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1. The term MET in exercise testing stands for metabolic equivalent of task or simply metabolic
equivalent, and is a physiological measure of energy cost of physical activity. One MET unit is 3.5 ml of
oxygen per kg per minute (245 ml for a 70 kg man) or 1 kcal (4.18 kj) per kg per hour. This would mean
that the resting caloric consumption for a 70 kg person would be: 70 MET units per hour or 1680 kcal in
24 hours. Very slow walking at 3 km per hour (1.875 miles per hour) doubles the energy consumption.

2. The source of energy for physical activity is ATP.
a. In anaerobic glycolysis, each mole of glucose produces 2 moles of ATP and 2 moles of lactic
acid. The subsequent metabolism of lactate in the extra-skeletal tissue claims the oxygen debt.
Lactic acid production results in generation of CO2 by buffering of bicarbonate to CO2, and this
increases the respiratory quotient (RQ = CO2 eliminated / O2 consumed) to a value > 1.
b. 32 ATP molecules are produced when glucose is metabolized to CO2 and water in oxidative
c. One creatine-P molecule in muscle is the source of one ATP at 1 to 1 ratio, and the total muscle
content is about 450 mmol (the concentration, 15 mmol per liter of muscle water).

3. There are two types of muscles:
a. White muscle: has larger diameter fibers, low myoglobin content, and less mitochondria, larger creatine-
P and glycogen content, and fewer capillaries, and is involved in quick production of ATP by anaerobic
glycolysis. White muscles are involved in work of short duration and high intensity, such as sprinting and
weight lifting.
b. Red muscle: the opposite of white muscle, has more myoglobin, and uses glucose and fatty acids from
circulation for slow and sustained work.

4. Common measures of exercise intensity:
a. Heart rate
b. Tidal volume
c. Respiration rate
d. Oxygen consumption
e. CO2 production rate
f. Work load
g. Plasma lactate
h. Arterial blood gas
i. Subjective Rating of Perceived Exertion (RPE): Borg Scale

5. Oxygen consumption rises linearly with increasing work load, and then reaches the peak (VO2max),
which is, in a normal healthy person about 8 to 12 fold of the resting level, about 35 to 40 ml per kg per
minute. In world class athletes this value increases up to 80 to 90 ml per kg per minute. The world
record is 97 ml per kg per minute.

6. Anaerobic threshold (AT): The work load at which lactic acid accumulation begins so serum lactate is
increased, and RQ is greater than 1, and this occurs at about 60% of the maximum work load. Both VO2
max and AT are reduced by heart disease and sedentary life style. AT is a good predictor of endurance
performance. After AT, metabolic acidosis stimulates ventilation in addition to the stimulation by
increased CO2 production, and PCO2 falls below normal.

7. In a normal person without lung disease, ventilation and gas diffusion are not a limiting factor for
oxygen delivery; cardiac output (CO) is the limiting factor.

8. Cardiac Output (CO) = SV x HR. In a healthy young individual, CO increases about 4 fold; a 3 fold increase
is due to increased heart rate, and a 1.33 fold increase is due to increased stroke volume: 3 x 1.33 = 4.

9. Blood pressure (BP) increases slightly during exercise, mainly systolic BP, because of the increased CO.
Although peripheral vascular resistance decreases markedly but proportionately less than the increase
in CO, hence the slightly higher BP.

10. Cardiac consumption of oxygen increases more than 3 fold with peak exercise mainly because of the
increased HR, but also because of increased systolic BP, and the best indicator myocardial oxygen
consumption is: HR x Systolic BP.

11. The increased oxygen consumption of the heart must be met mainly by coronary vasodilation because,
unlike skeletal muscle which extracts only of the oxygen delivered in resting state and therefore has a
room to increase the extraction during exercise, cardiac muscle extracts 50% of oxygen at rest, and
therefore further increase in oxygen consumption must come largely from increased coronary blood
flow. This explains why angina occurs with coronary stenosis.

12. BORGs Rating of Perceived Exertion (RPE) scale was originally 15 (6 to 20) and is updated to 12 (0, 0.5, 1
to 10). RPE measures the subjective perception of the level of difficulty of exercise. RPE of 4 to 6
corresponds to 70 to 85% of maximum heart rate (220 age), and this level of exercise is recommended
for a healthy person. For a patient with heart disease the target is a heart rate of 70% of the maximum.

13. Karvonen Formula is another formula widely used to determine the appropriate level of exercise for a
person with heart disease (target heart rate zone) and is estimated as:
Lower limit: [(max heart rate resting heart rate) x 0.7] + resting heart rate
Upper limit: [(max heart rate resting heart rate) x 0.8] + resting heart rate

14. Oxygen consumption = CO x (arterial oxygen content mixed venous oxygen content). Another way of
determining oxygen consumption is:
(O2 content of inspired air O2 content of the expired air) x ventilation volume

15. Oxygen content of blood = oxygen bound to hemoglobin + dissolved oxygen =

= (Hgb x oxygen saturation fraction x 1.34 ml) + (PO2 x 0.003)
For a person with 15 g/dL of hemoglobin, 100 ml of oxygen contains about 20 ml of oxygen, and
1 liter contains 200 ml of oxygen.

16. Cardiovascular responses to exercise include:
a. Increased HR
b. Increased SV
c. Increased systolic BP with unchanged diastolic BP
d. Reduced peripheral vascular resistance almost inversely proportionate to increased CO
e. Increased oxygen extraction due to lower tissue PO2, acidic pH, and higher tissue PCO2
f. Increasing hemoglobin concentration due to veno-constriction and some splenic contraction
g. Increased catecholamine secretion

17. Slow adaptation to exercise:
a. More oxidative enzymes, and less glycolytic enzymes, more mitochondria
b. More capillaries
c. More slow fibers and less fast fibers
d. Increasing SV by ventricular dilatation (Athletes heart) and resting bradycardia
e. Increased blood volume

18. The main mechanism of increased cardiac output in a trained endurance athlete is increased cardiac
output caused by dilatation of the ventricles (heart rate is not higher), and this is the main mechanism of
increased oxygen delivery. A higher SV with the same heart rate means greater cardiac output. At rest,
cardiac output is not higher, and therefore CO is maintained normal by slower resting heart rate. Lance
Armstrongs heart rate at rest at his peak was reported to be 32/min.

19. Metabolic effects of chronic exercise include: Lower LDL and total cholesterol, TG, and higher HDL
cholesterol, increased insulin sensitivity, and increased BMR.

20. Overall long-term health benefits include: Lower incidence of osteoporosis, diabetes, and breast cancer,
and emotional well-being and weight loss.

21. The caloric content of one lb of fat is calculated as following: one lb equals 453 g. Since the water
content of fat tissue is 14%, 86% of 453 g is the weight of fat: 453 x 0.86 = 389 g. Since each g of fat gives
off 9 calories, 389 g will give off 3500 kcal. Thus, to lose one lb of fat requires consumption of 3500 kcal.

22. Recommendation for exercise: 30 to 45 minutes of moderate aerobic exercise per day, 3 to 4 times a

23. A sudden death during exercise is one of the dangers of exercise, but overall chance of sudden death is
lower in a person who regularly exercises than in a person who does not, including those with a heart

24. Hyponatremia is common in marathon running, and contributing factors include water drinking, Na loss
from sweating, and release of water when glycogen is metabolized; each g of glycogen contains 2.7 ml
of water, and a typical glycogen consumption is about 6oo g in a marathon run.

25. About 80% of energy for vigorous exercise, e.g. marathon run, comes from metabolism of
carbohydrates, mainly glycogen. Fat is a minor source of energy during peak exercise. Transportation of
fatty acid from adipose tissue to the muscle is a slow process, as fatty acid must be bound to albumin for

26. In a healthy normal person, cardiac output during a peak exercise increases about 4 fold of the resting
level, and 3 fold increase is due to increased heart rate, and 1.33 fold increase due to increased stroke

27. Since oxygen consumption during peak exercise increases 10 to 12 fold, while CO increases only 4 fold,
the difference is explained by increased oxygen extraction by the muscle. Typical increase in oxygen
extraction is about 3 fold; oxygen saturation drops from arterial to mixed venous blood from 100 to 75%
at rest, and at peak exercise from 100 to 25%.

28. The best estimate of myocardia oxygen consumption during exercise is the heart rate and systolic BP;
since the heart rate triples, and systolic BP increases somewhat during exercise, myocardial oxygen
consumption increases more than 3 fold during peak exercise.

29. Increased myocardial oxygen consumption during exercise is met mostly by increased coronary blood
flow, because even in resting state the heart extracts 50% of oxygen delivered (the rest of the body
extracts only 25%), it does not have much room to increase the extraction further. This is the reason
why angina is common when a person with severe coronary stenosis exercises.

30. Chronic isotonic exercise tends to cause dilatation of the left ventricle (athletes heart), and this is
mainly responsible for the higher CO and higher VO2max in a trained athlete. Since SV is greater, for the
same maximum heart rate, CO is greater.

31. At rest, these trained athletes have bradycardia. A person who has 150 ml of SV needs the heart rate of
only 33 per minute in order to have CO of 5 liters per minute.