1. Individualized physical training in CV prevention and rehabilitation
Dominique Hansen, PhD, FESC

2. Disclosure statement
None to be declared

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

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

5. Fat mass reduction (obesity)

6. 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

7. Blood pressure reduction (hypertension)

8. Blood pressure reduction (hypertension)

9. 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

10. Blood glucose reduction (type 2 diabetes)

11. Blood glucose reduction (type 1 diabetes)

12. 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

13. Blood lipid improvement (dyslipidemia)
Complex interactions
Diet
Pharmacologic intervention

14. Physical fitness (deconditioning)

15. 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

16. 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

17. Optimization of exercise prescription
Optimized effectiveness

18. Optimized exercise in obesity
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

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

20. 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

21. Optimized exercise in type 1 diabetes
End exercise session with high-intensity exercise.
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

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

23. Optimized exercise in deconditioned subjects
Greater improvements in VO2peak anticipated when:
Starting at lower VO2peak
Programmes are prolonged
HIIT is applied (vs. MIT)
Milanovic Z, et al. Sports Med 2015; 45:

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

25. Type 2 diabetes
Dyslipidemia
Obesity
Hypertension
Type 1 diabetes
Insulin resistance

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

27. Comparing different clinicians

28. Comparing different clinicians

29. Comparing different clinicians
Hansen D, et al. Eur J Prev Cardiol 2018

30. Comparing different clinicians
Hansen D, et al. Eur J Prev Cardiol 2018

31. Comparing different clinicians
Hansen D, et al. Eur J Prev Cardiol 2018

32. A gap is present between…
Clinical practice
Guidelines

34. EXPERT Tool
Digital, interactive decision support tool for exercise prescription
Endorsed by the European Association of Preventive Cardiology

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

36. EXPERT tool

37. EXPERT tool

38. EXPERT tool

39. EXPERT tool

40. 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

41. 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 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

42. EXPERT output EXPERT simulation Exercise prescription:
Intensity: HR 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

43. 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

44. 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

45. EXPERT output EXPERT simulation Exercise prescription:
Intensity: HR 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

46. 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