1. The EXPERT tool: focus on prevention
Dominique Hansen, PhD, FESC

2. Exercise in prevention of CVD: why?

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

4. But how good are we in improving cardiovascular disease risk by exercise intervention?

5. Fat mass reduction (obesity)

6. Fat mass reduction (obesity)
Focus is very often on body weight
Distinction must be made between lean and adipose tissue mass
Medical imaging
Alternative: waist circumference

7. Blood pressure reduction (hypertension)

8. Blood pressure reduction (hypertension)

9. Blood pressure reduction (hypertension)
Reductions in SBP and DBP by ±7% and ±5 mmHg, respectively
Cornelissen VA, et al. Hypertension 2005;46:667–75.
Tsai JC, et al. Clin Exp Hypertens 2002;24:315–24.
Pitsavos C, et al. Hellenic J Cardiol 2011;52:6–14.
But complex, because of impact of
Assessment methodology
Interference with blood pressure lowering medications

10. Blood glucose reduction (type 2 diabetes)

11. Blood glucose reduction (type 1 diabetes)

12. Blood lipid improvement (dyslipidemia)
Effects of endurance exercise depend on population:
Healty adults: reductions in TG
Kelley GA, et al. Clin Nutr 2012; 31; 156
CVD: reductions in TG and TC
Oldridge N. Future Cardiol 2012; 8: 729
Obesity: reductions in TG and TC
Kelley GA, et al. Int J Obes 2005; 29: 881
Type 2 diabetes: reductions in LDL, increase in HDL
Hayashino Y, et al. Diabetes Res Clin Pract 2012; 98: 349

13. Blood lipid improvement (dyslipidemia)
Complex interactions
Diet
Pharmacologic intervention

14. Physical fitness (deconditioning)

15. Are we good at improving CVD risk by exercise intervention?
Interim conclusion
Are we good at improving CVD risk by exercise intervention?
Yes, and larger effects
Glycemic control
Physical fitness
Yes, but smaller effects
Blood pressure and lipid profile No
Fat mass

16. Tailor your intervention
We should aim for maximum improvement of the CVD risk, but with optimal medical safety, to prevent cardiovascular disease
Tailor your intervention

17. Optimization of exercise prescription
Optimized effectiveness
Optimized medical safety

18. Optimized exercise in obesity
Optimize effectiveness
Maximise exercise volume (>250 min/week and >1500 kcal/week)
Select a sufficient exercise intensity (at least moderate intense)
Select whole-body exercises (walking, stepping, rowing, cross-training)
Prolong to >24 weeks
Optimize medical safety
Monitor orthopedic symptoms

19. Optimized exercise in hypertension
Optimize effectiveness
Maximise exercise frequency (≥5 days)
Reductions in BP are transient
Consider higher exercise intensity
Some studies discovered greater post-exercise BP reductions
Add handgrip strength training
Significant impact on sympathetic tone

20. Optimized exercise in hypertension
Optimize medical safety
Be aware of hypotensive symptoms
Patients are on BP lowering drugs…and become more sensitive
Stopping exercise suddenly should be avoided as it may result in a precipitous drop in SBP
B-blockers and diuretics may adversely affect thermoregulatory function, especially during exercise in warmer temperatures and cause hypoglycaemia in some individuals.
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.

21. Optimized exercise in dyslipidemia
Achieve a weekly caloric expenditure >900 kcal.
Prolong exercise intervention (>40 weeks)
Add resistance exercise training
Some studies describe greater impact on blood HDL-c concentration
Maximize medical safety
Statins may lead to myopathy

22. Optimized exercise in type 1 diabetes
Optimize clinical effectiveness
End exercise session with high-intensity exercise.
sec all-out bouts
Adrenergic stimulus leads to glucose release from liver
Prolong program
>6 months
Maximize exercise frequency (≥5 days)
Greater impact on insulin sensitivity, which is transient

23. Optimized exercise in type 1 diabetes
Optimize medical safety
Increased risk for episodes of rapidly occurring hypoglycemia as well as hyperglycemia during and after exercising
Frequent self-monitoring of blood glucose
Adaptation of insulin doses and adequate intake of carbohydrates before and during exercise.
If pre-exercise glucose is below 5.6mM, added CHO should be ingested before performing exercise.
If pre-exercise glucose is above 14mM, urine should be tested for ketone bodies. If positive, exercise should not be performed.
If pre-exercise glucose is above 17 mM physical exercise should not be performed regardless of ketone results.

24. Optimized exercise in type 1 diabetes
Optimize medical safety
Insulin pump may be the most flexible treatment option in patients with type 1 diabetes performing exercise
High-intensity exercise is contra-indicated in retinopathy
All individuals with peripheral neuropathy must wear proper footwear. No weight-bearing exercise if open foot lesions
Autonomic neuropathy is associated with increased CVD risk, therefore, a pre-exercise cardiac testing is required in these situations

25. Optimized exercise in type 2 diabetes
Optimize clinical effectiveness
Maximise exercise frequency (≥5 days).
Greater improvement in insulin sensitivity, which is transient
Add resistance exercise training.
Prolong exercise intervention
>6 months

26. Optimized exercise in type 2 diabetes
Optimize medical safety
Intake of sulfonylurea and meglitinide, or exogenous insulin injection, may lead to elevated risk for hypoglycemia

27. Optimized exercise in deconditioned subjects

28. But what about different combinations of CVD risk factors?
How to prescribe exercise in these patients?

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

30. EXPERT tool

31. EXPERT tool

32. EXPERT tool

33. EXPERT tool

34. Simulations of exercise prescription
Age:
Body height:
Body weight:
BMI:
Sex:
VO2max:
Resting HR:
Peak exercise HR:
Total cholesterol:
LDL:
Fasting glycaemia:
Blood pressure:
Medication intake:
Co-morbidities:
61 years
170 cm
97 kg
33.56 kg/m²
Male
2283 ml/min (100% of normal value)
69 bpm
141 bpm ?
125/80 mmHg
Beta blocker, ACE inhibitor, Antiplatelet
none

35. Tool starts with regular exercise prescription
EXPERT simulation
Tool starts with regular exercise prescription
150 min low-to-moderate intense endurance exercise training per week (spread over 3-5 days, achieving kcal) for at least 12 weeks
But further adjusts:
Intake of diuretics, betablockers, ACE inhibitor
Patient is thus hypertensive
Elevate exercise frequency, consider hand grip strength exercises
Obesity
Maximize caloric expenditure
Prolong intervention

36. EXPERT output EXPERT simulation 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: >24 weeks
Strength training: yes
Consider hand grip strength exercises

37. EXPERT simulation Age: Body height: Body weight: BMI: Sex: VO2max:
Resting HR:
Peak exercise HR:
Total cholesterol:
LDL:
Fasting glycaemia:
Blood pressure:
Medication intake:
Co-morbidities:
61 years
170 cm
97 kg
33.56 kg/m²
Male
1283 ml/min (65% of normal value)
69 bpm
141 bpm ?
125 mg/dl
125/80 mmHg
Beta blocker, ACE inhibitor, Antiplatelet, Metformin
none

38. Intake of diuretics, betablockers, ACE inhibitor
EXPERT simulation
Intake of diuretics, betablockers, ACE inhibitor
Patient is thus hypertensive
Elevate exercise frequency, consider hand grip strength exercises
Obesity
Maximize caloric expenditure
Prolong intervention
But further adjusts:
Low VO2peak
Start at lower intensity
Type 2 diabetes
Elevate exercise frequency, add strength training, prolong intervention

39. EXPERT output EXPERT simulation 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: >24 weeks
Strength training: yes
Consider hand grip strength exercises
Strength training for large muscle groups

40. EXPERT simulation Age: Body height: Body weight: BMI: Sex: VO2max:
Resting HR:
Peak exercise HR:
Total cholesterol:
LDL:
Fasting glycaemia:
Blood pressure:
Medication intake:
Co-morbidities:
61 years
170 cm
97 kg
33.56 kg/m²
Male
1283 ml/min (65% of normal value)
69 bpm
141 bpm ?
145 mg/dl
125/80 mmHg
Beta blocker, ACE inhibitor, Antiplatelet, Insulin
none

41. Intake of diuretics, betablockers, ACE inhibitor
EXPERT simulation
Intake of diuretics, betablockers, ACE inhibitor
Patient is thus hypertensive
Elevate exercise frequency, consider hand grip strength exercises
Obesity
Maximize caloric expenditure
Prolong intervention
Low VO2peak
Start at lower intensity
But further adjusts:
Type 1 diabetes
Elevate exercise frequency, add strength training, prolong intervention, end exercise session with HIT

42. EXPERT output EXPERT simulation 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: >24 weeks
Strength training: yes
Consider hand grip strength exercises
Strength training for large muscle groups
Additional training strategies
End exercise bout with HIT

43. Exercise intervention is potent to improve CVD risk
Conclusions
Exercise intervention is potent to improve CVD risk
However, there is room for further improvement
The EXPERT tool may assist in achieving this goal