Physical Activity and Cardiovascular Disease

Introduction

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Physical activity has a proportionally inverse effect on the CDV morbidity and mortality

  • Women and men demonstrate similar CVD risk lowering benefits by engaging in regular physical activity.
  • More activity is associated with a lower risk of developing cardiovascular disease when compared to less physical activity
  • The gradual introduction of activity (combined with physician evaluation prior to starting an exercise program) mitigates risks for eg totally sedentary people or weekend warriors.
  • Low levels of activity that can be achieved by adopting walking programs (lowering cardiovascular disease risks) and are generally safe and applicable to all adults across the age spectrum.[1]

Cardiovascular Disease

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The cardiovascular system consists of the heart and blood vessels. There is a wide array of problems that may arise within the cardiovascular system eg. endocarditis, rheumatic heart disease, abnormalities in the conduction system.

Cardiovascular disease (CVD) or heart disease refer to the following 4 entities:

  1. Coronary artery disease (CAD): Sometimes referred to as Coronary Heart Disease (CHD), results from decreased myocardial perfusion that causes angina, myocardial infarction (MI), and/or heart failure. It accounts for one-third to one-half of the cases of CVD.
  2. Cerebrovascular disease (CVD): Including stroke and transient ischemic attack (TIA)
  3. Peripheral artery disease (PAD): Particularly arterial disease involving the limbs that may result in claudication
  4. Aortic atherosclerosis: Including thoracic and abdominal aneurysms[2]

Early recognition of risk factors and primary prevention have significantly decreased the morbidity and mortality associated with CAD. Lifestyle modification with diet, exercise, and smoking cessation is crucial to reduce cardiovascular risk factors.

Physical activity is very beneficial for CAD risk reduction. Even a little is better than nothing.

  • At least 150 minutes per week of moderate-intensity activities and greater than 75 minutes a week of vigorous-intensity physical activities are helpful.
  • Moderate activities include brisk walking (2.4 to 4 mph), biking (5 to 9 mph), active yoga, and recreational swimming, whereas vigorous activities include jogging/running, biking (greater than 10 mph), playing tennis, swimming, etc.[3]
  • Moving from being totally sedentary to an activity level of approximately 72.2 minutes per week—a little over 10 minutes per day, also improves cardiorespiratory fitness.[1]

Physical Activity Effects on Cardiovascular Diseases

The World Health Organization (WHO) states that substantial health benefits, for CVD risk reduction, can be achieved by moderate-intensity PA of at least 150 minutes a week, or vigorous-intensity PA of at least 75 minutes a week, or any combination of moderate and vigorous-intensity PA. It is also emphasises that any amount of PA leads to health benefits.[4]

  • There is clear evidence of an inverse linear dose-response relation between the volume of physical activity and all-cause mortality rates in men and women, and in younger and older persons. Minimal adherence to current physical activity guidelines, which yield an energy expenditure of about 1000 kcal x wk(-1) is associated with a significant 20--30% reduction in risk of all-cause mortality. Further reductions in risk are observed at higher volumes of energy expenditure [5]
  • Physical activity improves systolic blood pressure, angina symptoms and exercises tolerance in patients without re-vascularisation [6]. and patients with re-vascularisation achieve improved physical activity, the quality of life, and exercise tolerance (also 29% reduced risk of cardiac events 20% and/or lower readmission rates)[7].
  • A 2018 review reported "Resistance Training leads to improvement in cardiac autonomic control of diseased individuals" Also noting that only current physical activity is protective – sports participation in youth does not provide protection in later life unless activity is maintained[8].

PA Effect on Hypertension/Blood Pressure

  • Inactive individuals have a 30-50% greater risk of high blood pressure/hypertension than fit and active individuals[9] (an inverse relationship between physical activity and the incidence of hypertension exists),
  • The acute effect of PA causes a reduction in blood pressure lasting 4 to 10 hours; therefore, daily activity may achieve clinically significant improvement[10]
  • Aerobic fitness training has the greatest benefit followed by dynamic resistance and isometric resistance at moderate intensity training [10][11][12].

Exercise in Coronary Artery Disease

The evidence for the benefit of exercise in Coronary Artery Disease (CAD) is compelling, exercise is indicated in the primary and secondary prevention of CAD. The benefits of exercise are greater than the results of PCI (Percutaneous Coronary Intervention) techniques. A recent randomised controlled trial studying the feasibility, acceptance, and short-term clinical effectiveness of the Physical Activity Toward Health (PATHway) system for maintaining PA and physical fitness of patients with cardiovascular diseases (CVD) after completion of an ambulatory center-based CR program showed positive outcomes with their internet-based remote home-based cardiac rehabilitation program[13].

A study of men with stable CAD[14], over a two year period, regular exercise intervention outperformed PCI on all measures:

  • "Event free survival" rates after 24 months were 78% in the exercise group versus 62% in the PCI cohort
  • At two years, maximal oxygen consumption (VO2max) had increased by 10% in the exercise group versus 7% in the PCI group.
  • Inflammatory markers improved in the exercise cohort: high-sensitive C-reactive protein levels and interleukin-6 levels were significantly reduced after two years of exercise by 41 and 18%, respectively ,no relevant changes were observed in the PCI group.

PA in Secondary Prevention of MI

Guidelines on secondary prevention for patients following a myocardial infarct recommend[15]:

  • Following MI, patients should be physically active for 20-30 minutes a day to the point of slight breathlessness.
  • People who are not active to this level should increase their activity gradually aiming to increase their exercise capacity. They should start at a level that is comfortable, and increase the duration and intensity of activity as they gain fitness. 

Although early mobilization using a cycle ergometer didn't increase physical activity as compared to standard physiotherapy sessions, a randomized controlled trial found Cycle Ergometer Use in the post-operative period following cardiac surgery to be a safe choice for patient rehabilitation[16][16][16]

Exercise in Chronic Heart Failure

The benefits of physical exercise in patients with Chronic Heart Failure (CHF) is established as well: exercise training in stable patients with mild to moderate CHF results in statistically significant improvements in maximum heart rate, maximum cardiac output, peak VO2, anaerobic threshold, 6 minute walk test and HRQL (quality of life questionnaire).

The results of a cross-sectional study suggest that a single self-report activity question may identify inactive patients with high specificity, as determined by an accelerometer, thus implying that a single SR item might be useful in screening for physically inactive patients with Heart Failure[17].

Symptoms of Cardiovascular Events

The classic symptoms of a cardiovascular event include;

  • Chest discomfort (pressure, squeezing, fullness, pain)
  • Discomfort in one or both arms, back, jaw or stomach
  • Shortness of breath
  • Cold sweat
  • Nausea
  • Lightheadedness[18]

Women may not experience the classic symptoms above. Instead, they are more likely to experience the following;

  • Unusual fatigue
  • Sleep disturbances
  • Weakness
  • Shortness of breath
  • Nausea/vomiting
  • Back or jaw pain. [19]

The American Heart Association designed a Healthy Heart Quiz: Are you able to recognise a Heart Attack? They have also produced a useful graphic on this topic.

Prodromal Symptoms

Increased long-term variability in systolic blood pressure was associated with a higher risk for cardiovascular events, mortality and disease.[20]

LowExBP independently predicts fatal and non-fatal cardiovascular events and all-cause mortality.[21]

Exercise Prescription[22]

The American College of Sports Medicine (ACSM) published guidelines which were based on their traditional exercise guidelines but adapted for the physiological differences in patients with CAD compared to healthy individuals. Patients with CAD should perform everyday physical activity as well as supervised exercise lessons.

[23]
  • Continuous exercise using large muscle groups (e.g. walking, swimming, group aerobics) fosters cardiovascular endurance. Upper extremity exercises (e.g. using an arm ergometer) may be useful for people with musculoskeletal problems in their lower extremities.
  • Resistance exercises should be provided in a circuit training approach. 10-12 exercises using 10-12 repetitions with sufficient resistance that can be performed comfortably. Cross-training is possible as well.

Frequency

  • A minimum of three non-consecutive days per week
  • With the increased frequency of exercise, the risk of musculoskeletal injuries increases

Duration

  • 10 minute warm-up and cool-down phases, including stretching and flexibility exercises.
  • 20-40 minute continuous or interval cardiovascular exercise. Interval training may be useful for people with peripheral vascular disease and intermittent claudication.

Intensity

Cardiovascular exercise in supervised programs should be of moderate intensity. Intensity can be determined using various methods;

  • 40-85% VO2 max
  • 40-85% maximal heart rate reserve (HRmax - resting heart rate) X 40-85% + resting heart rate
  • 55-90% of HRmax
  • The Rating of Perceived Exertion (RPE) is appropriate to monitor exercise intensity

Progression

  • Slow progression of exercise duration and intensity

Monitoring

  • Patient observation
  • Measure heart rate and rhythm
  • Measure blood pressure when clinically indicated (depending on the patient-specific risks for exercise-related complications)
  • Patients who exercise without direct supervision should exercise at a lower intensity

Contraindications for Exercises

Exercise and asthma.jpeg

Patients should exercise at a sub-symptom threshold to avoid provoking myocardial ischaemia, significant arrhythmias or symptoms of exercise intolerance. Patients at higher risk should exercise at lower levels of intensity.

Absolute contraindications to exercise;[24]

  • Uncontrolled or poorly controlled asthma
  • Cancer or blood disorders when treatment or disease cause leukocytes below 0.5 x10/L, haemoglobin below 60g/L or platelets below 20 x 10/L
  • COPD: Patients are required to be stable before training and oxygen saturation levels should be above 88-90%.
  • Diabetes if blood glucose is >13 mmol/L or <5.5 mmol/L
  • Patients with diabetic peripheral or autonomic neuropathy or foot ulcers should avoid weight-bearing exercise
  • Any diabetic with acute illness or infection
  • Heart disease - acute myocardial infarction or unstable angina until stable for at least 5 days, dyspnoea at rest, pericarditis, myocarditis, endocarditis, symptomatic aortic stenosis, cardiomyopathy, unstable or acute heart failure, uncontrolled tachycardia
  • Hypertension - resting blood pressures of a systolic >180mmHg or diastolic >100mmHg or higher should receive medication before regular physical activity with particular restrictions on heavy strength conditioning, which can create particularly high pressures
  • Osteoporosis - avoid activities with a high risk of falling
  • Fever - should be settled to avoid a risk of developing myocarditis
  • Unexplained dizzy spells
  • Acute pulmonary embolus or pulmonary infarction
  • Excessive or unexplained breathlessness on exertion
  • Any acute severe illness

Special Considerations

Antihypertensive medication can influence exercise and should be considered by the therapist when prescribing exercise. [25]

  • Beta Blockers decrease exercise capacity because it creates a ceiling effect, meaning it will not allow the heart rate rise beyond a certain point. Thus the target heart rate for monitoring should not be used. Rather let the patient use the rate of perceived exertion (RPE) or calculate the target heart with a graded stress test while the patient is using the medication.
  • Vasodilators, alpha - and calcium channel blockers may lead to a sudden blood pressure drop while exercising or afterwards.
  • Proper warming up and cooling down will help improve the blood pressure response to exercise
  • Educate patients to avoid the Valsalva manoeuvre during resistance training

Risk of Exercises

Risk of Exercise for patients with coronary heart disease: acute myocardial infarction, cardiac arrest, and sudden death. A recent systematic review and meta-analysis of the cardiovascular health of field-based athletes suggests an elevated risk for CVD in some athletes, primarily football players[26]. Incidence in supervised cardiac rehabilitation programs are:

  • 1 myocardial infarction per 294,000 patient hours
  • 1 cardiac arrest per 112, 000 patient hours
  • 1 death per 784,000 patient hours.

Over 80% of persons who reported cardiac arrest symptoms while exercising have been successfully resuscitated with prompt defibrillation [27].

Exercises and Medications

Exercise response to cardiac medications

Final Remarks

Physical inactivity is an established risk factor for cardiovascular diseases.

  • Golf.jpg
    Physiotherapists are encouraged to encourage and educate CAD clients re PA benefits.
  • Physical activity is recommended as a component of healthy lifestyle. In general, there is a graded inverse association of physical activity with CHD and total cardiovascular disease (the combination of CHD and stroke).
  • Overall PA increases quality of life and decreases health care costs. PA has many physiologic benefits.
  • Exercise training has been shown to increase maximal oxygen uptake (VO2max), improve endothelial function, and improve myocardial reserve flow.
  • Exercise in the form of cardiac rehabilitation sessions decreases depression in heart disease patients who suffer a major coronary event and reduces hospital admissions and shows a long-term decrease in all-cause mortality in patients heart failure patients with preserved ejection fraction. [28]

Resources

References

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  14. Walther C, Möbius-Winkler S, Linke A, Bruegel M, Thiery J, Schuler G, et al. Regular exercise training compared with percutaneous intervention leads to a reduction of inflammatory markers and cardiovascular events in patients with coronary artery disease. Eur J Cardiovasc Prev Rehabil. 2008;15(1):107-12.
  15. National Institute for Health and Care Excellence. MI-secondary prevention: Secondary prevention in primary and secondary care for patients following a myocardial infarction. 2013. NICE clinical guideline 172. London: National Institute for Health and Care Excellence. Available from: https://www.nice.org.uk/guidance/cg172/evidence/myocardial-infarction-secondary-prevention-appendices-a-h-pdf-248682926 [Accessed 3rd September 2019]
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