There is little controversy over the benefits to cardiovascular health of not smoking, eating a well balanced diet, maintaining mental well-being, taking regular exercise and keeping active, as demonstrated in large cohort studies. These health behaviours also play an etiological role in other noncommunicable diseases, such as cancer, respiratory disease, diabetes, osteoporosis and liver disease (WHO., 2003), which makes interventions to promote them potentially very cost-effective. However, there is considerable uncertainty about the best ways of helping people at high CVD risk to modify their behaviour.

1. Improvement in Symptoms of Exertional
Intolerance Following Exercise Training in
Cardiac Patient
Nihal Ashraf
MPT 3rd Sem.
Jamia Millia Islamia

2. • Systemic exertion intolerance disease/chronic fatigue syndrome
(SEID/CFS) is a long-term illness that affects many body systems.
• People with this illness are not able to do their usual activities.
Sometimes, they may be confined to bed.
• Exercise intolerance might sound like that feeling you get when you
don’t want to go to the gym or push yourself through a tough
workout, but it’s actually a bigger issue than that.
• Sure, everyone gets tired when pushing themselves through another
set of dips.

3. • But exercise intolerance is when you feel too fatigued to perform a
certain workout at your maximum effort level and for an extended
duration.
• This inability to perform isn’t simply because you’re tired, but due
to a larger problem, like chronic diastolic heart failure

5. • Exercise intolerance is the primary symptom of chronic diastolic
heart failure.
• It is part of the definition of heart failure and is intimately linked to
its pathophysiology.
• Exercise intolerance affects the diagnosis and prognosis of heart
failure.
• Understanding the mechanisms of exercise intolerance can lead to
developing and testing rationale treatments for heart failure.
• Exercise intolerance is the cardinal symptom of heart failure (HF)
and is of crucial relevance, because it is associated with a poor
quality of life and increased mortality.

6. • Heart failure is defined as a syndrome in which cardiac output is
insufficient to meet metabolic demands.
• This implies that insufficient cardiac output will be expressed
symptomatically.
• Heart failure may often manifest by occasional episodes of acute
decompensation with overt systemic volume overload and
pulmonary edema.
• Exertional fatigue and dyspnea, however, are the primary chronic
symptoms in outpatients, even when well compensated and non-
edematous, and whether associated with reduced or normal ejection
fraction (EF)

7. • In addition, these symptoms and other consequences of exercise
intolerance are potent determinants of health-related quality of life
in heart failure patients.
• Several investigators have reported that objective measures, and
even subjective estimates, of exercise tolerance predictor survival.

8. Assessing exercise and functional capacity
• It is important to define and differentiate exercise capacity and
functional capacity, because the 2 are often and erroneously
interchanged in the published data.
• Exercise capacity may be defined as “the maximum amount of
physical exertion that a subject can sustain,”
• Functional capacity may be defined as “the ability to perform
activities of daily living that require sustained, submaximal aerobic
metabolism”; both reflect the limitations associated with the
cardiovascular (CV) system.
• Cardiorespiratory fitness (CRF), on the other hand, is an umbrella
term that refers to CV, respiratory and muscular responses to
exercise

9. • Exercise intolerance can be objectively quantified using
semiquantitative assessments, such as interview (New York Heart
Association classification) and surveys (Minnesota Living with
Heart Failure or Kansas City Cardiomyopathy questionnaires),
• and quantitative methods, including timed walking tests (6 minute
walk distance) and graded exercise treadmill or bicycle exercise
tests.
• Cardiopulmonary exercise testing on a treadmill or a bicycle
ergometer provides the most accurate, reliable, and reproducible
assessments of exercise tolerance, and yields multiple important
outcomes, including METS, exercise time, exercise workload, blood
pressure and heart rate responses, and rate-pressure product.

11. DISTINCT CONTRIBUTORS OF EXERCISE
INTOLERANCE
 IMPAIRED CARDIAC RESERVE.
• HF can be defined as the inability to increase CO at a rate that
is commensurate with the body’s metabolic needs, or the
requirement of elevated ventricular filling pressure to increase CO.
• Limitations in exercise and functional capacity derive from an
insufficient increase in CO with exertion leading to lactic acidosis
and muscular fatigue or by the uncomfortable sensation of dyspnea
due to pulmonary venous congestion and increased respiratory
muscle work associated with elevated cardiac filling pressures.

12.  IMPAIRED PULMONARY RESERVE.
• Patients with HF may have impaired pulmonary reserve contributing
to reduced exercise capacity due to the impaired ventilatory
capacity, gas exchange, CV, and peripheral muscle abnormalities,
which may ultimately prevent adequate O2 transfer from the
atmosphere and/or utilization of O2 by the mitochondria.

13.  VASCULAR DYSFUNCTION AND SKELETAL MUSCLE
ABNORMALITIES
• Peak VO2 depends on both O2 delivery (i.e., CO and arterial
oxygen content, peripheral vascular function) and consumption (i.e.,
diffusion and extraction).
• With maximal exercise, skeletal muscle has the greatest O2
consumption.
• With aging and chronic illnesses, systemic O2 delivery is reduced
by a limit endothelial-dependent vasodilation precipitating a switch
to an anaerobic metabolism and aggravating fatigue and dyspnea.

14.  ANEMIA
• Reduced hemoglobin concentration leads to a reduction in AV-
O2content because extracting the same percentage of O2 means
extracting less total O2 content.
• Anemia may, therefore, cause exercise intolerance if the O2 carrying
capacity of the blood is impaired beyond the ability of the CV and
skeletal muscle systems to compensate, which generally happens
only for severe anemia, but may happen for a lesser degree of
anemia in patients with preexisting abnormalities, such as those with
HF.
• Anemia is common in patients with HF.
• Although anemia has several causes, the most common cause is iron
deficiency, which is intertwined with exercise intolerance
irrespective of the effect on O2-carrying capacity, because iron is a
key component of skeletal muscle O2 handling.

15. CONCLUSIONS
• Reduced exercise and functional capacity are the central hall marks
of HF.
• However, such abnormalities are also common denominators of
different comorbidities, making it difficult to differentiate the causes
of impaired exercise and functional capacity, particularly in heart
failure with reduced left ventricular ejection fraction (HFpEF).
• Determining the mechanism(s) of reduced exercise and
functional capacity would therefore allow for tailored
individualized interventions aimed at targeting the specific
pathophysiological mechanisms involved.

17. Thank You