AEROBIC EXERCISE INTENSITY PRESCRIPTION IN CARDIAC...

Geneva - April 14/16, 2011

AEROBIC EXERCISE INTENSITY PRESCRIPTION

IN CARDIAC REHABILITATION:

THE PHYSIOLOGICAL SIDE OF THE COIN

A. Mezzani

S. Maugeri Foundation, IRCCS - Scientific Institute of Veruno

Exercise Pathophysiology Laboratory - Cardiac Rehabilitation Division

Veruno (NO) - Italy

Aerobic training intensityprescription in CHF guidelines

60% ----> 80% peak VO2ACC/AHAJ Am Coll Cardiol 2009

40% ----> 70% peak VO2

EACPREur J Cardiovasc Prev Rehabil 2010

Geneva – April 14/16, 2011

JOINT EACPR/AACVPR POSITION STATEMENT FOR AEROBIC EXERCISE INTENSITY ASSESSMENT AND PRESCRIPTION

IN CARDIAC REHABILITATION

A. Mezzani (Co-Chair) 1, L.F. Hamm (Co-Chair) 2, A.M. Jones 3, P.E. McBride 4, T. Moholdt 5, J.A. Stone 6, A. Urhausen 7, M.A. Williams 8

1 Salvatore Maugeri Foundation IRCCS, Scientific Institute of Veruno - Exercise Pathophysiology Laboratory,

Cardiac Rehabilitation Division - Veruno (NO), Italy2 George Washington University Medical Center, School of Public Health and Health Services -

Department of Exercise Science - Washington, DC, USA3 University of Exeter, School of Sport and Health Sciences - Exeter, Devon, United Kingdom

4 University of Wisconsin, School of Medicine and Public Health -

Department of Medicine, and Medicine and Family Medicine - Madison, WI, USA5 Norwegian University of Science and Technology, K.G. Jebsen Center of Exercise in Medicine -

Department of Circulation and Medical Imaging - Trondheim, Norway6 University of Calgary - Calgary, Canada

7 Hospital Centre of Luxembourg - Centre of Locomotor System, Sports Medicine and Prevention -

CRP-Santé, Luxembourg8 Creighton University School of Medicine - Division of Cardiology -

Department of Medicine - Omaha, NE, USA


Criteria for adequate exercise intensity assessment and prescription

1) Knowledge of individual patient’s exercise intensity

domains (patho)physiological limits.

2) Knowledge of differences between both physiological

response to exercise in different intensity domains and

exercise models used for exercise intensity assessment

and prescription (incremental vs. constant-work-rate).

3) Knowledge of scientific evidence regarding efficacy and

safety of exercise in different intensity domains in

specific patients’ populations.


1st VT

Peak VO2

Basal

Exercise intensity domains

CP (2nd VT)

Mod

era

te

to h

igh

High

to s

eve

reLight

to m

odera

teSeve

reto

extr

eme

0

50

100

%

70



Light to moderateintensity !

Whipp BJ, in: Oxygen uptake kinetics. Routledge, 2005


Light to moderate

1stVT1stVT

1stVT

0 25 50 75

1.0

0.5

0

1.5

W

1st VT 2nd VT

Peak VO2

100

VO

2 (l/

min

)

CP

?

Light to moderate

Moderate to high

High to severe

sc


0

Phase I - Phase II

transition

40-40 80 120 160 200 240 280 320 360 400 440 480

Duration (s)

Exercise

Residual

0

500

750

1000

VO

2(m

l/m

in)

Mezzani A, Am J Physiol 2010


First ventilatory threshold

S1 = 0.86

S2 = 1.28

1st VT


VO2 (l/min)

VCO

2 (l/min)

Belardinelli R, J Am Coll Cardiol 1995

40% peak VO2

23% VO2R

Peak VO2 16.1 --> 18.9 ml/kg/min


Light to moderate-intensityaerobic training in CHF

Demopoulos L, J Am Coll Cardiol 1997

≤50% peak VO2

17-30% VO2R

Peak VO2 11.5 15.0 ml/kg/min



IntensityVO2

steady-state

Lactate

steady-state

CWR

exercise

duration

%peak VO2 ∞

%peak W

Training

modality

Light

to moderate Yes n.a. > 30 min Yes Continuous

Moderate

to highYes Yes ~ 20-30 min No Continuous

High

to severeNo No 3-20 min n.a.

Interval(3-8 min,

repeated)

Severe

to extremeNo No ≤3 min n.a.

Interval(15-60 s,

repeated)

CWR = constant-work-rate; n.a. = not applicable.


Moderate to high intensity !



Moderateto high

1stVT1stVT

1stVT

0 25 50 75

1.0

0.5

0

1.5

W

1st VT 2nd VT

100

VO

2 (l/

min

)

CP

Light to moderate

Moderate to high

High to severe


?

sc

Peak VO2

0

100

% Peak VO2/W % Peak VO2

Incrementalexercise

Constant-work-rateexercise

10

20

30

40

60

80

90

0

100

10

20

30

40

50

60

70

80

90

501st VT

70

Steady-state obtainable at higher relative intensity

Steady-statenot obtainable

Steady-state obtainable at same relative intensity

CP (2nd VT)

Lig

ht

to m

odera

teH

igh t

o se

vere

Mod

era

teto

hig

h


S = 107.58657893

r = 0.98526550

W

T

70 80 90 100 110 120 130 140 150 160 170 180 190 200 210 2200

500

1000

1500

2000

2500

Critical power


Mezzani A, Med Sci Sports Exerc 2010


W

= V

E/V

O2

= V

E/V

CO

2

2nd

VT1st

VT

Second ventilatory threshold


Roveda F, 90% of HR at 2ndVTJ Am Coll Cardiol 2003

Giannuzzi P, 60% peak VO2Circulation 2003

Beckers P, 90% of HR at 2ndVTEJCPR 2007

Van Craenenbroeck EM, 90% of HR at 2ndVTBasic Res Cardiol 2010


Moderate to high-intensityaerobic training in CHF


EDV (ml/m2)

ESV (ml/m2)

EF (%)

Baseline

147 41

110 34

25 4

6 Months

156 42 *†

118 34 †

25 5 †

Baseline

142 26

107 24

25 4

6 Months

135 2 *

97 24 *

29 4 *

Training Control

* = p <0.01; † = p <0.001 for interaction

Giannuzzi P, Circulation 2003

ELVD - CHF


IntensityVO2

steady-state

Lactate

steady-state

CWR

exercise

duration

%peak VO2 ∞

%peak W

Training

modality

Light


Moderate


High


Interval(3-8 min,

repeated)

Severe


Interval(15-60 s,

repeated)



Pull, please !High to severe intensity !



Highto severe

1stVT1stVT

1stVT

0 25 50 75

1.0

0.5

0

1.5

W

1st VT 2nd VT

100

VO

2 (l/

min

)

CP

Light to moderate

Moderate to high

High to severe


?

sc

Peak VO2


0

100

% Peak VO2/W % Peak VO2

Incrementalexercise

Constant-work-rateexercise

10

20

30

40

60

80

90

0

100

10

20

30

40

50

60

70

80

90

501st VT

70

Steady-state obtainable at higher relative intensity

Steady-statenot obtainable

Steady-state obtainable at same relative intensity

CP (2nd VT)

Lig

ht

to m

odera

teH

igh t

o se

vere

Mod

era

teto

hig

h

Warm-up

8 - 10 minutes

Acti

ve p

au

se

60 -

70%

3

min

ute

s

Acti

ve p

au

se

Acti

ve p

au

se

Cool-down

60 - 70%

3 - 5 minutes

60 -

70%

3

min

ute

s

60 -

70%

3

min

ute

s

60 - 70%

Interval

85 - 95%

4 minutes

Interval

4 minutes

Interval

4 minutes

Interval

4 minutes

85 - 95% 85 - 95% 85 - 95%

Intensity is expressed as % of individual peak heart rate


High to severe-intensityaerobic training in CHF

Aerobic interval training in CHF

Wisløff U, Circulation 2007



IntensityVO2

steady-state

Lactate

steady-state

CWR

exercise

duration

%peak VO2 ∞

%peak W

Training

modality

Light


Moderate


High


Interval(3-8 min,

repeated)

Severe


Interval(15-60 s,

repeated)


Aerobic training intensityprescription in CHF guidelines

60% ----> 80% peak VO2ACC/AHAJ Am Coll Cardiol 2009

40% ----> 70% peak VO2

EACPREur J Cardiovasc Prev Rehabil 2010


VO2R = VO2 reserve; HR = heart rate; HRR = heart rate reserve; 1stVT = first ventilatory threshold; RPE = rating of

perceived exertion; n.a = not applicable.


CHF patients in stable NYHA class I-III

IntensityPhysiological

upper limit

Performance

upper limit

Perceived

exertion

upper limit

Exercise

type/

duration

ACSM

classif.

Light

to

moderate

~50% peak VO2/VO2R

~60% peak HR

~50% HRR

Work rate

at 1stVT

<12

RPE Borg

scale

Continuous

≥30 min

VL

to Mod.

Moderate

to highn.a.

~ 70% peak

work rate

12-15

RPE Borg

scale

Continuous

15-30 min

Mod.

to H

High

to severePeak VO2

≥ 100% peak

work rate

16-18

RPE Borg

scale

Interval

(3-8 minutes,

repeated)

H

to Max.

Severe

to extreme? ? ? ? ?

VO2R = VO2 reserve; HR = heart rate; HRR = heart rate reserve; 1stVT = first ventilatory threshold; RPE = rating of

perceived exertion; n.a = not applicable.


Patients with implanted LVAD

IntensityPhysiological

upper limit

Performance

upper limit

Perceived

exertion

upper limit

Exercise

type/

duration

ACSM

classif.

Light

to

moderate

~50% peak VO2/VO2R

~60% peak HR

~50% HRR

Work rate

at 1stVT

<12

RPE Borg

scale

Continuous

≥30 min

VL

to Mod.

Moderate

to high? ? ? ? ?

High

to severe? ? ? ? ?

Severe

to extreme? ? ? ? ?


The choice of the aerobic training stimulus intensity in the

individual cardiac patient is still largely a matter of clinical

judgement.

The concept put forward in this paper is that aerobic exercise

prescription should be based on the choice of one exercise

intensity domain according to both the patient’s clinical and

pathophysiological picture and the peculiar response to and the

evidence-based benefits of exercise in that intensity domain.

The importance of patients’ functional evaluation through exercise

testing prior to starting a training program is strongly stressed,

and cardiopulmonary exercise testing is proposed as the gold

standard for a physiologically meaningful exercise intensity

assessment and prescription.


Gulp !

AEROBIC EXERCISE INTENSITY PRESCRIPTION IN CARDIAC...

Documents

Transcript of AEROBIC EXERCISE INTENSITY PRESCRIPTION IN CARDIAC...