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Swiss Sports & Exercise Medicine, 64 (2), 6–12, 2016
Physical activity and exercise training
in preventive cardiology
Trachsel LD
Präventive Kardiologie & Sportmedizin, Universitätsklinik für Kardiologie, Inselspital, Universitätsspital Bern
Abstract
Zusammenfassung
Physical activity (PA) and exercise training (ET) are central
and indispensable components for primary and secondary
prevention of cardiovascular disease (CVD). In healthy individuals, PA reduces all-cause and CV mortality and has confirmed beneficial effects on the cardiovascular risk profile.
In secondary prevention, PA counselling und ET are two of
the core components of a multidisciplinary cardiac rehabilitation (CR) program. Exercise-based CR is an established
strategy in the secondary prevention of CV disease. It improves survival, reduces hospital admissions, improves cardiorespiratory fitness (CRF), and quality of life (QoL). However, these beneficial effects require regular attendance under
professional supervision and adherence to recommended
guidelines. In patients with heart disease, proper patient assessment with a standardized exercise test as a basis for a
tailored ET prescription is required. In healthy subjects this
is advocated only in selected groups.
Current guidelines recommend at least 150 min/week of
moderate-intensity continuous aerobic PA in both healthy
individuals as well as those with cardiac disease. In healthy
adults, alternatively intensity can be increased and volume
can be halved. High intensity interval training (HIIT) is a
relatively new training modality and may be used complementary to continuous training in selected patient groups.
HIIT seems to be superior compared to moderate continuous
exercise in patients with cardio metabolic disease with regard
to effects on the CV risk profile, endothelial function, improvement in cardiorespiratory fitness, and a reverse cardiac
remodelling in patients with heart failure.
One of the major challenges in preventive cardiology is
the improvement of long-term adherence to PA recommendations. The aim of this article is to give an overview from
the preventive cardiologist’s point of view with a focus on
endurance ET prescription for the audience of sports and
exercise medicine physicians.
Körperliche Aktivität und strukturiertes Training sind zentrale und unabdingbare Komponenten in der kardiovaskulären Primär- und Sekundärprävention. Bei Gesunden reduziert körperliche Aktivität die kardiovaskuläre und
Gesamtmortalität mit günstigem Einfluss auf das kardiovaskuläre Risikoprofil. In der Sekundärprävention sind Beratung bezüglich körperlicher Aktivität und strukturiertes
Training zwei der Kernkomponenten eines multidisziplinären kardialen Rehabilitationsprogrammes. Bewegungs-basierte kardiale Rehabilitationsprogramme sind eine etablierte Strategie in der kardiovaskulären Prävention. Sie senken
die Mortalität, verhindern Rehospitalisationen, verbessern
die kardiorespiratorische Fitness und die Lebensqualität. Voraussetzung ist eine regelmässige Teilnahme, eine professionelle Supervision des Trainings und die Einhaltung der generellen Bewegungs-Empfehlungen. Bei Patienten mit einer
Herzerkrankung ist eine Standortbestimmung mittels standardisierten Belastungstests als Basis für ein massgeschneidertes Training von Bedeutung. Bei Gesunden wird dies nur
in speziellen Fällen empfohlen.
Die aktuellen Richtlinien empfehlen mindestens 150 Minuten/Woche moderat-kontinuierliche körperliche Aktivität
sowohl für Gesunde wie auch für Patienten mit einer Herzerkrankung. Als Alternative kann bei Gesunden die Intensität
erhöht und stattdessen die Dauer halbiert werden. Hochintensives Intervalltraining (HIIT) stellt bei speziellen Patientengruppen eine relativ neue Trainingsmodalität dar, die
komplementär zum etablierten kontinuierlich-moderaten
Training angesehen wird. Studien zeigen, dass HIIT der etablierten moderat-kontinuierlichen Trainingsmodalität überlegen sein könnte in Bezug auf Effekte auf das kardiovaskuläre Risikoprofil, die Endothelfunktion, die Verbesserung der
kardiorespiratorischen Fitness und nicht zuletzt in Bezug auf
den Effekt auf das kardiale Remodelling bei Herzinsuffizienz.
Eine der grössten zukünftigen Herausforderungen der
Präventiven Kardiologie ist die Verbesserung der Langzeitadhärenz bezüglich Einhaltung der Bewegungsempfehlungen. Dieser Artikel soll eine Übersicht geben aus Sicht der
Präventiven Kardiologie mit speziellem Fokus auf Verschreibung von Ausdauertraining für die Leserschaft aus dem Bereich der Sport- und Bewegungsmedizin.
Keywords:
physical activity, exercise training, cardiac rehabilitation,
cardiorespiratory fitness, interval training
Schlüsselwörter:
körperliche Aktivität, strukturiertes Training, kardiale Rehabilitation, kardiorespiratorische Fitness, Intervalltraining
6
Trachsel
Introduction
“Lack of activity destroys the good condition of every human
being, while movement and methodical physical exercise
save it and preserve it.”
Plato, Greek philosopher
Cardiovascular disease (CVD) remains the leading global
cause of death, accounting for 17.3 million deaths per year
worldwide. [1] Physical inactivity has been identified as one
of the leading risk factors for global mortality causing an
estimated 3.2 million premature deaths globally. [2] Physical
activity (PA) is defined as any body movement produced by
the contraction of skeletal muscles that results in a substantial increase in caloric requirement over resting energy expenditure. [3,4] In 1953, Morris and colleagues showed that
London’s double-decker bus drivers had a higher rate of coronary events compared to conductors. This was attributed
to the physically more active job of the conductors compared
to the physically inactive bus drivers. [5] This seminal study
was the first who confirmed the beneficial effects of PA in
cardiovascular (CV) health. Nowadays, multiple population-based trials have confirmed that there is an inverse correlation between PA and all-cause/CV mortality: even doses
as low as 15 min of PA per day appear to reduce CV disease
risk and all-cause mortality with the greatest health gains due
to the first 15–29 min of daily activity in previously inactive
individuals. [6–8] A recently published study found a strong
negative association of cardiorespiratory fitness (CRF) level
in middle aged healthy subjects with health care costs later
in life. [9] Over the last six decades the concept that PA and/
or structured exercise training (ET) reduce CV mortality has
been extended to patients with manifest heart disease (i.e.
patients with coronary artery disease (CAD), after percutaneous coronary intervention (PCI), coronary artery bypass
grafting (CABG), and heart failure (HF) patients). [10] ET is
a type of PA consisting of planned, structured, and repetitive
bodily movement done to improve and/or maintain CRF.
[3,4] Cardiac rehabilitation (CR) has the potential to improve
survival and reduce hospital admissions, if attended on a regular basis. [11] Exercise-based CR is an established strategy
in the secondary prevention of CV disease.
In a large meta-analysis published this year, which collected follow-up data of 14,486 patients with CAD and included 63 prospective randomized clinical trials, exercise-based CR was associated with a substantial reduction in
cardiovascular mortality and hospital admissions. The majority of analysed studies showed higher levels of health-related quality of life (QoL) following exercise-based CR compared to control subjects. [12] However, achievement of
sustainable effects on hard end-points have been challenged
recently. Amongst other studies from the United Kingdom
(UK), the RAMIT trial is the largest randomized controlled
trial on comprehensive CR after myocardial infarction. This
trial has failed to show beneficial effects on all-cause mortality, cardiac or psychological morbidity, risk factors,
health-related QoL or activity. [13] The study had major limitations. Besides being underpowered for the assessment of
mortality, the prescribed ET volume was only half of what
current recommendations state. Additionally, ET was not tailored based on a maximum exercise test, due to routine submaximal exercise testing in the UK at the entry of a CR
program. Consequently, the overall increase in CRF was only
about one third (0.52 MET, metabolic equivalent) of the
mean increase reported in a recent meta-analysis (1.55 MET).
Physical activity and exercise training in preventive cardiology
These low training volumes and small increases in CRF may
partially explain the reported inefficacy of UK CR to reduce
patient mortality. [14–16]
In heart failure patients mortality reduction, reduction of
re-hospitalization rate and the improvement in CRF is of utmost importance. [17,18] In a recent meta-analysis including
33 trials with 4740 HF patients, exercise-based CR revealed
no increased risk of all-cause mortality compared to controls,
but reduced the risk of hospital admissions and conferred
improvements in health-related QoL. [19] Furthermore, two
recent meta-analyses have emphasized the importance of aerobic endurance training on reverse left ventricular remodeling. [20,21] In chronic HF patients, the development of a
catabolic metabolic state is another aspect of interest. Skeletal myopathy is a major limitation of exercise capacity. Muscle wasting is an independent predictor of mortality in CHF
and is beneficially influenced by ET on a regular basis.
[22,23] Most patients included in exercise-based HF studies
had systolic dysfunction (HFrEF). However, ≈50% of patients
with HF have heart failure with preserved ejection fraction
(HFpEF), which is particularly common in older patients
with HF and in women. [24,25] Mortality data in HFpEF
patients are currently lacking. Recent data revealed that ET
in patients with HFpEF is associated with an improvement
in CRF and QoL. [26] The ExDHF study demonstrated that
a structured ET in patients with HFpEF has additional beneficial effects on LV diastolic function compared to patients
who received usual care. [27] Taking all these aspects into
account, it is comprehensible that PA counselling and a tailored as well as an initially supervised ET are two of the core
components of a multidisciplinary secondary prevention program. [28]
Physiological effect of exercise
The beneficial effects of exercise on CV risk factors like
body composition, blood pressure, blood glucose and lipid
profile are well known. [29–32] There seems to be an intensity-dependent effect with more favorable effects regarding
body composition, visceral fat and lipid profile at higher exercise intensities. [33,34] Other aspects of interest are the
molecular changes that occur in the CV system in response
to ET. A byproduct of regular physical exercise is the increase in shear stress of blood flowing through the main arteries leading to the production of vascular nitric oxide (NO)
by the up-regulation of endothelial nitric oxide synthase
(eNOS). [35] NO induces vasodilation, which results in the
lowering of peripheral resistance and increased perfusion of
the skeletal muscles. Furthermore, endothelial progenitor
cells are activated by ET, which preserve normal endothelial
function and stimulate vasculogenesis, and induce multiple
metabolic changes in the myocardium resulting in improved
tolerance for ischemia and reperfusion injury. [36–40] Last
but not least, arterial stiffness, which is associated with several pathologies like systolic hypertension and HF is lower
in subjects who regularly exercise compared to sedentary
controls. [41,42]
Risk assessment and Exercise testing
In healthy subjects aiming to participate in regular PA – particularly those aged 35 years or older- a self-assessment of
7
the habitual PA level, for example using a validated questionnaire (i.e. Physical Activity Readiness Questionnaire,
PAR-Q) and of the risk factors for CAD (for Switzerland
based on the AGLA-Score) is recommended for screening.
[43–45] Individuals deemed to be at risk require further evaluation by a qualified physician, additional maximal exercise
testing and possibly further evaluation is advocated. The results of a maximal exercise test supply individuals with adequate and personalized recommendations for appropriate
training intensities. [46] Proper patient assessment, which
includes a direct evaluation of exercise capacity, is an essential core component before the inclusion of a patient in a
secondary prevention program. [47] The gold standard is a
symptom -limited incremental standard exercise test (bicycle, treadmill), which allows direct or indirect determination
of exercise intensity, as a basis for a tailored ET prescription.
[28,48] Exercise intensity is strictly and causally linked to
energy expenditure during effort. In an oxygen-dependent
biological system, the latter is mostly described by oxygen
uptake (VO2) through the O2 energy equivalent. As a consequence, peak VO2 and the first and second ventilatory thresholds (i.e. the physiological descriptors of the O2 transport and
utilization system response to exercise) are the gold standard
references for the evaluation of aerobic metabolism function
and, consequently, for aerobic exercise intensity assessment
and prescription. [49–53] Direct measurement of respiratory
gases via a cardio-pulmonary exercise test (CPET) is recommended in the following cardiac patients groups for prognostic and diagnostic stratification: patients with HF (HFrEF,
HFpEF), congenital heart disease, pulmonary hypertension
and cardiomyopathy (such as hypertrophic cardiomyopathy).
[54]
Cardiorespiratory fitness as surrogate marker
of mortality
Cardiorespiratory fitness (CRF, measured as peak VO2) is a
marker of aerobic exercise capacity and can be expressed as
metabolic equivalents (MET), with 1 MET corresponding to
3.5 mL of oxygen per kilogram of body weight per minute
(mL/kg/min), the typical resting energy requirement for basal homeostasis.
In addition, CRF is an important surrogate marker of survival and well-being in healthy subjects and those with CV
disease, respectively. There is an inverse correlation of CRF
and mortality. [55] Each 1-MET increase in CRF is associated with a significant reduction in mortality and CAD
events, which compares favorably with the survival benefit
conferred by low-dose aspirin, statins, Beta-blockers, and
angiotensin-converting enzyme inhibitors after acute myocardial infarction. [56,57]
Exercise prescription
The principles of PA promotion and ET prescription are intended to guide health/fitness on the one hand, and to individually tailor ET for the apparently healthy adult as well as
adults with certain chronic (cardiac) diseases on the other.
The American College of Sports Medicine (ACSM) recommends in its companion evidence-based position stand to
employ the FITT-VP principle to prescribe ET (Table 1). [4]
Intensity guidance can easily be made by self-assessment
8
–
–
–
–
–
Frequency (how often)
Intensity (how hard)
Time (duration or how long)
Type (mode or what kind)
Additional: total Volume (amount) and Progression
(advancement)
Table 1: FITT-VP principle for exercise prescription [4]
(e.g. rate of perceived exertion (RPE), i.e., “Borg Scale”). [58]
Alternatively, peak heart rate (HR) can be determined with
an incremental self-test. Based on this, training intensities
can indirectly be calculated (Table 2). If CPET is available,
the first and second ventilatory threshold can directly be determined. In summary, training should be guided based on
workload and training zones and not on heart rate, particularly in cardiac patients.
Generally, PA promotion should be part of a structured
lifestyle counselling program. [4,47] PA promotion as well
as ET prescription is not only reserved to exercise physiologists and specialists in preventive medicine, but should also
be done in the doctor’s office by general practitioners (GP)
and sports and exercise physicians. In Switzerland, several
institutions such as the Swiss society of Sports Medicine propose physical activity promotion in primary care (PAPRICA)
to emphasize that GP’s play an essential role in PA promotion. [59]
In healthy adults, current European guidelines recommend
an aerobic PA volume of 150–300min/week of at least
moderate-intensity (Zone II, Table 2) to provide a reduction
in all-cause and cardiovascular mortality. As a time-efficient
alternative 60–90min/week of high-intensity may be performed, or an equivalent combination of the two types of
training. [60] While PA in the primary preventive setting can
be seen as an effective monotherapy, in secondary prevention
it is in concert with optimal medical therapy which it cannot
replace.
In patients with known CVD (including CAD, HF), aerobic ET is recognized as a class I, level of evidence A indication. [60] Among others, PA counselling and ET are two
additional core components of a multidisciplinary CR program. [28] A moderate intensity continuous ET (i.e., starting
at 50% of maximal work load and gradually increasing to
80% in CAD, and starting at the 1st and gradually increasing
to the 2nd ventilatory threshold in HF patients, respectively,
Figure 1A), scheduled as 30 min session 3–5 times per week,
under close supervision are recommended. [47,60]
Additionally, there is growing evidence that high-intensity interval training (HIIT) may be equivalent or even more
effective than moderate-intensity continuous exercise training (MICE) and can be performed safely with impressive
improvements in CRF and QoL in CAD patients as well as
in chronic HF patients, in whom reverse cardiac remodeling
was found with HIIT. [61–64] In patients with lifestyle-induced cardio metabolic disease significant beneficial effects
on the cardiovascular risk profile, oxidative stress and inflammation, as well as increases in the availability of NO by
HIIT were shown. [65]
Currently, the most commonly used HIIT model consists
of 4 times 4 min high intensity intervals (at 80% of maximal
work load or above the 2nd ventilatory threshold) and active
recovery phases of 3 min at low intensity (at 50% of maximal
Trachsel
Zone I
Zone II
Zone III
Intensity
Low
Moderate
High
Metabolism
Aerobic energy supply, no
relevant increase in lactic
acid. Predominant fatty acid
metabolism.
Aerobic and anaerobic energy supply. Steady-state of
lactic acid production and
-elimination. Predominant
Glycogen metabolism.
Anaerobic energy supply.
Lactic acid accumulation
and respiratory compensation.
Rate of perceived exertion
(BorgScale, 6–20)
<12
12–14
>14
% peak Heart rate*
<70%
70–90%
>90%
% Heart rate reserve†
<50%
Ergospirometry
Below the 1 ventilatory
threshold (<50% VO2 peak.)
50–80%
st
>80%
Between the 1 and 2 venti- Above 2nd ventilatory
latory threshold (50–80% VO2 threshold (>80% VO2 peak)
peak)
st
nd
* Peak heart rate (HR) should not be estimated by the formula: 220-age, because of large individual variation of intrinsic
heart rate. In healthy adults peak HR can be determined by an incremental self-test to full exhaustion (Borg >17). In patients
with heart disease peak HR should be determined based on a supervised exercise test. Please note that peak HR is 10–15
beats higher on a treadmill compared to bicycle.
† patients with chronotropic incompetence (e.g. on Beta-blockers) have a blunted HR increase. The determination of training
HR should be made with the Karvonen formula (based on heart rate reserve): peak HR – HR at rest. The recommended
training zone is: heart rate reserve *(factor 0.6 or 0.8) + HR at rest [78].
Table 2: Intensities for endurance training
workload or below the 1st ventilatory threshold, Figure 1B).
[49] The current recommendation is to use HIIT complementary, but not as a replacement for the more established MICE.
[66]
In much deconditioned HF patients a low intensity interval training with short bouts (10 to 30 seconds, at 50% of
maximal work load, or below the 1st ventilatory threshold)
and longer recovery periods is recommended (Figure 1C).
[66]
In patients with CAD, an additional resistance training
(RT) seems to be more effective than endurance training
alone. [67] Recommended is an expansion of endurance ET
to a dynamic RT 2 times/week (not pure isometric training)
in all clinically stable patients with and without HF. [66,68,69]
A combined ET/RT does not lead to a cardiac remodeling
with a more pronounced LV dilatation than ET alone. [70] In
chronic HF patients, Inspiratory muscle weakness (IMW) is
highly prevalent. In selected patients, the addition of inspiratory muscle training results in improvements in inspiratory
muscle strength, CRF, ventilator response to exercise, and
QoL. [71,72]
Conclusions
PA and ET are central and indispensable components of a
comprehensive strategy for the primary and secondary prevention of CAD. PA advice has to be part of a structured
lifestyle counselling program and should increasingly take
place in the doctor’s office and be promoted by general practitioners (GP), particularly in primary prevention. Current
international PA recommendations should be applied which
have been shown to result in sustainable effects. Exercise-based programs contribute to a decreased morbidity and
mortality, particularly in patients with CAD with or without
HF. Subjects/patients assessment need to be tailored and
should include high quality ET recommendations and therapy, delivered by specialists in sports and exercise medicine.
Continuous training and interval training can be used complementarily in patients with heart disease.
Perspective
Figure 1: Different training types for patients with heart disease based on the three zone model (adapted from [49,52]):
Zone I: low; Zone II: moderate; Zone III: high intensity zone
Physical activity and exercise training in preventive cardiology
One of the major challenges in preventive cardiology is the
improvement of long-term adherence (’patient empowerment’). Adherence to behavioral advice is associated with a
9
substantially lower risk of recurrent cardiovascular events,
particularly regarding ET recommendations. [73] Future directions with great potential are home-based and smartphone-based CR programs. Comparing home- versus centerbased CR programs, there seems to be no difference
regarding mortality risk, improvement in CRF, as well as
modifiable risk factors, and health-related QoL outcomes in
patients with CAD or HF. Additionally, there is no difference
with regard to healthcare costs produced by the two forms of
cardiac rehabilitation. [74,75] The addition of cardiac tele-rehabilitation to conventional center-based CR may even be
more effective and efficient than center-based CR alone, particularly with regard to sustainability of PA level. [76,77]
Practical implications
– Physical activity (PA) reduces all-cause and cardiovascular (CV) mortality and has beneficial effects on the cardiovascular risk profile in healthy individuals
– PA advice should increasingly take place in the doctor’s
office and be promoted by general practitioners, particularly in primary prevention
– In secondary prevention, PA counselling und structured
exercise training are two core components of a multidisciplinary cardiac rehabilitation (CR) program
– Exercise-based CR is an established strategy in the secondary prevention of CV disease and improves survival,
reduces hospital admissions, improves cardiorespiratory
fitness (CRF), and quality of life
– High intensity interval training (HIIT) can be used complementary to moderate continuous training and may be
even superior in patients with cardio metabolic disease
with regard to effects on the CV risk profile, endothelial
function, improvement in CRF, and a reverse cardiac remodeling in patients with heart failure
Acknowledgements
I appreciate the intellectual input and critical review of the
manuscript by Prisca Eser (PhD) and Matthias Wilhelm
(MD).
Conflict of interest: none declared
Corresponding author
Dr. med. Lukas D. Trachsel
Präventive Kardiologie & Sportmedizin
Universitätsklinik für Kardiologie
Inselspital, Universitätsspital Bern
3010 Bern
[email protected]
Telefon +41 31 632 89 70
Fax +41 31 632 89 77
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Schlussfolgerungen für die Praxis
– Körperliche Aktivität ist beim Gesunden mit einer Mortalitätsreduktion und einem günstigen Einfluss auf das kardiovaskuläre Risikoprofil vergesellschaftet
– Die Beratung bezüglich körperlicher Aktivität sollte vermehrt auch in der Arztpraxis durch den Grundversorger
stattfinden, speziell in der Primärprävention
– In der Sekundärprävention sind Beratung bezüglich körperlicher Aktivität und strukturiertes Training zwei Kernkomponenten eines multidisziplinären kardialen Rehabilitationsprogrammes
– Bewegungs-basierte kardiale Rehabilitationsprogramme
sind etabliert in der Sekundärprävention und senken die
Mortalität, verhindern Re-Hospitalisationen, verbessern
die kardiorespiratorische Fitness und die Lebensqualität
– Hochintensives Intervalltraining (HIIT) kann komplementär zum etablierten moderat kontinuierlichen Training eingesetzt werden und könnte bei Patienten mit kardio-metabolischer Erkrankung gar überlegen sein in Bezug auf
Effekte auf das kardiovaskuläre Risikoprofil, die Endothelfunktion, die Verbesserung der kardiorespiratorischen
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