Physical Activity and
Cardiovascular Disease
ANDREAS PITTARAS MD
Survival of the Fittest
“…in the last 15 years, many
epidemiological studies have shown
an unequivocal and robust
relationship of fitness, physical
activity, and exercise to reduce
overall and CVD mortality.”
Balady JG, New Engl J Med 2002;346 (11):852-53
Coronary Heart Disease and
Physical Activity of Work
Morris JN, et al. Lancet 1953:2:1053-1120
Approximately 50% lower risk of CHD
in those with physically demanding (i.e.
mail carriers) vs those with sedentary
occupations (i.e. desk clerks).
Physical Activity and the Incidence of
Coronary Heart Disease
Powell KE, et al. Annu Rev Public Health 1987; 8:253-87
• 121 studies reviewed; 43 were included.
• The relationship between sedentary
lifestyle and increase risk of CHD is
likely to be causal.
Relative Risk for CAD
Ann Review Public Health 1987; 8:253-87
RR
3
2.4
2.5
2.1
2
1
0
1.9
Physical
Inactivity
SBP>150
mm Hg
TC>268
mg/dL
Smoking
>1 pack
Population Attributable Risk by Risk Factor
Population Attributable Risk (%)
50
40
30
20
10
0
TC
Inactivity
BP
Smoking
Obesity
Diabetes
It is Estimated that 250,000
Deaths/Year in the USA are
Attributable to Lack of
Regular Physical Activity
Siegel PZ, at al., Weekly Reports 1991
Physical Activity Status in
US Population
•
•
•
•
20% - 22% - Exercise Regularly
40% - 54% - Some Activity
24% - 40% - Sedentary
34% of pts are being counseled by
physicians to begin or continue
exercise.
AHA Position Statement
Circulation 1991:86(1):340-44
Physical inactivity an as independent
risk factor for the development of
CHD equal in status to the
traditional risk factors of HTN,
DM, Dyslipidemia and smoking.
Exercise Type ?
• Most information is derived from
aerobic exercise studies.
• Some evidence from occupational
studies support that repeated busts
of high energy output may offer
protection against premature
coronary mortality.
Dynamic/Isotonic Exercise
Low
Intensity
Aerobic
FFA as Fuel
High
Intensity
Anaerobic
CHO as Fuel
-Walking
-Jogging
-Cycling
Strength
Training
Physiologic Adaptations to Exercise
Training
• Chronic exercise of proper
intensity, duration and frequency
imposes a demand on the body.
• Consequently, the body makes
appropriate and specific changes
to accommodate the imposed
demand.
Cardiovascular Adaptations with
Aerobic Exercise
Decrease
Increase
• Rest HR & BP
• LV Chamber
• Rest & Exercise • EDV
RPP
• SV
• Exercise HR &
• CO
BP (abs. WL)
• VO2 max
• ESV
Cardiovascular Adaptations with
Anaerobic Exercise
No Change
No Change
• Rest HR & BP • LV Chamber ?
• Rest &
• EDV ?
Exercise RPP • SV
• Exercise HR & • CO
BP (abs. WL) • VO max
2
• ESV
LVH with Aerobic and Anaerobic Exercise
Aerobic
Anaerobic
Volume Load
Pressure Load
Diastolic Stress
Systolic Stress
New Fibers in Series
New fibers in parallel
Chamber size
Wall Thickness
Eccentric LVH
Concentric LVH
CHD Death in Norwegian Men 40-59
years of Age (N=2,014)
Lie et al. Eur Heart J ’85; 147-57
P<0.001
6
4
2
0
1
2
3
Fitness Quartiles
4
Cross-country
Skiers
CVD Death in Men (N=10,224)
Blair et al. JAMA1989; 262:2395-2401
150
100
50
0
<7
7
8
9
METs
10
11
12+
A Prospective Study of Walking as
Compared with Vigorous Exercise in
the Prevention of CHD in Women
Manson JE, et al., NEJM 1999;341:650-8
•
•
•
•
•
N = 72,488 Female Nurses
Age : 40 to 65 yrs old in 1986
Free of CVD or Cancer
Follow-up: 8 yrs
Incidence of Coronary Events: 645 Fatal
or Non-Fatal MI
Physical Activity & RR Adjusted for
Confounding Factors (N=72,488)
Mason JE, et al. NEJM:’99;341:650-8
1.2
P<0.001
1
0.88
0.81
0.8
0.74
0.66
0.4
1
2
3
Physical Activity Quintiles
4
5
Relative Risk for Coronary Events and
Walking Pace (n=72,488)
Mason JE, et al. NEJM:’99;341:650-8
Relative Risk
1.1
1
0.75
0.8
0.64
0.5
0.2
>30/mile
20-30/mile
Walking Pace (min/mile)
<20/mile
Relative Risk for Coronary Events and
Walking Time
Mason JE, et al. NEJM:’99;341:650-8
RR
1.1
1
0.88
0.9
0.78
0.7
0.7
0.65
0.5
<10 min
10 to 29
30 to 59
60 to 179
Minutes Walking/Wk
180 +
Relative Risk for Coronary Events and
Walking Time in Women (n=72,488)
Mason JE, et al. NEJM:’99;341:650-8
RR
1.1
1
0.88
0.9
0.78
0.7
0.7
0.65
0.5
<10 min
10 to 29
30 to 59
60 to 179
Minutes Walking/Wk
180 +
FINDINGS
• Brisk Walking for 100-200 min/week
at a Pace of <20 min/mile or <13
min/km. Reduces the Risk for
Coronary Events in Women by 30 to
40 Percent.
• Similar Caloric Expenditure Yields
Similar Reductions in Risk for
Coronary Events.
Are Exercise Health Benefits
Long-Lasting?
The Harvard Alumni study (n=16,936)
has shown that Ex-Varsity athletes
retained lower risk for CHD only if
they maintained a physically active
lifestyle throughout life.
Paffenberger et al., Am J Epidemiol 1978 108(3):161-175
Relative Risk of CHD & Aerobic Activity
in Men (N=51,529)
Tanasescu M, et al. JAMA:’02;288:1994-2000
RR
P<0.001
1.1
1
0.87
0.9
0.79
0.7
0.58
0.5
None
<30 min/Wk
30-60 min/wk
>60 min/wk
Survival for Fit & Unfit Men (n=9,777)
Blair et al, JAMA 1995;273:1093-97
Survival Probability
1
Unfit to Fit
0.9
0.8
0.7
44% Reduction in Risk
Unfit to Unfit
0.6
0
4
8
12
Follow-up Interval (yrs)
16
18
How Much Physical
Activity?
How Much Exercise?
• Not an easy Question
• Exercise Intensity, Duration and
Frequency must be considered, as well
as the interaction.
• Caloric expenditure is one approach.
• Intensity still may play an independent
role.
Physical Activity and All –Cause and
CVD Mortality in Women >65 yrs
Gregg EW, et al. JAMA’03;289:2379--86
Relative Risk
CVD
1
1
1
0.77
0.73
0.7
0.7
0.68
0.65
0.62
0.6
0.58
0.4
<163
163-503
504-1045
Kcal/wk
1046-1906
>1907
Weekly Energy Expanded and Relative
Risk of CHD in Men (n=7,337)
Relative Risk
Lee, I-Min et al. Circulation 2003;107:1110-16
1
*
0.9
0.84
0.8
0.7
0.5
<1000
1000-2499
Kcal/Week
2500+
Age-adjusted First MI Rates by
Physical Activity (n=16,963)
Paffenbarger et al., Am J Epidem. 1978;108(3):161-75
80
MI/10,000 person-yrs
Total
60
Non-Fatal
40
Fatal
20
0
<500
500-999
1000-1999 2000-2999 3000-3999
Physical Activity ndex in Kcal/ Week
4000+
Exercise Intensity and Relative Risk of
CHD in Men (n=7,337)
Relative Risk
Lee I-Min, et al. Circulation 2003;107:1110-16
1
0.98
0.9
0.75
0.6
<3 METs
3-6 METs
Kcal/Week
>6 METs
Exercise Intensity and Relative Risk of
CHD in Men (n=7,337)
Lee I-Min, et al. Circulation 2003;107:1110-16
Relative Risk
1
0.81
0.8
0.62
0.6
0.5
None
Moderate
Vigorous
Very Vigorous
Relative Risk of All-Cause Death
and Exercise Capacity
Myers J et al. NEJM 2002;346:793-801
RR of Death
5
4.5
4.2
4
3
3
2.4
2.2
2
1.7
1.7
1.25
1
1
1
<6 METS
6-7.9 METS
8-9.9 METS
10-12.9 METS
>13 METS
0
1
2
3
Quintiles of Exercise Capacity
4
5
Survival Curves for Normal and CVD
Patients According to Exercise Capacity
Myers J et al. NEJM 2002;346:793-801
Conclusions
Myers J et al. NEJM 2002;346:793-801
• Exercise Capacity is a more powerful
predictor of mortality for CVD than
other established risk factors.
• A linear reduction in mortality. For
each 1 MET increase in exercise
capacity, a 12%, decrease in mortality
was observed.
Exercise Capacity and Risk
of Death in Women
Gulati M, et al. Circulation 2003;108:1554-59
Hazard Ratio
of Death
3.5
3.1
2.5
1.9
1.5
2
FRS-adjust
1.6
1
0.5
<5 MET
5-8 MET
>8 MET
Age-adjust
Exercise Capacity and Risk of Death in Women
Conclusions
Gulati M, et al. Circulation 2003;108:1554-59
• Exercise capacity is a strong and
independent predictor of all-cause
mortality in asymptomatic women,
even after adjusting for traditional
cardiac risk factors.
• For each 1 MET increase in exercise
capacity, a 17%, decrease in
mortality was observed.
Exercise Threshold for Health Benefits
METs
<4 – 5
7
10
?
• Kcal/wk
Threshold
Fast walk
6 km/hr
500 - 1000
Running
10 km/hr
3,000
• 120 min/wk
• 240 min/wk
750 - 1050
1500-2100
1,500
3,000
• Intensity
Exercise in Patients with
Risk factors and/or Chronic
Disease
Age-Adjusted CVD Death Rates &CHD
Risk Factors (n=26,980)
Blair, et al. JAMA 1996
51
Death
Death
Rate
Rate
60
27.5
50
46
46 51
40
40
30
10
20
0
22.5
46
10
23
24
23Low
0
Low
13.2
27.5
24
20
12.6
4.2
Moderate
10
3.6
High
Cardiorespiratory Fitness
4.2
3.6
Moderate
High
2
12.61
6.5
22.5
3
3
13.2None
6.5
2
1
None
Relative Risk of All-Cause Death
and Exercise Capacity
Myers J et al. 2002;346:793-801
RR of Death
2.5
>8 Mets
5-8 Mets
<5 Mets
1.6
1.5
1.5
1.3
1
1.35
1.3
1
1
1
1
0.5
HTN
DM
Smoke
BMI>29
C>220 mg/dl
CV Events and Physical Activity in
Diabetic Women (n=5125)
Hu F, et al. Ann Intern Med :’01;134;96-105
Relative Risk
1.1
1
0.93
0.82
0.7
*
0.54
0.3
<1
1-1.9
2-3.9
Hours/Wk
4-6.9
Body Weight/
Obesity
Relative Risk for Physical Activity &
BMI, Adjusted For Risk Factors
Mason JE, et al. NEJM:’99;341:650-8
RR
1
1
>29
N=72,488
<29
0.88
0.82
0.79
0.8
0.71
0.69
0.65
0.65
0.64
0.6
0.54
0.4
1
2
3
Physical Activity Quintiles
4
5
FINDINGS
• Brisk Walking for 100-200 min/week
at a Pace of <20 min/mile or <13
min/km. Reduces the Risk for
Coronary Events in Women by 30 to
40 Percent.
• Similar Caloric Expenditure Yields
Similar Reductions in Risk for
Coronary Events.
Relative Risk of All-Cause Death
and Exercise Capacity
Myers J et al. 2002;346:793-801
RR of Death
5
CVD
Normal
4.5
4.2
4
3
3
2.4
2.2
2
1.7
1.7
1.25
1
1
1
<6 METS
6-7.9 METS
8-9.9 METS
10-12.9 METS
>13 METS
4
5
0
1
2
3
Quintiles of Exercise Capacity
Conclusions
Myers J et al. 2002;346:793-801
• Exercise Capacity is a more powerful
predictor of mortality for CVD than
other established risk factors.
• A linear reduction in mortality. For
each 1 MET increase in exercise
capacity, a 12%, decrease in mortality
was observed.
STROKE
The NIH Consensus Development
Panel on Physical Activity and CVD
JAMA ‘96;276:241-46
Data are inadequate to determine
whether stroke incidence is
affected by physical activity or
exercise training.
Physical Activity and Risk of Stroke in Women
Hu FB, et al , JAMA 2000;283:2961-67
•
•
•
•
N=72,488 Female Nurses with no CVD or
Cancer at Baseline
Age: 40-65 years
Follow-up: 8 years (560,087 person-years)
407 Strokes
• 258 Ischemic
• 67 Subarachnoid Hemorrhages
• 42 Intracerebral & 40 of Unknown type
Multivariate Relative Risk of Total Strokes
Relative Risk
1.1
P=0.005
0.9
1
0.98
0.7
0.82
0.74
0.66
0.5
1
2
3
MET Quintiles
4
5
Multivariate RR for Ischemic Strokes
Relative Risk
1
P=0.003
0.8
1
0.87
0.6
0.83
0.76
0.52
0.4
1
2
3
MET Quintiles
4
5
Multivariate Relative Risk of Total
Strokes by Walking Activity
Relative Risk
P=0.01
1
0.8
1
0.6
0.76
0.78
0.7
0.66
0.4
0-0.5
0.6-2.0
2.1-3.8
METS
3.9-10
10+
Multivariate Relative Risk of Ischemic
Strokes by Walking Activity
Relative Risk
p=0.02
1
0.8
1
0.6
0.77
0.75
0.69
0.6
0.4
0-0.5
0.6-2.0
2.1-3.8
METS
3.9-10
10+
RR of Total Strokes by Walking Pace
Relative Risk
1
1
Age-Adjusted
1
Multivariate
P<0.001
0.81
0.8
0.66
0.6
0.49
0.36
0.4
0.2
<2mph
2-2.9 mph
3+ mph
Relative Risk of Hemorrhagic
Strokes by Walking Pace
Relative Risk
1
1
0.9
P<0.02
Age-Adjusted
P<0.06
Multivariate
0.82
0.73
0.7
0.57
0.5
0.5
0.3
<2mph
2-2.9 mph
3+ mph
Findings and Conclusions
Sedentary women who became active in
middle to late adulthood had significantly
lower risk for:
• Total Strokes :
27% - Age-adjusted
20% - Multivariate
• Ischemic Strokes:
38% - Age-adjusted
30% - Multivariate
Findings and Conclusions
•
•
Walking pace is strongly associated
with risk of stroke, Independent of
the number of hours spent walking.
Comparable magnitudes of risk
reduction with equivalent energy
expenditures from walking and
vigorous activity.
Cardiac Function
HTN
Dyslipidemia
Physical
Activity
Body
Fat
DM Type II
??
Endothelial Function
Hypertension
Kokkinos P., et al.
Cardiology Clinics 2001;19(3):507-516
Average Reduction in BP:
Active: 10.5/7.6 mm Hg
Controls: 3.8/1.3 mm Hg
BP Changes with Exercise
Kokkinos ,Pittaraset al. NEJM 1995;333:1462-7
mm Hg
0
-2
-4
-6
-8
SBP
DBP
P<0.05
-10
16 weeks
32 weeks
BP Changes with Exercise
mm Hg
0
-2
-4
2 Wks
-6
2 Wks
-8
16 Wks
16 Wks
-10
-12
SBP
DBP
Relative Risk of All-Cause Death and
Exercise Capacity in Hypertensive Patients
RR of Death
Myers J et al. 2002;346:793-801
2.2
2
1.7
1.3
1.2
1
0.7
0.2
>8 MET
5-8 MET
<5 MET
LVMI at Baseline and 16 Weeks
Kokkinos, Pittaras et al. NEJM 1995;333:1462-7
* p<0.05
170
163
155
*
143
140
125
Baseline
16 weeks
Wall Thickness at Baseline and 16 wks
Kokkinos, Pittaras et al. NEJM 1995;333:1462-7
mm
15
* p<0.05
*
14
13
*
12
11
PW
IVS
Left ventricular hypertrophy
is a powerful and independent
predictor of cardiovascular
events in patients with and
without obstructive
coronary disease.
Ghali JK et al., 1992; Ann Intern Med 1992;117:831-36
Koren MJ et al., 1991; Ann Intern Med 1991;114:345-52
Casale PN, et al., Ann Intern Med 1986;105:173-78
LV Mass and Stroke
Odds Ratio
7
Unadjusted
Adjusted
6.14
6
5.49
5
4
2.8
2.72
3
2
2.5
1.59
1
1
1
0
1
2
3
Quartiles of LV Mass
4
LVH, Physical Activity and Risk of Stroke
Adjusted Odds Ratio
5
4.5
4
3.5
3
2.5
2
1.5
1
1.59
1.78
Total
Men
0.5
1.42
1.64
1.79
Women
40-60 yrs
>60 yrs
0
LVH, Physical Activity & Risk of Stroke
Odds Ratio
4
3.48
3
2
1
0.66
1
0.4
0
No LVH
LVH
SBP Following Aerobic Training
Kokkinos et al, AJC 1997
p<0.01
220
219
219
200
*
199
198
*
180
187
171
160
*
140
138
131
120
Rest
6-Min
9-Min
*
Peak
May mitigate the
hemodynamic load
during daily physical
activities.
Attenuate the
development and/or
progression of LVH.
Heart Failure
Skeletal Muscle
Atrophy
Muscular
Changes
Patient Adapts
Sedentary Lifestyle
Diminished
Aerobic Capacity
Cardiorespiratory
Changes
Neurohormonal
Changes
Kokkinos et al.. AHJ:140(1): 2000
All Cardiac Event Survival for HF
Patients
Belardinelli et al, Circulation ‘ 99;99:1173-82
1
Trained
Survival
0.8
0.6
0.4
Untrained
0.2
0
0
200
400
600
800
Time (Days)
1000
1200
1400
1600
Hospitalization for Heart Failure
Belardinelli et al, Circulation ‘ 99;99:1173-82
Survival probability
1
Trained
0.8
0.6
Untrained
0.4
0
200
400
600
800
Time (Days)
1000
1200
1400
1600
Cardiac Deaths for HF Patients
Belardinelli et al, Circulation ‘ 99;99:1173-82
1
Trained
Survival
0.8
0.6
Untrained
0.4
0.2
0
200
400
600
800
Time (Days)
1000
1200
1400
1600
Lipid &
Lipoprotein
Metabolism
Changes in Lipids & Lipoproteins with
Exercise and Diet in Men
Wood et al., NEJM 1991;325:461-6
% Change
20
Control
Diet
Diet+Ex
10
0
HDL-C
-10
TG
-20
-30
LDL-C
Changes in Lipids & Lipoproteins with
Exercise and Diet in Women
% Change
20
Wood et al., NEJM 1991;325:461-6
Control
Diet
Diet+Ex
10
0
TG
-10
-20
LDL-C
HDL-C
Is There A Dose-Response
Relationship?
A dose-response relationship
between HDL-C Levels and
weekly distance run or weekly
caloric expenditure is supported
by most studies.
HDL-C and Km Run/Week:
A dose-Response Relationship
Kokkinos P., et al. Arch Intern Med ‘95;155:415-20
mg/dL
N=2,906
*
p<0.001
56
53
*
53
51
49
47
46
0-3
4 to 10
11 to 16
Km/Week
17 to 22
23 to 32
33+
Is There An Exercise Threshold?
The exercise-induced changes in
lipid metabolism are likely the result
of the interaction among exercise:
Intensity, Duration, Frequency
and Length of Training.
It is also likely that an exercise
threshold exists for each of these
exercise components.
HDL-C and Weekly Distance
Kokkinos P., et al. Arch Intern Med ‘95;155:415-20
mg/dL
58
N=2,906
*
56
p<0.001
54
53
53
17-22
23-32
*
51
50
49
47
46
0-3
4 to 10
11 to 16
Km/Week
32+
Carbohydrate
Metabolism
The Association between Cardiorespiratory
Fitness and Impaired Fasting Glucose and
Type II DM
Wei M, et al., Ann Intern Med 1999;130:89-96
•
•
•
•
•
N = 8,633 Non-Diabetic Men
Age : 30 to 79 yrs old
7,511 Had Normal Fasting Blood Glucose
Follow-up: 6 yrs
149 Developed DM and 593 Developed
Impaired Fasting Glucose
Cardiorespiratory Fitness & Relative
Risk for Type II Diabetes
Wei M, et al. Ann Intern Med:1999;130:89-96
Relative Risk
p<0.001
3.7
3.5
2.5
1.7
1.5
1
0.5
Low
Fitness
Levels
Moderate
High
Cardiorespiratory Fitness & Relative
Risk for Impaired Fasting Glucose
Wei M, et al. Ann Intern Med:’99;130:89-96
Relative Risk
2
1.9
p<0.001
1.5
1.5
1
1
0.5
Low
Moderate
Fitness Levels
High
Cardiorespiratory Fitness & RR for Impaired Fasting
Glucose & Type II Diabetes in Women (n=338)
Relative Risk
4.85
p<0.001
5
4
2.7
3
2
1
1
0
Low
Moderate
Fitness Levels
High
Cumulative Incidence of Diabetes
Diabetes Prevention Program Research Group NEJM 346 (6) 393-403
Cumulative Incidence of DM (%)
40
Placebo
30
Metformin
20
Lifestyle
10
0
0.5
1
1.5
2
2.5
Follow-up Interval (yrs)
3
3.5
4
Plasma Fasting Glucose
Diabetes Prevention Program Research Group NEJM 346 (6) 393-403
Plasma Glucose (mg/dl
115
Placebo
110
Metformin
Lifestyle
105
100
0
0.5
1
1.5
2
Follow-up Interval (yrs)
2.5
3
3.5
4
Glycosylated Hemoglobin
Diabetes Prevention Program Research Group NEJM 346 (6) 393-403
Glycosylated Hemoglobin (%)
6.3
Placebo
6.1
Metformin
5.9
Lifestyle
5.7
0
0.5
1
2
Follow-up Interval (yrs)
3
4
Conclusions
•
Lifestyle changes and treatment with
metformin both reduced the incidence
of DM in persons at high risk.
•
Lifestyle intervention was more
effective than metformin.
Number of pts need to be treated for
3 yrs to prevent 1 case of DM is 6.9
for the lifestyle intervention and 13.9
for metformin.
•
Plasma Glucose Levels Before
& After Aerobic Training
Plasma Glucose (mg/dl)
Smutok et al. Metabolism ‘93
200
Pre-Training
180
160
*
*
140
Post-Training
120
100
0
30
60
90
Minutes After Glucose Ingestion
120
Plasma Glucose Levels Before
& After Strength Training
Plasma Glucose (mg/dl)
Smutok et al. Metabolism ‘93 ‘
200
Pre-Training
*
180
*
160
*
140
Post-Training
120
100
0
30
60
90
Minutes After Glucose Ingestion
120
Plasma Insulin Levels Before
& After Aerobic Training
Plasma Insulin (U/ml)
Smutok et al. Metabolism ‘93
105
Pre-Training
85
*
65
*
45
Post-Training
25
5
0
30
60
90
Minutes After Glucose Ingestion
120
Plasma Insulin Levels Before
& After Strength Training
Plasma Insulin (U/ml)
Smutok et al. Metabolism ‘93
105
Pre-Training
85
65
*
45
*
Post-Training
25
5
0
30
60
90
Minutes After Glucose Ingestion
120
Body Weight/
Obesity
Relative Risk for Physical Activity &
BMI, Adjusted For Risk Factors
Mason JE, et al. NEJM:’99;341:650-8
RR
1.2
1
N=72,488
>29
<29
1
0.88
0.82
0.79
0.8
0.71
0.69
0.65
0.65
0.64
0.6
0.54
0.4
1
2
3
Physical Activity Quintiles
4
5
Cardiorespiratory Fitness & CVD
Mortality in Men (N=25,714)
Relative Risk
5
Wei M, et al.JAMA:’99;282(16);1547-53
5
4.5
Fit
Unfit
4
3.1
3
2
1.5
1.6
1
1
0
(Normal)
BMI<25
BMI 25-29.9
(Over WT)
BMI 30+
(Obese)
CVD Mortality Predictors in Normal
WT Men (BMI 18.5-24.9)
Wei M, et al.JAMA:’99;282(16);1547-53
Relative Risk
4
3.1
3
2.6
2.1
2.2
2
1.4
1
0
TC
Smoke
DM
HTN
Low Fit
CVD Mortality Predictors in
Overweight Men (BMI 25-29.9)
Wei M, et al.JAMA:’99;282(16);1547-53
Relative Risk
5
4.5
3.9
4
3.3
3
3.4
2.8
2
TC
Smoke
HTN
DM
Low Fit
CVD Mortality Predictors in
Obese Men (BMI >30)
Wei M, et al.JAMA:’99;282(16);1547-53
Relative Risk
5.5
4.9
5
4.7
4.5
4.4
4.5
3.5
Smoke
HTN
TC
DM
Low Fit
These findings suggest that it is
as important for a clinician to
assess the fitness status of
patients, (especially obese) as it
is to assess blood glucose, TC,
HTN and smoking habits.
Exercise Recommendations
• Aerobic Activity 3-5 times/wk
•
•
•
•
Brisk Walk to Slow Jog
60% to 80% of PMHR
100 to 200 minutes/week
1200 to 2400 Kcal/Wk
LVMI at Baseline and 16 Weeks in
Patients with LVH
g/m2
170
Kokkinos, Pittaras et al. New Engl J Med 1995;333:1462-7
* p<0.05
163
*
150
143
Baseline
130
16 weeks
Wall Thickness at Baseline and 16 wks
Kokkinos, Pittaras et al. New Engl J Med 1995;333:1462-7
mm
15
14.9
* p<0.05
*
14
14
13.3
13
*
12.3
12
11
PW
IVS
How Much Physical Activity ?
•
•
•
•
•
Do something
Choose something you enjoy
Start Low & Progress Slowly
Increase duration by 1-2 min/wk
Be Consistent (2-5 times/week)
Goal: 100-200 minutes/week
Exercise Training is Governed
By Three Principles
•
Specificity
•
Overload
•
Reversibility
The Specificity Principle
Biological Systems will Make
Specific Adaptations to
Accommodate an Imposed
Demand !
SPECIFICITY
Aerobic
Anaerobic
• Long Duration (>10
min)
• Low Intensity
(<85% of PMHR)
• ATP via TCA Cycle
• FFA as Fuel
• Short Duration
(<5 min)
• High Intensity
( >90% of PMHR)
• ATP via Glycolysis
• CHO as Fuel
The Overload Principle
The performance of a Biological
System will Improve Only If the
Demand Imposed upon it is
Greater than the System is
Currently Accustomed.
Overload Principle
Frequency, Duration
and/or Intensity Must be
Increased Periodically.
Reversibility Principle
Training adaptations diminish
if stimulation (training)
is discontinued for a length of
time (12 -90 days).
Exercise Components
•
Frequency - Times/Wk
•
•
•
Duration
Intensity
Length
- Min/Session
- How Hard
- How many Wks
Frequency
•
2- 5 Times per Week
•
Exercise Every Other Day
•
Multiple Short Daily Sessions
(5-10 min) for Those with
Functional Capacity < 3 METS
Duration
•
20-60 Minutes/Session of
Continuous Aerobic Activity
•
Multiple Daily Sessions (~ 10 min)
for Those with Functional
Capacity < 3 METs.
•
Slow, Progressive Increase
Length of Training
Most Exercise Benefits Are
Evident Within 12 Weeks of
Consistent Training.
ACSM Exercise Intensity
Classifications
METS
%PMHR
• Low
<4
35-59
• Moderate
4-6
60-79
• High
>6
> 80
Exercise For Overweight
& Obese Patients
Exercise Modality that
does not Impose Excessive
Orthopedic Stress
(walking, stationary bike,
aquatic exercises).
Exercise Intensity for Patients
on Chronotropic Medications
Base Exercise intensity on
50% to 80% of Peak HR
achieved during ETT.
METs & Kcal for 30 Minutes of Select
Physical Activities (80-kg person)
Activity
•
•
•
•
•
•
Fast Walk
Jog (12 min/mile)
Bike (Stationary)
Health Club
Dancing
Stair Climbing
METs
5
8
7
7
5
5
Kcal
200
320
280
280
200
200
Contraindications &
Recommendations for Exercise
• Complete Physical
•
•
•
•
Resting BP< 190/105 mm Hg
Exercise BP <240/120 mm Hg
Exercise SBP drop >10 mm Hg (baseline)
Unable to complete 5 METs (ETT) or climb
a flight of stairs without severe SOB or
symptoms.
Gill et al. JAMA 2000
Relative Risk of Onset of MI with
Physical Activity
8
7
Willich et al. NEJM '93
6
Relative Risk
4
1.3
2
0
Inactive
Active
Relative Risk of Onset of MI with
Physical Activity
Mittleman et al. NEJM '93
107
90
Relative Risk
60
20
30
8
2.4
0
0
1 to 2
3 to 4
5+
The relative MI Risk for a 50-yr-old
Non-smoking, Non-diabetic Man
during a given hour is 1 in 1 million.
If this man were sedentary and
engaged in heavy physical exertion
during that hour, his risk would
increase 100 times or 1 in 10,000.
Framingham Heart Study