The role of exercise training in

cardiometabolic disorder patients

Muhammad Ridwan, MD, MAppSc, FIHA

Cardiology Department, Faculty of Medicine, Syiah Kuala

University / Dr. Zainoel Abidin Hospital, Banda Aceh

Presented at 3rd InaPrevent, Jogjakarta, 6 Agustus 2017

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Risk Factors of Cardiometabolic Disorders

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 Sedentary lifestyle vs physical inactivity
• Sedentary behaviors are typically performed in a sitting/ lying
position and result in minimal energy expenditure (≤1.5 metabolic
equivalents [METS])
• Physical activity: any bodily movement produced by skeletal muscles
that requires energy expenditure (WHO, 2013), the opposite of
physical inactivity
• Physical inactivity  sedentary
• Daily activity, leisure activity  active person
• Exercise (insidental vs programmed)  fitness

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 Physical activity vs physical fitness

A recent meta-analysis comparing the

dose–response relationships between
leisure-time physical activity and
fitness and their association with
cardiovascular events. The risk
reduction per 10% increment in
physical fitness showed a sharp drop
for fitness between the 15th and 25th
percentiles of fitness while there was a
steady decline over the entire range of
physical activity levels. This indicates
the potential for a ‘threshold effect’,
i.e. a minimal physical fitness to
reduce one’s cardiovascular risk.

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Proportion of SCD according to achieved METs during
Maximal Exercise Testing

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Low Fitness is a major risk factor for all-cause
Mortality

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Primary Prevention: benefit of being FIT

• Expert panels (CDC, ACSM, AHA, US Surgeon): more active or fit

individuals tend to develop less coronary heart disease (CHD) than
their sedentary counterparts.
• If CHD develops in active or fit individuals, it occurs at a later age and
tends to be less severe.

• How about its secondary prevention role?

Myers J. Cardiology patient pages. Exercise and cardiovascular health. Circulation.
2003;107(1):e2-5. Epub 2003/01/08.

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Recent Cardiometabolic Management

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Acute exercise
response of
body

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Chronic
adaptation to
exercise

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Kachur S, Chongthammakun V, Lavie CJ, De Schutter A, Arena R, Milani RV, et al.
Impact of Cardiac Rehabilitation and Exercise Training Programs in Coronary Heart
Disease. Prog Cardiovasc Dis. 2017. Epub 2017/07/12.

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 Effects of Shear Stress and Exercise on Endothelial Function

eNOS : endothelial nitric oxide synthase; L-Arg, L-arginine; BH4, (6R)-5,6,7,8-tetrahydro-L-biopterin; ADMA, asymmetrical dimethylarginine.
Current Opinion in Pharmacology 2013, 13:218–225

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 ES for Aerobic Exercise Training and BP

Eckel RH, Jakicic JM, Ard JD, de Jesus JM, Houston Miller N, Hubbard VS, et al. 2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk:
a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129(25 Suppl 2):S76-99

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 Evidence Statements for
Physical Activity and
Lipids

Eckel RH, Jakicic JM, Ard JD, de Jesus JM, Houston Miller N,
Hubbard VS, et al. 2013 AHA/ACC guideline on lifestyle
management to reduce cardiovascular risk: a report of the
American College of Cardiology/American Heart Association
Task Force on Practice Guidelines. Circulation. 2014;129(25
Suppl 2):S76-99

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Coronary microcirculatory adaptations to
chronic Exercise in normal subjects.
ACh, acetylcholine; M, muscarinic receptor; NE,
norepinephrine; 1, 1-adrenergic receptor; 1, 1-
adrenergic
receptor; 2, 2-adrenergic receptor; Kv, voltage-gated K
channel; KCa, Ca2-activated K channel; NO, nitric oxide.
Modified from Duncker and Bache

Laughlin MH, Bowles DK, Duncker DJ. The

coronary circulation in exercise training. American
journal of physiology Heart and circulatory
physiology. 2012;302(1):H10-23

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Coronary angiogram with injection of radiographic contrast medium
into the right coronary artery (RCA) and complete filling of the
proximally occluded (red circle) left anterior descending coronary
artery (LAD) via collateral channels (arrows).

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 Role of Exercise on CPC

Model for mobilization of circulating progenitor cells (CPCs) from the bone marrow by shear stress. Laminar shear stress results in eNOS activation and increase of NO. MMP-
9/MMP-2 is activated, resulting in sKitL release. SKitL confers signals enhancing mobility of CPCs. Along with stromal-derived factor-1a (SDF-1a) gradient, CPCs are mobilized into
circulation. CPC indicates circulating progenitor cells; MMP, matrix metalloproteinase; VCAM-1, vascular cell adhesion molecule-1; VLA4, very late antigen-4. Current Opinion in
Pharmacology 2013, 13:218–225

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 Change of coronary collateral flow
index of the target vessel after 4 weeks.
In comparison with usual care, the
coronary collateral flow index after 4
weeks was significantly increased
in patients performing high-intensity
(P=0.005) and moderate-intensity
exercise (P=0.004) with no significant
difference between training intensities.

Circulation. 2016;133:1438-1448. Coronary Collateral Growth

Induced by Physical Exercise

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Gielen S, Schuler G, Hambrecht R. Exercise training in coronary
artery disease and coronary vasomotion. Circulation.
2001;103(1):E1-6
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Can exercise be beneficial for Heart Failure Patients?
What cause fatigue in HF?

• The underlying mechanisms are not clearly

identified.
• Systolic or diastolic dysfunction (pump
problems, many of us aware of this)
• impaired peripheral perfusion during
exercise
• reduced oxidative capacity of skeletal
muscle
• impaired muscle strength
• Reflex mechanisms associated with
metabolism of skeletal muscle.
• Psychosocial problems
Dexler and Coats. Annual Review of Medicine. Vol.
47:241-256 22
 Reported Changes in Peak VO2 in
Aerobic Exercise-Trained CHF Subjects

Subjects are from 8 single-site,

randomized clinical trials in
patients with
congestive heart failure

: exercise-trained subjects

control subjects.
.

Ades PA, Keteyian SJ, Balady GJ, Houston-Miller N, Kitzman DW, Mancini DM, et al. Cardiac rehabilitation exercise and self-care for chronic heart failure. JACC Heart failure.
2013;1(6):540-7

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 Beneficial Effects of Exercise in Chronic Heart Failure

Ades PA, Keteyian SJ, Balady GJ, Houston-Miller N, Kitzman DW, Mancini DM, et al. Cardiac rehabilitation exercise and self-care for
chronic heart failure. JACC Heart failure. 2013;1(6):540-7

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 Health-related Physical Fitness Components
• Cardiorespiratory endurance: the ability of the circulatory and respiratory system to supply oxygen
during sustained physical activity
• Body composition: the relative amounts of muscle, fat, bone, and other vital parts of the body
• Muscular strength: the ability of muscle to exert force
• Muscular endurance: the ability of muscle to continue to perform without fatigue
• Flexibility: the range of motion available at a joint

The ACSM Guideline on Exercise Testing and Prescription 2017

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Conclusions

• Exercise play important role in improving hemodinamic parameters,

metabolic parameters, protrombolic states, endothelial dysfunction,
fitness level, as well psychosocial issues.
• Exercise is precious medicine

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