Gary J. Balady

Resistance Exercise in Individuals With and Without Cardiovascular Disease Benefits, Rationale, Safety, and Prescription An Advisory From the Committee on Exercise, Rehabilitation, and Prevention, Council on Clinical Cardiology, American Heart Association

Position paper endorsed by the American College of Sports Medicine nnAlthough exercise programs have traditionally emphasized dynamic lower-extremity exercise, research increasingly suggests that complementary resistance training, when appropriately prescribed and supervised, has favorable effects on muscular strength and endurance, cardiovascular function, metabolism, coronary risk factors, and psychosocial well-being. This advisory reviews the role of resistance training in persons with and without cardiovascular disease, with specific reference to health and fitness benefits, rationale, the complementary role of stretching, relevant physiological considerations, and safety. Participation criteria and prescriptive guidelines are also provided.nnAlthough resistance training has long been accepted as a means for developing and maintaining muscular strength, endurance, power, and muscle mass (hypertrophy),1 2 its beneficial relationship to health factors and chronic disease has been recognized only recently.3 4 5 Prior to 1990, resistance training was not a part of the recommended guidelines for exercise training and rehabilitation for either the American Heart Association or the American College of Sports Medicine (ACSM). In 1990, the ACSM first recognized resistance training as a significant component of a comprehensive fitness program for healthy adults of all ages.6 nnBoth aerobic endurance exercise and resistance training can promote substantial benefits in physical fitness and health-related factors.3 5 Table 1⇓ summarizes these benefits and attempts to weigh them according to the current literature.3 Although both training modalities elicit benefits in most of the variables listed, the estimated weightings (ie, in terms of physiological benefits) are often substantially different. Aerobic endurance training weighs higher in the development of maximum oxygen uptake (Vo2max) and associated cardiopulmonary variables, and it more effectively modifies cardiovascular risk factors associated with the development of coronary artery disease. Resistance training offers greater development of muscular strength, endurance, and mass. It also assists in the …

Primary Prevention of Coronary Heart Disease: Guidance From Framingham A Statement for Healthcare Professionals From the AHA Task Force on Risk Reduction

The Framingham Heart Study has contributed importantly to understanding of the causes of coronary heart disease (CHD), stroke, and other cardiovascular diseases. Framingham research has helped define the quantitative and additive nature of these causes or, as they are now called, “cardiovascular risk factors.”1 The National Cholesterol Education Program (NCEP)2 3 has made extensive use of Framingham data in developing its strategy for preventing CHD by controlling high cholesterol levels. The NCEP guidelines2 3 adjust the intensity of cholesterol-lowering therapy with absolute risk as determined by summation of risk factors. The National High Blood Pressure Education Program (NHBPEP) has set forth a parallel approach for blood pressure control. In contrast to the NCEP,2 however, earlier NHBPEP reports issued through the Joint National Committee4 did not match the intensity of therapy to absolute risk for CHD. “Normalization” of blood pressure is the essential goal of therapy regardless of risk status. Blood pressure–lowering therapy is carried out as much for prevention of stroke and other cardiovascular complications as for reduction of CHD risk. Nonetheless, risk assessment could be important for making decisions about type and intensity of therapy for hypertension. Thus, the most recent Joint National Committee report5 gives more attention to risk stratification for adjustment of therapy for hypertension. Although Framingham data have already been influential in the development of national guidelines for risk factor management, the opportunity may exist for both cholesterol and blood pressure programs to draw more extensively from Framingham results when formulating improved risk assessment guidelines and recommending more specific strategies for risk factor modification.nnThe American Heart Association has previously used Framingham risk factor data to prepare charts for estimating CHD risk. Framingham investigators of the National Heart, Lung, and Blood Institute prepared the original charts and have now revised …

Guidelines for Clinical Exercise Testing Laboratories A Statement for Healthcare Professionals From the Committee on Exercise and Cardiac Rehabilitation, American Heart Association

Exercise testing is a noninvasive procedure that provides diagnostic and prognostic information and evaluates an individual’s capacity for dynamic exercise. Exercise testing facilities range from the sophisticated research setting to more conventional equipment in the family practitioner’s or internist’s office. Regardless of the range of testing procedures performed in any given laboratory, basic equipment, personnel, and protocol criteria are necessary to conduct meaningful tests and ensure the comfort and safety of the patient. nnThis statement provides a guide to initiating and maintaining a high quality clinical laboratory for administering graded exercise tests to adults. Pediatric testing is addressed separately.1 nn### Environment nnExercise testing equipment varies in size. The testing room should be large enough to accommodate all the equipment necessary, including emergency equipment and defibrillator, while maintaining walking areas and allowing adequate access to the patient in emergency situations. Compliance with local fire codes and with procedures for other types of emergencies (eg, earthquake, hurricane) is essential. nnThe laboratory should be well lighted, clean, and well ventilated with temperature and humidity control. Including posters or pictures of outdoor scenes can reduce boredom and anxiety, particularly if the room has no windows. A wall-mounted clock with a “sweep” second hand or a digital counter is useful. The examining table should have space for towels, tape, and other items needed for patient preparation and testing. A curtain for privacy during patient preparation is useful. Minimizing interruptions and maintaining privacy allows the patient and laboratory personnel to concentrate on the testing procedure. nnTo assess the level of effort, a large-print scale of perceived exertion2 (Table 1⇓) should be mounted on the wall in clear view of the patient. The same scale has been used to assess symptoms of fatigue, dyspnea, or leg fatigue/pain.3 Dyspnea can also be measured by means of …

Safety and Utility of Exercise Testing in Emergency Room Chest Pain Centers An Advisory From the Committee on Exercise, Rehabilitation, and Prevention, Council on Clinical Cardiology, American Heart Association

Rapid triage and management of patients with an acute chest pain syndrome is an integral part of routine emergency room clinical activities. Specialized chest pain centers have been developed to better risk stratify patients in the emergency department setting using noninvasive test protocols to cost-effectively identify those patients who can be safely discharged with an acceptably low risk of cardiac events. 1‐16 The aim of this report is to summarize and interpret the evidence regarding the safety and utility of exercise testing in the evaluation of patients with chest pain who present to the emergency department. The rationale for implementation of a chest pain unit in the emergency department, use of different noninvasive test procedures and serum markers, and patient treatment will not be reviewed in detail except as they pertain to the use of exercise testing. Historical Perspective The role of exercise testing after stabilization of hospitalized patients with unstable angina has been extensively described. 17‐28 Swahn et al 23 reported on 400 patients ,65 years of age who underwent symptom-limited predischarge exercise testing after stabilization of unstable angina using an electrically braked bicycle ergometer starting at 10 W with continuous load increases of 10 W/min. The incidence of exercise-induced ST-segment depression

Exercise standards. A statement for healthcare professionals from the American Heart Association. Writing Group.

1m m was 33% in 272 men and 116 women. An abnormal exercise electrocardiogram (ECG) was recorded in 51% to 53% of patients with an abnormal ECG at rest versus 16% to 19% when the resting ECG was normal. Peak workload achieved was greater in men than in women, although the peak rate-pressure product was similar. After 1 year, there were 49 cardiac events in the 276 men who performed the exercise test compared with only 5 cardiac events in the 118 women.24 Exercise-induced ST-segment depression and low peak rate-pressure product independently identified risk of myocardial infarction or cardiac death. Exercise test variables were not predictive of cardiac events for the women enrolled in this study. Madsen et al25 reported on 257 patients stabilized for unstable angina, 26 of whom had a cardiac death or nonfatal myocardial infarction over a median 14-month follow-up. The presence of ST depression or negative T waves on the resting ECG or exerciseinduced ST depression or angina during the exercise test was predictive of cardiac events. Severi et al 26 reported on 374 patients who had an exercise stress test and underwent coronary angiography during the same admission. In the 54 patients with a normal rest and normal exercise ECG, only 4% of patients had 3-vessel coronary disease, and no patient had left main disease; 8-year survival was 100%. In the 86 patients with a normal resting ECG but abnormal exercise ECG, 3-vessel or left main coronary disease was present in 22% and 9%, respectively; 8-year survival was 97%. In the 59 patients with an abnormal resting ECG and normal exercise ergometry study, 3-vessel or left main coronary disease was noted in 19% of patients; 8-year survival was 88%. In the 175 patients with an abnormal rest and abnormal exercise ECG, only 2% of patients had normal vessels; 3-vessel or left main coronary disease was noted in 41% and 12%, respectively; 8-year survival was 70%. Similar prognostic findings were reported by Fruergaard et al.27