PHYSICAL EXERCISE

Aerobic exercise

• Regular aerobic exercise is part of a healthy lifestyle and lessens several coronary risk factors.
• For lifelong compliance it needs to be enjoyable, convenient, and preferably social, hence the programme should fit individual needs. Examples are:
  • brisk walking
  • swimming
  • vigorous dancing
  • cross-country skiing
  • alternate walking and running
  • cycling
  • skipping
  • jogging
  • rowing
  • calisthenics
• Most people at low risk can undertake unsupervised exercise, after suitable instructions (see below).
• Exercise intensity is gauged by heart rate response (unless this is modified by cardiac drugs, e.g. beta-blockers), and by a subjectively perceived level of exertion.
• Exercise dosage comprises its frequency, duration and intensity.
• Before commencing the programme, a graded exercise ECG is recommended, for certain groups, to decide the level of activity that can be attained without adverse effects. This is required for sedentary persons aged over 35 years, patients with known coronary disease, those with a family history of premature coronary disease, and those at very high global risk of heart disease.
• Heart rate response can be self-monitored, and instructing patients to do so helps them achieve an appropriate level of exercise. The following heart rates during exercise are suitable for normal persons, but not for those taking cardiac drugs; target rates may need to be modified in the light of exercise ECG findings:

Age	Target rate per minute
20-29	115 - 145
30-39	110 - 140
40-49	105 - 130
50-59	100 - 125
60-69	95 - 115

Note: target rate equals 60 - 75 % maximum rates for age

The exercise regimen

• 5 - 10 minute warm-up phase, e.g. stretching, range-of-motion exercise.
• 20 - 30 minute aerobic phase, attaining target heart rate.
• 5 - 10 minute cool-down phase of gradually decreasing intensity of exercise.
• For the previously sedentary person, both, duration and intensity of the aerobic phase are set low initially, increasing progressively as fitness develops.

Duration and frequency

• Using target heart rates shown, and the duration given, the subject should exercise 4 - 5 times weekly.
• Alternatively, increased duration of aerobic phase (45 - 60 minutes) with frequency 2 - 3 times weekly.

The need for supervision

• Persons at high risk should exercise under supervision of a clinician, at least initially; those at low risk may, but need not, be supervised.
• High-risk patients requiring medically supervised exercise include those with:
  • severely depressed ventricular function
  • significantly reduced exercise capacity
  • high grade ventricular arrhythmias
  • hypotension or cardiac ischaemia at low exercise level
  • inability to self-monitor exercise intensity
  • persistently excessive heart rate during exercise
  • ECG monitoring may be necessary
• Persons at low risk, exercising unsupervised, should be made aware of the difference between acceptable tiredness (with rapid recovery) and excessive fatigue which must be avoided.
• Cough, chest pain or faintness during exercise should be reported to the doctor.
• Brisk walking is a valuable activity, especially for the unsupervised category, and is suitable for the elderly and previously sedentary coronary patients.

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