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Progressive Resistance Training

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  • 1. Progressive Resistance Training Use in Cardiovascular Disease and Safety Considerations Professor Maria A. Fiatarone Singh, MD, FRACP
  • 2. Introduction and Background
    • Progressive resistance training may be used in individuals at high risk for cardiovascular disease
    • Progressive resistance training may be used in individuals with coronary artery disease, hypertension, congestive heart failure, cardiac rehabilitation following heart surgery, and cardiac transplantation
  • 3. Benefits of PRT in Cardiovascular Disease
    • Reduction in cardiac risk factors:
      • hypertension,
      • visceral obesity,
      • hyperinsulinemia,
      • insulin resistance,
      • dyslipidemia,
      • sedentariness
  • 4. Benefits of PRT in Cardiovascular Disease
    • Improvement in ischemic symptoms:
      • claudication
      • angina
    • Less need for medications:
      • angina
      • diabetes
      • hypertension
      • lipid lowering agents
      • depression
  • 5. Benefits of PRT in Cardiovascular Disease
    • Improvement in peripheral skeletal muscle morphology and function:
      • mass,
      • strength,
      • oxidative capacity,
      • glycogen storage,
      • glucose transport
      • blood flow,
      • amino acid uptake and protein synthesis,
      • A/V O 2 extraction
  • 6. Benefits of PRT in Cardiovascular Disease
    • Improvement in functional and exercise capacity:
      • increased submaximal and maximal cardiovascular exercise capacity
      • increased anerobic threshold
      • decreased double product (HR x SPBP)
      • decreased perceived exertion
      • improved performance of activities of daily living
  • 7. Benefits of PRT in Cardiovascular Disease
    • Antidote to glucocorticoid side-effects in organ transplant recipients:
      • myopathy
      • osteopenia
  • 8. PRT after cardiac transplantation: effect on muscle mass Braith, MSSE 30:483-89 1998
  • 9. Benefits of PRT in Cardiovascular Disease
    • Improvement in psychological function:
      • depressive symptoms,
      • self-efficacy
  • 10. Permanent cardiovascular contraindications to PRT
    • End stage congestive heart failure
    • Inoperable critical aortic stenosis
    • Uncontrolled malignant arrhythmias
    • Unstable angina at rest
    • Inoperable aortic or cerebral aneurysm
    • Severe proliferative diabetic retinopathy
  • 11. Potential cardiovascular risks of PRT
    • Hypertension
    • Hypotension
    • Arrhythmias
    • Ischemia
    • Aneurysm leak or rupture
    • Hemorrhage
    • Retinal hemorrhage, worsening of proliferative retinopathy
  • 12. Potential cardiovascular risks of PRT
    • Hypertension
      • Acutely , PRT increases systolic and diastolic BP, MAP, Total peripheral resistance
      • Chronically PRT has a sustained effect to reduce systolic and diastolic BP for at least 24 hrs post-exercise
      • PRT may be initiated in controlled hypertensives in concert with other RX
      • Uncontrolled hypertension should be treated prior to the initiation of PRT
  • 13. Blood pressure monitoring during leg press 1RM: 72 yo with type 2 diabetes
  • 14. Blood pressure monitoring during seated row 1RM: 72 yo with type 2 diabetes
  • 15. Blood pressure response to PRT
    • Rapid rise in systolic and diastolic blood pressure with onset of isometric or concentric contraction
    • Fall in blood pressure during eccentric contraction; to baseline or below within 1-2 seconds of release of contraction
    • Normal levels during rest intervals between sets
  • 16. Magnitude of blood pressure response to PRT
    • Increase proportional to:
      • Relative load (%MCV or %1RM)
      • Size of muscle mass involved (variable)
      • Duration of contractions
      • Onset of muscular fatigue
      • Use of isometric handgrip
      • Use of Valsalva maneuver (attempting to exhale against a closed glottis)
  • 17. Potential cardiovascular risks of PRT
    • Hypotension during exercise
      • May reflect left main coronary artery disease, dehydration, venous pooling, autonomic neuropathy, cardiac denervation, cardiac failure, critical aortic stenosis, bradycardia, heart block, drug effect
      • Do not start or continue PRT if this occurs until consultation with physician
  • 18. Prevention of Hypotension during PRT
    • Dehydration
    • Venous pooling
      • Cardiac transplant
      • Autonomic neuropathy
      • Diabetes
      • Drugs
    • Maintain fluid intake
    • Walk between exercises;alternate arms and legs; maintain normal breathing pattern; perform standing calf raises, avoid overhead press; end session with 5-min cool down walk
  • 19. Potential cardiovascular risks of PRT
    • Arrhythmias:
      • Ventricular or atrial arrhythmias may occur with increased myocardial oxygen demand (double product)
      • Lower HR during PRT compared to aerobic exercise may reduce relative risk
      • May indicate ischemia, electrolyte disturbance, fluid imbalance, heart failure, other systemic disease
  • 20. Potential cardiovascular risks of PRT
    • Ischemia:
      • Elevation of diastolic pressure and modest increase in heart rate may reduce risk relative to aerobic exercise:
        • Coronary perfusion pressure maintained during diastole (better supply)
        • Myocardial oxygen demand lower than during aerobic exercise (such as stairclimbing)
  • 21. No cases of myocardial infarction, angina, or sudden death in literature during PRT (including CAD and CHF patients) Over 26,000 subjects undergoing 1RM testing every 2 years at Cooper Clinic and Univ Florida: No cardiovascular events
  • 22. Strong Medicine Unit Balmain Hospital, Sydney 1999-2002
    • Over 8,000 individual training sessions in elderly subjects with chronic disease
    • No significant cardiovascular events
    • 2,000 muscle strength testing sessions
    • No significant injury
    • 3 falls, no fracture, one heart block on testing
  • 23. Potential cardiovascular risks of PRT
    • Aneurysm leak or rupture:
      • Rise in mean arterial pressure predisposes to dissection/rupture
      • Aortic aneurysm which is > 5cm in transverse diameter is at greatest risk of rupture
      • Repaired aneurysms not a contraindication to exercise training (aerobic or resistive)
      • Case reports of subarachnoid hemorrhage associated with weight lifting may have been intracerebral aneurysms (1% of population)
  • 24. Potential cardiovascular risks of PRT
    • Hemorrhage
      • Patients at risk:
        • anticoagulation/aspirin for atrial fibrillation, valve replacement, stroke, venous thrombosis, cardiac prophylaxis or surgery
      • Soft tissue injury due to pressure of weight machines or free weights
      • Fall
      • Muscle or ligament tear during contraction
  • 25. Potential cardiovascular risks of PRT
    • Retinal hemorrhage, worsening of proliferative retinopathy:
      • Position stands proscribe strenuous aerobic activity or weight lifting in severe proliferative diabetic retinopathy
      • Case reports of hemorrhage or retinal detachment; no rigorous studies
      • Intraocular pressure proportional to mean arterial pressure (MAP)
  • 26. Minimizing risk of ocular complications, elevated intraocular pressure
    • Avoid direct trauma to eye
    • Keep head above level of heart
    • Avoid high impact, jarring activities
    • Minimize IOP by lowering load, avoiding sustained isometric contractions, Valsalva maneuver
    • No strenuous exercise early after laser or other ocular surgery (? 2 wks)
  • 27. General PRT training principles to minimize cardiovascular risks
    • No Valsalva maneuver during lifts
    • No breath holding
    • No isometric contractions
    • No sustained contractions
    • Increase rest intervals between repetitions
    • Keep load between 60 and 80% of 1RM
    • No sets “to fatigue”
  • 28. PRT training principles to minimize cardiovascular risk
    • No training if:
      • New onset chest pain
      • Unstable angina
      • Uncontrolled arrhythmias
      • Uncontrolled hypertension
      • Untreated aortic or other aneurysm
      • Overanticoagulation
      • Recent MI or cardiac surgery until cleared
      • Recent intracerebral hemorrhage until cleared
      • Severe proliferative retinopathy
      • Recent ophthalmologic surgery until cleared
  • 29. Summary
    • PRT is indicated in the prevention and treatment of cardiovascular disease
    • Stable patients with CAD, CHF, Hypertension, Peripheral vascular disease, Diabetes, Stroke, Organ transplant are candidates for PRT
    • Standard PRT principles which should be used in all individuals minimize cardiovascular risk