SHOULD I CHECK MY PATIENT’S FITNESS LEVEL?

Robert M Pepper, DO, FAAFPAssociate Professor of Clinical Sciences

West Virginia School of Osteopathic Medicinerpepper@osteo.wvsom.edu

CRF

Ability respiratory and circulatory systems to deliver oxygen to working muscles during sustained exercise

Maxim

al intensity

VO2 MAX AND CV DISEASE

MENAGE 20-39 40-49 50-59 60+

20% >50 >47 >42 >37

20% <36 <34 <31 <26

AGE 20-39 40-49 50-59 60

20% >41 >38 >34 >31

20% <29 <24 <24 <23

WOMEN

VO2 max normative values: Male

Schwartz W, Reibold RC. Aviat Space Environ Med 1990

VO2 max normative values: Female

Schwartz W, Reibold RC. Aviat Space Environ Med 1990

Fitness≠

Exercise

NON-MODIFIABLE

•Age•Gender•Genotype

• Physical Activity• Smoking• Obesity• Cardiopulmonary disease

MODIFIABLE

CRF

CARDIORESPIRATORY FITNESS MEASURES

VO2 Max:maximum amount of O2 that can be utilized during intense sustained exercise

CARDIORESPIRATORY FITNESS MEASURES

METSMetabolic Equivalent Tasks

METABOLIC EQUIVALENT TASKS

1 MET = energy produced average person seated at rest

METS AVERAGE WALKING SPEED

Walking 3.1 mph

3.4 METS

METS x 3.5= VO2 Max

<9 9-14 >14

AVOIDING SCA

Low vs High CRF 48% SCA

1 MET 14%

CardiorespiratoryFitnessandRiskofSuddenCardiacDeathinMenandWomenintheUnitedStatesMayoClinicProceedings,2016-07-01,Volume91,Issue7,Pages849-857

ALMOST SMOKING

Low aerobic capacity in middle-aged men associated with increased mortality rates during 45 years of follow-up.

European Journal Preventive Cardiology, July 2016

1913 TRIAL: 792♂ X 45 YEARS

Smoking > VO2max > HTN > Lipids

European Journal Preventive Cardiology, July 2016

Association of Leisure-Time Physical Activity With Risk of 26 Types of Cancer in 1.44 Million Adults.JAMA Intern Med. 2016;176(6):816-825.

esophageal adenocarcinoma (HR, 0.58; 95% CI, 0.37-0.89), liver (HR, 0.73; 95% CI, 0.55-0.98), lung (HR, 0.74; 95% CI, 0.71-0.77), kidney (HR, 0.77; 95% CI, 0.70-0.85), gastric cardia (HR,

Esophageal

LiverLung

KidneyGastricEndometrial

LeukemiaMyelomaBladder

HeadandNeck

RectalColonBreast

HIGHEST IMPACT: ALL CAUSE MORTALITY

•Smoking•Cardiorespiratory fitness

Smoke/Exercise

Lipids

Hypertension

lipids

hypertension

cardiorespiratoryfitness

smoking

Measure me!

Wen et al Lancet 378, 1244-1253 (2011)

AHA SCIENTIFIC STATEMENT

ALL HEALTHY ADULTS SHOULD HAVE CRF MEASURED

CIRCULATION NOV 30,2016

AHA SCIENTIFIC STATEMENT

•MORE RISK FACTORS: START EARLIER

•FOR CRF ASSESSMENT, NOT DIAGNOSIS CAD

CIRCULATION NOV 30,2016

CHRONIC DISEASE

•KNOWN CORONARY DISEASE•CONGESTIVE HEART FAILURE•COPD•PERIPHERAL ARTERY DISEASE

MAXIMAL HEART RATE WITH CPX MEASURES

VO2 Max TestingAll Healthy

Adults

Max Exercise

#2

Submax#3

Calculator#4: easy/fast

Gas Exchange

Gold standard

CRF TESTING STEP 1: DECONDITIONED OR UNSURE

Duke Activity Status Index

“DASI”

DASI

Maximum: 9.89 METS (VO2≅34)

Low to low-moderate fitness

STEP 2: CRFVO2 CALCULATOR

DASI >9 or younger, higher level of functioning

Cardiac Exercise Research Group “CERG”

CRF: STEP 2CERG VO2 CALCULATOR

•Need resting and maximum heart rate

•Vital statistics•Exercise volume and frequency

•Age•Height (cm)•Weight (kg)•No B-blockers

•Max heart rate•Exercise frequency

•Resting HR•Waist (cm)

VO2 MAX

HTTPS://WWW.NTNU.EDU/CERG

MAX HEART RATE then

VO2 AND METS CALCULATORS: AMERICAN HEART ASSOCIATION

Not a substitute for maximal exercise testing

limits prosC

alcu

lato

rs

Max heart rate

• Resting heart rate

• Waist circumference

More stats• Exercise

frequency• Exercise

intensity

VO2 Max

CRF ASSESSMENT: ACTIVE

Submaximal•6 minute walk test•Rockport One Mile walk Test Maximal•Ramp protocols: Treadmill or Bike

VO2 Max TestingAthletes only?

Max Exercise

#2

Submax#3

Calculator#4: easy/fast

Gas Exchange

Gold standard

ATS 6MWT

•No definitive parameters•Better for treatment assessment

•<500 meters ?poor prognosis

1 MILE WALK TEST (ROCKPORT)

PROS• Minimal resources• Done independently

• Cohort limitations (30-69 yoa)

• Need accurate measurements

• Time

LIMITATIONS

VO2 MAX TESTING

CALCULATOR

CERG• Underestimates fit

• Requires subjective data

• Not substitute for exercise test

6MWT

• For advanced deconditioning

1 mile walk test

• Cohort dependent

• Multiple measurements

• Time=GXT

SUBMAXIMAL

VO2 Max TestingAthletes only?

Max Exercise

#2

Submax#3

Calculator#4: easy/fast

Gas Exchange

Gold standard

MAXIMAL EXERCISE TESTING

•Not for diagnosis of CAD!

•Exercise capacity evaluation

MAXIMAL EXERCISE TESTING=LAB, NOT OFFICE

•Known Coronary disease•Congestive Heart Failure•Peripheral Arterial Disease•Chronic Obstructive Pulmonary Disease

CRF: ACTIVEMAXIMAL EXERCISE TESTING

STEP 1

•Administer pre test questionnaire

•Par-Q+ validated

MAXIMAL EXERCISE TESTING

•Easy•Inexpensive•Most are walking

VALIDATED TREADMILL PROTOCOLS

•Bruce protocol•Balke•Modified Balke

MOST

REFERENCE ARTICLES

Estimating VO2 peak from a nonexercise prediction model: the HUNT Study, Norway.

Nes, BM et alMed Sci Sports Exerc: 2011 Nov;43(11):2024-30.

Reference Articles