KINE 639 - Dr. Green

1
KINE 639 - Dr. Green Section 8 ACSM Standards
and Exercise Rx
2
Components of a Good Medical History and Physical
Exam
Physical Exam
Medical History

• height, weight, body composition, temperature
• ear, nose, mouth, neck (lymphatic), throat,
  
• genitourinary exams
• supine, standing, exercise HRs and BPs,
  ECGs
• palpation of cardiac apical impulse and abdomen
• auscultation of the heart lungs
• palpation auscultation of carotid,
• abdominal femoral arteries
• palpation inspection of extremities for
• edema and palpation of peripheral pulses
• inspection for xanthoma finger clubbing

• all previous diagnoses
• examination findings, paying
• special attention to orthopedic
• and cardiorespiratory history
• detailed description history
• of current symptoms
• recent illness, hospitalizations,
• and surgical procedures
• current medications and drug
• allergies
• family, work exercise history
• lifestyle history including
• exercise and eating habits,
• recreational drug and alcohol

3
Risk Factors for CAD According to the ACSM AHA

• ? Age not listed by ACSM for risk
  stratification
• Men gt 45 Women gt 55 (or premature menopause,
  hysterectomy)
• ? Family History
• MI or sudden death prior to 55 for father or
  1st degree male relative
• MI or sudden death prior to 65 for mother or
  1st degree female relative
• ? Smoking current or quit within past 6 months
• ? Hypertension
• Blood Pressure gt 140/90 or currently taking
  blood pressure medication
• ? Hypercholesterolemia (high cholesterol)
• TC gt 200 mg/dl or LDL-C gt 130 mg/dl (preferred)
  or currently medicated
• HDL-C lt 35 mg/dl (HDL-C level gt 60 mg/dl is a
  negative risk factor)
• ? Diabetes
• fasting glucose gt 110 mg/dl confirmed on 2
  separate occasions
• ? Physical Inactivity
• those not meeting physical activity guidelines
  set by the surgeon general
• not accumulating 30 min. or more of moderate
  activity most days of the week
• ? Obesity
• BMI gt 30 kg/m2 or waist girth gt 100 cm (39.4
  inches)

4
The Metabolic Syndrome Syndrome X

• An atherogenic state in which a person has at
  least 3 of the following
• Disproportionate amounts of abdominal fat
• (waist gt 40 in. for men, 35 in. for women)
• Hypertension (SBP gt 130, DBP gt 85
• Insulin resistance (blood sugar gt 110 mg/dl)
• Prothrombic state (u levels of coagulation
  factors)
• Proinflammatory state
• (u levels of C-reactive protein, produced by the
  liver in inflammatory states, u cytokines,
  a macrophage activator)
• Dyslipidemia
• (triglyc. gt 150 mg/dl, HDL-C lt 40 mg/dl in men
  lt 50 mg/dl in women)
• Affects 47 million American adults ( 1 in 5 )
• Drastically increases chance of MI, stroke, and
  diabetes

5
Major Signs Symptoms Suggestive Of
Cardiopulmonary and Vascular Disease

• Pain or discomfort in chest, neck, jaw or arms
  (anginal type symptoms)
• Shortness of breath at rest with mild exertion
  or usual activities
• Dizziness or syncope
• Orthopnea (needing to be upright to breathe) or
  nocturnal dyspnea
• Ankle edema
• Palpitation in the chest or tachycardia
• Intermittent claudication (lower leg pain)
• Heart murmur

6
Components of the Graded Exercise Test
Pre-Test 12-lead ECG in supine and exercise
postures blood pressure in supine and
exercise postures Exercise 12-lead ECG
during last minute of each stage or every 3
minutes blood pressure during last minute
of each stage exertional and, if necessary,
angina scales symptoms noted r 12-lead
ECG, BP, scales, symptom description Post- Test
IPE 12-lead ECG IPE blood pressure
IPE exertion scale while at max exercise and,
if necessary, angina scales Recovery
12-lead ECG
every 1 - 2 minutes for at least 5 minutes
blood pressure every 1 - 2 minutes until it
returns to near pre-test level symptomatic
rating scale assessments if symptoms persist
7
ACSM GXT Physician Supervision Recommendations

• M.D. Supervision recommended for
  Graded Exercise Testing
• submax max
• testing testing
• lt 45 lt 55 no more than 1 ACSM
  risk marker no no
• Older persons or those having 2 or more ACSM risk
  markers no yes
• Signs, symptoms, of CV disease or known yes
  yes
• CV, pulmonary, or metabolic disease

8
Types of Cardiovascular and Cardiopulmonary
Testing

• graded exercise testing (GXT) with 12 lead
  electrocardiography
• metabolic GXT (measurement of VO2 and VCO2)
• pharmacological GXT (use of sympathomimetic
  drugs to u HR BP)

Sensitivity, Specificity and Diagnosis in Medical
Testing
Sensitivity the percentage of people with
disease that actually test positive
Specificity the percentage of people without
disease that test negative Predictive Value
the percentage of people with a test that
actually have CAD
TP TP FN
TN TN FP
TP TP FP
Sensitivity and specificity for GXT with 12- lead
ECG Sensitivity x 70 Specificity x 80
9
Health Risk Continuum and Graded Exercise
Testing Consider the following two people, both
of whom had a GXT ( d ST-segments)
Gender female Gender male Family
History negative Family History father died
of MI at 42 Age 17 Age 70 TC 146 TC 31
0 HDL-C 69 HDL-C 29 LDL-C 92 LDL-C 191 BP
114 / 76 BP 156 / 96 Smoking never Smoki
ng 150 pack years Peak VO2 52 ml / kg /
min Peak VO2 22 ml / kg / min Diabetes never
Diabetes Type 1 since age 23 Exercise
habits 3x / week for 50 min. Exercise
habits none ST- segments and Hemodynamics of
GXT ST-segments and Hemodynamics of
GXT Upsloping depression noted only at peak
downsloping depression noted at low
exercise resolved within 15 seconds of
workload - persisted 8 minutes after exercise
exercise termination
termination BP 174 / 84 at peak exercise
BP 246 / 110 at peak exercise BP 118 / 72
10 min. post exercise BP 208 / 102 10
min. post exercise (Most likely a False
test) (Most likely a True test)
Healthy Increased Health Risk
10
Factors influencing follow-up testing decisions
for a positive GXT
GXT results (ST depression depth) smoking
status age rest exercise BP status family
history other diseases lipids
status lifestyle
Non-invasive Stress Coronary Nuclear
Imaging Echocardiography
Angiography
11
Absolute Contraindications to Graded Exercise
Testing (ACSM)

• recent significant ECG changes (ischemia)
• recent MI (within 2 days)
• symptomatic ventricular arrhythmia
• symptomatic supraventricular arrhythmia
• uncontrolled symptomatic heart failure

• suspected or known dissecting aneurysm
• acute myocarditis pericarditis
• thrombophlebitis or intracardiac thrombi
• acute pulmonary embolus or infarction
• acute infection
• severe aortic stenosis

Abdominal Aortic Aneurysm
X-section of Aneurysm
12
Relative Contraindication to Graded Exercise
Testing (ACSM)

• uncontrolled metabolic disease
• diabetes
• thyrotoxicosis
• myxedema
• chronic active infectious disease
• AIDS
• mononucleosis
• hepatitis
• physical limitations
• neuromuscular problems
• musculoskeletal problems
• rheumatoid arthritis

• resting SBP gt 200 mmHg
• resting DBP gt 110 mmHg
• moderate valvular heart disease
• electrolyte abnormalities
• hypertrophic cardiomyopathy/
• outflow tract obstruction
• tachyarrhythmias or bradyarrhythmias
• ventricular aneurysm
• dangerous ventricular ectopy (not in ACSM
  guidelines)
• successive run of 3 or more PVCs (run of
  V-tach.)
• PVCs compose gt 30 of complexes
• PVCs falling on a T-wave (R on T)

13
Indications for Terminating a GXT (ACSM)
Absolute
Relative

• d SBP gt 10 mmHg signs of ischemia
• moderate to severe angina
• u CNS problems
• (ataxia, dizziness, syncope)
• (may reflect inadequate cerebral flow)
• poor perfusion (cyanosis, pallor)
• technical difficulties
• sustained V-tach
• ST-segment elevation gt 1 mm in leads
• without diagnostic Q-waves

• d SBP gt 10 mmHg
• shift in the ECG axis
• horizontal or downsloping ST-segment
• depression gt 2mm
• multifocal PVC's or 3 PVC's in a row
• PSVT, heart blocks, bradyarrhythmias
• (especially wide QRS complex rhythms)
• fatigue, shortness of breath, leg cramps
• any u in chest pain
• SBP gt 250 mmHg
• DBP gt 115 mmHg

14
Differences in Physiological Responses
to Exercise in Those with CAD

• lower maximum oxygen consumption
• blunted cardiac output response
• blunted heart rate response
• blunted stroke volume response
• decreased ejection fraction
• AVO2 difference widens earlier in exercise and
  is blunted
• lower rate of circulatory adjustment to
  workload
• Hossack, Bruce, et al. Am J Cardiol 52 1983

15
Test Results Warranting Medical Referral

• significant ST-segment changes from baseline
• horizontal-to-downsloping ST segment
  depression gt 1 mm (ischemia)
• ST segment elevation in normal ECG (very
  probable ischemia)
• ST segment elevation in leads with MI
  Q-wave (wall motion abnormalities)
• significant ventricular or supraventricular
  ectopy or rhythm
• not necessarily associated with absence
  or presence of CAD
• any chest or arm pain induced or increased with
  exercise
• failure to increase or significant drop in HR or
  SBP during exercise
• normal 10 beats / MET 10 mmHg / MET
• maximal SBP of lt 140 mmHg suggests poor
  prognosis
• hypertensive response to exercise (SBP gt 225
  mmHg)
• exercise induced BBB
• exercise induced 2nd or 3rd degree AV block

16
ACSM Exercise Participation Recommendation
Physical GXT Recommended Prior to Exercise
Participation

• moderate vigorous
• exercise exercise
• lt 45 lt 55 no more than 1 ACSM
  risk marker no no
• Older persons or those having 2 or more ACSM risk
  markers no yes
• Signs, symptoms, of CV disease or known yes
  yes
• CV, pulmonary, or metabolic disease

17
VO2 Heart Rate Relationship for Exercise Rx
70 HR max Heart
Rate 60 VO2 max
VO2 max VO2 or Workload
max HR
85 HR max
80 VO2 max
60 HRR
80 HRR
18
Endurance Exercise Rx for Healthy People ACSM
Guidelines

• Frequency
• 3 to 7 sessions per week
• Intensity
• 70 - 85 of peak HR (60 - 80 of peak VO2 )
• 40 - 50 of peak VO2 initially for sedentary
  people
• Heart Rate Reserve Method for Calculating THR
  (Karvonen Formula)
• THR Intensity x (MHR RHR) RHR
• ? Intensity 60 Functional capacity in
  METS
• RPE 12 16 on Borg Scale (5 to 8 on a 10 point
  scale)
• While exercising, a conversation should be
  possible
• Duration
• 20 60 minutes, an average being 20 30
  minutes
• Overuse injuries increase dramatically with
  a duration gt 45 min.

19
Progression Rate for Exercise Rx ACSM Guidelines
Focus of Exercise Rx ADHERENCE

• Initial Conditioning Stage
• may lasts up to 4 weeks for previously
  sedentary individuals
• 3 days / week
• 40 - 50 HRR (slightly higher if subject is
  active)
• 15 minutes (even less if client has been very
  sedentary)

• Improvement / Progression Stage
• lasts 4 to 5 months
• u duration and frequency before intensity
• 3 - 5 days / week
• u intensity to 70 - 85 HRR
• u duration to at least 30 minutes

• Maintenance Stage
• Review goals (consider re-testing for more
  accurate Rx)
• 3 -5 days / week
• 70 - 85 HRR
• minimum of 30 minutes

20
Exercise Rx for Impaired and Sedentary
People ACSM Guidelines

• Frequency and Duration
• Functional Capacity lt 3 METS 3 sessions of 5
  minutes (daily)
• Functional Capacity 3 5 METS 1 2 sessions
  (daily)
• Functional Capacity gt 5 METS normal parameters
• Intensity
• 40 - 50 of peak VO2 initially for sedentary
  people
• Progress by increasing duration and frequency
  before intensity
• Always below pain and symptom threshold

21
Contraindications to Cardiac Rehabilitation

• Unstable Angina
• SBP gt 200 mm Hg or DBP gt 110 mmHg
• Orthostatic BP drop of gt 20 mmHg with symptoms
• Severe aortic stenosis
• Uncontrolled atrial or ventricular arrhythmias
• Uncontrolled sinus tachycardia
• Uncompensated heart failure
• 3rd degree AV block without pacemaker
• Active pericarditis or myocarditis
• Recent embolism
• Thrombophlebitis
• Resting ST segment depression or elevation gt 2
  mm
• Uncontrolled diabetes (glucose gt 400 mg / dl
• Acute systemic illness or metabolic problems
• Orthopedic problems that would preclude exercise

22
Exercise RX for Cardiac Patients ACSM Guidelines

• Inpatient (Phase 1)
• Self care activities and ambulation as
  precursors
• Resting HR 10 to 30 beats/min
• 2-4 session/day for 3 10 minutes per session
• Progress by u bout duration and then d number of
  bouts
• Borg Scale lt 13
• ECG and hemodynamics should be constantly
  monitored
• Outpatient (Phase II)
• Functional capacity lt 5 METS inpatient
  parameters
• Functional capacity gt 5 METS low end of normal
  parameters
• Progress to a goal of 20 30 minutes 3 times /
  week
• Progress to a goal of burning a minimum of 1000
  Kcal / week
• ECG monitor required for those with
• LV malfunction
• Signs of ischemia
• Arrhythmias
• Low functional capacities

23
Exercise Intensity Threshold Guidelines for
Cardiac Rehabilitation

• Set intensity level below
• Onset of angina (at least 10 beats per minute
  below)
• Plateau or decrease in SBP
• SBP of 240 or DBP of 110
• ST- segment depression of 1 mm
• Signs of left ventricular dysfunction (heart
  failure)
• Signs of increasing ventricular ectopy or
  ventricular arrhythmias
• Significant AV block
• Significant supraventricular arrhythmias
  (tachycardia, A-fibrillation, etc.)