekAvoid complicationsWarm up and cool downCareful selection of exercise type and intensityPatient educationMonitoring of blood glucose by patient and overall program by medical personnelPhysical Activity/Exercise and Diabetes; Diabetes care, vol. 27, supplement 1, January 2004
24 Recommendations for Patients With Type 2 Diabetes 3. Compliance:Make exercise enjoyableConvenient locationPositive feedback from involved medical personnel and familyPhysical Activity/Exercise and Diabetes; Diabetes care, vol. 27, supplement 1, January 2004
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 therapyStop when there is a 10 to 15mmHg fall in BP during exercise and further evaluation should be performedBegin pharmacological treatment prior t starting exercise program if BP > 160/100
27 Rehabilitation in Coronary Heart Disease Mainly endurance trainingat 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/weekResistance training in additionat an intensity of 30-50% (up to 60-80%) of 1 RM (one repetition maximum), repetitions, 1-3 sets twice weekly