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

2. Disclosure statement
None to be declared

4. Is cardiac rehabilitation important?

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

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

7. 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:
Pattyn N, et al. Sports Med. 2013; 43:

8. Importance of optimal CV risk management

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

13. 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

14. 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

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

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

17. Comparing different clinicians

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

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

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

21. A gap is present between…
Clinical practice
Guidelines

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

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

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

25. 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

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

27. EXPERT tool
Hansen D, et al. Sports Med 2018; 48:

28. 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.

29. EXPERT-tool recommendation centre

30. EXPERT-tool recommendation editing

31. 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: cm
Body weight: 56 kg
Sex: female
VO2max: 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

32. 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 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?

33. 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?

34. 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: cm
Body weight: 65 kg
Sex: male
VO2max: 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

35. 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

36. EXPERT-tool training center (educational use)

37. Integration with HeartHab self-management app

38. 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

39. 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

40. 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