Cardiovascular Disease and Exercise

What is cardiovascular disease (CVD)?

Disorders involving the heart and circulation include coronary heart disease, stroke, and heart failure. CVD is the leading cause of death in the US for both men and women (4). Physical activity can help prevent disease or restore lost function.

Heart Failure (HF)

• Due to cardiac muscle dysfunction, the heart progressively pumps less blood to the body. When the demand for blood is not met with supply from the heart (2).
• Left-sided heart failure is due to damage to the left ventricle causing blood to back up in the left atrium and then the lungs causing trouble breathing and a cough (2).
• Right-sided heart failure causes fluid to back up into the veins and general swelling.
• Systolic dysfunction in HF reduced ejection fraction: causes decreased myocardial contractility leading to decreased cardiac output of blood. This is because the ejection fraction of blood leaving the left ventricle is less than 40% (2).
• Diastolic dysfunction with preserved ejection fraction is due to the poor filling of the ventricle leading to decreased volume ejected overall but the fraction per beat is normal 55-75% (3a).

Coronary Artery Disease (CAD)

The heart receives blood from the coronary vessels. The coronary arteries can become blocked by fatty plaques resulting from high LDL and total cholesterol combined with fibrous tissue (4,5). This plaque can grow over time and cause a narrowing of the blood vessels called atherosclerosis. This narrowing can reduce blood flow and cause chest pain due to ischemia in the heart muscle which may be deadly. 

Peripheral Arterial Disease (PAD)

Fatty deposits can build up in the artery walls and restrict blood flow to the organs and extremities. A common finding in PAD is an ankle-brachial index of <.9, meaning the blood pressure in the feet is less than in the arms. This can lead to reduced blood flow and reduced sensation in the feet. A common symptom is intermittent claudication where walking causes aching in the calf muscle that is relieved with rest (5).

Peripheral Vascular Disease (PVD)

Failure of the veins that return blood to your heart. This can lead to insufficiency of the valves in your veins causing fluid buildup in your extremities. Muscle pump action of the calf muscle can return blood to the heart with contractions. Having PVD can increase the risk of a heart attack or stroke by 4-5 times (4).

Hypertension 

Abnormally high blood pressure due to resisted flow due to narrowed or constricted vessels, increased blood volume, and high heart rate (4). Defined as systolic BP over 140 mmHg, and/or a diastolic of 90 mmHg. Risk factors include smoking, obesity, diet, drugs, stress, hyperlipidemia, inactivity, and genetics (4). Primary prevention of the development of hypertension and obesity can reduce the risk of CVD.

Myocardial Infarction (MI) aka Heart Attack

The heart requires blood for oxygen to contract. In an MI, the heart muscle demands more blood than can be supplied. This deficit deprives the tissue of blood causing ischemia over a long period causes cell death. This can cause chest pain or angina, radiating pain down the arms, and or jaw pain (4). Because of the risk of MI, exercise should always be kept under an intensity that triggers angina or MI symptoms (5).

Risk Factors for CVD (1)

Age:

45 and older for men or 55 and older for women.

Family history:

Sudden death of first-degree male relative before 55 in fathers or 65 in mothers.

Smoking

Sedentary:

Not performing 30 minutes of moderate-intensity exercise three days a week over the last three months.

Obesity:

BMI > 30 kg x m^-2

• • Waist 
    • >40 in for men
    • >35 in for women

Hypertension:

SBP > 140 mmHg, DBP > 90 mmHg

• • In individuals between 40 and 70 of age, an increase of 20 mmHg SBP and 10 mmHg DBP doubles the risk of CVD (1).

Dyslipidemia

Serum Cholesterol > 200 mg x dL, LDL > 130 mg/dL, and HDL < 40 mg/dL contribute to an increased risk for CVD. HDL >60 mg/dL is considered to be protective from CVD (1).

Diabetes

Fasting 8-hr glucose >126 mg x dL, 2-hr oral glucose tolerance test >200 mg x dL, HbA1C >6.5 are all signs you may have issues controlling blood glucose.

Prevention 

Primary prevention:

Reducing the risk of disease before development. For instance, exercise can lower blood pressure and may reduce the progress of HTN (5). Physical activity improves fitness and reduces the risk of CVD (1). A decrease in heart rate and blood pressure at rest reduces the demand on the heart. This happens because as you become fitter, there is an increase in VO2 Max, your stroke volume improves, and risk factors for MI such as blood lipids may improve (4). Sedentary living can increase your risk for CVD. For instance, with an increase in 2 hours spent on a screen, there is a 17% increased risk of cardiovascular disease (1). During bed rest, studies have shown reduced function of veins, increased blood pressure, and narrowing of arteries. With heart failure, lower physical activity is associated with greater mortality and a worse prognosis (2).

Secondary Prevention:

Improving the outcome of a disease once it has been acquired. The American College of Sports Medicine believes exercise is medicine because physical activity can prevent and treat chronic diseases such as heart disease (6). This is because exercise is beneficial for those at risk for MI, and has been seen to decrease inflammatory markers such as CRP, decrease stress and damage on the coronary arteries, and increase new blood vessel growth which can help recovery from MI (5). For the treatment of CVD, cardiac rehabilitation, medication, diet, surgery, and stress management. Regular exercise can also decrease clotting risk and the risk of a second MI while improving quality of life (5). In those with PAD, exercise can improve the distance before pain is felt and decrease the mortality risk (5). Exercise has also been shown to reduce blood pressure, and reverse atherosclerotic plaques (5). Patients who chose to enroll in cardiac rehabilitation to exercise have shown decreased symptoms and reduced occurrence of a second cardiovascular event (5).

Aerobic exercise

Endurance exercise can lower resting SBP and DBP by 5-7 mmHg, and delay hypertension progression (5).

Purpose:

Improve the quality of life, improve vo2 max, and reduce the amount of hospital days. Aerobic exercise may improve the left ventricle ejection fraction by 2-3% and chance of survival (2).

Frequency (2,5):

• Daily, or 3-7x for CVD
• 3-5x for PAD

Intensity: 

• CVD: Moderate RPE <11-14/20, 40-69% HRR, Deconditioned 30-39% HRR, or 20-30 beats above resting
• PAD: 40%-59% VO2 reserve or until moderate pain (5).
• 50-90% vo2 max.
• Intensity should be below the ischemic threshold to reduce the risk of damage and MI.
• A warmup and cooldown should be used to increase and decrease heart rate gradually.

Time:

• CVD: 1500-2000 Kcal each week or 20-60 minutes per session.
  • Low-fit individuals may benefit from daily bouts starting with 1-5 minutes and progressing to 10-15 minutes repeated 2-3 times a day (5). 
• PAD: 30-50 min.
  • If PAD is severe, may begin with 15 minutes total and progress 5 minutes every 2-4 weeks. 
• ACSM’s goal is 150 minutes a week at a moderate intensity or 75 min of vigorous intensity (5).

Type:

• CVD: Exercises that target major muscle groups such as the treadmill or cycle ergometer (5).
• PAD: Weight-bearing such as walking overground or on the treadmill.

High-Intensity Interval Exercise (HIIT)

Purpose:

For stable heart failure, a physical therapist may decide to do HIIT  to improve VO2 max and decrease the risk of mortality. Can improve VO2 max, daily function, and strength.

Frequency:

2-3x week

Intensity:

>90% Vo2 Max

Time:

35 total minutes with 1-5 minutes working and 1-5 minutes active resting. Repeat for 8-12 weeks.

Type:

Treadmill or cycle ergometer

Resistance Training (2,5)

Purpose:

Improve aerobic capacity, 6 MWT, quality of life, and strength.  

Frequency: 

• CVD: 2-3x 
• PAD: 2-4x

Intensity: 

• CVD & PAD 60-80% 1RM
• Vigorous resistance training may cause medical complications due to the increased blood pressure.

Time: 

• CVD: 8-12 exercises with 1-4 sets per exercise
• PAD: 8-12 exercises with 2-3 sets per exercise with 8-12 repetitions. 
• Alternatively 45-60 minutes per session pending tolerance.

Type:

• CVD: Elastic bands, light dumbbells, and machines
• PVD: all major muscle groups, with emphasis on lower extremity.
• Avoid heavy weights using the Valsalva maneuver or causing pain.

Combined Aerobics and resistance

Purpose: Improved strength and muscle endurance with improved quality of life, better than aerobics alone.

Flexibility

Inactivity after hospitalization may lead to stiff joints and shortened muscles. Stretching major joints for 15-30 seconds for 2-4 repetitions can help preserve function.

Inspiratory Muscle Training

Purpose:

improves maximum inspiratory pressure, exercise tolerance and quality of life.

Frequency:

• 5-7 days a week

Intensity:

>30 maximum inspiratory pressure, or >60% MIP

Time:

30 minutes/day, for 8-12 weeks

Neuromuscular Electrical Stimulation

Electrodes are placed on the skin over muscle bellies to encourage contraction and function. This is usually done as a skilled intervention in physical therapy to combat atrophy and promote strength.

Purpose:

To improve muscle strength and endurance, VO2 max, distance in 6 MWT, and quality of life (2).

Time & Frequency:

30-60 minutes for 5-7 days a week for 5-10 weeks.

Precautions (2)

After a CVD event, admission into the hospital’s cardiac rehabilitation program requires medical stability. After admission, you will begin working on the basics such as standing up from bed and building positional tolerance. Discharge from the hospital into an outpatient facility to continue rehab monitored by EKG to improve functional capacity (1). With progress, the monitoring with an EKG is replaced by supervision by a healthcare professional and is recommended until cleared for independent exercise in the community.

• The presence of cardiac arrhythmias, comorbidities such as diabetes, chest pain, orthostatic hypotension, and tolerance to activity impacts the level of care required to exercise safely (1). Ignoring cardiac signs can exacerbate the dysfunction and result in cardiac events, fainting, and death.
• Orthostatic hypotension is a decrease in SBP by 20 mmHg or DBP by 10 mmHg caused by a change in position. For instance, standing up from sitting drops your blood pressure and may result in fainting, dizziness, and confusion.

Stop exercise immediately if: (1),(2)

• Unable to speak comfortably, or respiratory rate >40-45 BPM.
• Heart rate decreases by 10 BPM
• SBP decreases >10 BPM
  • >220 mmHg
  • For every increase of 1 MET, there should be a 10 mmHg increase in SBP (3a). 
• DBP is greater than 105 mmHg
• MAP increases > 10 mmHg
• SpO2 < 90%
• Cardiac arrhythmia 
• Chest pain (Angina)
  • Stable
    • Pain is predictable with a threshold of workload on the heart SBP x HR. Must work with a healthcare professional for exercise prescription.
  • Unstable
    • Symptoms of chest pain at rest or little exertion. Medical attention should be a priority because a heart attack may be occurring (5).
• Wheezing or chest tightness

Do not begin exercise if 

• SBP >180 or DBP >110, must be cleared by a physician and is typically controlled with drug therapy (5).
• MAP <60 can decrease blood getting to organs. 
• Heart rate <50 or >140 BPM unless cleared.
• Severe shortness of breath or cold sweats.
• Unstable chest pain.
• Onset of a new or worsening cardiac dysrhythmia.
• Onset of s3 heart sound.
• Requires sitting in a chair to sleep.
• Weight gain of >5 lbs in 3 days.

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Disclaimer: 

This content is for educational purposes only and does not constitute the practice of physical therapy, nursing, or other professional health care services, including the giving of medical advice, and no doctor/patient relationship is formed. Using information or materials for any reason is at the user’s risk. This content is not a substitute for professional medical advice, diagnosis, or treatment. Users should not disregard or delay in obtaining medical advice for any medical condition they may have and should seek the assistance of their healthcare professionals for any such conditions. Physical activity should be tailored to each person considering unique lifestyles, health factors, and comorbidities by a health professional. Additionally, exercise is one piece of cardiac rehabilitation, smoking, medication, nutrition, stress, and comorbidities should also be considered by a healthcare professional.

References

1. Bayles, M. P., Swank, A. M., & American College of Sports Medicine (Eds.). (2018). ACSM’s exercise testing and prescription (First edition). Wolters Kluwer.
2. Shoemaker, M. J., Dias, K. J., Lefebvre, K. M., Heick, J. D., & Collins, S. M. (2020). Physical Therapist Clinical Practice Guideline for the Management of Individuals With Heart Failure. Physical Therapy, 100(1), 14–43. https://doi.org/10.1093/ptj/pzz127
3. https://www.aptaacutecare.org/
   1. Acute Care Vital Sign Interpretation 2021
   2. Acute Care Laboratory Values Interpretation resource 2023 Update
4. Potteiger, D. J. (2017). ACSM’s Introduction to Exercise Science (3rd edition). LWW.
5. Magyari, P., Lite, R., Kilpatrick, M., Schoffstall, J., & American College of Sports Medicine (Eds.). (2018). ACSM’s resources for the exercise physiologist: A practical guide for the health fitness professional (Second edition). Wolters Kluwer Health.
6. News Detail. (n.d.). ACSM_CMS. Retrieved March 16, 2024, from https://www.acsm.org/news-detail
7. Thomas, R. J., Beatty, A. L., Beckie, T. M., Brewer, L. C., Brown, T. M., Forman, D. E., Franklin, B. A., Keteyian, S. J., Kitzman, D. W., Regensteiner, J. G., Sanderson, B. K., & Whooley, M. A. (2019). Home-Based Cardiac Rehabilitation: A Scientific Statement From the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Heart Association, and the American College of Cardiology. Journal of the American College of Cardiology, 74(1), 133–153. https://doi.org/10.1016/j.jacc.2019.03.008