1. Md. Jamal Uddin Sr. Chest Physiotherapist and Lead Cardiac Rehabilitation Department of Cardiac Surgery, Ibrahim Cardiac Hospital & Research Institute (ICH&RI) Guest Researcher University of Southern Denmark and REHPA, Denmark And University of Exeter Medical School, Exeter, UK) Council Member-(ICCPR) Fellow on Cardiac Rehabilitation-AACVPR E-mail: uddinj83@gmail.comuddinj83@gmail.com Md. Jamal Uddin Sr. Chest Physiotherapist and Lead Cardiac Rehabilitation Department of Cardiac Surgery, Ibrahim Cardiac Hospital & Research Institute (ICH&RI) Guest Researcher University of Southern Denmark and REHPA, Denmark And University of Exeter Medical School, Exeter, UK) Council Member-(ICCPR) Fellow on Cardiac Rehabilitation-AACVPR E-mail: uddinj83@gmail.comuddinj83@gmail.com

2. Physical Activities ExerciseExercise Cardiac- respiratory Anaerobic Muscular and Joint Strengthening Balance Aerobic Cardiac Endurance Muscular Endurance Flexibility

3. Physical activity: Defined as any bodily movement produced by skeletal muscles that requires energy expenditure. Exercise: Defined as any physical activity that is planned, structured, and repetitive for the purpose of conditioning any part of the body. Exercise is used to improve health, maintain fitness and is important as a means of physical rehabilitation.

4. Muscle endurance Muscle endurance refers to the ability of a muscle to perform a continuous effort without fatiguing. Cycling, step machines and sit up tests are often used to measure Muscular endurance. Muscle endurance Muscle endurance refers to the ability of a muscle to perform a continuous effort without fatiguing. Cycling, step machines and sit up tests are often used to measure Muscular endurance. Cardio-respiratory endurance: The ability of the lungs, heart, and blood vessels to deliver adequate amounts of oxygen to the cells to meet the demands of prolonged physical activity Cardio-respiratory endurance: The ability of the lungs, heart, and blood vessels to deliver adequate amounts of oxygen to the cells to meet the demands of prolonged physical activity

5.  Oxygen uptake (VO 2 ): Amount of oxygen consumed by the body  Maximal oxygen uptake (VO 2max ): Maximum amount of oxygen the body is able to use per minute of physical activity, expressed in l/min or ml/kg/min; the best indicator of cardio- respiratory or aerobic fitness Aerobic Exercise: Exercise that requires oxygen to produce the necessary energy (ATP) to carry out the activity  Anaerobic Exercise: Exercise that does not require oxygen to produce the necessary energy (ATP) to carry out the activity

6. Absolute: Expressed in liters per minute (l/min) ◦ Used to determine energy (caloric) expenditure ◦ Each liter of oxygen consumed by the body burns about 5 calories Relative: Expressed in milliliters per kilogram of body weight per minute (ml/kg/min) ◦ Used to determine cardiorespiratory endurance fitness categories

7.  Heart rate (HR)  Stroke volume (SV)  Arterio-venous oxygen difference (a-vO 2 diff) VO 2 in l/min = (HR x SV x a-vO 2 diff) ÷ 100,000  Example ◦ SV = 79 ml ◦ HR = 76 bpm ◦ a-vO 2 diff = 5 ml/100 cc VO 2 in l/min = (76 x 79 x 5) ÷ 100,000 =.3 l/min

8. VO 2 Conversion: Absolute to Relative  l/min (absolute VO 2 ) to ml/kg/min (relative VO 2 )  Multiply l/min by 1000 and divide by body weight in kg (1 kg = 2.2046 lbs)  Example: ◦ BW = 70 kg (154.3 lbs) ◦ VO 2max = 3.42 l/min ◦ VO 2max in ml/kg/min = 3.42 x 1000 ÷ 70 = 48.9 ml/kg/min

11. ImmediateNonoxidativeOxidative Duration of Activity0-10 seconds10 seconds-2 minutes ≥2 minutes Intensity of ActivityVery highHighLow Rate of ATP Production Immediate, very rapid Rapid (2 ATP per 1 molecule glucose) Slower, but prolonged (38 ATP per 1 molecule of glucose) FuelATP and Creatine Phosphate Glycogen and Glucose Glucose, Fat, Protein Oxygen?No (Anaerobic) Yes (Aerobic) Limited by?Creatine PhosphateLactic AcidFuel sources, fatigue

12.  Higher maximal oxygen uptake  Increase in the oxygen-carrying capacity of the blood  Decrease in resting heart rate and an increase in cardiac muscle strength  Lower heart rate at given workloads  Increase in number and size of the mitochondria  Increase in the number of functional capillaries  Faster recovery time  Lower blood pressure and blood lipids  An increase in fat- burning enzymes

13.  After obtaining your maximal oxygen uptake, you can determine your current level of cardiorespirato ry fitness by consulting this table

14.  The human body burns about 5 calories for each liter of oxygen consumed  A person with a VO 2max of 3.5 l/min exercising at 60% of maximum uses 2.1 (3.5 X.60) liters of oxygen per minute and burns 10.5 (2.1 X 5) calories per minute of physical activity  Using this principle, one can determine the total caloric expenditure of a given session of physical activity

15.  Use FITT variables ◦ Frequency (how often you exercise) ◦ Intensity (how hard you exercise) ◦ Type (mode of exercise) ◦ Time (duration of exercise)

17.  To improve your cardiorespiratory fitness, maintain your heart rate between the 60 and 85% training intensities

18. A perception scale to monitor or interpret the intensity of aerobic exercise

19.  6 Minute Walk Test  Treadmill Test  CPET by breath to breath

22.  Karvonen Formula  Target HR = (HRmax − HRrest) × % intensity) + HRrest  Predicted maximal HR  e.g. if patient is 40 years of age and resting HR 75 and is required to work at 60% - 75% of HRmax  220 – Age =220 – 40 = 180 (HRmax) Target HR: (180-75) × 70% +75 (105 ×.7) +75 (73.5 +75) 148.5 Range of Target HR or Predicted maximal HR  180 x 60% = 108  180 x 75% = 135  Therefore the Range of Target HR or Predicted maximal HR is (108 -135)  Note: Remember that Beta Blockers reduces the heart rate @ rest & during exercise. Please take off 20- 30 BPM

23. Creatine phosphate and stored ATP– first few seconds Creatine phosphate and stored ATP – first few seconds Glycolysis– after approx. 8-10 seconds Glycolysis – after approx. 8-10 seconds Aerobic respiration– maximum rate after 2-4 min of exercise Aerobic respiration – maximum rate after 2-4 min of exercise Repayment of oxygen debt– lactic acid converted back to pyruvic acid, rephosphorylation of creatine (using ATP from oxidative phosphorylation), glycogen synthesis, O 2 re-binds to myoglobin and Hb) Repayment of oxygen debt – lactic acid converted back to pyruvic acid, rephosphorylation of creatine (using ATP from oxidative phosphorylation), glycogen synthesis, O 2 re-binds to myoglobin and Hb)

26. ↑ Cardiac output  ↑ Coronary flow (fivefold)  ↑ Endothelial cell shear stress  ↑ Endothelial-dependent vasodilation + cholinergic fibers stimulation (sympathetic system)

27. Rate of perceived exertion (Borg ) Exercise training level Perceived breathing rate % Maximal heart rate from symptom limited exercise test LOW (RPE Chart ≤ 11 Frequently used for low exercise) MODERATE (RPE Chart 11-14 Frequently used for moderate exercise) HIGH (RPE Chart 12-16 Frequently used for High exercise) SING TALK GASP (50 – 60)% (60 – 75)% (75 – 85)% Correlation of training level with perceived exertion and Heart rate

29.  Predictor of exercise capacity_European Journal of Preventive Cardiology-2016.pdf Predictor of exercise capacity_European Journal of Preventive Cardiology-2016.pdf  Zangger-2017.pdf Zangger-2017.pdf

32.  Predictor of exercise capacity_European Journal of Preventive Cardiology-2016.pdf Predictor of exercise capacity_European Journal of Preventive Cardiology-2016.pdf  Psychometric properties of HeartQoL.pdf Psychometric properties of HeartQoL.pdf  Validation of Exercise Capacity as a Surrogate Endpoint.pdf Validation of Exercise Capacity as a Surrogate Endpoint.pdf