2020 ESC Guidelines on sports cardiology and exercise in patients with cardiovascular disease
In October’s issue of Metabolic Health Digest, we covered recommended guidelines for the individual with cardiovascular risk factor and exercise in the elderly. In continuation to those 2020 ESC guidelines, we are going to summarize “exercise program recommended for patients with the chronic coronary syndrome for leisure time and competitive sports participation” and “recommended exercise for patients with chronic heart failure” in this month.
Antonio Pelliccia, Sanjay Sharma and other members of the European Society of Cardiology (2020) have come up with exercise recommendation in different types of cardiac problems.
Objective:
To provide safe and evidence-based exercise programs for patients with chronic coronary syndrome for leisure time and competitive sports participation.
To provide exercise programs for patients with chronic heart failure.
Method:
The guideline was developed from the currently available evidence and scientific and medical knowledge. The selected articles were later classified and graded depending on the usefulness/ efficacy of the procedure and methodology of clinical trials.
Recommended guidelines:
• Recommendations for sports participation
Asymptomatic chronic coronary syndrome (CCS) can be defined as coronary artery disease (CAD) without inducible myocardial ischemia on a functional imaging or conventional exercise stress test. For such individuals, as per the assessment and history participation in all types of exercise, including competitive sports, is recommended. Only if there is a considerable risk of an adverse event, individuals should be restricted from competitive sport.
• Recommendation for Established (long-standing) CCS
Encouragement for minimal physical activity is recommended for general and cardiovascular health for those with stable angina, asymptomatic and symptomatic individuals stabilized <1 year after ACS, or individuals with recent revascularization, and asymptomatic and symptomatic individuals >1 year after initial diagnosis or revascularization. Advice on intensive exercise and participation depends on several factors such as type and level of sport competition, fitness level of the individual patient, the profile of cardiovascular risk factor, presence of exercise-induced myocardial ischemia, exercise-induced arrhythmia, evidence of myocardial dysfunction. Low-risk individuals may engage in all competitive sports on an individual basis. Only age-related restrictions for older patients needs to be applied. Competitive sports should be restricted in individuals with ischemia. Such individuals may practice regular recreational exercise of low and moderate-intensity under clinical surveillance. These individuals may also participate in leisure sports, 2-3 times/week, in selected cases, if the intended activity is below (around 10 beats) the ischemic threshold and below the level of arrhythmias.
• Recommendation for Myocardial ischemia without obstructive disease in the epicardial coronary artery
Experts suggest following the same exercise recommendations as mentioned for long-standing CCS.
• Recommendations for initiating exercise after acute coronary syndrome
For a reduction in cardiac mortality and hospitalization in patients with CAD, exercise-based cardiac rehabilitation is recommended. Exercise activity suitable for individuals along with psychological and motivational support should be considered for individuals with CAD during initial days.
• Recommendations for exercise in young individuals/athletes with anomalous origins of coronary arteries (AOCA)
Sports activities for individuals with AOCA should be considered after evaluation and testing. In asymptomatic individuals with an anomalous coronary artery that does not course between the large vessels, does not have a slit-like orifice with the reduced lumen and/or intramural course, competition may be considered, after adequate counselling on the risks, provided there is an absence of inducible ischemia. In case of surgical repair of an AOCA, participation in all sports may be considered, at the earliest 3 months after surgery, only if they are asymptomatic and there is no evidence of inducible myocardial ischemia or complex cardiac arrhythmias during the maximal exercise stress test. Participation in most competitive sports with a moderate and high cardiovascular demand among individuals with AOCA with an acutely angled take-off or an anomalous course between the large vessels is not recommended.
• Recommendations for exercise/sports in individuals with myocardial bridging
Participation in competitive and leisure-time sports should be considered in asymptomatic individuals with myocardial bridging and without inducible ischemia or ventricular arrhythmia during maximal exercise testing. Competitive sports are not recommended in individuals with myocardial bridging and persistent ischemia or complex cardiac arrhythmias during maximal exercise stress testing
• Recommended exercise training dose for patients with chronic heart failure
Maximum exercise intensities should be monitored by heart monitor for prescribed exercise. If any exercise-induced arrhythmias are not observed then all types of recreational exercise activities as permitted. Regular follow up every 3-6 months should be scheduled after exercise recommendation. Different recreational activities are given below:
1) Aerobic Exercise
Frequency: 3-5 days/ week, optimally daily
Intensity: 40-80% of VO2 peak
Duration: 20-60 minutes
Mode: continuous or interval
2) Resistance Exercise
Frequency: 2-3 days/ week, balanced training daily
Intensity: Borg rating of perceived exercise (RPE) < 15 (40-6-% of 1 RM)
Duration: 10-15 repetitions in at least 1 set of 8-10 different upper and lower body exercises
3) Respiratory Exercises
Frequency: several sessions per week till 10-12 weeks
Intensity: 30% to 60% of maximal inspiratory pressure
Duration: 15-30 min
4) Aquatic exercises
Aquatic exercise is not recommended for patients with Heart failure. A recent study has shown that aquatic exercise training may be safe and clinically effective but more investigation is required.
• Recommendations for exercise prescription in heart failure with a reduced or mid-range ejection fraction
Regular discussion about exercise participation and the benefits of an individualized exercise prescription is recommended. Exercise-based cardiac rehabilitation is recommended in all stable individuals to improve exercise capacity, quality of life, and to reduce the frequency of hospital readmission. Clinical reassessment should be considered when the intensity of exercise is increased. Motivational and psychological support along with personalized recommendations under supervision should be considered. Low- to moderate-intensity recreational sporting activities and participation in structured exercise programs may be considered in stable individuals. High-intensity interval training programs may be considered in low-risk patients who want to return to high-intensity aerobic and mixed endurance sports.
• Recommendations for participation in sports in heart failure
Before considering a sports activity, a preliminary optimization of heart failure risk factor control and therapy, including device implantation (if appropriate), is recommended. Participation in sports activities should be considered in individuals with heart failure who are at low risk, based on a complete assessment. Non-competitive (low- to moderate-intensity recreational) skill, power, mixed, or endurance sports may be considered in stable, asymptomatic, and optimally treated individuals with HFmrEF. High-intensity recreational sports, adapted to the capabilities of the individual patient, may be considered in selected stable, asymptomatic, and optimally treated individuals with HFmrEF with an age-matched exercise capacity beyond average. Non-competitive (low-intensity recreational skill-related sports) may be considered in stable, optimally treated individuals with HFrEF. High-intensity power and endurance sports are not recommended in patients with HFrEF irrespective of symptoms.
• Recommendations for exercise and participation in sport in individuals with heart failure with a preserved ejection fraction
Moderate endurance and dynamic resistance exercise, together with lifestyle intervention and optimal treatment of cardiovascular risk factors are recommended. Competitive sports may be considered in selected stable patients without abnormalities on maximal exercise testing.
• Recommendations for exercise and participation in sport in heart transplant recipients
Regular exercise through cardiac rehabilitation, combining moderate-intensity aerobic and resistance exercise, is recommended to revert pathophysiology to pre-transplantation time, reduce cardiovascular risk induced by post-transplantation medical treatment, and improve clinical outcome. Recreational (low-intensity recreational) sports participation should be considered and encouraged in stable, asymptomatic individuals after therapy optimization. Eligibility for competitive sports involving low and moderate-intensity exercise may be considered in selected, asymptomatic individuals with an uncomplicated follow-up.
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