Complex exercise management

• Exercise prescription and guidelines

  1. General

  2. ECG during initial stages of exercise

  3. Awareness of medications affecting HR

  4. Aerobic exercise is generally considered a priority

  5. Must research appropriate rate of progression

  6. Must select appropriate modalities

  7. Longer cool-down (blood pooling from medications)
• Exercise prescription and guidelines for Peripheral vascular disease

  1. Improve the pain response, develop work capacity, reduce risk of CAD

  2. Increase ability to perform ADL thus improving QOL
• Exercise prescription and guidelines for Heart Disease

  1. Aerobic training

  2. HR monitoring is important (typically use 60-80% HRmax)

  3. Must use test results to set intensities

  4. RPE is also important (typically use 11-15/20)

  5. Use intermittent work periods with 3-5 min rest

  6. Training intensity becomes a percentage of the HR at the onset of complications rather than a percentage of the maximum HR
• Exercise prescription and guidelines for Myocardial Infarction

  1. Acute issues - Cardiologist in charge of program

  2. Physical activity commences ASAP

  3. Short walks, exertion-free

  4. Max HR should be considered HRrest + 20 b/min, Regular frequency (3-4 times per day)

  5. Longer term: Peak training intensity = 10 b/min below symptomatic intensity, after 6 weeks
• Exercise prescription and guidelines for Hypertension

  1. Increase work capacity/VO2max, increase caloric expenditure

  2. Control blood pressure, Increase muscular endurance
• Exercise prescription and guidelines for Valvular disease

  Reduce risk of MI, increase ability to perform activities of daily living thus improving QOL
• Exercise prescription and guidelines for Heart disease & myocardial infarction

  1. Reduce cardiovascular workload by improving efficiency

  2. Increase muscular endurance, restore/improve performance of ADL
• Exercise prescription and guidelines for Heart Disease

  1. Resistance training

  2. A valuable component for Class I patients

  3. Prescribe multi-joint exercises ensuring sufficient recovery

  4. No isometric exercises for Class II-IV patients - may lead to ischemic symptoms - myocardium unable to cope with demands

  5. Reduce cardiovascular workload by improving efficiency

  6. Increase muscular endurance

  7. Improve performance of activities of daily living
• Exercise prescription and guidelines for Heart failure

  1. Improve peripheral oxygen kinetics

  2. Increase ability to perform ADL thus improving QOL
• Exercise Prescription and Guidelines for Hypertension

  1. Aerobic

  2. Focus on body mass reduction

  3. Aim to expend at least ~1000kJ/day

  4. Target = 30 minutes per session, 4-7 sessions per week, <70%VO2max intensity

  5. Resistance training

  6. Low load/high rep (15-20 reps)

  7. Circuit training is ideal

  8. No valsalva manoeuvres

  9. Longer rest between sets
• Exercise Prescription and Guidelines for Myocardial Infarction

  1. Multiple modes

  2. Month 1: 2-3 sessions per week, 15-20 min, 2.5-5km/h on treadmill

  3. Months 2-6: 4-5 sessions per week, 30-40 min, 85% HRreserve

  4. Aim to build to at least 6 hours of activity per week

  5. Must ensure adequate warm up and cool down

  6. Can incorporate resistance training - high repetition range
• Myocardial Infarction

  1. Acute issues - Cardiologist in charge of program

  2. Physical activity commences ASAP

  3. Short walks, exertion-free

  4. Max HR should be considered HRrest + 20 b/min, Regular frequency (3-4 times per day)

  5. Longer term: Peak training intensity = 10 b/min below symptomatic intensity, after 6 weeks: 30 min walk
• Main goals for Myocardial Infarction

  • Reduce cardiovascular workload by improving efficiency
  • Increase muscular endurance
  • Restore performance of activities of daily living
• Main goals for Hypertension

  • Increase work capacity/VO2max
  • Increase caloric expenditure
  • Control blood pressure
  • Increase muscular endurance
• Exercise Prescription and Guidelines for Cardiac Valvular Disease

  1. Exercise is not a form of treatment for this condition

  2. Surgical procedures can replace/repair faulty valves

  3. Increased risk of sudden death during exercise

  4. More concerned with whether the individual is able to participate in exercise at certain intensities

  5. Dyspnea and RPE must be monitored

  6. Grading of sports/exercises into intensity categories

  7. Static/Dynamic, Low/Moderate/High (See Table 7.1 in LeMura & von Duvillard, 2004)
• Main Goals for <70%VO2max intensity

  • Increase work capacity/VO2max
  • Increase caloric expenditure
  • Control blood pressure
  • Increase muscular endurance
• Main Goals for Peripheral Vascular Disease

  • Improve the pain response
  • Develop work capacity
  • Reduce risk of CAD
  • Increase ability to perform activities of daily living thus improving quality of life
• Exercise Prescription and Guidelines for Heart Failure

  1. Primary goal is to improve functional capacity

  2. Aerobic training most common form

  3. 40-85% VO2peak (it is possible to work at high % of VO2)

  4. 20-60 minutes

  5. 3-5 days per week

  6. Cycling or walking

  7. Mostly adaptations in the periphery (decrease peripheral resistance)

  8. Resistance training is also important

  9. Single joint exercises place less strain on myocardium

  10. Reduced blood lactate concentration following training
• Exercise Prescription and Guidelines for Peripheral Vascular Disease


  1. Primary goal is to improve circulation and regain lost limb function

  2. Frequency: >3 per week

  3. Intensity: 50-80% HRmax, but usually assess by claudication pain tolerance - onset or maximal?

  4. Duration: minimum 15min, build to >30min

  5. Mode: Weight bearing, typically walking

  6. Type: Intermittent usually to MCP
• Exercise Prescription and Guidelines for <70%VO2max intensity

  1. Resistance training

  2. Low load/high rep (15-20 reps)

  3. Circuit training is ideal

  4. No valsalva manoeuvres

  5. Longer rest between sets
• Main Goals for Cardiac Valvular Disease

  • Reduce risk of MI
  • Increase ability to perform activities of daily living thus improving quality of life
• Main Goals for Heart Failure

  • Improve peripheral oxygen kinetics
  • Increase ability to perform activities of daily living thus improving quality of life
• Symptoms of Myocardial Infarction

  • Chest pain (angina)
  • Shortness of breath
  • Anxiety
• No significant effects observed, but the drugs are still under investigation blocking the effect of a chemical that causes the small blood vessels to constrict losartan, valsartan, irbesartan, candesartan, eprosartan, telmisartan, olmesartan Angiotensin II Receptor Blockers increased risk of
• Cardiovascular Diseases


  • Last week
  • Coronary Heart Disease
  • Hypertension
  • Vascular Disease
  • Management of conditions
  • Clinical testing
• This week

  • Other conditions
  • Medications
  • Exercise prescription
• Heart Failure

  • A systematic inability for the heart to deliver adequate blood to metabolising tissue
  • Systolic Heart Failure: Impaired ventricular contraction
  • Diastolic Heart Failure: Impaired ventricular filling
  • Usually a result of valve malfunction
  • Often occurs in conjunction with MI
  • Elevated load on heart
  • Elevation of blood catecholamines leading to greater chance of arrhythmia
  • Inhibition of exercise response
• Cardiac Valvular Disease

  • Malfunction of Cardiac valves
  • Mitral valve
  • Tricuspid valve
  • Valvular regurgitation: Leaflets of valves fail to close properly leading to backflow of blood through valves in heart causing volume overload of ventricles and enlargement of the chamber which can lead to Heart Failure
  • Stenosis: Leaflets of valves fail to open properly leading to higher resistance encountered and higher pressure required for flow causing hypertrophy of ventricular walls which can lead to Heart Failure
• Myocardial Infarction


  • A cessation of blood flow to the myocardium (heart tissue) through a coronary artery blockage
  • Usually a result of atherosclerotic plaque rupture
  • Not necessarily the termination of the heart beat
• Assessment via Echocardiograph and Doppler imaging
• Treatment for Myocardial Infarction

  • Oxygen
  • Nitroglycerin
  • Defibrillation
• Check out this basic description of Heart Failure: https://www.youtube.com/watch?v=GnpLm9fzYxU
• Medications for Cardiovascular Diseases

  • Beta blockers
  • Alpha blockers
  • Angiotensin converting enzyme inhibitors (ACEI)
  • Calcium channel blockers
  • Anti-anginal agents
  • Cardiac glycosides
  • Diuretics
  • Statins
  • Anti-arrhythmic agents
  • Anti-thrombogenic agents
• Risk factors for Myocardial Infarction

  • Same as CHD
• Causing the blood vessels to widen or relax

  isosorbide, dinitrate hydralazine, nitrates, minoxidil
• Beta Blockers


  • Less tolerance for physical activity; too-low blood pressure; worsening of asthma symptoms
• Diuretics


  • Persistent cough; kidney problems; weakness or dizziness; skin rashes; an altered sense of taste; too-high potassium levels
• Blocking the effect of a chemical that causes the small blood vessels to constrict

  losartan, valsartan, irbesartan, candesartan, eprosartan, telmisartan, olmesartan
• Increasing the force of the heart's contractions and slowing certain types of irregular heartbeats

  digoxin; digitoxin
• Angiotensin II Receptor Blockers

  • Increased risk of bleeding; easy bruising
  • Preventing blood clots from forming that can lead to stroke