exercise prescription and primary prevention of cardiovascular disease
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Thomas S. Metkus, Jr, Kenneth L. Baughman and Paul D. ThompsonExercise Prescription and Primary Prevention of Cardiovascular Disease
Print ISSN: 0009-7322. Online ISSN: 1524-4539 Copyright © 2010 American Heart Association, Inc. All rights reserved.
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Exercise Prescription and Primary Prevention ofCardiovascular DiseaseThomas S. Metkus, Jr, MD; Kenneth L. Baughman, MD†; Paul D. Thompson, MD
Case presentation: Mr R. is a 48-year-old man with hypertension
and dyslipidemia. He is 5�8� tall andweighs 177 lb, with a body mass indexof 26.9 kg/m2. He swam competitivelyin college but has performed littlephysical activity since. He holds anoffice job and has no symptoms ofangina, dyspnea, or palpitations. Hisbrother recently had a myocardial in-farction at 50 years of age. Mr. R. asksyour advice about an exercise programthat will reduce his risk of future myo-cardial infarction.
Coronary heart disease (CHD) re-mains a major cause of morbidity andmortality, and effective strategies forprimary prevention of CHD are criti-cal. Physical inactivity is one of sev-eral modifiable risk factors that con-tribute to CHD risk.1 This articlepresents a practical approach to pre-scribing exercise for primary preven-tion of CHD.
Benefits of Aerobic andAnaerobic Exercise
Observational studies have reporteddecreased numbers of CHD events insubjects who perform regular aerobicactivity.2,3 There is a dose-response
relationship between CHD and aerobicphysical activity, and even 1 hour ofwalking per week is associated withlower risk.4 Strength training may im-part additional benefit.5 Exercise train-ing positively impacts several cardiacrisk factors (Table 1).6–11
Target Population, Risks,and Contraindications
to ExerciseThe American Heart Association andothers have issued recommendationsfor aerobic exercise and resistancetraining for healthy adults 18 to 65years of age.12,13 The most commonnoncardiac risk of exercise training ismusculoskeletal injury, a risk that canbe mitigated by a gradual increase inthe intensity of exercise. Of greaterconcern is the risk of exercise-inducedcardiac events. Compared with seden-tary activity, vigorous exercise mayincrease the risk of sudden cardiacdeath as much as 16.9-fold during andimmediately after activity.14 Similarly,the relative risk of myocardial infarc-tion during vigorous exercise is in-creased 2- to 10-fold.15 This risk ishighest among chronically sedentarypatients who undertake vigorous exer-
cise abruptly, those with a history ofcardiovascular disease, and those withprodromal symptoms.16 Despite the in-creased relative risk with a discreteepisode of exercise, the annual abso-lute risk of a cardiac event is small andestimated at 1 sudden death per 15 000to 18 000 participants.15 Risk can bedecreased by paying attention to newsymptoms and gradually increasing theintensity of the physical activity. Therisks of exercise for most patients areoutweighed by the potential benefits.Contraindications to exercise includedecompensated heart failure, severeaortic stenosis, uncontrolled arrhyth-mia, and acute coronary syndromes.
Patients with recent acute coronarysyndromes should be restricted fromvigorous exercise training until theyhave been asymptomatic for at least 1week and have been undergoing stablemedical therapy.17 Such patientsshould be referred to a medically su-pervised cardiac rehabilitation pro-gram and should undergo exercisestress testing to exclude any exercise-induced abnormalities that would alterthe exercise training program. Patientswho have undergone percutaneous oropen coronary revascularization can
From the Department of Medicine (T.S.M.) and Advanced Heart Disease Center (K.L.B.), Brigham and Women’s Hospital, Boston, Mass; and theDivision of Cardiology, Henry Low Heart Center (P.D.T.), Hartford Hospital, Hartford, Conn.
†Deceased.Correspondence to Thomas S. Metkus, Jr, MD, 75 Francis St, Boston, MA 02115. E-mail [email protected](Circulation. 2010;121:2601-2604.)© 2010 American Heart Association, Inc.
Circulation is available at http://circ.ahajournals.org DOI: 10.1161/CIRCULATIONAHA.109.903377
CLINICIAN UPDATE
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also initiate training 1 to 2 weeks afteran uncomplicated procedure.17
Preparticipation ScreeningSedentary patients should undergo apreparticipation history and physicalexamination that focuses on CHD riskfactors and detects existing cardiacconditions. The American College ofCardiology and American Heart Asso-ciation recommend exercise treadmilltesting for asymptomatic patients withdiabetes mellitus, men older than 45years of age, and women older than 55years of age before they undertakevigorous exercise,18 with the decisionto incorporate myocardial imagingbased on the baseline ECG and thepretest probability of coronary arterydisease.19 Other organizations recom-mend no stress testing for asympto-matic patients undertaking a moderate-intensity exercise program with gradualincreases in activity.20 Given the lowabsolute risk associated with exerciseand the fact that positive exercise testsin asymptomatic individuals primarilypredict angina and not sudden death or
myocardial infarction,21 we recom-mend preparticipation exercise testingin those with possible ischemic symp-toms or who need reassurance beforethey start an exercise program. Allpatients undertaking an exercise pro-gram should be educated as to theimportance of symptoms of chest, arm,or jaw discomfort; syncope or presyn-cope; palpitations; and dyspnea. Pa-tients experiencing these symptomsshould be evaluated before they con-tinue their program.
Initiating anExercise Program
Exercise recommendations should begiven in conjunction with other healthmaintenance advice such as smokingcessation, weight loss, and moderationof alcohol use. Present recommenda-tions are for healthy adults to obtain atleast 150 minutes of moderate or 60minutes of vigorous exercise weekly(Table 2). Moderate exercise, such asbrisk walking, golfing, shooting a bas-ketball, doubles tennis, and lightswimming, is practically explained to
patients as activity not so intense thatone cannot converse comfortably dur-ing exercise.12 Vigorous-intensity ac-tivity, such as jogging and running,singles tennis, shoveling snow, cross-country skiing, and full-court basket-ball, is practically defined as a level ofexertion that precludes comfortableconversation.12 The specific form ofexercise should be enjoyable and sus-tainable. Treadmills, stair-climbingmachines, and elliptical trainers arehelpful adjuncts for patients who can-not exercise outdoors or who havedifficulty with high-impact activitiessuch as jogging on asphalt. The exactintensity level or machine settings dur-ing sessions is less important thanensuring that the patient exercises tojust below the point at which breathingmakes conversation difficult; however,for most patients, a treadmill setting of 3to 4 miles per hour or an exercise bicyclesetting of 10 miles per hour approxi-mates moderate-level activity.12
A simple goal is for patients to walkbriskly for 30 minutes daily. For thepreviously sedentary patient, this
Table 1. Effect of Exercise Training on Cardiac Risk Factors
Risk Factor Effect(s)
Diabetes mellitus Meta-analysis of exercise programs in diabetic patients demonstrates mean decrease in hemoglobin A1C of 0.8%6
Dyslipidemia Meta-analysis of exercise programs demonstrated a mean increase in high-density lipoprotein of 2.5 mg/dL7
Hypertension Meta-analysis of exercise programs demonstrated a reduction in blood pressure of 3.4/2.4 mm Hg8
Cigarette smoking An exercise program resulted in higher levels of abstinence from smoking at 3 and 12 months9
Obesity Lifestyle modification including exercise resulted in a mean 6.7-kg weight loss at 1 year10
Psychosocial health A program of cardiac rehabilitation resulted in significant decreases in depression, anxiety, hostility, somatization, and psychosocialstress11
Table 2. Recommended Exercise Routines in Addition to Activities of Daily Living5,12,17
Type of Exercise Frequency Intensity Length
Aerobic: Walking, stair-climbing,elliptical machine, dancing, lightswimming, cycling on flatground
At least 5 days per week Moderate 30 min total in segments of no less than10 min
Aerobic: Running, singlestennis, swimming
At least 3 days per week Vigorous 20 min
Resistance training: Bicepscurls, military presses, shouldershrugs, 1-arm bent rowing,bent-knee pushups, quartersquats, toe raises, andbent-knee abdominal crunches
At least 2 days per week Moderate, allowing for completion of setwithout straining
8–12 repetitions per set starting at a single settwice per week
Moderate and vigorous activities can be combined toward the goal amount of activity.
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amount of physical activity may seemintimidating and may preclude initia-tion of an exercise program. Thesepatients should embark on a gradualapproach such as detailed in the Fig-ure. The initial “prescription,” walking10 minutes per day 5 days per week,should be given with plans forfollow-up in 4 to 6 weeks. If thepatient has achieved this initial goal,the length of each session should beincreased in an iterative fashion untilthe patient is walking at least 30 min-utes on most days of the week. Oncethis level of physical activity isachieved, the patient should be coun-seled that increased levels of physicalfitness and activity above recom-mended goals will likely accruegreater protection against CHD.13 Re-sistance training should next be addedto develop and preserve skeletal mus-cle strength (Table 2). If patients areunable to comply with any stage of thisgraded increase, they should be en-couraged and reminded that it is nor-mal for behavioral change to be chal-lenging; the last “prescription” that thepatient was able to complete comfort-ably should then be reinitiated. Re-peated failure to achieve anticipated
exercise goals may necessitate a morecareful assessment for occult cardio-vascular disease.
Modification of dietary habits maybe synergistic with exercise in prevent-ing CHD. More than 25% of thepopulation-attributable risk for myo-cardial infarction is due to physicalinactivity, and approximately 13% ofrisk is due to a diet low in fruits andvegetables.1 A “Mediterranean diet”rich in fruits and vegetables, nuts andlegumes, low-fat dairy products, fish,and monounsaturated fatty acids suchas those in olive oil is causally associ-ated with decreased incidence of myo-cardial infarction.22 The focus at theinitiation of an exercise program, how-ever, should be on instituting sustain-able lifestyle changes with respect toboth diet and exercise over time ratherthan instituting multiple major lifestylechanges simultaneously. The patient’sgoals should guide the order in whichdietary changes and initiation of exer-cise programs are introduced, be itconcurrently or sequentially.
ConclusionsMr. R. should be screened with historyand physical examination for contrain-
dications to exercise training, and ifnone are found, he should begin amoderate form of exercise, such aswalking. We would recommend hebegin 10 minutes of walking or otherenjoyable moderate exercise 5 timesper week. He should add 5 minutes toeach session as tolerated until reaching30 minutes per session. At this point,he should add resistance training of themajor muscle groups of the body (Ta-ble 2). Resistance training should beperformed twice weekly with a weightthat allows for 10 to 12 comfortablerepetitions. Increases in activity be-yond goal levels should be encouragedand guided by the patient’s personalgoals and lifestyle preferences.
In conclusion, there is strong evidencethat exercise and physical fitness protectagainst CHD. Cardiac risks of physicalactivity can be mitigated by appropriatepreparticipation screening, patient coun-seling, and a gradual, staged approach toan exercise program. Frequent follow-upand physician encouragement are es-sential elements of successful initia-tion of an exercise program. Finally,physicians should endeavor to presentthemselves as positive role models topatients by maintaining their ownphysical fitness and by participating inexercise programs.
Editor’s NoteKenneth L. Baughman, MD, a coauthor ofthis Clinician Update, died of an accidentalcause on November 16, 2009, during theAmerican Heart Association meeting inOrlando, Fla. Ken was an expert in ad-vanced heart failure. We remember him asa warm, caring individual who was anaccomplished triathlete. He mentored manystudents, residents, fellows, and faculty col-leagues and was always generous with histime and sage with his advice.—Samuel Z. Goldhaber, MD, Section Editor
DisclosuresNone.
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Figure. An approach to staged exercise prescriptions: Any enjoyable, moderate-intensity activity such as those listed in Table 2 may be substituted for walking. Specificstrength training exercises are also listed in Table 2. Rx indicates prescription.
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