1. Exercise Prescription for Cardiovascular diseases
Dr. Leung Tat Chi, Godwin
Specialist in Cardiology
8 September 2007

2. Prevention of atherosclerotic Vascular Disease by Physical Exercise
Physical activity reduces the incidence of CAD
Physical inactivity is a major CAD risk factor
The relation is strong, with the most physically active subject is generally demonstrated CAD rates half those of the most sedentary group
Independent of other risk factors
Not protective in later years without lifelong physical activity
Benefit seen in middle age and older age groups
Powell KE, Thompson PD, Caspersen CJ, et al. Physical activity and the incidence of coronary heart disease. Annu Rev Public Health. 1987;8:

3. Reduction of Atherosclerotic Risk Factors
Physical activity both prevents and treats establish atherosclerotic risk factors:
Elevated blood pressure
Insulin resistance
Glucose intolerance
Elevated triglyceride concentration, low HDL-C
Obesity
Exercise + weight reduction >>>>  LDL-C and increase HDL
Thompson et al, Exercise and Physical Activity in Cardiovascular Disease. Circulation June 24, 2003; 107:

4. Response of Blood Lipids to Exercise Training
Meta-analysis of 52 exercise training trials of >12 weeks
Include 4700 patients
Change in lipid profile
HDL-C increase 4.6%
Reduction in LDL-C by 5.0%
Reduction in TG by 3.7%
Leon AS, Sanchez O. Meta-analysis of the effects of aerobic exercise training on blood lipids. Circulation. 2001;104(suppl II):II Abstract.

5. Response of Blood Pressure to Exercise Training
44 randomized controlled trials include 2674 patients
Average change in blood pressure
SBP decrease by 3.4 mmHg
DBP decrease by 2.4 mmHg
Hypertensive patient
SBP decrease by 7.4 mmHg
DBP decrease by 5.8 mmHg
Normotensive patient
SBP decrease by 2.6 mmHg
DBP decrease by 1.8 mmHg
BP drop is not dose related
Fagard RH. Exercise characteristics and the blood pressure response to dynamic physical training. Med Sci Sports Exerc. 2001;33(6 suppl)

6. 2 mmHg decrease in mean systolic blood pressure
Blood Pressure Reductions as Little as 2 mmHg Reduce the Risk of Cardiovascular Events by up to 10%
Meta-analysis of 61 prospective, observational studies
1 million adults
12.7 million person-years
7% reduction in risk of ischemic heart disease mortality
2 mmHg decrease in mean systolic blood pressure
Data from a meta-analysis of 61 prospective, observational studies has provided powerful evidence that throughout middle and old age, blood pressure (BP) is strongly and directly related to vascular mortality.1 These findings show, for example, that a 10 mmHg lower systolic BP is associated over the long-term with a 40% lower risk of stroke death and a 30% lower risk of death from ischemic heart disease (IHD) or other vascular causes. Importantly, within each decade of life between 40 and 89 years the proportional difference in the risk of vascular death associated with a given absolute difference in mean BP is roughly equivalent down to at least 115 mmHg for systolic BP and 75 mmHg for diastolic BP (below which there is little evidence). Thus, there was no evidence of a J curve across all middle and older age groups.
Perhaps most striking is the practical implications of these data: even a small, 2 mmHg fall in mean systolic BP would be associated with large absolute reductions in premature deaths and disabling strokes.1 As shown here, a 2 mmHg lower mean systolic BP could lead to a 7% lower risk of IHD death and a 10% lower risk of stroke death.1
Reference
Lewington S, et al. Lancet. 2002;360:1903–1913
10% reduction in risk of stroke mortality
Lewington S, et al. Lancet. 2002;360:1903–1913

7. Lifestyle modification
Recommendation
SBP reduction
Physical activity
Engage in regular aerobic physical activity such as brisk walking (at least 30 mins per day, most days of the week)
4-9mmHg
Moderation of alcohol consumption
Limit consumption to no more than 2 drinks (e.g., 24 oz beer, 10 oz wine, or 3 oz 80-proof whiskey) per day in most men and to no more than 1 drink per day in women and lighter-weight persons
2-4mmHg

8. Lifestyle modification
Recommendation
SBP reduction
Weight Reduction
Maintain normal BW (BMI kg/m2)
5-20mmHg/10kg
Adopt DASH eating plan
Diet rich in fruits, vegetables, and low-fat diary products with a reduced content of dietary cholesterol as well as saturated and total fat
6-14mmHg
Dietary sodium restriction
Reducing dietary sodium to no more than 100 mmol/day (2-4g Na or 6g NaCl)
2-8mmHg

9. Effect of Exercise-based Cardiac Rehabilitation on Cardiac Events
Outcome
Mean Difference
95% Cl
Statistically Significant?
Exercise-only intervention
Total mortality
-27%
-2% to –40%
Yes
Cardiac mortality
-31%
-6% to –49%
Nonfatal MI
-4%
-31% to +35% No
Comprehensive rehabilitation
-13%
-29% to +5%
-26%
-4% to –43%
-12%
-30%-+12%
Cl indicates confidences intervals. Cls not including zero are statistically significant.
Meta analysis include 51 randomized trials
Include 8440 patients: CABG, PTCA, MI, angina, middle-age men
Supervised exercise for 6 months, follow up 2 years later
Jolliffe JA, Rees K, Taylor RS, et al. Exercise-based rehabilitation for coronary heart disease. Cochrane Database Syst Rev. 2001(1):CD001800

10. The Exercise Training Intervention after Coronary Angioplasty
Randomised 118 patients after coronary revascularization
6 months of exercise training vs usual care
Trained patients significant increases in peak VO2 (26%)
Quality of life parameters increases in 27%
Fewer cardiac events (11.9% vs 32.2%)
Hospital readimissions (18.6% vs 46%)
Residual coronary stenosis decrease by 30%
Recurrent cardiac event reduced by 29%
BelardinelliR, Paolini I, Cianci G, et al. Exercise Training Intervention after Coronary Angioplasty: the ETICA trial. J Am Coll Cardiol., 2001;37:

11. Risk Cardiac rehabitation programs
Cardiac arrest: 1 in (patient-hours of participation)
Nonfatal MI: 1: in
Death : 1:

12. Aerobic Activity
Muscle-Strengthening Activity
Recommendation
Frequency
Intensity
Duration
Number of Exercises
Sets and repetitions
Flexibiltiy/Balance
Healthy adults, 2007.
(ACSM/AHA Recommendation)
A minimum of 5 d/wk for moderate intensity, or a minimum of 3 d/wk for vigorous intensity
Moderate intensity between 3.0 and 6.0 METS; vigorous intensity above 6 METS
Accumulate at least 30 min/d of moderate-intensity activity, in bouts of at least 10 min each; continuious vigorous activity for at least 20 min/d
At least 2 d/wk
8-10 exercises involving the major muscle groups
8-12 repetitions
Older adults, 2007 (ACSM/AHA Recommendation)
Moderate intensity at 5 to 6 on a 10-point scale; vigorous intensity at 7 to 8 on 10-point scale
10-15 repetitions
At least 2 d/wk flexibiltiy; for those at risk of falls, include exercises to maintain or improve balance

13. Aerobic Activity
Muscle-Strengthening Activity
Recommendation
Frequency
Intensity
Duration
Number of Exercises
Sets and repetitions
Flexibiltiy/Balance
Hypertension, 2004
(ACSM Recommendation)
Most, preferably all days per week
Moderate intensity at 40 -<60% of VO2max reserve (vigorous intensity acceptable for selected adults)
Accumulate min/d of moderate-intensity activity, in bouts of at least 10 min each;
2-3 d/wk (resistance training an adjunct to aerobic activity)
8-10 exercises involving the major muscle groups
1 set of 8-15 repetitions (more than 1 set acceptable for selected adults)
Cholesterol, 2001, National Cholesterol Education Program
Most days of the week, preferably daily
Moderate intensity
At least 30 min/d
Muscle-strengthening activities recommended as beneficial
Flexibility regarded as beneficial

14. Aerobic Activity
Muscle-Strengthening Activity
Recommendation
Frequency
Intensity
Duration
Number of Exercises
Sets and repetitions
Flexibiltiy/Balance
Coronary artery disease, 2001, AHA (aerobic recommendation)
At least 3 d/wk
Moderate intensity at % of HR reserve (vigorous intensity as tolerated at 60-85% of HR reserve
At least 30 min
Cardiovascular disease, 2000, AHA (flexibility and resistance training recommendation)
A minimum of 5 d/wk for moderate intensity, or a minimum of 3 d/wk for vigorous intensity
Moderate intensity at 5 to 6 on a 10-point scale; vigorous intensity at 7 to 8 on 10-point scale
Accumulate at least 30 min/d of moderate-intensity activity, in bouts of at least 10 min each; continuious vigorous activity for at least 20 min/d
At least 2 d/wk
8-10 exercises involving the major muscle groups
10-15 repetitions
At least 2 d/wk flexibiltiy; for those at risk of falls, include exercises to maintain or improve balance

15. Hypertension and Exercise Position Stand (Evaluation)
Severity
Secondary cause
CV risk factors
Target organ damage (TOD)
CVD complications

16. Hypertension and Exercise Position Stand (Evaluation)
Supervised exercise stress test
High intensity exercise program (VO2 R >60%)
Patients with TOD/DM or BP >180/110 before engaging in moderate-intensity exercise (VO2R 40 to 60%)
Patients with CVD (stroke, heart failure, IHD)
Avoid high intensity exercise (vigorous program best initiated at dedicated rehabilitation centre)

18. Hypertension and Exercise Position Stand
Emphasis on aerobic activity. VO2R 40 to 60%. RPE
Avoid high-intensity resistance training (lower intensity, higher repetitions).
Clients should maintain hypertensive medications, if prescribed.
Do not exercise if resting SBP > 200 mm Hg or DBP > 115 mm Hg. Maintain BP <220/105 during exercise
Begin pharmacological treatment prior to starting exercise program if BP > 160/100
Diuretics increase the potential for dehydration
Beta-blockers and diuretics impair the ability to regulate body temperature.
S/S of heat illness
Adequate hydration
Proper clothing

19. Resistance training/ Valsalva maneuver
Forced expiration against a closed glottis
Increase in intrathoracic pressure leading to decreased venous return and potentially reduced cardiac output
At the release of the “strain,” venous return is dramatically increased, increasing cardiac output and elevation of BP
Symptoms of lightheadedness or dizziness may occur if cardiac output is reduced.
With relaxation, individuals may experience headache while pressure remains elevated.
In patients with heart disease, symptoms of myocardial ischemia may ensue as a result of elevated BP and increased myocardial work.

20. Adherence
Education regarding the importance of regular exercise for BP control
Especially responsive if information comes from their personal physician
Knowledge of the immediate BP-lowering effects of exercise (PEH)

21. Cardiac rehabilitation
Core components
Medical assessment
Nutrition counseling
Risk factor management (lipid, DM, weight, smoking)
Psychosocial management
Activity counseling and exercise training

22. Cardiovascular System Assessment
Patients with known coronary artery disease should undergo a supervised evaluation of the ischemic response to exercise, ischemic threshold, and the propensity to arrhythmia during exercise.
In many cases, left ventricular systolic function at rest and during its response to exercise should be assessed.
Physical Activity/Exercise and Diabetes; Diabetes care, vol. 27, supplement 1, January 2004

23. Exercise testing Integral component of the rehab process
Establishment of appropriate specific safety precautions
Guide training intensity
Target exercise training heart rates
Initial levels of exercise training work rates
Risk stratification
Should be performed on all cardiac patients entering an exercise training program

24. Exercise prescription for individuals with CAD (Risk Stratification)
Mildly increased risk
Preserved LV systolic function (EF > 50%)
Normal exercise tolerance for age
> 50 years old > 10METS
50 to >9METS
60 to >8METS
> >7METS
Absence of exercise induced ischemia
Absence of hemodynamically significant stenosis of a major coronary artery (>50%)
Successful revascularization

25. Exercise prescription for individuals with CAD (Risk Stratification)
Substantially increased risk
Impaired LV systolic function (<50%)
Evidence of exercise-induced myocardial ischemia
Hemodynamically significant stenosis of a major coronary artery (>50%)

29. Medically Supervised Exercise
Moderate to High risk subjects
Medical supervision required until safety established
ECG and BP monitoring (usually > 12 sessions)
Low risk subjects
Benefit from medically supervised programs
Safe
Group dynamics
ECG monitoring (useful during the early phase, 6 – to 12 sessions)

30. Exercise prescription for individuals with CAD
Inpatients
Walking
Active but non-resistance range-of-motion exercise of the upper extremities

31. Inpatient exercise program
Intensity
RPE <13
Post MI: HR <120BPM or HR(rest) + 20 BPM
Duration
Intermittent bouts 3 to 5 mins, as tolerated
Frequency
3 to 4 times per day (day 2-3)
Two times per day with increased duration of exercise bouts (beginning on day 4)
Initial activities should be monitored, and symptoms HR, BP recorded

32. Rehabilitation in Coronary Heart Disease
Mainly endurance training
at an intensity of 50 (-60) -75% of symptom-limited VO2max (or heart rate reserve) for 30 minutes 3-4 times weekly (minimum), full benefit is obtained with 5-6 times/week
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

34. Outpatients Large-muscle group activities
Moderate intensity: 40 to 60% of VO2 max
At least 30 minutes
Preceded by warm-up and followed by cool-down (for 5 to 10 minutes)
At least 3 times weekly
Follow-up supervised group sessions are recommended

35. Exercise prescription without exercise test
Initial exercise intensity
2 to 3 METs
1 to 2 mph, 0% grade on treadmill
100 to 300 kg.m.min-1 ( W) on cycle ergometer
RPE: 11-13
Gradual increments of 0.5 to 1.0 METs as tolerated
Target heart rate
20 beats/min above standing rest
Frequency
30 – 45 minutes per day 5 d/wk,

36. Exercise prescription in the presence of ischemia
Inappropriate for those with angina < 3METS
Aim to increase anginal threshold
Prolonged warm up and cool
Upper body exercises may precipitate angina more readily
Heart rate and work rate below the identified threshold of ischemia
Should be a minimum of 10 beats/min below the heart rate at which the abnormality occurs
Intermittent, shorter duration-type on a more frequent basis

37. Home exercise rehabilitation
Lower cost
Convenience
Promote independence
Comparable safey and efficacy
Good communication between patients and staff required

38. Heart Failure Benefits of exercise
Functional capacity, improved leg blood flow and oxidative capacity, neurohormones, autonomic tone
Initiated at a low to moderate level (25 to 60% of VO2max)
VO2max determined by direct gas exchange measurements
Careful supervision and monitoring
Brief training session
Lengthened warm up and cool down
RPE: 11 to 14
Safety and efficacy of resistance training not well established

39. After cardiac procedure
CABG
Avoid upper body exercise for 3 months
PCI
Resume exercise no sooner than 5 to 7 days
Catheterization access sites should be healed

40. Pacemakers and implantable cardioverter defrillators
Type and settings of pacemaker should be noted
Avoid high intensity resistance exercise
Fixed-rate pacemakers
Activity intensity must be gauged by other methods
RPE
ICD
Limit target heart rate at least 10 to 15 beats/min lower than the threshold discharge rate

41. AHA Scientific Statement: Recommendations for the Acceptability of Recreational (Noncompetitive) Sports Activities and Exercise in Patients With Genetic CVD
GCVD
HCM, LQTS, Marfan syndrome, ARVC, Brugada syndrome
Recreational sports are categorized with regard to high, moderate and low levels of exercise
Graded on relative scale (from 0 to 5) for eligibility
0 to 1: indicating generally not advised or strongly discouraged
4 to 5: indicating probably permitted
2 to 3: indicating intermediate and to be assessed clinically in an individual basis

42. AHA Scientific Statement: Recommendations for the Acceptability of Recreational (Noncompetitive) Sports Activities and Exercise in Patients With GCVDs
Intensity Level
HCM
LQTS
Marfan Syndrome
ARVC
Brugada Symdrome
High
Basketball 2 1
Full court
Half court
Body building
Ice hockey
Racquetball/squash
Rock climbing
Running (downhill)
Skiing (cross-country) 3 4
Soccer
Tennis (singles)
Touch (flag) football
Windsurfing
Recommendations for Physical Activity and Recreational Sports Participation for Young Patients with Genetic Cardiovascular Diseases, Circulation. 2004; 109: )

43. AHA Scientific Statement: Recommendations for the Acceptability of Recreational (Noncompetitive) Sports Activities and Exercise in Patients With GCVDs
Intensity Level
HCM
LQTS
Marfan Syndrome
ARVC
Brugada Symdrome
Moderate
Baseball/softball 2 4
Biking 3 5
Modest hiking
Motocycling 1
Jogging
Sailing
Surfing
Swimming (lap)
Tennis (doubles)
Treadmill/stationary bicycle
Weightlifting (free weights)
Hiking
Recommendations for Physical Activity and Recreational Sports Participation for Young Patients with Genetic Cardiovascular Diseases, Circulation. 2004; 109: )

44. AHA Scientific Statement: Recommendations for the Acceptability of Recreational (Noncompetitive) Sports Activities and Exercise in Patients With GCVDs
Intensity Level
HCM
LQTS
Marfan Syndrome
ARVC
Brugada Symdrome
Low
Bowling 5 4
Golf
Horseback riding 3
Scuba diving
Skating
Snorkeling
Weights (non-free weights)
Brisk walking
Recommendations for Physical Activity and Recreational Sports Participation for Young Patients with Genetic Cardiovascular Diseases, Circulation. 2004; 109: )

45. Recommendation Thank You!
Health professionals should personally engage in an active lifestyle
Thank You!

46. References
Exercise standards for testing and training: a statement for healthcare professionals from the American Heart Association. Circulation. 2001;104:
Exercise and physical activity in the prevention and treatment of atherosclerotic cardiovascular disease: AHA scientific statement. Circulation. 2003;107:
Recommendations for Physical Activity and Recreational Sports Participation for Young Patients with Genetic Cardiovascular Diseases, Circulation. 2004; 109:
ACSM’s guidelines for exercise testing and prescription. 7th edition
36th Bethesda Conference. Eligibility recommendations for competitive athletes with cardiovascular abnormalities. JACC 19 April 2005
Recommendations for preparticipation screening and the assessment of cardiovascular disease in masters athletes. Circulation. 2001;103:
Physical activity and public health in older adults: Recommendation from the American College of Sports Medicine and the American Heart Association. Circulation. 2007;116:
ACSM Position Stand. Exercise and Hypertension. hypertension. Med. Sci. Sports Exerc. 36:533–553, 2004.
Resistance Exercise in Individuals With and Without Cardiovascular Disease: 2007 Update Circulation. 2007;116: