Dominique Hansen, PhD, FESC Exercise prescription in patients with multiple cardiovascular diseases and risk factors: bringing it all together in the EXPERT tool Dominique Hansen, PhD, FESC

Exercise in cardiovascular disease: why?

Exercise in cardiovascular disease: why?

Exercise in cardiovascular disease: guidelines exercise >150 min/week (spread over >2 exercise sessions/week) low-to-moderate endurance intensity weekly caloric expenditure of 1000-2000 kcal/week combination with resistance exercises Piepoli MF, et al. Eur J Prev Cardiol 2010;17:1-17

Exercise in cardiovascular disease: guidelines Piepoli MF, et al. Eur J Prev Cardiol 2016;23:NP1-96

Difficulties ahead

Exercise prescription becomes more difficult Improved medical diagnosis and intervention Patients with renal, pulmonary and metabolic disease, cancer, etc. live longer and may develop CVD, which is noticed better …and the other way around The population is ageing Co-morbid population Including sarcopenia and frailty Complex medication schemes Psychosocial impact

Exercise prescription becomes more difficult End result of all these trends We more often encounter patients with: Multiple diseases Multiple CVD risk factors Polypharmacy Compromised exercise capacity Abnormalities during exercise (testing) A need for a more tailored approach

Exercise prescription becomes more difficult Complexity of patient case Clinical effectiveness and medical safety of exercise intervention?

Exercise prescription becomes more difficult Consult the guidelines? And what about combinations of different exercise schemes for different indications?

EXPERT tool Hansen D, et al. Eur J Prev Cardiol 2017; in press

EXPERT tool

EXPERT tool

EXPERT tool

Simulations of exercise prescription Case 1 Age: Body height: Body weight: BMI: Sex: VO2max: Resting HR: Peak exercise HR: Total cholesterol: LDL: Fasting glycemia: Blood pressure: Medication:   Primary Indication: Key risk factors: Exercise modifiers: Anomalies: 72 years 154 cm 61 kg 25.7 kg/m² Female 940 ml/min – 80% of normal value 67 bts/min 109 bts/min 193 mg/dl 104 mg/dl ? 120/80 mmHg Antiplatelets, betablocker, ACE inhibitor, diuretic, statins, metformin Urgent CABG – Pacemaker Type II diabetes, dyslipidemia, hypertension None

Case 1: EXPERT simulation Intake of diuretics, betablockers, ACE inhibitor Patient is thus hypertensive Elevate exercise frequency, consider hand grip exercises CABG Strength training is mandatory Pacemaker Be carefull with HR training zones Statin intake Patient is thus dyslipidemic: elevate caloric expenditure (>900 kcal/week), maximize training program duration Type 2 diabetes Strength training is mandatory, elevate exercise frequency, maximize training program duration

Case 1: EXPERT simulation Final EXPERT output Exercise prescription: Intensity: HR 84-92 bts/min Frequency: build up to at least 5 days/week Exercise session duration: from 30 up to 60 min/session Minimal program duration: >40 weeks Strength training: yes Additional training types In case of CABG surgery, strength training for the arm muscles are only allowed when the sternum is stabilized, >900 kcal/week of energy expenditure should be achieved, Additional isometric handgrip exercise training is advised

Case 1: EXPERT simulation Final EXPERT output Safety precautions Exercise training has to be adjusted on the time course of wound healing and all other potential complications. Thoracic shear and pressure stress has to be strictly avoided during the first 6-8 weeks after sternotomy If SBP rises >250 mmHg and/or DBP >115 mmHg during exercise, the training session should be terminated as this may indicate the need to adjust medical therapy. Suddenly stopping exercise should be avoided as it may result in a precipitous drop in blood pressure. Statins may induce myopathy Calculated heart rate zone is not valid anymore when beta blocker therapy is changed.

Simulations of exercise prescriptions Case 2 Age: Body height: Body weight: BMI: Sex: VO2max: Resting HR: Peak exercise HR: Total cholesterol: LDL: Fasting glycemia: Blood pressure: Medication: Primary Indication: Key risk factors: Exercise modifiers: 82 years 183 cm 84 kg 25.08 kg/m² Male 888 ml/min – 52% of normal value 81 bts/min 85 bts/min 116 mg/dl 50 mg/dl 95 mg/dl 115/90 mmHg Antiplatelets, statins, diuretics, betablockers, ACE inhibitor Heart failure (NYHA III), pacemaker Dyslipidemia, hypertension Renal failure

Case 2: EXPERT simulation Low VO2peak Start at lower intensity Diuretics, betablockers, ACE inhibitor Patient is thus hypertensive Elevate exercise frequency, consider hand grip exercises Heart failure (NYHA III) Moderate-intense training or HIT may be used Strength training is mandatory Pacemaker Be carefull with HR training zones Statin intake Patient is thus dyslipidemic: elevate caloric expenditure and maximize training program duration Renal failure

Case 2: EXPERT simulation Final EXPERT output Exercise prescription: Intensity: HR 83 bts/min, start at lower intensity Frequency: build up to at least 5 days/week Exercise session duration: from 30 up to 60 min/session Minimal program duration: >40 weeks Strength training: yes Additional training types Add inspiratory muscle training (IMT), >900 kcal/week of energy expenditure should be achieved, additional isometric handgrip exercise training is advised, flexibility and balance exercises should be added

Case 2: EXPERT simulation Final EXPERT output Safety precautions Haemodialysis patients should pay attention with upper limbs resistance exercises, due to the arterio-venous fistulas. Peritoneal dialysis patients are recommended to exercise with emptied abdominal cavities. Intra-dialytic exercise training should be performed during the first two hours of dialysis sessions. Patients should be informed about the nature of cardiac prodromal symptoms and exercise-related warning symptoms including chest pain or discomfort, abnormal dyspnoea, dizziness or malaise and should seek prompt medical care if such symptoms develop. Intense isometric exercise, such as heavy-weight lifting, can have a marked pressor effect and should be avoided.

Simulations of exercise prescriptions Case 3 Age: Body height: Body weight: BMI: Sex: VO2max: Resting HR: Peak exercise HR: Total cholesterol: LDL: Fasting glycemia: Blood pressure: Medication: Primary Indication: Key risk factors: Exercise modifiers: 79 years 171 cm 54 kg 18.5 kg/m² Male 810 ml/min – 56% of normal value 67 bts/min 115 bts/min 185 mg/dl ? 135 mg/dl 120/80 mmHg Antiplatelets, statins, betablockers, ACE inhibitor, bronchodilator, corticoid PCI Dyslipidemia, hypertension COPD, sarcopenia

Case 3: EXPERT simulation Low VO2peak Start at lower intensity Diuretics, betablockers, ACE inhibitor Patient is thus hypertensive Elevate exercise frequency, consider hand grip exercises Sarcopenia Strength training is now the basis of the program Statin intake Patient is thus dyslipidemic: elevate caloric expenditure and maximize training program duration PCI Follow the standard exercise recommendation COPD Strength training is mandatory Respiratory exercises are mandatory

Case 3: EXPERT simulation Final EXPERT output Exercise prescription: Intensity: HR 86-95 bts/min, start lower intensity Frequency: build up to at least 5 days/week Exercise session duration: from 30 up to 60 min/session Minimal program duration: >40 weeks Strength training: yes, it is the basis Additional training types >900 kcal/week of energy expenditure should be achieved, additional isometric handgrip exercise training is advised, muscle electrostimulation and breathing exercises should be added, balance training or tai chi may be added

Case 3: EXPERT simulation Final EXPERT output Safety precautions Oxygen supplementation should be initiated when oxygen saturation drops below 90%. Monitor physiologic parameters (BP, HR) and symptoms (Borg scale) during exercise, and do not exceed 12/20 in Borg scale. Physiotherapists or exercise physiologists should assist during exercises Prefer a gradual increase in workload, from sitting to standing position for performing exercises, and gradually increase in number of repetitions and sets. In PCI patients, exercise training may be started immediately after healing of the punctured vessel. This may be as early as one day after the intervention.

Conclusion Exercise prescription in multi-morbid patients can be challenging Clinical guidelines provide exercise recommendations for seperate diseases and risk factors, and are of paramount importance However, a digital instrument (EPAC EXPERT) tool may assist clinicians in how to prescribe exercise in patients were many different diseases are present