Ileana L. Piña

Statement on exercise. Benefits and recommendations for physical activity programs for all Americans. A statement for health professionals by the Committee on Exercise and Cardiac Rehabilitation of the Council on Clinical Cardiology, American Heart association.

Physical inactivity is recognized as a risk factor for coronary artery disease. Regular aerobic physical activity increases exercise capacity and plays a role in both primary and secondary prevention of cardiovascular disease.1 2 3 4 5 The known benefits of regular aerobic exercise and current recommendations for implementation of exercise programs are described in this revised report.6 nnExercise training increases cardiovascular functional capacity and decreases myocardial oxygen demand at any level of physical activity in apparently healthy persons as well as in most subjects with cardiovascular disease. Regular physical activity is required to maintain these training effects. The potential risk of physical activity can be reduced by medical evaluation, risk stratification, supervision, and education.4 nnExercise can help control blood lipid abnormalities, diabetes, and obesity. In addition, aerobic exercise adds an independent blood pressure–lowering effect in certain hypertensive groups with a decrease of 8 to 10 mm Hg in both systolic and diastolic blood pressure measurements.7 8 9 10 There is a direct relation between physical inactivity and cardiovascular mortality, and physical inactivity is an independent risk factor for the development of coronary artery disease.11 12 13 14 There is a dose-response relation between the amount of exercise performed from approximately 700 to 2000 kcal of energy expenditure per week and all-cause mortality and cardiovascular disease mortality in middle-aged and elderly populations.14 15 The greatest potential for reduced mortality is in the sedentary who become moderately active.15 Most beneficial effects of physical activity on cardiovascular disease mortality can be attained through moderate-intensity activity (40% to 60% of maximal oxygen uptake, depending on age).14 15 16 The activity can be accrued through formal training programs or leisure-time physical activities. Although most of the supporting data are based on studies in men, more recent findings …

Effectiveness-Based Guidelines for the Prevention of Cardiovascular Disease in Women—2011 Update: A Guideline From the American Heart Association

Substantial progress has been made in the awareness, treatment, and prevention of cardiovascular disease (CVD) in women since the first women-specific clinical recommendations for the prevention of CVD were published by the American Heart Association (AHA) in 1999.1 The myth that heart disease is a “mans disease” has been debunked; the rate of public awareness of CVD as the leading cause of death among US women has increased from 30% in 1997 to 54% in 2009.2 The age-adjusted death rate resulting from coronary heart disease (CHD) in females, which accounts for about half of all CVD deaths in women, was 95.7 per 100 000 females in 2007, a third of what it was in 1980.3,4 Approximately 50% of this decline in CHD deaths has been attributed to reducing major risk factors and the other half to treatment of CHD including secondary preventive therapies.4 Major randomized controlled clinical trials such as the Womens Health Initiative have changed the practice of CVD prevention in women over the past decade.5 The investment in combating this major public health issue for women has been significant, as have the scientific and medical achievements.nnDespite the gains that have been made, considerable challenges remain. In 2007, CVD still caused ≈1 death per minute among women in the United States.6 These represent 421 918 deaths, more womens lives than were claimed by cancer, chronic lower respiratory disease, Alzheimer disease, and accidents combined.6 Reversing a trend of the past 4 decades, CHD death rates in US women 35 to 54 years of age now actually appear to be increasing, likely because of the effects of the obesity epidemic.4 CVD rates in the United States are significantly higher for black females compared with their white counterparts (286.1/100 000 versus …

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 …

Guidelines for the Prevention of Stroke in Women A Statement for Healthcare Professionals From the American Heart Association/American Stroke Association

Purpose— The aim of this statement is to summarize data on stroke risk factors that are unique to and more common in women than men and to expand on the data provided in prior stroke guidelines and cardiovascular prevention guidelines for women. This guideline focuses on the risk factors unique to women, such as reproductive factors, and those that are more common in women, including migraine with aura, obesity, metabolic syndrome, and atrial fibrillation. Methods— Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council’s Scientific Statement Oversight Committee and the AHA’s Manuscript Oversight Committee. The panel reviewed relevant articles on adults using computerized searches of the medical literature through May 15, 2013. The evidence is organized within the context of the AHA framework and is classified according to the joint AHA/American College of Cardiology and supplementary AHA Stroke Council methods of classifying the level of certainty and the class and level of evidence. The document underwent extensive AHA internal peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the AHA Science Advisory and Coordinating Committee. Results— We provide current evidence, research gaps, and recommendations on risk of stroke related to preeclampsia, oral contraceptives, menopause, and hormone replacement, as well as those risk factors more common in women, such as obesity/metabolic syndrome, atrial fibrillation, and migraine with aura. Conclusions— To more accurately reflect the risk of stroke in women across the lifespan, as well as the clear gaps in current risk scores, we believe a female-specific stroke risk score is warranted.

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 …

AACVPR/ACCF/AHA 2010 Update: Performance Measures on Cardiac Rehabilitation for Referral to Cardiac Rehabilitation/Secondary Prevention Services A Report of the American Association of Cardiovascular and Pulmonary Rehabilitation and the American College of Cardiology Foundation/American Heart Association Task Force on Performance Measures (Writing Committee to Develop Clinical Performance Measures for Cardiac Rehabilitation)

Over the past decade, there has been an increasing awareness that the quality of medical care delivered in the United States is variable. In its seminal document dedicated to characterizing deficiencies in delivering effective, timely, safe, equitable, efficient, and patient-centered medical care, the Institute of Medicine described a quality “chasm”.1 Recognition of the magnitude of the gap between the care that is delivered and the care that ought to be provided has stimulated interest in the development of measures of quality of care and the use of such measures for the purposes of quality improvement and accountability.nnConsistent with this national focus on healthcare quality, the American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) have taken a leadership role in developing measures of the quality of care for cardiovascular disease (CVD) in several clinical areas Table 1. The ACCF/AHA Task Force on Performance Measures was formed in February 2000 and was charged with identifying the clinical topics appropriate for the development of performance measures and assembling writing committees composed of clinical and methodological experts. When appropriate, these committees include representatives from other organizations with an interest in the clinical topic under consideration. The committees are informed about the methodology of performance measure development and are instructed to construct measures for use both prospectively and retrospectively, rely upon easily documented clinical criteria, and where appropriate, incorporate administrative data. The data elements required for the performance measures are linked to existing ACCF/AHA clinical data standards to encourage uniform measurements 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

AACVPR/ACCF/AHA 2010 Update: Performance Measures on Cardiac Rehabilitation for Referral to Cardiac Rehabilitation/Secondary Prevention Services

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

AACVPR/ACCF/AHA 2010 Update: Performance Measures on Cardiac Rehabilitation for Referral to Cardiac Rehabilitation/Secondary Prevention Services: A Report of the American Association of Cardiovascular and Pulmonary Rehabilitation and the American College of Cardiology Foundation/American Heart Association Task Force on Performance Measures

Over the past decade, there has been an increasing awareness that the quality of medical care delivered in the United States is variable. In its seminal document dedicated to characterizing deficiencies in delivering effective, timely, safe, equitable, efficient, and patient-centered medical care, the Institute of Medicine described a quality “chasm”.1 Recognition of the magnitude of the gap between the care that is delivered and the care that ought to be provided has stimulated interest in the development of measures of quality of care and the use of such measures for the purposes of quality improvement and accountability.nnConsistent with this national focus on healthcare quality, the American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) have taken a leadership role in developing measures of the quality of care for cardiovascular disease (CVD) in several clinical areas Table 1. The ACCF/AHA Task Force on Performance Measures was formed in February 2000 and was charged with identifying the clinical topics appropriate for the development of performance measures and assembling writing committees composed of clinical and methodological experts. When appropriate, these committees include representatives from other organizations with an interest in the clinical topic under consideration. The committees are informed about the methodology of performance measure development and are instructed to construct measures for use both prospectively and retrospectively, rely upon easily documented clinical criteria, and where appropriate, incorporate administrative data. The data elements required for the performance measures are linked to existing ACCF/AHA clinical data standards to encourage uniform measurements of …

Reprint—AACVPR/ACCF/AHA 2010 Update: Performance Measures on Cardiac Rehabilitation for Referral to Cardiac Rehabilitation/Secondary Prevention Services

Over the past decade, there has been an increasing awareness that the quality of medical care delivered in the United States is variable. In its seminal document dedicated to characterizing deficiencies in delivering effective, timely, safe, equitable, efficient, and patient-centered medical care, the Institute of Medicine described a quality “chasm”.1 Recognition of the magnitude of the gap between the care that is delivered and the care that ought to be provided has stimulated interest in the development of measures of quality of care and the use of such measures for the purposes of quality improvement and accountability.nnConsistent with this national focus on healthcare quality, the American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) have taken a leadership role in developing measures of the quality of care for cardiovascular disease (CVD) in several clinical areas Table 1. The ACCF/AHA Task Force on Performance Measures was formed in February 2000 and was charged with identifying the clinical topics appropriate for the development of performance measures and assembling writing committees composed of clinical and methodological experts. When appropriate, these committees include representatives from other organizations with an interest in the clinical topic under consideration. The committees are informed about the methodology of performance measure development and are instructed to construct measures for use both prospectively and retrospectively, rely upon easily documented clinical criteria, and where appropriate, incorporate administrative data. The data elements required for the performance measures are linked to existing ACCF/AHA clinical data standards to encourage uniform measurements of …