NYHA Classification System for Heart Failure
Class I: No limitation of physical activity. No shortness of
breath, fatigue, or heart palpitations with ordinary physical
activity.
Class II. Slight limitation of physical activity. Shortness of
breath, fatigue, or heart palpitations with ordinary physical
activity, but patients are comfortable at rest.
Class III. Marked limitation of activity. Shortness of breath,
fatigue, or heart palpitations with less than ordinary physical
activity, but patients are comfortable at rest.
Class IV. Severe to complete limitation of activity.
Shortness of breath, fatigue, or heart palpitations with any
physical exertion and symptoms appear even at rest.
PRINCIPI DI TERAPIA DELL’INSUFFICIENZA
CARDIACA
1- Aumentare la forza di contrazione del cuore (inotropi positivi)
2- Ridurre la massa di volume da spostare (diuretici)
3- Ridurre le resistenze periferiche (vasodilatatori)
4- Ridurre il (lavoro) ritorno venoso (nitroderivati)
Inotropi positivi
1- Digitalici
Inibizione pompa Na/K-ATPasi causa aumento concentrazione intracellulare Ca
Diverse isoforme di pompa
Digitale inibisce Na/K-ATPasi cardiaca e neuronale
Sintomi cardiaci: effetto inotropo positivo, alterazioni conduzione cardiaca: aritmie
Sintomi neuronali: attivazione vagale, effetto cronotropo negativo, attivazione peristalsi
Tossicità: aloni visivi, alteraz psichiche
2- Inibitori PDE tessuto specifici
Diuretici
Riduzione volume liquidi extracellulari e precarico; in genere non modificano la
gettata
Diuretici dell’ansa dosi multiple giornaliere con adeguato monitoraggio di peso e di
elettroliti plasmatici
-Tiazidici: potenziano efficacia d. dell’ansa quando effetto è insufficiente o pz
diventa refrattario; possono essere utilizzati come terapia a lungo termine
(monoterapia) in pz con modesta insuff. Cardiaca
Resistenza ai diuretici: dovuta a deplezione di volume intravascolare o riduzione
gettata e p.a. di origine cardiogena
Vasodilatatori possono ridurre efficacia diuretici per riduzione perfusione renale
ACEi e antiAT1 possono aumentare efficacia diuretici o ridurla (per eccessiva
riduzione pressione di filtrazione, specie in pz con stenosi renale)
Vasodilatatori
ACEi e vasodilatatori a vario meccanismo d’azione
Unica classe (ampia) di farmaci che significativamente riduce mortalità: vero per
ACEi o combinazione Idralazina-isosorbide dinitrato
Principi di meccanismo d’azione:
Riduzione precarico: riduzione congestione polmonare con effetti minimi su
gettata
Riduzione del postcarico: riduzione della pressione parietale ventricolare porta a
miglioramento della funzione sistolica
ACEI
Oltre a inibire effetti periferici di AngII, riducono formazione aldosterone e il grado di
attivazione del sistema simpatico
In pz con insuff cardiaca, elevata attività intrarenale di AngII: aumenta la frazione di
filtrazione e quindi riassorbimento tubulare ( p. idrostatica e  p. oncotica): quindi
ACEi potenziano attività diuretici, diminuiscono perdita di K e di acqua riducendo
gravità di ipoNaemia tipica di insuff. cardiaca avanzata
Attenzione:limitano meccanismi autoregolatori di funzione renale (soprattutto
pressione di perfusione)
Studies On Left Ventricular Disfunction (1991): riduzione significativa mortalità con
ACEi in aggiunta a digitale e diuretici
CONSENSUS: nessun vantaggio e effetti collaterali dannosi se somministrati entro
poche ore da infarto complicato con insuff ventricolare sinistra
Gruppo Italiano Studio Sopravvivenza nell’Infarto Miocardico: vantaggi per pz con
infarto (anche senza alterazioni ventricolari sinistre)
Conclusione: se somministrati a poche ore dall’infarto, monitorare attentamente le
condizioni emodinamiche
Nitrati
Isosorbide dinitrato: efficace e sicuro per ridurre pressione di riempimento
ventricolare in insuff. Card. acuta e cronica
A dosi terapeutiche effetto preponderante è riduzione precarico
Efficacia aumentata se in combinazione con Idralazina
Tolleranza ai nitrati limita efficacia a lungo termine (lasciar cadere Cp a zero
per almeno 8 ore)
Via di somministrazione comune: cerotto
ALTRI VASODILATATORI
Idralazina
Efficace antiipertensivo se usato in combinazione con f che oscurino le risposte
compensatorie simpatiche e idrosaline
In insuff cardiaca riduce postcarico (dx e sin) riducendo resistenze periferiche
senza indurre risposte simpatiche
Pochi effetti su vene: combinare con nitrati!
Induce significativo miglioramento emodinamico in pz con insuff cardiaca
avanzata e già in trattamento con diuretici, digitale e ACEi.
Calcio antagonisti
Utili solo per insuff da cause diastoliche (ipertens, miopatia ipertrofica idiopatica)
Felodipina e amlodipina: A minore attività inotropo negativa
European Heart Journal , Volume 20, Number 6 , Pp. 456-464
The effect of physical training on hormonal status and exertional
hormonal response in patients with chronic congestive heart failure
K. Kiilavuoria,f1, H. Näveria, H. Leinonena and M. Härkönenb
revised July 28, 1998; accepted July 29, 1998
The training group exercised on a bicycle ergometer for 30min three times a week for 3
months. The load corresponded to 50–60% of their peak oxygen consumption. For the
next 3 months they exercised at home according to personal instructions.
Results
Submaximal exercise capacity increased significantly and peak oxygen consumption
tended to improve by 12% in the training group. The plasma noradrenaline at rest tended
to decrease by 19%.
Circulation. 1988;78:506–515
Exercise training in patients with severe left ventricular dysfunction.
Hemodynamic and metabolic effects
MJ Sullivan, MB Higginbotham and FR Cobb
Department of Medicine, Duke University Medical Center, Durham, NC 27710.
4-6 months of conditioning by exercising 4.1 +/- 0.6 hr/wk at a heart rate corresponding to
75% of peak oxygen consumption
Exercise training resulted in a decrease in heart rate at rest and submaximal exercise and a
23% increase in peak oxygen consumption from 16.8 +/- 3.8 to 20.6 +/- 4.7 ml/kg/min (p less
than 0.01).
Peripheral adaptations that contributed to improved exercise performance:
At peak exercise, systemic arteriovenous oxygen difference increased from 13.1 +/- 1.4 to
14.6 +/- 2.3 ml/dl (p less than 0.05). …………increase in peak-exercise leg blood flow from
2.5 +/- 0.7 to 3.0 +/- 0.8 l/min (p less than 0.01).
Arterial and femoral venous lactate levels were markedly reduced during submaximal exercise
after training, even though cardiac output and leg blood flow were unchanged at these
workloads.
Thus, ambulatory patients with chronic heart failure can achieve a significant
training effect from long-term exercise. Peripheral adaptations, including an
increase in peak blood flow to the exercising leg, played an important role in
improving exercise tolerance.
Journal of the American College of Cardiology Volume 25, Issue 6 , May 1995, Pages 1239-1249
Physical training in patients with stable chronic heart failure: Effects on
cardiorespiratory fitness and ultrastructural abnormalities of leg muscles
MDRainer Hambrechta et al. Germany
an ambulatory training program
After 6 months, patients in the training group achieved an increase in oxygen uptake at
the ventilatory threshold of 23% (from 0.86 ± 0.2 to 1.07 ± 0.2 liters/min, p < 0.01 vs.
control group) and at peak exercise of 31% (from 1.49 ± 0.4 to 1.95 ± 0.4 liters/min, p <
0.01 vs. control group). There was no significant change in oxygen uptake at the
ventilatory threshold and at peak exercise in the control group. ……………………….
Conclusions.
Regular physical training increases maximal exercise tolerance and delays
anaerobic metabolism during sub-maximal exercise in patients with stable
chronic heart failure. Improved functional capacity is closely linked to an
exercise-induced increase in the oxidative capacity of skeletal muscle.
Physical Activity and a Healthy Heart
As a general rule, it's better for people with heart failure to stay active. That
might sound like contradictory advice, since the heart is already having trouble
keeping up with the body's demands. Why make it work even harder?
Moderate physical activity can help the heart get stronger. Most people find that
exercise improves their symptoms, reduces stress and boosts energy levels.
Regular physical activity also may lead to other important health advantages,
including weight control, weight loss, better circulation and blood pressure, and
lower cholesterol levels — all of which are especially important if you have heart
failure.
The healthcare team will work with you to develop an appropriate exercise plan.
Often they'll start by giving you a stress test to measure your heart function
during exercise (either walking on a treadmill or riding an exercise bike). This
helps the physician know how much activity your heart can handle.
Physical Activity and a Healthy Heart
Cardiac rehabilitation programs
Many people with heart failure aren't used to regular exercise or feel nervous
about starting. That's when a cardiac rehabilitation program can be helpful. A
cardiac rehab program lets patients start exercising slowly in a supervised
setting, either at a hospital or outpatient center. While patients exercise on a
treadmill, stationary bike or indoor track a few times a week, nurses or
therapists monitor them for any discomfort or changes in symptoms. Over time
the tolerance for exercise is likely to increase. Also, many people find it easier to
stick with a structured program — and then keep exercising when it's over.
Cardiac rehab programs often provide additional classes in smoking cessation,
nutrition and stress management.
Physical Activity and a Healthy Heart
Exercise tips
DO...
•Wear comfortable clothes and flat shoes with laces or sneakers.
•Start slowly. Gradually build up to at least 30 minutes of activity, five or more times per week (or
whatever your doctor recommends). If you don't have a full 30 minutes, try two 15-minute
sessions or three 10-minute sessions to meet your goal.
•Exercise at the same time of day so it becomes a habit. For example, you might walk Monday
through Friday from noon to 12:30 p.m.
•Drink a cup of water before, during and after exercising (but check with the doctor, because
some people need to limit their fluid intake).
•Ask family and friends to join you. You'll be more likely to keep exercising.
•Note your activities on a calendar or in a log book. Write down the distance or length of time of
your activity and how you feel after each session. If you miss a day, plan a make-up day or add
10–15 minutes to your next session.
•Use variety to keep your interest up. Walk one day, swim the next time, then go for a bike ride on
the weekend.
•Join an exercise group, health club or YMCA. Many churches and senior centers offer exercise
programs, too. (Get your doctor's permission first.)
•Look for chances to be more active during the day. Walk the mall before shopping, choose a
flight of stairs over an escalator, or take 10–15 minute walking breaks while watching TV or sitting
for some other activity.
Physical Activity and a Healthy Heart
DON'T...
•Get discouraged if you stop for awhile. Get started again gradually and work up to your old pace.
•Do isometric exercises that require holding your breath, bearing down or sudden bursts of energy. If
you're taking part in an exercise class or physical therapy, ask the leader or therapist what these are. Also
avoid lifting weights and competitive or contact sports, such as football.
•Engage in any activity that causes chest pain, shortness of breath, dizziness or lightheadedness. If these
happen, stop what you're doing right away.
•Exercise right after meals, when it's very hot or humid, or when you just don't feel up to it.
Whether you take part in a formal exercise program, if you have heart failure, you need to make time for
moderate aerobic physical activity, like walking, swimming or biking. You should always stay within your
physician's recommendations and your own comfort zone. Here's a checklist of what to do and what to
avoid.
WHAT ARE THE LIFESTYLE RECOMMENDATIONS FOR CONGESTIVE
HEART FAILURE?
Between 30% to 47% of patients who require hospitalization for heart failure are
back in the hospital again within six months. Many people return because of
lifestyle factors, such as poor diet, failure to comply with medications, and social
isolation.
Home Support and Rehabilitation Programs
Home care: …..elderly people who had no emotional support at home had triple the risk of a
heart attack after hospitalization for heart failure…. . (In women, this risk was eightfold.)
…….. programs that offer intensive follow-up to ensure that the patient complies with lifestyle
changes and medication regimens at home are reducing rehospitalization and costs and
improving survival……….
WHAT ARE THE LIFESTYLE RECOMMENDATIONS FOR CONGESTIVE
HEART FAILURE?
Monitoring Weight Changes
Heart failure patients should weigh themselves each morning and keep a record.
Any changes are important:
A sudden increase in weight of more than two or three pounds (1-1.5 Kg) may
indicate fluid accumulation and should prompt an immediate call to the physician.
Rapid wasting weight loss over a few months is a very serious sign and may
indicate the need for surgical intervention.
WHAT ARE THE LIFESTYLE RECOMMENDATIONS FOR CONGESTIVE
HEART FAILURE?
Dietary Factors
Mediterranean Diet. There is some evidence suggesting that the Mediterranean diet helps
protect the heart and may even reduce the risk for heart failure after a first heart attack. Its
emphasis on whole grains, fish, olive oil, garlic, and moderate, daily intake of wine may have
many benefits for the heart. The diet recommends the following:
A relatively high fat intake (about 35% to 45% of daily calories, mostly in monounsaturated
and polyunsaturated fats.) The Mediterranean diet is known for its use of olive oil, but the
greatest benefits found in a major study of this diet appeared to be derived from the use of
canola oil, which is rich in omega-3 fatty acids. Olive oil, in fact, does not contain omega-3
fatty acids. On the other hand, olive oil, may have beneficial effects independent from those
on lipids, such as improving insulin and blood glucose levels and reducing blood pressure.
Daily glass or two of wine.
The same protein intake as the AHA, although fish is the primary source. (It avoids high-fat
dairy and meat products.) In fact, one 2001 study suggested that fish-consumption, not wine,
that is the heart-protective ingredient in this diet.
Lower carbohydrate intake than AHA. Emphasizes not only fresh fruits and vegetables, but
also higher amounts of nuts, legumes, beans, and whole grains.
Foods seasoned with garlic, onions, and herbs.
WHAT ARE THE LIFESTYLE RECOMMENDATIONS FOR CONGESTIVE
HEART FAILURE?
Dietary Factors
DASH Diet. A diet known as Dietary Approaches to Stop Hypertension (DASH) is now
recommended as an important step in managing blood pressure so it may be useful for many
patients with heart failure. This diet is not only rich in important nutrients and fiber but also
includes foods that contain two and half times the amounts of electrolytes, potassium,
calcium, and magnesium as are found in the average American diet.
Potassium-rich foods, which are important for patients with heart failure, include bananas,
oranges, prunes, cantaloupes, carrots, spinach, celery, alfalfa, mushrooms, lima beans,
potatoes, avocados and broccoli. It is important to note, however, that patients taking
Aldactone, those with kidney dysfunction, and some of those taking ACF inhibitors may have
to restrict their potassium intake.
The diet also stresses avoiding saturated fats, as any healthy diet does, although it includes
calcium-rich dairy products that are no- or low-fat. When choosing fats, it also advises
monounsaturated oils, and it stresses whole grains, fresh fruits and vegetables every day.
WHAT ARE THE LIFESTYLE RECOMMENDATIONS FOR CONGESTIVE
HEART FAILURE?
Dietary Factors
Salt Restriction.
All heart failure patients should limit their salt intake, and in severe cases, very stringent salt
restriction may be necessary. Patients should not add salt to their cooking and their meals.
They should also avoid foods high in sodium; these include ham, bacon, hot dogs, lunch
meats, prepared snack foods, dry cereal, cheese, canned soups, soy sauce, and condiments.
Some patients may need to reduce their water intake as well. People with high cholesterol
levels or diabetes require additional dietary precautions. [For more information, see WellConnected Report #43, Heart-Healthy Diet. ]
Exercise
Traditionally, people with heart failure were discouraged from exercising. Now,
exercise, when performed under medical supervision, is proving to be extremely
important for many patients with stable conditions.
Studies have reported that patients with stable conditions who engage in regular
moderate exercise (twice a week) experience a better quality of life and lower
mortality rates than those who don't.
Linee guida critiche
Attenzione. L’attività fisica non è consiogliabile per tutte le forme di in sufficienza
cardiache
Sempre avere la supervisione di un medico quando un paziente con insufficienza
cardica inizia un programma di attività motoria
Individui per il quali vi è prescrizione di attività fisica ma che non sono allenati
devono iniziare con un progarmma di esercizi leggeri di 5-15 min ripetuti più volte.
L’obiettivo è di costruire gradualmente un impegno di 45 min 3-5 volte la
settimana di cammino, nuoto, esercizio aerobico.
Accontentarsi di meno se ciò non è possibile
Benefici da specifici esercizi
Allenamento progressivo alla forza
Utile perché ricostruisce massa muscolare
Con pesi leggeri, macchine (anche solo per gambe)
Even simply performing daily handgrip exercises can improve blood flow through the
arteries.
Treadmill o ciclette
Aumentano resistenza allo sforzo
Warnings on Alternative and So-Called Natural Remedies
It should be strongly noted that alternative or natural remedies are not regulated and their
quality is not publicly controlled. In addition, any substance that can affect the body's
chemistry can, like any drug, produce side effects that may be harmful. Even if studies
report positive benefits from herbal remedies, the compounds used in such studies are, in
most cases, not what are being marketed to the public.
There have been a number of reported cases of serious and even lethal side effects from
herbal products. In addition, some so-called natural remedies were found to contain
standard prescription medication. Most problems reported occur in herbal remedies
imported from Asia, with one study reporting a significant percentage
IPERTENSIONE ESSENZIALE
L’ipertensione è la causa principale di ictus, di alterazioni coronariche che sfociano
nell’infarto. E’ la maggior causa di insufficienza cardiaca, renale e di aneurisma
dissecante dell’aorta
Definita come condizione di p.a > 140/90 ; in realtà la probabilità di insorgenza
delle malattie di cui sopra è molto inferiore con p.a max <120 e p.a. <80
P.A. : equilibrio tra gettata cardiaca e resistenze periferiche : Diversi livelli di
intervento
1. Riduzione gettata cardiaca :
inibizione contrattilità miocardica
riduzione pressione di riempimento ventricolare via tono venoso o volume
(effetti renali)
2. Riduzione resistenze periferiche
inibizione contrattilità vasi di resistenza
inibizione sistemi che regolano resistenze periferiche (es. simpatico)
3. Interventi farmacologici da condurre su siti diversi (vedi tavola): inutile
contemporanea somministrazione di farmaci dotati dello stesso
meccanismo d’azione
LIVELLI DI INTERVENTO
Non farmacologici
Esercizio fisico : esercizio costante isotonoco riduce p.a di 10 mmHg
( ?riduzione vol ematico, catecol, e aumento atrial natriuretic factor ?)
Restrizione dietetica : riduzione assunzione sali a 5 g/die (equivale a 2 mg/die di
sodio) abbassa p.a. max fino a 12 mm e p.a. min fino a 6 mmHg. Più sensibili
soggetti >40a e soggetti con alta p.a.
Riduzione peso. Alto tono simpatico ; insulina media riassorbimento di Na
Alcool : ridurre a < 30 ml/die
Rilassamento e biofeed-back : no dati statistici
Dieta potassica : efficace perché riduce aldosterone ? Utile in pz con modesta
ipertensione, in genere associata con dieta iposodica ; no in pz con ACEi
Trattamenti farmacologici
Terapia multifarmacologica
Bassi dosaggi
Attenzione alla tossicità
Sequenza
Strumenti non farmacologici
ACEi o losartani
Diuretici
Beta-bloccanti, Ca-antagonisti (DHP) a lento rilascio
Alfa2-agonisti
Idralazina
Farmaci delle emergenze: alfa-bloccanti, nitroprussiato, minoxidil
Johns Hopkins Bayview Medical Center's exercise and hypertension slide
presentation
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Johns Hopkins Bayview Medical Center's exercise and hypertension slide
presentation
http://www.jhbmc.jhu.edu/cardiology/Rehab/ExerciseHTN/index.htm
Exaggerated BP Responses to Exercise
Excess SBP may predict future hypertension
Among normotensive men who had an exercise test between 1971-1982, those who
developed hypertension in 1986 were 2.4 times more likely to have had an
exaggerated BP response to exercise
Exaggerated BP response increased future hypertension risk by 300% after adjusting
for all other risk factors
Exaggerated BP was change from rest in SBP>60 mm Hg at 6 METS; SBP> 70 mm
Hg at 8 METS; DBP> 10 mm Hg at any workload
J Clin Epidemiol 51(1): 1998
Subjects in CARDIA study with exaggerated exercise BP response at baseline were
1.70 times more likely to develop hypertension 5 years later
Johns Hopkins Bayview Medical Center's exercise and hypertension slide
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Lifestyle Management of Hypertension
Lose weight if overweight
Limit alcohol intake
Exercise
Reduce sodium intake to < 2.3 grams/day
Maintain adequate dietary potassium, calcium, and magnesium intake
Stop smoking
Reduce dietary fat and cholesterol
Johns Hopkins Bayview Medical Center's exercise and hypertension slide
presentation
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Medical Therapy and Implications for Exercise Training
•Pharmacologic and nonpharmocologic treatment can greatly reduce mortality
•Because hypertension clusters with hyperlipidemia, hyperinsulinemia, glucose
intolerance, and obesity, treatment must consider the total risk burden
•Some antihypertensive agents have side-effects and some worsen other risk
factors
•Exercise and diet often improve multiple risk factors with virtually no side-effects
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Exercise and Hypertension
JNC (1997) and ACSM (1993) recommend exercise to
lower BP
JNC treatment guideline
High normal BP Lifestyle modification
Stage 1 Lifestyle for 3-6 months before starting medications
Stage 2 Lifestyle including exercise for 3-6 months before starting medications if
BP only risk factor
Stage 3 and 4 Medication to control BP before vigorous exercise is undertaken
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Risk Stratification
Risk Group A
No risk factors; no target organ disease (TOD)/clinical
cardiovascular disease (CCD)
Risk Group B
At least 1 risk factor not including diabetes; no
TOD/CCD
Risk Group C
TOD/CCD and/or diabetes, with or without other risk
factors
Johns Hopkins Bayview Medical Center's exercise and hypertension slide
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Lifestyle Changes for Hypertension and Cardiovascular
Risk
Reduce excess body weight by caloric restriction and exercise
Reduce dietary sodium to •2.4 g
Maintain adequate dietary intake of potassium, calcium, and magnesium
Limit daily alcohol consumption to < 2 oz of whiskey, 10 oz wine, 24 oz beer
Exercise moderately each day
Engage in relaxation techniques
Cessation of smoking
Johns Hopkins Bayview Medical Center's exercise and hypertension slide
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Possible Mechanisms of BP Reduction with Exercise
Training
Lower cardiac output and peripheral vascular resistance at rest and at any given
submaximal level of work
Decreased HR
Decreased sympathetic and increased parasympathetic tone
Reduction in blood catecholamine levels and plasma renin activity
Reduction in central fat independent of changes in body weight or body mass
index
Altered renal function to increase elimination of sodium leading to reduce fluid
volume
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NIH Consensus Development Conference on Physical
Activity and Cardiovascular Health (1995)
•Review of 47 studies of endurance training and hypertension
•70% of exercise groups decreased SBP by an average of 10.5 mm
Hg from 154 mm Hg
•78% decreased DBP by an average of 8.6 mm Hg from 98 mm Hg
•Only one study showed increased BP with exercise
•Beneficial responses are 80 times more frequent than negative
responses and 3 times more frequent as equivocal responses
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Exercise Guidelines
No special guidelines for mild to moderate hypertension
ACSM recommends endurance training for mild hypertension
3-5 days/week
20-60 minutes
50-85% of maximal oxygen uptake
ACSM also says that lower intensities may be required until BP control is
achieved although no specific guidelines exist
Johns Hopkins Bayview Medical Center's exercise and hypertension slide
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Resistive Training
Resistive exercise produces the most striking increases in BP
Because resistive exercise also results in less of a HR increase compared
with aerobic exercise the total myocardial burden may be less than aerobic
exercise
Combined training (weight and aerobic exercise) has been shown to reduce
both SBP and DBP by as much as 13 mm Hg each
Combined Aerobic and Resistive Training and Mild
Hypertension
Kelemen, Effron, Valenti, Stewart: JAMA 1990:263:2766-2771
Johns Hopkins Bayview Medical Center's exercise and hypertension slide
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Screening and Testing
BP should measured regularly in all persons > 3 years (Guide to
Clinical Preventive Services)
Current opinion is that normotensive persons should be screened
every 2 years
ACSM does not recommend mass exercise testing to determine future
hypertension risk
Exercise testing before participation in moderate to vigorous exercise
should follow usual risk stratification guidelines
Because hypertension clusters with other risk factors, many hypertensive
individuals are likely candidates for exercise testing
Johns Hopkins Bayview Medical Center's exercise and hypertension slide
presentation
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Exercise and Hypertension Summary
Hypertension is a major risk factor for CVD.
Exercise is a key component in the prevention and treatment of hypertension.
Exercise training can be expected to reduce SBP and DBP by 7-10 mm Hg.
Some studies show that even greater benefits are possible.
Exercise also has a favorable effect on other CVD risk factors like lipids and
diabetes.
Medical screening for exercise participation to predict hypertension is not
necessary. Persons with known hypertension should follow usual risk stratification
guidelines for exercise testing.
Exercise Guidance in Hypertension
Kerry J. Stewart, EdD
THE PHYSICIAN AND SPORTSMEDICINE - VOL 28 - NO. 10 - OCTOBER 2000
Exercise Guidelines
Aerobic exercise. For mild hypertension, the American College of Sports
Medicine (ACSM) (6) recommends 20 to 60 minutes of aerobic exercise 3 to 5
days per week, at 50% to 85% of maximal oxygen uptake. For patients with
stage 2 or stage 3 hypertension, exercise should be at 40% to 70% of maximal
oxygen uptake after patients begin pharmacologic therapy.
Resistance exercise. One concern about resistance training has been that it
produces exaggerated BP responses. While an acute bout of resistance
exercise does result in greater increases in BP compared with aerobic exercise,
heart rate does not increase as much. As such, the rate-pressure product, which
represents myocardial oxygen demand, may be lower with resistance versus
aerobic exercise (7,8). A recent position paper of the American Heart Association
(9) recommends mild-to-moderate resistance exercise, at 30% to 60% of
maximal effort, for improving muscle strength and endurance, preventing and
managing diverse chronic medical conditions, modifying coronary risk factors
including hypertension, and enhancing psychological well-being.
Exercise Guidance in Hypertension
Kerry J. Stewart, EdD
THE PHYSICIAN AND SPORTSMEDICINE - VOL 28 - NO. 10 - OCTOBER 2000
Screening and exercise testing. The ACSM does not recommend exercise
testing specifically to determine BP responses (6). However, if an exercise test is
done for other purposes--for example, as part of a physical exam--BP responses
to exercise provide an indication of risk stratification. Because hypertension often
clusters with hyperlipidemia, hyperinsulinemia, and obesity, many hypertensive
individuals will be candidates for exercise testing based on risk stratification
guidelines.
Antihypertensive drugs and exercise. Medical management of hypertension is
often complicated by concomitant hyperlipidemia, a sedentary lifestyle,
hyperinsulinemia, glucose intolerance, reduced arterial compliance, sympathetic
overactivity, and obesity. Unfortunately, some antihypertensive agents adversely
affect other risk factors, and adherence to medication is often a problem. On the
other hand, lifestyle changes improve multiple risk factors without any side effects.
In some patients, exercise can reduce or eliminate the need for antihypertensive
medication (8).
EXERCISE MAY NOT BE GOOD ENOUGH TO REDUCE
MILD HYPERTENSION IN OLDER PEOPLE, HOPKINS
EXPERTS SAY
Reductions in fat and increases in muscle key indicators of
who will benefit most
Moderate levels of exercise may not be enough to control mild hypertension in men and
women over age 55, the age group most at risk of later developing potentially fatal heart
failure, a new four-year study reports……….
….. Current guidelines from the American College of Sports Medicine recommend 30- to
45-minute periods of combined aerobic exercise and moderate weightlifting, three to five
times per week, with an expected reduction in blood pressure of 8 millimeters to 10
millimeters of mercury (mm/Hg)……..
………. Previous studies, says Stewart, who led the new study, examined mostly younger
men in whom high blood pressure has different characteristics and causes than are the
case in older people. Hypertension in younger adults is often due to a high cardiac
output when at rest and during exercise, where the heart beats faster than it has to, he
adds. However, hypertension in mature adults results from changes in the walls of the
large arteries that carry blood throughout the body. These blood vessels become less
elastic or flexible, a condition known as arterial stiffening, and this causes blood
pressure to rise
EXERCISE MAY NOT BE GOOD ENOUGH TO REDUCE
MILD HYPERTENSION IN OLDER PEOPLE, HOPKINS
EXPERTS SAY
Reductions in fat and increases in muscle key indicators of
who will benefit most
……….Upon closer examination, the Johns Hopkins team found that people most likely to
decrease both systolic and diastolic blood pressure also were those who lost the most body
fat, particularly abdominal fat, and gained the most muscle. These changes in body
composition were more closely related to reductions in blood pressure than improvements in
fitness. Overall, results for both improvements in fitness and body composition were nearly
identical for men and women…….
……."Older people should still be encouraged to exercise because it produces numerous
health benefits, but their expectations need to be modified about how much good the
exercise alone will do for reducing systolic blood pressure. They may also need to
understand it could take much more time for them to reach blood pressure goals, and it may
require more intensive exercise programs. Although participants followed the prescribed
program according to guidelines without fail, it does not seem to be enough for full blood
pressure control in older people…………….