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Case studyn nMr.Wong is a 48-year old male,sales representative who travels oftenn n170cm,84kg,BMI 29n nHis brother just suffered from MI at age 40.n nConcerned about his healthn nWant to do start exercise and lose weight.Case studyMr.Wong is a 48-yea1Evaluationn nClassify client according to Risk Stratification Criterian nACSM/ACP/ACCVPR/AHAACSM/ACP/ACCVPR/AHAn nIdentify Major Coronary Artery Disease Risk Factorsn nIdentify signs or symptoms suggestive of cardiopulmonary diseasen nIdentify secondary risk factorsn nObesity,alcohol consumption,stress levelsObesity,alcohol consumption,stress levels.EvaluationClassify client acco2Case Studyn nRecently diagnosed to have type 2 DM,put on Recently diagnosed to have type 2 DM,put on DaonilDaoniln nBP 160/90 mmHg on metoprolol 50mg bdBP 160/90 mmHg on metoprolol 50mg bdn nHalf pack a day smoking habit due to stress of Half pack a day smoking habit due to stress of his jobhis jobn nHis brother just suffered from MI at age 40.His brother just suffered from MI at age 40.n nCholesterol level:6.2mmol/l,HDL 0.90 mmol/l,Cholesterol level:6.2mmol/l,HDL 0.90 mmol/l,LDL 3.8mmol/lLDL 3.8mmol/ln nTG:2.4 mmol/lTG:2.4 mmol/ln nNo regular exerciseNo regular exercisen nNo signs or symptoms of cardiopulmonary No signs or symptoms of cardiopulmonary diseasedisease.Case StudyRecently diagnosed t3Positive Risk Factors for CHD ACSM ACSM(2006)(2006)Family HistoryFamily Historyn nMyocardial infarction,coronary revascularization Myocardial infarction,coronary revascularization(bypass surgery)or sudden death before:(bypass surgery)or sudden death before:n nthe age of 55 years in father or other male first degree the age of 55 years in father or other male first degree relative(i.e.brother or son)relative(i.e.brother or son)n nthe age of 65 years in mother or other female first the age of 65 years in mother or other female first degree relative(i.e.sister or daughter)degree relative(i.e.sister or daughter)Cigarette smokingCigarette smokingn nCurrent cigarette smoker or those who have quit Current cigarette smoker or those who have quit in the last six monthsin the last six monthsHypertensionHypertensionn nClient on Hypertensive medicationsClient on Hypertensive medicationsn nResting SBP Resting SBP 140 mmHg and/or DBP 140 mmHg and/or DBP 90 mm Hg 90 mm HgFasting Glucosen Fasting blood glucose of 100mg/dL 5.6mmol/L).Positive Risk Factors for CHD 4DyslipidemiaDyslipidemian nTotal serum cholesterol 200mg/dL (5.2 mmol/L)orTotal serum cholesterol 200mg/dL (5.2 mmol/L)orn nHigh density lipoprotein(HDL)40mg/dL (1.03 mmol/L)High density lipoprotein(HDL)130mg/dL (3.4mmol/L)Low density lipoprotein(LDL)130mg/dL (3.4mmol/L)ObesityObesityn nBody Mass Index(BMI)Body Mass Index(BMI)30 kg/m 30 kg/m2 2 or orn nWaist girth=102 cm(M);=88 cm(F)orWaist girth=102 cm(M);=88 cm(F)orn nWaist/hip ration=0.95(M);=0.86(F)Waist/hip ration=0.95(M);=0.86(F)Sedentary LifestyleSedentary Lifestylen nNot participating in a regular exercise programNot participating in a regular exercise programn nAccumulating less than 30 minutes moderate intensity exercise 3-5 days Accumulating less than 30 minutes moderate intensity exercise 3-5 days weeklyweeklyPositive Risk Factors for CHD ACSM ACSM(2006)(2006)High level of HDLHigh level of HDLn nHDL cholesterol 1.6 mmol/L(60 mg/dl)HDL cholesterol 1.6 mmol/L(60 mg/dl)Negative Risk Factors for CHD ACSM ACSM(2006)(2006).DyslipidemiaPositive Risk Fact5Initial Risk Stratificationn nLow riskLow riskn nMen45 years of age and women 55 years of Men45 years of age and women 40 years,+/-CVD risk factorsAge 40 years,+/-CVD risk factorsAge 30 years and Age 30 years and Type 1 or 2 diabetes of 10 years duration Type 1 or 2 diabetes of 10 years duration Presence of any additional risk factor for coronary artery Presence of any additional risk factor for coronary artery diseasediseasePresence of microvascular disease(proliferative retinopathy or Presence of microvascular disease(proliferative retinopathy or nephropathy,including microalbuminuria)nephropathy,including microalbuminuria)Peripheral vascular disease Peripheral vascular disease Autonomic neuropathyAutonomic neuropathy.Cardiovascular System Assessme11Medications.Medications.12n nA constellation of cardiovascular risk factors A constellation of cardiovascular risk factors related to hypertension,abdominal obesity,related to hypertension,abdominal obesity,dyslipidemia,and insulin resistancedyslipidemia,and insulin resistancen nCertain drugs used to treat hypertension may Certain drugs used to treat hypertension may accelerate the appearance of new-onset accelerate the appearance of new-onset diabetes.In particular,both blockers and diabetes.In particular,both blockers and diuretics have been implicated in this effect.diuretics have been implicated in this effect.A constellation of cardiovascu13n nALLHATALLHATn nIn high risk hypertensive patients,the diuretic,chlorthalidone,was 43%In high risk hypertensive patients,the diuretic,chlorthalidone,was 43%more likely than the ACEI,lisinopril,to produce diabetes,but was also more likely than the ACEI,lisinopril,to produce diabetes,but was also 18%more likely than the calcium channel blocker,amlodipine,to produce 18%more likely than the calcium channel blocker,amlodipine,to produce this adverse effectthis adverse effect.n nHOPEHOPEn nThe development of new diabetes was reduced by 34%(p0.001)in the The development of new diabetes was reduced by 34%(p190mmHg systolic)Unusually high blood pressures(190mmHg systolic)during low-level activity may warrant adjustment in during low-level activity may warrant adjustment in medical therapymedical therapyn nStop when there is a 10 to 15mmHg fall in BP during Stop when there is a 10 to 15mmHg fall in BP during exercise and further evaluation should be performedexercise and further evaluation should be performedn nBegin pharmacological treatment prior t starting exercise Begin pharmacological treatment prior t starting exercise program if BP 160/100program if BP 160/100.Hypertension.26Rehabilitation in Coronary Heart Disease Mainly Mainly endurance trainingendurance training at an intensity of 50(-60)-75%of symptom-limited at an intensity of 50(-60)-75%of symptom-limited VO2max(or heart rate reserve,which is the VO2max(or heart rate reserve,which is the difference between maximal and resting heart rate)difference between maximal and resting heart rate)for 30 minutes 3-4 times weekly(minimum),full for 30 minutes 3-4 times weekly(minimum),full benefit is obtained with 5-6 times/weekbenefit is obtained with 5-6 times/weekResistance trainingResistance training in addition in additionat an intensity of 30-50%(up to 60-80%)of 1 RM at an intensity of 30-50%(up to 60-80%)of 1 RM(one repetition maximum),12-15 repetitions,1-3 sets(one repetition maximum),12-15 repetitions,1-3 sets twice weekly twice weekly.Rehabilitation in Coronary Hea27n nEnd.End.28
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