National Heart Foundation of Australia physical activity recommendations for people with cardiovascular disease

ACKNOWLEDGEMENTS
National Heart Foundation of Australia physical activity recommendations for people with cardiovascular disease
Short Title: Heart Foundation physical activity recommendations for people with CVD

Physical activity recommendations for people with CVD Executive Working Group:
Tom Briffa Roger Allan Andrew Maiorana Brian Oldenburg Neville Sammel Anthony Stubbs Noella Sheerin Principal author Chair

On behalf of the Physical activity recommendations for people with CVD Working Group* and National Forum Participantsp
Roger Allan Chair, Cardiac Clinical Division for South East Sydney and the Illawara, Chair, National Heart Foundation of Australia (NHFA) Clinical Issues Committee (CIC)* NSW Health Department; NHFA CICp National Heart Foundation of Australia National Heart Foundation of Australia* The University of Queensland; Chair, NHFA National Physical Activity Committee (NPAC)* Australian Physiotherapy Associationp National Heart Foundation of Australiap Royal Australian College of General Practice and NHFA CIC* Central Sydney Division of General Practicep National Heart Foundation of Australiap Australian Practice Nurses Associationp Australian Association of Exercise and Sports Science; Australian Cardiac Rehabilitation Association* National Heart Foundation of Australiap Sports Medicine Australiap Queensland University of Technology; NHFA NPAC Cardiac Society of Australia and New Zealand; Royal Australian College of Physicians* National Heart Foundation of Australiap National Heart Foundation of Australia* National Heart Foundation of Australia* Australian Divisions of General Practice; Sutherland Division of General Practice, NSWp

Bill Bellew Andrew Boyden Tom Briffa Wendy Brown Belinda Cary Rachelle Foreman Mark Harris David Lim Jeanie McKenzie Val McKenzie Andrew Maiorana Amanda Nagle Kevin Norton Brian Oldenburg Neville Sammel Trevor Shilton Noella Sheerin Anthony Stubbs Rowan Vickers

Funded by the National Heart Foundation of Australia Suggested citation: Briffa T, Maiorana A, Allan R, et al. On behalf of the Executive Working Group and National Forum Participants. National Heart Foundation of Australia physical activity recommendations for people with cardiovascular disease. Sydney (Australia): National Heart Foundation of Australia; January 2006

These guidelines are endorsed by the following organisations:

National Heart Foundation of Australia physical activity recommendations for people with cardiovascular disease

Contents
Executive Summary Summary of recommendations It is recommended that: Purpose and scope of the recommendations How to use these recommendations Terminology Rating of the evidence for recommendations Summary of evidence and recommendations Background Physical inactivity – burden and disease Benefits of physical activity for people with CVD The evidence for physical activity in the management of CVD Limitation of current evidence Risks associated with physical activity Medico-legal considerations Pre-activity evaluation People who should not engage in physical activity People who require supervision Indications for a person to stop physical activity Evidence and recommendations for physical activity in people with CVD Physical activity and CVD Broad recommendation for management For people with diagnosed CHD Post-discharge ACS – evidence Post-discharge ACS – management Chronic stable CHD – evidence Chronic stable CHD – management People with heart failure – evidence Heart failure – management Pacemakers, implantable cardioverter defibrillators, congenital and valvular heart disease For older people with CVD – evidence For older people with CVD – management Stroke, PVD or diabetes – evidence Stroke, PVD or diabetes – management 3 4 4 5 5 6 7 8 10 10 10 10 11 12 12 12 13 13 13 14 14 14 15 15 15 15 16 16 17 17 17 18 18 18

Contents

1

National Heart Foundation of Australia physical activity recommendations for people with cardiovascular disease Physical Activity and additional risk factors Effects of physical activity on the risk factors for CVD Blood pressure High density lipoprotein cholesterol and triglyceride concentrations Insulin resistance and glucose tolerance Depression and social isolation Risk factor – management Patient implementation Physical activity promotion in general practice Evidence for the promotion of physical activity in general practice Progression and maintenance of physical activity Progression Maintenance Practical/special considerations Resuming sports participation References Appendices Appendix 1 Appendix 2 Appendix 3 Appendix 4 Heart Foundation physical activity algorithm for people with stable CVD 19 19 19 19 19 19 19 20 20 20 21 21 21 21 21 22 25 25 26 27 28 30 2 Contents .

PVD. insufficient physical activity* is second only to tobacco smoking as the modifiable behavioural risk factor most associated with the burden of disease. In the primary care setting there are a number of initiatives. A principal task in this process was to conduct a literature review that focused on key publications since the 1996 US Surgeon General's Report on ‘Physical activity and health’. * ‘Sufficient’ physical activity is at least 150 minutes of moderate-intensity activity accrued over at least five sessions (of 10 minutes or more) in the previous 7 days Executive Summary 3 . These conditions include coronary heart disease (CHD). Health professionals directly involved with recommending or monitoring physical activity levels for people with CVD may also find this document to be an invaluable resource.g. depression and social isolation in those with CVD is also briefly considered. The purpose of these recommendations is to provide general practitioners and physicians with evidence-based physical activity information for specific. stroke and other cardiac conditions (e. non-government organisations and governments. lipid profile. heart failure. The provision of accurate. The recommendations provide a general framework for appropriate practice.National Heart Foundation of Australia physical activity recommendations for people with cardiovascular disease Executive Summary National Heart Foundation of Australia physical activity recommendations for people with cardiovascular disease In Australia. The impact of physical activity on coexisting risk factors such as blood pressure.2 The importance of including lifestyle management in the prevention and treatment of chronic disease has been well recognised by medical practitioners.3 The document is structured to present evidence of the benefit for physical activity for each diagnostic category. safe physical activity advice by doctors to people with CVD. overweight and obesity. stable cardiovascular conditions. stroke and peripheral vascular disease (PVD). which is followed by evidence-based management recommendations. policies and infrastructure systems to support general practice to deliver lifestyle interventions. subject to the medical practitioner's judgement (or assessment) of each case. This document addresses a gap in the information for physical activity in the management of people with well-compensated clinically stable CVD.1 The significance of physical inactivity can not be underestimated in an environment where cardiovascular disease (CVD) is Australia's leading cause of premature death and disability and where the proportion of adult Australians who are not sufficiently active for health benefit increased from 49% to 54% between 1997 and 2000. valvular heart disease and implantable cardiac devices). insulin resistance. should improve individual health outcomes. if followed. The recommendations were developed using an evidence-based consensus approach under the guidance of an expert working group and through a process of national consultation with other major stakeholders. The highest level of evidence for the recommendations is for CHD and heart failure followed by diabetes.

those with implantable cardiac devices. G G Additionally well-compensated clinically stable people with CVD are likely to gain additional muscle fitness from light to moderate resistance activities. clinically stable people with CVD including. over time. written physical activity advice to people with wellcompensated. all people with PVD or diabetes and survivors of a stroke with sufficient residual function should progress over time to the recommended dose. congenital and valvular heart disease. clinically stable CVD. G G It is recommended that: G doctors and clinicians should routinely provide brief. the severity of their cardiovascular condition. unless contraindicated. if not all days of the week. as described in the National Heart Foundation of Australia & Australian Cardiac Rehabilitation Association Recommended Framework for Cardiac Rehabilitation 2004’. The amount of activity can be accumulated in short bouts. or certificate of registration in medicine.National Heart Foundation of Australia physical activity recommendations for people with cardiovascular disease Summary of recommendations The National Heart Foundation of Australia recommends that to benefit health. or angioplasty ± stenting for CVD should take into consideration the implications of the surgery/procedure when commencing physical activity. appropriate. people with advanced CVD or severely impaired functional capacity may have to down-regulate the recommended dose of physical activity. with additional training or work experience encompassing adult education principles and physical activity programs. 4 Summary of recommendations . † ‘Supervised by a trained health professional with a degree. A person's current level of activity. or other allied health professional or Aboriginal and Torres Strait Islanders health worker. people with CVD should aim. diploma. nursing. survivors of a recent cardiovascular event should be offered participation in supervised† exercise rehabilitation where available and practical. people who have recently had surgery. G well-compensated. to include 30 minutes or more of moderate-intensity physical activity on most. should progress over time to the recommended dose. co-morbidities and personal preferences should determine the approach and rate of progress towards these goals. such as three 10-minute sessions each day.

They combine the population health and clinical evidence into one document for the benefit of general practitioners. For more detailed prescriptive exercise advice refer to other resource material.com. rather they are based on key national and international scientific publications since the US Surgeon General’s Report of 1996. physicians and other clinicians involved in recommending or promoting physical activity for people with wellcompensated clinically stable CVD. congenital or valvular heart disease and/or diabetes are also briefly addressed.National Heart Foundation of Australia physical activity recommendations for people with cardiovascular disease Purpose and scope of the recommendations The case for reducing future CVD risk in those with the disease is compelling.5.heartfoundation. stroke. For the purposes of this document such conditions include CHD. They underpin the doctor/patient interface summary document‡ and can be read in conjunction with other reference materials such as the Heart Foundation's best-practice guidelines. Persons with a pacemaker.6. How to use these recommendations These recommendations provide a general framework for appropriate practice to be followed. wellcompensated. The Heart Foundation recognises the importance of what are often referred to as 'lifestyle changes' such as increased physical activity. and PVD. The recommendations are not a comprehensive review of the literature.4. clinically stable cardiovascular conditions. subject to the medical practitioner or clinician's judgment in each individual case. a balanced approach to nutrition.7 ‡ See page 30 or download at http://www.au Purpose and scope of the recommendations 5 . heart failure. These recommendations provide general practitioners and physicians with evidence-based physical activity information for specific. moderation in alcohol consumption and smoking cessation as legitimate management strategies following diagnosis of CVD. implantable cardioverter defibrillator.

This level of activity is not routinely recommended for people with CVD Type of physical activity The number of times physical activity is performed in a given time period (e. week) The time in minutes of each bout of physical activity Rhythmic. spanning ST elevation myocardial infarction (STEMI). noticeable increase in the depth and rate of breathing while still being able to whistle or talk comfortably Physical activity associated with a marked increase in depth and rate of breathing (puffing and panting).National Heart Foundation of Australia physical activity recommendations for people with cardiovascular disease Terminology Physical activity Any bodily movement produced by skeletal muscles that result in energy expenditure§ The systematic execution of physical activity for a specific purpose A marker of the ability to perform physical activity The total amount of energy expended in physical activity The rate of energy expenditure during physical activity Physical activity associated with a slight increase in breathing rate Physical activity associated with a moderate. 6 Purpose and scope of the recommendations . non-ST elevation myocardial infarction (non-STEMI) through to an accelerated pattern of angina without evidence of myonecrosis8 People with CVD who are symptomatic with minimal exertion or at rest (NYHA Functional Class III and IV respectively) and/or whose left ventricular function is at least moderately impaired Advanced CVD or severely impaired functional capacity § Definitions for PA and exercise taken from NHFA Physical activity for people with heart disease 1999.g.g. day. unable to whistle or talk. repetitive physical activity that substantially increases energy expenditure over an extended duration Range of movement muscular activity against a light to moderate resistance (e. lifting weights) Persons with CVD receiving appropriate pharmacotherapy without evidence of new or progressive signs or symptoms indicative of clinical deterioration Exercise Physical fitness Dose Intensity Low/light intensity Moderate intensity Vigorous intensity Mode Frequency Duration Endurance activity Resistance activity Well-compensated clinically stable condition Acute coronary syndrome (ACS) A broad spectrum of clinical presentations.

Evidence obtained from comparative studies with historical control.National Heart Foundation of Australia physical activity recommendations for people with cardiovascular disease Rating of the evidence for recommendations Evidence is graded according to National Health and Medical Research Council (NHMRC) Levels of evidence for clinical interventions and grades of recommendation Level of evidence I Study design Evidence obtained from a systematic review of all relevant randomised controlled trials. or interrupted time series with a parallel control group. Evidence obtained from comparative studies with concurrent controls and allocation not randomised (cohort studies). Evidence obtained from welldesigned pseudo-randomised controlled trials (alternate allocation or some other method). or interrupted time series with a control group. Grades of recommendation A Rich body of high-quality RCT data B II III-1 B Limited body of RCT data or high-quality non-RCT data B III-2 III-3 C Limited evidence C IV D No evidence available – panel consensus judgment/ NB The levels of evidence and grades of recommendations are adapted from the National Health and Medical Research Council's levels of evidence for clinical interventions and the US National Institutes of Health clinical guidelines (Details can be found at http://www.nhlbi.gov/guidelines/obesity/ob_home.nih.nhmrc. / = Expert opinion Rating of the evidence for recommendations 7 .au/publications/_files/cp30. Evidence obtained from case series.gov. case-control studies.pdf (Appendix B) and http://www.htm>. Evidence obtained from at least one properly designed randomised controlled trial. two or more single-arm studies. either post-test or pre-test and posttest. Last accessed July 2005.

days of the week. participate in a short period (up to 12 weeks) of supervised exercise rehabilitation. or more. Well-compensated. over time. of up to moderate intensity physical activity on most. Level of evidence II Recommendations Doctors and clinicians should routinely provide brief. of up to moderate intensity physical activity on most. if not all days of the week. Well-compensated.National Heart Foundation of Australia physical activity recommendations for people with cardiovascular disease Summary of evidence and recommendations Evidence Brief physical activity advice from primary carers is effective in increasing levels of physical activity. Well-compensated. or more. if not all. congenital heart disease or implantable cardiac devices should progress. if not all days of the week. or more. Those with advanced CVD may have to downregulate the recommended dose. clinically stable people with valvular heart disease. clinically stable people with CVD should progress over time to 30 minutes (all together or in shorter bouts). unstable angina pectoris (UAP). clinically stable people with heart failure should progress over time to 30 minutes (all together or in shorter bouts). appropriate. congenital or valvular heart disease. should be offered and. Well-compensated. coronary artery bypass grafting (CABG) or percutaneous coronary interventions (PCI). Grade B Exercise rehabilitation soon after an ACS event or coronary revascularisation is effective in accelerating functional capacity and lowering subsequent risk for cardiovascular events. I A Habitually physically active older men with CVD have a lower risk of all-cause and cardiovascular mortality. where available. written physical activity advice to patients with well-compensated clinically stable CVD. IV D 8 Summary of Evidence and Recommendations . of up to moderate intensity physical activity on most. to 30 minutes (all together or in shorter bouts). I A Regular physical activity increases the functional capacity of people with implantable cardiac devices. clinically stable recent (<2/52) survivors of a myocardial infarction (MI). III-2 B Regular physical activity increases the functional capacity of people with heart failure.

if not all days of the week. PVD or diabetes. if not all days of the week. of up to moderate intensity physical activity on most. of moderate intensity physical activity on most. all people with PVD. or more. over time. clinically stable people with CVD should initiate resistance activity under supervision by a trained health professional. Well-compensated. all older people with CVD should progress. to 30 minutes (all together or in shorter bouts).National Heart Foundation of Australia physical activity recommendations for people with cardiovascular disease Evidence Older habitually physically active people with CVD show improved functional capacity and mental wellbeing. Level of evidence II Recommendations Unless contraindicated. Unless contraindicated. diabetes and stroke survivors with sufficient residual function should progress over time to 30 minutes (all together or in shorter bouts). II B Summary of Evidence and Recommendations 9 . Grade B Regular physical activity improves functional capacity among people with stroke. II B Prescriptive light to moderate resistance activity is safe and improves muscle fitness among people with CVD. or more.

4. The evidence for physical activity in the management of CVD Regular physical activity incorporating large muscle groups (such as walking. preevaluation and specific recommendations for increasing activity are outlined. cycling. reducing insulin resistance. healthy eating. endurance and vascular function.11 Associated benefits of regular physical activity for those with CVD include: augmented physiological functioning and improved quality of life.11 Regular physical activity may improve an individual's cardiovascular risk profile by lowering blood pressure. resistance work) is instrumental in the prevention and treatment of heart.12 In the sections that follow.1 Insufficient physical activity is the primary modifiable behavioural risk factor associated with disease burden in women.9 Physical inactivity is a major modifiable risk factor that is impacting on the health of all Australians accounting for 6. further research is required to elucidate potential survival benefits with physical activity for older patients with CHD.2 Despite this improvement. Australia has experienced major falls in CVD death rates over the past 30 years and this has mainly been due to advances in the treatment and care of heart. It is important to remember that regular moderate physical activity should be part of an overall approach to risk factor modification incorporating smoking cessation.10 Research shows that regular endurance physical activity produces cardiovascular adaptations that increase work capacity.2 There is also evidence that habitual physical activity reduces the risk of developing numerous chronic diseases. heart. and breast and colon cancer. contraindications to physical activity.4 G G Benefits of physical activity for people with CVD All people with CVD can benefit from habitual and regular physical activity unless otherwise contraindicated. medico-legal considerations. managing depression and social isolation. osteoporosis. a survival benefit with exercise training among patients with heart failure14 with further studies required7 to confirm these data. Habitual physical activity also reduces the risk of developing CHD and ameliorates symptoms in those with the disease. 8. stroke and vascular diseases remain Australia's leading cause of premature death and disability. and is second only to tobacco smoking for men. modulating lipids. while treating biomedical risk factors such as dyslipidaemia. the risks associated with physical activity. managing unhealthy body weight and enhancing psychosocial status/mental wellbeing. including CVD. specific information about the evidence for physical activity in the management of CVD.000 deaths with annual direct costs conservatively estimated at $377 million can be attributed to physical inactivity. stroke and vascular diseases. and swimming and. depression. obesity. resistance activity can improve muscular strength. similarly. and PVD. Also of concern is the trend that has seen the proportion of adult Australians who are not sufficiently active for health benefit increase from 49% to 54% between 1997 and 2000. type 2 diabetes.7% of the total disease burden attributable to risk factors. in certain circumstances.4 Further.4 G 10 Background . high blood pressure and diabetes. stroke.National Heart Foundation of Australia physical activity recommendations for people with cardiovascular disease Background Physical inactivity – burden and disease Each year.

and ongoing medical review. coronary revascularisation or with angiographic coronary disease provided a 27% (95% CI. Background 11 . the survival benefits of habitual physical activity for people with CVD are largely drawn from studies based on exercise training involving mostly men engaging in light to moderate intensity physical activity. Inc. Limitations of current evidence Functional and quality of life gains aside.2004.6:23-27 copyright 2004 by Le Jacq Communications. Fitness and Mortality in the Primary and Secondary Prevention of Coronary Artery Disease: Does the Effort Justify the Outcome? Am J Med Sports. B et. with varying degrees of supervision. 2% to 40%) reduction in total mortality and 31% (95% CI. In a Cochrane review.15 regular endurance physical activity in patients following an acute coronary syndrome (ACS) event.National Heart Foundation of Australia physical activity recommendations for people with cardiovascular disease Figure 1: Potential cardio protective effects of regular physical activity¶ Antiatherosclerotic Improves lipids Psychologic Depression Antithrombotic Platelet adhesiveness Fibrinolysis Anti-ischaemic Myocardial 02 demand Coronary flow Antiarrhythmic Vagal tone Lowers BP Stress Adrenergic activity HR variability Reduces adiposity Social support Fibrinogen Endothelial dysfunction Insulin sensitivity Inflammation ¶ Blood viscosity Moderate ≥ 55% maximum heart rate Reproduced with permission of Franklin. al. The majority of these studies pre-date the recent major interventional and pharmacological advances in CVD management. Further research is warranted to confirm the survival benefit of regular physical activity in those people with established CVD receiving contemporary medical therapy. 6% to 49%) decline in cardiac mortality.

clinically stable CVD. overall CVD risk. respectively.4 If there is uncertainty about the safety of physical activity. Nevertheless. Any pre-activity evaluation should involve a medical review. flexibility.21 The same may also be true of persons with CVD. patients should be taking relevant pharmacological therapies and reducing their overall coronary risk profile in accordance with national guidelines.18 People with CVD.22 12 Risks associated with physical activity / Pre-activity evaluation . Further.000 hours of participation in physical activity.17 The risk of a major or fatal cardiac event occurring among participants attending supervised cardiac rehabilitation programs in the United States of America (USA) is estimated to be 1 for every 117.4 In healthy people the greatest health improvements occur when a person of any age moves from participating in little or no regular physical activity to undertaking regular light-tomoderate intensity physical activity. refer to tertiary services. The most common risk associated with physical activity in the general population is musculoskeletal injury16 with a particularly low estimated prevalence of injury for walking.19. it is important to tailor physical activity to an individual's co-morbidities.20 Typically. physical examination and a history of physical activity to ensure there is no contraindication to becoming more active. who are least physically active and/or are performing above the physical activity dose recommended.18. muscle strength. Medico-legal considerations This document is intended to assist GPs in providing specific evidence-based physical activity advice to their patients with well-compensated. clinical CVD and other co-morbidities. including diminished functioning associated with prolonged immobilisation and in older persons with reduced muscle mass.10 It is not necessary that individuals starting a low to moderate progressive program of physical activity perform an exercise tolerance test. The extent of a pre-activity evaluation depends on the intensity of anticipated physical activity and on the persons’ symptoms. gardening and cycling. signs. are more likely to experience a recurrent cardiovascular event compared with compliers. or for those aspiring to regular vigorous exercise. Where GPs feel unable to provide detailed advice. muscle power.000 and 750. and sensory function. injury risk and the risk of a cardiovascular event can be reduced if the dose of physical activity is increased gradually over time. balance.National Heart Foundation of Australia physical activity recommendations for people with cardiovascular disease Risks associated with physical activity It is well established that the benefits of moderate intensity physical activity outweigh the risks. they may of course. exercise testing with echocardiography or radionuclide scintigraphy should be considered. Pre-activity evaluation A detailed clinical assessment prior to recommending low to moderate physical activity is generally unwarranted and counterproductive.

hunger.L-1 or >15mmol. systole ≥ 180 and diastole ≥ 110 mmHg acute infection or fever. The recommendation for supervision may also apply to survivors of stroke and to those with diabetes or PVD. 2). All people with CHD and/or diabetes should be provided with a written action plan for chest pain/discomfort or diabetes symptom management (Appendices 1. symptoms occurring at lower levels of exertion or at rest) diabetic with poor blood glucose level control e. in particular if exerciseinduced. weakness.g. palpitations G People who require supervision Those with advanced CVD.L-1 G G G G G G G G G G G G G G G G G G squeezing. < 6mmol. discomfort or typical pain in the centre of the chest or behind the breastbone ± spreading to the shoulders. light headedness or feeling faint difficulty breathing nausea uncharacteristic excessive sweating palpitations associated with feeling unwell undue fatigue leg ache that curtails function physical inability to continue for people with diabetes: shakiness. People who should not engage in physical activity 13 . if any of the following occur:23 G unstable angina symptoms such as chest discomfort and shortness of breath on low activity uncontrolled cardiac failure severe aortic stenosis uncontrolled hypertension or with grade 3 (severe) hypertension e. It should document a stepwise course of action to managing symptoms. monitor symptoms/arrhythmias and establish appropriate physical activity intensity following an acute cardiac event or coronary revascularisation. neck.g. or are feeling unwell (not limited to but including acute myocarditis or pericarditis) resting tachycardia and/or arrhythmias uncontrolled diabetes change in clinical status (e. jaw and/or arms symptoms reminiscent of previous myocardial ischaemia dizziness.10 To maximise the safety and benefits of physical activity the GP when advising physical activity should re-state: G G G the risks and benefits of physical activity for the individual the importance of keeping intensity at or below a moderate level the importance of following the chest pain/ discomfort and/or diabetes symptom management plan. psychologically impaired by the disease or who request group support will benefit most from a time-limited period of supervised cardiac or exercise rehabilitation incorporating endurance and resistance activity. A short period of supervision (up to 12 weeks) may be beneficial to reduce anxiety.National Heart Foundation of Australia physical activity recommendations for people with cardiovascular disease People who should not engage in physical activity People with any of the following contraindications should not engage in physical activity without medical review prior to commencing physical activity:23 G Indications for a person to stop physical activity Clinical advice should be given to stop physical activity. People who experience these signs or symptoms should be advised to follow their chest pain/discomfort or diabetes management plan or discontinue physical activity until reviewed by their general practitioner. Direct supervision with or without electrocardiographic monitoring of moderate intensity physical activity is not necessary for the majority of people with CVD. tingling lips.g.

Where appropriate. 14 Evidence and recommendations for physical activity in people with CVD . These functionally diminished groups typically commence with even shorter activity bouts punctuated with frequent rest periods. and enhances mental wellbeing in well-compensated.15 G G G G G G The greatest potential for functional benefits is in those people who were least active prior to commencing regular physical activity and these benefits may be achieved even at relatively low levels of physical activity. and in the case of acute coronary syndrome survivors. over time. such as 3 x 10 minute sessions. clinically stable people with CVD. if not all days of the week.25 Importantly. the habitually inactive and those with low physical fitness. low to moderate intensity resistance activity provides people with CVD the physical strength and self-confidence to perform most activities of daily living. Broad recommendation for management The National Heart Foundation of Australia (NHFA) recommends that. There is increasing recognition that low to moderate level resistance activity improves muscular strength and endurance. The amount of activity can be accumulated in shorter bouts. clinically stable CVD offers: G diminution of symptoms improved functional capacity enhanced coronary reactivity decreased use of medication greater mental wellbeing enhanced quality of life. according to clinical status. endurance. a reduction in cardiovascular mortality. people with established CVD should aim to achieve 30 minutes or more of moderate intensity physical activity (such as brisk walking) on most. Level of evidence II. grade of recommendation B Additional research is warranted to establish the efficacy of resistance training in non-supervised settings and to elicit other physiological and metabolic benefits among those with CVD.11. power and muscle mass among healthy adults. Resistance activity is best initiated under the supervision of a trained health professional where.24 Responses to resistance activity are largely determined by the relative intensity of physical activity and are no greater than those experienced during endurance physical activity at a similar relative intensity. this recommendation has been modulated for specific cardiovascular conditions.National Heart Foundation of Australia physical activity recommendations for people with cardiovascular disease Evidence and recommendations for physical activity in people with CVD Physical activity and CVD Increased physical activity in people with wellcompensated. direction can be given with its introduction and progression. those with advanced CVD may not tolerate the recommended dose.5.4 Resistance activity is well accepted in developing and maintaining muscular strength. In particular.

clinically stable MI survivors. All post-discharge ACS patients should be advised to ambulate at home within their musculoskeletal pain-free range. Chronic stable CHD – evidence Physical activity is effective in reducing all-cause mortality among well-compensated. Level of evidence IV. Level of evidence I. whilst lowering subsequent risk for cardiovascular events. A typical walking program for AMI survivors is shown in the text box.15 Regular physical activity alone reduced mortality by 27% (95%CI. most patients should be encouraged towards achieving the recommended dose. or with CAD identified by angiography. advise patients to continue any physical activity program that was given in hospital or from a cardiac procedures centre. personal preference and functional limitations. Those who have undergone angioplasty ± stenting should be advised to curtail any structured physical activity for several days. with angina pectoris. grade of recommendation D It is recommended that patients attend supervised exercise rehabilitation where this is available. It is also recommended that for post-surgical patients who suffer wound complications and/or sternal movement. consideration should be given to the implications of the surgery/procedure when commencing physical activity. enhanced quality of life and surveillance during recovery. this goal maybe achieved at a healthcare facility under the supervision of a trained healthcare professional. If appropriate. Minimum Time (Minutes) Times per day Week Pace 1 2 3 4 5 – 10 10 – 15 15 – 20 20 – 25 2 2 2 1–2 Stroll Comfortable Comfortable Comfortable/ stride out Comfortable/ stride out Comfortable/ stride out Post-discharge ACS – management The recommended physical activity schedule will depend on the patient's clinical condition. Over time. When tailoring physical activity advice for these patients.National Heart Foundation of Australia physical activity recommendations for people with cardiovascular disease For people with diagnosed CHD Post-discharge ACS – evidence Survivors of AMI are usually progressed through a staged walking or equivalent activity schedule according to their clinical status. or longer in the case of a large post-procedural hematoma. 2% to 40%). particularly if habitually active. Where available or indicated. The benefit to survivors of AMI is accelerated functional improvement. following CABG surgery or PCI. grade of recommendation D Notwithstanding a change in clinical status. Level of evidence IV. attainment of daily low to moderate physical activity for at least 30 minutes is recommended during this post-discharge recovery phase. grade of recommendation A Survivors of ACS who have undergone successful coronary stenting and with little or no residual left ventricular impairment may undertake an accelerated physical activity schedule. Level of evidence 1. (See Recommended Framework for Cardiac Rehabilitation 2004 for more detail6). grade of Recommendation A 5 25 – 30 1–2 6 30 1–2 Reference NHFA Physical Activity after Heart Attack and Surgery (2003). their physical activity should be reviewed by the treating surgical team. grade of recommendation B For people with diagnosed CHD 15 . Level of evidence I.

inclusive of resistance training.7 Different trials incorporating differing doses of exercise for people with heart failure have reported the following improvements: G Commence with multiple short duration (5 –10 minutes) sessions of low to moderate intensity physical activity (e. People with well-compensated stable CVD Aim for the recommended dose of physical activity. Note.g. less frequently) and interim targets. stroll on flat ground) interspersed with regular rest periods. comfortable walk on the flat or gentle slope) interspersed with short rest periods.g. experience reduced myocardial oxygen demand at rest and for any level of submaximal work. Physical activity management and recommendations are presented firstly for people with well-compensated stable CHD and then for those with advanced CHD. and increase their submaximal endurance time to the onset of symptoms and improve overall capacity.27 From the available evidence. People with advanced CHD defined as having at least moderate left ventricular impairment and symptomatic with minimal exertion or at rest. Thus. grade of recommendation D G function further from their ischaemic threshold. the emphasis should be centred on frequency and duration. Gradually increase the session duration or frequency (through the day and number of days) of light physical activity. people who were physically active immediately prior to developing CHD may commence at an increased dose and progress more expeditiously.National Heart Foundation of Australia physical activity recommendations for people with cardiovascular disease Typically. which results in symptoms of fatigue or dyspnoea on exertion. People with heart failure – evidence Heart failure relates to the inability of the heart to meet the metabolic demands of the tissues. Level of evidence I. people who are well-conditioned. as tolerated. on alternate days. exercise conditioning allows people with CHD to: G People with advanced CHD Progress towards the recommended dose of physical activity subject to achieving lower dose (low intensity. Gradually increase the session duration. thereafter lift intensity to moderate until the recommended dose is achieved. shorter duration. Peak oxygen uptake also increases. Evidence-based definitions of chronic heart failure (CVH) are available in Guidelines for the Prevention. Level of evidence IV. towards accumulating 30 minutes on most days. a mean increase in peak oxygen . progressing to dyspnoea at rest.26 have the highest rate of recurrent events.000 patient-hours of exercise training. Initially. Detection and Management of People with Chronic Heart Failure in Australia 2005. appears safe for people with well-compensated clinically stable heart failure with no deaths reported in over 60. taking many weeks to achieve interim targets. followed by intensity once interim targets are met. physical activity conditioning. Those with advanced heart disease will inevitably progress more slowly. grade of recommendation B G Commence with multiple short duration (2–10 minutes) sessions of light intensity physical activity (e. consumption (peak VO2) of 20 % (range 12% –31%)28 16 For people with diagnosed CHD .6 G Chronic stable CHD – management All people with CHD are considered to be at high absolute risk of recurrent cardiovascular events compared with those without disease.

Class IV people should be encouraged to undertake gentle mobilisation as symptoms allow. according to clinical status. direction can be given with its introduction. grade of recommendation D Heart failure – management The functional ability of people with heart failure varies greatly. grade of recommendation D G Further. grade of recommendation A G Importantly. on most. progression and maintenance. grade of recommendation C People with NYHA Functional Class I or II: these people with heart failure should progress gradually as tolerated to at least 30 minutes (continuously or in intervals of exercise) of up to moderate intensity physical activity.14 Pacemakers.35. are older or more deconditioned with advanced disease (New York Heart Association [NYHA] III–IV.37 Exercise therapy in these studies was reported as being safe.39 Level of evidence III-2. Level of evidence IV. People with NYHA Functional Class III or IV: NYHA Functional Class III people will require shorter intervals of activity at lower intensity. regular low to moderate exercise is safe in older people with well-compensated clinically stable heart failure. and is poorly correlated with resting ejection fraction33.34 necessitating the modulation of the recommended dose. G For older people with CVD – evidence The prevalence of CVD is highest among older Australians. Similarly. In the British Regional Heart Study. grade of recommendation B Whether exercise training improves survival among the elderly with CHD is unclear.30 with some limited evidence for an improvement in cardiac function31 exercise training has also been associated with amelioration of symptoms28 and enhancement of psychosocial functioning. recognising down regulation where appropriate to meet the needs and clinical status of the individual. implantable cardioverter defibrillators. including brief abstence. G G For people with diagnosed CHD 17 . in the dose of physical activity until clinical stability is achieved. congenital and valvular heart disease Consensus expert opinion underpins that persons with any of the above cardiac conditions aim for the recommended dose of physical activity. Level of evidence IV.National Heart Foundation of Australia physical activity recommendations for people with cardiovascular disease G exercise training for people with heart failure predominately affects peripheral adaptations29. Regular physical activity for people with symptomatic heart failure is best initiated under the supervision of a trained exercise professional where. appendix 3). and where levels of supervision increase as functional class deteriorates. deterioration in a person's clinical status may necessitate a reduction. with more frequent rest days.38 Level of evidence II. involving older men with CHD who undertook low to moderate physical activity these men had significantly lower all-cause mortality over the 5-year follow-up than their sedentary controls. especially if they adhere to physical activity for more than 28 weeks. without significant complications or adverse outcomes.32 Level of evidence I.2 Older men with heart disease show improved functional capacity and mental wellbeing from engaging in regular physical activity.36. findings from a recent meta-analysis indicate improved clinical outcomes in CHF patients who are physically active. if not all days of the week.

family/career support.and microvascular complications may necessitate down modulation of the recommended dose to minimise further problems inherent to this condition.42 Secondary mediators of physical activity participation include depression.2 People with either type 1 or type 2 diabetes of all ages.6 % of the population) had diabetes in 1999 –2000.5 diabetes40 and PVD. followed by increasing duration. with 24. Level of evidence IV.600 Australians aged 25 years and over (7. post-stroke fatigue and cultural issues. Level of evidence II. Stroke. For the more than forty thousand Australians who suffer a stroke each year.13 It is well recognised that people with PVD and diabetes as well as stroke survivors. with some degree of paralysis of one side of the body. grade of recommendation D Consideration should be given to any continuing neurological deficits or co-morbidities when tailoring physical activity advice for a stroke survivor. demonstrated that progressive physical activity is an effective treatment for improving walking distance.41 18 For people with diagnosed CHD . with good glycaemic control and free of complications.2 Recent high quality literature reviews of people with exercise-induced claudication.4% increase in the age standardised hospitalisation rate for PVD. grade of recommendation B Currently. Older people with heart disease or co-morbidities will inevitably progress more slowly. and may take many weeks to achieve interim targets. the emphasis should be centred on frequency (through the day and number of days). Initially.National Heart Foundation of Australia physical activity recommendations for people with cardiovascular disease For older people with CVD – management Consider modifying the dose to include low to moderate intensity and emphasise multiple shorter bouts daily. approximately one-third will make a complete recovery. PVD or diabetes – evidence Regular moderate physical activity has been recognised as an essential therapy to assist with risk-reduction for the prevention and treatment of stroke. or a range of other problems that may affect their quality of life and their ability to function in society. benefit from accumulating 30 minutes or more of moderate physical activity on most.288 hospitalisations for PVD in 2001– 02. PVD or diabetes – management Physical activity recommendations for stroke survivors with sufficient residual function are equivalent to the general dose recommendation. a third will die within 12 months and the remaining survivors will be permanently disabled. difficulty in communicating. between 1993–94 and 2001– 02 there was a 21. about 945.43 The presence of macro.4.5 Level of evidence II. if not all days of the week. However. will benefit from modification of multiple risk factors through a combination of intensive lifestyle interventions and pharmacotherapy.13 Level of evidence II. there are no Australian prevalence data for PVD. grade of recommendation B Stroke. grade of recommendation B Based on measured blood glucose levels.

Level of evidence IV. the influence of physical activity on cardiovascular risk factors is transient. declining approximately 5 and 7 mmHg systole and diastole. grade of recommendation D.44 The effect size of physical activity on individual risk factors is modulated by the dose of activity.7%. dyslipidaemia and hypertension. Insulin resistance and glucose tolerance There is accumulating evidence that physical activity. Similar reductions in blood pressure lasting for many hours have also been demonstrated among hypertensive people following an isolated exercise session. insulin resistance and glucose intolerance. the landmark Recovery in Coronary Heart Disease (ENRICHD) trial44 demonstrated the potential value that regular physical activity combined with conventional medical management improved mental health outcomes in depressed and socially isolated patients recovering from AMI. individual variation and any accompanying reductions in body mass secondary to kilojoule restriction. grade of recommendation B. low high-density lipoprotein cholesterol (HDL-C) concentrations.National Heart Foundation of Australia physical activity recommendations for people with cardiovascular disease Physical Activity and additional risk factors Effects of physical activity on the risk factors for CVD Physical activity favourably alters a number of established atherosclerotic risk factors. Evidence is also emerging for physical activity as a treatment for depression and social isolation in patients following AMI. grade recommendation B Physical activity can also be the basis for achieving and maintaining a healthy weight in persons with diabetes. including elevated blood pressure.47 Level of evidence I. with expedited diminishing effect following cessation of physical activity. physical inactivity. However. especially when accompanied by weight loss.6% and reductions in triglyceride of 3. respectively.46 Risk factor – management People with stable CVD and with coronary risk factors modifiable by physical activity should be encouraged to aim to achieve the recommended activity dose. Further. more substantial changes to these biomedical risk markers are likely to be achieved with appropriate concomitant pharmacological therapy.45 Level of Evidence I.49 The increased risk contributed by these psychosocial factors is of similar order to the more conventional CHD risk factors such as smoking. raised triglyceride concentrations. Blood pressure Blood pressure lowering effects of endurance physical activity is largest in those people with hypertension. and obesity. grade of recommendation D High density lipoprotein cholesterol and triglyceride concentrations A meta-analysis of studies involving adults who participated in at least moderate intensity aerobic physical activity for >12 weeks showed an average increase in HDL-C levels of 4. Level of evidence IV. grade recommendation A Physical Activity and additional risk factors 19 . Importantly. reduces insulin resistance and glucose intolerance.48 Depression and social isolation Depression and social isolation have recently been identified as independent risk factors for the prognosis of CHD.40 Level of evidence II. The merit of habitual physical activity in managing depression and social isolation in those with CVD is largely unknown. co-morbidities not withstanding.

Many of the patients with chronic conditions that GPs and practice nurses regularly see will benefit from being more physically active. In 2002.National Heart Foundation of Australia physical activity recommendations for people with cardiovascular disease Patient implementation Physical activity promotion in general practice Given population wide access to people of all ages General Practice is an important setting for promoting physical activity. non-government organisations and industry for lifestyle initiatives. A recent study of Australian doctors has shown that GPs feel it is part of their role to discuss physical activity with their patients and increase their patients' activity levels. can lead to modest (up to 10%) short-term increases in physical activity participation.54 They conclude that brief physical activity interventions involving verbal advice in combination with supporting written material.53. This combines motivational interviewing with a tailored approach to increasing an individual's level of physical activity. Evidence for the promotion of physical activity in general practice Currently there are three reviews of physical activity interventions delivered through general practice.55 The practical application can be achieved through the ‘5 As’ approach identified in Appendix 4. CVD is just one of many conditions that will benefit from this approach.50 GPs are regarded as a reliable source of health information and the consultation represents a unique opportunity to provide personalised counselling on behaviour change.52. For those with cardiovascular conditions the chronic disease management framework is one such opportunity where physical activity can be incorporated as a management strategy. 20 Patient implementation .51 Future opportunities for implementation exist with government. 85% of the Australian population attended a GP at least once. The integrated approach to chronic disease management and the recent advances in information technology and medical software development will enable the seamless incorporation of lifestyle interventions into the medical treatment and prevention of chronic conditions.

especially during warmer times of the year. including brief abstinence in some cases. They should also be advised to apply sun screen and wear a hat when undertaking physical activity in the outdoors. In this event care should be taken to closely monitor body weight and changes in signs and symptoms suggestive of peripheral/ pulmonary oedema. including high humidity. take medicines as prescribed. everyone should be advised to: G maintain adequate hydration prior. G G G Maintenance General practitioners can play a pivotal role with a person's adherence to physical activity. Having achieved at least 30 minutes on most and preferably all days of the week.National Heart Foundation of Australia physical activity recommendations for people with cardiovascular disease Progression and maintenance of physical activity Progression People commencing activity for the first time or re-establishing activity after a period of sedentarism should be encouraged to build up gradually to the recommended dose. Progression of physical activity will be slower for those with advanced CVD or co-morbidities. Longer disruptions associated with progression of disease or new co-morbidities will require greater modulations in intensity. the emphasis should be centred on frequency (through the day and number of days) followed by duration. Missing an occasional day each week is understandable and there is no need to play catch-up. Initially. refrain from drinking alcohol prior to accumulating the day's physical activity and from consuming a large meal in the hours immediately prior to activity. particularly of the musculoskeletal system. Progressing physical activity too quickly carries an increased risk of injury. curtail the time and intensity of physical activity during temperature extremes. the person's current level of physical activity and physical activity history and any additional cardiovascular or other co-morbidity that may impact on person's ability to safely participate. during and following physical activity. If for any reason a person’s habitual physical activity is curtailed for several weeks it is prudent to resume at a lower intensity and for a shorter duration. Having achieved the recommended dose. People on fluid restrictions and diuretics may be required to increase their level of hydration slightly or reduce their diuretic dose. duration and frequency. with particular consideration given for antianginal medicines timed for optimal therapeutic benefit during physical activity. G wear comfortable footwear and loose clothing suitable for the prevailing conditions. Part of the assessment should include identifying the intensity level of the sport. consideration may be given to progressing to moderate intensity activity. Resuming sports participation Those people with well-compensated clinically stable CVD interested in beginning or resuming competitive sport should discuss the appropriateness of such actions with their medical practitioners. Progression and maintenance of physical activity 21 . Practical/special considerations During physical activity. people should be actively encouraged and supported to continue the habit.

The Cardiac Society of Australia and New Zealand (CSANZ). et al. Bauman A. weightlifting. Smart N. Taylor RS. Exercise-based rehabilitation for coronary heart disease.34:838–44. 2004. Exercise for intermittent claudication (Cochrane Review). Circulation 2004. outdoor bicycling. 17. Stevenson C. Aroney CN. 2004. 10. Powell KE. 14. Ernst E. Physical activity. 19. Ainsworth BE. Resistance exercise in Individuals with and without cardiovascular disease. Vos T. Exercise and physical activity in the prevention and treatment of atherosclerotic cardiovascular disease. Marwick TH. 7. 2004. Allen RM. New England Journal of Medicine 1984.311:874–7. National Heart Foundation of Australia.114:902–6. 2003. Balady GJ. 20. Thompson PD. et al. National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand. stroke and vascular diseases – Australian facts 2004 (Cardiovascular Diseases Series No. Medical Journal of Australia 2005. et al. 6. 16. The American Journal of Medicine 2004. Medicine and Science in Sports and Exercise 1998. Ltd. Safety of medically supervised outpatient cardiac rehabilitation exercise therapy: a 16-year follow-up. 12. Reducing risk in heart disease. Weiss N. 2004. ExTraMATCH Collaborative. 13. 9. injury and risk factors. Mathers C. Heath G. Buchner D. Rees K. Armstrong T. Medicine and Science in Sports and Exercise 2001. et al. Kresnow MJ. Fletcher R. 5. Exercise training meta-analysis of trials in patients with chronic heart failure (ExTraMATCH). Epidemiology of musculoskeletal injuries among sedentary and physically active adults. and aerobics.National Heart Foundation of Australia physical activity recommendations for people with cardiovascular disease References 1. Recommended framework for cardiac rehabilitation '04. Gordon NF. 2004. et al. Australian Institute of Health and Welfare (AIHW).Physical activity and health: a report of the Surgeon General USDHHS. et al. Hootman JM. British Medical Journal 2004. Stephenson J. Danforth E Jr. National data elements for the clinical management of acute coronary syndromes. Department of Health. Cosa F. 2. Journal of the American Medical Association 1982. The incidence of primary cardiac arrest during vigorous exercise. AIHW and National Heart Foundation of Australia. health improvement and prevention. Bonzheim K. 21. Pollock ML. The costs of illness attributable to physical inactivity in Australia. Injury rates from walking. A preliminary study. 1996. 22). Medicine and Science in Sports and Exercise 2002. et al.247:2535–8. At least five a week.1(CD001800). Pina IL. Department of Health. Heart. Carleton RA. Franklin B. 22.30(8):246–9. Gordon S. 2001. Jensen MD. 8.33(6Suppl):S351–8.107:3109–16. Chest 1998. Gulanick M. 328(7433):189–96.109:2031–41. Circulation 2003. 22 References . Macera CA. Kesaniemi YK. 15. The CSANZ. Commonwealth of Australia. Fowler B. Incidence of death during jogging in Rhode Island from 1975 through 1980. et al.101:828–33.172: 592–6. Center for Disease Control and Prevention. The Australia burden of disease study: measuring the loss of health from disease.116:693–706. 18. Exercise training for patients with heart failure: a systematic review of factors that improve mortality and morbidity. Funk EJ. Chew DPB. National Heart Foundation of Australia. National Center for Chronic Disease Prevention and Health Promotion. 4. 2003. National Heart Foundation of Australia/Australian Cardiac Rehabilitation Association. Safety and performance guidelines for clinical exercise stress testing. Cochrane Database Systematic Review. United States Department of Health and Human Services (USDHHS). In: The Cochrane Library: John Wiley & Sons. et al. 3. Thompson PD. Circulation 2000. et al. Leng GC. et al. Physical activity and exercise recommendations for stroke survivors. Franklin B.182 (9 Suppl):S1–S16. Medical Journal of Australia 2000. et al. Siscovick D. Dose-response issues concerning physical activity and health: an evidence-based symposium. 11. Jolliffe JA.

Chatterjee K. Wannamethee SG. No. Esterbooks DJ. cardiothoracic ratio. Bricker JT. ACC/AHA 2002 guideline update for exercise testing: summary article. 41. Hambrecht R. and Gillespie C. Journals of Gerontology Series A: Biological Sciences and Medicine Sciences 1995.107:1210–25.7(1):6–19.4098:1531–40. Ejection fraction. 28.50A:M7–11.52(474):47–55. Yu J. Australian Institute of Health and Welfare (AIHW). 25. McKelvie RS. Tomlinson C. Effect of aerobic and resistance exercise training on vascular function in heart failure. 30.41(1):159–68. Jelinek M. ventricular arrhythmias.22:678–83. National Heart Foundation of Australia and National Stroke Foundation of Australia. et al. References 23 . A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise testing Guidelines). stroke and vascular diseases . Lloyd-Williams F. Gibbons RJ. Apstein CS. Cohn JN. 2000. Exercise training as a therapy for chronic heart failure: can older people benefit? Journal of the American Geriatric Society 2003. Shabetai R. Waldmann ML. and plasma norepinephrine as determinants of prognosis in heart failure. Froelicher ES. Effects of endurance training on mitochrondrial ultrastructure and fiber type distribution in skeletal muscle of patients with stable chronic heart failure.279(4):H1999–2005. Walker M. Mair FS. Smith LK. Heart and Circulatory Physiology 2000. Tabet JY. Circulation 1993.23(10):806–14. Leitner M. Balady GJ. 27. Cohen-Solal A. 29. European Heart Journal 1993. et al. Wenger NK.51(5):699–709. et al. 35. Exercise training and heart failure: a systematic review of current evidence. Circulation 2003. Balady GJ. 2004. Cardiac rehabilitation. et al.National Heart Foundation of Australia physical activity recommendations for people with cardiovascular disease 23. 14 No. peak exercise oxygen consumption. Circulation 2003. National Heart Foundation of Australia. AIHW Cat. 26. Shaper AG. Maiorana A. 2005. Krum H. British Journal of General Practice 2002. McMurdo ME. Heart. 31. Strutherd AD. Pina IL.108(5):554–9. et al. 32. Witham MD. et al. Updating the evidence that physical activity is good for health: an epidemiological review 2000–2003. Non-invasively determined surrogate of cardiac power ('circulatory power') at peak exercise is a powerful prognostic factor in chronic heart failure. The V-HeFT VA Cooperative Studies Group. 36. et al.76(12):977–9. Maresh CM. detection and management of people with chronic heart failure in Australia. Williams MA. A controlled trial of exercise training in older coronary patients. Department of Health and Human Services. On behalf of the National Heart Foundation of Australia and Cardiac Society of Australia & New Zealand Chronic Heart Failure Clinical Practice Guidelines Expert Writing Panel.55:263–6. Milani RV. American Journal of Cardiology 1985.87(6 Suppl):V15–6. CVD 13). 34. Agency for Health Care Policy and Research and the National Heart. 1995. O'Driscoll G. Journal of the American College of Cardiology 2003. 33. Journal of the American College of Cardiology 1997. Littman AB. Sindone A. McCartney N. Fiehn E. Circulation. Public Health Service. Temporelli PL. et al.Australian facts 2001 (Cardiovascular Disease Series No. Lung and Blood Institute. 40. Corra U. Abrams J. Journal of the American College of Cardiology 2002. rehabilitation and prevention. Logeart D. Early exercise training in patients older than 65 years compared with that in younger patients after acute myocardial infarction or coronary artery bypass grafting.29:1067–73. Exercise and heart failure. Comparison of hemodynamic responses to cycling and resistance exercise in congestive heart failure secondary to ischemic cardiomyopathy. 37. Ades P .102:1358–63. 39. Journal of Science and Medicine in Sport 2004. ACC/AHA 2002 Guideline update for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1999 Guidelines for the management of patients with chronic stable angina). Antiremodeling effect of long-term exercise training in patients with stable chronic heart failure: results of the exercise in left ventricular dysfunction and chronic heart failure (ELVD-CHF) Trial. Guidelines for the prevention. Dembo L. AIHW. American Journal of Physiology. et al. et al. et al. Physical activity and mortality in older men with diagnosed coronary heart disease. Johnson GR. 24. The American Journal of Cardiology 1995. 38. Lavie CJ. Benefits of cardiac rehabilitation and exercise training in secondary prevention in the elderly. Bauman AE. Journal of the American College of Cardiology 1993. Gibbons RJ. et al. Giannuzzi P .

Department of Health and Human Services.1249/01. Knox S. Medicine and Science in Sports and Exercise 2001. et al. Medicine and Science in Sports and Exercise. 48. Does counselling help patients get active? Systematic review of the literature.3A.33(11):1855–61. 56. 2003. Journal of Family Practice 2000. and mortality after myocardial infarction in the ENRICHD Trial. Response of blood lipids to exercise training alone or combined with dietary intervention.National Heart Foundation of Australia physical activity recommendations for people with cardiovascular disease 42. Position stand: Exercise and hypertension. Glasgow RE. 2005. Journal of Science and Medicine in Sport 2004. Babyak MA. 2000. National Public Health Partnership. Riley KM. 52. Getting Australia active: Towards better practice for the promotion of physical activity. 47. National Stroke Foundation. Journal of the American Medical Association 2003.178:272–6.289(22):2913–6. General practice activity in Australia 2003-04. National Institute of Clinical Studies. Melbourne. 43. et al.36(5):746–755. American Diabetes Association and the American College of Sports Medicine. Medicine and Science in Sports and Exercise 2001. 53. et al. et al. Medical Journal of Australia 2003. 46. Beliefs. 24 References . Exercise. 45. Medicine and Science in Sports and Exercise 2004. Cohen SJ. Bailey WC. 51. Britt H.7(1 suppl):52–59. 2004. Eakin EG. Physical activity promotion through primary care.88514. Sanchez OA. Petrella RJ. DOI: 10. Estabrooks PA. U. Review of primary care-based physical activity intervention studies: effectiveness and implications for practice and future research. Blumenthal JA. 2002. Public Health Service. Esler MD. Harris P .48:72–80. Kulikowich JM. Leon AS. National Stroke Foundation. The effectiveness of physical activity interventions for the treatment of overweight and obesity and type 2 diabetes. Bellew B. attitudes and practices among GPs in relation to the promotion of physical activity in general practice – a qualitative study. GEP 16). Bauman A. 44. Fiore MC. Vita P . Miller YD. 49. 54. "Stress" and coronary heart disease: psychosocial risk factors. depression. Pescatello LS. Colquhoun DM. American College of Sports Medicine. 50.(27Suppl):1S58–63. Clinical practice guideline. Australian Institute of Health and Welfare. et al. The after affects of dynamic exercise on ambulatory blood pressure. No.MSS. Dzewaltowski D.33(6 Suppl):S502–15. (AIHW Cat. 533–553. Treating tobacco use and dependence. Canadian Family Physician 2002.S. Carney RM. Lattanzio CN. Physical activity/exercise and diabetes.49(2):158–68. Glasgow RE.0000115224. 55. Diabetes Care 2004. Smith BJ. Miller GC. Bunker SJ. Clinical guidelines for stroke rehabilitation and recovery (draft). Dunstan DW.

Note: in particular circumstances where an ambulance is not readily available. Take aspirin (150–300mg) unless your doctor has advised you not to take it. If rest does not bring rapid relief of the chest pain/discomfort. Stop and rest immediately 2. If symptoms are not relieved completely within 10–15 minutes by medication and rest. such as in a rural environment: G Quickly notify the nearest hospital. health clinic or doctor for advice. Call 000 for an ambulance immediately and rest quietly while waiting for transport or assistance – regard this pain/discomfort as a heart attack. take your nitrate medication (e. and It maybe appropriate to arrange for someone to drive you to the hospital. chest pains or discomfort while doing physical activity you should: 1.National Heart Foundation of Australia physical activity recommendations for people with cardiovascular disease Appendices Appendix 1 Chest Pain/Discomfort Action Plan Always carry your nitrate medication when you engage in physical activity. then 3.g. 6. G Appendices 25 . The dose of nitrate medication may be repeated 5 minutes after the initial dose 5. Inform your doctor as soon as possible about this episode of chest pain/discomfort If the pain/discomfort does not go away with rest and 1 tablet or spray then: 4. ‘Anginine’ or ‘Isordil’ sub-lingual tablets placed under your tongue or ‘Nitrolingual’ spray) and if the pain/ discomfort goes away with rest and 1 tablet or spray. If you develop angina.

December 2003.g.g.g.e. G G G G G G ** Active practice: taking the lead in prescribing physical activity. Moderator’s Guide. sandwich. during and after prolonged physical activity if using insulin or oral insulin secretagogue for extra carbohydrate needs and/or delayed hypoglycaemia** Advise patients about how to prevent or manage hypoglycaemic events including potential post exercise hypoglycaemia (i. jelly beans Advise patients if pre exercise BGL is <6mmol/L to eat before engaging in physical activity e. and Advise patients to check feet after physical activity for blisters. NSW Division. need for carbohydrates and fluids) Advise patients against physical activity if they are unwell or if their BGL is elevated e. 26 Appendices . > 15mmol/L Advise patients to carry a rapid acting sugar source at all times e. fruit Advise patients to wear correct supportive footwear. warm areas or redness.National Heart Foundation of Australia physical activity recommendations for people with cardiovascular disease Appendix 2 General Physical activity safety advice for people with diabetes G Inform patients to check their blood glucose level (BGL) before. National Heart Foundation of Australia.

Symptoms of CHF present at rest (severe CHF) >7 Class I Class II 5 Class III 2–3 Class IV 1. palpations.5ml O2. Brown and Co.kg-1 body weight Appendices 27 . 1964. dyspnoea or angina pectoris (mild CHF) Marked limitation on physical activity.6 †† adapted from the criteria committee of the New York Association: Nomenclature and criteria for the diagnosis of the heart and great vessels (6th Edition). Ordinary physical activity results in fatigue. 1 MET=3. Boston: Little. Less than ordinary physical activity leads to symptoms (moderate CHF) Unable to carry on any physical activity without discomfort. dyspnoea or palpations (asymptomatic LV dysfunction) Slight limitation on physical activity. # MET (Metabolic Equivalent) is defined as the resting VO2 for a 40-year-old 70kg man.min-1. Ordinary physical activity does not cause fatigue. .National Heart Foundation of Australia physical activity recommendations for people with cardiovascular disease Appendix 3 New York Heart Association Grading for Heart Failure†† NHYA Grading Metabolic# Equivalent No limitations.

It is essential to assess each patient's risk factor profile and ensure that there are no contraindicators to initiating or increasing physical activity. can lead to modest (about 10%) short term increases in physical participation. To tailor the materials to each patient. it is realistic to expect that one in ten patients who receive a physical activity intervention will increase their physical activity. osteoarthritis. overweight.53.56 The following questions should be used when assessing a patient’s physical activity levels and will be 28 Appendices . habits and preferences. Assess: screen patients to identify current physical activity levels. those who would benefit from a physical activity intervention (patients with CVD. baseline activity levels and physical activity preferences) are also beneficial Improvements were seen with interventions by GPs. i.54 Therefore. diabetes. stroke. These reviews conclude that brief interventions involving verbal advice in combination with supporting written material. The ‘5As’ are an evidence-based framework for structuring smoking cessation in health care settings and part of the ‘US Treating Tobacco Use and Dependence clinical practice guidelines’. Address some of the barriers that may have been identified earlier.53 Ask: identify target patients with risk factors.National Heart Foundation of Australia physical activity recommendations for people with cardiovascular disease Appendix 4 Key Components of successful intervention strategies Several international reviews have assessed the effectiveness of physical activity interventions in the general practice setting. Advise: provide brief advice or counselling about the benefits of physical activity (tailored to each patient's situation) and outline appropriate ways in which they may initiate or increase physical activity levels. hypertension. Assist: provide written materials such as pamphlets or leaflets. nurses and health educators G G G G Based on these findings the ‘5 As’ should be used to develop a physical activity intervention. Key findings from these reviews showed that: G Interventions that focused on physical activity alone were more successful than those that included multiple risk factor intervention Brief counselling was as effective as more lengthy counselling Provision of written materials was associated with better outcomes Tailoring the intervention to patient characteristics (readiness to exercise. consider a written exercise prescription that outlines individual goals and recommendations. and identify any barriers to participation. It is also important to tailor the program towards each patient's readiness to change. Strategies that target individuals in this way can help to provide education that is appropriate for each patient's needs and situations (see below for assessment questions). osteoporosis.e. hypercholesterolemia. and those recovering from a fall or fracture). Arrange: follow-up and/or referral to allied health professionals or to community providers of appropriate exercise programs.

0 1 2 3 4 5 6 7+ Score 2. Activity Scoring Key To determine the patient's score for each of the three questions add the scores for questions 1. A GP should of course take into account their own knowledge of the patient when making their activity assessment and prescription. 0.National Heart Foundation of Australia physical activity recommendations for people with cardiovascular disease used as part of the National Lifestyle Prescription initiated by the Commonwealth Department of Health. A score of 5 or more indicates that the patient is doing the recommended amount of physical activity per week. as per the National Physical Activity Guidelines. 2 and 3 to obtain a total activity score. 0 1 2 3 4 5 6 7+ Score 3. How many times a week do you usually do 20 minutes or more of vigorous-intensity physical activity that makes you sweat or puff and pant? (e. How many times a week do you usually do 30 minutes or more of walking? (e. and so on. at least two and a half hours of moderate intensity activity. One hour of continuous moderate physical activity counts as two periods of 30 minutes.g. digging. carrying light loads. jogging. their score for that question will be 2. 1. How many times a week do you usually do 30 minutes or more of moderate-intensity physical activity that increases your heart rate or makes you breathe harder than normal? (e.g. if the patient has circled 2 for question one. Appendices 29 . The aim is to find out how many periods of 30 minutes of moderate (20 minutes of vigorous) physical activity you do in a week. 0 1 2 3 4 5 6 7+ Score Total Thank you for your help. bicycling at a regular pace or doubles tennis). walking from place to place for exercise. 1 = Low 2 – 4 = Nearly There 5+ = Active The recommended level of physical activity is equivalent to 5 or more points. heavy lifting. For example. leisure or recreation). aerobics or fast bicycling).g. that is.

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National Heart Foundation of Australia physical activity recommendations for people with cardiovascular disease Notes Notes 31 .

National Heart Foundation of Australia physical activity recommendations for people with cardiovascular disease 32 Notes .

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