Exercise Prescription in Patients with Different Combinations of Cardiovascular Disease Risk Factors

Cardiovascular disease (CVD) is a group of conditions primarily involving the heart, blood vessels and others which are a result of poor blood supply. Examples include ischemic heart disease, heart failure, peripheral arterial disease and stroke. Over the past decade, CVD has become the single largest cause of death worldwide. Exercise is a prominent treatment modality which aims to reduce known risk factors of CVD such as obesity, hypertension, dyslipidaemia and T2DM. 

Despite knowing exercise reduces ‘risk of CVD’ it can be complicated knowing what exercise and what specific plans to advise for patients with multiple risk factors. What commonly occurs is ‘generic advice’ such as aerobic exercise adhering to PA guidelines of at least 150 minutes of aerobic exercise per week typically spread over 3-5 days. Is this suitable for everyone, and what if someone has multiple risk factors. What is best for them and what should be done?

This is the question the ‘EXPERT Working Group’ has answered with the creation of a new tool to aid clinicians. The ‘EXPERT Tool‘ is a digital training and decision support system which has been launched to improve exercise prescription for patients with CVD risk. More specifically for those in different risk subpopulations. The Working Group have produced a consensus statement which summarises the available high quality evidence into clinician advice based on each subgroup. A few of the subgroups have been summarised below.

Obesity

Definition: BMI >30kg/m2 or a waist circumference >94cm in Men and >80cm in Women.

Aim of Exercise: to lower fat tissue as much as possible.

What Works: Calorie restriction + aerobic exercise over 6 months in which there is a weekly increase in calorie intake as well as exercise volume. The ideal exercises to include in a plan is moderate-intensity exercises such as rowing and cross-training. The addition of strength training is poorly supported by evidence.

Safety Considerations: Obese individuals are prone to overuse symptoms due to large mechanical loads and altered biomechanics. A thorough MSK assessment should take place prior to adopting new exercises. The best way to reduce risk is to gently progress training volume and low-weight bearing exercises initially.

Hypertension

Definition: Systolic BP >140 mmHg +/- Diastolic BP >90 mmHg.

Aim of Exercise: Reduce BP <140 systolic.

What Works: Mixture of aerobic and dynamic resistance exercise for at least 30 mins/day (continuosly or intermittently in bouts for at least 10 minutes) at least 5 days/week.

The aerobic exercise should be at 40-60% of HrR. The dynamic resistance training is performed at 50-70% of 1RM with 8-10 exercises for large muscle groups initially 1 set building to 2 & 3.

Safety Considerations: Patients should be informed about the prodromal symptoms of cardiac disease such as dizziness, chest pain, malaise and abnormal breathing and they should seek immediate medical care if symptoms develop. Depending on the level of risk of the individual, regular reviews by the clinician is advised. Intensive heavy weight lifting (which often appears as dynamic) should be avoided along with holding breath which exercising. If resting systolic BP >160 mmHG high intensity exercise should be avoided and a medical review should take place, the same for systolic BP >250 mmHG rises during training. In this second case exercise should be stopped immediately and medical advice sought.

High & Low LDL

Definition: This can be very complicated, in a nut shell it is anyone with an abnormal amount of lipids

Aim of Exercise: Lower LDL <100 mg/dl for high-risk patients or <70 mg/dl for very high-risk individuals.

What Works: Resistance training targeting at least 5 large muscle groups, with 8-10 reps at 70-85% of 1RM for 3 sets. This should gradually be increased from baseline strength. This can be combined with moderate-intensity exercise with a calorific expenditure of >900 calories per week.

Safety Considerations: There isn’t a lot of evidence investigating safety precautions for this patient group however they may have some of the other risk factors and therefore these should also be considered.

The statement considered other risk factors such as T1 and T2 DM. Please read the full text to discover what the statement said.

Medication Considerations

For those patients taking beta-blockers, there will be an altered HR-Workload relationship which may affect determination of intensity. Other medications to be aware of are alpha-blockers and vasodilators which can lead to increased decreases in BP after exercising at high intensities, emphasis should be on cool-down phases for these patients. Also caution should be shown when exercising whilst taking statins due to the presence of myopathy. If patients exhibit signs of muscle pain / ache that appears unusual they should seek the prescribers advice.

General Advice

Begin exercise at a low intensity and build up slowly and in line with physical adaptations made. Everyone will be different and monitoring parameters like HR and exertion are important.

Conclusion

With the introduction of the EXPERT Tool clinicians will be able to move away from generic exercise advise and towards a more specific individualised approach and feel confident in making it safe and effective.

Pharmacology and Physiotherapy

This online course will review the effects, side effects, potential drug interactions and how these will influence ideal physical therapy management with a specific focus on antidepressants and exercise.

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