Post on 18-Dec-2015
2009 - Angiology Care Unit - Padua - Italy - www.ANGIO-PD.it
AZIENDAOSPEDALIERA UNIVERSITA’PADOVA
1
University Hospital of Padua - Italy
Angiology Care Unit
G.M. Andreozzi
Physical Training in the Treatment of Peripheral
Arterial Disease(Intermittent Claudication)
2009 - Angiology Care Unit - Padua - Italy - www.ANGIO-PD.it
AZIENDAOSPEDALIERA UNIVERSITA’PADOVA
Physical Training in Claudicants
Physical ExercisePhysiological Tool for Prevention and Treatment of Cardio – Vascular Diseaseseffective and cheapTask Force Multisocietaria (Fed. Medico Sportiva Italiana & Soc. It. Cardiologia dello Sport):Documento Cardiologico di Consenso su: La prescrizione dell’esercizio fisico in ambito cardiologico. (FMSI & SIC-sport Ed) Roma 9 maggio 2006
Physical Training effective mean for claudicant patients
Hirsch AT, Haskal ZJ, Hertzer NR: ACC/AHA Guidelines for the management of PAD. JACC 2006; 20 (10): 1-75
- low application- dyshomogenous procotols
2009 - Angiology Care Unit - Padua - Italy - www.ANGIO-PD.it
AZIENDAOSPEDALIERA UNIVERSITA’PADOVA
Physical Training in Claudicants
The largest metanalysis on the results of Physical Training in Patients with Intermittent Claudication show and increase of ACDbetween 74 (a) and 230% (b)…
a) Girolami B et al: Arch Intern Med. 1999; 159:337-345 b) Leng GC et al: Exercise for intermittent claudication (Cochrane review). in: Cochrane library, 3, 2002. Oxford: Update Software.
0 50 100 150 200 250
m
Leng (b)
Girolami (a)
… unaccepatable for other therapeutic tools
… as pharmacological therapy
2009 - Angiology Care Unit - Padua - Italy - www.ANGIO-PD.it
AZIENDAOSPEDALIERA UNIVERSITA’PADOVA
Physical Training Protocol (3 days weekly x 6 weeks = 18 days)
Int Angiol 2008 27(5):401-7
2009 - Angiology Care Unit - Padua - Italy - www.ANGIO-PD.it
AZIENDAOSPEDALIERA UNIVERSITA’PADOVA
5
Management of Intermittent Claudication
2009 - Angiology Care Unit - Padua - Italy - www.ANGIO-PD.it
AZIENDAOSPEDALIERA UNIVERSITA’PADOVA
Sub Maximal Test (speed 1,5 km/h slope 62%)
Single Exercise Load Patient walks until 60-70% of walking ability measured by sub
maximal test
Maximal Treadmill TestConstant Load (speed 3,2 km/h, slope 12-15%)Parameters: ICD, ACD, recovery time (rt)
Near maximal pain but without reaching it
Resting Restore (standing or sitting)until the patient can restart the walking(indicative setting could be a resting periodequal to recovery time measured during maximal test)
Daily Training SessionEXERCISE-REST-EXERCISE pattern should be repeated,
reaching at least 30 min of effective walking time
Single Exercise LoadPatient walks until 60-70% of new walking performance
(incremental protocol of the training programme)
Day 10 - New Assessment of Walking AbilitySub Maximal Treadmill (same speed and slope of the starting day)
Physical Training Protocol (3 days weekly x 6 weeks = 18 days)
2009 - Angiology Care Unit - Padua - Italy - www.ANGIO-PD.it
AZIENDAOSPEDALIERA UNIVERSITA’PADOVA
Intermittent Claudication - Skeletal Muscle Pathophysiology
0
10
20
30
40
50
60
70%
F-1 F-2A F-2B
Histochemistry Prevalence of Muscle's Fibres
CONTROLS CLAUDICANTS
Askew CD et al: J Vasc Surg 2005 41:802-807
reduction of FAST 2B fibersincrease of INTERMEDIATE 2A fibers
SKELETAL MUSCLES
TWITCH
CHARACTERISTIC
METABOLIC
PROFILE
FUNCTION
TYPE 1 SLOW OXIDATIVE
high mitocondrial content adapted for
prolonged work
TYPE 2
(A)
INTERMEDIATE INTERMEDIATE
OXID - GLYCOL
INTERMEDIATE
TYPE 2
(B)
FAST GLYCOLYTIC more
rapidly fatigue
Steinacker JM et al: J Vasc Surg 2000 31:443-449
WEIGHTBEARING
2009 - Angiology Care Unit - Padua - Italy - www.ANGIO-PD.it
AZIENDAOSPEDALIERA UNIVERSITA’PADOVA
8
Inflammatory Activation during Maximal Exercise Treadmill Test
2009 - Angiology Care Unit - Padua - Italy - www.ANGIO-PD.it
AZIENDAOSPEDALIERA UNIVERSITA’PADOVA
9
Inflammatory Activation during Maximal Exercise Treadmill Test
IL-1 IL-6
Cordova R, Martini R, … Andreozzi GM: Flogistic arterial activity or own inflammatory attitude:what acts on PAD evolution? Int Angiol 2003 22 s1 21-22
Andreozzi GM et al: Circulating levels of Cytokines (IL-6 and IL-1),in patients with Intermittent Claudication, at rest, after maximal exercise treadmill test and during restore phase. Int Angiol 2007 26(3):245-52
2009 - Angiology Care Unit - Padua - Italy - www.ANGIO-PD.it
AZIENDAOSPEDALIERA UNIVERSITA’PADOVA
10
FMD and Maximal Exercise
% F
MD
2009 - Angiology Care Unit - Padua - Italy - www.ANGIO-PD.it
AZIENDAOSPEDALIERA UNIVERSITA’PADOVA
11
Physical Training Protocol (18 days) - Results
* p < 0,001** p < 0,0001
0
50
100
150
200
m.
before after
ICD
0
50
100
150
200
250
300
m.
before after
ACD
0
50
100
150
200
250
sec.
before after
recovery time
0,4
0,6
0,8
before after
ABI
** **
***
Moderate Claudication (33)
0102030405060708090
m.
before after
ICD
020406080
100120140160
m.
before after
ACD
0
50
100
150
200
250
sec.
before after
recovery time
0,6
0,8
before after
ABI
** **
***
Severe Claudication (41)
2009 - Angiology Care Unit - Padua - Italy - www.ANGIO-PD.it
AZIENDAOSPEDALIERA UNIVERSITA’PADOVA
12
Physical Training and Endothelial Function
Before (-33,28%) After (-19,83) p<0,01
% F
MD
2009 - Angiology Care Unit - Padua - Italy - www.ANGIO-PD.it
AZIENDAOSPEDALIERA UNIVERSITA’PADOVA
13
Paradoxical Effect of Physical Exercise on Endothelial Function
Murry CE, Jennings , Reimer KA: Preconditioning with ischemia: a delay oflethal cell injury in ischemic myocardium. Circulation 1986 74:1124-36Schott RJ, Rohamann S, Braun ER, Sharper W: Ischemic preconditioningreduces infarct size in swine myocardium. Circ Res 1990 66:1133-42
Ischemic Preconditioning: metabolic adaptationto low intensity repeated ischemia…
Di Perri T, Laghi Pasini F: Fisiopatologia e farmacologia del sistema adenosinico.Rel. 92° Congr SIMI Luigi Pozzi Ed. Roma 1981Di Perri T, Capecchi PL: Le arteriopatie obliteranti periferiche.In Allegra C, Andreozzi GM, Coccheri S, Di Perri T: Managementdel paziente arteriopatico. Excerpta Medica Milano 1999Capecchi PL, Laghi Pasini F, Cati G et al. Experimental model ofshort-time exercise-induced preconditioning in PAOD patients.Angiology 1997 48:469-480
… with ADP release, acting on specific receptorsof smooth muscle cells and endothelial cells
Acute Exercise: inflammatory, prothrombotic andvasoconstrictor activities
Chronic Exercise (training): improvement of physical efficiency,inflammatory reduction and enhancement of vasodilation and fibrinolysis
2009 - Angiology Care Unit - Padua - Italy - www.ANGIO-PD.it
AZIENDAOSPEDALIERA UNIVERSITA’PADOVA
Training Effectiveness
The largest metanalysis on the results of Physical Training in Patients with Intermittent Claudication show and increase of ACDbetween 74 (a) and 230% (b)a) Girolami B et al: Arch Intern Med. 1999; 159:337-345
b) Leng GC et al: Exercise for intermittent claudication (Cochrane review). in: Cochrane library, 3, 2002. Oxford: Update Software.
0 50 100 150 200 250
m
Leng (b)
severe
moderate
Girolami (a)
2009 - Angiology Care Unit - Padua - Italy - www.ANGIO-PD.it
AZIENDAOSPEDALIERA UNIVERSITA’PADOVA
Training Effectiveness
Andreozzi GM, et al: Effectiveness and costs of a short-course supervised training programin claudicants. Proposal for a shared protocol with aerobic working load. Int Angiol 2008 27(5):401-7
2009 - Angiology Care Unit - Padua - Italy - www.ANGIO-PD.it
AZIENDAOSPEDALIERA UNIVERSITA’PADOVA
16
Physical Exercise and Physical Activity
2009 - Angiology Care Unit - Padua - Italy - www.ANGIO-PD.it
AZIENDAOSPEDALIERA UNIVERSITA’PADOVA
17
Physical Exercise and Physical Activity
Effort (strain)
strenuous (agonistic activity)
physical and training activities, aimed at
competitive and extreme sport, which
reachs and overpass the maximal aerobic capacity
strong(occasinal
agonistic activity)
physical activity reaching the maximal aerobic
capcity
moderate(playful and
recreative activity)
regular or occasional physical activities which
does not reach the maximal aerobic capacity
Physical Activity
agonistic physical and training activities, aimed at competitive sport
playful and/or recreative
regular or occasional physical activities without maximal load
2009 - Angiology Care Unit - Padua - Italy - www.ANGIO-PD.it
AZIENDAOSPEDALIERA UNIVERSITA’PADOVA
18
Cardiovascular Effects of Physical Training
[a] Cerneca F, Crocetti G, Gombacci A, at al:Variations in hemostatic parameters after near-maximum exercise andspecific tests in athletes. J Sports Med Phys Fitness 1999;39:31–6
[b] Abbot RD, Rodriguez BL, Burchfield CM, et al. Physical activity inolder middle-aged men and reduced risk of stroke: the Honolulu Heart Program.Am J Epidemiol 1994;139:881–93
[c] Contini M, Pacini S, et al: Modification of plasma glycosaminoglycans in long distance runners.Br J Sports Med 2004;38:134–137
Improvement of hemostatic pattern in athletesafter maximal aerobic exercise [a]
Improvement of hemostatic pattern in aged peopledoing regular physical activity [b]
These results are closely related withan improvement of the EFmediators: endothelial GAGs (glycocalix)[c]
EPCs [d]
[d] Shantsila E, Lip GY: Endothelial function and endothelial progenitors:possible mediators of the benefits from physical exercise?Eur J Cardiovasc Prev Rehabil 2009 in press
2009 - Angiology Care Unit - Padua - Italy - www.ANGIO-PD.it
AZIENDAOSPEDALIERA UNIVERSITA’PADOVA
19
Clical Applications of Physical Exercise, Prevention and Therapy
2009 - Angiology Care Unit - Padua - Italy - www.ANGIO-PD.it
AZIENDAOSPEDALIERA UNIVERSITA’PADOVA
20
Clinical Applications of Physical Exercise, Prevention and Therapy
SECONDARY
PREVENTION
PRIMARY PREVENTION
PRIMORDIAL PREVENTION
THERAPY
prevent the appearanceof risk factors
2009 - Angiology Care Unit - Padua - Italy - www.ANGIO-PD.it
AZIENDAOSPEDALIERA UNIVERSITA’PADOVA
21
Clinical Applications of Physical Exercise, Prevention and Therapy
SECONDARY
PREVENTION
PRIMARY PREVENTION
PRIMORDIAL PREVENTION
THERAPY
prevent the appearanceof risk factors
prevent the clinical appearanceof the disease
prevent the appearance of new CV events
playful and/or recreative physical activityregular or occasional physical activities reaching the maximal aerobic capacity
2009 - Angiology Care Unit - Padua - Italy - www.ANGIO-PD.it
AZIENDAOSPEDALIERA UNIVERSITA’PADOVA
22
Clinical Applications of Physical Exercise, Prevention and Therapy
SECONDARY PREVENTION
PRIMARY PREVENTION
PRIMORDIAL PREVENTION
THERAPY
prevent the appearanceof risk factors
prevent the clinical appearanceof the disease
prevent the appearance of new CV events
the effort should be moderate and tailored on the own capacityof the patient, always avoiding
the maximal aerobic capacity, fatigue or discomfort!
2009 - Angiology Care Unit - Padua - Italy - www.ANGIO-PD.it
AZIENDAOSPEDALIERA UNIVERSITA’PADOVA
23
Clinical Applications of Physical Exercise, Prevention and Therapy
SECONDARY PREVENTION
PRIMARY PREVENTION
PRIMORDIAL PREVENTION
THERAPY
prevent the appearanceof risk factors
prevent the clinical appearanceof the disease
prevent the appearance of new CV events
treatment of intermittentclaudication to improve
the walking capacity
physical exercise should be moderate and well tailored on the own capacity of the patient
2009 - Angiology Care Unit - Padua - Italy - www.ANGIO-PD.it
AZIENDAOSPEDALIERA UNIVERSITA’PADOVA
24
Indications for the Physical Activity and Exercise
Healthy People
The strenuous physical efforts are reserved to the athletes in the phase of full agonistic activity.
Healthy people, without ATS risk factors,to maintain a good physical efficiency,could be utilized also a strong effort,without overpass the own aerobic thresholds.
Cardio-Vascular Prevention and Treatment
In the primary cardiovascular prevention is indicated the moderate effort, with occasional sessions of strong effort, only if well tolerated!
In the secondary cardiovascular prevention, andin the treatment of intermittent claudication (or in the rehabilitation after AMI) the effort should be moderate and tailored on the own capacity of the patient, always avoiding fatigue or discomfort!
2009 - Angiology Care Unit - Padua - Italy - www.ANGIO-PD.it
AZIENDAOSPEDALIERA UNIVERSITA’PADOVA
25
University Hospital of Padua - Italy
Angiology Care Unit
G.M. Andreozzi
Physical Training in the Treatment of Peripheral
Arterial Disease(Intermittent Claudication)