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Case study Mr. Wong is a 48-year old male, sales representative who travels often Mr. Wong is a 48-year old male, sales representative who travels often.

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Presentation on theme: "Case study Mr. Wong is a 48-year old male, sales representative who travels often Mr. Wong is a 48-year old male, sales representative who travels often."— Presentation transcript:

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

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

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

4 Positive Risk Factors for CHD ACSM (2006) Family History Myocardial infarction, coronary revascularization (bypass surgery) or sudden death before : 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 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) 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 Current cigarette smoker or those who have quit in the last six monthsHypertension Client on Hypertensive medications Client on Hypertensive medications Resting SBP > 140 mmHg and/ or DBP > 90 mm Hg Resting SBP > 140 mmHg and/ or DBP > 90 mm Hg Fasting Glucose Fasting blood glucose of >100mg/dL 5.6mmol/L)

5 Dyslipidemia Total serum cholesterol > 200mg/dL (5.2 mmol/L) or Total serum cholesterol > 200mg/dL (5.2 mmol/L) or High density lipoprotein (HDL) < 40mg/dL (1.03 mmol/L) High density lipoprotein (HDL) < 40mg/dL (1.03 mmol/L) Low density lipoprotein (LDL) > 130mg/dL (3.4mmol/L) Low density lipoprotein (LDL) > 130mg/dL (3.4mmol/L)Obesity Body Mass Index (BMI) > 30 kg/m 2 or Body Mass Index (BMI) > 30 kg/m 2 or Waist girth >= 102 cm (M); >= 88 cm (F) or Waist girth >= 102 cm (M); >= 88 cm (F) or Waist/hip ration >= 0.95 (M); >= 0.86 (F) Waist/hip ration >= 0.95 (M); >= 0.86 (F) Sedentary Lifestyle Not participating in a regular exercise program Not participating in a regular exercise program Accumulating less than 30 minutes moderate intensity exercise 3-5 days weekly Accumulating less than 30 minutes moderate intensity exercise 3-5 days weekly Positive Risk Factors for CHD ACSM (2006) High level of HDL HDL cholesterol > 1.6 mmol/L (60 mg/dl) HDL cholesterol > 1.6 mmol/L (60 mg/dl) Negative Risk Factors for CHD ACSM (2006)

6 Initial Risk Stratification Low risk Low risk Men<45 years of age and women <55 years of age 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 Younger individuals who are asymptomatic and meet no more than one risk factor threshold Moderate risk 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 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 High Risk Individuals with one or more signs/symptoms or known cardiovascular, pulmonary, or metabolic disease 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? What recommendations in reference to medical examination and testing prior to participation in an exercise program? A. Medical examination and exercise testing A. Medical examination and exercise testing B. Physician Supervision of exercise test B. Physician Supervision of exercise test

8 Consider the following criteria during your evaluation: Consider the following criteria during your evaluation: Age and gender Age and gender Moderate Vs vigorous exercise program Moderate Vs vigorous exercise program Physician present during testing Physician present during testing Submaximal or maximal graded exercise test Submaximal or maximal graded exercise test Type of test (treadmill, leg ergometer, step) Type of test (treadmill, leg ergometer, step) Absolute and relative contraindications to exercise testing 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 A constellation of cardiovascular risk factors related to hypertension, abdominal obesity, dyslipidemia, and insulin resistance 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. 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 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. 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 HOPE The development of new diabetes was reduced by 34% (p<0.001) in the ramipril- treated group. 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) 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 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) 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. 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. 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 Metoprolol changed to ACE inhibitors/ ARB Metformin Metformin Statin Statin

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

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

19 Exercise prescription Address each of the following Address each of the following Aerobic endurance Aerobic endurance Strength training Strength training Flexibility 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) 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). 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 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 Apr 20

22 Rehabilitation in Coronary Heart Disease Mainly endurance training 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 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 Resistance training in addition at an intensity of 30-50% (up to 60-80%) of 1 RM (one repetition maximum), repetitions, 1-3 sets twice weekly at 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: Aerobic Intensity: 50-70% of maximum aerobic capacity Duration: 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

25 .

26 Hypertension Monitor blood pressure before, during, and after exerciseMonitor blood pressure before, during, and after exercise Unusually high blood pressures (>190mmHg systolic) during low-level activity may warrant adjustment in medical therapyUnusually 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 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 Begin pharmacological treatment prior t starting exercise program if BP > 160/100

27 Rehabilitation in Coronary Heart Disease Mainly endurance training 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 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 Resistance training in addition at an intensity of 30-50% (up to 60-80%) of 1 RM (one repetition maximum), repetitions, 1-3 sets twice weekly at an intensity of 30-50% (up to 60-80%) of 1 RM (one repetition maximum), repetitions, 1-3 sets twice weekly

28 End End


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