should i check my patient’s fitness level? · submax #3 calculator #4: easy/fast gas exchange...
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SHOULD I CHECK MY PATIENT’S FITNESS LEVEL?
Robert M Pepper, DO, FAAFPAssociate Professor of Clinical Sciences
West Virginia School of Osteopathic [email protected]
CRF
Ability respiratory and circulatory systems to deliver oxygen to working muscles during sustained exercise
Maxim
al intensity
VO2 MAX AND CV DISEASE
MENAGE 20-39 40-49 50-59 60+
20% >50 >47 >42 >37
20% <36 <34 <31 <26
AGE 20-39 40-49 50-59 60
20% >41 >38 >34 >31
20% <29 <24 <24 <23
WOMEN
VO2 max normative values: Male
Schwartz W, Reibold RC. Aviat Space Environ Med 1990
VO2 max normative values: Female
Schwartz W, Reibold RC. Aviat Space Environ Med 1990
Fitness≠
Exercise
NON-MODIFIABLE
•Age•Gender•Genotype
• Physical Activity• Smoking• Obesity• Cardiopulmonary disease
MODIFIABLE
CRF
CARDIORESPIRATORY FITNESS MEASURES
VO2 Max:maximum amount of O2 that can be utilized during intense sustained exercise
CARDIORESPIRATORY FITNESS MEASURES
METSMetabolic Equivalent Tasks
METABOLIC EQUIVALENT TASKS
1 MET = energy produced average person seated at rest
METS AVERAGE WALKING SPEED
Walking 3.1 mph
3.4 METS
METS x 3.5= VO2 Max
<9 9-14 >14
AVOIDING SCA
Low vs High CRF 48% SCA
1 MET 14%
CardiorespiratoryFitnessandRiskofSuddenCardiacDeathinMenandWomenintheUnitedStatesMayoClinicProceedings,2016-07-01,Volume91,Issue7,Pages849-857
ALMOST SMOKING
Low aerobic capacity in middle-aged men associated with increased mortality rates during 45 years of follow-up.
European Journal Preventive Cardiology, July 2016
1913 TRIAL: 792♂ X 45 YEARS
Smoking > VO2max > HTN > Lipids
European Journal Preventive Cardiology, July 2016
Association of Leisure-Time Physical Activity With Risk of 26 Types of Cancer in 1.44 Million Adults.JAMA Intern Med. 2016;176(6):816-825.
esophageal adenocarcinoma (HR, 0.58; 95% CI, 0.37-0.89), liver (HR, 0.73; 95% CI, 0.55-0.98), lung (HR, 0.74; 95% CI, 0.71-0.77), kidney (HR, 0.77; 95% CI, 0.70-0.85), gastric cardia (HR,
Esophageal
LiverLung
KidneyGastricEndometrial
LeukemiaMyelomaBladder
HeadandNeck
RectalColonBreast
HIGHEST IMPACT: ALL CAUSE MORTALITY
•Smoking•Cardiorespiratory fitness
Smoke/Exercise
Lipids
Hypertension
lipids
hypertension
cardiorespiratoryfitness
smoking
Measure me!
Wen et al Lancet 378, 1244-1253 (2011)
AHA SCIENTIFIC STATEMENT
ALL HEALTHY ADULTS SHOULD HAVE CRF MEASURED
CIRCULATION NOV 30,2016
AHA SCIENTIFIC STATEMENT
•MORE RISK FACTORS: START EARLIER
•FOR CRF ASSESSMENT, NOT DIAGNOSIS CAD
CIRCULATION NOV 30,2016
CHRONIC DISEASE
•KNOWN CORONARY DISEASE•CONGESTIVE HEART FAILURE•COPD•PERIPHERAL ARTERY DISEASE
MAXIMAL HEART RATE WITH CPX MEASURES
VO2 Max TestingAll Healthy
Adults
Max Exercise
#2
Submax#3
Calculator#4: easy/fast
Gas Exchange
Gold standard
CRF TESTING STEP 1: DECONDITIONED OR UNSURE
Duke Activity Status Index
“DASI”
DASI
Maximum: 9.89 METS (VO2≅34)
Low to low-moderate fitness
STEP 2: CRFVO2 CALCULATOR
DASI >9 or younger, higher level of functioning
Cardiac Exercise Research Group “CERG”
CRF: STEP 2CERG VO2 CALCULATOR
•Need resting and maximum heart rate
•Vital statistics•Exercise volume and frequency
•Age•Height (cm)•Weight (kg)•No B-blockers
•Max heart rate•Exercise frequency
•Resting HR•Waist (cm)
VO2 MAX
HTTPS://WWW.NTNU.EDU/CERG
MAX HEART RATE then
VO2 AND METS CALCULATORS: AMERICAN HEART ASSOCIATION
Not a substitute for maximal exercise testing
limits prosC
alcu
lato
rs
Max heart rate
• Resting heart rate
• Waist circumference
More stats• Exercise
frequency• Exercise
intensity
VO2 Max
CRF ASSESSMENT: ACTIVE
Submaximal•6 minute walk test•Rockport One Mile walk Test Maximal•Ramp protocols: Treadmill or Bike
VO2 Max TestingAthletes only?
Max Exercise
#2
Submax#3
Calculator#4: easy/fast
Gas Exchange
Gold standard
ATS 6MWT
•No definitive parameters•Better for treatment assessment
•<500 meters ?poor prognosis
1 MILE WALK TEST (ROCKPORT)
PROS• Minimal resources• Done independently
• Cohort limitations (30-69 yoa)
• Need accurate measurements
• Time
LIMITATIONS
VO2 MAX TESTING
CALCULATOR
CERG• Underestimates fit
• Requires subjective data
• Not substitute for exercise test
6MWT
• For advanced deconditioning
1 mile walk test
• Cohort dependent
• Multiple measurements
• Time=GXT
SUBMAXIMAL
VO2 Max TestingAthletes only?
Max Exercise
#2
Submax#3
Calculator#4: easy/fast
Gas Exchange
Gold standard
MAXIMAL EXERCISE TESTING
•Not for diagnosis of CAD!
•Exercise capacity evaluation
MAXIMAL EXERCISE TESTING=LAB, NOT OFFICE
•Known Coronary disease•Congestive Heart Failure•Peripheral Arterial Disease•Chronic Obstructive Pulmonary Disease
CRF: ACTIVEMAXIMAL EXERCISE TESTING
STEP 1
•Administer pre test questionnaire
•Par-Q+ validated
MAXIMAL EXERCISE TESTING
•Easy•Inexpensive•Most are walking
VALIDATED TREADMILL PROTOCOLS
•Bruce protocol•Balke•Modified Balke
MOST
REFERENCE ARTICLES
Estimating VO2 peak from a nonexercise prediction model: the HUNT Study, Norway.
Nes, BM et alMed Sci Sports Exerc: 2011 Nov;43(11):2024-30.
Reference Articles