The EXPERT tool: focus on prevention Dominique Hansen, PhD, FESC

Exercise in prevention of CVD: why?

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

But how good are we in improving cardiovascular disease risk by exercise intervention?

Fat mass reduction (obesity)

Fat mass reduction (obesity) Focus is very often on body weight Distinction must be made between lean and adipose tissue mass Medical imaging Alternative: waist circumference

Blood pressure reduction (hypertension)

Blood pressure reduction (hypertension)

Blood pressure reduction (hypertension) Reductions in SBP and DBP by ±7% and ±5 mmHg, respectively Cornelissen VA, et al. Hypertension 2005;46:667–75. Tsai JC, et al. Clin Exp Hypertens 2002;24:315–24. Pitsavos C, et al. Hellenic J Cardiol 2011;52:6–14. But complex, because of impact of Assessment methodology Interference with blood pressure lowering medications

Blood glucose reduction (type 2 diabetes)

Blood glucose reduction (type 1 diabetes)

Blood lipid improvement (dyslipidemia) Effects of endurance exercise depend on population: Healty adults: reductions in TG Kelley GA, et al. Clin Nutr 2012; 31; 156 CVD: reductions in TG and TC Oldridge N. Future Cardiol 2012; 8: 729 Obesity: reductions in TG and TC Kelley GA, et al. Int J Obes 2005; 29: 881 Type 2 diabetes: reductions in LDL, increase in HDL Hayashino Y, et al. Diabetes Res Clin Pract 2012; 98: 349

Blood lipid improvement (dyslipidemia) Complex interactions Diet Pharmacologic intervention

Physical fitness (deconditioning)

Are we good at improving CVD risk by exercise intervention? Interim conclusion Are we good at improving CVD risk by exercise intervention? Yes, and larger effects Glycemic control Physical fitness Yes, but smaller effects Blood pressure and lipid profile No Fat mass

Tailor your intervention We should aim for maximum improvement of the CVD risk, but with optimal medical safety, to prevent cardiovascular disease Tailor your intervention

Optimization of exercise prescription Optimized effectiveness Optimized medical safety

Optimized exercise in obesity Optimize effectiveness Maximise exercise volume (>250 min/week and >1500 kcal/week) Select a sufficient exercise intensity (at least moderate intense) Select whole-body exercises (walking, stepping, rowing, cross-training) Prolong to >24 weeks Optimize medical safety Monitor orthopedic symptoms

Optimized exercise in hypertension Optimize effectiveness Maximise exercise frequency (≥5 days) Reductions in BP are transient Consider higher exercise intensity Some studies discovered greater post-exercise BP reductions Add handgrip strength training Significant impact on sympathetic tone

Optimized exercise in hypertension Optimize medical safety Be aware of hypotensive symptoms Patients are on BP lowering drugs…and become more sensitive Stopping exercise suddenly should be avoided as it may result in a precipitous drop in SBP B-blockers and diuretics may adversely affect thermoregulatory function, especially during exercise in warmer temperatures and cause hypoglycaemia in some individuals. 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.

Optimized exercise in dyslipidemia Achieve a weekly caloric expenditure >900 kcal. Prolong exercise intervention (>40 weeks) Add resistance exercise training Some studies describe greater impact on blood HDL-c concentration Maximize medical safety Statins may lead to myopathy

Optimized exercise in type 1 diabetes Optimize clinical effectiveness End exercise session with high-intensity exercise. 2-4 10-20 sec all-out bouts Adrenergic stimulus leads to glucose release from liver Prolong program >6 months Maximize exercise frequency (≥5 days) Greater impact on insulin sensitivity, which is transient

Optimized exercise in type 1 diabetes Optimize medical safety Increased risk for episodes of rapidly occurring hypoglycemia as well as hyperglycemia during and after exercising Frequent self-monitoring of blood glucose Adaptation of insulin doses and adequate intake of carbohydrates before and during exercise. If pre-exercise glucose is below 5.6mM, added CHO should be ingested before performing exercise. If pre-exercise glucose is above 14mM, urine should be tested for ketone bodies. If positive, exercise should not be performed. If pre-exercise glucose is above 17 mM physical exercise should not be performed regardless of ketone results.

Optimized exercise in type 1 diabetes Optimize medical safety Insulin pump may be the most flexible treatment option in patients with type 1 diabetes performing exercise High-intensity exercise is contra-indicated in retinopathy All individuals with peripheral neuropathy must wear proper footwear. No weight-bearing exercise if open foot lesions Autonomic neuropathy is associated with increased CVD risk, therefore, a pre-exercise cardiac testing is required in these situations

Optimized exercise in type 2 diabetes Optimize clinical effectiveness Maximise exercise frequency (≥5 days). Greater improvement in insulin sensitivity, which is transient Add resistance exercise training. Prolong exercise intervention >6 months

Optimized exercise in type 2 diabetes Optimize medical safety Intake of sulfonylurea and meglitinide, or exogenous insulin injection, may lead to elevated risk for hypoglycemia

Optimized exercise in deconditioned subjects

But what about different combinations of CVD risk factors? How to prescribe exercise in these patients?

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

EXPERT tool

EXPERT tool

EXPERT tool

EXPERT tool

Simulations of exercise prescription Age: Body height: Body weight: BMI: Sex: VO2max: Resting HR: Peak exercise HR: Total cholesterol: LDL: Fasting glycaemia: Blood pressure: Medication intake: Co-morbidities: 61 years 170 cm 97 kg 33.56 kg/m² Male 2283 ml/min (100% of normal value) 69 bpm 141 bpm ? 125/80 mmHg Beta blocker, ACE inhibitor, Antiplatelet none

Tool starts with regular exercise prescription EXPERT simulation Tool starts with regular exercise prescription 150 min low-to-moderate intense endurance exercise training per week (spread over 3-5 days, achieving 1000-2000 kcal) for at least 12 weeks But further adjusts: Intake of diuretics, betablockers, ACE inhibitor Patient is thus hypertensive Elevate exercise frequency, consider hand grip strength exercises Obesity Maximize caloric expenditure Prolong intervention

EXPERT output EXPERT simulation Exercise prescription: Intensity: HR 98-111 bts/min Frequency: build up to at least 5 days/week Exercise session duration: from 30 up to 60 min/session Minimal program duration: >24 weeks Strength training: yes Consider hand grip strength exercises

EXPERT simulation Age: Body height: Body weight: BMI: Sex: VO2max: Resting HR: Peak exercise HR: Total cholesterol: LDL: Fasting glycaemia: Blood pressure: Medication intake: Co-morbidities: 61 years 170 cm 97 kg 33.56 kg/m² Male 1283 ml/min (65% of normal value) 69 bpm 141 bpm ? 125 mg/dl 125/80 mmHg Beta blocker, ACE inhibitor, Antiplatelet, Metformin none

Intake of diuretics, betablockers, ACE inhibitor EXPERT simulation Intake of diuretics, betablockers, ACE inhibitor Patient is thus hypertensive Elevate exercise frequency, consider hand grip strength exercises Obesity Maximize caloric expenditure Prolong intervention But further adjusts: Low VO2peak Start at lower intensity Type 2 diabetes Elevate exercise frequency, add strength training, prolong intervention

EXPERT output EXPERT simulation Exercise prescription: Intensity: HR 90-98 bts/min Frequency: build up to at least 5 days/week Exercise session duration: from 30 up to 60 min/session Minimal program duration: >24 weeks Strength training: yes Consider hand grip strength exercises Strength training for large muscle groups

EXPERT simulation Age: Body height: Body weight: BMI: Sex: VO2max: Resting HR: Peak exercise HR: Total cholesterol: LDL: Fasting glycaemia: Blood pressure: Medication intake: Co-morbidities: 61 years 170 cm 97 kg 33.56 kg/m² Male 1283 ml/min (65% of normal value) 69 bpm 141 bpm ? 145 mg/dl 125/80 mmHg Beta blocker, ACE inhibitor, Antiplatelet, Insulin none

Intake of diuretics, betablockers, ACE inhibitor EXPERT simulation Intake of diuretics, betablockers, ACE inhibitor Patient is thus hypertensive Elevate exercise frequency, consider hand grip strength exercises Obesity Maximize caloric expenditure Prolong intervention Low VO2peak Start at lower intensity But further adjusts: Type 1 diabetes Elevate exercise frequency, add strength training, prolong intervention, end exercise session with HIT

EXPERT output EXPERT simulation Exercise prescription: Intensity: HR 90-98 bts/min Frequency: build up to at least 5 days/week Exercise session duration: from 30 up to 60 min/session Minimal program duration: >24 weeks Strength training: yes Consider hand grip strength exercises Strength training for large muscle groups Additional training strategies End exercise bout with HIT

Exercise intervention is potent to improve CVD risk Conclusions Exercise intervention is potent to improve CVD risk However, there is room for further improvement The EXPERT tool may assist in achieving this goal