considerations for exercise testing & prescription: cardiac population cardiac wellness...

Considerations for Exercise Testing Considerations for Exercise Testing & Prescription: Cardiac Population& Prescription: Cardiac Population

Cardiac Wellness Institute of Calgary

Updated May 2010

Material to be CoveredMaterial to be Covered

ACSMACSM’’s Resource Manual for Guidelines for s Resource Manual for Guidelines for Exercise Testing and Prescription Exercise Testing and Prescription ‘‘RR’’ (6 (6thth Edition): Edition):

– Chapters 10, 18, 21, 22, 27, 35Chapters 10, 18, 21, 22, 27, 35 ACSMACSM’’s Guidelines For Exercise Testing And s Guidelines For Exercise Testing And

Prescription Prescription ‘‘GG’’ (8 (8thth Edition): Edition):

– Chapters 2, 3, 5, 6, 7, 9Chapters 2, 3, 5, 6, 7, 9

– Appendix CAppendix C ACSMACSM’’s Clinical Certification Review (3s Clinical Certification Review (3rdrd

Edition)Edition)

Health Appraisal, Risk Health Appraisal, Risk Assessment & Safety of Assessment & Safety of

ExerciseExercise

Guidelines - Chapter 2Guidelines - Chapter 2Resource Manual - Chapter 10Resource Manual - Chapter 10

Pre-ScreeningPre-Screening RationaleRationale

– Identify and exclude those with contraindicationsIdentify and exclude those with contraindications

– Identify those at risk for or have CVD, PD & MD and Identify those at risk for or have CVD, PD & MD and should participate in supervised exerciseshould participate in supervised exercise

– Detection of individuals at increased risk for disease Detection of individuals at increased risk for disease because of age, symptoms, risk factors who should because of age, symptoms, risk factors who should undergo further evaluationundergo further evaluation

– Recognize special needs that influence testing and Recognize special needs that influence testing and programming proceduresprogramming procedures

Figure 2.3-G: Logic model for risk stratificationFigure 2.3-G: Logic model for risk stratification– Aids in determining risk stratification and the need for Aids in determining risk stratification and the need for

medical clearancemedical clearance

Pre-ScreeningPre-Screening

Self Administered Screening:Self Administered Screening:– PAR-Q (Figure 2.1-G)PAR-Q (Figure 2.1-G)

– AHA/ACSM Health Fitness Preparticipation Screening AHA/ACSM Health Fitness Preparticipation Screening questionnaire (Figure 2.2-G)questionnaire (Figure 2.2-G)

Professionally Guided ScreeningProfessionally Guided Screening– Review of detailed medical history and specific risk Review of detailed medical history and specific risk

stratification (table 2.1-2.3-G)stratification (table 2.1-2.3-G)

– Detailed recommendations for physical activity, Detailed recommendations for physical activity, medical examination, exercise testing, and physician medical examination, exercise testing, and physician supervisionsupervision

Initial ACSM Risk Initial ACSM Risk StratificationStratification

Table 2-1 (p.23-G): Table 2-1 (p.23-G): – Low risk:Low risk: Asymptomatic men and women who have Asymptomatic men and women who have

≤1 CVD risk factor from table 2.3≤1 CVD risk factor from table 2.3

– Moderate risk:Moderate risk: Asymptomatic men and women who Asymptomatic men and women who have ≥2 risk factors from table 2.3have ≥2 risk factors from table 2.3

– High risk:High risk: Known CVD, PD, or MD or one or more Known CVD, PD, or MD or one or more signs or symptoms from table 2.2signs or symptoms from table 2.2

Case StudyCase StudyRisk StratificationRisk Stratification

35 year old normotensive asymptomatic male35 year old normotensive asymptomatic male Exercises 3X/wkExercises 3X/wk LDL 2.8mmol/L HDL 1.1mmol/LLDL 2.8mmol/L HDL 1.1mmol/L Continues to smoke 1pack/day even though his Continues to smoke 1pack/day even though his

father died of MI at 40father died of MI at 40

Risk stratification: MODERATE

49 year old hypertensive sedentary female49 year old hypertensive sedentary female WC = 105cmWC = 105cm Total cholesterol = 5.7mmol/L HDL=0.6mmol/LTotal cholesterol = 5.7mmol/L HDL=0.6mmol/L Shortness of breath at rest, exacerbated by Shortness of breath at rest, exacerbated by

ADLADL’’ss

Risk stratification: HIGH


45 year old non smoking male45 year old non smoking male Exercising 5X/wkExercising 5X/wk Total cholesterol = 4.2mmol/LTotal cholesterol = 4.2mmol/L BMI = 23.4kg/mBMI = 23.4kg/m22

Resting BP = 110/68mmHgResting BP = 110/68mmHg

Risk stratification: MODERATE


Risk Stratification for Risk Stratification for Cardiac PatientsCardiac Patients

Box 2.3-G (AACVPR)Box 2.3-G (AACVPR)Box 2.2-G (AHA)Box 2.2-G (AHA)

Low Risk Stratification for Low Risk Stratification for Cardiac PatientsCardiac Patients (AACVPR) Box 2.3-G(AACVPR) Box 2.3-G

Exercise test findings (All must be present):Exercise test findings (All must be present): Normal hemodynamics with exercise & recoveryNormal hemodynamics with exercise & recovery Absence of complex ventricular dysrhythmias Absence of complex ventricular dysrhythmias

with exercise or recoverywith exercise or recovery Asymptomatic with absence of AP with exercise Asymptomatic with absence of AP with exercise

or recoveryor recovery

FunctionalFunctional capacity capacity 7METs 7METs

Low Risk Stratification for Low Risk Stratification for Cardiac Patients ContCardiac Patients Cont’’dd (AACVPR)(AACVPR)

Non-exercise test findings:Non-exercise test findings: LVEF LVEF 50% 50% No resting complex ventricular dysrhythmiasNo resting complex ventricular dysrhythmias Uncomplicated MI or revasc procedureUncomplicated MI or revasc procedure Absence of CHFAbsence of CHF Absence of signs and symptoms of Absence of signs and symptoms of

post-event/post-procedure ischemiapost-event/post-procedure ischemia Absence of clinical depressionAbsence of clinical depression

Moderate Risk StratificationModerate Risk Stratification

Exercise test findings (One or more):Exercise test findings (One or more):−Presence of angina or other significant Presence of angina or other significant

symptomssymptoms

−Mild to moderate level of silent ischemia Mild to moderate level of silent ischemia during test or recoveryduring test or recovery ST depression <2mm from baselineST depression <2mm from baseline

−Functional capacity <5 METsFunctional capacity <5 METs

−Non-exercise test findings:Non-exercise test findings:

−Rest LVEF 40 - 49%Rest LVEF 40 - 49%

High Risk StratificationHigh Risk Stratification

Exercise test findings:Exercise test findings:− Complex dysrhythmias with exercise or recoveryComplex dysrhythmias with exercise or recovery

− Presence of angina or other significant symptoms at low Presence of angina or other significant symptoms at low levels of exertion levels of exertion

− Presence of abnormal hemodynamics with exercise & Presence of abnormal hemodynamics with exercise & recoveryrecovery

− High level of silent ischemia during test or recoveryHigh level of silent ischemia during test or recovery ST depression >2mm from baselineST depression >2mm from baseline

High Risk StratificationHigh Risk Stratification

Non-exercise test findings:Non-exercise test findings:

− Rest LVEF Rest LVEF 40%40%

− History of cardiac arrest or sudden deathHistory of cardiac arrest or sudden death

− Complex dysrhythmias at restComplex dysrhythmias at rest

− Complicated MI or cardiac surgery Complicated MI or cardiac surgery

− Presence of CHFPresence of CHF

− Signs and symptoms of post-event/post-procedure Signs and symptoms of post-event/post-procedure ischemiaischemia

− Presence of clinical depressionPresence of clinical depression

AHA Risk StratificationAHA Risk Stratification Box 2.2-GBox 2.2-G

Cardiac patients (Classes B,C,D):Cardiac patients (Classes B,C,D):– Class B:Class B: presence of known, stable CVD with low risk presence of known, stable CVD with low risk

for complications with vigorous exercise, but slightly for complications with vigorous exercise, but slightly greater than for apparently healthygreater than for apparently healthy

– Class C:Class C: moderate to high risk for cardiac moderate to high risk for cardiac complications during exercise and/or unable to self-complications during exercise and/or unable to self-regulate activity or understand recommended activity regulate activity or understand recommended activity levellevel

– Class D:Class D: unstable disease with activity restriction unstable disease with activity restriction

AHA Risk StratificationAHA Risk Stratification

Provides:Provides:– DiagnosesDiagnoses

– Clinical characteristicsClinical characteristics

– Activity guidelinesActivity guidelines

– Supervision requiredSupervision required

– EKG and BP monitoring recommendationsEKG and BP monitoring recommendations

Does not consider comorbiditiesDoes not consider comorbidities

Exercise TestingExercise Testing

Guidelines - Chapters 3, 5 & 6 Guidelines - Chapters 3, 5 & 6 Resource Manual - Chapters 18, 21 & 22Resource Manual - Chapters 18, 21 & 22

Pre-Test EvaluationPre-Test Evaluation

Medical history (Box 3.1-G)Medical history (Box 3.1-G) Physical exam (MD) (Box 3.2-G)Physical exam (MD) (Box 3.2-G) Laboratory tests by level of risk (Box 3.3-G)Laboratory tests by level of risk (Box 3.3-G) Blood pressure evaluation (Table 3.1G)Blood pressure evaluation (Table 3.1G)

– SBP SBP 120mmHg; DBP 120mmHg; DBP 80mmHg80mmHg

Cholesterol targets (Table 3.2-G)Cholesterol targets (Table 3.2-G)

Contraindications to Exercise Contraindications to Exercise TestingTesting

Box 3.5-G Risk: Benefit ratioBox 3.5-G Risk: Benefit ratio Absolute contraindicationsAbsolute contraindications

– Not to be tested until condition(s) stabilize/treatedNot to be tested until condition(s) stabilize/treated

– May not apply post MI May not apply post MI

Relative contraindicationsRelative contraindications– Careful evaluation risk/benefit ratioCareful evaluation risk/benefit ratio

Non-diagnostic tests Non-diagnostic tests –– LBBB, LVH LBBB, LVH– Testing useful for exercise prescription purposes, Testing useful for exercise prescription purposes,

assess hemodynamic response, arrhythmiaassess hemodynamic response, arrhythmia

Pre-Test ProceduresPre-Test Procedures

Obtain informed consentObtain informed consent Patient instructionsPatient instructions

– No food, alcohol, caffeine, tobacco for 3 hoursNo food, alcohol, caffeine, tobacco for 3 hours

– Adequate restAdequate rest

– Accompaniment Accompaniment

– Clothing recommendationsClothing recommendations

– Diagnostic tests: no medsDiagnostic tests: no meds

– Non-diagnostic tests: on medsNon-diagnostic tests: on meds

– List of medicationsList of medications

– Ample fluidsAmple fluids

Clinical Exercise TestingClinical Exercise Testing Diagnostic exercise testingDiagnostic exercise testing

– Age and genderAge and gender

– Symptomatic individualsSymptomatic individuals

– Asymptomatic: when multiple RF presentAsymptomatic: when multiple RF present

– Starting vigorous exercise programStarting vigorous exercise program

– Occupational settingOccupational setting

Assess disease severity & prognosisAssess disease severity & prognosis Post MI to make decisions about therapy & Post MI to make decisions about therapy &

safety in performing ADLsafety in performing ADL’’ss Functional TestingFunctional Testing

Clinical Exercise Testing Clinical Exercise Testing Other ConsiderationsOther Considerations

ModalityModality Protocol Protocol HR & BP measurement during testHR & BP measurement during test EKG monitoringEKG monitoring RPE, Dyspnea, Anginal scalesRPE, Dyspnea, Anginal scales Gas exchange & ventilatory responsesGas exchange & ventilatory responses Blood gasesBlood gases Frequency for monitoring (Table 5-2)Frequency for monitoring (Table 5-2) Indications for termination (Box 5-2)Indications for termination (Box 5-2) Post Exercise PeriodPost Exercise Period

Clinical Exercise TestingClinical Exercise TestingOther ConsiderationsOther Considerations

SupervisionSupervision– Expect acute MI & cardiac arrest to occur at Expect acute MI & cardiac arrest to occur at

combined rate of 1/2500 testscombined rate of 1/2500 tests

– Physician supervised (or immediately available), with Physician supervised (or immediately available), with experienced medical support & supplies to deal with experienced medical support & supplies to deal with emergencyemergency

– Cognitive skills to supervise tests (Box 5-3)Cognitive skills to supervise tests (Box 5-3)

Exercise Testing with ImagingExercise Testing with ImagingResource - Chapter 22Resource - Chapter 22Guidelines - Chapter 5Guidelines - Chapter 5

Exercise Echocardiography Exercise Echocardiography Exercise Nuclear ImagingExercise Nuclear Imaging Pharmacological Stress TestingPharmacological Stress Testing Electron Beam Computed TomographyElectron Beam Computed Tomography

Interpretation of Clinical Test Interpretation of Clinical Test DataData

Purpose: Diagnosis vs PrognosisPurpose: Diagnosis vs Prognosis– Quantitative measure of:Quantitative measure of:

Exercise tolerance (VOExercise tolerance (VO22 peak) peak)

Hemodynamics (SBP, DBP, HR)Hemodynamics (SBP, DBP, HR) Associated change(s) in heart function (EKG)Associated change(s) in heart function (EKG) Limiting clinical s/sLimiting clinical s/s Gas exchange and ventilatory responsesGas exchange and ventilatory responses

Clinical significance (Box 6-1)Clinical significance (Box 6-1)

ECG Responses to ECG Responses to Exercise TestingExercise Testing

Guidelines - Appendix C, Chapter 6Guidelines - Appendix C, Chapter 6Resource - Chapter 27Resource - Chapter 27

EKG WaveformsEKG Waveforms Normal Responses with ExerciseNormal Responses with Exercise

Minor change in P wave morphologyMinor change in P wave morphology P & T superimposing in successive beatsP & T superimposing in successive beats Q wave amplitude in septal leadsQ wave amplitude in septal leads Slight Slight R wave amplitude R wave amplitude

ContCont’’dd

T wave amplitudeT wave amplitude Minimal shortening of QRS durationMinimal shortening of QRS duration J point depressionJ point depression Rate-related shortening of QT Rate-related shortening of QT

intervalinterval

Abnormal EKG ResponsesAbnormal EKG ResponsesST Segment DisplacementST Segment Displacement

ST ElevationST Elevation– May be seen in normal ECG (early repol.) and May be seen in normal ECG (early repol.) and

decreases with increased HRdecreases with increased HR

– Ex-induced in leads with Q wave infarction may be Ex-induced in leads with Q wave infarction may be indicative of wall motion abnormality, ischemia, or indicative of wall motion abnormality, ischemia, or bothboth

– In otherwise N EKG: elevation represents significant In otherwise N EKG: elevation represents significant ischemia & localizes the ischemia to area in ischemia & localizes the ischemia to area in myocardiummyocardium


ST segment depressionST segment depression– Most common manifestation of ischemiaMost common manifestation of ischemia

– Horizontal or downsloping more indicative of Horizontal or downsloping more indicative of ischemia than upslopingischemia than upsloping

– Positive test Positive test 1mm or horizontal or down sloping 1mm or horizontal or down sloping 80msec after j-point80msec after j-point

– Slowly upsloping = borderline responseSlowly upsloping = borderline response

ContCont’’dd

ST segment depressionST segment depression– Does not localize areas of ischemia nor indicate Does not localize areas of ischemia nor indicate

which coronary artery is involvedwhich coronary artery is involved

– More leads with More leads with = more severe disease = more severe disease

– If change is only in recovery it is a true positive If change is only in recovery it is a true positive response, important diagnostic findingresponse, important diagnostic finding

– LBBB: uninterpretable for ST changeLBBB: uninterpretable for ST change

– RBBB: V4, V5, V6, II, III, aVF used for interpretation, RBBB: V4, V5, V6, II, III, aVF used for interpretation, V1, V2, V3 uninterpretableV1, V2, V3 uninterpretable

Abnormal EKG ResponsesAbnormal EKG ResponsesST Segment Normalization/No changeST Segment Normalization/No change

EKG abnormal at rest:EKG abnormal at rest:– T wave inversionT wave inversion

– ST-segment depressionST-segment depression

May return to normal during anginal symptoms May return to normal during anginal symptoms or during exerciseor during exercise

Abnormal EKG ResponsesAbnormal EKG ResponsesDysrhythmiasDysrhythmias

Potential mechanismsPotential mechanisms Sympathetic driveSympathetic drive

in pHin pH

extra & intracellular electrolytesextra & intracellular electrolytes

– OO22 tension tension

Mechanisms contribute to circuit re-entry, Mechanisms contribute to circuit re-entry, enhanced automaticity, and triggered activity enhanced automaticity, and triggered activity (Box 27-2)(Box 27-2)

Abnormal EKG ResponsesAbnormal EKG Responses Supraventricular DysrhythmiasSupraventricular Dysrhythmias

Premature Atrial complexes (PAC):Premature Atrial complexes (PAC):– Premature beat with a narrow QRS produced from Premature beat with a narrow QRS produced from

atrial site other than SA node, are not of concern atrial site other than SA node, are not of concern when isolatedwhen isolated

Atrial/Supraventricular tachycardia:Atrial/Supraventricular tachycardia:– Any dysrhythmia originating above AV node. Any dysrhythmia originating above AV node.

Mechanisms found on pg 433/434Mechanisms found on pg 433/434

Atrial fibrillation/flutter (Pg 433) Atrial fibrillation/flutter (Pg 433)

DysrhythmiaDysrhythmia

Supraventricular Tachycardia

Abnormal EKG ResponsesAbnormal EKG Responses Ventricular DysrhythmiasVentricular Dysrhythmias

Premature Ventricular Complexes (PVC): Premature Ventricular Complexes (PVC): – beats produced from site in ventricle before next beats produced from site in ventricle before next

wave of depolarization from SA nodewave of depolarization from SA node

– Have wide QRS complex and may occur in various Have wide QRS complex and may occur in various combinations (Box 27-3) combinations (Box 27-3)

Ventricular Tachycardia (VT)Ventricular Tachycardia (VT)– 3 or more consecutive PVCs at a rate of 100+3 or more consecutive PVCs at a rate of 100+

– Sustained= > 30 sec, Nonsustained= < 30 secSustained= > 30 sec, Nonsustained= < 30 sec

Torsades de Pointes, Vent Fibrillation (Pg 436)Torsades de Pointes, Vent Fibrillation (Pg 436)

DysrhythmiasDysrhythmias

Ventricular Tachycardia (VT)

Dysrhythmia Dysrhythmia Criteria for Test Criteria for Test TerminationTermination

Absolute:Absolute:– Sustained ventricular tachycardiaSustained ventricular tachycardia

Relative:Relative:– Multifocal PVCs, triplets, SVT, heart block, Multifocal PVCs, triplets, SVT, heart block,

bradyarrhythmias bradyarrhythmias

– Development of bundle branch block that cannot be Development of bundle branch block that cannot be distinguished from VTdistinguished from VT

Heart Rate Response to Heart Rate Response to Exercise Testing Exercise Testing (Guidelines - Chapter 6)(Guidelines - Chapter 6)

Linear - 10 Linear - 10 2bpm/MET 2bpm/MET Chronotropic IncompetenceChronotropic Incompetence

– Inability to appropriately increase HR during exerciseInability to appropriately increase HR during exercise

– Peak HR 20 bpm < Age- predicted HR max (doesnPeak HR 20 bpm < Age- predicted HR max (doesn’’t t apply to those on Beta Blockers)apply to those on Beta Blockers)

HR Recovery at 1 minute is abnormal if < 12 HR Recovery at 1 minute is abnormal if < 12 bpm decrease in first minutebpm decrease in first minute

SBP Response to Exercise SBP Response to Exercise TestingTesting (Box 6.1-G)(Box 6.1-G)

Normal responseNormal response– 10 10 2mmHg/MET; may plateau at peak 2mmHg/MET; may plateau at peak

Termination criteria:Termination criteria:– SBP SBP 250mmHg 250mmHg

– Fails to rise or fall Fails to rise or fall 10mmHg10mmHg Sign of ischemia or poor LV functionSign of ischemia or poor LV function <140 mmHg at max = poor prognosis<140 mmHg at max = poor prognosis

Normal response:Normal response:– No No or decrease or decrease

Termination criteriaTermination criteria– >115 mm Hg>115 mm Hg

DBP Response to Exercise DBP Response to Exercise TestingTesting (Box 6.1-G)(Box 6.1-G)

Anginal Symptoms During Anginal Symptoms During Exercise TestingExercise Testing (Box 6.1-G)(Box 6.1-G)

ANGINAL SCALEANGINAL SCALE

1+ Mild, barely noticeable1+ Mild, barely noticeable

2+ Moderate, bothersome2+ Moderate, bothersome

3+ Moderately severe, very uncomfortable*3+ Moderately severe, very uncomfortable*

4+ Most severe or intense pain ever experienced*4+ Most severe or intense pain ever experienced*

*Test termination criteria*Test termination criteria

Gas Exchange and Ventilatory Gas Exchange and Ventilatory ResponsesResponses (Guidelines- 6)(Guidelines- 6)

Used to index patient effort during testUsed to index patient effort during test ProvidesProvides important information about CV fitness important information about CV fitness

& prognosis& prognosis Estimate anaerobic/lactate thresholdEstimate anaerobic/lactate threshold

– Helps avoid metabolic acidosis, hyperventilation and Helps avoid metabolic acidosis, hyperventilation and reduced capacity to perform workreduced capacity to perform work

Exercise Prescription for Exercise Prescription for Cardiac PatientsCardiac Patients

Guidelines Guidelines –– Chapter 9 Chapter 9Resource manual Resource manual –– Chapter 35 Chapter 35

Exercise Prescription for Exercise Prescription for Cardiac PatientsCardiac Patients

Inpatient (Guidelines- Chapter 9)Inpatient (Guidelines- Chapter 9)– Early assessment and mobilizationEarly assessment and mobilization– Identification and education of risk factorsIdentification and education of risk factors– Assessment of pt. readiness for activityAssessment of pt. readiness for activity

– Discharge planningDischarge planning OutpatientOutpatient

– Develop safe exercise programDevelop safe exercise program– Provide appropriate supervisionProvide appropriate supervision– Return patient to normal activities and assist in modifying Return patient to normal activities and assist in modifying

daily activities where necessarydaily activities where necessary– Secondary prevention and risk factor modificationSecondary prevention and risk factor modification

Exercise PrescriptionExercise PrescriptionOutpatient Cardiac PatientsOutpatient Cardiac Patients

Risk stratification according to Boxes 2.3 Risk stratification according to Boxes 2.3 (AACVPR), 2.2 (AHA) p. 30 -33(AACVPR), 2.2 (AHA) p. 30 -33

No contraindications to exercise (Guidelines Box No contraindications to exercise (Guidelines Box 9.2, p.209)9.2, p.209)

Patients without exercise testPatients without exercise test– Conservative risk strat & exercise prescriptionConservative risk strat & exercise prescription

Exercise PrescriptionExercise PrescriptionOutpatient Cardiac PatientsOutpatient Cardiac Patients

Design considerationsDesign considerations– Safety factors Safety factors

Clinical statusClinical status Risk stratRisk strat Exercise capacityExercise capacity Ischemic/anginal thresholdIschemic/anginal threshold Cognitive/Psych impairmentCognitive/Psych impairment

– Vocation & avocational requirementsVocation & avocational requirements

– Orthopedic limitationsOrthopedic limitations

– Pre-morbid and current activitiesPre-morbid and current activities

– Personal health & fitness goalsPersonal health & fitness goals

Exercise dosage determinationExercise dosage determinationDuration & frequencyDuration & frequency

Chapter 9 - GuidelinesChapter 9 - Guidelines

FFrequencyrequency IIntensityntensity TTimeime TTypeype

FrequencyFrequency

Most days of the week (4-7)Most days of the week (4-7) For those with limited exercise capacities, For those with limited exercise capacities,

multiple short sessions (<10min) are multiple short sessions (<10min) are recommended recommended

Participants should be encouraged to do some Participants should be encouraged to do some exerciseexercise session independently (without session independently (without supervision)supervision)

IntensityIntensity

Various methods can be used to prescribe intensity:Various methods can be used to prescribe intensity: Rating of perceived exertion (RPE), 6-20 scaleRating of perceived exertion (RPE), 6-20 scale

– Early rehab upper limit: 11-13 (fairly light to somewhat Early rehab upper limit: 11-13 (fairly light to somewhat hard)hard)

– Progress to 14-16 if asymptomaticProgress to 14-16 if asymptomatic

– High inter-individual variabilityHigh inter-individual variability

– Used with the Talk Test (CWIC)Used with the Talk Test (CWIC)

40-80% of exercise capacity using HR reserve or 40-80% of exercise capacity using HR reserve or Karvonen method if maximal exercise data is available.Karvonen method if maximal exercise data is available.

– Use table 9.1-G when no data is availableUse table 9.1-G when no data is available

– This method necessitates a HR monitorThis method necessitates a HR monitor

FITT IntensityFITT Intensity Other ConsiderationsOther Considerations

THR always 10bpm below:THR always 10bpm below:– 1mm horizontal or downsloping ST segment 1mm horizontal or downsloping ST segment – Anginal symptoms or other CV insufficiencyAnginal symptoms or other CV insufficiency

– SBP SBP 250mmHg, plateau SBP or 250mmHg, plateau SBP or SBPSBP

– DBP DBP 115mmHg115mmHg

FITT IntensityFITT Intensity Other ConsiderationsOther Considerations

THR always 10bpm below:THR always 10bpm below: frequency ventricular arrhythmiasfrequency ventricular arrhythmias

– Other significant EKG disturbancesOther significant EKG disturbances

– Radionuclide evidence LV dysfunctionRadionuclide evidence LV dysfunction

– Mod/sev wall motion abnormality with exMod/sev wall motion abnormality with ex

– Other s/s of intoleranceOther s/s of intolerance

– Consider timing of medicationConsider timing of medication

TimeTime

Warm-up/Cool-down activities should last 5-10 Warm-up/Cool-down activities should last 5-10 minutes eachminutes each

Aerobic conditioning= 20-60minutes is goalAerobic conditioning= 20-60minutes is goal

– May have to start with multiple short boutsMay have to start with multiple short bouts

– Increase time by 10-20% per week, as per Increase time by 10-20% per week, as per patient tolerancepatient tolerance

Same as Table 9.2-G in the eighth edition

TypeType

Large-muscle-group aerobic activities, Large-muscle-group aerobic activities, emphasizing caloric expenditureemphasizing caloric expenditure

Include upper and lower extremitiesInclude upper and lower extremities Variety of activitiesVariety of activities Use of various exercise equipmentUse of various exercise equipment

– Arm ergometer, cycle ergometer, elliptical, rower, Arm ergometer, cycle ergometer, elliptical, rower, stair climber, treadmillstair climber, treadmill

Progression From Medical Progression From Medical Supervision to Independent ExerciseSupervision to Independent Exercise

Ideally, most should participate in supervised Ideally, most should participate in supervised program to facilitate exercise & lifestyle changesprogram to facilitate exercise & lifestyle changes

Criteria for independent exercise:Criteria for independent exercise:– Cardiac symptoms stable/absentCardiac symptoms stable/absent

– Stable ECG, BP, HR responsesStable ECG, BP, HR responses

– Knowledge of exercise principles, symptom Knowledge of exercise principles, symptom managementmanagement

– MotivationMotivation

Resistance Training in Resistance Training in Cardiac PatientsCardiac Patients Guidelines - Chapter 9Guidelines - Chapter 9

Meet eligibility criteria (Box 9.7) Meet eligibility criteria (Box 9.7) Type:Type:

– Elastic bands, light free weights (1-5lb), wall pulleys, Elastic bands, light free weights (1-5lb), wall pulleys, machinesmachines

Technique:Technique:– Slow, controlled movementsSlow, controlled movements

– Regular breathing pattern (no holding)Regular breathing pattern (no holding)

– Avoid sustained, tight gripAvoid sustained, tight grip

– RPE 11-13RPE 11-13

– Monitor symptomsMonitor symptoms

Prescription Guidelines: RTPrescription Guidelines: RT

2-4 sets/muscle group, 12-15 reps, 8-10 2-4 sets/muscle group, 12-15 reps, 8-10 exercisesexercises

2-3 days/week2-3 days/week Exhale on exertionExhale on exertion Increase weight 2-5lbs/wk (arms), 5-10lbs/wk Increase weight 2-5lbs/wk (arms), 5-10lbs/wk

(legs)(legs)

Special Patient PopulationsSpecial Patient Populations

Guidelines - Chapter 9Guidelines - Chapter 9Resource Manual - Chapter 35Resource Manual - Chapter 35

Special Patient PopulationsSpecial Patient PopulationsAngina or Silent IschemiaAngina or Silent Ischemia

Ischemia Ischemia –– inadequate blood flow to meet myocardial inadequate blood flow to meet myocardial oxygen demandoxygen demand

– Generally result of critical lesion > 70% Generally result of critical lesion > 70%

Angina Angina –– pain associated with ischemia pain associated with ischemia

Silent Ischemia Silent Ischemia –– no pain associated with ischemic no pain associated with ischemic threshold (EKG changes)threshold (EKG changes)

Goal of training:Goal of training:

anginal & ischemic threshold by decreasing anginal & ischemic threshold by decreasing myocardial oxygen demand at any given submax myocardial oxygen demand at any given submax exertionexertion

Prescription guidelines:Prescription guidelines:– Prolonged WU & CDProlonged WU & CD

– THR THR 10bpm below ischemic threshold 10bpm below ischemic threshold

Other possible strategies:Other possible strategies:– Pre-ex nitroglycerinPre-ex nitroglycerin

– Intermittent, shorter duration ex on frequent basisIntermittent, shorter duration ex on frequent basis

NTG protocolNTG protocol Know signs and symptomsKnow signs and symptoms

Special Patient PopulationsSpecial Patient PopulationsAngina or Silent IschemiaAngina or Silent Ischemia

Inability of heart to deliver blood d/t impairment Inability of heart to deliver blood d/t impairment in cardiac outputin cardiac output

Classic symptoms are exercise intolerance or Classic symptoms are exercise intolerance or dyspnea on exertiondyspnea on exertion

30-40% lower exercise capacity than healthy 30-40% lower exercise capacity than healthy individualsindividuals

Intensity: 40/50%-70% Heart Rate Reserve Intensity: 40/50%-70% Heart Rate Reserve (HRR)(HRR)

May need to start with short boutsMay need to start with short bouts

Special Patient PopulationsSpecial Patient Populations::Congestive Heart FailureCongestive Heart Failure

Dyspnea ScaleDyspnea Scale

+1+1 Light, barely noticeable Light, barely noticeable

+2+2 Moderate, bothersome Moderate, bothersome

+3+3 Moderately severe, very uncomfortable Moderately severe, very uncomfortable

+4+4 Most severe or intense dyspnea ever Most severe or intense dyspnea ever experienced experienced

Dyspnea ScaleDyspnea Scale

NothingNothing 0 0

Very, very slight 0.5Very, very slight 0.5

Very slight 1Very slight 1

SlightSlight 22

ModerateModerate 33

Somewhat severe 4Somewhat severe 4

SevereSevere 5 5

66

Very severe 7Very severe 7

88

99

Very, very severe 10Very, very severe 10

Special Patient PopulationsSpecial Patient PopulationsICDICD

Manage tachydysrhythmias with burst pacing or Manage tachydysrhythmias with burst pacing or shockshock

Know cutoff rateKnow cutoff rate At risk of receiving inappropriate shocks during At risk of receiving inappropriate shocks during

exercise if HR exceeds programmed threshold exercise if HR exceeds programmed threshold or pt develops ex-induced SVTor pt develops ex-induced SVT

Closely monitor with EKG, pulse palpation to Closely monitor with EKG, pulse palpation to safely up-titrate exercise intensitysafely up-titrate exercise intensity

Magnet availableMagnet available

Special Patient PopulationsSpecial Patient PopulationsPacemakerPacemaker

Standard 4 letter code:Standard 4 letter code:– 11stst letter letter –– chamber paced A(atria), V(ventricle), chamber paced A(atria), V(ventricle),

D(dual)D(dual)

– 22ndnd Letter Letter –– chamber sensed A, V, D chamber sensed A, V, D

– 33rdrd Letter Letter –– response to sensed event response to sensed event

– 44thth Letter Letter –– rate-response capabilities of the rate-response capabilities of the pacemakerpacemaker

Examples: VVI, VVIR, AAI, DDDRExamples: VVI, VVIR, AAI, DDDR

Special Patient PopulationsSpecial Patient PopulationsPacemaker & ICDPacemaker & ICD

Hx resuscitated cardiac death, V.dysrhythmias, Hx resuscitated cardiac death, V.dysrhythmias, disease of sinus node or conduction systemdisease of sinus node or conduction system

PM & ICD pts adapt to physical conditioning PM & ICD pts adapt to physical conditioning similar to pts with CAD who are HR responsivesimilar to pts with CAD who are HR responsive

Special Patient PopulationsSpecial Patient PopulationsPacemaker & ICDPacemaker & ICD

Intensity: 10% below activation. 10 bpm below Intensity: 10% below activation. 10 bpm below HR for activation of ICDHR for activation of ICD

Activities that stretch the armsActivities that stretch the arms Resume non-ballistic activities after 8 wksResume non-ballistic activities after 8 wks Ballistic after 12 weeksBallistic after 12 weeks Pacemaker patients should not raise arms Pacemaker patients should not raise arms

above shoulders for 3 weeksabove shoulders for 3 weeks

Special Patient PopulationsSpecial Patient PopulationsFixed Rate PacemakerFixed Rate Pacemaker

Attenuated rise in cardiac outputAttenuated rise in cardiac output Little to no chronotropic reserve, not linear to Little to no chronotropic reserve, not linear to

VOVO22

Extend WU & CDExtend WU & CD SBP monitoring throughoutSBP monitoring throughout Functional capacity may be impaired Functional capacity may be impaired

Special Patient PopulationsSpecial Patient PopulationsCardiac TransplantCardiac Transplant

Marked exercise intolerance, believed to be d/t Marked exercise intolerance, believed to be d/t lack of myocardial innervationslack of myocardial innervations

Med mgt focuses mainly on preventing rejectionMed mgt focuses mainly on preventing rejection Often have elevated rest HR & BPOften have elevated rest HR & BP Attenuated increase in HR with exerciseAttenuated increase in HR with exercise Lower peak HR, and delayed recoveryLower peak HR, and delayed recovery

Prescription guidelines:Prescription guidelines: WU & CD time, post HR remain high WU & CD time, post HR remain high

– RPE 11-14 should be main intensity toolRPE 11-14 should be main intensity tool

– Avoid HR prescription for at least 1 yrAvoid HR prescription for at least 1 yr

Resistance trainingResistance training– Restrict upper-body until sternum is healed (6-12 Restrict upper-body until sternum is healed (6-12

weeks)weeks)

– 7-10 exercises, 2x/wk7-10 exercises, 2x/wk

Special Patient PopulationsSpecial Patient PopulationsCardiac TransplantCardiac Transplant

Special Patient PopulationsSpecial Patient PopulationsCardiac SurgeryCardiac Surgery

CABG and valve surgeryCABG and valve surgery Range of Motion (ROM) in early days following Range of Motion (ROM) in early days following

procedures to prevent adhesions, postural procedures to prevent adhesions, postural problemsproblems– Common chest & shoulder pathologyCommon chest & shoulder pathology

Aerobic intensity = 40/50%-85% HRRAerobic intensity = 40/50%-85% HRR Resistance training Resistance training

– Restrict upper body movement until sternum is healed Restrict upper body movement until sternum is healed (6-12 wks)(6-12 wks)

Special Patient PopulationsSpecial Patient PopulationsPCIPCI

Aerobic & RT can begin almost immediatelyAerobic & RT can begin almost immediately Ex rx similar to that for regular cardiac patients Ex rx similar to that for regular cardiac patients

& may progress more rapidly if minor myocardial & may progress more rapidly if minor myocardial damage & less inactivity pre & post proceduredamage & less inactivity pre & post procedure

Groin checkGroin check Monitor S/S of restenosis Monitor S/S of restenosis Should aim for 1500-2000 kCal of physical Should aim for 1500-2000 kCal of physical

activity each weekactivity each week

Metabolic EquationsMetabolic Equations

ACSM certification review - Chapter 11ACSM certification review - Chapter 11Guidelines - Chapter 7Guidelines - Chapter 7

Metabolic CalculationsMetabolic Calculations

Chapter 11 of ACSM certification review is the Chapter 11 of ACSM certification review is the most comprehensive resource for metabolic most comprehensive resource for metabolic calculationscalculations

See table 7.2 (ACSM guidelines) for formulasSee table 7.2 (ACSM guidelines) for formulas Figure 7.2 (ACSM guidelines) shows application Figure 7.2 (ACSM guidelines) shows application

of various methods for prescribing exercise of various methods for prescribing exercise intensityintensity

Metabolic equationsMetabolic equations

1. How many minutes per week would a 70 kg man 1. How many minutes per week would a 70 kg man have to exercise to achieve a net caloric expenditure have to exercise to achieve a net caloric expenditure of 2100 kcal if he exercise at 6 METs?of 2100 kcal if he exercise at 6 METs?

AEROBICAEROBIC

1) 6 METs = 5METs net expenditure = 17.5 ml/kg/min1) 6 METs = 5METs net expenditure = 17.5 ml/kg/min

2) 17.5 ml/kg/min = 1225 ml/min = 1.225 L/min2) 17.5 ml/kg/min = 1225 ml/min = 1.225 L/min

3) 1.225L/min O3) 1.225L/min O2 2 = 6 kcal= 6 kcal

4) 2100 kcal/6kcal/min = 350 minutes or 50 minutes/day4) 2100 kcal/6kcal/min = 350 minutes or 50 minutes/day


2. What is the oxygen consumption equivalent to 10 2. What is the oxygen consumption equivalent to 10 METs for a 155lb male?METs for a 155lb male?

ConversionsConversions:: 10 METs 10 METs = = 35mL/kg/min35mL/kg/min 155lb 155lb 1kg/2.2lb 1kg/2.2lb == 70.45kg70.45kg

35mL/kg/min35mL/kg/min75.45kg75.45kg = 2456.75mL/min = 2456.75mL/min

2456.75mL/min 2456.75mL/min (1L (1L//1000mL)1000mL)== 2.47L/min2.47L/min


3. What resistance (in Kp) should you set a 3. What resistance (in Kp) should you set a Monark cycle ergometer at to elicit a VOMonark cycle ergometer at to elicit a VO22 of of 2750mL/min while cycling at 50 RPM? The 2750mL/min while cycling at 50 RPM? The subject is 65subject is 65”” tall & weighs 110lb. tall & weighs 110lb.

ConversionsConversions::

110lb 110lb 1kg1kg//2.2lb 2.2lb == 50kg 50kg

2750mL/min2750mL/min//50kg 50kg == 55mL/kg/min 55mL/kg/min

(50 rev/1min) (50 rev/1min) (6M/rev) (6M/rev) == 300M/min 300M/min


3. What resistance (in Kp) should you set a Monark 3. What resistance (in Kp) should you set a Monark cycle ergometer at to elicit a VOcycle ergometer at to elicit a VO22 of 2750mL/min of 2750mL/min while cycling at 50 RPM? The subject is 65while cycling at 50 RPM? The subject is 65”” tall & tall & weighs 110lb.weighs 110lb.

55mL/kg/min 55mL/kg/min == ([1.8 ([1.8 F F 300] 300]//50kg) 50kg) ++ 3.5mL/kg/min 3.5mL/kg/min ++ 3.5mL/kg/min 3.5mL/kg/min

Rearrange:Rearrange:

55ml/kg/min 55ml/kg/min –– 7mL/kg/min 7mL/kg/min == 48 mL/kg/min 48 mL/kg/min

48mL/kg/min(50kg)48mL/kg/min(50kg) == 4.4Kp4.4Kp

[1.8 [1.8 300M/min])300M/min])

considerations for exercise testing & prescription: cardiac population cardiac wellness...

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