Exercise & Medicine Dr. Wong Bun Lap Bernard Specialist in Cardiology HKMA Council Member.

Exercise & MedicineExercise & Medicine

Dr. Wong Bun Lap BernardDr. Wong Bun Lap BernardSpecialist in CardiologySpecialist in Cardiology

HKMA Council MemberHKMA Council Member

Genius is one percent Genius is one percent inspiration,inspiration,

Ninety-nine percent Ninety-nine percent perspirationperspiration

~ Thomas Alva Edison 1847-1931~ Thomas Alva Edison 1847-1931

Interesting DefinitionsInteresting Definitions Exercise

– Physical activity that is planned, structured, repetitive, and purposeful, usually aimed at a improving or maintaining physical fitness.

Physical activities– Any body movement produced by skeletal mu

scles that results in energy expenditure beyond resting expenditure.

~ Richard C Pasternak, Braunwald’s Heart Disease, A textbook of cardiovascular medicine, 7th Edition 2005’

Heart DiseaseHeart DiseaseA very common diseaseA very common disease

2nd Killer – 5,390 deaths in 2003’ (14.8/day)

Public resources demanding– More than 60,000 hospital admissions per

year– Only for ischemic heart diseases

• 17,523 (48/day) admissions & 1,780 deaths per year

~ Statistical Report 2003/2004, Hospital Authority ~ Census & Statistic Department, Department of Health

Heart DiseaseHeart DiseaseA very common diseaseA very common disease

A coronary artery disease community survey in HK 95-96’– Prevalences 2.4% – 164,523 in 6,855,125 HK population1

A projection from US data– Prevalences 6.80%2 – Estimated 466,148 in 6,855,125 HK population– we are seeing the “tip of iceberg” only

1. Janus et al, 1997. Hong Kong cardiovascular risk factor prevalence study 1995-1996.

2. US Census Bureau 2004’

The Benefits of ExerciseThe Benefits of ExercisePrimary PreventionPrimary Prevention

• Brisk walking, 30mins/day, 5 times/week– 30% ↓vascular events in 3.5 years follow-up1

• 3 hours of brisk walking/week = 1.5 hours of vigorous exercise per week2

• Resistance exercise and weight training were also beneficial3

1. Manson JE, Greenland P, LaCroix AZ, et al: Walking compared with vigorous exercise for the prevention of cardiovascular events in women N Eng J. Med 347;716, 2002

2. Manson JE, Hu FB, Rich Edward JW , et al: a prospective study of walking as compared with vigouous exercise in the prevention of coronary artery disease in women. N Eng J. Med 341:650, 1999

3. Tanasescu M, Leitzmann MF, Rimm EB, et al: Exercise type and intensity in relation to coronary heart disease in men. JAMA 288:1994, 2002

The Benefits of ExerciseThe Benefits of ExercisePrimary PreventionPrimary Prevention

• “ No pain, no gain” approach is out!1

• Centers for Disease Control and Prevention and the American College of Sports Medicine 1995’

– Every person should accumulate at least 30minutes of moderate-intensity physical activity daily

1. Lee IM, Rexrode KM, Cook NR, et al: Physical activity and coronary heart disease is “No pain,no

gain “ passe? JAMA 285:1447, 2001

The Benefits of ExerciseThe Benefits of ExerciseSecondary PreventionSecondary Prevention

Physical activity with 1000kcal/wk – 20-30% ↓ all cause mortality1

For patients without revascularization– Exercise training improves SBP, angina symptoms and exercis

e tolerance2

For patients with revascularization– Improvement in QoL, exercise tolerance– ↓29% cardiac events – ↓re-admissions (18.6 vs 46%)3

1. Lee I-M, Skerett PJ: Physical activity and all-cause mortality—What is the dose response relation? Med. Sci Sports exerc33(6Suppl):S459,2001

2. Hambrecht R. Wolf A, Gielen S, et al: Effects of exercise on coronary endoothelial function in patients wwith coronary artery disease. Am J Cadriol 90:124, 2002

3. Belardinelli R, Paolini I, Cianci G, et al: Exercise training intervention after coronary angioplasty: The ETICA trial. J Am Coll Cardiol 37:1891, 2001

Safety of Exercise Safety of Exercise

Exercise without medical advice:– Sudden Cardiac Arrest: 1 per 60,000 pt. hours1

Supervised Programs:– Cardiac events: 8.9 per 1,000,000 pt. hours– Myocardial Infarction: 3.4 per 1,000,000 pt. hours– Mortality: 1.3 per 1,000,000 pt. hours2

1. Fletcher GF, Balady GJ, Amsterdam EA, et al: Exercise standards for testing and training: A statement for healthcarecare professionals from the American eart Association. Circulation 104:1694, 2001

2. Ades PA: Cardiac rehabilitation and secondary prevention of coronary heart disease. N Eng J Med 345:892, 2001

Principles of ExercisePrinciples of Exercise

Avoid:• Unstable angina• SBP ≥ 180mmHg or DBP ≥ 100mmHg• Symptomatic orthostatic BP drop > 20mmHg• Critical aortic stenosis• Acute systemic illness or fever• Uncontrolled arrhythmia• Uncompensated CHF• 3rd degree AV Block (complete heart block)• Acute pericarditis & myocarditis• Recent embolism• Thrombophlebitis• Resting ST displacement ≥ 2mm• Uncontrolled DM• Electrolyte disturbance• hypovolemia

Principles of Exercise PrescriptionPrinciples of Exercise Prescription

2. Treadmill exercise stress test initial assessment

• Cardiovascular status assessment• Exercise induced arrhythmia• Execise induced ischemia• Trend of Blood pressure during exercise• Trend of SaO2 during exercise


2. Treadmill exercise stress test initial assessment• Functional capacity assessment- Activity of daily living:

- Lying quietly 1.0METS- Sitting: light activity 1.5METS- Walking from house to car/bus 2.5METS- Watering plants 2.5METS- Taking out trash 3.0METS- Walking the dog 3.0METS- Household tasks, moderate effort 3.5METS- Vacuuming 3.5METS


2. Treadmill exercise stress test initial assessment• Functional capacity assessment

– Leisure activities• Playing piano 2.3METS• Golf (with cart) 2.5METS• Walking (2mph) 2.5METS• Ballroom Dancing 2.9METS• Walking (3mph) 3.3METS• Cycling (Leisurely) 3.5METS• Golf (without cart) 4.4METS• Swimming (slow) 4.5METS• Walking (4mph) 4.5METS• Tennis (doubles) 5.0METS• Ballroom Dancing (fast) 5.5METS• Cycling (mod) 5.7METS• Hiking (no load) 6.9METS• Swimming 7.0METS• Walking (5mph) 8.0METS• Jogging (10min/mile) 10.2METS• Rope skipping 12.0METS• Squash 12.1METS

Principles of ExercisePrinciples of Exercise

Regular treadmill exercise stress test reassessment

– Ascess the impact of medical and exercise management

– Provide feedback to patient– Plan of future management

Tips on DM patientsTips on DM patients

Pre- exercise treadmill Stress test was indicated:1. Age > 402. Age > 30 with

– DM > 10 yrs– HT– Smoking– Hyperlipidemia– Retinopathy– Nephropathy (microalbuminuria)

3. Coronary Artery Disease4. CVA5. Peripheral vascular disease6. Autonomic neuropathy7. Renal Failure


• Postpone exercise if – Hstix > 16.5mmol/L– Hstix >13mmol/L with ketones in urine

• Monitor Hstix before, (during) and after exercise

• Ideal pre-exercise 6.7 – 10mmol/L

• Ingest Carbohydrate : Hstix 4.4-5.5mmol/L2


• prevent injury – peripheral neuropathy– Lower extremity care – Swimming/cycling/rowing better than

walking/jogging

• Autonomic neuropathy– Blunted BP/P response– Postural hypotension– Heat stroke


• Silent myocardial ischemia• Proliferative retinopathy

– Consult opthalmologist– Low-impact exercise

• Adequate hydration• DM identification card3,4

1. Ronald J Signal, Geln P Kenny, David H. Wasswerman, carmen Castaneda-Sceppa et al. (Oct 2004) Physic al Activity, exercise and Type 2 Diabetes Care, 27(10), 2518-2539

2. Barry A. Franklin, Mitchell H. Whaley, & Edward T. Howley, et al. (2000). American College of Sports Medicine’s Guidelines for exercise testing and presciption, 6 th ed. Baltimore: Lippincott Williams & Wilkins

3. Birrer, Richard B., Sedaghat, & Vahid-David et al. (May 2003). Exercise and Diabetes Mellitus, Physician & Sports Medicine, 31(5).

4. American Diabetes Association. (January2004). Physical activity/Exercise and Diabetes, Diabetes Care, 27, Supplement 1.

After Doctors’ ConsultationAfter Doctors’ Consultation

Just Do It !Just Do It !

DIY !DIY !

DIY!DIY!

Exercise & Medicine Dr. Wong Bun Lap Bernard Specialist in Cardiology HKMA Council Member.

Documents

Transcript of Exercise & Medicine Dr. Wong Bun Lap Bernard Specialist in Cardiology HKMA Council Member.