““Exercise Safely: How Big Is The RiskExercise Safely: How Big Is The Risk

James W. Ziccardi DO, FACCJames W. Ziccardi DO, FACC

Pheidippides delivers the news of the victory of the Pheidippides delivers the news of the victory of the Athenians over the Persians Athenians over the Persians

““The condition of the athlete is not The condition of the athlete is not natural.”natural.”

--Hippocrates--Hippocrates

•

Over the last several decades there has been a Over the last several decades there has been a dramatic change in activity levels of the population dramatic change in activity levels of the population in their 50’s and older participating in moderate and in their 50’s and older participating in moderate and sometimes high levels of exercise, including sometimes high levels of exercise, including marathons. Since cardiac disease risk increases marathons. Since cardiac disease risk increases with age, many of these participants will have with age, many of these participants will have underlying cardiovascular disease and be at risk for underlying cardiovascular disease and be at risk for an acute event during or after performing exercise. an acute event during or after performing exercise. Patients with known cardiac disease may also be on Patients with known cardiac disease may also be on several medications, the side effects of which may several medications, the side effects of which may be potentiated by exercise or inhibit obtaining be potentiated by exercise or inhibit obtaining reasonable levels of performance. The potential reasonable levels of performance. The potential cardiovascular risk of exercise, especially in cardiovascular risk of exercise, especially in reference to endurance events, actions to reduce reference to endurance events, actions to reduce risk, the potential side effects of cardiac risk, the potential side effects of cardiac medications and choosing drug regimens medications and choosing drug regimens hemodynamically favorable to exercise will be hemodynamically favorable to exercise will be reviewed.reviewed.

Cardiac Complications of Cardiac Complications of Endurance RunningEndurance Running

1.1. Acute Mydocardial InfarctionAcute Mydocardial Infarction2.2. Arrhthmia: SVT, AFIB, PVCArrhthmia: SVT, AFIB, PVC3.3. Sudden Death: VT, V-FIBSudden Death: VT, V-FIB4.4. HypotensionHypotension

Non-Cardiac Problems Non-Cardiac Problems Complicating Cardiac DiseaseComplicating Cardiac Disease

1. Dehydration1. Dehydration

2. Hyponatremia2. Hyponatremia

3. Hyperthermia3. Hyperthermia

4. Hypothermia4. Hypothermia

Risk of Death – Distance RunningRisk of Death – Distance Running

1. 10K to ½ Marathon1. 10K to ½ Marathon Men 38 to 84 Y.O.A.Men 38 to 84 Y.O.A. Incidence: 1/327,344Incidence: 1/327,344 (Frere J. 2004)(Frere J. 2004)

2. Marathon 2. Marathon 1/50,0001/50,000 Marine Corp, Twin Cities Marathon 1982 – 1994Marine Corp, Twin Cities Marathon 1982 – 1994 4 deaths (3 during race, 15-24 mi.)4 deaths (3 during race, 15-24 mi.) (Maron B. (Maron B.

1996)1996)

3.3. JoggersJoggers Rhode Island, 1975-1980. 1 Death/Yr./7,620 Joggers Rhode Island, 1975-1980. 1 Death/Yr./7,620 Joggers Without known cad. 1/15,240Without known cad. 1/15,240 (Thompson P. 1982)(Thompson P. 1982)

4. Marathon – Post Infarction - Safety4. Marathon – Post Infarction - Safety 8 Pt. Boston Marathon – No CV Events (4/73)8 Pt. Boston Marathon – No CV Events (4/73) Age 36 to 57Age 36 to 57 (Kavanagh T. 1974)(Kavanagh T. 1974)

Cardiac Arrests in Long Cardiac Arrests in Long Distance Running RacesDistance Running Races

10.9 Million Runners, 59 arrests (51 10.9 Million Runners, 59 arrests (51 men)men)– Ages 43 +/- 13 yrsAges 43 +/- 13 yrs– Incidence rate = .54/100k Incidence rate = .54/100k

Majority Due to CADMajority Due to CAD 1.01 per 100k in the marathon 1.01 per 100k in the marathon

Best PrognosisBest Prognosis– Bystander cardiopulmonary resuscitationBystander cardiopulmonary resuscitation– Dx other than HCM Dx other than HCM

NEJM: Jan 12, 2012 NEJM: Jan 12, 2012

CV Risks in Cardiac CV Risks in Cardiac RehabilitationRehabilitation

30 programs: 1960-197730 programs: 1960-1977– 1 Non-Fatal MI in 346,733 Pt. Hrs1 Non-Fatal MI in 346,733 Pt. Hrs– 1 Fatal MI in 116,402 Pt. Hrs1 Fatal MI in 116,402 Pt. Hrs

142 Programs: 1980-1984142 Programs: 1980-1984– 1 Non-Fatal MI in 294k Pt. Hrs1 Non-Fatal MI in 294k Pt. Hrs– 1 Cardiac Death in 780k in Pt. Hrs1 Cardiac Death in 780k in Pt. Hrs– 21 Cardiac Sudden Death (17 resuscitated) Chest: 199821 Cardiac Sudden Death (17 resuscitated) Chest: 1998

167 Programs: 105 Centers, 51k Patients, 2,361,967 Hrs167 Programs: 105 Centers, 51k Patients, 2,361,967 Hrs– 1 Cardiac Death in 60k Pt. Hrs (Medicine and Science in Sports 1 Cardiac Death in 60k Pt. Hrs (Medicine and Science in Sports

and Exercise July 1994)and Exercise July 1994)

Acute Coronary Thrombosis in Acute Coronary Thrombosis in Boston Marathon Runners Boston Marathon Runners

(2011)(2011) 3 Myocardial infractions (Men) Post 3 Myocardial infractions (Men) Post

CompletionCompletion All:All:

– Had coronary thrombosisHad coronary thrombosis– Traveled more than 4 Hrs. by Plane PriorTraveled more than 4 Hrs. by Plane Prior– Elevated Thrombin, Anti-Thrombin Elevated Thrombin, Anti-Thrombin

ComplexComplex– None on cardiac medicationsNone on cardiac medications

NEJM: Jan 12, 2012NEJM: Jan 12, 2012

Sudden Cardiac DeathSudden Cardiac Death

Detrimental Effects of Detrimental Effects of Prolonged Endurance ExerciseProlonged Endurance Exercise

Increased: Heart Rate, BP and prolonged Increased: Heart Rate, BP and prolonged periods of Anaerobic Exercise. periods of Anaerobic Exercise.

Increased: Aortic Stiffness, documented by Increased: Aortic Stiffness, documented by increased Pulse Wave Velocity.increased Pulse Wave Velocity.

Greater: Coronary Calcium and increased Greater: Coronary Calcium and increased Calcified Plaque Volume- 274mm cubed in Calcified Plaque Volume- 274mm cubed in prolonged endurance exercise group vs prolonged endurance exercise group vs 169mm cubed in the control group.169mm cubed in the control group.

Scwartz, Am. Coll. Card. Sc. Sess., 3/16/10Scwartz, Am. Coll. Card. Sc. Sess., 3/16/10

Timing of Infarction/ExerciseTiming of Infarction/Exercise

(A) Increased: In First Hour Post Exercise(A) Increased: In First Hour Post Exercise

1. 218 Pts.: 4.4% Reported Heavy Exertion 1 Hr. Prior to MI1. 218 Pts.: 4.4% Reported Heavy Exertion 1 Hr. Prior to MI

2. Fitness Level: Sedentary – 107 X Risk2. Fitness Level: Sedentary – 107 X Risk– Exercise: 1 – 2 X Week – 19.4 X RiskExercise: 1 – 2 X Week – 19.4 X Risk

3 – 4 X Week – 8.6 X Risk3 – 4 X Week – 8.6 X Risk

4 – 5 X Week – 2.4 X Risk 4 – 5 X Week – 2.4 X Risk

**Heavy physical exertion is much more likely to Heavy physical exertion is much more likely to trigger infarction in the least fit.trigger infarction in the least fit. (Mittleman M. (Mittleman M. 1993)1993)

Mechanisms of MI/ExerciseMechanisms of MI/Exercise

1. Increased Inflammatory/Hemostatic Markers1. Increased Inflammatory/Hemostatic Markers Increased: VWFIncreased: VWF

: D-Dimer: D-Dimer

: WBC: WBC

: Platelet Aggregation: Platelet Aggregation

: CRP: CRP (Siegel A. 2001)(Siegel A. 2001)

2. Changes in Cardiac Markers2. Changes in Cardiac Markers Increased: Troponin I, Elevated 4 Hr. – 72 Hr.Increased: Troponin I, Elevated 4 Hr. – 72 Hr.

: CPK – MB – Peak 24 Hr.: CPK – MB – Peak 24 Hr.

: Myoglobin – Peak 4 Hr. : Myoglobin – Peak 4 Hr.

: BNP Peak 24 Hr.: BNP Peak 24 Hr. (Siegel A. 2001)(Siegel A. 2001)

3. Plaque Rupture3. Plaque Rupture

Coagulation-Thrombolysis is in Coagulation-Thrombolysis is in equilibrium during exerciseequilibrium during exercise

Post-Exercise: A Post-Exercise: A Hypercoagulable State is Hypercoagulable State is PresentPresent

Plaque Rupture/ThrombosisPlaque Rupture/Thrombosis

Atherosclerotic Heart DiseaseAtherosclerotic Heart Disease

- Primary Cause of Death in Exercise Related - Primary Cause of Death in Exercise Related DiseaseDisease

81 Died suddenly, 75 Deaths – 281 Died suddenly, 75 Deaths – 2ndnd to CAD to CAD

(Ragosta M. 1984)(Ragosta M. 1984)

Plaque Rupture/Intra-Coronary ClotsPlaque Rupture/Intra-Coronary Clots

- 640 Pts: (64) – Exercise VS. (576) – Rest- 640 Pts: (64) – Exercise VS. (576) – Rest

- Clots 2MM Present in: 64% of Exercising Patients- Clots 2MM Present in: 64% of Exercising Patients

: 35% at Rest: 35% at Rest (Giri S. 1999)(Giri S. 1999)

Prodromal SymptomsProdromal Symptoms

(A). Chest Pain, Unexpected Dyspnea, Palpitations(A). Chest Pain, Unexpected Dyspnea, Palpitations (B). Seek Attention Immediately(B). Seek Attention Immediately (C). Denial (IE) Jim Fixx (Tragedy)(C). Denial (IE) Jim Fixx (Tragedy)

1. (6/13) Deaths during or immediately after exercise had 1. (6/13) Deaths during or immediately after exercise had prodromal symptoms before the event.prodromal symptoms before the event. (Thompson P. 1979)(Thompson P. 1979)

2. (36) Marathoners/Sudden Death: 71% had prodromal 2. (36) Marathoners/Sudden Death: 71% had prodromal symptoms.symptoms.

(Noakes T. 1987)(Noakes T. 1987)

3. (47%) prodromal symptoms at rest with ACS/Sedentary Men, 3. (47%) prodromal symptoms at rest with ACS/Sedentary Men, 8% of athletes exercising. 8% of athletes exercising. (Ciampricotti R. 1994(Ciampricotti R. 1994

CV Meds – No Significant Effect CV Meds – No Significant Effect on Exercise Capacityon Exercise Capacity

1. Alpha-blockers – prazosin, terazosin and doxazosin.1. Alpha-blockers – prazosin, terazosin and doxazosin. 2. ACE Inhibitors/ARBS – captopril, lisinopril, quinapril, 2. ACE Inhibitors/ARBS – captopril, lisinopril, quinapril,

ramipril/losartan, ramipril/losartan, valsartan valsartan 3. Venodilators – nitrates.3. Venodilators – nitrates. Calcium Channel Blockers – the dihydropyridines, diltiazem and Calcium Channel Blockers – the dihydropyridines, diltiazem and

verapamil.verapamil.

Cardiovascular MedsCardiovascular MedsHaving the Potential to Effect ExerciseHaving the Potential to Effect Exercise

1. Beta-blockers: inderal, metoprolol, atenolol and bisoprolol1. Beta-blockers: inderal, metoprolol, atenolol and bisoprolol 2. Alpha beta-blockers: labetalol, carvedilol2. Alpha beta-blockers: labetalol, carvedilol 3. Calcium channel blockers: verapamil3. Calcium channel blockers: verapamil 4. Amiodarone – alpha beta-blocker4. Amiodarone – alpha beta-blocker 5. Central alpha-blockers – clonidine5. Central alpha-blockers – clonidine 6. Diuretics – thiazides, loop diuretics, potassium sparing6. Diuretics – thiazides, loop diuretics, potassium sparing 7. Pure Vasodilators – hydralazine7. Pure Vasodilators – hydralazine

– (*1-5 have potential to limit heart rate response to (*1-5 have potential to limit heart rate response to exercise)exercise)

Beta - BlockersBeta - Blockers

1. Decrease heart rate and cardiac output1. Decrease heart rate and cardiac output 2. Decrease myocardial contractility2. Decrease myocardial contractility 3. Decrease coronary blood flow3. Decrease coronary blood flow 4. Decrease muscle blood flow4. Decrease muscle blood flow 5. Cause premature fatigue during exercise5. Cause premature fatigue during exercise

A. Especially in non-selective beta-blockersA. Especially in non-selective beta-blockers B. Increased rating of perceived exertion (local)B. Increased rating of perceived exertion (local)

– a. Alters glycolytic metabolisma. Alters glycolytic metabolism– b. Decreased muscle blood flowb. Decreased muscle blood flow

Beta – Blockers, ContinuedBeta – Blockers, Continued

6. Decrease in VO2 max6. Decrease in VO2 max 7. Decreased heart dissipation during exercise in hot 7. Decreased heart dissipation during exercise in hot

weather.weather. 8. May cause hyperkalemia8. May cause hyperkalemia 9. Beta-blockers are certainly necessary in many patients 9. Beta-blockers are certainly necessary in many patients

who have coronary artery disease, however, an attempt who have coronary artery disease, however, an attempt should be made to adjust the dosage of beta-blockers to should be made to adjust the dosage of beta-blockers to attain at least 70% of predicted maximal heart rate or keep attain at least 70% of predicted maximal heart rate or keep heart rate at levels below that causing ST depression, heart rate at levels below that causing ST depression, angina, adequate controlled ventricular response of atrial angina, adequate controlled ventricular response of atrial fibrillation or acceptable suppression of exercise induced fibrillation or acceptable suppression of exercise induced arrhythmia. arrhythmia. (Gullested L. 1996)(Gullested L. 1996)

DiureticsDiuretics

1. Will decrease plasma volume, which is the opposite effect of 1. Will decrease plasma volume, which is the opposite effect of endurance training, which increases plasma volume, however endurance training, which increases plasma volume, however cardiac output may not be appreciably affected.cardiac output may not be appreciably affected.

2. Hypokalemia may occur. Potassium regulates the maintenance 2. Hypokalemia may occur. Potassium regulates the maintenance of muscle blood flow. During exercise, marked hypokalemia may of muscle blood flow. During exercise, marked hypokalemia may cause rhabdomyolysis and acute renal failure. cause rhabdomyolysis and acute renal failure.

3. Diuretics may also cause low magnesium, which can precipitate 3. Diuretics may also cause low magnesium, which can precipitate tetani and may cause hypocalcemia and further aggravate tetani and may cause hypocalcemia and further aggravate hypokalemia.hypokalemia.

4. Potassium sparing diuretics may obviously spare potassium and 4. Potassium sparing diuretics may obviously spare potassium and magnesium, however, frequent monitoring of serum potassium magnesium, however, frequent monitoring of serum potassium should be performed to exclude hyperkalemia.should be performed to exclude hyperkalemia.

5. Hyponatremia, dehydration and hypovolemia. Certainly 5. Hyponatremia, dehydration and hypovolemia. Certainly hyponatremia would also be more easily precipitated in excessive hyponatremia would also be more easily precipitated in excessive water drinkers who are “tanking up” for a long run.water drinkers who are “tanking up” for a long run.

Vasodilators and Central Alpha Vasodilators and Central Alpha BlockersBlockers

1. Vasodilators1. Vasodilators– Hydralazine – may cause edema and reflex tachycardia. Hydralazine – may cause edema and reflex tachycardia.

It is usually never used alone but in combination with a It is usually never used alone but in combination with a diuretic and/or beta-blocker and would be a poor choice diuretic and/or beta-blocker and would be a poor choice for someone exercising.for someone exercising.

2. Central Alpha Blockers2. Central Alpha Blockers– Clonidine – may cause fatigue, bradycardia and/or heart Clonidine – may cause fatigue, bradycardia and/or heart

block.block.

MiscellaneousMiscellaneous

1. Amiodarone – will decrease heart rate and long term, may cause 1. Amiodarone – will decrease heart rate and long term, may cause pulmonary complications leading to severe pulmonary insufficiency.pulmonary complications leading to severe pulmonary insufficiency.

2. Pacemaker – should be activity modulated and programmed to 2. Pacemaker – should be activity modulated and programmed to react to appropriate levels of exercise to avoid pacer syndrome, react to appropriate levels of exercise to avoid pacer syndrome, allow an adequate heart rate to be attained at peak exercise.allow an adequate heart rate to be attained at peak exercise.

3. Post exercise hypotension – all anti hypertensive exaggerate the 3. Post exercise hypotension – all anti hypertensive exaggerate the post exercise hypotensive response seen in normal subjects.post exercise hypotensive response seen in normal subjects.

4. HMG – CoA reductase – inhibitors (statins) can cause muscle 4. HMG – CoA reductase – inhibitors (statins) can cause muscle soreness. Rhabdomyolosis, increased skeletal muscle injury. soreness. Rhabdomyolosis, increased skeletal muscle injury.

(Thompson P. 1997)(Thompson P. 1997)

Cardiovascular DrugsCardiovascular Drugs

The cardiovascular drugs that have the most The cardiovascular drugs that have the most favorable profile would be the class of favorable profile would be the class of alpha blockers, ACE inhibitors and ARB’s – alpha blockers, ACE inhibitors and ARB’s – venodilators, nitrates and slow calcium venodilators, nitrates and slow calcium channel blockers with the exception of channel blockers with the exception of verapamil, which may cause a significant verapamil, which may cause a significant decrease in heart rate response at peak decrease in heart rate response at peak exercise. Also, of all the calcium channel exercise. Also, of all the calcium channel blockers, it is more likely to cause muscle blockers, it is more likely to cause muscle spasm or muscle fatiguespasm or muscle fatigue. .

Medications That May Medications That May Prohibit Hyper-Coagulable Prohibit Hyper-Coagulable

State Post-ExerciseState Post-ExerciseASAASABeta BlockersBeta BlockersStatinsStatinsACE InhibitorsACE Inhibitors

ASAASA Decreased platelet aggregationDecreased platelet aggregation Inhibit Cox-1 which produces Inhibit Cox-1 which produces

Thromboxane A-2Thromboxane A-2– Necessary for platelet aggregationNecessary for platelet aggregation

Decreased Tissue Factor in Decreased Tissue Factor in atherosclerotic plaquesatherosclerotic plaques

Lowers CRPLowers CRP

Beta BlockersBeta Blockers

Blocks adrenaline increase in Factor Blocks adrenaline increase in Factor VIIIVIII

Reduces sympathetic response to Reduces sympathetic response to exercise/arrhythmiasexercise/arrhythmias

Reduces oxidative stressReduces oxidative stress Reduces CRPReduces CRP

StatinsStatins Down regulation of coagulation Down regulation of coagulation

cascadecascade Beneficial effect on endothelial Beneficial effect on endothelial

dependent vasodilationdependent vasodilation Reduced Thrombin productionReduced Thrombin production Anti-inflammatory propertiesAnti-inflammatory properties May stabilize plaquesMay stabilize plaques Lowers CRPLowers CRP

Ace InhibitorsAce Inhibitors

Anti-inflammatory and anti-fibrotic Anti-inflammatory and anti-fibrotic propertiesproperties

Reduces Tissue Factor in Reduces Tissue Factor in atherosclerotic plaquesatherosclerotic plaques

Reduces CRPReduces CRP

Principles to Guide CV Therapy in Patients Principles to Guide CV Therapy in Patients Who are Moderate to Competitive in their Levels of Who are Moderate to Competitive in their Levels of

ExerciseExercise 11. Risk profile for all patients prior to starting exercise program.. Risk profile for all patients prior to starting exercise program.

2. Stress testing in patients who have multiple risk factors.2. Stress testing in patients who have multiple risk factors.

3. Aggressively treat diabetes, hypertension, hyperlipidemia.3. Aggressively treat diabetes, hypertension, hyperlipidemia.

4. Instruct patients not to ignore prodromal symptoms. 4. Instruct patients not to ignore prodromal symptoms.

5. Choose medications that are appropriate both for the patient’s 5. Choose medications that are appropriate both for the patient’s diagnosis yet are least likely to limit their activity.diagnosis yet are least likely to limit their activity.

6. Patient’s need to understand that they may need to readjust their 6. Patient’s need to understand that they may need to readjust their exercise levels that are safe for them, i.e., keep heart rate response exercise levels that are safe for them, i.e., keep heart rate response below angina or production of ST depression. Many times this is the below angina or production of ST depression. Many times this is the difficult part of the equation (tell a runner that he or she needs to slow difficult part of the equation (tell a runner that he or she needs to slow down.)down.)

7.Recommended heart rate monitors to all CV patients who exercise so 7.Recommended heart rate monitors to all CV patients who exercise so that they can stay within their acceptable heart rate zone. that they can stay within their acceptable heart rate zone.

Principles to Guide CV Therapy in Patients Principles to Guide CV Therapy in Patients Who are Moderate to Competitive in their Levels of Who are Moderate to Competitive in their Levels of

ExerciseExercise 8. Recommend that each patient carry an ID card with as much 8. Recommend that each patient carry an ID card with as much

medicalmedicalinformation as possible. This may include lists of drugs, information as possible. This may include lists of drugs, miniaturized copy of EKG, etc.miniaturized copy of EKG, etc.

9. Stress the importance of warm up and cool down to avoid 9. Stress the importance of warm up and cool down to avoid precipitation of angina and/or arrhythmia in the early stages of precipitation of angina and/or arrhythmia in the early stages of exercise and post exercise postural hypotension.exercise and post exercise postural hypotension.

10. It may be wise for the patient to have their own blood 10. It may be wise for the patient to have their own blood pressure cuff and frequently check their blood pressure and pressure cuff and frequently check their blood pressure and weight prior to and after exercise as during long endurance runs, weight prior to and after exercise as during long endurance runs, especially the morning of. It might also be wise to reduce the especially the morning of. It might also be wise to reduce the dosage of medications that are administered on a daily basis.dosage of medications that are administered on a daily basis.

11. Balancing exercise levels and CV meds is at least time 11. Balancing exercise levels and CV meds is at least time consuming and may require frequent visits for serial exercise consuming and may require frequent visits for serial exercise testing to determine the dosage or choice of these medications.testing to determine the dosage or choice of these medications.

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SummarySummaryIndividuals participating in long distance Individuals participating in long distance

running have a minimal risk for precipitation of acute running have a minimal risk for precipitation of acute cardiac events. This risk can probably be lowered by cardiac events. This risk can probably be lowered by taking proper precautions and following prudent taking proper precautions and following prudent recommendations. Addressing treatable risk factors recommendations. Addressing treatable risk factors and risk profiling patients prior to participation is and risk profiling patients prior to participation is paramount. Patients on cardiac medications need to paramount. Patients on cardiac medications need to be made aware of potential side effects, which may be made aware of potential side effects, which may be precipitated by exercise and the ability of these be precipitated by exercise and the ability of these medications to limit performance. Following these medications to limit performance. Following these principles, those with risk factors or known coronary principles, those with risk factors or known coronary artery disease, can reduce their risk for cardiac artery disease, can reduce their risk for cardiac events during exercise and participate at levels of events during exercise and participate at levels of exercise promoting fitness and endurance.exercise promoting fitness and endurance.

SummarySummary

Physicians treating this group of patients should be Physicians treating this group of patients should be able to recommend activity levels with able to recommend activity levels with hemodynamic parameters and prescribe hemodynamic parameters and prescribe cardiovascular medications both appropriate for cardiovascular medications both appropriate for the patient’s disease, yet preserving adequate the patient’s disease, yet preserving adequate hemodynamic response. Albeit a small cardiac hemodynamic response. Albeit a small cardiac risk will persist, especially in longer endurance risk will persist, especially in longer endurance events, which each participant needs to events, which each participant needs to understand. Further data needs to be collected to understand. Further data needs to be collected to increase understanding of these risks. Hopefully, increase understanding of these risks. Hopefully, future findings will assist in the reduction of acute future findings will assist in the reduction of acute cardiac events related to exercise. cardiac events related to exercise.

HypothesisHypothesis

Patients with known stable CAD Patients with known stable CAD who are receiving optimal who are receiving optimal medical treatment may be a medical treatment may be a lower risk for cardiovascular lower risk for cardiovascular events than a similar events than a similar age/gender groups during and age/gender groups during and in the one hour post-exercise in the one hour post-exercise periodperiod

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Suggested ReadingSuggested Reading

1. ACSM’s Guide for Exercise Testing and 1. ACSM’s Guide for Exercise Testing and Prescription—Eighth Edition. 2010. Lippincott Prescription—Eighth Edition. 2010. Lippincott Williams and Wilkins.Williams and Wilkins.

2. Thompson PD: Exercise and Sports Cardiology. 2. Thompson PD: Exercise and Sports Cardiology. 2001. McGraw Hill. 2001. McGraw Hill.