Case study

1
Case study

• Mr. Wong is a 48-year old male, sales
  representative who travels often
• 170cm, 84kg , BMI 29
• His brother just suffered from MI at age 40.
• Concerned about his health
• Want to do start exercise and lose weight

2
Evaluation

• Classify client according to Risk Stratification
  Criteria
• ACSM/ ACP/ACCVPR/ AHA
• Identify Major Coronary Artery Disease Risk
  Factors
• Identify signs or symptoms suggestive of
  cardiopulmonary disease
• Identify secondary risk factors
• Obesity, alcohol consumption, stress levels

3
Case Study

• Recently diagnosed to have type 2 DM, put on
  Daonil
• BP 160/90 mmHg on metoprolol 50mg bd
• Half pack a day smoking habit due to stress of
  his job
• His brother just suffered from MI at age 40.
• Cholesterol level 6.2mmol/l , HDL 0.90 mmol/l,
  LDL 3.8mmol/l
• TG 2.4 mmol/l
• No regular exercise
• No signs or symptoms of cardiopulmonary disease

4
Positive Risk Factors for CHD ACSM (2006)

• Family History
• Myocardial infarction, coronary revascularization
  (bypass surgery) or sudden death before
• the age of 55 years in father or other male first
  degree relative (i.e. brother or son)
• the age of 65 years in mother or other female
  first degree relative (i.e. sister or daughter)
• Cigarette smoking
• Current cigarette smoker or those who have quit
  in the last six months
• Hypertension
• Client on Hypertensive medications
• Resting SBP gt 140 mmHg and/ or DBP gt 90 mm Hg

• Fasting Glucose
• Fasting blood glucose of gt100mg/dL 5.6mmol/L)

5
Positive Risk Factors for CHD ACSM (2006)

• Dyslipidemia
• Total serum cholesterol gt 200mg/dL (5.2 mmol/L)
  or
• High density lipoprotein (HDL) lt 40mg/dL (1.03
  mmol/L)
• Low density lipoprotein (LDL) gt 130mg/dL
  (3.4mmol/L)
• Obesity
• Body Mass Index (BMI) gt 30 kg/m2 or
• Waist girth gt 102 cm (M) gt 88 cm (F) or
• Waist/hip ration gt 0.95 (M) gt 0.86 (F)
• Sedentary Lifestyle
• Not participating in a regular exercise program
• Accumulating less than 30 minutes moderate
  intensity exercise 3-5 days weekly

Negative Risk Factors for CHD ACSM (2006)

• High level of HDL
• HDL cholesterol gt 1.6 mmol/L (60 mg/dl)

6
Initial Risk Stratification

• Low risk
• Menlt45 years of age and women lt55 years of age
• Younger individuals who are asymptomatic and meet
  no more than one risk factor threshold
• Moderate risk
• Older individuals (men? 45 years of age women ?
  55 years of age) or those who meet the threshold
  for two or more risk factors
• High Risk
• Individuals with one or more signs/symptoms or
  known cardiovascular, pulmonary, or metabolic
  disease

7

• What recommendations in reference to medical
  examination and testing prior to participation in
  an exercise program?
• A. Medical examination and exercise testing
• B. Physician Supervision of exercise test

8

• Consider the following criteria during your
  evaluation
• Age and gender
• Moderate Vs vigorous exercise program
• Physician present during testing
• Submaximal or maximal graded exercise test
• Type of test (treadmill, leg ergometer, step)
• Absolute and relative contraindications to
  exercise testing

9
ACSM Recommendations for Pre-participation
screening Algorithm
10
ACSM Recommendations for Pre-participation
screening Algorithm cont
11
Cardiovascular System Assessment

• A graded exercise test may be helpful if a
  patient, about to embark on a moderate to
  high-intensity physical activity program, is at
  high risk for underlying cardiovascular disease,
  based on one of the following criteria
• Age gt40 years , /- CVD risk factors
• Age gt30 years and
• Type 1 or 2 diabetes of gt10 years' duration
• Presence of any additional risk factor for
  coronary artery disease
• Presence of microvascular disease (proliferative
  retinopathy or nephropathy, including
  microalbuminuria)
• Peripheral vascular disease
• Autonomic neuropathy

12
Medications
13

• A constellation of cardiovascular risk factors
  related to hypertension, abdominal obesity,
  dyslipidemia, and insulin resistance
• Certain drugs used to treat hypertension may
  accelerate the appearance of new-onset diabetes.
  In particular, both ß blockers and diuretics have
  been implicated in this effect.

14

• ALLHAT
• In high risk hypertensive patients, the diuretic,
  chlorthalidone, was 43 more likely than the
  ACEI, lisinopril, to produce diabetes, but was
  also 18 more likely than the calcium channel
  blocker, amlodipine, to produce this adverse
  effect.
• HOPE
• The development of new diabetes was reduced by
  34 (plt0.001) in the ramipril-treated group.
• LIFE (Losartan Intervention For Endpoint
  Reduction in Hypertension)
• The ARB, losartan, was associated with a 25
  relative risk reduction in new-onset diabetes
  when compared with the ß blocker, atenolol
• VALUE (The Valsartan Antihypertensive Long-term
  Use Evaluation)
• Valsartan, was associated with 23 RRR in
  new-onset diabetes when compared with the calcium
  channel blocker, amlodipine.

15

• ARB/ACEI may have positive effects on insulin
  action and potentially plays a meaningful role in
  protecting high-risk hypertensive patients from
  developing diabetes.

16
Medications

• Metoprolol changed to ACE inhibitors/ ARB
• Metformin
• Statin

17
Exercise stress test

• METS achieved 8.5
• Peak heart rate 165 beats per minute
• Peak blood pressure of 200/88 mmHg.
• No exercise induced ischemia

18
Questions

• Please write an initial exercise prescription
• Any adjustments and practical tips in patients
  with DM and HT?

19
Exercise prescription

• Address each of the following
• Aerobic endurance
• Strength training
• Flexibility
• Include each of the following in your
  prescription
• frequency
• times/day, days/week
• Intesnisy
• 5HRR, VO2max, HRmax, 1RM, MVC, etc
• Duration
• warm-up, cool-down, exercise component, rest
  between sets, etc
• Mode of exercise
• types of exerciise, stretching techniques,
  resistance training, etc
• Rate of progression

20
ACSM and CDC Recommendation

• American College of Sports Medicine (ACSM) and
  Centers for Disease Control and Prevention (CDC),
  1995 (Pate et al., 1995)
• Recommendation Every adult should engage in
  moderate-intensity physical activity for 30
  minutes or longer on most, preferably all, days
  of the week. Moderate intensity is defined as 40
  to 60 of maximal oxygen consumption (VO2max).
  The 30-minute activity can also consist of
  shorter exercise bouts (minimum of 10 minutes)
  that are accumulated throughout the day (e.g.,
  walking to work, shopping).

Finnish Medical Society Duodecim. Physical
activity in the prevention, treatment and
rehabilitation of diseases. 2004 Apr 20
21
ACSM Recommendation for Hypertension

• 40-70 of VO2max, i.e. 55-80 of the maximal
  heart rate. The lower range of intensity is
  sufficient for the elderly.
• 3 or 4 times weekly for at least 30 minutes at a
  time
• Various endurance exercise modes are suitable.
  Resistance training (preferably circuit training)
  should not be the only form of exercise but
  should be combined with endurance training.
• Training at an intensity of about 50 of the
  maximal exercise performance (moderate-intensity)
  is sufficient with regard to resting blood
  pressure reduction (Fagard, 2001).

Finnish Medical Society Duodecim. Physical
activity in the prevention, treatment and
rehabilitation of diseases. 2004 Apr 20
22
Rehabilitation in Coronary Heart Disease

• Mainly endurance training
• at an intensity of 50 (-60) -75 of
  symptom-limited VO2max (or heart rate reserve,
  which is the difference between maximal and
  resting heart rate) for 30 minutes 3-4 times
  weekly (minimum), full benefit is obtained with
  5-6 times/week
• Resistance training in addition
• at an intensity of 30-50 (up to 60-80) of 1 RM
  (one repetition maximum), 12-15 repetitions, 1-3
  sets twice weekly

23
Recommendations for Patients With Type 2 Diabetes

• Exercise program
• Type Aerobic
• Intensity 50-70 of maximum aerobic capacity
• Duration 20-60 minutes
• Frequency 3-5 times per week
• Avoid complications
• Warm up and cool down
• Careful selection of exercise type and intensity
• Patient education
• Monitoring of blood glucose by patient and
  overall program by medical personnel

Physical Activity/Exercise and Diabetes Diabetes
care, vol. 27, supplement 1, January 2004
24
Recommendations for Patients With Type 2 Diabetes

• 3. Compliance
• Make exercise enjoyable
• Convenient location
• Positive feedback from involved medical personnel
  and family

Physical Activity/Exercise and Diabetes Diabetes
care, vol. 27, supplement 1, January 2004
25
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Hypertension

• Monitor blood pressure before, during, and after
  exercise
• Unusually high blood pressures (gt190mmHg
  systolic) during low-level activity may warrant
  adjustment in medical therapy
• Stop when there is a 10 to 15mmHg fall in BP
  during exercise and further evaluation should be
  performed
• Begin pharmacological treatment prior t starting
  exercise program if BP gt 160/100

27
Rehabilitation in Coronary Heart Disease

• Mainly endurance training
• at an intensity of 50 (-60) -75 of
  symptom-limited VO2max (or heart rate reserve,
  which is the difference between maximal and
  resting heart rate) for 30 minutes 3-4 times
  weekly (minimum), full benefit is obtained with
  5-6 times/week
• Resistance training in addition
• at an intensity of 30-50 (up to 60-80) of 1 RM
  (one repetition maximum), 12-15 repetitions, 1-3
  sets twice weekly

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• End