1. Dominique Hansen, PhD, FESC
Exercise prescription in patients with multiple cardiovascular diseases and risk factors: bringing it all together in the EXPERT tool
Dominique Hansen, PhD, FESC

2. Exercise in cardiovascular disease: why?

4. Exercise in cardiovascular disease: why?

5. Exercise in cardiovascular disease: guidelines
exercise >150 min/week (spread over >2 exercise sessions/week)
low-to-moderate endurance intensity
weekly caloric expenditure of kcal/week
combination with resistance exercises
Piepoli MF, et al. Eur J Prev Cardiol 2010;17:1-17

6. Exercise in cardiovascular disease: guidelines
Piepoli MF, et al. Eur J Prev Cardiol 2016;23:NP1-96

7. Difficulties ahead

8. Exercise prescription becomes more difficult
Improved medical diagnosis and intervention
Patients with renal, pulmonary and metabolic disease, cancer, etc. live longer and may develop CVD, which is noticed better
…and the other way around
The population is ageing
Co-morbid population
Including sarcopenia and frailty
Complex medication schemes
Psychosocial impact

9. Exercise prescription becomes more difficult
End result of all these trends
We more often encounter patients with:
Multiple diseases
Multiple CVD risk factors
Polypharmacy
Compromised exercise capacity
Abnormalities during exercise (testing)
A need for a more tailored approach

10. Exercise prescription becomes more difficult
Complexity of patient case
Clinical effectiveness and medical safety of exercise intervention?

11. Exercise prescription becomes more difficult
Consult the guidelines?
And what about combinations of different exercise schemes for different indications?

12. EXPERT tool
Hansen D, et al. Eur J Prev Cardiol 2017; in press

13. EXPERT tool

14. EXPERT tool

15. EXPERT tool

16. Simulations of exercise prescription
Case 1
Age:
Body height:
Body weight:
BMI:
Sex:
VO2max:
Resting HR:
Peak exercise HR:
Total cholesterol:
LDL:
Fasting glycemia:
Blood pressure:
Medication:
Primary Indication:
Key risk factors:
Exercise modifiers:
Anomalies:
72 years
154 cm
61 kg
25.7 kg/m²
Female
940 ml/min – 80% of normal value
67 bts/min
109 bts/min
193 mg/dl
104 mg/dl ?
120/80 mmHg
Antiplatelets, betablocker, ACE inhibitor, diuretic, statins, metformin
Urgent CABG – Pacemaker
Type II diabetes, dyslipidemia, hypertension
None

17. Case 1: EXPERT simulation
Intake of diuretics, betablockers, ACE inhibitor
Patient is thus hypertensive
Elevate exercise frequency, consider hand grip exercises
CABG
Strength training is mandatory
Pacemaker
Be carefull with HR training zones
Statin intake
Patient is thus dyslipidemic: elevate caloric expenditure (>900 kcal/week), maximize training program duration
Type 2 diabetes
Strength training is mandatory, elevate exercise frequency, maximize training program duration

18. Case 1: EXPERT simulation
Final EXPERT output
Exercise prescription:
Intensity: HR bts/min
Frequency: build up to at least 5 days/week
Exercise session duration: from 30 up to 60 min/session
Minimal program duration: >40 weeks
Strength training: yes
Additional training types
In case of CABG surgery, strength training for the arm muscles are only allowed when the sternum is stabilized, >900 kcal/week of energy expenditure should be achieved, Additional isometric handgrip exercise training is advised

19. Case 1: EXPERT simulation
Final EXPERT output
Safety precautions
Exercise training has to be adjusted on the time course of wound healing and all other potential complications.
Thoracic shear and pressure stress has to be strictly avoided during the first 6-8 weeks after sternotomy
If SBP rises >250 mmHg and/or DBP >115 mmHg during exercise, the training session should be terminated as this may indicate the need to adjust medical therapy.
Suddenly stopping exercise should be avoided as it may result in a precipitous drop in blood pressure.
Statins may induce myopathy
Calculated heart rate zone is not valid anymore when beta blocker therapy is changed.

20. Simulations of exercise prescriptions
Case 2
Age:
Body height:
Body weight:
BMI:
Sex:
VO2max:
Resting HR:
Peak exercise HR:
Total cholesterol:
LDL:
Fasting glycemia:
Blood pressure:
Medication:
Primary Indication:
Key risk factors:
Exercise modifiers:
82 years
183 cm
84 kg
25.08 kg/m²
Male
888 ml/min – 52% of normal value
81 bts/min
85 bts/min
116 mg/dl
50 mg/dl
95 mg/dl
115/90 mmHg
Antiplatelets, statins, diuretics, betablockers, ACE inhibitor
Heart failure (NYHA III), pacemaker
Dyslipidemia, hypertension
Renal failure

21. Case 2: EXPERT simulation
Low VO2peak
Start at lower intensity
Diuretics, betablockers, ACE inhibitor
Patient is thus hypertensive
Elevate exercise frequency, consider hand grip exercises
Heart failure (NYHA III)
Moderate-intense training or HIT may be used
Strength training is mandatory
Pacemaker
Be carefull with HR training zones
Statin intake
Patient is thus dyslipidemic: elevate caloric expenditure and maximize training program duration
Renal failure

22. Case 2: EXPERT simulation
Final EXPERT output
Exercise prescription:
Intensity: HR 83 bts/min, start at lower intensity
Frequency: build up to at least 5 days/week
Exercise session duration: from 30 up to 60 min/session
Minimal program duration: >40 weeks
Strength training: yes
Additional training types
Add inspiratory muscle training (IMT), >900 kcal/week of energy expenditure should be achieved, additional isometric handgrip exercise training is advised, flexibility and balance exercises should be added

23. Case 2: EXPERT simulation
Final EXPERT output
Safety precautions
Haemodialysis patients should pay attention with upper limbs resistance exercises, due to the arterio-venous fistulas.
Peritoneal dialysis patients are recommended to exercise with emptied abdominal cavities.
Intra-dialytic exercise training should be performed during the first two hours of dialysis sessions.
Patients should be informed about the nature of cardiac prodromal symptoms and exercise-related warning symptoms including chest pain or discomfort, abnormal dyspnoea, dizziness or malaise and should seek prompt medical care if such symptoms develop.
Intense isometric exercise, such as heavy-weight lifting, can have a marked pressor effect and should be avoided.

24. Simulations of exercise prescriptions
Case 3
Age:
Body height:
Body weight:
BMI:
Sex:
VO2max:
Resting HR:
Peak exercise HR:
Total cholesterol:
LDL:
Fasting glycemia:
Blood pressure:
Medication:
Primary Indication:
Key risk factors:
Exercise modifiers:
79 years
171 cm
54 kg
18.5 kg/m²
Male
810 ml/min – 56% of normal value
67 bts/min
115 bts/min
185 mg/dl ?
135 mg/dl
120/80 mmHg
Antiplatelets, statins, betablockers, ACE inhibitor, bronchodilator, corticoid
PCI
Dyslipidemia, hypertension
COPD, sarcopenia

25. Case 3: EXPERT simulation
Low VO2peak
Start at lower intensity
Diuretics, betablockers, ACE inhibitor
Patient is thus hypertensive
Elevate exercise frequency, consider hand grip exercises
Sarcopenia
Strength training is now the basis of the program
Statin intake
Patient is thus dyslipidemic: elevate caloric expenditure and maximize training program duration
PCI
Follow the standard exercise recommendation
COPD
Strength training is mandatory
Respiratory exercises are mandatory

26. Case 3: EXPERT simulation
Final EXPERT output
Exercise prescription:
Intensity: HR bts/min, start lower intensity
Frequency: build up to at least 5 days/week
Exercise session duration: from 30 up to 60 min/session
Minimal program duration: >40 weeks
Strength training: yes, it is the basis
Additional training types
>900 kcal/week of energy expenditure should be achieved, additional isometric handgrip exercise training is advised, muscle electrostimulation and breathing exercises should be added, balance training or tai chi may be added

27. Case 3: EXPERT simulation
Final EXPERT output
Safety precautions
Oxygen supplementation should be initiated when oxygen saturation drops below 90%.
Monitor physiologic parameters (BP, HR) and symptoms (Borg scale) during exercise, and do not exceed 12/20 in Borg scale. Physiotherapists or exercise physiologists should assist during exercises
Prefer a gradual increase in workload, from sitting to standing position for performing exercises, and gradually increase in number of repetitions and sets.
In PCI patients, exercise training may be started immediately after healing of the punctured vessel. This may be as early as one day after the intervention.

28. Conclusion
Exercise prescription in multi-morbid patients can be challenging
Clinical guidelines provide exercise recommendations for seperate diseases and risk factors, and are of paramount importance
However, a digital instrument (EPAC EXPERT) tool may assist clinicians in how to prescribe exercise in patients were many different diseases are present