1. E XERCISE P RESCRIPTION I N P ATIENTS W ITH C ARDIOVASCULAR D ISEASE L EANDRO C. B ONGOSIA, MD, FPCP, FPCC, FACC

3. 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

4. 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

5. Definition of terms Exercise Prescription – is primarily focused on relatively higher intensity exercise to achieve specific goals to restore age and gender- appropriate exercise capacity. Cardiology Clinics 2001

6. 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 to a 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

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

8. 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.

9. 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

10. Exercise Prescription Goals:  Promote health  Ensure safety  Enhance physical fitness

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

12. 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

13. The Process of Developing an Exercise Prescription Assessment Interpretation Prescription Mode Frequency DurationIntensity Precautions Progression

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

15. 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

16. Components of Exercise Prescription Mode(cont.) Resistance Training: - Does little to increase VO 2 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

17. Components of Exercise Prescription B. Intensity For Cardiac Patients: 40% - 60% VO 2 max “Above a minimal level required to induce a training effect but below the metabolic rate that evokes abnormal signs or symptoms”

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

19. 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

20. 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

21. 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.

22. 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

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

24. 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.

25. 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.

26. 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.

27. 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

28. 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

29. 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.

30. 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

31. 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

32. Muscle strength declines by 15% per decade after age 70, however with exercise (resistance training) can result in 25 to 100% or more strength gains in older adults.

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

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

35. Resistance training should always be preceded by an aerobic component and should always incorporate a specific muscle and joint warm up exercise and a cool down exercise

36. Division of an exercise program 1.Warm up 2.Pre-stretching 3.Dexterity 4.Resistance / wt. bearing 5.Endurance 6.Balance 7.Cool Down 5 to 10 minutes 10 minutes 15 minutes 20 to 30 minutes 5 to 10 minutes Hessert, J of Fam Med 2005

37. S ummary of Exercise Prescription among Patients with CVD CVD Intensity Comments Angina or equivalent Shuler G, et al. Circulation 1992;86:1-11 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

38. 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 Shuler G, et al. Circulation 1992;86:1-11 Achieve 1,500-2,000 kcal of energy expenditure thru activity each week Restrict upper body movement until sternum is healed (6 - 12 weeks)

39. 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

40. Summary of Exercise Prescription among Patients with CVD CVD Intensity Comments Pacemaker, ICD, CRT Shuler G, et al. Circulation 1992;86:1-11 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

41. Summary of Exercise Prescription among Patients with CVD CVD Intensity Comments CAD 40-85% of HRR Shuler G, et al. Circulation 1992;86:1-11 To affect mortality, frequency, duration and intensity of training should sum to yield a weekly energy expenditure of > 1,500 kcal/week

42. 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

43. Guidelines for Exercise Rx for Cardiac Patients (ACSM)  Mode: Select rhythmical aerobic activities that can be maintained continuously involving large muscle muscle groups  Intensity: Prescribe between 40 - 85% VO 2 max  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 Summary and Conclusion: