Optimizing exercise prescription: EXPERT tool Dominique Hansen, PhD, FESC

Disclosure statement None to be declared

Is cardiac rehabilitation important?

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

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

Impact of exercise intervention on CVD risk Risk factor Primary prevention Secondary prevention Fat mass SBP DBP HDL LDL TC HbA1c (in diabetes) VO2peak Chen YC, et al. Eur J Cardiovasc Nurs. 2017: 16: 397-408 Pattyn N, et al. Sports Med. 2013; 43: 121-33.

Importance of optimal CV risk management

Do different exercise interventions matter in the (secondary) prevention of cardiovascular disease?

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

Approach in tailoring exercise Patient phenotype Prevalent CV diseases CVD risk profile Blood lipid profile Glycemic control Fat mass Medication intake Physical fitness and exercise response Exercise prescription Hansen D, et al. Eur J Prev Cardiol 2018: in press

But what about different combinations of CVD risk factors? How good are we in prescribing exercise in these patients?

Compare exercise prescriptions from different clinicians to the same (complex) patient and observe …whether they agree between themselves …whether they agree with guidelines

Comparing different clinicians

Comparing different clinicians Hansen D, et al. Eur J Prev Cardiol 2018; 25: 682-91

Comparing different clinicians Hansen D, et al. Eur J Prev Cardiol 2018; 25: 682-91

Comparing different clinicians Hansen D, et al. Eur J Prev Cardiol 2018; 25: 682-91

A gap is present between… Clinical practice Guidelines

Hansen D, et al. Eur J Prev Cardiol 2017; 24: 1017-31 Hansen D, et al. Eur Heart J 2017; 38: 2318-20

EXPERT Tool Digital, interactive decision support tool for exercise prescription Endorsed by the European Association of Preventive Cardiology Access: https://expert-tool.edm.uhasselt.be License: www.escardio.org/Education/Practice-Tools/CVD-prevention-toolbox/expert-tool

The EXPERT-tool algorithm Hansen D, et al. Eur J Prev Cardiol 2017; 24: 1017-31

Approach in tailoring exercise Patient phenotype Prevalent CV diseases CVD risk profile Blood lipid profile Glycemic control Fat mass Medication intake Physical fitness and exercise response Exercise prescription Hansen D, et al. Eur J Prev Cardiol 2018: in press

EXPERT tool Hansen D, et al. Eur J Prev Cardiol 2017; 24: 1017-31

EXPERT tool Hansen D, et al. Sports Med 2018; 48: 1781-97

as a recommendation tool for the professional EXPERT tool as a recommendation tool for the professional as an educational tool in university as a training tool in a hospital / rehab center integrated with a mobile patient app (e.g. HeartHab app UHasselt) -> S. Sankaran, et al.

EXPERT-tool recommendation centre

EXPERT-tool recommendation editing

Simulation July Age: 53 years Body height: 160 cm Body weight: 56 kg Exercise intensity (based on HR) Exercise session duration Exercise frequency Minimal program duration Addition of strength training? Additional exercise types? Simulation July Age: 53 years Body height: 160 cm Body weight: 56 kg Sex: female VO2max: 1350 ml/min (96% of predicted normal value) Resting HR: 65 bts/min Peak exercise HR: 135 bts/min Total cholesterol: 165 mg/dl Fasting glycemia: 129 mg/dl Blood pressure: 125/75 mmHg Medication intake: statin, beta-blocker Referred to rehabilitation for: elevated CVD risk Co-morbidities: none Additional information: gonarthrosis present

Tool starts with regular exercise prescription 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 betablocker: patient is thus hypertensive Intake of statin: patient is thus dislipidemic Elevated fasting blood glucose: type 2 diabetes?

Simulation INTENSITY Moderate: HR up to 120 bts/min SESSION DURATION There are no known contra-indication for moderate-intense exercise training. The superiority of high-intensity exercise training remains uncertain at the moment. SESSION DURATION From 30 building up to 60 min Because the patient is on statin therapy, the patient per definition experiences hypercholesterolemia. To lower blood cholesterol concentrations, a weekly exercise energy expenditure >900 kcal is advised. To achieve these goals exercise duration must be sufficiently long.   FREQUENCY 5 days/week The patient is hypertensive, even with beta-blocker therapy, and suffers from (previously undiagnosed) type 2 diabetes. To lower blood pressure and sufficiently improve glycemic control, daily exercise training is recommended. MINIMAL PROGRAM DURATION 12 weeks (but actually much longer) For the treatment of hypercholesterolemia and type 2 diabetes prolonged exercise interventions are recommended. It is thus advised to try to elevate daily physical activity level for this period after the out-patient rehabilitation program. STRENGTH TRAINING Yes: glycemic control is affected significantly by strength training exercises. ADDITIONAL TRAINING STRATEGIES Additional isometric handgrip exercise training is advised to lower blood pressure. Safety precautions?

Simulation Jack Age: 70 years Body height: 175 cm Body weight: 65 kg Exercise intensity (based on HR) Exercise session duration Exercise frequency Minimal program duration Addition of strength training? Additional exercise types? Jack Age: 70 years Body height: 175 cm Body weight: 65 kg Sex: male VO2max: 1250 ml/min (67% of predicted normal value) Resting HR: 56 bts/min Peak exercise HR: 112 bts/min Total cholesterol: 167 mg/dl Fasting glycemia: 89 mg/dl Blood pressure: 135/65 mmHg Medication intake: statin, beta-blocker Referred to rehabilitation for: PCI Co-morbidities: COPD, frailty/sarcopenia Observation during CPET: Myocardial ischemia at HR 100 bts/min

Simulation INTENSITY Moderate: HR up to 89 bts/min SESSION DURATION There are no medical indications for avoiding moderate-intense exercise training. However, due to deconditioning, it may be relevant to start at a lower exercise intensity but reach the target exercise intensity as soon as possible. Potential modifier: change in myocardial ischemia threshold SESSION DURATION 20 up to 60 min Because the patient is on statin therapy, the patient per definition experiences hypercholesterolemia. To lower blood cholesterol concentrations, a weekly exercise energy expenditure >900 kcal is advised. To achieve this goal exercise duration must be sufficiently long. FREQUENCY 5 days/week The patient is hypertensive, even with beta-blocker therapy. To lower blood pressure daily exercise training is recommended. MINIMAL PROGRAM DURATION 12 weeks (but actually a lot longer) This patient suffers from COPD : this co-morbidity leads to prolongation of the exercise intervention. It is thus advised to try to elevate daily physical activity level for this period after the in- our out-patient rehabilitation program. STRENGTH TRAINING Yes: Patients with COPD often are very often sarcopenic (the patient actually is). ADDITIONAL TRAINING STRATEGIES Add inspiratory muscle training (IMT) because COPD is present. Additional isometric handgrip exercise training is advised for the treatment of hypertension. Breathing exercises should be added for the treatment of COPD. Muscle electrostimulation may be added for COPD and sarcopenia. Potential modifier: progression in COPD

EXPERT-tool training center (educational use)

Integration with HeartHab self-management app

Survey in family physicians Subsequent papers on exercise prescription Next steps? RCT to assess clinical effectiveness of ‘usual CR’ vs ‘EXPERT-tool assisted CR’ Survey in UK Survey in family physicians Subsequent papers on exercise prescription

Some CVD risk factors should be affected with greater magnitude Conclusions Some CVD risk factors should be affected with greater magnitude The variance in exercise perscriptions between clinicians can be large The EXPERT tool may be of clinical assistance

Members of EXPERT working group Colleagues of EDM from Hasselt university Prof. dr. Karin Coninx & dr. Gustavo Rovelo Ruiz Members of EXPERT survey working group