Transcript Exercise in Diabetes Mellitus Patients – from the view

Exercise Prescription for
Cardiovascular disease
Dr. Leung Tat Chi, Godwin
Specialist in Cardiology
3 Feb 2007
Current Recommendation of
PA for Health Promotion
1996 U.S. Surgeons’ General Report: Physical Activity and
Health (USDHHS / CDC / ACSM)
• Individuals should engage in 30 minutes
or more of moderate intensity physical
activity on most days (preferably all) of
the week
• effectively reduce the risk of coronary
heart disease, type 2 diabetes,
hypertension, stroke and cancer of the
breast and colon
Prevention of Atherosclerotic
Vascular Disease by Physical
Exercise
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Physical activity reduces the incidence of CAD
Physical inactivity is a major CAD risk factor
The relation is strong, with the most physically
active subject generally demonstrated CAD rates
half those of the most sedentary group
Independent of other risk factors
Not protective in later years without lifelong
physical activity
Benefit seen in middle age and older age groups
Powell KE, Thompson PD, Caspersen CJ, et al. Physical activity and the incidence of coronary heart disease. Annu Rev Public Health. 1987;8:253-287
Reduction of Atherosclerotic
Risk Factors
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Physical activity both prevents and treats
establish atherosclerotic risk factors:
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Elevated blood pressure
Insulin resistance
Glucose intolerance
Elevated triglyceride concentration, low HDL-C
Obesity
Exercise + weight reduction >>>>  LDL-C
and increase HDL
Thompson et al, Exercise and Physical Activity in Cardiovascular Disease. Circulation June 24, 2003; 107:3109-3166
Response of Blood Lipids to
Exercise Training
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Meta-analysis of 52 exercise training trials
of >12 weeks
 Include 4700 patients
 Change in lipid profile
– HDL-C increase 4.6%
– Reduction in LDL-C by 5.0%
– Reduction in TG by 3.7%
Leon AS, Sanchez O. Meta-analysis of the effects of aerobic exercise training on blood lipids. Circulation. 2001;104(suppl II):II-414-415. Abstract.
Response of Blood Pressure to
Exercise Training
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44 randomized controlled trials include 2674
patients
 Average change in blood pressure
– SBP decrease by 3.4 mmHg
– DBP decrease by 2.4 mmHg
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Hypertensive patient
– SBP decrease by 7.4 mmHg
– DBP decrease by 5.8 mmHg
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Normotensive patient
– SBP decrease by 2.6 mmHg
– DBP decrease by 1.8 mmHg
BP drop is not dose
related
Fagard RH. Exercise characteristics and the blood pressure response to dynamic physical training. Med Sci Sports Exerc. 2001;33(6 suppl)
Response of Insulin Resistance to
Exercise Training
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Physical activity reduces insulin resistance
and glucose intolerance, postprandial
hyperglycemia, and possibly hepatic
glucose output
 9 randomized trials include 337 patients
 Reports reduction of hemoglobin HbA1c of
0.5% to 1%
Thompson PD, Crouse SF, Goodpaster B, et al. The acute versus the chronic response to exercise. Med Sci Sports Exerc. 2001;33(6 suppl)
Effect of Exercise-based Cardiac
Rehabilitation on Cardiac Events
Outcome
Mean Difference
95% Cl
Statistically Significant?
Exercise-only intervention
Total mortality
-27%
-2% to –40%
Yes
Cardiac mortality
-31%
-6% to –49%
Yes
Nonfatal MI
-4%
-31% to +35%
No
Comprehensive rehabilitation
Total mortality
-13%
-29% to +5%
No
Cardiac mortality
-26%
-4% to –43%
Yes
Nonfatal MI
-12%
-30%-+12%
No
Cl indicates confidences intervals. Cls not including zero are statistically significant.
•Meta analysis include 51 randomized trials
•Include 8440 patients: CABG, PTCA, MI, angina, middle-age men
•Supervised exercise for 6 months, follow up 2 years later
Jolliffe JA, Rees K, Taylor RS, et al. Exercise-based rehabilitation for coronary heart disease. Cochrane Database Syst Rev. 2001(1):CD001800
The Exercise Training Intervention
after Coronary Angioplasty
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Randomised 118 patients after coronary
revascularization
6 months of exercise training vs usual care
Trained patients significant increases in peak VO2
(26%)
Quality of life parameters increases in 27%
Fewer cardiac events (11.9% vs 32.2%)
Hospital readimissions (18.6% vs 46%)
Residual coronary stenosis decrease by 30%
Recurrent cardiac event reduced by 29%
BelardinelliR, Paolini I, Cianci G, et al. Exercise Training Intervention after Coronary Angioplasty: the ETICA trial. J Am Coll Cardiol., 2001;37:1891-1900
Risk
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Cardiac rehab programs
– Cardiac arrest: 1 in 117000 (patient-hours of
participation)
– Nonfatal MI: 1: in 220000
– Death : 1: 750000
BP Classification
Lifestyle modification
Modification
Recommendation
Physical activity Engage in regular aerobic
physical activity such as brisk
walking (at least 30 mins per
day, most days of the week)
Moderation of
alcohol
consumption
SBP
reduction
4-9mmHg
Limit consumption to no more 2-4mmHg
than 2 drinks (e.g., 24 oz beer,
10 oz wine, or 3 oz 80-proof
whiskey) per day in most men
and to no more than 1 drink
per day in women and lighterweight persons
Lifestyle modification
Modification
Recommendation
SBP
reduction
Weight Reduction
Maintain normal BW (BMI
18.5-24.9kg/m2)
520mmHg/10kg
Adopt DASH eating
plan
Diet rich in fruits,
vegetables, and low-fat
diary products with a
reduced content of dietary
cholesterol as well as
saturated and total fat
6-14mmHg
Dietary sodium
restriction
Reducing dietary sodium to 2-8mmHg
no more than 100
mmol/day (2-4g Na or 6g
NaCl)
Exercise prescription for Hypertension
Follow general recommendations for aerobic exercise prescription,
with slight reduction in intensity (40-70% of VO2max or HRR, i.e. 5580% of the maximal heart rate.) The lower range of intensity is
sufficient for the elderly.
3 or 4 times weekly for at least 30 minutes at a time
Various endurance exercise modes are suitable. Resistance training
(preferably circuit training) should not be the only form of exercise but
should be combined with endurance training.
 Emphasis on large muscle group aerobic activity.
 Avoid high-intensity resistance training (lower intensity, higher
repetitions).
Training at an intensity of about 50% of the maximal exercise
performance (moderate-intensity) is sufficient with regard to resting
blood pressure reduction (Fagard, 2001).
Finnish Medical Society Duodecim. Physical activity in the prevention, treatment and rehabilitation of diseases. 2004 Apr 20
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Hypertension
Patients should maintain hypertensive medications, if prescribed.
• Monitor blood pressure before, during, and after exercise
• Unusually high blood pressures (>190mmHg systolic) during lowlevel activity may warrant adjustment in medical therapy
 Stop when there is a 10 to 15mmHg fall in BP during exercise and
further evaluation should be performed
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Begin pharmacological treatment prior t starting exercise program if
BP > 160/100
Cardiovascular System
Assessment
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Patients with known coronary artery disease should
undergo a supervised evaluation of the ischemic response
to exercise, ischemic threshold, and the propensity to
arrhythmia during exercise.
In many cases, left ventricular systolic function at rest and
during its response to exercise should be assessed.
Physical Activity/Exercise and Diabetes; Diabetes care, vol. 27, supplement 1, January 2004
Exercise testing
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Integral component of the rehab process
– Establishment of appropriate specific safety precautions
– Guide training intensity
– Target exercise training heart rates
– Initial levels of exercise training work rates
– Risk stratification
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Should be performed on all cardiac patients
entering an exercise training program
Exercise prescription for individuals with
CAD (Risk Stratification)
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Mildly increased risk
– Preserved LV systolic function (EF > 50%)
– Normal exercise tolerance for age
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> 50 years old
50 to 59
60 to 60
>70
> 10METS
>9METS
>8METS
>7METS
– Absence of exercise induced ischemia
– Absence of hemodynamically significant stenosis of a
major coronary artery (>50%)
– Successful revascularization
Exercise prescription for individuals with
CAD (Risk Stratification)
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Substantially increased risk
– Impaired LV systolic function (<50%)
– Evidence of exercise-induced myocardial
ischemia
– Hemodynamically significant stenosis of a
major coronary artery (>50%)
Eligibility recommendations for competitive
athletes with cardiovascular abnormalities
Mildly increased risk CAD: IA, IIA
Medically Supervised Exercise
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Moderate to High risk subjects
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Class C
Medical supervision required until safety established
ECG and BP monitoring (usually > 12 sessions)
Low risk subjects
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Class B
Benefit from medically supervised programs
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Safe
Group dynamics
ECG monitoring (useful during the early phase, 6 – to 12 sessions)
Unmonitored exercise
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For conditioning
1 to 2 weeks post MI
Walking
–
Safe, low-impact, controllable
Exercise prescription for
individuals with CAD
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Inpatients
– Walking
– Active but non-resistance range-of-motion
exercise of the upper extremities
Inpatient exercise program
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Intensity
– RPE <13
– Post MI: HR <120BPM or HR(rest) + 20 BPM
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Duration
– Intermittent bouts 3 to 5 mins, as tolerated
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Frequency
– 3 to 4 times per day (day 2-3)
– Two times per day with increased duration of exercise bouts
(beginning on day 4)
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Initial activities should be monitored, and symptoms HR,
BP recorded
Outpatients
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Large-muscle group activities
 Moderate intensity: 40 to 60% of VO2 max
 At least 30 minutes
 Preceded by warm-up and followed by
cool-down
 At least 3 times weekly
 Follow-up supervised group sessions are
recommended
Cardiac rehabilitation
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Core components
– Medical assessment
– Nutrition counseling
– Risk factor management (lipid, DM, weight,
smoking)
– Psychosocial management
– Activity counseling and exercise training
Outpatients exercise program
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Setting a safe upper limit for Intensity
– Moderate intensity exercise (40 to 60% VO2max)
– Brisk walking, treadmill, cycle, stair-climbing, rowing machine
– Initial intensity
 40 to 60% of heart rate reserve
 Can be increased to 85% (high intensity) if tolerated
– RPE
 11 to 13 (between fairly light to somewhat hard)
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Duration may be increased as appropriate after safe
activity levels established
 Intensity may be increased as heart rate response to
exercise decreases with conditioning
Exercise prescription without
exercise test
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Initial exercise intensity
– 2 to 3 METs
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1 to 2 mph, 0% grade on treadmill
100 to 300 kg.m.min-1 (12.5- 50W) on cycle ergometer
– RPE: 11-13
– Gradual increments of 0.5 to 1.0 METs as tolerated
– Target heart rate
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20 beats/min above standing rest
– Frequency
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30 – 45 minutes per day 5 d/wk,
Exercise prescription in the
presence of ischemia
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Inappropriate for those with angina < 3METS
 Aim to increase anginal threshold
 Prolonged warm up and cool
 Upper body exercises may precipitate angina more readily
 Heart rate and work rate below the identified threshold of
ischemia
 Should be a minimum of 10 beats/min below the heart rate
at which the abnormality occurs
 Intermittent, shorter duration-type on a more frequent basis
Heart Failure
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Benefits of exercise
– Functional capacity, improved leg blood flow and oxidative
capacity, neurohormones, autonomic tone
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Initiated at a low to moderate level (25 to 60% of VO2max)
VO2max determined by direct gas exchange measurements
 Careful supervision and monitoring
 Brief training session
 Lengthened warm up and cool down
 RPE: 11 to 14
 Safety and efficacy of resistance training not well
established
After cardiac procedure
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CABG
– Avoid upper body exercise for 3 months
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PCI
– Resume exercise no sooner than 5 to 7 days
– Catheterization access sites should be healed
Pacemakers and implantable
cardioverter defibrillators
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Type and settings of pacemaker should be noted
 Fixed-rate pacemakers
– Activity intensity must be gauged by other methods
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RPE
ICD
– Limit target heart rate at least 10 to 15 beats/min lower
than the threshold discharge rate
AHA Scientific Statement: Recommendations
for the Acceptability of Recreational
(Noncompetitive) Sports Activities and Exercise
in Patients With Genetic CVD
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GCVD
– HCM, LQTS, Marfan syndrome, ARVC, Brugada syndrome
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Recreational sports are categorized with regard to high,
moderate and low levels of exercise
Graded on relative scale (from 0 to 5) for eligibility
– 0 to 1: indicating generally not advised or strongly discouraged
– 4 to 5: indicating probably permitted
– 2 to 3: indicating intermediate and to be assessed clinically in an
individual basis
AHA Scientific Statement: Recommendations
for the Acceptability of Recreational
(Noncompetitive) Sports Activities and Exercise
in Patients With GCVDs
Intensity Level
HCM
LQTS
Marfan
Syndrome
ARVC
Brugada
Symdrome
Basketball
0
0
2
1
2
Full court
0
0
2
1
2
Half court
1
1
0
1
1
Body building
0
0
1
0
0
Ice hockey
0
2
2
0
2
Racquetball/squash
1
1
1
1
1
Rock climbing
0
0
2
0
2
Running (downhill)
2
2
2
1
1
Skiing (cross-country)
2
3
2
1
4
Soccer
0
0
2
0
2
Tennis (singles)
0
0
3
0
2
Touch (flag) football
1
1
3
1
3
Windsurfing
1
0
1
1
1
High
Recommendations for Physical Activity and Recreational Sports Participation for Young Patients with Genetic Cardiovascular Diseases,
Circulation. 2004; 109:2807-2816)
AHA Scientific Statement: Recommendations
for the Acceptability of Recreational
(Noncompetitive) Sports Activities and Exercise
in Patients With GCVDs
Intensity Level
HCM
LQTS
Marfan
Syndrome
ARVC
Brugada
Symdrome
Baseball/softball
2
2
2
2
4
Biking
4
4
3
2
5
Modest hiking
4
5
5
2
4
Motocycling
3
1
2
2
2
Jogging
3
3
3
2
5
Sailing
3
3
2
2
4
Surfing
2
0
1
1
1
Swimming (lap)
5
0
3
3
4
Tennis (doubles)
4
4
4
3
4
Treadmill/stationary bicycle
5
5
4
3
5
Weightlifting (free weights)
1
1
0
1
1
Hiking
3
3
3
2
4
Moderate
Recommendations for Physical Activity and Recreational Sports Participation for Young Patients with Genetic Cardiovascular Diseases,
Circulation. 2004; 109:2807-2816)
AHA Scientific Statement: Recommendations
for the Acceptability of Recreational
(Noncompetitive) Sports Activities and Exercise
in Patients With GCVDs
Intensity Level
HCM
LQTS
Marfan
Syndrome
ARVC
Brugada
Symdrome
Bowling
5
5
5
4
5
Golf
5
5
5
4
5
Horseback riding
3
3
3
3
3
Scuba diving
0
0
0
0
0
Skating
5
5
5
4
5
Snorkeling
5
0
5
4
4
Weights (non-free weights)
4
4
0
4
4
Brisk walking
5
5
5
5
5
Low
Recommendations for Physical Activity and Recreational Sports Participation for Young Patients with Genetic Cardiovascular Diseases,
Circulation. 2004; 109:2807-2816)
Recommendation
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Health professionals should personally
engage in an active lifestyle
References
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Exercise standards for testing and training: a statement for healthcare
professionals from the American Heart Association. Circulation.
2001;104:1694-1740
Exercise and physical activity in the prevention and treatment of
atherosclerotic cardiovascular disease: AHA scientific statement.
Circulation. 2003;107:3109-3116
Recommendations for Physical Activity and Recreational Sports
Participation for Young Patients with Genetic Cardiovascular Diseases,
Circulation. 2004; 109:2807-2816
ACSM’s guidelines for exercise testing and prescription. 7th edition
36th Bethesda Conference. Eligibility recommendations for
competitive athletes with cardiovascular abnormalities. JACC 19 April
2005
Recommendations for preparticipation screening and the assessment of
cardiovascular disease in masters athletes. Circulation. 2001;103:327334.