- Email: [email protected]
The role of exercise in cardiac disorders
PATHOGENESIS, RISK FACTORS AND PREVENTION
The role of exercise in cardiac disorders
Key points C
Regular exercise reduces cardiovascular risk, but there is currently uncertainty about the impact of extreme levels of exercise
C
Certain conditions preclude participation in competitive sports because of increased cardiovascular risk
C
Exercise capacity is a useful marker of disease state; it can also be used in conjunction with imaging techniques to provide a robust assessment of whether a patient has significant underlying coronary artery disease
C
Cardiac rehabilitation programmes, of which supervised exercise forms a key part, reduce future cardiovascular events and improve quality of life
Jonathan Hinton Michael Mahmoudi
Abstract Physical activity (PA) has been demonstrated to have a powerful role in reducing cardiovascular risk and is therefore universally recommended by international guidelines. Although there is a dose-dependent risk reduction with increasing levels of PA, there is some concern that extreme levels of PA can result in adverse cardiovascular outcomes. It is important to adapt PA advice to each individual, and in particular to note that there are conditions that are not compatible with competitive sport because of increased cardiovascular risk. Exercise also has an key role in the assessment of patients presenting with symptoms that could potentially result from cardiovascular disease, both as a measure of the impact of the disease and as a diagnostic tool.
examples of PA and the relative intensity of these. Although this mechanism of assessing the intensity of PA is helpful, it is also important to consider the relative intensity: less fit patients use more energy to perform the same PA. An assessment of relative intensity can be easily gained by either comparing the peak heart rate to the age-predicted maximum (220 beats per minute minus age) or using the ‘talk test’ (an assessment of the frequency of breathing; Table 1).3 Importantly, moderate-intensity PA produces less improvement in cardiorespiratory fitness than strenuous PA.1 It is difficult to define the exact amount of exercise required for optimum health; specifically, there does not seem to be an upper limit of moderate-intensity PA-related health benefit.1,3 There is, however, no evidence that high levels of very strenuous exercise provide any increased benefit.1 International guidelines advise that individuals should aim to achieve at least 30 minutes per day of a moderate-intensity activity for 5 days per week or 15 minutes per day of a strenuous activity for 5 days per week, or a combination of these.3 When considering prescribing PA, it is important to review both the patient’s current levels of PA and their co-morbid status because in certain circumstances it is appropriate to initially encourage very low levels of PA with a gradual increase.3 When considering how to promote sustained improvement in PA, it is often effective to set goals and encourage adaptations to daily routine to include PA, such as using active rather than passive modes of travel.3 Although the evidence relating to muscle-strengthening activities is less extensive, there is a clear consensus among guidelines that adults should also perform these activities twice a week.3 These should focus on the major muscle groups, and movements should include the full range of motion of any joint.3 This has been well established to stimulate bone formation, and, particularly in combination with aerobic PA, there is some evidence that it reduces both blood pressure and lipid concentrations.3
Keywords Cardiac rehabilitation; cardiovascular risk; diagnosis; exercise; MRCP; physical activity; primary prevention; secondary prevention
Introduction Physical activity (PA) forms a large part of the lives of some individuals, but for most it is often not a routine part of daily living. It is therefore important to consider the impact that PA can have on cardiovascular risk, and to consider the risk associated with PA in patients with cardiovascular disease. Exercise can also form an important part of tests to diagnose ischaemic heart disease (IHD), as well as having a key role in rehabilitation after a cardiac event.
Exercise in cardiovascular risk reduction Population studies have consistently shown that PA not only has a beneficial impact on cardiovascular risk factors, but also reduces both all-cause and cardiovascular mortality.1e3 Aerobic PA, which involves movements of large muscle groups in a repetitive fashion, has been the most closely studied form of PA in relation to cardiovascular risk.1e3 It is important to assess not only the duration of PA, but also the intensity. The intensity of PA is often measured in metabolic equivalents (METs), where 1 MET is defined as the amount of oxygen consumed while sitting at rest. Table 1 demonstrates some
Jonathan Hinton BM MRCP is a Cardiology Registrar at University Hospital Southampton, UK. Competing interests: none declared. Michael Mahmoudi BSc MB BS PhD FACC FRCP is an Associate Professor in Interventional Cardiology at the University of Southampton and Honorary Consultant Interventional Cardiologist at University Hospital Southampton NHS FT, UK. Competing interests: none declared.
MEDICINE --:-
Exercise as a source of cardiovascular risk The general population should be reassured and encouraged to undertake more PA, given the very low associated levels of
1
Ó 2018 Published by Elsevier Ltd.
Please cite this article in press as: Hinton J, Mahmoudi M, The role of exercise in cardiac disorders, Medicine (2018), https://doi.org/10.1016/ j.mpmed.2018.06.008
PATHOGENESIS, RISK FACTORS AND PREVENTION
predisposition to developing cardiac disease in whom exercise is not beneficial. Interestingly, this has been demonstrated in arrhythmogenic right ventricular cardiomyopathy, where presentation occurs earlier with increased PA.1 It is, however, uncertain whether this feature is seen in other conditions.1 Competitive sport in athletes is associated with a small but important risk of sudden cardiac arrest (0.76 cases per 100,000 athleteeyears) and therefore requires special consideration (see Further reading). Certain cardiomyopathies, IHD, arrhythmogenic conditions, valvular heart disease and other conditions preclude participation in many competitive sports except sometimes those in category 1A (Table 2)4 Although data demonstrating the benefits of PA are clear, there is uncertainty regarding the impact of excessive exercise, which particularly relates to endurance athletes including marathon runners, triathletes, cross-country skiers and cyclists.1 Exercise-induced troponin release, myocardial fibrosis, cardiac dysfunction after exercise, arrhythmias, accelerated coronary artery calcification and increased cardiovascular mortality compared with recommended levels of PA have all been demonstrated in this group.1 Despite this and studies suggesting a U-shaped relationship between amount of PA and mortality, there are some weaknesses with these data; therefore overall it has been recommended that, even in endurance athletes, the benefits of exercise outweigh the risks.1
Intensity of PA Intensity
METs
Examples
Percentage of Impact on max heart rate talking
Light
1.1e2.9 Light 50e63 housework Slow walking Croquet Moderate 3e5.9 Brisk walking 64e76 Vacuuming Doubles tennis Ballroom dancing Strenuous >6 Jogging 77e93 Heavy gardening Swimming Cycling > 15 km/hour
No impact
Increased respiratory rate but able to talk in full sentences Unable to talk in sentences owing to work of breathing
METs, metabolic equivalents. Source: Adapted from Piepoli et al.3
Table 1
The role of exercise in diagnosis
adverse cardiovascular events (5e17 sudden deaths per million per year).3 However, some groups of patients with pre-existing cardiovascular conditions should adjust their PA. When considering the risk of an activity, it is important to classify PA in terms of the relative intensity of both the static and dynamic elements (Table 2). There are also rare individuals with a genetic
Clinicians can rapidly gain subjective insight into the severity, progress and response to treatment of cardiovascular disease by asking individuals about their exercise capacity. The 6-minute walk test can provide a useful, objective measure of exercise capacity as well as evidence for the effectiveness of treatment, and can be used as a guide to prognosis (see Further reading). The 6-minute walk test is performed according to a self-paced standardized protocol; this not only measures the distance walked, but also symptoms, oxygen saturations and heart rate (see Further reading). Cardiopulmonary exercise testing is a more formal assessment of exercise capacity that measures oxygen uptake, carbon dioxide production and ventilation during a progressive exercise test (see Further reading). Cardiopulmonary exercise testing can provide useful prognostic data in a variety of cardiovascular conditions, as well as a detailed evaluation of functional status before major surgery (see Further reading). Exercise can also be used as a part of diagnostic testing in cardiovascular disease, particularly to diagnose IHD. Historically, exercise tolerance testing was frequently used to assess the likelihood of IHD; in this, the individual exercised according to a certain protocol, most commonly on a treadmill using a Bruce protocol. Although this is a simple test, the sensitivity and specificity are poor so it is no longer recommended for diagnosing IHD disease. It does, however, still have a role in assessing the need for surgery in patients with asymptomatic severe aortic stenosis, as well as the assessment of possible exercise-related arrhythmias. Exercise, in combination with either echocardiography or nuclear imaging, still has an important place in the non-invasive diagnosis of IHD.
Intensity of dynamic and static elements by sport Low dynamic
Moderate dynamic
High dynamic
Low static
Bowling Cricket Golf
Fencing Table tennis Doubles tennis Baseball
Moderate static
Driving and racing Equestrian sports Sailing Archery Gymnastics Field events Rock-climbing Windsurfing Weight-lifting
Badminton Race walking Running (marathon) Cross-country skiing Squash Rugby Football Tennis (single)
Bodybuilding Downhill skiing Wrestling Snowboarding
Boxing Cycling Canoeing Rowing Triathlon
High static
Adapted from Pelliccia et al. (see Further reading).
Table 2
MEDICINE --:-
2
Ó 2018 Published by Elsevier Ltd.
Please cite this article in press as: Hinton J, Mahmoudi M, The role of exercise in cardiac disorders, Medicine (2018), https://doi.org/10.1016/ j.mpmed.2018.06.008
PATHOGENESIS, RISK FACTORS AND PREVENTION
The role of exercise in recovery
4 Maron BJ, Udelson JE, Bonow RO, et al. Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: task force 3: hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy and other cardiomyopathies, and myocarditis: a scientific statement from the American Heart Association and American College of Cardiology. Circulation 2015; 132: e273e80. 5 Dalal HM, Doherty P, Taylor RS. Cardiac rehabilitation. Br Med J 2015; 351: h5000.
A key component of cardiac rehabilitation is a structured, supervised exercise programme.1 These programmes can reduce cardiovascular mortality, future hospital admissions and cardiovascular risk factors, and significantly improve quality of life.5 The risk of sudden cardiac arrest in this group is low but present.1 There is a suggestion from observational trials that highintensity or high-volume exercise can actually attenuate the cardiovascular benefits to the level of individuals who remain inactive.1 A
FURTHER READING Albouaini K, Egred M, Alahmar A, Wright DJ. Cardiopulmonary exercise testing and its application. Heart 2007; 93: 1285e92. Landry CH, Allan KS, Connelly KA, et al. Sudden cardiac arrest during participation in competitive sports. N Engl J Med 2017; 377: 1943e53. Pelliccia A, Fagard R, Bjørnstad HH, et al. Recommendations for competitive sports participation in athletes with cardiovascular disease: a consensus document from the study group of sports Cardiology of the working group of cardiac rehabilitation and exercise physiology and the working group of myocardial and pericardial diseases of the European Society of Cardiology. Eur Heart J 2005; 26: 1422e45. Rasekaba T, Lee AL, Naughton MT, Williams TJ, Holland AE. The sixminute walk test: a useful metric for the cardiopulmonary patient. Intern Med J 2009; 39: 495e501.
KEY REFERENCES 1 Eijsvogels TM, Molossi S, Lee DC, Emery MS, Thompson PD. Exercise at the extremes: the amount of exercise to reduce cardiovascular events. J Am Coll Cardiol 2016; 67: 316e29. 2 Varghese T, Schultz WM, McCue AA, et al. Physical activity in the prevention of coronary heart disease: implications for the clinician. Heart 2016; 102: 904e9. 3 Piepoli MF, Hoes AW, Agewall S, et al. 2016 European guidelines on cardiovascular disease prevention in clinical practice: the sixth joint task force of the European Society of Cardiology and other societies on cardiovascular disease prevention in clinical practice (constituted by representatives of 10 societies and by invited experts). Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). Eur Heart J 2016; 37: 2315e81.
TEST YOURSELF To test your knowledge based on the article you have just read, please complete the questions below. The answers can be found at the end of the issue or online here. keen marathon runner and wanted to get back to this as soon as possible.
Question 1 A 49-year-old man attended for review of his cardiovascular risk. He was asymptomatic, had no previous medical history and had never smoked. His cholesterol and blood pressure did not require any treatment. He asked how much exercise he should undertake for optimum cardiovascular health.
Investigation Echocardiogram showed moderately impaired left ventricular systolic function
Which of these is the most accurate advice to provide? A. There is no evidence that exercise is of benefit in individuals without any cardiovascular risk factors e he should only exercise if he wants to B. He should focus on muscle-building exercises as these have the best long-term results C. He should focus on achieving high volumes of highintensity exercise such as marathon running D. He should aim to achieve at least 30 minutes of moderateintensity activity for 5 days per week E. There is no specific advice about the amount or intensity of exercise, but he should follow the advice that more is better
Which of these is the most appropriate advice about resuming running? A. He should attend cardiac rehabilitation, undertaking a structured exercise programme, and the risk can then be reviewed B. He should refrain from all forms of exercise until he is seen in clinic C. He should wait for 3 months before any marathon training, but after this there is no associated risk D. As the myocardium has been fully revascularized and he is on appropriate treatment, he can start training again. E. He should consider changing from marathon running to long-distance cycling as this is better tolerated
Question 2 A 65-year-old man was seen as an inpatient after percutaneous revascularization for an anterior myocardial infarction. He had been advised to take appropriate secondary prevention. He was a
MEDICINE --:-
Question 3 A 58-year-old man was referred for surgical revascularization for triple vessel coronary artery disease. He had had a myocardial
3
Ó 2018 Published by Elsevier Ltd.
Please cite this article in press as: Hinton J, Mahmoudi M, The role of exercise in cardiac disorders, Medicine (2018), https://doi.org/10.1016/ j.mpmed.2018.06.008
PATHOGENESIS, RISK FACTORS AND PREVENTION
infarction 6 months previously, and since then persistent angina, not adequately controlled by medical therapy. He also had a long-standing productive cough. He had a 40 packeyear smoking history. On clinical examination, his heart rate was 88 beats/minute, blood pressure 134/92 mmHg, and body mass index 30 kg/m2.
What is the most appropriate test of his exercise tolerance to perform before surgery? A. A 6-minute walking test B. Cardiopulmonary exercise test C. Exercise tolerance test using the Bruce protocol D. Exercise stress echocardiography E. Measurement of metabolic equivalents on exercise
Investigation Chest X-ray showed a cardiothoracic ratio of 55%, with clear lung fields
MEDICINE --:-
4
Ó 2018 Published by Elsevier Ltd.
Please cite this article in press as: Hinton J, Mahmoudi M, The role of exercise in cardiac disorders, Medicine (2018), https://doi.org/10.1016/ j.mpmed.2018.06.008
The role of exercise in cardiac disorders
Key points C
Regular exercise reduces cardiovascular risk, but there is currently uncertainty about the impact of extreme levels of exercise
C
Certain conditions preclude participation in competitive sports because of increased cardiovascular risk
C
Exercise capacity is a useful marker of disease state; it can also be used in conjunction with imaging techniques to provide a robust assessment of whether a patient has significant underlying coronary artery disease
C
Cardiac rehabilitation programmes, of which supervised exercise forms a key part, reduce future cardiovascular events and improve quality of life
Jonathan Hinton Michael Mahmoudi
Abstract Physical activity (PA) has been demonstrated to have a powerful role in reducing cardiovascular risk and is therefore universally recommended by international guidelines. Although there is a dose-dependent risk reduction with increasing levels of PA, there is some concern that extreme levels of PA can result in adverse cardiovascular outcomes. It is important to adapt PA advice to each individual, and in particular to note that there are conditions that are not compatible with competitive sport because of increased cardiovascular risk. Exercise also has an key role in the assessment of patients presenting with symptoms that could potentially result from cardiovascular disease, both as a measure of the impact of the disease and as a diagnostic tool.
examples of PA and the relative intensity of these. Although this mechanism of assessing the intensity of PA is helpful, it is also important to consider the relative intensity: less fit patients use more energy to perform the same PA. An assessment of relative intensity can be easily gained by either comparing the peak heart rate to the age-predicted maximum (220 beats per minute minus age) or using the ‘talk test’ (an assessment of the frequency of breathing; Table 1).3 Importantly, moderate-intensity PA produces less improvement in cardiorespiratory fitness than strenuous PA.1 It is difficult to define the exact amount of exercise required for optimum health; specifically, there does not seem to be an upper limit of moderate-intensity PA-related health benefit.1,3 There is, however, no evidence that high levels of very strenuous exercise provide any increased benefit.1 International guidelines advise that individuals should aim to achieve at least 30 minutes per day of a moderate-intensity activity for 5 days per week or 15 minutes per day of a strenuous activity for 5 days per week, or a combination of these.3 When considering prescribing PA, it is important to review both the patient’s current levels of PA and their co-morbid status because in certain circumstances it is appropriate to initially encourage very low levels of PA with a gradual increase.3 When considering how to promote sustained improvement in PA, it is often effective to set goals and encourage adaptations to daily routine to include PA, such as using active rather than passive modes of travel.3 Although the evidence relating to muscle-strengthening activities is less extensive, there is a clear consensus among guidelines that adults should also perform these activities twice a week.3 These should focus on the major muscle groups, and movements should include the full range of motion of any joint.3 This has been well established to stimulate bone formation, and, particularly in combination with aerobic PA, there is some evidence that it reduces both blood pressure and lipid concentrations.3
Keywords Cardiac rehabilitation; cardiovascular risk; diagnosis; exercise; MRCP; physical activity; primary prevention; secondary prevention
Introduction Physical activity (PA) forms a large part of the lives of some individuals, but for most it is often not a routine part of daily living. It is therefore important to consider the impact that PA can have on cardiovascular risk, and to consider the risk associated with PA in patients with cardiovascular disease. Exercise can also form an important part of tests to diagnose ischaemic heart disease (IHD), as well as having a key role in rehabilitation after a cardiac event.
Exercise in cardiovascular risk reduction Population studies have consistently shown that PA not only has a beneficial impact on cardiovascular risk factors, but also reduces both all-cause and cardiovascular mortality.1e3 Aerobic PA, which involves movements of large muscle groups in a repetitive fashion, has been the most closely studied form of PA in relation to cardiovascular risk.1e3 It is important to assess not only the duration of PA, but also the intensity. The intensity of PA is often measured in metabolic equivalents (METs), where 1 MET is defined as the amount of oxygen consumed while sitting at rest. Table 1 demonstrates some
Jonathan Hinton BM MRCP is a Cardiology Registrar at University Hospital Southampton, UK. Competing interests: none declared. Michael Mahmoudi BSc MB BS PhD FACC FRCP is an Associate Professor in Interventional Cardiology at the University of Southampton and Honorary Consultant Interventional Cardiologist at University Hospital Southampton NHS FT, UK. Competing interests: none declared.
MEDICINE --:-
Exercise as a source of cardiovascular risk The general population should be reassured and encouraged to undertake more PA, given the very low associated levels of
1
Ó 2018 Published by Elsevier Ltd.
Please cite this article in press as: Hinton J, Mahmoudi M, The role of exercise in cardiac disorders, Medicine (2018), https://doi.org/10.1016/ j.mpmed.2018.06.008
PATHOGENESIS, RISK FACTORS AND PREVENTION
predisposition to developing cardiac disease in whom exercise is not beneficial. Interestingly, this has been demonstrated in arrhythmogenic right ventricular cardiomyopathy, where presentation occurs earlier with increased PA.1 It is, however, uncertain whether this feature is seen in other conditions.1 Competitive sport in athletes is associated with a small but important risk of sudden cardiac arrest (0.76 cases per 100,000 athleteeyears) and therefore requires special consideration (see Further reading). Certain cardiomyopathies, IHD, arrhythmogenic conditions, valvular heart disease and other conditions preclude participation in many competitive sports except sometimes those in category 1A (Table 2)4 Although data demonstrating the benefits of PA are clear, there is uncertainty regarding the impact of excessive exercise, which particularly relates to endurance athletes including marathon runners, triathletes, cross-country skiers and cyclists.1 Exercise-induced troponin release, myocardial fibrosis, cardiac dysfunction after exercise, arrhythmias, accelerated coronary artery calcification and increased cardiovascular mortality compared with recommended levels of PA have all been demonstrated in this group.1 Despite this and studies suggesting a U-shaped relationship between amount of PA and mortality, there are some weaknesses with these data; therefore overall it has been recommended that, even in endurance athletes, the benefits of exercise outweigh the risks.1
Intensity of PA Intensity
METs
Examples
Percentage of Impact on max heart rate talking
Light
1.1e2.9 Light 50e63 housework Slow walking Croquet Moderate 3e5.9 Brisk walking 64e76 Vacuuming Doubles tennis Ballroom dancing Strenuous >6 Jogging 77e93 Heavy gardening Swimming Cycling > 15 km/hour
No impact
Increased respiratory rate but able to talk in full sentences Unable to talk in sentences owing to work of breathing
METs, metabolic equivalents. Source: Adapted from Piepoli et al.3
Table 1
The role of exercise in diagnosis
adverse cardiovascular events (5e17 sudden deaths per million per year).3 However, some groups of patients with pre-existing cardiovascular conditions should adjust their PA. When considering the risk of an activity, it is important to classify PA in terms of the relative intensity of both the static and dynamic elements (Table 2). There are also rare individuals with a genetic
Clinicians can rapidly gain subjective insight into the severity, progress and response to treatment of cardiovascular disease by asking individuals about their exercise capacity. The 6-minute walk test can provide a useful, objective measure of exercise capacity as well as evidence for the effectiveness of treatment, and can be used as a guide to prognosis (see Further reading). The 6-minute walk test is performed according to a self-paced standardized protocol; this not only measures the distance walked, but also symptoms, oxygen saturations and heart rate (see Further reading). Cardiopulmonary exercise testing is a more formal assessment of exercise capacity that measures oxygen uptake, carbon dioxide production and ventilation during a progressive exercise test (see Further reading). Cardiopulmonary exercise testing can provide useful prognostic data in a variety of cardiovascular conditions, as well as a detailed evaluation of functional status before major surgery (see Further reading). Exercise can also be used as a part of diagnostic testing in cardiovascular disease, particularly to diagnose IHD. Historically, exercise tolerance testing was frequently used to assess the likelihood of IHD; in this, the individual exercised according to a certain protocol, most commonly on a treadmill using a Bruce protocol. Although this is a simple test, the sensitivity and specificity are poor so it is no longer recommended for diagnosing IHD disease. It does, however, still have a role in assessing the need for surgery in patients with asymptomatic severe aortic stenosis, as well as the assessment of possible exercise-related arrhythmias. Exercise, in combination with either echocardiography or nuclear imaging, still has an important place in the non-invasive diagnosis of IHD.
Intensity of dynamic and static elements by sport Low dynamic
Moderate dynamic
High dynamic
Low static
Bowling Cricket Golf
Fencing Table tennis Doubles tennis Baseball
Moderate static
Driving and racing Equestrian sports Sailing Archery Gymnastics Field events Rock-climbing Windsurfing Weight-lifting
Badminton Race walking Running (marathon) Cross-country skiing Squash Rugby Football Tennis (single)
Bodybuilding Downhill skiing Wrestling Snowboarding
Boxing Cycling Canoeing Rowing Triathlon
High static
Adapted from Pelliccia et al. (see Further reading).
Table 2
MEDICINE --:-
2
Ó 2018 Published by Elsevier Ltd.
Please cite this article in press as: Hinton J, Mahmoudi M, The role of exercise in cardiac disorders, Medicine (2018), https://doi.org/10.1016/ j.mpmed.2018.06.008
PATHOGENESIS, RISK FACTORS AND PREVENTION
The role of exercise in recovery
4 Maron BJ, Udelson JE, Bonow RO, et al. Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: task force 3: hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy and other cardiomyopathies, and myocarditis: a scientific statement from the American Heart Association and American College of Cardiology. Circulation 2015; 132: e273e80. 5 Dalal HM, Doherty P, Taylor RS. Cardiac rehabilitation. Br Med J 2015; 351: h5000.
A key component of cardiac rehabilitation is a structured, supervised exercise programme.1 These programmes can reduce cardiovascular mortality, future hospital admissions and cardiovascular risk factors, and significantly improve quality of life.5 The risk of sudden cardiac arrest in this group is low but present.1 There is a suggestion from observational trials that highintensity or high-volume exercise can actually attenuate the cardiovascular benefits to the level of individuals who remain inactive.1 A
FURTHER READING Albouaini K, Egred M, Alahmar A, Wright DJ. Cardiopulmonary exercise testing and its application. Heart 2007; 93: 1285e92. Landry CH, Allan KS, Connelly KA, et al. Sudden cardiac arrest during participation in competitive sports. N Engl J Med 2017; 377: 1943e53. Pelliccia A, Fagard R, Bjørnstad HH, et al. Recommendations for competitive sports participation in athletes with cardiovascular disease: a consensus document from the study group of sports Cardiology of the working group of cardiac rehabilitation and exercise physiology and the working group of myocardial and pericardial diseases of the European Society of Cardiology. Eur Heart J 2005; 26: 1422e45. Rasekaba T, Lee AL, Naughton MT, Williams TJ, Holland AE. The sixminute walk test: a useful metric for the cardiopulmonary patient. Intern Med J 2009; 39: 495e501.
KEY REFERENCES 1 Eijsvogels TM, Molossi S, Lee DC, Emery MS, Thompson PD. Exercise at the extremes: the amount of exercise to reduce cardiovascular events. J Am Coll Cardiol 2016; 67: 316e29. 2 Varghese T, Schultz WM, McCue AA, et al. Physical activity in the prevention of coronary heart disease: implications for the clinician. Heart 2016; 102: 904e9. 3 Piepoli MF, Hoes AW, Agewall S, et al. 2016 European guidelines on cardiovascular disease prevention in clinical practice: the sixth joint task force of the European Society of Cardiology and other societies on cardiovascular disease prevention in clinical practice (constituted by representatives of 10 societies and by invited experts). Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). Eur Heart J 2016; 37: 2315e81.
TEST YOURSELF To test your knowledge based on the article you have just read, please complete the questions below. The answers can be found at the end of the issue or online here. keen marathon runner and wanted to get back to this as soon as possible.
Question 1 A 49-year-old man attended for review of his cardiovascular risk. He was asymptomatic, had no previous medical history and had never smoked. His cholesterol and blood pressure did not require any treatment. He asked how much exercise he should undertake for optimum cardiovascular health.
Investigation Echocardiogram showed moderately impaired left ventricular systolic function
Which of these is the most accurate advice to provide? A. There is no evidence that exercise is of benefit in individuals without any cardiovascular risk factors e he should only exercise if he wants to B. He should focus on muscle-building exercises as these have the best long-term results C. He should focus on achieving high volumes of highintensity exercise such as marathon running D. He should aim to achieve at least 30 minutes of moderateintensity activity for 5 days per week E. There is no specific advice about the amount or intensity of exercise, but he should follow the advice that more is better
Which of these is the most appropriate advice about resuming running? A. He should attend cardiac rehabilitation, undertaking a structured exercise programme, and the risk can then be reviewed B. He should refrain from all forms of exercise until he is seen in clinic C. He should wait for 3 months before any marathon training, but after this there is no associated risk D. As the myocardium has been fully revascularized and he is on appropriate treatment, he can start training again. E. He should consider changing from marathon running to long-distance cycling as this is better tolerated
Question 2 A 65-year-old man was seen as an inpatient after percutaneous revascularization for an anterior myocardial infarction. He had been advised to take appropriate secondary prevention. He was a
MEDICINE --:-
Question 3 A 58-year-old man was referred for surgical revascularization for triple vessel coronary artery disease. He had had a myocardial
3
Ó 2018 Published by Elsevier Ltd.
Please cite this article in press as: Hinton J, Mahmoudi M, The role of exercise in cardiac disorders, Medicine (2018), https://doi.org/10.1016/ j.mpmed.2018.06.008
PATHOGENESIS, RISK FACTORS AND PREVENTION
infarction 6 months previously, and since then persistent angina, not adequately controlled by medical therapy. He also had a long-standing productive cough. He had a 40 packeyear smoking history. On clinical examination, his heart rate was 88 beats/minute, blood pressure 134/92 mmHg, and body mass index 30 kg/m2.
What is the most appropriate test of his exercise tolerance to perform before surgery? A. A 6-minute walking test B. Cardiopulmonary exercise test C. Exercise tolerance test using the Bruce protocol D. Exercise stress echocardiography E. Measurement of metabolic equivalents on exercise
Investigation Chest X-ray showed a cardiothoracic ratio of 55%, with clear lung fields
MEDICINE --:-
4
Ó 2018 Published by Elsevier Ltd.
Please cite this article in press as: Hinton J, Mahmoudi M, The role of exercise in cardiac disorders, Medicine (2018), https://doi.org/10.1016/ j.mpmed.2018.06.008