Opportunities in Testing and Training Patients with...
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Opportunities in Testing and Training Patients with Cardiovascular Disease
Jeffrey Soukup, Ph.D., ACSM-CEP
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Disclosures
• No Disclosures
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Objectives
• To review current statements by the AHA/ACC, European
Association of Cardiovascular Prevention and Rehabilitation,
ACSM and AACVPR, that suggest that exercise testing needs
to be part of the exercise prescriptive process in CR
• To describe the limitations of relying on the 6MWT to predict
changes in functional capacity and estimate peak VO2
• To describe the potential differences in performance
outcomes with HIIT vs. MCT
• To describe two methods for performing HIIT
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PRE-POST FUNCTIONAL CAPACITY
OUTCOME MEASURES
1. To list the guiding recommendations for pre-program exercise
testing
2. To describe the limitations of relying on the 6MWT to predict
changes in functional capacity and peak oxygen uptake
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This reference is dated but remains pertinent as these guidelines remain in effect
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Gibbons, R et al. ACC/AHA 2002 Guideline Update for Exercise Testing: Summary Article. A Report of the American College of Cardiology/American Heart Association task Force on Practice Guidelines. Am. J.Cardiol. 2002;40(8)1531-1540)
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• European Association of Cardiovascular Prevention &
Rehabilitation
– “Cardiopulmonary exercise testing is a methodology that has
profoundly changed the approach to patient’s functional
evaluation, linking performance and physiologic parameters to
the underlying metabolic substratum and providing highly
reproducible exercise capacity descriptors”
Mezzani et al. European Society of Cardiology, Standards for the use of cardiopulmonary exercise testing for the functional evaluation of cardiac patients: a report from the Exercise Physiology section of the European Association for Cardiovascular Prevention and Rehabilitation, European Journal of Cardiology Prevention and Rehabilitation, 16;249-267, 2009.
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• American Heart Association
– “Exercise testing remains a remarkably durable and versatile
tool that provides valuable diagnostic and prognostic information
regarding patients with cardiovascular disease”
and
– “the addition of ventilatory gas exchange measurements during
exercise testing provides a wide array of unique and clinically
useful incremental information that heretofore has been poorly
understood and underutilized by the practicing clinician.”
Circulation. 2010; 122: 191-225
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• American College of Sports Medicine
– “…exercise testing at baseline is essential for the development
of an exercise prescription in patients who have suffered from
MI with or without revascularization, as well as those patients
who have undergone coronary revascularization alone.”
Pescatello, L. (Senior Editor) ACSM’s Guidelines for Exercise Testing and Prescription (9th edition) Lippincott, Williams & Wilkins, page 241, 2013)
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• American Association of Cardiovascular & Pulmonary
Rehabilitation
– To establish a safe and effective program of comprehensive
cardiovascular risk reduction and rehabilitation, each patient
should undergo a careful medical evaluation and exercise test
before participating in an outpatient Cardiopulmonary
Rehabilitation program.”
– “The 6-minute walk test can be used as a surrogate test to
assess exercise capacity when standard treadmill or cycle
testing is not available.”
• I do not agree with this
AACVPR Guidelines Cardiac Rehabilitation & Secondary Prevention (5th edition), page 58.
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Significant correlation between 6MWD & Peak VO2
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Interpreting Correlations
Taken from: Hinkle, Wiersma, and Jurs, Applied Statistics for the Behavioral Sciences (4th edition) page 120, 1998.
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• The distance walked correlates moderately with peak oxygen
uptake and there is a learning curve
In Certain Populations…
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VO2 Reserve for MIE = ~51.4%VO2 Reserve for VIE = ~71.9%
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y = 0.0406x + 2.5409R² = 0.3391
n = 18
0
5
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250 300 350 400 450 500 550 600
Pre
Pe
ak V
O2
(m
l/kg
/min
)
Pre 6MWD (m)
Relation of 6MWT Distance and Peak VO2
R = .582
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According to Hinkel, Wiersma & Jurs…
• The R2 equals the proportion of the total variance in Y that
can be associated with the variance in X
• More specifically, the R2 equals the proportion of the total
variance in peak oxygen consumption that can be associated
with the variance in 6MWD
• So, an R = 0.58 R2 = .3391 which means that 34% of the
variation in peak VO2 can be associated with the variance in
6MWD
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y = 0.236x + 12.831R² = 0.0192
n = 18
-30.00
-20.00
-10.00
0.00
10.00
20.00
30.00
40.00
-20.0 -15.0 -10.0 -5.0 0.0 5.0 10.0 15.0 20.0 25.0 30.0
Pe
rce
nt
Ch
ange
of
VO
2 (
ml/
kg/m
in)
Percent Change of 6MWD
Relation of Percent Changes of 6MWD and Peak VO2
R = .139
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Interpreting Correlations
Taken from: Hinkle, Wiersma, and Jurs, Applied Statistics for the Behavioral Sciences (4th edition) page 120, 1998.
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The Six Minute Walk Test
• Is a valuable assessment of functional capacity and good
index for therapeutic efficacy when:
– the sample population is very low functioning (eg. oxygen
uptake less than or = 15 mL/kg/min)
– the sample population being compared is homogenous
• pulmonary
• HF
• Aortic Stenosis
• Cardiomyopthy
– the testing protocol is standardized (ATS guidelines)
• Poorly predicts peak VO2 and should be used with caution to
establish the exercise prescription for an individual patient
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HIGH INTENSITY INTERVAL TRAINING VS
MODERATE CONTINUOUS TRAINING
1. To describe the potential differences in performance outcomes
with HIIT vs. MCT
2. To describe two methods for performing HIIT
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Potential Benefits of HIIT
• HIIT may provide greater improvement than MCT in:
– Cardiorespiratory endurance
– Preservation of coronary artery lumen diameter
– Anti-inflammatory responses
– LV geometry and myocardial performance
• HIIT has been shown to be safe in high-risk populations such
as those with HF
• HIIT is referenced in ACSM’s GETP 10 Exercise Training
Considerations for Outpatient CR
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MCT = 60-80% HRR, HIIT = W:80-90% HRR at 4 min & R:60-70% HRR at 3 min (isocaloric)
Keteyian et al. JCRP 2014;34, 98-105.
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Am Heart J. 2009;158:734-741
HIIT = W:90-95% peak HR at 4 min, R:60-70% peak HR at 3 min
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P = 0.01 for difference between groups
P<0.05 for DES; P>0.05 for BMS
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WHY DES Improvements vs. BMS
• Late luminal loss (LLL) = minimal luminal diameter (MLD)
after the index procedure minus the MLD at 6 months
• LLL has been correlated to intimal hyperplasia
• Neointimal hyperplasia has been linked to:
– low local shear stress
– Inflammatory response to vessel injury
• DES – the drug that is released may be reducing the effect of
low shear stress and/or reducing the inflammatory responses
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MCT = 70% peak HR, HIIT = W:90-95% peak HR at 3 min, R:50-60% peak HR at 3 min
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HIIT at the Mayo Clinic
• HIIT for Everyone
• HIIT based on RPE responses using BORG scale
– Hard = 15-17
– Easy = 11-13
• Started when patient is able to complete 20 minutes of MCT
• Begin with 30 second intervals
• Adjust/advance per individual
• Goal is 4:4 hard:easy with total duration 35-45 minutes
• BP & HR continue to get monitored
• No telemetry in most cases
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ACSM GETP 10 exerpt:
ACSM GETP 10, 2017, page 236.
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• Questions?