Effect of Exercise on CVS and Exercise Rx.pptx

Effect of Exercise on Cardiovascular System
and Exercise Prescription
Presented by-
Soniya Lohana
II MPT
Department of Sports Physiotherapy
12/16/2022 1
Effect of Exercise on CVS & Exercise Rx

Contents
Introduction
Basic Overview of Cardiovascular System
Effect of Exercise on Cardiovascular System and its components
Exercise Prescription
Evidences
12/16/2022 2

Introduction
The cardiovascular system serves a number of important functions in the body
and supports every other physiological system.
The major cardiovascular functions are:
• Delivery of oxygen and other nutrients
• Removal of carbon dioxide and other metabolic waste products
• Transport of hormones and other molecules
• Support of thermoregulation and control of body fluid balance
• Maintenance of acid–base balance
• Regulation of immune function
12/16/2022 3

Human Heart
12/16/2022 Effect of Exercise on CVS & Exercise Rx 4

Effects of Exercise on Cardiovascular System
• With exercise, oxygen demands by the active muscles increase significantly.
• Therefore, more nutrients are used, metabolic processes speed up, body
temperature rises.
• Primary goal is increased flow to working muscle by altering cardiovascular
control in every tissue.
12/16/2022 5

Cardiovascular Responses Vs Adaptations
RESPONSES ADAPTATIONS
• Short term
•Physiology
•Function
•Long term
•Anatomy
•Structure

CVS
HR
SV
CO
BP
BLOOD
FLOW
BLOOD
12/16/2022 7
From rest to exercise, changes occur in all of the following components

Heart Rate responses during Acute Exercise
• Resting Heart Rate (RHR) – 60-80 beats/min
In highly conditioned endurance athletes, low as 28-40 beats/min
Can also be affected by environmental factors
• HR increases directly in proportion to the increase in exercise intensity
• Anticipatory Response
- Increase in Heart Rate just prior to initiation of exercise
- Physiological Preparation of Exercise
- Release of nor-epinephrine- Sympathetic nervous system

EXERCISE INTENSITY HEART RATE

Maximum Heart Rate (HRmax)
- Highest HR value achieved in an all-out effort to the point of volitional fatigue.
-Constant but can change year to year due to normal age related decline.
HRmax = 220-Age in years or HRmax = 208-(0.7 × Age in years)
Steady State Heart Rate
-When exercise intensity held constant at any sub maximal workload, HR increases rapidly
until it reaches a plateau.
- With each subsequent increase in intensity, reaches new value within 2-3 min.
- Lower steady state HR at a fixed exercise intensity- valid predictor of greater
cardiorespiratory fitness

Adaptations in Heart Rate
• RHR – decreases by approx 1 beat/ min with each week of aerobic training
for few weeks after which it rapidly decreases.
Training appears to increase parasympathetic activity in the heart while
decreasing sympathetic activity.
• Training induced bradycardia vs pathological bradycardia
• HRmax- typically remains unchanged; lower in trained athletes than untrained
• Heart Rate Recovery- The time taken for HR to return to its resting rate.

12/16/2022 Sports Psychology 13
Title: High Intensity Interval Training Leads to Greater Improvements in Acute Heart Rate Recovery and
Anaerobic Power as High Volume Low Intensity Training
Thomas L. Stöggl et al. 2017
Aim: To explore if training regimes utilizing diverse training intensity distributions result in different
responses on neuromuscular status, anaerobic capacity/power and acute heart rate recovery (HRR) in well-
trained endurance athletes.
Methods: Thirty-six participants (male [n = 33] and female [n = 3]) runners, cyclists, triathletes and cross-
country skiers [peak oxygen uptake: (VO2peak): 61.9 ± 8.0 mL·kg−1·min−1] were randomly assigned to one
of three groups (blocked high intensity interval training HIIT; polarized training POL; high volume low
intensity oriented control group CG/HVLIT applying no HIIT). A maximal anaerobic running/cycling test
(MART/MACT) was performed prior to and following a 9-week training period.
Conclusion: Only a training regime that includes a significant amount of HIIT improves the neuromuscular
status, anaerobic power and the acute HRR in well-trained endurance athletes. A training regime that
followed more a low and moderate intensity oriented model (CG/HVLIT) had no effect on any performance
or HRR outcomes.

Title: Maximal rate of heart rate increase correlates with fatigue/ recovery status in female cyclists
Maximillian J. Nelson et al. 2017
Aim: The maximal rate of heart rate increase (rHRI), a marker of heart rate acceleration has been shown to
correlate with performance changes in response to changes in training load in male athletes; however, it
has not been established if it also correlates with performance changes in female athletes.
Methods: rHRI and cycling performance were assessed in six female cyclists following 7 days of light
training (LT), 14 days of heavy training (HT) and a 10 day taper period. rHRI was the first derivative and was
recorded during 5 min of cycling at 100 W. Cycling performance was assessed as work done (kJ) during time-
trials of 5 (5TT) and 60 (60TT) min duration.
Conclusion: rHRI during the transition from rest to light exercise correlates with training induced-changes in
exercise performance in females, suggesting that rHRI may be a useful monitoring tool for female athletes.

Title: Heart rate recovery in elite athletes: the impact of age and exercise capacity
Jelena Suzic Lazic, 2015
Aim: To determine HRR after maximal exercise among elite athletes with respect to age.
Methods: A total of 274 elite male Caucasian athletes were randomly selected from the larger sample and
divided into two groups: adolescent (group Y) and adult athletes (≥18 years; group A). They performed
maximal cardiopulmonary exercise testing on a treadmill. Heart rate recovery was calculated as the rate of
decline of HR from peak exercise to rates 1, 2 and 3 min after cessation of exercise (HRR1, HRR2 and
HRR3).
Conclusion: The HRR during 3 min post-exercise should be reported for the purpose of better assessing
functional adaptation to exercise among elite athletes as well as the age associated differences in recovery.
Higher values of HRR1 should be expected in older athletes, and HRR3 could be used as an index of aerobic
capacity, irrespective of age.

Stroke Volume Responses
Volume of blood pumped out of left ventricle during systolic
cardiac contraction
Determined by
• Volume of venous blood returned to heart
• Ventricular distensiblity
• Ventricular contractility
• Aortic/ Pulmonary artery pressure
End-Diastolic Volume
PRE-LOAD
AFTER-LOAD

Exercise
Large volume of blood
during diastole
(increased
preload/EDV)
Increased
stretch in
ventricular walls
More forceful
contraction to
eject greater
volume of blood
Frank-Starling Mechanism

INCREASE IN
STROKE
VOLUME
MYOCARDIAL/VENTRICULAR
CONTRACTILITY
VENTRICULAR
VOLUME/VENOUS RETURN
EXERCISE
60 TO 70 ML/BEAT
AT REST
110 TO 130 ML/BEAT
DURING MAXIMAL
EXERCISE.
12/16/2022 18
AFTERLOAD/ TOTAL
PERIPHERAL RESISTANCE

Stroke Volume Adaptations
• Increased End Diastolic Volume (EDV) caused by increased plasma volume
and greater diastolic filling time secondary to lower heart rate.
• Increased Left Ventricular force of Contraction – hypertrophy of cardiac
muscle, increased ventricular stretch from increased pre-load, leading to
greater elastic recoil.
• Reduced systemic Vascular resistance (decreased afterload) contributes to
increased volume of blood pumped from LV with each beat.

Title: Assessment of Exercise Stroke Volume and Its Prediction From Oxygen Pulse in Paralympic Athletes
With Locomotor Impairments: Cardiac Long-Term Adaptations Are Possible
Marco Bernardi et al. 2020
Aim: To compare two groups of PAthl, one with SCI and the other with either amputation (AMP) or post
poliomyelitis syndrome (PM), assessing the (1) peak cardiorespiratory responses and determinants (SV and
HR) of CO during maximal and submaximal arm cranking exercise (ACE), respectively; (2) correlations
between peak oxygen uptake (VO2peak) and the highest SV obtained during submaximal exercise; and (3)
correlations between oxygen pulse (O2 pulse, ratio between VO2 and HR) and both SV and O2 arterio-
venous difference [(a-v)O2diff].
Methods: Each athlete (19 PAthl with SCI, 9 with AMP, and 5 with PM) completed a continuous incremental
cardiopulmonary ACE test to volitional fatigue to assess peak responses. In a different session, CO was
indirectly measured through carbon dioxide (CO2) rebreathing method at sub-maximal exercise intensities
approximating 30, 50, and 70% of the VO2peak.
Conclusion: In PAthl with different HCs: (1) significant differences, as a consequence of the different HC,
exist in the determinants of CO at maximal and submaximal ACE; (2) SV is a significant determinant of
VO2peak, suggesting cardiac adaptations possible also in PAthl with SCI; and (3) SV can be predicted from
O2 pulse measurements during submaximal exercise in both groups of PAthl.

Cardiac Output Responses
• Cardiac Output is the product of heart rate and stroke volume
• Resting cardiac output= 5.0L/min but varies in proportion to the size of the person.
• Maximal cardiac output= 20L/min in sedentary individuals to 40 or more L/min in
elite endurance athletes.
• Maximal cardiac output is the function of both body size & endurance training.
• Major function of it is to meet the muscle’s increased demand for oxygen.
• VO2max is ultimately limited by inability of cardiac output to increase further.
(Q=HR × SV)

Exercise
Begins
Increase in
SV
Skeletal
Muscles
Oxygen
Delivery
Sympathetic
Stimulation
Of Vessels
Overall
Vasodilation
In The
Muscle
Increase in
Cardiac
Output
12/16/2022 24

Cardiac Output Adaptations
• Does not change much following endurance training because SV and HR
reciprocally compensate.
• However, may cardiac output may decrease slightly due to increase in (a-v)O2
difference (greater oxygen extraction by tissues) or decrease in rate of
oxygen consumption (increased mechanically efficiency)
• Maximal cardiac output increases considerably and is largely responsible for
increase in V02max – from 14-20L/min in untrained individuals to 25-35L/min
in trained individuals to 40L/min in highly conditioned endurance athletes.

Title: Oral Consumption of Vitamin K2 for 8 Weeks Associated With Increased Maximal Cardiac Output
During Exercise
Brian K. McFarlin et al. 2017
Aim: To determine if 8 wk of dietary supplementation with Vitamin K2 could alter cardiovascular responses to
a graded cycle ergometer test.
Methods: A randomized controlled trial was conducted in the Applied Physiology Laboratory of the
Department of Biological Sciences at the University of North Texas (Denton, TX, USA). Participants were
aerobically trained males and female athletes (N = 26). Participants were randomly assigned either to a control
group that received a rice flour placebo or to an intervention group that received vitamin K2. For weeks 1 to 4,
participants received 300 mg/d; for weeks 5 to 8, they received 150 mg/d. Subjects assigned to the control
group received similar doses to mirror the intervention group. Subjects consumed the supplements during an
8-wk period while they maintained their typical exercise habits. GXT was conducted on electronically braked
cycle ergometer.
Conclusion: Vitamin K2 supplementation was associated with a 12% increase in maximal cardiac output, with
with a trend toward an increase in heart-rate AUC. No significant changes occurred in SV. Although vitamin K2
supplementation has previously been reported to improve cardiovascular function in diseased patients, the
current study is the first to report its potential in active individuals. More research is needed to fully evaluate
the potential effects of the observed effects.

Title: Blunted Cardiac Output from Overtraining Is Related to Increased Arterial Stiffness.
Alexandra M. Coates et al. 2018
Aim: To assess changes in arterial stiffness and central hemodynamics, and their relationship to exercising
SV, after 3 wk of overload training.
Methods: Twenty-six cyclists and triathletes completed 3 wk of either regular training (CON; n = 13) or
overload training (OL; n = 13).Testing took place before (PRE) and after regular or overload training (POST).
Resting measures included brachial blood pressure, HR, carotid–femoral pulse wave velocity (PWV) to
assess arterial stiffness, and carotid pulse wave analysis to assess wave reflections and central
hemodynamics. An incremental cycle test was used to assess peak power,maximal HR, and maximal lactate
to assess overtraining status. Cardiac output (Q˙ ), SV, and HR were assessed using cardiac impedance.
Conclusion: Overload training results in increased resting arterial stiffness and reduced SV during exercise,
with no changes to resting central hemodynamics.

The Integrated Cardiac Response to Exercise
Reclining Seated Standing Walking Jogging Fast-paced running
HR- 50 bpm - 55bpm - 60bpm
• SV- lying to standing- gravity causes blood to pool in legs reducing venous blood return
and thus decreased SV.
• To compensate HR increases to maintain cardiac output (Q=HR × SV)
HR- 60bpm - 90bpm - 140bpm - 180bpm
• When level of exercise exceeds 40%-60% of individual’s maximal exercise capacity, SV
either plateaus or continues to increase at much slower rate.
• Q determined by increase in HR and SV in highly trained athletes.

Blood Pressure Responses
• Systolic blood pressure(SBP) increases in direct proportion to the increase
in exercise intensity.
• Diastolic pressure(DBP) does not change significantly and may even
decrease
• Increased SBP aids in substrate delivery to working muscles.
• After increasing initially, mean arterial pressure reaches a steady state
during sub-maximal steady state endurance exercise. If prolonged, SBP
might start to decrease gradually though DBP remains constant. This occurs
due to total peripheral resistance (TPR)

DURING
EXERCISE SBP
AS
INCREASE
IN
EXERCISE
INTENSITY
CO
CAN
EXCEED 200
mmhg
240 TO 250
mmhg in
ATHLETES.
MEAN
ARTERIAL
BP
12/16/2022 30

DBP
INCREASE IN
DBP 15 MMHG
OR MORE
CVD
STOPPING
DIAGNOSTIC
EXERCISE
TEST.
12/16/2022 31

Blood Pressure Adaptations
• Resting blood pressure generally is reduced by endurance training in those
with borderline or moderate hypertension but not in healthy, normotensive
subjects.
• Reductions in both systolic and diastolic blood pressure of approximately 6 to 7
mmHg may result in hypertensive subjects.
• Following endurance training, BP is reduced at a given submaximal exercise
intensity; but at maximal exercise capacity, SBP is increased and DBP is
decreased.
• Resistance exercise can cause large transient increase in both SBP & DBP during
heavy weight lifting, it does not affect resting blood pressure

Title: Blood pressure response to maximal dynamic exercise testing in an athletic population
Axel Pressler et al. 2018
Aim: Exaggerated blood pressure (BP) response to exercise testing has been linked to left ventricular
hypertrophy and myocardial fibrosis in competitive athletes. Due to frequent training, athletes are
particularly exposed to high BP levels, but data on the magnitude and distribution of BP response to exercise
in athletic populations is scarce.
Methods: Cycle ergometry was performed in 2419 healthy competitive adolescent, professional and master
athletes (age 12-26 years, range 9-74, 27% women, 84 disciplines) for pre-participation screening. Fulfilling
both subjective and at least two out of three objective exhaustion criteria (maximal heart rate >85%
predicted, lactate 7 mmol/l, rate of perceived exertion 17) was required. Echocardiography was also
performed.
Conclusion: SBP response to exercise testing is markedly exaggerated particularly in male endurance
athletes. The prognostic significance of these findings regarding long term cardiovascular alterations requires
further clarification

Title: The Effect of Tempo of Musical Treatment and Acute Exercise on Vascular Tension and Cardiovascular
Performance: A Case Study on Trained Non-Athletes
Sugiharto et al. 2018
Aim: To investigate the fundamental correlation between musical tempo and physiological response particularly
on vascular tension and cardiorespiratory activity in the trained non-athletes.
Methods: This pre-posttest randomized design study involving non-athletes with age ranged from 19-21 years
old, resting cardiac 60-80 beat/minute, maximal oxygen consumption (VO2 max) 37- 49 ml/KgBW, average body
mass index (BMI) and hemoglobin level (Hb), and without smoking history. The experimental data were collected
from 60 participants that divided into four criteria. The placebo was treated with high exercise in the acute
model while another group was exposed by moderate exercise with fast and slow musical tempo during
treatment for 20 minutes. The monitoring of vascular tension and cardiovascular performance were done by
using standardized clinical test.
Conclusion: Co-treatment of slow beat musical and acute moderate exercise can reduce the progression of
hypertension in the trained non-athletes.

Blood Flow Responses
• Acute increases in cardiac output and BP during exercise causes increased
total blood flow to the body.
• Increased blood to areas where needed, primarily the exercising muscles.
• Sympathetic control of the cardiovascular system redistributes blood so
that areas with greatest metabolic need receive more blood than areas
with low demands.

Redistribution of Blood During Exercise

EXERCISE BEGINS
SYMPATHATIC
STIMULATION
OF VESSELS
ACTIVE
SKELETAL
MUSCLES
INCREASE IN
pH,CO2, TEMP
METABOLIC
RATE INCREASE
DURING
EXERCISE
VASOCONSTRICTION
OXYGEN
DELIVERY
MORE CO
TRIGGER
VASODILATION
INCREASED
BLOOD FLOW
12/16/2022 39

Blood Flow Adaptations
With endurance training, the cardiovascular system adapts to increase blood
flow to exercising muscles to meet their higher demand for oxygen and
metabolic substrates.
Four factors account for this enhanced blood flow to muscle following training:
• Increased capillarization- new capillaries
• Greater recruitment of existing capillaries
• More effective blood flow redistribution from inactive regions
• Increased total blood volume

Responses of Blood
• Carries oxygen and nutrients to the tissues and clears away waste products of
metabolism.
• With exercise, more oxygen is required by the active muscles therefore more
oxygen is extracted from the blood by increase in (a-v)O2 difference as venous
concentration decreases.
• 10% to 15% reduction in plasma volume as plasma is pushed out of the capillaries
by increased hydrostatic pressure as BP rises and fluid is drawn to the muscles.
• Haemoconcentration occurs as plasma decreases where relative number of RBC’s
per unit blood increases, increasing the oxygen carrying capacity.

Adaptations of Blood
• Total blood volume – Increased by endurance training increases; rapid and
larger effect at higher training intensities.
• Plasma Volume- increase in plasma protein, particularly albumin.
• Red Blood Cells - Although the actual number of RBC’s increase, the
hematocrit may actually decrease causing pseudoanemia.
• Reduced blood viscosity – smooth flow, enhances oxygen delivery to active
muscles
• Turnover rate of RBC’s – higher with intense training.
Plasma Protein
Concentration
Oncotic
Pressure
Fluid
reabsorbed
from interstitial
fluid into blood
vessels
Exercise
increase release
of antidiuretic
hormone &
aldosterone
Reabsorption of
water and
sodium in the
kidneys
Increased blood
plasma

Title: Hemodynamics of post-exercise versus post-hot water immersion recovery
Michael A. Francisco et al. 2021
Aim: This study aimed to compare the hemodynamics of the recovery periods following exercise versus hot
water immersion.
Methods: 12 subjects (6 women, 22.7 ± 0.8 yr; body mass index: 21.8 ± 2.1 kg/m2) exercised for 60min at 60%
VO2 peak or were immersed in 40.5C water for 60min on separate days, in random order. Measurements
were made before, during, and for 60-min post intervention (i.e., recovery) and included heart rate, arterial
pressure, core temperature, and subjective measures. Brachial and superficial femoral artery blood flows
were assessed using Doppler ultrasonography and cardiac output was measured using the acetylene wash-in
method.
Conclusion: Acute hot water immersion may provide similar or greater vascular changes during the hour
following the intervention compared with acute exercise, but with a less taxing cardiac workload during the
intervention.

Heart Size
• As an adaptation to the increased work demand, cardiac muscle mass and ventricular
volume increases with training.
• Training-induced cardiac hypertrophy, is a normal adaptation to chronic endurance
training.
• The left ventricle, has increased demands place on it and thus undergoes the greatest
adaptation in response to endurance training. The type of ventricular adaptation
depends on the type of exercise training performed.
• In runners, cyclists and strength athletes internal diameter of left ventricle (LVID),
total left ventricular mass(LVM), mean wall thickness (MWT) were greater.

Athlete’s Heart
• Regular participation in sport is associated with modest increase in
ventricular wall thickness and cavity size as well as end diastolic filling.
• This reversible physiological cardiac remodeling enables enhanced left
ventricular filling & helps in production of large SV even at rapid heart rate
for sustained increase in cardiac output.

Title: Influence of Vigorous Physical Activity on Structure and Function of the Cardiovascular System in Young
Athletes—The MuCAYA-Study
Lisa Baumgartner et al. 2019
Aim: Junior athletes exercise between 10 and 20 h a week with intensities exceeding moderate levels by far. The
cardiovascular system has to increase its work 5-6 times compared to moderate intensities. This may result in potentially
pathological adaptations of the cardiovascular system.
Methods: Children and adolescents, 7–18 years, presenting for their annual pre-participation screening at the Institute of
Preventive Pediatrics, Faculty of Sports and Health Sciences, Technical University of Munich (TUM), were examined in
this prospective cross-sectional study. Vascular parameters measured by ultrasound are carotid intima-media thickness
(cIMT), vascular stiffness, and the vascular diameter (D) to calculate the IMT:Diameter-Ratio (IDR). Cardiac function is
evaluated by a 12-lead ECG, and echocardiographic parameters (end-diastolic left ventricular diameter, left ventricular
diastolic posterior wall thickness, diastolic septal thickness, left ventricular mass and relative wall thickness, ejection fraction,
and shortening fraction). A cardiopulmonary exercise test was performed on a bicycle ergometer, muscular strength is
assessed with the handgrip test, and physical activity with the MoMo questionnaire.
Conclusion: The positive influence of physical activity on the cardiovascular system is affected by negative adaptations of
intensive training stimuli and years of intensive endurance exercise in adults. This is reflected by changes in myocardial
morphology and myocardial function as well as vascular structure and vascular function. In young athletes, increased wall
thickness and increased lumen of the left ventricle were observed. This raises the question whether there is too much
exercise from a cardiovascular point of view

The cardiovascular system after exercise
Steven A. Romero et al. 2017
• Recovery of the cardiovascular system after exercise occurs across a period of minutes to hours, during
which many characteristics of the system, even how it is controlled, change over time. Some of these
changes may be necessary for long-term adaptation to exercise training, yet some can lead to
cardiovascular instability during recovery. Furthermore, some of these changes may provide insight
into when the cardiovascular system has recovered from prior training and is physiologically ready for
additional training stress.
• This review focuses on the most consistently observed hemodynamic adjustments and the underlying
causes that drive cardiovascular recovery and will highlight how they differ following resistance and
aerobic exercise and to what extent these can guide an athlete’s training.
• In Conclusion, The cardiovascular system after exercise exists in a physiologic state that differs from both
rest and exercise. It has a physiology of its own, including the phenomena of post exercise hypotension,
sustained post exercise vasodilation, and activation of a histamine signaling pathway.
•

Screening Prior to Participation
• Goal of screening: Early detection of occult CVS disorder as many of these
conditions could be effectively managed through activity modification and
medical intervention to decrease risk of sudden cardiovascular death (SCD)
• Potential triggers for exercise induced fatal arrhythmia include surges in
catecholamine levels, dehydration, electrolyte imbalances & increased
platelet aggregation.
• In sports where isometric stress is a significant component, participation is
prohibited. (power-lifting, wrestling, judo, sprinting, rowing & canoeing)

EXERCISE PRESCRIPTION

Principles of Exercise Prescription
FITT-VP
• Frequency (how often)
• Intensity (how hard)
• Time (duration or how long)
• Type (mode or what kind)
• Volume (amount)
• Progression (advancement)
Reference: ACSM Guidelines for Exercise Testing and Prescription- 10th edition

• The optimal exercise prescription should address cardiorespiratory (aerobic)
fitness (CRF), muscular strength and endurance, flexibility, body composition,
and neuromotor fitness.
• A single exercise session should include the following phases:
oWarm-up
oConditioning and/or sports-related exercise
oCool-down
oStretching

Title: High blood pressure response to exercise predicts future development of hypertension in young athletes
Stefano Caselli et al. 2018
Aim: Due to superior exercise performance, athletes show higher blood pressure (BP) at peak exercise
compared to untrained individuals. Thus, higher reference values for peak exercise systolic and diastolic BP were
reported specifically for athletes. However, the prognostic significance of high blood pressure response (HBPR)
to exercise has not yet been clarified.
Methods & Results :141 normotensive athletes with HBPR to exercise were compared to 141 normotensive
athletes with normal blood pressure response (NBPR) to exercise, matched for gender, age, body size, and type of
sport. All athletes were followed up for 6.5 ± 2.8 years. Athletes were evaluated with clinical evaluation (BP,
ECG), Exercise testing and Echocardiography. Over follow-up, no cardiac events occurred; 24 athletes were
diagnosed essential hypertension (8.5%). Specifically, 19 (13.5%) belonged to the HBPR compared with 5 (3.5%)
in the NBPR group (P = 0.003).
Conclusion: The present study showed that an exaggerated BP response to exercise increased the risk for
incident hypertension in highly trained and normotensive athletes over a middle-term period.

Exercise Prescription for Individuals with Hypertension
Aerobic Resistance Flexibility
Frequency 5-7 days/week 2-3 days/week ≥2-3 days/week
Intensity Moderate intensity (i.e.
40%-59% VO2R or HRR,
RPE 12-13 on a 6-20 scale)
60%-70% 1 RM; may
progress to 80% 1RM.
Stretch to the point of
feeling tightness or slight
discomfort
Time ≥30 min/day of
continuous exercise. If
intermittent begin with
minimum of 10 min bouts
2-4 sets of 8-12
repetitions for each of the
major muscle groups
Hold static stretch for 10-
30 secs; 2-4 repetitions of
each exercise
Type Prolonged rhythmic
activities using large
muscle groups (walking,
cycling, swimming)
Resistance machines, free
weights, and/or body
weight
Static, dynamic and/or
PNF stretching.

Exercise Recommendations for the Athlete With Coronary Artery Disease
Prashant Rao & David Shipon
Aim: A framework for formulating exercise prescriptions for those with CAD
in order to achieve the “optimal” dose of exercise for each individual.
Recent findings
Multiple epidemiological studies demonstrate that exercise is inversely
associated with atherosclerotic coronary artery disease (CAD), yet the risk of
an acute coronary event is transiently elevated during vigorous exercise. In
turn, CAD is the most common cause of exercise-related sudden cardiac
death (SCD) in older athletes. When prescribing exercise recommendations
for athletes with CAD, we should maintain equipoise between the benefits
derived from sports participation and the risk of an adverse cardiac event.
Summary
Athletes are not immune from atherosclerotic CAD, and we should perform
risk assessments regardless of physical and athletic prowess.
Cardiopulmonary exercise testing may be a useful tool to develop
individualized exercise regimens for athletes with CAD.

• High intensity interval training (HIIT) is a type of training that has become
increasingly popular in the general population and has long been a form of
exercise that competitive athletes have used to improve performance.
• Among patients with stable coronary heart disease on evidence-based therapy,
HIIT performed during supervised cardiac rehabilitation achieved a greater
improvement in peak exercise capacity and submaximal endurance compared to
moderate-intensity continuous training.
• However, there is a paucity of data in relation to HIIT in athletes with CAD
exercising in an unsupervised setting, and we would limit its prescription to be
performed under supervision. In addition, we would avoid this training modality
altogether if there was evidence of inducible ischemia until further studies are
performed.

• All athletes however, much like the general population, should undergo a
medically supervised, exercise-based cardiac rehabilitation program after
an acute coronary syndrome or revascularization procedure.
• Specific to athletes recovering from myocardial infarction, the size of infarct,
and extent of myocardial scar are important considerations to guide the
timing and intensity of an exercise program.

Exercise Prescription for Out-patient Cardiac Rehabilitation
Aerobic Resistance Flexibility
Frequency Minimally 3 days/week
Preferably ≥5 days/week
2-3 nonconsecutive
days/week
≥2-3 days/week with daily
being most effective
Intensity With an exercise test- 40%-
70% VO2R or HRR or VO2peak.
Without exercise test, use
seated or standing HRrest+ 20-
30 bpm
Perform 10-15 repetitions of
each exercise without
significant fatigue; RPE 11-13
on 6-20 scale or 40%-60% of
1 RM
Stretch to the point of feeling
tightness or slight discomfort
Time 20-60 min 1-3 sets; 8-10 different
exercises focused on major
muscle groups.
15 secs hold for static
stretching; ≥4 repetitions of
each exercise
Type Arm ergometer, upper and
lower(dual action), extremity
ergometer, upright and
recumbent cycles, steppers,
elliptical, stair climber,
treadmill
Select equipment that is safe
and comfortable for the
patient to use
Static, dynamic focused on
major joints of limbs and
lower back; consider PNF
technique.

12/16/2022 Effect of Exercise on CVS and Exercise Rx 66
Title: The European Association of Preventive Cardiology Exercise Prescription in Everyday Practice and
Rehabilitative Training (EXPERT) tool: A digital training and decision support system for optimized exercise
prescription in cardiovascular disease. Concept, definitions and construction methodology
Dominique Hansen et al. 2017
Aim: To develop a digital training and decision support system for exercise prescription in cardiovascular
disease patients in clinical practice: EXPERT tool
Methods: EXPERT working group members were requested to define (a) diagnostic criteria for specific
cardiovascular diseases, cardiovascular disease risk factors, and other chronic non-cardiovascular conditions,
(b) primary goals of exercise intervention, (c) disease-specific prescription of exercise training (intensity,
frequency, volume, type, sessionand programme duration), and (d) exercise training safety advices. The
impact of exercise tolerance, common cardiovascular medications and adverse events during exercise testing
were further taken into account for optimized exercise prescription.
Conclusion: This digital training and decision support system may contribute in overcoming barriers in exercise
implementation in common cardiovascular diseases.

COVID-19 & Cardiovascular System- its
effects in athletes

Title: Return to sports after COVID-19 infection. Do we have to worry about myocarditis?
Philpp Schellhorn, Karin Klingel, Christrof Burgstahlar
Are athletes at risk for COVID-19?
Despite the fact that athletes do not belong to the risk group for severe COVID-19, numerous individuals and
occasionally entire sports teams have been affected by COVID-19 infections. It can be assumed that the
frequency of mild or asymptomatic persons will be significantly higher in this subgroup when compared with
the general public. Nevertheless, a potential risk of a myocardial involvement cannot be excluded even in
asymptomatic athletes.
Myocarditis is one of the leading causes of sport associated sudden cardiac death in the group of athletes
under 35 years of age. Athletes frequently present with non-specific symptoms such as fatigue, malaise,
reduced performance, muscle soreness, or increased resting heart rate, which can often be misinterpreted in
the context of other differential diagnoses (e.g. training-related exhaustion/overtraining, depression,or
psychosomatic disorders). Descriptions of mild COVID-19-associated myocarditis are very rare or even non-
existent. Nevertheless, in the assessment of eligibility for participation in sport for athletes in recovery from
COVID-19, these might be very helpful for further risk stratification and for guiding reintegration to training and
competition.
Summary: The cardiovascular effects and long-term consequences of COVID-19 are currently unclear. The
question of eligibility for sport and the point of return to sport following both asymptomatic and symptomatic
COVID-19 with or without suspected involvement of the myocardium is currently becoming more and more
important in leisure as well as in competitive sports.

12/16/2022 69
Title: Evaluating the probable effects of the COVID-19 epidemic detraining on athletes’ physiological traits
and performance
Nima Nakisa, Mahboobeh Ghasemzadeh Rahbardar 2021
Routine dynamic endurance exercise triggers various alterations in the structure and function of the
cardiovascular system and increases the blood volume simultaneously. Particularly, the procedure of exercise-
induced cardiac remodeling is described by elevated or preserved diastolic function, slight to moderate
biventricular eccentric hypertrophy, biatrial dilation, as well as blood volume expansion. Exercise-induced
cardiac remodeling has been documented amongst elite athletes and recreational exercisers who perform
relatively lower intensities and volumes of exercise. Elevations in red blood cell volume of 4% could be
predictable after 15 weeks of endurance training in exercisers. Some investigations stated that reductions in
chamber size and left ventricular wall thickness observed after periods of detraining among elite athletes.
Another study that was carried out on recreational marathon runners disclosed that an abrupt and sustained
reduction in exercise volume for 8weeks induces regression in exercise-induced cardiac remodeling and
attenuates plasma volume. This regression occurs after distinct structure-specific time courses (early and
late) described by early reductions in the thickness and mass of left ventricle wall right ventricle chamber
size. Additionally, it was reported that maximal heart rate increased by 5% over 84 days detraining in
endurance-trained athletes. It was also suggested that improved submaximal heart rates, accompanied by a
reduced length of the isovolumetric contraction phase time at rest, might be due to an amplified
sympathoadrenergic tone in the detraining period.

Exercise Prescription during Detraining
In conclusion:
In order to retain cardiorespiratory endurance,
-athletes have to train at least three times a week
- training intensity must be at least 70% of the usual training intensity
-the reduction of training frequency must be more moderate (not more
than 20- 30%).
-Performing alternate training types such as cross-training could delay
detraining in athletes if similar-mode exercises are performed.
-However, dissimilar-mode cross-training might also be advantageous to
the moderately trained individual.

References
1. Physiology of sport and exercise. Jack H.Wilmore Fifth
2. Therapeutic exercise- Carolyn Kisner
3. Essentials of exercise physiology- William D.Mcardle. Edition Four Edition
4. ACSM Guidelines for Exercise Testing and Prescription- 10th edition
5. Coates, A. M., P. J. Millar, And J. F. Burr. Blunted Cardiac Output from Overtraining Is Related to Increased
Arterial Stiffness.Med. Sci. Sports Exerc., Vol. 50, No. 12, pp. 2459–2464, 2018.
6. Bernardi M, Guerra E, Rodio A, Dante D, Castellano V, Peluso I, Schena F and Bhambhani Y (2020)
Assessment of Exercise Stroke Volume and Its Prediction From Oxygen Pulse in Paralympic Athletes With
Locomotor Impairments: Cardiac Long-Term Adaptations Are Possible. Front. Physiol. 10:1451.
7. Exercise Recommendations for the Athlete With Coronary Artery DiseasePrashant Rao & David
Shipon Current Treatment Options in Cardiovascular Medicine volume 21, Article number: 82 (2019)
8. Thomas L. Stöggl et al. 2017 High Intensity Interval Training Leads to Greater Improvements in Acute Heart
Rate Recovery and Anaerobic Power as High Volume Low Intensity Training
9. Maximal rate of heart rate increase correlates with fatigue/ recovery status in female cyclistsMaximillian J.
Nelson et al. 2017
10. Heart rate recovery in elite athletes: the impact of age and exercise capacity Jelena Suzic Lazic, 2015

11. Oral Consumption of Vitamin K2 for 8 Weeks Associated With Increased Maximal Cardiac Output During
Exercise Brian K. McFarlin et al. 2017
12. The cardiovascular system after exercise. Steven A. Romero et al. 2017
13. Influence of Vigorous Physical Activity on Structure and Function of the Cardiovascular System in Young
Athletes—The MuCAYA-Study Lisa Baumgartner et al. 2019
14. Blood pressure response to maximal dynamic exercise testing in an athletic population Axel Pressler et al. 2018
15. The Effect of Tempo of Musical Treatment and Acute Exercise on Vascular Tension and Cardiovascular
Performance: A Case Study on Trained Non-AthletesSugiharto et al. 2018
16. Dominique Hansen et al. 2017. The European Association of Preventive Cardiology Exercise Prescription in
Everyday Practice and Rehabilitative Training (EXPERT) tool: A digital training and decision support system for
optimized exercise prescription in cardiovascular disease. Concept, definitions and construction methodology
17. Exercise Recommendations for the Athlete With Coronary Artery Disease Prashant Rao & David Shipon
18. High blood pressure response to exercise predicts future development of hypertension in young
athletesStefano Caselli et al. 2018
19. Evaluating the probable effects of the COVID-19 epidemic detraining on athletes’ physiological traits and
performance. Nima Nakisa, Mahboobeh Ghasemzadeh Rahbardar 2021
20. Return to sports after COVID-19 infection. Do we have to worry about myocarditis?Philpp Schellhorn, Karin
Klingel, Christrof Burgstahlar

12/16/2022 73

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