Exercise Prescription for Cardiovascular diseases Dr. Leung Tat Chi, Godwin Specialist in Cardiology...

Exercise Prescription for Exercise Prescription for Cardiovascular diseasesCardiovascular diseases

Dr. Leung Tat Chi, Godwin

Specialist in Cardiology

27 April 2008

Prevention of Atherosclerotic Prevention of Atherosclerotic Vascular Disease by Physical Vascular Disease by Physical

ExerciseExercise Physical activity reduces the incidence of CAD Physical inactivity is a major CAD risk factor The relation is strong, with the most physically

active subject is generally demonstrated CAD rates half those of the most sedentary group

Independent of other risk factors Not protective in later years without lifelong

physical activity Benefit seen in middle age and older age groups

Powell KE, Thompson PD, Caspersen CJ, et al. Physical activity and the incidence of coronary heart disease. Annu Rev Public Health. 1987;8:253-287

Reduction of Atherosclerotic Reduction of Atherosclerotic Risk FactorsRisk Factors

Physical activity both prevents and treats establish atherosclerotic risk factors:

– Elevated blood pressure– Insulin resistance– Glucose intolerance– Elevated triglyceride concentration, low HDL-C– Obesity

Exercise + weight reduction >>>> LDL-C and increase HDL

Thompson et al, Exercise and Physical Activity in Cardiovascular Disease. Circulation June 24, 2003; 107:3109-3166

Response of Response of Blood LipidsBlood Lipids to to Exercise TrainingExercise Training

Meta-analysis of 52 exercise training trials of >12 weeks

Include 4700 patientsChange in lipid profile

– HDL-C increase 4.6%– Reduction in LDL-C by 5.0%– Reduction in TG by 3.7%

Leon AS, Sanchez O. Meta-analysis of the effects of aerobic exercise training on blood lipids. Circulation. 2001;104(suppl II):II-414-415. Abstract.

Response of Response of Blood PressureBlood Pressure to to Exercise TrainingExercise Training

44 randomized controlled trials include 2674 patients

Average change in blood pressure– SBP decrease by 3.4 mmHg– DBP decrease by 2.4 mmHg

Hypertensive patient– SBP decrease by 7.4 mmHg– DBP decrease by 5.8 mmHg

Normotensive patient– SBP decrease by 2.6 mmHg– DBP decrease by 1.8 mmHg

Fagard RH. Exercise characteristics and the blood pressure response to dynamic physical training. Med Sci Sports Exerc. 2001;33(6 suppl)

BP drop is not dose related

BP drop is not dose related

Blood Pressure Reductions as Little as 2 mmHg Reduce the Risk of Cardiovascular Events by up to 10% Meta-analysis of 61 prospective, observational studies 1 million adults 12.7 million person-years

2 mmHg decrease in mean systolic blood

pressure

10% reduction in risk of stroke mortality

7% reduction in risk of ischemic heart disease mortality

Lewington S, et al. Lancet. 2002;360:1903–1913

Lifestyle modification

Modification Recommendation SBP reduction

Physical activity Engage in regular aerobic physical activity such as brisk walking (at least 30 mins per day, most days of the week)

4-9mmHg

Moderation of alcohol consumption

Limit consumption to no more than 2 drinks (e.g., 24 oz beer, 10 oz wine, or 3 oz 80-proof whiskey) per day in most men and to no more than 1 drink per day in women and lighter-weight persons

2-4mmHg

Lifestyle modificationModification Recommendation SBP

reduction

Weight Reduction Maintain normal BW (BMI 18.5-24.9kg/m2)

5-20mmHg/10kg

Adopt DASH eating plan

Diet rich in fruits, vegetables, and low-fat diary products with a reduced content of dietary cholesterol as well as saturated and total fat

6-14mmHg

Dietary sodium restriction

Reducing dietary sodium to no more than 100 mmol/day (2-4g Na or 6g NaCl)

2-8mmHg

Effect of Exercise-based Cardiac Effect of Exercise-based Cardiac

Rehabilitation on Cardiac EventsRehabilitation on Cardiac Events Outcome Mean Difference 95% Cl Statistically Significant?

Exercise-only intervention

Total mortality -27% -2% to –40% Yes

Cardiac mortality -31% -6% to –49% Yes

Nonfatal MI -4% -31% to +35% No

Comprehensive rehabilitation

Total mortality -13% -29% to +5% No

Cardiac mortality -26% -4% to –43% Yes

Nonfatal MI -12% -30%-+12% No

Cl indicates confidences intervals. Cls not including zero are statistically significant.

Jolliffe JA, Rees K, Taylor RS, et al. Exercise-based rehabilitation for coronary heart disease. Cochrane Database Syst Rev. 2001(1):CD001800

•Meta analysis include 51 randomized trials

•Include 8440 patients: CABG, PTCA, MI, angina, middle-age men

•Supervised exercise for 6 months, follow up 2 years later

The Exercise Training Intervention The Exercise Training Intervention after Coronary Angioplasty after Coronary Angioplasty

Randomised 118 patients after coronary revascularization

6 months of exercise training vs usual care Trained patients significant increases in peak VO2

(26%) Quality of life parameters increases in 27% Fewer cardiac events (11.9% vs 32.2%) Hospital readimissions (18.6% vs 46%) Residual coronary stenosis decrease by 30% Recurrent cardiac event reduced by 29%

BelardinelliR, Paolini I, Cianci G, et al. Exercise Training Intervention after Coronary Angioplasty: the ETICA trial. J Am Coll Cardiol., 2001;37:1891-1900

Risk Risk

Cardiac rehabitation programs – Cardiac arrest: 1 in 117000 (patient-hours of p

articipation)– Nonfatal MI: 1: in 220000– Death : 1: 750000

Aerobic Activity Muscle-Strengthening Activity

Recommendation Frequency Intensity Duration Frequency Number of Exercises

Sets and repetitions

Flexibiltiy/Balance

Healthy adults, 2007.

(ACSM/AHA Recommendation)

A minimum of 5 d/wk for moderate intensity, or a minimum of 3 d/wk for vigorous intensity

Moderate intensity between 3.0 and 6.0 METS; vigorous intensity above 6 METS

Accumulate at least 30 min/d of moderate-intensity activity, in bouts of at least 10 min each; continuious vigorous activity for at least 20 min/d

At least 2 d/wk

8-10 exercises involving the major muscle groups

8-12 repetitions

Older adults, 2007 (ACSM/AHA Recommendation)


Moderate intensity at 5 to 6 on a 10-point scale; vigorous intensity at 7 to 8 on 10-point scale


At least 2 d/wk


10-15 repetitions

At least 2 d/wk flexibiltiy; for those at risk of falls, include exercises to maintain or improve balance




Flexibiltiy/Balance

Hypertension, 2004

(ACSM Recommendation)

Most, preferably all days per week

Moderate intensity at 40 -<60% of VO2max reserve (vigorous intensity acceptable for selected adults)

Accumulate 30 - 60 min/d of moderate-intensity activity, in bouts of at least 10 min each;

2-3 d/wk (resistance training an adjunct to aerobic activity)


1 set of 8-15 repetitions (more than 1 set acceptable for selected adults)

Cholesterol, 2001, National Cholesterol Education Program

Most days of the week, preferably daily

Moderate intensity

At least 30 min/d

Muscle-strengthening activities recommended as beneficial

Flexibility regarded as beneficial




Flexibiltiy/Balance

Coronary artery disease, 2001, AHA (aerobic recommendation)

At least 3 d/wk

Moderate intensity at 40 -60% of HR reserve (vigorous intensity as tolerated at 60-85% of HR reserve)

At least 30 min

Cardiovascular disease, 2000, AHA (flexibility and resistance training recommendation)


Moderate intensity at 5 to 6 on a 10-point scale; vigorous intensity at 7 to 8 on 10-point scale


At least 2 d/wk


10-15 repetitions

At least 2 d/wk flexibiltiy; for those at risk of falls, include exercises to maintain or improve balance

Hypertension and ExerciseHypertension and ExercisePosition Stand (Evaluation)Position Stand (Evaluation)

SeveritySecondary causeCV risk factorsTarget organ damage (TOD)CVD complications

Exercise is a major lifestyle modification needed to prevent, treat and control

hypertension


Supervised exercise stress test– High intensity exercise program (VO2 R

>60%)– Patients with TOD/DM or BP >180/110 before

engaging in moderate-intensity exercise (VO2R 40 to 60%)

– Patients with CVD (stroke, heart failure, IHD) Avoid high intensity exercise (vigorous program

best initiated at dedicated rehabilitation centre)

Special ConsiderationSpecial Consideration Beta-blockers and diuretics impair the ability to re

gulate body temperature. S/S of heat illness Adequate hydration Proper clothing Optimal times of the day

Beta blockers can alter submaximal and maximal exercise capacity

Alpha blockers, CCB, vasodilators Provoke hypotensive episodes after abrupt cessation of activity Extend the cool-down period

Diuretics increase the potential for dehydration

Hypertension and ExerciseHypertension and ExercisePosition StandPosition Stand

Emphasis on aerobic activity. VO2R 40 to 60%. RPE 12-13.

Avoid high-intensity resistance training (lower intensity, higher repetitions).

Clients should maintain hypertensive medications, if prescribed.

Do not exercise if resting SBP > 200 mm Hg or DBP > 115 mm Hg. Maintain BP <220/105 during exercise

Begin pharmacological treatment prior to starting exercise program if BP > 160/100

Resistance training/ Valsalva maResistance training/ Valsalva maneuverneuver

Forced expiration against a closed glottis Increase in intrathoracic pressure leading to decreased ven

ous return and potentially reduced cardiac output At the release of the “strain,” venous return is dramatically

increased, increasing cardiac output and elevation of BP Symptoms of lightheadedness or dizziness may occur if ca

rdiac output is reduced. With relaxation, individuals may experience headache whi

le pressure remains elevated. In patients with heart disease, symptoms of myocardial isc

hemia may ensue as a result of elevated BP and increased myocardial work.

AdherenceAdherence

Education regarding the importance of regular exercise for BP control

Especially responsive if information comes from their personal physician

Knowledge of the immediate BP-lowering effects of exercise (up to 22 hr) (PEH)

Cardiac rehabilitationCardiac rehabilitation

Core components– Medical assessment– Nutrition counseling– Risk factor management (lipid, DM, weight,

smoking)– Psychosocial management– Activity counseling and exercise training

Cardiac rehabilitationCardiac rehabilitation

Phase I– Inpatient

Phase II– Up to 12 weeks of ECG monitored exercise

Phase III– Clinical supervision

Phase IV– No ECG, medical supervision

Cardiovascular System Cardiovascular System AssessmentAssessment

Patients with known coronary artery disease should undergo a supervised evaluation of the ischemic response to exercise, ischemic threshold, and the propensity to arrhythmia during exercise.

In many cases, left ventricular systolic function at rest and during its response to exercise should be assessed.

Physical Activity/Exercise and Diabetes; Diabetes care, vol. 27, supplement 1, January 2004

Exercise testingExercise testing

Integral component of the rehab process– Establishment of appropriate specific safety precautions– Guide training intensity– Target exercise training heart rates– Initial levels of exercise training work rates– Risk stratification

Should be performed on all cardiac patients entering an exercise training program

Exercise prescription for individuals with Exercise prescription for individuals with CAD (Risk Stratification)CAD (Risk Stratification)

Mildly increased risk– Preserved LV systolic function (EF > 50%)– Normal exercise tolerance for age

> 50 years old > 10METS 50 to 59 >9METS 60 to 60 >8METS >70 >7METS

– Absence of exercise induced ischemia– Absence of hemodynamically significant stenosis of a

major coronary artery (>50%)– Successful revascularization

Exercise prescription for individuals with Exercise prescription for individuals with CAD (Risk Stratification)CAD (Risk Stratification)

Substantially increased risk– Impaired LV systolic function (<50%)– Evidence of exercise-induced myocardial ische

mia– Hemodynamically significant stenosis of a maj

or coronary artery (>50%)

Medically Supervised Medically Supervised ExerciseExercise

Moderate to High risk subjects– Medical supervision required until safety established– ECG and BP monitoring (usually > 12 sessions)

Low risk subjects– Benefit from medically supervised programs

Safe Group dynamics

– ECG monitoring (useful during the early phase, 6 – to 12 sessions)

Rehabilitation in Coronary Rehabilitation in Coronary Heart DiseaseHeart Disease

• Mainly endurance training • at an intensity of 50 (-60) -75% of symptom-

limited VO2max (or heart rate reserve) for 30 minutes 3-4 times weekly (minimum), full benefit is obtained with 5-6 times/week

• Resistance training in addition• at an intensity of 30-50% (up to 60-80%) of 1

RM (one repetition maximum), 12-15 repetitions, 1-3 sets twice weekly

Outpatients exercise programOutpatients exercise program

Setting a safe upper limit for Intensity– Moderate intensity exercise (40 to 60% VO2max)– Brisk walking, treadmill, cycle, stair-climbing, rowing machine– Initial intensity

40 to 60% of heart rate reserve Can be increased to 85% (high intensity) if tolerated

– RPE 11 to 13 (between fairly light to somewhat hard)

Duration may be increased as appropriate after safe activity levels established

Intensity may be increased as heart rate response to exercise decreases with conditioning

Exercise prescription without Exercise prescription without exercise testexercise test

Initial exercise intensity– 2 to 3 METs

1 to 2 mph, 0% grade on treadmill 100 to 300 kg.m.min-1 (12.5- 50W) on cycle ergometer

– RPE: 11-13– Gradual increments of 0.5 to 1.0 METs as tolerated– Target heart rate

20 beats/min above standing rest

– Frequency 30 – 45 minutes per day 5 d/wk,

Exercise prescription in the Exercise prescription in the presence of ischemiapresence of ischemia

Inappropriate for those with angina < 3METS Aim to increase anginal threshold Prolonged warm up and cool Upper body exercises may precipitate angina more readily Heart rate and work rate below the identified threshold of

ischemia Should be a minimum of 10 beats/min below the heart rate

at which the abnormality occurs Intermittent, shorter duration-type on a more frequent basis

Home exercise rehabilitationHome exercise rehabilitation

Lower costConveniencePromote independenceComparable safey and efficacyGood communication between patients and

staff required

Heart FailureHeart Failure

Benefits of exercise– Functional capacity, improved leg blood flow and oxidative capacity,

neurohormones, autonomic tone Initiated at a low to moderate level (25 to 60% of VO2max) VO2max determined by direct gas exchange measurements Careful supervision and monitoring Brief training session Lengthened warm up and cool down RPE: 11 to 14 Safety and efficacy of resistance training not well established

After cardiac procedureAfter cardiac procedure

CABG– Avoid upper body exercise for 3 months

PCI– Resume exercise no sooner than 5 to 7 days– Catheterization access sites should be healed

Pacemakers and implantable carPacemakers and implantable cardioverter defrillatorsdioverter defrillators

Type and settings of pacemaker should be noted Avoid high intensity resistance exercise Fixed-rate pacemakers

– Activity intensity must be gauged by other methods RPE

ICD– Limit target heart rate at least 10 to 15 beats/min lower

than the threshold discharge rate

AHA Scientific Statement: Recommendations AHA Scientific Statement: Recommendations for the Acceptability of Recreational for the Acceptability of Recreational

(Noncompetitive) Sports Activities and Exercise (Noncompetitive) Sports Activities and Exercise in Patients With Genetic CVDin Patients With Genetic CVD

GCVD– HCM, LQTS, Marfan syndrome, ARVC, Brugada syndrome

Recreational sports are categorized with regard to high, moderate and low levels of exercise

Graded on relative scale (from 0 to 5) for eligibility– 0 to 1: indicating generally not advised or strongly discouraged– 4 to 5: indicating probably permitted– 2 to 3: indicating intermediate and to be assessed clinically in an in

dividual basis

AHA Scientific Statement: Recommendations foAHA Scientific Statement: Recommendations for the Acceptability of Recreational (Noncompetitr the Acceptability of Recreational (Noncompetitive) Sports Activities and Exercise in Patients Wive) Sports Activities and Exercise in Patients W

ith GCVDsith GCVDs

Intensity Level HCM LQTS Marfan Syndrome

ARVC Brugada Symdrome

High

Basketball 0 0 2 1 2

Full court 0 0 2 1 2

Half court 1 1 0 1 1

Body building 0 0 1 0 0

Ice hockey 0 2 2 0 2

Racquetball/squash 1 1 1 1 1

Rock climbing 0 0 2 0 2

Running (downhill) 2 2 2 1 1

Skiing (cross-country) 2 3 2 1 4

Soccer 0 0 2 0 2

Tennis (singles) 0 0 3 0 2

Touch (flag) football 1 1 3 1 3

Windsurfing 1 0 1 1 1

Recommendations for Physical Activity and Recreational Sports Participation for Young Patients with Genetic Cardiovascular Diseases, Circulation. 2004; 109:2807-2816)


ith GCVDsith GCVDs



Moderate

Baseball/softball 2 2 2 2 4

Biking 4 4 3 2 5

Modest hiking 4 5 5 2 4

Motocycling 3 1 2 2 2

Jogging 3 3 3 2 5

Sailing 3 3 2 2 4

Surfing 2 0 1 1 1

Swimming (lap) 5 0 3 3 4

Tennis (doubles) 4 4 4 3 4

Treadmill/stationary bicycle 5 5 4 3 5

Weightlifting (free weights) 1 1 0 1 1

Hiking 3 3 3 2 4



ith GCVDsith GCVDs



Low

Bowling 5 5 5 4 5

Golf 5 5 5 4 5

Horseback riding 3 3 3 3 3

Scuba diving 0 0 0 0 0

Skating 5 5 5 4 5

Snorkeling 5 0 5 4 4

Weights (non-free weights) 4 4 0 4 4

Brisk walking 5 5 5 5 5


Case studyCase study

Mr. Wong is a 50-year old male, sales representative who travels often

BP 150/90 mmHg Medications: atenolol 50mg daily, lisinopril 10mg dail

y Resting HR: 60/min 170cm, 84kg , BMI 29 His brother just suffered from MI at age 40. Concerned about his health Want to do start exercise and lose weight

EvaluationEvaluation

Classify client according to Risk Stratification Criteria– ACSM/ ACP/ACCVPR/ AHA

Identify Major Coronary Artery Disease Risk Factors

Identify signs or symptoms suggestive of cardiopulmonary disease

Identify secondary risk factors– Obesity, alcohol consumption, stress levels

Consider the following criteria during your evaluation:– Age and gender– Moderate Vs vigorous exercise program– Physician present during testing– Submaximal or maximal graded exercise test– Type of test (treadmill, leg ergometer, step)– Absolute and relative contraindications to exerc

ise testing

What recommendations in reference to medical examination and testing prior to participation in an exercise program?


Supervised exercise stress test– High intensity exercise program (VO2 R

>60%)– Patients with TOD/DM or BP >180/110 before

engaging in moderate-intensity exercise (VO2R 40 to 60%)

– Patients with CVD (stroke, heart failure, IHD) Avoid high intensity exercise (vigorous program

best initiated at dedicated rehabilitation centre)

QuestionsQuestions

Please write an initial exercise prescriptionAny adjustments and practical tips in

patients with HT?




Flexibiltiy/Balance

Hypertension, 2004

(ACSM Recommendation)

Most, preferably all days per week

Moderate intensity at 40 -<60% of VO2max reserve (vigorous intensity acceptable for selected adults)

Accumulate 30 - 60 min/d of moderate-intensity activity, in bouts of at least 10 min each;

2-3 d/wk (resistance training an adjunct to aerobic activity)


1 set of 8-15 repetitions (more than 1 set acceptable for selected adults)

Cholesterol, 2001, National Cholesterol Education Program

Most days of the week, preferably daily

Moderate intensity

At least 30 min/d

Muscle-strengthening activities recommended as beneficial

Flexibility regarded as beneficial

Special ConsiderationSpecial Consideration

Beta-blockers and diuretics impair the ability to regulate body temperature.

S/S of heat illness Adequate hydration Proper clothing Optimal times of the day

Beta blockers can alter submaximal and maximal exercise capacity

Alpha blockers, CCB, vasodilators Provoke hypotensive episodes after abrupt cessation of activity Extend the cool-down period

Diuretics increase the potential for dehydration

5 days per week (F) 40 to 60% VO2 max/HRR reserve (I)

12-14 RPE 30 – 60 min per session (T) Rhythmical & aerobic, large muscle activities

(running, jogging, cycling …etc.) (T)

Exercise PrescriptionExercise Prescription

Case StudyCase Study

M/60 Recently diagnosed to have type 2 DM, put on Daonil BP 160/90 mmHg on metoprolol 50mg bd Half pack a day smoking habit due to stress of his job Cholesterol level: 6.2mmol/l , HDL 0.90 mmol/l, LD

L 3.8mmol/l TG: 2.4 mmol/l No regular exercise No signs or symptoms of cardiopulmonary disease

A constellation of cardiovascular risk factors related to hypertension, abdominal obesity, dyslipidemia, and insulin resistance

Certain drugs used to treat hypertension may accelerate the appearance of new-onset diabetes. In particular, both β blockers and diuretics have been implicated in this effect.

ALLHAT– In high risk hypertensive patients, the diuretic, chlorthalidone, was 43% more likely than th

e ACEI, lisinopril, to produce diabetes, but was also 18% more likely than the calcium channel blocker, amlodipine, to produce this adverse effect.

HOPE– The development of new diabetes was reduced by 34% (p<0.001) in the ramipril-treated gro

up.

LIFE (Losartan Intervention For Endpoint Reduction in Hypertension)– The ARB, losartan, was associated with a 25% relative risk reduction in new-onset diabetes

when compared with the β blocker, atenolol

VALUE (The Valsartan Antihypertensive Long-term Use Evaluation)– Valsartan, was associated with 23% RRR in new-onset diabetes when compared with the ca

lcium channel blocker, amlodipine.

ARB/ACEI may have positive effects on insulin action and potentially plays a meaningful role in protecting high-risk hypertensive patients from developing diabetes.

MedicationsMedications

Metoprolol changed to ACE inhibitors/ ARB

Metformin Statin

Will you subject patient to exercise stress test before writing exercise prescription?

Exercise stress testExercise stress test

METS achieved: 8VO2max = 28 ml kg-1 min-1

Peak heart rate: 160 beats per minutePeak blood pressure of 200/88 mmHg.No exercise induced ischemia

QuestionsQuestions

Please write an initial exercise prescriptionAny adjustments and practical tips in

patients with DM and HT?

Exercise prescriptionExercise prescription Address each of the following

– Aerobic endurance– Strength training– Flexibility

Include each of the following in your prescriptionfrequency

times/day, days/weekIntensity

HRR, %VO2max, %HRmax, %1RM, %MVC, etcDuration

warm-up, cool-down, exercise component, rest between sets, etcMode of exercise

types of exercise, stretching techniques, resistance training, etcRate of progression

Target heart rate zoneTarget heart rate zone

HRR (40%)– = (160-60) x 0.4 + 60– = 100

– (60%) – =120

Exercise Intensity – Exercise Intensity – Concepts of METs and Ex HR Concepts of METs and Ex HR

MET (metabolic equivalent) – A unit of metabolic equivalent, or MET, is defined as the number of calories consumed by an organism per minute in an activity relative to the Basal metabolic rate

1 MET is equivalent to a metabolic rate consuming 3.5 milliliters of oxygen per kilogram of body weight per minute.

1 MET is equivalent to a metabolic rate consuming 1 kilocalorie per kilogram of body weight per hour.

Low Intensity: 3-5 METs

Moderate Intensity: 4-7 METs

High Intensity: 8-12 METs

Simple Estimation of Ex IntensitySimple Estimation of Ex Intensity

e.g. A 75 kg man plays basketball game for 30 min, Kcal = ?

Kcal = METs x duration x Wt/60 = 8 x 30 x 80/60

= 8 x 30 x 80/60 = 320 KCal

METs: a multiple of the resting rate of oxygen consumption (of a seated individual at rest)

1 MET = 3.5 ml kg-1 min-1 VO2

Compendium of Physical Activities (MSSE, 1993: 71-80)

Target VO2 Target VO2

What will be the intensity exercise?

Lower range: – 28-3.5 x 0.4 + 3.5= 13.3 ml kg-1 min-1

Higher range:– 18.2 ml kg-1 min-1

Recommended work rateRecommended work rate

VO2 = (0.1 (speed)) + 1.8 (speed) (grade) + 3.5ml kg-1 min-1

– For treadmill grade 2.5%

Speed = 13.3 ml kg-1 min-1/0.145 =91.7m/min or 5.5 kph @2.5%

RecommendationRecommendation

Health professionals should personally engage in an active lifestyle

Thank You!Thank You!

ReferencesReferences Exercise standards for testing and training: a statement for healthcare professio

nals from the American Heart Association. Circulation. 2001;104:1694-1740 Exercise and physical activity in the prevention and treatment of atheroscleroti

c cardiovascular disease: AHA scientific statement. Circulation. 2003;107:3109-3116

Recommendations for Physical Activity and Recreational Sports Participation for Young Patients with Genetic Cardiovascular Diseases, Circulation. 2004; 109:2807-2816

ACSM’s guidelines for exercise testing and prescription. 7th edition 36th Bethesda Conference. Eligibility recommendations for competitive athlete

s with cardiovascular abnormalities. JACC 19 April 2005 Recommendations for preparticipation screening and the assessment of cardio

vascular disease in masters athletes. Circulation. 2001;103:327-334. Physical activity and public health in older adults: Recommendation from the

American College of Sports Medicine and the American Heart Association. Circulation. 2007;116:000-000

ACSM Position Stand. Exercise and Hypertension. hypertension. Med. Sci. Sports Exerc. 36:533–553, 2004.

Resistance Exercise in Individuals With and Without Cardiovascular Disease: 2007 Update Circulation. 2007;116:572-584

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