Transcript Exercise in Diabetes Mellitus Patients – from the view

Exercise Prescription for
Cardiovascular diseases
Dr. Leung Tat Chi, Godwin
Specialist in Cardiology
8 September 2007
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 is 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

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

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

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)
Blood Pressure Reductions as Little as 2 mmHg
Reduce the Risk of Cardiovascular Events by up to
10%
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Meta-analysis of 61 prospective, observational studies
1 million adults
12.7 million person-years
7% reduction in risk
of ischemic heart
disease mortality
2 mmHg decrease in
mean systolic blood
pressure
10% reduction in risk
of stroke mortality
Lewington S, et al. Lancet. 2002;360:1903–1913
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)
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
Exercise training/ Angina
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Symptomatic improvement in exercise
tolerance
– Reduction in HR and SBP or rate-pressure
product
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Improve myocardial oxygen delivery
Reduce abnormal vasoconstrictive response
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

Cardiac rehabitation programs
– Cardiac arrest: 1 in 117000 (patient-hours of
participation)
– Nonfatal MI: 1: in 220000
– Death : 1: 750000
Aerobic Activity
Muscle-Strengthening Activity
Recommendation
Frequency
Intensity
Duration
Healthy adults,
2007.
(ACSM/AHA
Recommendation)
A
minimum
of 5 d/wk
for
moderate
intensity,
or a
minimum
of 3 d/wk
for
vigorous
intensity
Moderate
intensity
between
3.0 and
6.0 METS;
vigorous
intensity
above 6
METS
Older adults, 2007
(ACSM/AHA
Recommendation)
A
minimum
of 5 d/wk
for
moderate
intensity,
or a
minimum
of 3 d/wk
for
vigorous
intensity
Moderate
intensity
at 5 to 6
on a 10point
scale;
vigorous
intensity
at 7 to 8
on 10point
scale
Frequency
Number
of
Exercises
Sets and
repetitions
Accumulate at
At least 2
least 30 min/d
d/wk
of moderateintensity activity,
in bouts of at
least 10 min
each;
continuious
vigorous
activity for at
least 20 min/d
8-10
exercises
involving
the major
muscle
groups
8-12
repetitions
Accumulate at
At least 2
least 30 min/d
d/wk
of moderateintensity activity,
in bouts of at
least 10 min
each;
continuious
vigorous
activity for at
least 20 min/d
8-10
exercises
involving
the major
muscle
groups
10-15
repetitions
Flexibiltiy/
Balance
At least 2
d/wk
flexibiltiy;
for those at
risk of falls,
include
exercises to
maintain or
improve
balance
Aerobic Activity
Muscle-Strengthening Activity
Recommendation
Frequency
Intensity
Duration
Frequency
Number
of
Exercises
Sets and
repetitions
Hypertension,
2004
(ACSM
Recommendation)
Most,
preferably
all days per
week
Moderate
intensity
at 40 <60% of
VO2max
reserve
(vigorous
intensity
acceptable
for
selected
adults)
Accumulate
30 - 60 min/d
of moderateintensity
activity, in
bouts of at
least 10 min
each;
2-3 d/wk
(resistance
training an
adjunct to
aerobic
activity)
8-10
exercises
involving
the major
muscle
groups
1 set of 815
repetitions
(more than
1 set
acceptable
for selected
adults)
Cholesterol, 2001,
National
Cholesterol
Education Program
Most days
of the
week,
preferably
daily
Moderate
intensity
At least 30
min/d
Musclestrengthening
activities
recommended
as beneficial
Flexibiltiy/
Balance
Flexibility
regarded as
beneficial
Aerobic Activity
Muscle-Strengthening Activity
Recommendation
Frequency
Intensity
Duration
Frequency
Coronary artery
disease, 2001,
AHA (aerobic
recommendation)
At least 3
d/wk
Moderate
intensity
at 40 60% of
HR
reserve
(vigorous
intensity
as
tolerated
at 6085% of
HR
reserve
At least 30 min
Cardiovascular
disease, 2000,
AHA (flexibility
and resistance
training
recommendation)
A minimum
of 5 d/wk
for
moderate
intensity, or
a minimum
of 3 d/wk
for vigorous
intensity
Moderate
intensity
at 5 to 6
on a 10point
scale;
vigorous
intensity
at 7 to 8
on 10point
scale
Accumulate at
At least 2
least 30 min/d
d/wk
of moderateintensity activity,
in bouts of at
least 10 min
each;
continuious
vigorous
activity for at
least 20 min/d
Number
of
Exercises
Sets and
repetitions
Flexibiltiy/
Balance
8-10
exercises
involving
the major
muscle
groups
10-15
repetitions
At least 2
d/wk
flexibiltiy;
for those at
risk of falls,
include
exercises to
maintain or
improve
balance
Hypertension and Exercise
ACSM Position Stand (Evaluation)

Severity
 Secondary cause
 CV risk factors
 Target organ damage (TOD)
 CVD complications
Hypertension and Exercise
Position Stand (Evaluation)

Supervised exercise stress test
– High intensity exercise program (VO2 R >60%)
– Patients with TOD/DM or BP >180/110 before
engaging in moderate-intensity exercise (VO2R
40 to 60%)
– Patients with CVD (stroke, heart failure, IHD)

Avoid high intensity exercise (vigorous program
best initiated at dedicated rehabilitation centre)
BP Classification
Hypertension and Exercise
Position Stand
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Emphasis on aerobic activity. VO2R 40 to 60%. RPE
12-13.
Avoid high-intensity resistance training (lower
intensity, higher repetitions).
Clients should maintain hypertensive medications, if
prescribed.
Do not exercise if resting SBP > 200 mm Hg or DBP
> 115 mm Hg. Maintain BP <220/105 during exercise
Begin pharmacological treatment prior to starting
exercise program if BP > 160/100
Diuretics increase the potential for dehydration
Beta-blockers and diuretics impair the ability to
regulate body temperature.


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S/S of heat illness
Adequate hydration
Proper clothing
Resistance training/ Valsalva
maneuver
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Forced expiration against a closed glottis
Increase in intrathoracic pressure leading to decreased
venous return and potentially reduced cardiac output
 At the release of the “strain,” venous return is dramatically
increased, increasing cardiac output and elevation of BP
 Symptoms of lightheadedness or dizziness may occur if
cardiac output is reduced.
 With relaxation, individuals may experience headache
while pressure remains elevated.
 In patients with heart disease, symptoms of myocardial
ischemia may ensue as a result of elevated BP and
increased myocardial work.
Adherence
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Education regarding the importance of
regular exercise for BP control
 Especially responsive if information comes
from their personal physician
 Knowledge of the immediate BP-lowering
effects of exercise (PEH)
Cardiac rehabilitation
Recent MI, PCI, open heart surgery, heart
failure
 Core components
– Medical assessment
– Nutrition counseling
– Risk factor management (lipid, DM, weight,
smoking)
– Psychosocial management
– Activity counseling and exercise training
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

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

Should be performed on all cardiac patients
entering an exercise training program
Exercise prescription for individuals with
CAD (Risk Stratification)

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 70
>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)

Substantially increased risk
– Impaired LV systolic function (<50%)
– Evidence of exercise-induced myocardial
ischemia
– Hemodynamically significant stenosis of a
major coronary artery (>50%)
Medically Supervised Exercise

Moderate to High risk subjects
–
–
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Medical supervision required until safety established
ECG and BP monitoring (usually > 12 sessions)
Low risk subjects
–
Benefit from medically supervised programs
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–
Safe
Group dynamics
ECG monitoring (useful during the early phase, 6 – to
12 sessions)
Exercise prescription for
individuals with CAD

Inpatients
– Walking
– Active but non-resistance range-of-motion
exercise of the upper extremities
Inpatient exercise program

Intensity
– RPE <13
– Post MI: HR <120BPM or HR(rest) + 20 BPM

Duration
– Intermittent bouts 3 to 5 mins, as tolerated

Frequency
– 3 to 4 times per day (day 2-3)
– Two times per day with increased duration of exercise bouts
(beginning on day 4)

Initial activities should be monitored, and symptoms HR,
BP recorded
Rehabilitation in Coronary
Heart Disease
• Mainly endurance training
• at an intensity of 50 (-60) -75% of symptomlimited VO2max (or heart rate reserve) for 30
minutes 3-4 times weekly (minimum), full
benefit is obtained with 5-6 times/week
• Resistance training in addition
• at an intensity of 30-50% (up to 60-80%) of 1
RM (one repetition maximum), 12-15
repetitions, 1-3 sets twice weekly
Resistant training
Patients with CVD

Stable symptoms
 Acceptable functional capacity (>4 METs)
– Can participate in low-to moderate intensity RT without
further medical diagnostic testing

Patients with recent MI, percutaneous or surgical
coronary revascularization, or open heart surgery
should preferably exercise in supervised cardiac
rehabilitation programs
Adverse signs and symptoms
RT should be stopped

Dizziness
 Excessive shortness of breath
 Chest pain or pressure
 Heart rhythm irregularities
Outpatients

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 (for 5 to 10 minutes)
 At least 3 times weekly
 Follow-up supervised group sessions are
recommended
Exercise prescription without
exercise test

Initial exercise intensity
– 2 to 3 METs


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

20 beats/min above standing rest
– Frequency

30 – 45 minutes per day 5 d/wk,
Exercise prescription in the
presence of ischemia

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
Home exercise rehabilitation

Lower cost
 Convenience
 Promote independence
 Comparable safey and efficacy
 Good communication between patients and
staff required
Heart Failure

Benefits of exercise
– Functional capacity, improved leg blood flow and oxidative
capacity, neurohormones, autonomic tone


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

CABG/ open heart surgery
– Avoid upper body exercise (lifting weights > 50%
MVC) for 8 to 12 weeks
– Allow sternum to heal

PCI
– Resume exercise no sooner than 5 to 7 days
– Catheterization access sites should be healed
Pacemakers and implantable
cardioverter defrillators

Type and settings of pacemaker should be noted
 Avoid high intensity resistance exercise
 Fixed-rate pacemakers
– Activity intensity must be gauged by other methods


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

GCVD
– HCM, LQTS, Marfan syndrome, ARVC, Brugada syndrome


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

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;103:327-334.
Physical activity and public health in older adults: Recommendation from the
American College of Sports Medicine and the American Heart Association.
Circulation. 2007;116:000-000
ACSM Position Stand. Exercise and Hypertension. hypertension. Med. Sci.
Sports Exerc. 36:533–553, 2004.
Resistance Exercise in Individuals With and Without Cardiovascular Disease:
2007 Update Circulation. 2007;116:572-584