Case study
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Mr. Wong is a 48-year old male, sales
representative who travels often
170cm, 84kg , BMI 29
His brother just suffered from MI at age 40.
Concerned about his health
Want to do start exercise and lose weight
Evaluation
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Classify client according to Risk Stratification
Criteria
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ACSM/ ACP/ACCVPR/ AHA
Identify Major Coronary Artery Disease Risk
Factors
Identify signs or symptoms suggestive of
cardiopulmonary disease
Identify secondary risk factors
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Obesity, alcohol consumption, stress levels
Case Study
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Recently diagnosed to have type 2 DM, put on Daonil
BP 160/90 mmHg on metoprolol 50mg bd
Half pack a day smoking habit due to stress of his job
His brother just suffered from MI at age 40.
Cholesterol level: 6.2mmol/l , HDL 0.90 mmol/l, LDL
3.8mmol/l
TG: 2.4 mmol/l
No regular exercise
No signs or symptoms of cardiopulmonary disease
Positive Risk Factors for CHD ACSM
Family History
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(2006)
Myocardial infarction, coronary revascularization
(bypass surgery) or sudden death before :
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the age of 55 years in father or other male first degree
relative (i.e. brother or son)
the age of 65 years in mother or other female first
degree relative (i.e. sister or daughter)
Cigarette smoking
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Current cigarette smoker or those who have quit
in the last six months
Hypertension
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Client on Hypertensive medications
Resting SBP > 140 mmHg and/ or DBP > 90 mm Hg
Fasting Glucose
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Fasting blood glucose of >100mg/dL 5.6mmol/L)
Positive Risk Factors for CHD
ACSM
(2006)
Dyslipidemia
 Total serum cholesterol > 200mg/dL (5.2 mmol/L) or
 High density lipoprotein (HDL) < 40mg/dL (1.03 mmol/L)
 Low density lipoprotein (LDL) > 130mg/dL (3.4mmol/L)
Obesity
 Body Mass Index (BMI) > 30 kg/m2 or
 Waist girth >= 102 cm (M); >= 88 cm (F) or
 Waist/hip ration >= 0.95 (M); >= 0.86 (F)
Sedentary Lifestyle
 Not participating in a regular exercise program
 Accumulating less than 30 minutes moderate intensity exercise 3-5 days
weekly
Negative Risk Factors for CHD
(2006)
High level of HDL
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HDL cholesterol > 1.6 mmol/L (60 mg/dl)
ACSM
Initial Risk
Stratification
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Low risk
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Moderate risk
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Men<45 years of age and women <55 years of
age
Younger individuals who are asymptomatic and
meet no more than one risk factor threshold
Older individuals (men 45 years of age; women
 55 years of age) or those who meet the
threshold for two or more risk factors
High Risk
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Individuals with one or more signs/symptoms or
known cardiovascular, pulmonary, or metabolic
disease
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What recommendations in reference to medical
examination and testing prior to participation in
an exercise program?
A. Medical examination and exercise testing
 B. Physician Supervision of exercise test
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Consider the following criteria during your
evaluation:
Age and gender
 Moderate Vs vigorous exercise program
 Physician present during testing
 Submaximal or maximal graded exercise test
 Type of test (treadmill, leg ergometer, step)
 Absolute and relative contraindications to exercise
testing
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ACSM Recommendations for: Pre-participation
screening Algorithm
ACSM Recommendations for: Pre-participation
screening Algorithm cont’
Cardiovascular System Assessment
A graded exercise test may be helpful if a patient, about to
embark on a moderate to high-intensity physical activity
program, is at high risk for underlying cardiovascular disease,
based on one of the following criteria:
Age >40 years , +/- CVD risk factors
Age >30 years and
Type 1 or 2 diabetes of >10 years' duration
Presence of any additional risk factor for coronary artery disease
Presence of microvascular disease (proliferative retinopathy or
nephropathy, including microalbuminuria)
Peripheral vascular disease
Autonomic neuropathy
Medications
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A constellation of cardiovascular risk factors related to
hypertension, abdominal obesity, dyslipidemia, and
insulin resistance
Certain drugs used to treat hypertension may accelerate
the appearance of new-onset diabetes. In particular,
both β blockers and diuretics have been implicated in
this effect.
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ALLHAT
 In high risk hypertensive patients, the diuretic, chlorthalidone, was 43% more likely
than the ACEI, lisinopril, to produce diabetes, but was also 18% more likely than the
calcium channel blocker, amlodipine, to produce this adverse effect.
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HOPE
 The development of new diabetes was reduced by 34% (p<0.001) in the ramipriltreated group.
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LIFE (Losartan Intervention For Endpoint Reduction in Hypertension)
 The ARB, losartan, was associated with a 25% relative risk reduction in new-onset
diabetes when compared with the β blocker, atenolol
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VALUE (The Valsartan Antihypertensive Long-term Use Evaluation)
 Valsartan, was associated with 23% RRR in new-onset diabetes when compared with
the calcium channel blocker, amlodipine.
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ARB/ACEI may have positive effects on insulin action
and potentially plays a meaningful role in protecting
high-risk hypertensive patients from developing
diabetes.
Medications
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Metoprolol changed to ACE inhibitors/ ARB
Metformin
Statin
Exercise stress test
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METS achieved: 8.5
Peak heart rate: 165 beats per minute
Peak blood pressure of 200/88 mmHg.
No exercise induced ischemia
Questions
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Please write an initial exercise prescription
Any adjustments and practical tips in patients
with DM and HT?
Exercise prescription
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Address each of the following
 Aerobic endurance
 Strength training
 Flexibility
Include each of the following in your prescription
frequency
times/day, days/week
Intesnisy
5HRR, %VO2max, %HRmax, %1RM, %MVC, etc
Duration
warm-up, cool-down, exercise component, rest between sets, etc
Mode of exercise
types of exerciise, stretching techniques, resistance training, etc
Rate of progression
ACSM and CDC
Recommendation
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American College of Sports Medicine (ACSM) and Centers for
Disease Control and Prevention (CDC), 1995 (Pate et al., 1995)
Recommendation: Every adult should engage in moderateintensity physical activity for 30 minutes or longer on most,
preferably all, days of the week. Moderate intensity is defined as
40 to 60% of maximal oxygen consumption (VO2max). The 30minute activity can also consist of shorter exercise bouts
(minimum of 10 minutes) that are accumulated throughout the
day (e.g., walking to work, shopping).
Finnish Medical Society Duodecim. Physical activity in the prevention, treatment and rehabilitation of diseases. 2004 Apr 20
ACSM Recommendation for
Hypertension
40-70% of VO2max, i.e. 55-80% 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.
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
Rehabilitation in Coronary Heart
Disease
• Mainly endurance training
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at an intensity of 50 (-60) -75% of symptom-limited
VO2max (or heart rate reserve, which is the difference
between maximal and resting heart rate) for 30 minutes 3-4
times weekly (minimum), full benefit is obtained with 5-6
times/week
Resistance training in addition
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at an intensity of 30-50% (up to 60-80%) of 1 RM (one
repetition maximum), 12-15 repetitions, 1-3 sets twice weekly
Recommendations for Patients With
Type 2 Diabetes
Exercise program:
Type: Aerobic
Intensity: 50-70% of maximum aerobic capacity
Duration: 20-60 minutes
Frequency: 3-5 times per week
Avoid complications
Warm up and cool down
Careful selection of exercise type and intensity
Patient education
Monitoring of blood glucose by patient and overall program by medical
personnel
Physical Activity/Exercise and Diabetes; Diabetes care, vol. 27, supplement 1, January 2004
Recommendations for Patients With
Type 2 Diabetes
3. Compliance:
Make exercise enjoyable
Convenient location
Positive feedback from involved medical personnel
and family
Physical Activity/Exercise and Diabetes; Diabetes care, vol. 27, supplement 1, January 2004
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Hypertension
• Monitor blood pressure before, during, and after exercise
• Unusually high blood pressures (>190mmHg systolic) during
low-level 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
Rehabilitation in Coronary Heart
Disease
• Mainly endurance training
•
•
at an intensity of 50 (-60) -75% of symptom-limited
VO2max (or heart rate reserve, which is the difference
between maximal and resting heart rate) 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
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End