Cardiac rehabilitation is increasingly recognized as an essential part of the continuum of care for patients with cardiovascular disease. The discipline has evolved over the last 15 years to reflect the importance of targeted initiatives in the management of cardiovascular risk factors.
The rapidly expanding field of preventive cardiology has brought with it several major advances in the past decade. Changes in guidelines for cholesterol management focusing on the identification of “statin eligible groups” and removal of actual low-density lipoprotein cholesterol (LDL-C) targets, in particular, as well as lower targets for blood pressure in updated hypertension guidelines, have made a major impact on healthcare.
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Effects of physical training on quality of life
Increased physical capacity due to modifications at two levels:
It increased in:
Elevation of the angina threshold due to a decrease in HR and SBP (at rest and at levels submaximal effort)
Effects of physical training on quality of life
– Decrease in fibrinogen and aggregability platelet, with increased fibrinolytic activity
– Increased capillary
– Greater diameter of extramural coronary arteries
– Increased collateral circulation
– Improvement in O2 supply / demand, lower sensitivity of beta receptors
– Improvement in ventricular function
– Improvement in endothelial function
– Decreased inflammatory activity
– Lower level of catecholamines (rest and submaximal exercise)
– Decreased activity of the renin-angiotensin system
– Decreased peripheral resistance
– Better neuro-vegetative response to stress
– Increase in RR variability
– Elevation of the ventricular fibrillation threshol
Is often associated with hypertension, hypercholesterolemia, hypertriglyceridemia, and insulin resistance.
Obesity is also frequently associated with erectile dysfunction, which physical training can contribute to prevent.
Several studies show a U-shaped association between BMI and mortality, which means that both low and high BMI are associated with increased risk of premature death.
Evidence-based physical training
The importance of physical activity for weight loss assessed by body weight or BMI is controversial, but physical training leads to a reduction in fat mass and abdominal obesity, in addition to counteracting loss of muscle mass during dieting. Strong evidence exists that physical activity is important for preventing weight gain in general, as well as for maintaining body weight after weight loss.
A Cochrane Review from 2006 (Shaw et al., 2006) comprising 3476 overweight or obese individuals studied 41 randomised controlled trials and concluded that:
1) Physical activity alone induced significant weight loss, while physical activity combined with a restricted diet and dietary counselling was more effective.
2) High-intensity physical activity was more effective than moderate activity.
3) A prerequisite was that the physical training had to be quantifiable.
4) The physical training intervention mainly consisted of walking, using an exercise bike, jogging, and weight training.
5) The intensity of the training was greater than 60% of the maximum oxygen uptake/ heart rate.
6) The participants exercised most frequently for 40– 50 min per session, 3– 5 times a week
7) The combination of exercise and diet resulted in an average greater weight loss and a greater decrease in BMI than diet alone.
8) The Cochrane Review showed that physical training for overweight and obese adults had positive effects on both body weight and risk factors for cardiovascular disease.
Type of training
For weight loss, a large volume of moderately intense aerobic exercise is recommended, preferably in combination with strength training. Because physical fitness has an independent impact on preventing diseases associated with obesity, it is recommended that moderate physical activity be combined with activities that build fitness in the form of high-intensity physical activity. The goal is at least 60 min of moderately intense physical activity daily. Many overweight and obese patients have, however, concomitant hypertension or symptomatic ischemic cardiovascular disease. As a result, recommendations must be individualised.
Hyperlipidemia is a group of disorders of lipoproteinmetabolism entailing elevated blood levels of certain forms of cholesterol and triglyceride. Primary hyperlipidemia caused by environmental and genetic factors are by far the most frequent, accounting for 98% of all cases. Isolated hypercholesterolemia and combined dyslipidemia are the most frequent types of dyslipidemia, and are due to excessive intake of fat in most people.
These types of dyslipidemia entail an elevated risk of atherosclerosis. There is consensus that physical activity protects against the development of cardiovascular diseases and it has been suggested that one of many mechanisms could be a positive effect of exercise on the lipid profile of the blood. Epidemiological studies indicate that physical activity prevents hyperlipidemia
Evidence-based physical training
Today, evidence shows that a large volume of physical training, independent of weight loss, has a beneficial effect on the lipid profile of the blood. A number of review articles summarize this knowledge.
A 2007 meta-analysis studied the effect of training on high-density lipoprotein (HDL) cholesterol.
The training comprised walking, cycling or swimming. Training had a significant but moderate effect on HDL cholesterol. The minimum amount of physical activity needed to cause an effect was 120 min of physical activity weekly or an energy expenditure equivalent to 3780 kJ. The duration of the physical activity was more important than its intensity. Each time the duration of the physical activity was increased by 10 min, the HDL cholesterol level increased on average by 1.4 mg/dL (0.036 mmol/L).
The average effect of physical activity on HDL is clinically relevant, albeit somewhat smaller than the effect achieved when using drugs that lower lipid levels. It is estimated that each time HDL increases 0.025 mmol/L, the cardiovascular risk goes down by 2% for men and by at least 3% for women.
A review article from 2014 (Mann et al., 2014) includes 13 published investigations and two review articles and conclude that both aerobic, resistance exercise and the combination of aerobic and resistance training have impact on cholesterol levels and blood lipids.
A randomized clinical controlled trial evaluated the effect of training volume and intensity in a study comprising 111 physically inactive overweight men with mild to moderate hyperlipidemia (Kraus et al.,2002). This clinical trial demonstrate that there is a significantly better effect from a high volume of physical training on virtually all lipid parameters.
Training increases the ability of muscles to better burn fat instead of glycogen. This is achieved by activation of a number of enzymes in the skeletal muscle necessary for lipid turnover.
Type of training
There is solid evidence that physical training should be of a large volume, assessed as the distance covered, or energy expended. There is evidence for an effect of both aerobic training and resistance training.
If light to moderately intense physical activity is preferred, then it is necessary to train twice as long compared to doing high-intensity physical activity.
Many patients with hyperlipidemia have hypertension or symptomatic ischemic heart disease. Recommendations should thus be largely tailored to the individual.
Treatment should follow the general recommendations for physical activity for adults, but it is recommended that the volume be increased, for example, to 60 min of moderately intense physical activity daily most days of the week. Alternatively, it is possible to increase the intensity and halve the time or to alternate.
According to the previously mentioned dose– response study (Kraus et al., 2002), it is advantageous to walk or run at least 20 km a week, preferably 30, in order to control one’s cholesterol level with physical activity.
There are no general contraindications; however, measures will depend on the co-morbidity. With hypertension, strength training should be performed with light weights and low contraction velocity.
Metabolic syndrome is also known as insulin resistance syndrome, as one of the traits of the disorder is reduced insulin activity. There are several definitions for metabolic syndrome but it encompasses abdominal obesity, insulin resistance, hypertension, and hyperlipidemia.
The International Diabetes Federation (Ford, 2005) defines metabolic syndrome as follows:
Abdominal obesity, i.e., waist circumference ≥94 cm for men and ≥80 cm for women, plus at least two of the following four risk factors:
Metabolic syndrome is a precursor of type 2 diabetes and largescale epidemiological studies show that physical activity can prevent the onset of metabolic syndrome.
Evidence-based physical exercise
It is not formally possible to assess the isolated effect of exercise with respect to diet in the most relevant studies (Eriksson & Lindgarde, 1998; Tuomilehto et al., 2001; Knowler et al., 2002)
Physical exercise and abdominal obesity.
Visceral fat constitute an independent risk factor for developing heart disease. A cross-sectional study showed that overweight men with a high level of fitness have a significantly lower visceral fat than overweight men with a poor level of fitness (O’Donovan et al., 2009).
A group of young, healthy, normal weight men who normally walked 10 000 paces every day reduced their paces to 1500 per day over a period of 2 weeks. They experienced a significant rise in volume of visceral fat (7%) despite a total average weight loss of 1.2 kg (Olsen et al., 2008).
Irrespective of other fat deposits, abdominal obesity is a major risk factor for hyperlipidemia
(Nguyen-Duy et al., 2003; Janiszewski et al., 2008), lower glucose tolerance (Janssen et al., 2002), insulin resistance (Ross et al., 2002), systemic inflammation (Forouhi et al., 2001), hypertension (Hayashi et al.,2004), type 2 diabetes (Boyko et al., 2000), and all cause mortality (Kuk et al., 2006).
There is a link between regular physical activity, with or without weight loss, and reduction in visceral fat volume.
Increasing physical activity to 60 min/day over 3 months has been found to reduce visceral fat volume by about 30% . It should be emphasized, however, that changes in visceral fat volume as a response to physical exercise vary considerably and that it is not possible to identify a clear correlation between amount of physical exercise and reduction in visceral fat.
In relation to reduction of visceral fat tissue deposits, however, no specific method exists (surgery, diet, physical activity, etc.)
Middle-aged, normal weight or overweight men, and overweight women can expect to see a reduction in visceral fat volume (_ 10 to _ 19%) after 3 months of regular physical activity. These results also apply to older, overweight individuals (60– 80 years).
Type of training
Resistance and aerobic exercises can both be recommended as effective treatments for people with the metabolic syndrome. A meta-analysis included 12 trials (n = 626) and concluded that although differences in some diabetic control and physical fitness measures between resistance exercise and aerobic exercise groups reached statistical significance, there is no evidence that they are of clinical importance.
There is also no evidence that resistance exercise differs from aerobic exercise in impact on cardiovascular risk markers or safety. Using one or the other type of exercise for type 2 diabetes may be less important than doing some form of physical activity.
Future long-term studies focusing on patient relevant outcomes are warranted.