E XERCISE P RESCRIPTION I N P ATIENTS W ITH C ARDIOVASCULAR D ISEASE L EANDRO C. B ONGOSIA, MD,...
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Transcript of E XERCISE P RESCRIPTION I N P ATIENTS W ITH C ARDIOVASCULAR D ISEASE L EANDRO C. B ONGOSIA, MD,...
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EXERCISE PRESCRIPTION IN PATIENTS WITH
CARDIOVASCULAR DISEASE
LEANDRO C. BONGOSIA, MD, FPCP, FPCC, FACC
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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
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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
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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
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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
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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.
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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
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Theoretical relation between health and fitness benefits and the amount or intensity of exercise:
Health
Fitness
Quantity of exercise
Bene
fits
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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
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The Process of Developing an Exercise Prescription
Assessment
Interpretation
PrescriptionMode
Frequency
Duration Intensity
Precautions
Progression
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Components of Exercise Prescription:
A. ModeB. IntensityC. DurationD. FrequencyE. Progression
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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
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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
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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”
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Components of Exercise Prescription
B. Intensity (cont.)
1. Establishing a training/target HR2. Using MET method3. Rate of Perceived Exertion
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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
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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
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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.
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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
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Components of Exercise Prescription
D. Frequency3 – 5 days/week
3 days/week ---- 60% – 80% HRR
ACSM
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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.
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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.
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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.
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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
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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
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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.
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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
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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
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Restrictions of Resistance Training
• Unstable angina• Uncontrolled HPN ( BP > 160/100)• Uncontrolled arrhythmias• Recent CHF• Severe Valvular Heart disease or hypertrophic
cardiomyopathy
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Restrictions of Resistance Training
• Poor left ventricular function• Inadequate functional capacity, less than
or equal to 5 METS (not an absolute contraindication)
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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
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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
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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)
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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
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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
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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
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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
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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:
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