Exercise & Medicine
a practical guideline on daily clinical practice
with special focus on hypertension, diabetes and ischemic heart disease
Dr. Wong Bun Lap Bernard
Specialist in Cardiology
Genius is one percent
inspiration,
Ninety-nine percent
perspiration
~ Thomas Alva Edison 1847-1931
Interesting Definitions
Exercise (ek’ser-siz)
– the performance of physical exertion for
improvement of health or the correction of
physical deformity.
~Dorland’s Illustrated Medical Dictionary 27th edition, 1988’
Interesting 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
muscles that results in energy expenditure
beyond resting expenditure.
~ Richard C Pasternak, Braunwald’s Heart Disease,
A textbook of cardiovascular medicine, 7th Edition 2005’
Heart Disease
A 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 Disease
A 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 History of Cardiac
Rehabilitation (US)
1912
1912 – 1950
1951
1951-1960s
1964
1971
Herrick J.B. Association of American Physicians
Modern Concept of coronary thrombosis and
myocardial infarction (MI)
Lewis T
Absolute bed rest 6-8 wks with total nursing care
to prevent further ischemic, LV aneurysm, ventricular
rupture, arrhythmia, recurrent MI, sudden cardiac death
Levine SA & Lown B
Encourage pt to sit 1-2 hours from D1 of MI to avoid
deconditioning
Practices varies
Bed rest 1day – 4 weeks
Hospitalization 2-6 weeks
WHO: Rehabilitation of Patients with Cardiovascular
Diseases. (Technical report Series No 270) Geneva
Wenger NK, Gilbert C., Skoropa M.; Cardiac conditioning after
myocardial infarction. An early intervention program. J. Card.
Rehabil2:17, 1971
The Benefits of Exercise
Primary 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 Exercise
Primary 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 Exercise
Secondary Prevention
Physical activity with 1000kcal/wk
–
20-30% ↓ all cause mortality1
For patients without revascularization
–
Exercise training improves SBP, angina symptoms and
exercise 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
Belardinelli R, Paolini I, Cianci G, et al: Exercise training intervention after coronary angioplasty:
The ETICA trial. J Am Coll Cardiol 37:1891, 2001
3.
Mechanisms
for
Morbidity and Mortality reduction
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•
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•
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•
1.
2.
5mmHg ↓SBP in HT patients1
↓TG
↑HDL
LDL molecular improvement
↓58% of DM incidence2
↓HBA1C in DM patients
↓ CRP, plasma fibrinogen, plasminogen activator inhibitor-1 level,
blood viscosity, platelet count, factor VIII, IX, von Willebrand factor
↑tPA
Whelton Sp, Chin A, Xin X, He J: effect of aerobic exercise on blood pressure: A metaanalysis
of randomized controlled trials. Ann Intern Med 136:493, 2002
Knowler WC, Barrett-Connor E, Fowler SE, et al:Reduction in the incidence of type 2 diabetes
with lifestyle intervention or metformin. N Engl J Med 346:393, 2002
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.
2.
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
Ades PA: Cardiac rehabilitation and secondary prevention of coronary heart disease. N Eng J Med 345:892,
2001
Principles of Exercise Prescription
1. Cardiology assessment, management &
stabilization of patient
2. Treadmill exercise stress test initial
assessment
3. Tips on Exercise prescription
4. Regular clinical follow-up for exercise
progress and symptoms reassessment
5. Regular treadmill exercise stress test
reassessment
Principles of Exercise Prescription
1. Cardiology assessment, management &
stabilization of patient
– Diagnosis
– Management
•
•
•
•
Acute
Chronic
Medical
Interventional
Principles of Exercise Prescription
1.
Cardiology assessment, management & stabilization of patient
–
Stabilization of patient and avoid:
•
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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 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
Principles of Exercise Prescription
2.
•
-
Treadmill exercise stress test initial assessment
Functional capacity assessment
Activity of daily living:
-
Lying quietly
Sitting: light activity
Walking from house to car/bus
Watering plants
Taking out trash
Walking the dog
Household tasks, moderate effort
Vacuuming
1.0METS
1.5METS
2.5METS
2.5METS
3.0METS
3.0METS
3.5METS
3.5METS
Principles of Exercise Prescription
2.
•
Treadmill exercise stress test initial assessment
Functional capacity assessment
–
Leisure activities
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Playing piano
Golf (with cart)
Walking (2mph)
Ballroom Dancing
Walking (3mph)
Cycling (Leisurely)
Golf (without cart)
Swimming (slow)
Walking (4mph)
Tennis (doubles)
Ballroom Dancing (fast)
Cycling (mod)
Hiking (no load)
Swimming
Walking (5mph)
Jogging (10min/mile)
Rope skipping
Squash
2.3METS
2.5METS
2.5METS
2.9METS
3.3METS
3.5METS
4.4METS
4.5METS
4.5METS
5.0METS
5.5METS
5.7METS
6.9METS
7.0METS
8.0METS
10.2METS
12.0METS
12.1METS
Principles of Exercise Prescription
3. Tips on Exercise prescription
A. Endurance training
•
•
Frequency: 3-7d/wk
Intensity:
•
•
•
•
65-85% of Max HR on treadmill exam
10 beats below ST depression, arrhythmia, Sx
20% above resting HR
Duration: 20-60mins
Principles of Exercise Prescription
3. Tips on Exercise prescription
A. Endurance training
•
Modality:
•
•
•
•
•
•
•
Walking, jogging, running,
Stairclimber
Cycling
Rowing
Cross-country ski machine
Swimming
aerobics
Principles of Exercise Prescription
B. Resistance training
– Frequency: 2-3d/wk
– 1-3 sets of 8-15 RM for each muscle group
– Increase weight slowly, 2-5 lbs/wk for UL & 510 lbs/wk for LL)
– Start only 2-3 wks after myocardial infarction
– Pure isometric exercise is not recommended
Principles of Exercise Prescription
4.Regular clinical follow-up for exercise progress
and symptoms reassessment
– To assess the cardiovascular status
• Chest pain, dizziness, LOC, palpitation, dypsnoea, appetite,
BO/PU, resting BP & P.
– To assess the progress of exercise tolerance
– Advancing the prescription according to
• The improvement in fitness
• To increase in steps of 5 – 10% of max. heart rate
• To maintain ~ 85% of max. heart rate during the whole
exercise session
Principles of Exercise Prescription
5. Regular treadmill exercise stress test
reassessment
– Ascess the impact of medical and exercise
management
– Provide feedback to patient
– Plan of future management
Tips on Hypertensive patients
• Avoid pure isometric exercise
• Side effect of Anti-HT medications:
– Beta-blockers: lethargy
– Diuretics: dehydration
– ABCD: Post-exertional BP↓
• Control BP first →Exercise Second!
• Treadmill is a very good test for BP trend
on exertion
Tips on DM patients
Pre- exercise treadmill Stress test was indicated:
1. Age > 40
2. Age > 30 with
–
–
–
–
–
–
DM > 10 yrs
HT
Smoking
Hyperlipidemia
Retinopathy
Nephropathy (microalbuminuria)
3. Coronary Artery Disease
4. CVA
5. Peripheral vascular disease
6. Autonomic neuropathy
7. Renal Failure
Tips on DM patients
Type I DM (IDDM)1
– Aerobic exercise
– Low – moderate intensity
– 20-60mins/day
– 4 – 6 days per week
Tips on DM patients
Type II (NIDDM)
– Aerobic exercise
• Moderate intensity
• 150mins/wk (moderate)
• 3days/wk
– Resistance-training exercise
•
•
•
•
•
Moderate intensity
3 sets of 8-10 repetitions
All major muscle groups
Weight cannot be lifted > 8-10times
3days/week
Tips on DM patients
• 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 4.45.5mmol/L2
Tips on DM patients
• Avoid late evening exercise →nocturnal
hypoglycemia
• prevent injury
– peripheral neuropathy
– Lower extremity care
– Swimming/cycling/rowing better than walking/jogging
• Autonomic neuropathy
– Blunted BP/P response
– Postural hypotension
– Heat stroke
Tips on DM patients
•
•
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
Barry A. Franklin, Mitchell H. Whaley, & Edward T. Howley, et al. (2000). American College of Sports
Medicine’s Guidelines for exercise testing and presciption, 6th ed. Baltimore: Lippincott Williams & Wilkins
Birrer, Richard B., Sedaghat, & Vahid-David et al. (May 2003). Exercise and Diabetes Mellitus, Physician &
Sports Medicine, 31(5).
American Diabetes Association. (January2004). Physical activity/Exercise and Diabetes, Diabetes Care, 27,
Supplement 1.
2.
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4.
The greatest mistake physicians make is
that they attempt to cure the body without
attempting to cure the mind; yet the mind
and body are one and should not be treated
separately!
~ Plato 427-347 BC
In a Nutshell
DIY!
DIY !
DIY !
DIY!
DIY!
DIY!
DIY!
DIY!