Physical Activity and Cardiovascular Disease ANDREAS PITTARAS MD

Physical Activity and Cardiovascular Disease

ANDREAS PITTARAS MD

Survival of the Fittest

“…in the last 15 years, many epidemiological studies have shown

an unequivocal and robust relationship of fitness, physical activity, and exercise to reduce overall and CVD mortality.”

Balady JG, New Engl J Med 2002;346 (11):852-53

Coronary Heart Disease and Physical Activity of Work

Morris JN, et al. Lancet 1953:2:1053-1120

Approximately 50% lower risk of CHD in those with physically demanding (i.e. mail carriers) vs those with sedentary

occupations (i.e. desk clerks).

Physical Activity and the Incidence of Coronary Heart Disease

Powell KE, et al. Annu Rev Public Health 1987; 8:253-87

• 121 studies reviewed; 43 were included.

• The relationship between sedentary lifestyle and increase risk of CHD is likely to be causal.

Relative Risk for CAD

1.92.1

2.4 2.5

0

1

2

3

Ann Review Public Health 1987; 8:253-87RR

Physical Inactivity

SBP>150 mm Hg

TC>268 mg/dL

Smoking >1 pack

Population Attributable Risk by Risk Factor

0

10

20

30

40

50

TC Inactivity BP Smoking Obesity Diabetes

Population Attributable Risk (%)

It is Estimated that 250,000 Deaths/Year in the USA are

Attributable to Lack of Regular Physical Activity

Siegel PZ, at al., Weekly Reports 1991

Physical Activity Status in US Population

• 20% - 22% - Exercise Regularly

• 40% - 54% - Some Activity

• 24% - 40% - Sedentary

• 34% of pts are being counseled by physicians to begin or continue

exercise.

AHA Position Statement

Circulation 1991:86(1):340-44

Physical inactivity an as independent risk factor for the development of

CHD equal in status to the traditional risk factors of HTN,

DM, Dyslipidemia and smoking.

Exercise Type ?

• Most information is derived from aerobic exercise studies.

• Some evidence from occupational studies support that repeated busts of high energy output may offer protection against premature coronary mortality.

-Walking-Jogging-Cycling

High Intensity

AnaerobicCHO as Fuel

Low Intensity Aerobic

FFA as Fuel

Dynamic/Isotonic Exercise

Strength Training

Physiologic Adaptations to Exercise Training

• Chronic exercise of proper intensity, duration and frequency imposes a demand on the body.

• Consequently, the body makes appropriate and specific changes to accommodate the imposed demand.

Cardiovascular Adaptations with Aerobic Exercise

Decrease • Rest HR & BP

• Rest & Exercise RPP

• Exercise HR & BP (abs. WL)

• ESV

Increase

• LV Chamber

• EDV

• SV

• CO

• VO2 max

Cardiovascular Adaptations with Anaerobic Exercise

No Change

• Rest HR & BP

• Rest & Exercise RPP

• Exercise HR & BP (abs. WL)

• ESV

No Change

• LV Chamber ?

• EDV ?

• SV

• CO

• VO2 max

LVH with Aerobic and Anaerobic Exercise

AerobicVolume Load

Diastolic Stress

New Fibers in Series

Chamber size

Eccentric LVH

AnaerobicPressure Load

Systolic Stress

New fibers in parallel

Wall Thickness

Concentric LVH

CHD Death in Norwegian Men 40-59 years of Age (N=2,014)

0

2

4

6

1 2 3 4 Cross-countrySkiers

Lie et al. Eur Heart J ’85; 147-57

P<0.001

CH

D D

aeth

in 7

yr/

100

Fitness Quartiles

CVD Death in Men (N=10,224)

0

50

100

150

<7 7 8 9 10 11 12+

Blair et al. JAMA1989; 262:2395-2401

CV

D D

eath

/10,

000

per

son

-yea

rs

METs

A Prospective Study of Walking as Compared with Vigorous Exercise in

the Prevention of CHD in Women

Manson JE, et al., NEJM 1999;341:650-8

• N = 72,488 Female Nurses• Age : 40 to 65 yrs old in 1986• Free of CVD or Cancer• Follow-up: 8 yrs• Incidence of Coronary Events: 645

Fatal or Non-Fatal MI

Physical Activity & RR Adjusted for Confounding Factors (N=72,488)

1

0.880.81

0.74

0.66

0.4

0.8

1.2

1 2 3 4 5

Mason JE, et al. NEJM:’99;341:650-8

Physical Activity Quintiles

P<0.001

Relative Risk for Coronary Events and Walking Pace (n=72,488)

1

0.75

0.64

0.2

0.5

0.8

1.1

>30/mile 20-30/mile <20/mile


Walking Pace (min/mile)

Relative Risk

Relative Risk for Coronary Events and Walking Time

1

0.78

0.88

0.7

0.65

0.5

0.7

0.9

1.1

<10 min 10 to 29 30 to 59 60 to 179 180 +


Minutes Walking/Wk

RR

Relative Risk for Coronary Events and Walking Time in Women (n=72,488)

1

0.78

0.88

0.7

0.65

0.5

0.7

0.9

1.1

<10 min 10 to 29 30 to 59 60 to 179 180 +


Minutes Walking/Wk

RR

F I N D I N G S• Brisk Walking for 100-200 min/week

at a Pace of <20 min/mile or <13 min/km. Reduces the Risk for Coronary Events in Women by 30 to 40 Percent.

• Similar Caloric Expenditure Yields Similar Reductions in Risk for Coronary Events.

Are Exercise Health BenefitsLong-Lasting?

The Harvard Alumni study (n=16,936) has shown that Ex-Varsity athletes retained lower risk for CHD only if they maintained a physically active

lifestyle throughout life.

Paffenberger et al., Am J Epidemiol 1978 108(3):161-175

Relative Risk of CHD & Aerobic Activity in Men (N=51,529)

1

0.87

0.79

0.58

0.5

0.7

0.9

1.1

None <30 min/Wk 30-60 min/wk >60 min/wk

Tanasescu M, et al. JAMA:’02;288:1994-2000

P<0.001

RR

Survival for Fit & Unfit Men (n=9,777)

0.6

0.7

0.8

0.9

1

0 4 8 12 16 18Follow-up Interval (yrs)

Unfit to Fit

Unfit to Unfit

Blair et al, JAMA 1995;273:1093-97

Survival Probability

44% Reduction in Risk

How Much Physical Activity?

How Much Exercise?• Not an easy Question

• Exercise Intensity, Duration and Frequency must be considered, as well as the interaction.

• Caloric expenditure is one approach.• Intensity still may play an independent

role.

Physical Activity and All –Cause and CVD Mortality in Women >65 yrs

1 1

0.73

0.65

0.77

0.7

0.620.6

0.68

0.58

0.4

0.7

1

<163 163-503 504-1045 1046-1906 >1907

Gregg EW, et al. JAMA’03;289:2379--86

Kcal/wk

Relative Risk

CVD

Weekly Energy Expanded and Relative Risk of CHD in Men (n=7,337)

1

0.80.84

0.5

0.7

0.9

<1000 1000-2499 2500+

Lee, I-Min et al. Circulation 2003;107:1110-16

Kcal/Week

Relative Risk

*

Age-adjusted First MI Rates by Physical Activity (n=16,963)

0

20

40

60

80

<500 500-999 1000-1999 2000-2999 3000-3999 4000+

Physical Activity ndex in Kcal/ Week

Total

Paffenbarger et al., Am J Epidem. 1978;108(3):161-75 MI/10,000 person-yrs

Non-Fatal

Fatal

Exercise Intensity and Relative Risk of CHD in Men (n=7,337)

10.98

0.75

0.6

0.9

<3 METs 3-6 METs >6 METs

Lee I-Min, et al. Circulation 2003;107:1110-16

Kcal/Week

Relative Risk

Exercise Intensity and Relative Risk of CHD in Men (n=7,337)

1

0.81

0.620.6

0.5

0.8

None Moderate Vigorous Very Vigorous

Lee I-Min, et al. Circulation 2003;107:1110-16Relative Risk

Relative Risk of All-Cause Death and Exercise Capacity

4.5

4.2

2.4

3

1.7

2.2

1.25

1.7

1 1

0

1

2

3

4

5

1 2 3 4 5

Quintiles of Exercise Capacity

<6 METS 6-7.9 METS 8-9.9 METS 10-12.9 METS >13 METS

RR of Death Myers J et al. NEJM 2002;346:793-801

Survival Curves for Normal and CVD Patients According to Exercise Capacity

Myers J et al. NEJM 2002;346:793-801

Conclusions

• Exercise Capacity is a more powerful predictor of mortality for CVD than other established risk factors.

• A linear reduction in mortality. For each 1 MET increase in exercise capacity, a 12%, decrease in mortality was observed.

Myers J et al. NEJM 2002;346:793-801

Exercise Capacity and Risk of Death in Women

21.6

10.5

1.5

2.5

3.5

<5 MET 5-8 MET >8 MET

Age-adjust

FRS-adjust

Hazard Ratio of Death

Gulati M, et al. Circulation 2003;108:1554-59

3.1

1.9

Exercise Capacity and Risk of Death in Women

Conclusions

• Exercise capacity is a strong and independent predictor of all-cause mortality in asymptomatic women, even after adjusting for traditional cardiac risk factors.

• For each 1 MET increase in exercise capacity, a 17%, decrease in mortality was observed.

Gulati M, et al. Circulation 2003;108:1554-59

Exercise Threshold for Health Benefits

METs < 4 – 5 7 10 ?

Threshold

• Intensity Fast walk Running

6 km/hr 10 km/hr• Kcal/wk 500 - 1000 3,000

• 120 min/wk 750 - 1050 1,500• 240 min/wk 1500-2100 3,000

Exercise in Patients with Risk factors and/or Chronic

Disease

Age-Adjusted CVD Death Rates &CHD Risk Factors (n=26,980)

46

22.513.2

2410 6.523

4.2 3.60

10

20

30

40

50

Low Moderate High

None

1

2

3

Blair, et al. JAMA 1996

Cardiorespiratory Fitness

Death Rate

51

27.512.6

46

22.513.224

10 6.523

4.2 3.60

20

40

60

Low Moderate High

None

1

2

3

Death Rate

12.6

51

27.5

46


1

1.3

1

1.3

1

1.35

1

1.6

1

1.5

0.5

1.5

2.5

HTN DM Smoke BMI>29 C>220 mg/dl

>8 Mets <5 Mets 5-8 Mets

RR of Death Myers J et al. 2002;346:793-801

CV Events and Physical Activity in Diabetic Women (n=5125)

1

0.93

0.82

0.54

0.3

0.7

1.1

<1 1-1.9 2-3.9 4-6.9

Hu F, et al. Ann Intern Med :’01;134;96-105Relative Risk

Hours/Wk

*

Body Weight/ Obesity

Relative Risk for Physical Activity & BMI, Adjusted For Risk Factors

1

0.79

0.88

0.71

0.82

0.65 0.65 0.64

0.69

0.54

0.4

0.6

0.8

1

1 2 3 4 5



RR

>29

<29N=72,488

F I N D I N G S• Brisk Walking for 100-200 min/week

at a Pace of <20 min/mile or <13 min/km. Reduces the Risk for Coronary Events in Women by 30 to 40 Percent.

• Similar Caloric Expenditure Yields Similar Reductions in Risk for Coronary Events.


4.5

4.2

2.4

3

1.7

2.2

1.25

1.7

1 1

0

1

2

3

4

5

1 2 3 4 5Quintiles of Exercise Capacity

<6 METS 6-7.9 METS 8-9.9 METS 10-12.9 METS >13 METS


Normal CVD

Conclusions

• Exercise Capacity is a more powerful predictor of mortality for CVD than other established risk factors.

• A linear reduction in mortality. For each 1 MET increase in exercise capacity, a 12%, decrease in mortality was observed.

Myers J et al. 2002;346:793-801

S T R O K E

The NIH Consensus Development Panel on Physical Activity and CVD

JAMA ‘96;276:241-46

Data are inadequate to determine

whether stroke incidence is

affected by physical activity or

exercise training.

Physical Activity and Risk of Stroke in Women

Hu FB, et al , JAMA 2000;283:2961-67

• N=72,488 Female Nurses with no CVD or Cancer at Baseline

• Age: 40-65 years

• Follow-up: 8 years (560,087 person-years)

• 407 Strokes• 258 Ischemic• 67 Subarachnoid Hemorrhages• 42 Intracerebral & 40 of Unknown type

Multivariate Relative Risk of Total Strokes

1 0.98

0.820.74

0.66

0.5

0.7

0.9

1.1

1 2 3 4 5

MET Quintiles

Relative Risk

P=0.005

Multivariate RR for Ischemic Strokes

1

0.87 0.830.76

0.52

0.4

0.6

0.8

1

1 2 3 4 5

MET Quintiles

Relative Risk

P=0.003

Multivariate Relative Risk of Total Strokes by Walking Activity

1

0.76 0.780.7 0.66

0.4

0.6

0.8

1

0-0.5 0.6-2.0 2.1-3.8 3.9-10 10+

Relative Risk

P=0.01

METS

Multivariate Relative Risk of Ischemic Strokes by Walking Activity

1

0.77 0.750.69

0.6

0.4

0.6

0.8

1

0-0.5 0.6-2.0 2.1-3.8 3.9-10 10+

Relative Risk

METS

p=0.02

RR of Total Strokes by Walking Pace

1 1

0.66

0.81

0.36

0.49

0.2

0.4

0.6

0.8

1

<2mph 2-2.9 mph 3+ mph

Relative Risk

P<0.001

Age-Adjusted

Multivariate

Relative Risk of Hemorrhagic Strokes by Walking Pace

1 1

0.73

0.82

0.5

0.57

0.3

0.5

0.7

0.9

<2mph 2-2.9 mph 3+ mph

Relative Risk

P<0.02 Age-Adjusted

MultivariateP<0.06

Findings and Conclusions

Sedentary women who became active in middle to late adulthood had significantly lower risk for:

• Total Strokes : 27% - Age-adjusted 20% -

Multivariate • Ischemic Strokes: 38% - Age-adjusted

30% - Multivariate

Findings and Conclusions• Walking pace is strongly

associated with risk of stroke, Independent of the number of hours spent walking.

• Comparable magnitudes of risk reduction with equivalent energy expenditures from walking and vigorous activity.

Body Fat

HTN Dyslipidemia

DM Type II

Physical Activity

Endothelial Function

??

Cardiac Function

Hypertension

Kokkinos P., et al. Cardiology Clinics 2001;19(3):507-516

Average Reduction in BP: Active: 10.5/7.6 mm Hg Controls: 3.8/1.3 mm Hg

BP Changes with Exercise

-10

-8

-6

-4

-2

0

mm Hg

16 weeks 32 weeks

Kokkinos ,Pittaraset al. NEJM 1995;333:1462-7

SBP

DBPP<0.05

BP Changes with Exercise

-12

-10

-8

-6

-4

-2

0

mm Hg

SBP DBP

2 Wks

16 Wks16 Wks

2 Wks

Relative Risk of All-Cause Death and Exercise Capacity in Hypertensive Patients

1

1.3

2

0.2

0.7

1.2

1.7

2.2

>8 MET 5-8 MET <5 MET


LVMI at Baseline and 16 Weeks

163

143

125

140

155

170

Kokkinos, Pittaras et al. NEJM 1995;333:1462-7

*

* p<0.05

Baseline 16 weeks

Wall Thickness at Baseline and 16 wks

11

12

13

14

15

PW IVS

mm

Kokkinos, Pittaras et al. NEJM 1995;333:1462-7

*

*

* p<0.05

Left ventricular hypertrophy is a powerful and independent

predictor of cardiovascular events in patients with and

without obstructive coronary disease.

Ghali JK et al., 1992; Ann Intern Med 1992;117:831-36 Koren MJ et al., 1991; Ann Intern Med 1991;114:345-52 Casale PN, et al., Ann Intern Med 1986;105:173-78

LV Mass and Stroke

1 1

1.59

2.5

2.72 2.8

5.49

6.14

0

1

2

3

4

5

6

7

1 2 3 4

Odds Ratio

Quartiles of LV Mass

Unadjusted Adjusted

Rodriguez et al., JACC 2002;39(2):1482-8

LVH, Physical Activity and Risk of Stroke

1.59 1.781.42 1.64 1.79

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

Total Men Women 40-60 yrs >60 yrs

Adjusted Odds Ratio Rodriguez et al., JACC 2002;39(2):1482-8

3.53

4.79

2.9

3.923.29

Active

LVH, Physical Activity & Risk of Stroke

1

0.4

3.48

0.66

0

1

2

3

4

No LVH LVH

Odds Ratio

SedentaryActiv

e

Rodriguez et al., JACC 2002;39(2):1482-8

SBP Following Aerobic Training

138131

198

171

219

187

219

199

120

140

160

180

200

220

Rest 6-Min 9-Min Peak

*

*

*

p<0.01

*

Kokkinos et al, AJC 1997

May mitigate the May mitigate the hemodynamic load hemodynamic load

during daily physical during daily physical activities.activities.

Attenuate the Attenuate the development and/or development and/or progression of LVH.progression of LVH.

Heart Failure

Skeletal Muscle

Atrophy Patient Adapts

Sedentary LifestyleDiminished

Aerobic Capacity

Muscular Changes

CardiorespiratoryChanges

Neurohormonal Changes

Kokkinos et al.. AHJ:140(1): 2000

All Cardiac Event Survival for HF Patients

0

0.2

0.4

0.6

0.8

1

0 200 400 600 800 1000 1200 1400 1600Time (Days)

Surv

ival

Trained

Untrained

Belardinelli et al, Circulation ‘ 99;99:1173-82

Hospitalization for Heart Failure

0.4

0.6

0.8

1

0 200 400 600 800 1000 1200 1400 1600Time (Days)

Surv

ival

pro

babi

lity


Trained

Untrained

Cardiac Deaths for HF Patients

0.2

0.4

0.6

0.8

1

0 200 400 600 800 1000 1200 1400 1600Time (Days)

Surv

ival


Trained

Untrained

Lipid & Lipoprotein Metabolism

Changes in Lipids & Lipoproteins with Exercise and Diet in Men

-30

-20

-10

0

10

20

Wood et al., NEJM 1991;325:461-6% Change

TG LDL-C

HDL-C

Control Diet Diet+Ex

Changes in Lipids & Lipoproteins with Exercise and Diet in Women

-20

-10

0

10

20

Wood et al., NEJM 1991;325:461-6% Change

TG

LDL-C HDL-C

Control Diet Diet+Ex

Is There A Dose-Response Relationship?

A dose-response relationship between HDL-C Levels and

weekly distance run or weekly caloric expenditure is supported

by most studies.

HDL-C and Km Run/Week:A dose-Response Relationship

47

49

51

53 53

56

460-3 4 to 10 11 to 16 17 to 22 23 to 32 33+

Kokkinos P., et al. Arch Intern Med ‘95;155:415-20mg/dL

Km/Week

*

*p<0.001N=2,906

Is There An Exercise Threshold?

The exercise-induced changes in lipid metabolism are likely the result of the interaction among exercise:

Intensity, Duration, Frequency and Length of Training.

It is also likely that an exercise threshold exists for each of these exercise components.

HDL-C and Weekly Distance

47

49

51

53 53

56

46

50

54

58

0-3 4 to 10 11 to 16 17-22 23-32 32+

Kokkinos P., et al. Arch Intern Med ‘95;155:415-20

Km/Week

mg/dL

N=2,906

p<0.001

*

*

Carbohydrate Metabolism

The Association between Cardiorespiratory Fitness and Impaired Fasting Glucose and

Type II DM

Wei M, et al., Ann Intern Med 1999;130:89-96

• N = 8,633 Non-Diabetic Men

• Age : 30 to 79 yrs old

• 7,511 Had Normal Fasting Blood Glucose

• Follow-up: 6 yrs

• 149 Developed DM and 593 Developed Impaired Fasting Glucose

Cardiorespiratory Fitness & Relative Risk for Type II Diabetes

3.7

1.7

1

0.5

1.5

2.5

3.5

Low Moderate High

Wei M, et al. Ann Intern Med:1999;130:89-96

Fitness Levels

Relative Risk

p<0.001

Cardiorespiratory Fitness & Relative Risk for Impaired Fasting Glucose

1.9

1.5

1

0.5

1

1.5

2

Low Moderate High

Wei M, et al. Ann Intern Med:’99;130:89-96

Fitness Levels

Relative Risk

p<0.001

Cardiorespiratory Fitness & RR for Impaired Fasting

Glucose & Type II Diabetes in Women (n=338)

4.85

2.7

1

0

1

2

3

4

5

Low Moderate High

Fitness Levels

Relative Risk

p<0.001

Cumulative Incidence of Diabetes

0

10

20

30

40

0.5 1 1.5 2 2.5 3 3.5 4

Follow-up Interval (yrs)

Placebo

Diabetes Prevention Program Research Group NEJM 346 (6) 393-403

Cumulative Incidence of DM (%)

Lifestyle

Metformin

Plasma Fasting Glucose

100

105

110

115

0 0.5 1 1.5 2 2.5 3 3.5 4


Placebo


Plasma Glucose (mg/dl

Lifestyle

Metformin

Glycosylated Hemoglobin

5.7

5.9

6.1

6.3

0 0.5 1 2 3 4


Placebo


Glycosylated Hemoglobin (%)

Lifestyle

Metformin

Conclusions• Lifestyle changes and treatment

with metformin both reduced the incidence of DM in persons at high risk.

• Lifestyle intervention was more effective than metformin.

• Number of pts need to be treated for 3 yrs to prevent 1 case of DM is 6.9

for the lifestyle intervention and 13.9 for metformin.

Plasma Glucose Levels Before & After Aerobic Training

100

120

140

160

180

200

0 30 60 90 120

Minutes After Glucose Ingestion

Plasma Glucose (mg/dl)Smutok et al. Metabolism ‘93

Post-Training

Pre-Training

*

*

Plasma Glucose Levels Before & After Strength Training

100

120

140

160

180

200

0 30 60 90 120


Plasma Glucose (mg/dl) Smutok et al. Metabolism ‘93 ‘

Post-Training

Pre-Training*

*

*

Plasma Insulin Levels Before & After Aerobic Training

5

25

45

65

85

105

0 30 60 90 120


Plasma Insulin (U/ml) Smutok et al. Metabolism ‘93

Post-Training

Pre-Training

*

*

Plasma Insulin Levels Before & After Strength Training

5

25

45

65

85

105

0 30 60 90 120


Plasma Insulin (U/ml) Smutok et al. Metabolism ‘93

Post-Training

Pre-Training

* *

Body Weight/ Obesity

Relative Risk for Physical Activity & BMI, Adjusted For Risk Factors

1

0.79

0.88

0.71

0.82

0.65 0.65 0.640.69

0.54

0.4

0.6

0.8

1

1.2

1 2 3 4 5



RR

>29

<29

N=72,488

Cardiorespiratory Fitness & CVD Mortality in Men (N=25,714)

1

3.1

1.5

4.5

1.6

5

0

1

2

3

4

5

BMI<25 BMI 25-29.9 BMI 30+

Wei M, et al.JAMA:’99;282(16);1547-53Relative Risk

(Normal)

(Over WT)

(Obese)

Fit

Unfit

CVD Mortality Predictors in Normal WT Men (BMI 18.5-24.9)

1.4

2.1 2.2

2.6

3.1

0

1

2

3

4

TC Smoke DM HTN Low Fit


CVD Mortality Predictors in Overweight Men (BMI 25-29.9)

2.8

3.33.4

3.9

4.5

2

3

4

5

TC Smoke HTN DM Low Fit

Wei M, et al.JAMA:’99;282(16);1547-53

Relative Risk

CVD Mortality Predictors in Obese Men (BMI >30)

4.44.5

4.7

4.95

3.5

4.5

5.5

Smoke HTN TC DM Low Fit


These findings suggest that it is as important for a clinician to

assess the fitness status of patients, (especially obese) as it is to assess blood glucose, TC,

HTN and smoking habits.

Exercise Recommendations

• Aerobic Activity 3-5 times/wk

• Brisk Walk to Slow Jog

• 60% to 80% of PMHR

• 100 to 200 minutes/week• 1200 to 2400 Kcal/Wk

LVMI at Baseline and 16 Weeks in Patients with LVH

163

143

130

150

170

Kokkinos, Pittaras et al. New Engl J Med 1995;333:1462-7

Baseline 16 weeks

*

* p<0.05

g/m2

Wall Thickness at Baseline and 16 wks

13.3

12.3

14.9

14

11

12

13

14

15

PW IVS

mm

Kokkinos, Pittaras et al. New Engl J Med 1995;333:1462-7

*

** p<0.05

How Much Physical Activity ?

• Do something

• Choose something you enjoy

Start Low & Progress Slowly

• Increase duration by 1-2 min/wk

• Be Consistent (2-5 times/week)

• Goal: 100-200 minutes/week

Exercise Training is Governed By Three Principles

• Specificity

• Overload

• Reversibility

The Specificity Principle

Biological Systems will Make

Specific Adaptations to

Accommodate an Imposed

Demand !

SPECIFICITY

Aerobic• Long Duration (>10

min)

• Low Intensity (<85% of PMHR)

• ATP via TCA Cycle

• FFA as Fuel

Anaerobic• Short Duration

(<5 min)

• High Intensity ( >90% of PMHR)

• ATP via Glycolysis

• CHO as Fuel

The Overload Principle

The performance of a Biological

System will Improve Only If the

Demand Imposed upon it is

Greater than the System is

Currently Accustomed.

Overload Principle

Frequency, Duration

and/or Intensity Must be Increased Periodically.

Reversibility Principle

Training adaptations diminish

if stimulation (training)

is discontinued for a length of

time (12 -90 days).

Exercise Components

• Frequency - Times/Wk

• Duration - Min/Session

• Intensity - How Hard

• Length - How many Wks

Frequency

• 2- 5 Times per Week

• Exercise Every Other Day

• Multiple Short Daily Sessions

(5-10 min) for Those with

Functional Capacity < 3 METS

Duration• 20-60 Minutes/Session of

Continuous Aerobic Activity

• Multiple Daily Sessions (~ 10

min) for Those with Functional

Capacity < 3 METs.

• Slow, Progressive Increase

Length of Training

Most Exercise Benefits Are Evident Within 12 Weeks of

Consistent Training.

ACSM Exercise Intensity Classifications

METS %PMHR

• Low <4 35-59

• Moderate 4-6 60-79

• High > 6 > 80

Exercise For Overweight & Obese Patients

Exercise Modality that does not Impose Excessive

Orthopedic Stress (walking, stationary bike,

aquatic exercises).

Exercise Intensity for Patients on Chronotropic Medications

Base Exercise intensity on

50% to 80% of Peak HR

achieved during ETT.

METs & Kcal for 30 Minutes of Select Physical Activities (80-kg person)

Activity METs Kcal• Fast Walk 5 200• Jog (12 min/mile) 8 320• Bike (Stationary) 7 280• Health Club 7 280• Dancing 5 200• Stair Climbing 5 200

Contraindications & Recommendations for Exercise

• Complete Physical

• Resting BP< 190/105 mm Hg

• Exercise BP <240/120 mm Hg• Exercise SBP drop >10 mm Hg (baseline)

• Unable to complete 5 METs (ETT) or climb

a flight of stairs without severe SOB or symptoms. Gill et al. JAMA 2000

Relative Risk of Onset of MI with Physical Activity

7

1.3

0

2

4

6

8

Relative R

isk

Inactive Active

Willich et al. NEJM '93

Relative Risk of Onset of MI with Physical Activity

107

20

82.4

0

30

60

90

Relative R

isk

0 1 to 2 3 to 4 5+

Mittleman et al. NEJM '93

The relative MI Risk for a 50-yr-old Non-smoking, Non-diabetic Man during a given hour is 1 in 1 million. If this man were sedentary and engaged in heavy physical exertion during that hour, his risk would increase 100 times or 1 in 10,000.

Framingham Heart Study

Documents

Physical Activity and Cardiovascular Disease ANDREAS PITTARAS MD