EXERCISE PRESCRIPTION IN PATIENTS WITH
CARDIOVASCULAR DISEASE
LEANDRO C. BONGOSIA, MD, FPCP, FPCC, FACC
Definition of terms
Physical Activity – any bodily movement produced
by contraction of the skeletal muscle that results in
energy expenditure
Exercise – planned, structured, and repetitive
bodily movement done to improve or maintain one
or more components of physical fitness
Definition of terms
Physical Fitness – an attained set of attributes
that relate to the ability to perform physical
activity. This includes cardiorespiratory
endurance, muscle power, balance, flexibility
and body composition.
Singh, J Gerontology 2002
Dionne, Elsevier 2003
Why the need to exercise?
• Regular exercise performed at low to moderate
intensity is associated with improvements in risk
factors.
• Improvement in functional class and increased
feeling of independence leading to a higher quality
of life
• Improvements in physical function have been seen
after short term exercises of 3 to 4 months with
interventions that include both aerobic and
resistance.
Mazzeo, J Sports Med 2001
Hessert, J of Fam Med 2005
Dionne, Elsevier 2003
Rate-pressure product
Exercise training and myocardial oxygen
consumption
Pre-training
Post-training
Work rate
Ades PA, et al. Circulation 2006;113:2706-2712
Exercise prescription
• The exercise prescription is ideally based on
the results of a maximal incremental exercise
test.
• However, because of the muscular specificity
of exercise testing and training, the mode of
the exercise test should be tailored.
Purpose of Exercise Prescription
• To provide a safe and effective program
• To define individual patient guidelines by
describing frequency, intensity , duration and
mode of exercise
Theoretical relation between health and fitness
benefits and the amount or intensity of exercise:
Benefits
Health
Fitness
Quantity of exercise
Guidelines for Exercise Prescription
• ACSM and CDC recommends 30 minutes of
moderate intensity physical activity on most
days of the week.
• Priority should be given to exercises that
enhance everyday movements and an
individual’s ability to function independently.
Mazzeo, J Sports Med 2001
Hessert, J of Fam Med 2005
The Process of Developing an Exercise
Prescription
Assessment
Interpretation
Prescription
Mode
Progression
Precautions
Frequency
Duration
Intensity
Components of Exercise Prescription:
A. Mode
B. Intensity
C. Duration
D. Frequency
E. Progression
Components of Exercise Prescription
A. Mode
• Endurance exercise - uses large muscle
groups over prolonged periods on activities
that are rhythmic and aerobic in nature
• Should avoid high impact activities
particularly early on in the exercise program
Components of Exercise Prescription
Mode(cont.)
Resistance Training:
- Does little to increase VO2 max
- Effective method for muscle strength and endurance
- Prevents and manages a variety of chronic medical
conditions
- Enhance independence in elderly patients
- Attenuates rate - pressure product when lifting any
given load
Components of Exercise Prescription
B. Intensity
For Cardiac Patients: 40% - 60% VO2max
“Above a minimal level required to induce a training
effect but below the metabolic rate that evokes
abnormal signs or symptoms”
Components of Exercise Prescription
B. Intensity (cont.)
1. Establishing a training/target HR
2. Using MET method
3. Rate of Perceived Exertion
Training/Target HR Method
Percent (%) maximal HR

Calculates a fixed % of measured or estimated
heart rate (220-age)
 Examples: 1. HRmax = 120/min
60 % of 120 = 72/min
2. HRmax (estimated)
Age = 60 yrs.
220 – 60 =160
60% of 160 = 96
Training / Target HR Method
Heart Rate Reserve (Karvonen)
HRR = HRmax - HR rest
Karvonen Method = defines a HRR, multiplied by %
desired and adjusting for the resting HR
= (HRmax - HR rest) 40-80% + HR rest
Example:
HRmax = 150
HR rest = 70
HRR=150-70 = 80
If target is 60%, 80 x 0.6 = 48
HRR = 48 + 70 = 118
Components of Exercise Prescription
B. Intensity(cont.)
MET Method
- prescribes intensity by workload or activities
associated with MET values
Rate of Perceived Exertion
- particularly useful in patients where HR
response is blunted ( beta blocker tx or cardiac
transplant), AF, pacemakers with fixed rate.
Components of Exercise Prescription
C. Duration
20 to 60 minutes of continuous or intermittent
(minimum of 10-min bouts) aerobic activity
accumulated throughout the day
ACSM
Components of Exercise Prescription
D. Frequency
3 – 5 days/week
3 days/week ---- 60% – 80% HRR
ACSM
Components of Exercise Prescription
E. Progression
General Principle:
Increase in exercise every 1 to 3
weeks achieving 20 to 30 minutes of
continuous exercise before
prescribing additional increase in
intensity.
Five interacting elements of exercise
prescription
Warm up
- important for older adults prone
to musculoskeletal injuries and
cardiac events
- light movements simulating the
actual exercise activities.
Five interacting elements of exercise
prescription
Exercise Intensity
- low to moderate intensity initially
to improve emerging risk factors.
- later on moderate intensity exercises
should be emphasized.
MODERATE INTENSITY IS DEFINED AS
FOLLOWS:




55 to 70% of HR max (220 – age)
40 to 60% of HRR
40 to 60% of 208 – (0.7 x age)
Rate of Perceived Exertion at 12 to 13
Caloric Cost of Exercise
(METS x 3.5 x body weight in Kg/200=kcal/min
Example: Mr A. weighing 85 kg exercising at 8
mets on treadmill. How much calories shall
he expend for 30 min?
8 x 3.5 x 85/200 = 11.9 or 12 kcal/min x 30
Caloric cost per 30 min of exercise = 360 kcal
Balady GJ, Cardiology Clinics, Vol 19, No.3 Aug 2001
Five interacting elements of exercise
prescription
Duration
- this should be increased first prior
to increasing intensity
- 30 minutes per day
Frequency
- most or all days of the week
- if vigorous exercise is done,
should be done only 3x a week.
Five interacting elements of exercise
prescription
Type / Mode
- based on the fitness level
- exercises which can be incorporated into
everyday life instead of a structured activity
- enjoyable and minimal potential for injury
- results to better compliance
Mazzeo, J Sports Med 2001
Why the need to include resistance
training?
Sedentary individuals lose 20 to 40% of muscle
mass over the course of adult life. Muscle
mass cannot usually be maintained into old
age even with regular aerobic activities.
Appropriate progressive resistance training of
3 to 6 months was shown to increase muscle
strength by 40 to 150% and mass by 1 to 3 kg.
Singh, J Gerontology 2002
Restrictions of Resistance Training
•
•
•
•
•
Unstable angina
Uncontrolled HPN ( BP > 160/100)
Uncontrolled arrhythmias
Recent CHF
Severe Valvular Heart disease or hypertrophic
cardiomyopathy
Restrictions of Resistance Training
• Poor left ventricular function
• Inadequate functional capacity, less than
or equal to 5 METS (not an absolute
contraindication)
Division of an exercise program
1.
2.
3.
4.
Warm up
Pre-stretching
Dexterity
Resistance / wt.
bearing
5. Endurance
6. Balance
7. Cool Down
5 to 10 minutes
5 to 10 minutes
10 minutes
15 minutes
20 to 30 minutes
5 to 10 minutes
5 to 10 minutes
Hessert, J of Fam Med 2005
Summary of Exercise Prescription among
Patients with CVD
CVD
Intensity
Comments
Angina or
equivalent
40 - 50% of HRR
with necessary
adjustment to keep
upper HRR limit to
no more than 10
beats below
ischemic threshold
Consider prophylactic
NTG 15 min before
anticipated exertion
if symptoms limit
routine ADL’s or
ability to exercise
Shuler G, et al. Circulation 1992;86:1-11
Summary of Exercise Prescription among
Patients with CVD
CVD
Intensity
Comments
Myocardial
Infarction
PCI
40 – 85% of HRR
Achieve 1,500-2,000 kcal
of energy expenditure
thru activity each week
CABG or
Valve surgery
40-85% of HRR
Restrict upper body
movement until sternum
is healed (6 - 12 weeks)
Shuler G, et al. Circulation 1992;86:1-11
Summary of Exercise Prescription among
Patients with CVD
CVD
Intensity
Heart failure 40(50)-70% of HRR
Comments
If needed, initially guide
exercise intensity at 60%
of HRR and adjust duration
to 3 bouts of 10 min each
progressing to 30 - 40 min.
As patient progresses,
maintain upper rate below
ventilatory threshold
Summary of Exercise Prescription among
Patients with CVD
CVD
Pacemaker,
ICD, CRT
Intensity
10% below
activation
threshold
Comments
Avoid activities that stretch
the arms. After 8 weeks
nonballistic activities may
be resumed and ballistic
activities may be resumed
after 12 weeks
Shuler G, et al. Circulation 1992;86:1-11
Summary of Exercise Prescription among
Patients with CVD
CVD
CAD
Intensity
40-85% of HRR
Comments
To affect mortality,
frequency, duration and
intensity of training
should sum to yield a
weekly energy
expenditure of > 1,500
kcal/week
Shuler G, et al. Circulation 1992;86:1-11
Summary of Exercise Prescription among
Patients with CVD
Hypertension
- If BP is uncontrolled, avoid weight lifting
- Borderline HPN under medications: may
use light weights and avoid Valsalva
- 3 sets of 8 to 15 repetitions using major
muscle groups 3 to 4x a week
- Those on dialysis should have light
weights to promote the anabolic effects
Summary and Conclusion:
Guidelines for Exercise Rx for Cardiac Patients
(ACSM)
 Mode: Select rhythmical aerobic activities that can
be maintained continuously involving large muscle
muscle groups
 Intensity: Prescribe between 40 - 85% VO2max
 Duration: Schedule 20 to 60 minutes of continuous or
intermittent activity
 Frequency: Schedule exercise 3 to 5 days a week
 Progression: Progress every 1 to 3 weeks as tolerated with
increase in duration first