In 1945, more babies were born than in any previous year, and from 1946 to 1964, 70% more children were born than in the previous 2 decades. This post–World War II “baby boom” created a population trend with great impact on our society and will continue until the last of the boomers turn 65 years in 2030. Americans aged 65 years and older grew 11-fold in the past century and will double in the first 30 years of this century (Figure 1). In addition to the baby boom, life expectancy has increased by 29.6 years (62%). Americans aged 80 years and older are the fastest growing segment of our population. As such, Americans are more likely to be educated, less likely to live in poverty, and more likely to be living with chronic illness and some level of disability (54).
Along with the increase in the age of our population as well as the likelihood of living with a chronic illness, the overall cost of health care in the United States has skyrocketed. Health care costs continue to increase faster than almost any other goods or service. Current trends in cost sharing that shift more responsibility in terms of financing and managing illness will drive more consumers toward physical activity—the most significant single intervention against the loss of function and progression of illness. As illustrated by the past election and current activity of the Congress, addressing health care costs will continue to be one of America's most pressing challenges in the foreseeable future (52).
With the aging of society, inflation of health care costs, reduction of mortality related to cardiovascular diseases (CVDs) (without a change in prevalence), and an increase in risk related to lifestyle, there will be a greater demand for allied health care professionals with the knowledge, skills, and abilities to help individuals maintain health and quality of life. There are a myriad of publications showing the benefits of physical activity and exercise from both the government as well as leading agencies in physical activity and exercise (10,17,18,39). As such, the baby boomers are interested in ways to maintain their health, maintain function and an active lifestyle, and prevent the development of and/or manage such chronic conditions as CVD.
BURDEN OF CARDIOVASCULAR DISEASE
As a background to CVD, diseases of the heart, a component of CVD, are the leading cause of death in the United States. CVDs are a broader classification of diseases of circulation including all arteries, arterioles, capillaries, and veins including hypertension, coronary artery disease, heart failure, and stroke (38) (for more information on U.S. mortality rates refer Figure 2). CVD crosses both gender and ethnic boundaries and accounts for approximately 24% of all deaths annually (27). The American Heart Association forecasts that by 2030, 40.5% of the population will have some form of CVD (25).
The good news is that there is a current trend (1998–2008) showing an overall reduction (−30.6%) in the number of deaths associated with CVD (51). The bad news is during this time, the prevalence of CVD remains relatively unchanged, the total number of inpatient cardiovascular operations and procedures increased to 22%, as well as the prevalence of many of the risk factors for CVDs such as obesity, diabetes, and physical inactivity (51). This illustrates the need for advancements in behavioral and lifestyle interventions to keep pace with medical technology and pharmacological advances. In addition, it increases the likelihood that the exercise professionals will prescribe exercise and train individuals with the known CVD.
CVD has both genetic and environmental factors that can be thought of as modifiable and nonmodifiable risk factors for the progression of the disease. Nonmodifiable risk factors include age, family history, and gender. Generally speaking as a person ages, their risk for CVD increases; additionally, this age-related risk is much less in younger women, but once menopause is reached, the risk for women becomes similar to their male counterparts. Additionally, if a person has a first-degree blood relative who has had CVD, their risk for developing CVD increases (4).
In addition to the genetic risks associated with CVD, several environmental factors have been shown to contribute to the progression of the disease. This list includes hypertension, dyslipidemia, poor nutrition, tobacco usage, obesity, diabetes, and physical inactivity. These risk factors are termed modifiable, as with appropriate measures, these risks can be mollified and/or modified to reduce one's overall chances for developing or progressing known CVD. In addition, if known CVD is present, alteration of body composition, blood glucose/insulin control, tobacco use, diet, exercise, and pharmacological therapies can have the effect of stabilizing and/or reversing the disease process to some extent (9,53).
CVDs are progressive, and although there is evidence of stagnation and reversal in individuals who practice comprehensive lifestyle changes, for the majority of those being treated with “traditional care,” the disease progresses. Exercise training is a key strategy in primordial, primary, and secondary prevention of CVDs. Sedentary lifestyle has the distinction of being classified as a major modifiable risk factor which means there is evidence of mechanisms (cause and effect)—it is a cause of CVDs, lack of exercise is independent: in and of itself, separate of other mechanisms causes CVD; and it raises the risk of developing CVD disproportionately (relative risk > 2) (1,8). Sedentary lifestyle has a relative risk similar to smoking ≥1 pack of cigarettes per day, and the risk of a sedentary lifestyle is greater than other major-modifiable risk factors for CVDs: hypertension, hyperlipidemia or dyslipidemia, and obesity (8,42). Exercise has the distinction among the major modifiable risk factors of mitigating all the other risk factors. Exercise has even been shown to increase the efficacy of smoke cessation (33) and has a strong and persistent negative association with tobacco use (48) (for more information on the role exercise plays in the treatment of CVDs refer Table 1).
In addition to the therapeutic effects of exercise, there is a significant diagnostic and prognostic value related to CVDs. The ability to sustain exercise at or above 13 metabolic equivalents of task (METs, or metabolic equivalents) is associated with a favorable prognosis; likewise, the inability to sustain a 5-MET workload carries a strong negative prognosis (1,16). Exercise-induced ischemia is still a key predictor of underlying and significant CVD, and the loss of exercise tolerance is one of the most common signs or symptoms leading to diagnosis. Exercise professionals versed in the acute cardiovascular responses to exercise and adept at monitoring and confirming either a proper versus improper acute response, especially related to inotropic, hemodynamic, and chronotropic response, which may signal the presence and/or progression of CVDs, may help exercisers to recognize and seek diagnosis and treatment from their physician early in the disease progression. Commonly, individuals ignore exercise intolerance, reduce exercise and physical activity in response to signs and symptoms, and become aware of significant underlying CVD only through an out of hospital emergency such as a myocardial infarction or sudden cardiac arrest (13,31,57). Despite recent advances in emergency cardiac care, the majority of individuals who discover they have CVD by this method do not survive to treat the CVD (13,31,57).
The exercise professional may assist in the prevention of CVDs-related events by performing a preexercise evaluation as outlined in the ACSM's Guidelines for Testing and Prescription with clients for the purpose of risk stratification and education and conducting exercise testing at baseline and as part of progression of the exercise prescription and quality improvement practices (1). In addition, monitoring of exercise sessions and specifically verifying the proper acute responses to exertion provide ongoing surveillance concomitant with reducing risk for developing or progressing CVDs. Understanding how exercise is therapeutic and diagnostic and how to apply risk stratification practices will allow exercise professionals to play an increasing role in the prevention and management of CVD along the prevention spectrum (primordial, primary, and secondary prevention).
CONTRAINDICATIONS TO TRAINING
Contraindications for exercise testing and training have been established for individuals for whom it is thought that the risks outweigh the benefit. Examples are those with exercise-induced complex arrhythmia, hemodynamic incompetence, complicated acute posterior myocardial infarction, unstable angina, and silent significant ischemia. For these individuals, increased stress related to exertion may precipitate cardiac arrest or myocardial ischemia (1). The paradox becomes the deleterious effects of sedentary behaviors and bed rest, especially on the cardiovascular system, which over time results in detraining such that the simplest of activities represents vigorous exercise intensity.
In general, these contraindications do not suggest that the “sicker” individual should limit his/her access to a structured exercise program or be left to their own devices, rather referral to programs with appropriate levels of supervision (including those with direct physician supervision) may prevent further loss of functional capacity and quality of life. Conversely, these individuals are the specific population that needs to be targeted and supervised in a way to introduce safe and effective exercise/physical activity practices. Exercise professionals who can identify, address, and mitigate specific risks for untoward exercise-related events and simultaneously increase the expectation of benefits of training are the pillars of professional practice. Absolute and relative contraindications for exercise testing and participation can be found in the American College of Sports Medicine's (ACSM) Guidelines for Exercise Testing and Prescription (1).
The prescription of exercise intensity for individuals with CVDs should incorporate relative and absolute measures of exercise intensity. Relative measures may include heart rate, rating of perceived exertion, rate-pressure product (RPP), and oxygen saturation (among other measures). Absolute measures such as quantification of workload in METs, pace, and calories/unit of time should also be incorporated. Ideally, exercise intensity would be derived from a symptom-limited, volitional maximum exercise tolerance test using the highest achieved heart rate, blood pressure (BP), RPP (to be discussed in the next section), and workload or these measures at the onset of symptoms, arrhythmia, or evidence of ischemia. Relative measures of exercise intensity help to verify an appropriate acute response to exercise.
Acute responses include increase in stroke volume [indicated by an increase in systolic blood pressure (SBP)], increase in cardiac output [indicated by an increase in heart rate (HR) and SBP], vasodilatation (indicated by stagnation or drop in diastolic BP at steady-state heart rate), and chronotropic (increase in heart rate and regular rhythm). Most often irregularities or abnormal acute responses to exertion precedes untoward events and can be avoided by an experienced professional who monitors exercise intensity and verifies acute adaptation. For example, failure of SBP to rise commensurate with workload may be a sign of impending trouble and may be avoided by adjusting exercise intensity or terminating exercise. See Box 1 for a listing of common terminology.
Box 1 Definitions of terms and significance of hemodynamic monitoring Cited Here...
Hemodynamic: a study of the forces involved in circulating blood through the body.
Hemodynamic monitoring: a general term for determining the functional status of the cardiovascular system as it responds to acute stress such as exercise or myocardial infarction. This may include frequent assessments of BP, pulse, heart rate, rhythm, mental status and intracardiac pressure changes, and cardiac output. Example: during acute exercise an increase in SBP can be used as an indirect index of stroke volume.
Inotropic: influencing the force of muscular contractility. Example: exercise can create a positive inotropic state of the heart.
Chronotropic: influencing the rate of muscular contractility. Example: appropriate increase in heart rate, typically measured in beats per minute.
Monitoring of the intropic and chronotropic responses to exertion indicate proper hemodynamic response to exertion. Heart rate (chronotropic) × stroke volume (intropic) = cardiac output.
Rate-pressure product: a measure of exercise intensity that indicates the oxygen demand of the myocardium (central myocardial system) and is derived by monitoring BP (SBP) and HR. Myocardial oxygen consumption is driven by the contractility of the heart muscle, interwall tension (not measured by the exercise professional), and rate of contraction (heart rate) (55).
Auscultation of BP pre-exercise, during, and postexercise is a valuable modality for exercise professionals monitoring exercise participation. SBP provides an indication of inotropic response to exertion. Failure of SBP to rise commensurate with a workload may indicate a lack of increase in stroke volume. In addition, the use of RPP may provide an indirect index of myocardial oxygen demand. RPP is a simple calculation of HR × SBP and can be used as a yardstick for appropriate exercise prescription. When a gauge of RPP is determined for onset of symptoms during a stress test, the RPP can be used during exercise monitoring. Care should be taken not to exceed predetermined RPP during an exercise session. RPP may more precisely correlate with exercise-induced ischemia and wall motion abnormalities. Additionally, failure of SBP to increase or a falling SBP may be detected by the attentive professional and action may be taken avoiding untoward events. When auscultating BP, the trained professional will check heart rate, rhythm, and pressure, all of which are useful in verifying an appropriate acute response to exertion (for more information on BP monitoring, refer to Table 2).
GENERAL ORDER OF EXERCISE SESSION
A brief warm-up is recommended to allow the body to acclimate the increased cardiovascular load that will transpire during the exercise session. Additionally, the warm-up can be used to verify that the participant is responding appropriately to the gradual increase in workload. Verification of the acute adaptation to exercise (BP and heart rate) should occur during this time frame.
- Warmup should take place before each and every exercise session.
- Warmup should be active and begin with lower body and full-body movements and progress to upper-body movements.
- Intensity: 5–20% of VO2reserve and heart rate reserve. Rate of perceived exertion (RPE) 8–10 (6–20) (based on symptom-limited volitional maximal exercise stress test).
- Duration: 5–20 minutes or until gradual ascent to target heart rate is achieved (1).
Cardiorespiratory exercise is described as rhythmic large muscle movements aimed at increasing the function of the cardiovascular system (1). A dose–response relationship exists for volume of exercise and corresponding adaptation to cardiovascular fitness. Manipulation of frequency, intensity, and duration are factors to consider in creating a viable exercise prescription. Progression in intensity, duration, or frequency will result in greater adaptation to training (1,17).
- Frequency: moderate-to-vigorous intensity 3–5 d/wk, low-to-moderate intensity all or most days of the week.
- Continue verification of acute adaptation:
- ○Chronotropic: increased HR without arrhythmia.
- ○Hemodynamic: increase in SBP commensurate with increase in workload (compared with baseline BP in same posture).
- ○Absence of signs or symptoms related to exertion.
- Intensity: 40–80% VO2reserve and heart rate reserve. RPE, 11–16 (6–20) (based on symptom-limited volitional maximal exercise stress test).
- Duration: 20–60 minutes and influenced by risk factors such as hypertension and obesity.
- ○Interval training may be preferred at onset of training regimen.
- ○Increase work to rest ratios with the ultimate goal of continuous training.
- ○Duration may be preferentially increased before intensity and frequency in detrained individual (1).
MUSCULAR STRENGTH AND ENDURANCE
There is an abundance of data to suggest that there is a dose–response relationship with resistance training and overall resultant strength gain (45,46,49,50). Interpretation of the dose–response data suggest that as little as one set of each exercise will have a significant benefit especially for the beginner or detrained individual. Therefore, beginning a resistance training program with as little as one set per exercise will have a significant benefit in the resultant strength gain. Gradual progression in volume and intensity over time will yield additional adaptations to muscular strength (44,45,49,50). It should be noted that these recommendations should be considered for an untrained or detrained individual. Proper placement within the structured guidelines is the job of the trained exercise professional. Additionally, individuality in the resistance training exercise prescription should be considered if greater levels of muscular strength, MET level, vocational need, and/or functional tolerance are present or necessary.
- 8–10 exercises of major muscle groups
- Frequency: 2–3 d/wk—nonconsecutive.
- Begin with a pretraining phase to learn proper technique of the resistance training exercises and improve proprioception and intermuscular coordination.
- Intensity: 30–40% of 1 repetition maximum (1RM) for lower body and between 50 and 60% for upper body (based on symptom-limited volitional maximal strength test), RPE <11.
- Duration: single sets of 10–15 repetitions per exercise for 1–2 weeks depending on tolerance. Should be able to lift the weight without straining.
- Progress to 60–70% 1RM, RPE 12–13 (based on symptom-limited volitional maximal strength test), HR <80% heart rate reserve, SBP <80% maximum BP, or RPP on symptom-limited volitional maximal exercise stress test).
- Duration: single sets of 8–12 repetitions to the point of muscular fatigue but not muscular failure.
- Intensity: progress to 60–80% 1RM, RPE ≤14 (based on symptom-limited volitional maximal strength test), HR <80% heart rate reserve, SBP <80% maximum BP or RPP on symptom-limited volitional maximal exercise stress test).
- Once 80% 1RM is achieved, progress to multiple sets of each exercise (2–4 sets).
- Rest intervals should be between 2 and 3 minutes between sets (6,29,30,44,45,49,50).
GUIDELINES FOR RT WITH CVD
- Perceived exertion during resistance training that approximates <11 to no more than 14 on the Borg category scale (“fairly light” to “somewhat hard/hard”).
- Train dominantly large muscle groups before small muscle groups.
- Lift weights in a slow and controlled manner (1 second concentric and 1 second eccentric).
- Avoid exercises with large isometric contraction components especially gripping.
- Avoid valsalva and emphasize rhythmic breathing.
- Gradually increase load rather than number of repetitions.
- BP should be measured during the last repetition of the last set.
- Increase recovery time between sets to maintain BP, RPP, and HR to or below thresholds.
- Avoid postures with head below heart and rapid and frequent postural changes especially from supine or prone to standing.
- Immediate cessation of exercise with dizziness, excessive shortness of breath, chest pain or pressure, and heart rhythm irregularities (1,6,29,30,56).
A general flexibility program has been shown to increase muscular range of motion helping joints move through the full range of motion (1). Additionally, a regular flexibility program is a good way to increase blood flow to all muscle groups. Although research is equivocal regarding the role stretching has on injury prevention, overall flexibility is a general component of overall fitness and as such a necessary part of a comprehensive physical activity/exercise program. Static stretching of all major muscle groups.
- Frequency: 2–3 d/wk.
- Intensity: stretches should be to the point of tightness or mild discomfort (pain free).
- Duration: 10–30 seconds per stretch (30–60 seconds for older individuals) for each stretch repeating each stretch 2–4 times (a total of 60 seconds per joint).
- Type: static stretching is the preferred modality of stretching for this population.
A brief period of lower-intensity large muscle group movements (cool down) should be performed to return the physiological measures to near baseline (1). A similar prescriptive approach to the warm-up can be used for the cool down, however, a reverse order should be followed. Cool down should be emphasized in populations with known CVD. This period of time reduces the risk associated with the transition from steady-state work back to resting levels and needs to be performed as the final component of every exercise session. The flexibility component of the exercise prescription can be seamlessly transitioned into the cool down. Emphasis should be placed on breathing, progressive relaxation, and imagery.
- Cool down should take place after each and every exercise session.
- Cool down should be active and begin with full-body movements and progress in the seated or supine postures.
- Intensity: 20–5% of VO2reserve and heart rate reserve. RPE 10–8 or lower (6–20) (based on symptom-limited volitional maximal exercise stress test).
- Duration: 5–20 minutes or until gradual of vitals to near or baseline measures is achieved (1).
With the aging of society, the increase in chronic conditions (such as CVD), and the related inflation of the costs associated with managing chronic illnesses, there is a heightened need for allied health professionals who can systematically apply exercise prescription guidelines to reduce the risk for special populations. These professionals will increase the benefits and reduce the risks of special populations engaging in effective exercise programs. This article provides a perspective and context for exercise professionals developing prescription for a specific client with CVD. Exercise professionals should use evidence-based practices to individualize prescription.
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