EXERCISE PRESCRIPTION IN PATIENTS WITH

CARDIOVASCULAR DISEASE

LEANDRO C. BONGOSIA, MD, FPCP, FPCC, FACC

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

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

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 2005Dionne, Elsevier 2003

Pre-training

Post-training

Work rate

Rate

-pre

ssur

e pr

oduc

tExercise training and myocardial oxygen consumption

Ades PA, et al. Circulation 2006;113:2706-2712

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.

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

Theoretical relation between health and fitness benefits and the amount or intensity of exercise:

Health

Fitness

Quantity of exercise

Bene

fits

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

The Process of Developing an Exercise Prescription

Assessment

Interpretation

PrescriptionMode

Frequency

Duration Intensity

Precautions

Progression

Components of Exercise Prescription:

A. ModeB. IntensityC. DurationD. FrequencyE. Progression

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

Components of Exercise Prescription

Mode(cont.)Resistance Training:- Does little to increase VO2 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

Components of Exercise Prescription

B. Intensity

For Cardiac Patients: 40% - 60% VO2max

“Above a minimal level required to induce a training effect but below the metabolic rate that evokes abnormal signs or symptoms”

Components of Exercise Prescription

B. Intensity (cont.)

1. Establishing a training/target HR2. Using MET method3. Rate of Perceived Exertion

Training/Target HR Method

Percent (%) maximal HR Calculates a fixed % of measured or estimated

heart rate (220-age)

Examples: 1. HRmax = 120/min60 % of 120 = 72/min

2. HRmax (estimated)Age = 60 yrs.220 – 60 =16060% of 160 = 96

Training / Target HR Method

Heart Rate Reserve (Karvonen)HRR = HRmax - HR restKarvonen Method = defines a HRR, multiplied by %

desired and adjusting for the resting HR= (HRmax - HR rest) 40-80% + HR rest

Example: HRmax = 150HR rest = 70HRR=150-70 = 80

If target is 60%, 80 x 0.6 = 48

HRR = 48 + 70 = 118

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.

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

Components of Exercise Prescription

D. Frequency3 – 5 days/week

3 days/week ---- 60% – 80% HRR

ACSM

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.

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.

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.

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

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

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.

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

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

Restrictions of Resistance Training

• Unstable angina• Uncontrolled HPN ( BP > 160/100)• Uncontrolled arrhythmias• Recent CHF• Severe Valvular Heart disease or hypertrophic

cardiomyopathy

Restrictions of Resistance Training

• Poor left ventricular function• Inadequate functional capacity, less than

or equal to 5 METS (not an absolute contraindication)

Division of an exercise program

1. Warm up2. Pre-stretching3. Dexterity4. Resistance / wt.

bearing5. Endurance6. Balance7. Cool Down

5 to 10 minutes 5 to 10 minutes

10 minutes 15 minutes

20 to 30 minutes 5 to 10 minutes 5 to 10 minutes

Hessert, J of Fam Med 2005

Summary 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 keepupper HRR limit tono more than 10 beats below ischemic threshold

Consider prophylacticNTG 15 min before anticipated exertionif symptoms limitroutine ADL’s orability to exercise

Summary of Exercise Prescription among Patients with CVD

CVD Intensity CommentsMyocardial 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 kcalof energy expenditurethru activity each week

Restrict upper bodymovement until sternumis healed (6 - 12 weeks)

Summary of Exercise Prescription among Patients with CVD

CVD Intensity CommentsHeart failure 40(50)-70% of HRR If needed, initially guide

exercise intensity at 60%of HRR and adjust durationto 3 bouts of 10 min eachprogressing to 30 - 40 min.As patient progresses,maintain upper rate below ventilatory threshold

Summary of Exercise Prescription among Patients with CVD

CVD Intensity CommentsPacemaker, ICD, CRT

Shuler G, et al. Circulation 1992;86:1-11

10% belowactivation threshold

Avoid activities that stretchthe arms. After 8 weeksnonballistic activities maybe resumed and ballistic activities may be resumedafter 12 weeks

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

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

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% VO2max

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 withincrease in duration first

Summary and Conclusion: