2023+CSANZ立场声明：心脏康复中运动和体力活动的评估和处方临床指南（英文版）.pdf

Heart,Lung and Circulation(2023)-,-1443-9506/23/$36.00https:/doi.org/10.1016/j.hlc.2023.06.854POSITION STATEMENTA Clinical Guide for Assessment andPrescription of Exercise and PhysicalActivity in Cardiac Rehabilitation.A CSANZ Position StatementChristian Verdicchio,PhDa,b,1,*,Nicole Freene,PhDc,d,1,Matthew Hollings,PhDa,1,Andrew Maiorana,PhDe,f,Tom Briffa,PhDg,Robyn Gallagher,PhDa,Jeroen M.Hendriks,PhDb,h,Bridget Abell,PhDi,Alex Brown,PhDj,David Colquhoun,MBBS,PhDk,l,Erin Howden,PhDm,n,Dominique Hansen,PhDo,Stacey Reading,PhDp,Julie Redfern,PhDaaFaculty of Medicine and Health,University of Sydney,Sydney,NSW,AustraliabCentre for Heart Rhythm Disorders,University of Adelaide,SAHMRI and Royal Adelaide Hospital,Adelaide,SA,AustraliacPhysiotherapy,Faculty of Health,University of Canberra,Canberra,ACT,AustraliadHealth Research Institute,University of Canberra,Canberra,ACT,AustraliaeAllied Health Department,Fiona Stanley Hospital,Perth,WA,AustraliafCurtin School of Allied Health,Curtin University,Perth,WA,AustraliagSchool of Population and Global Health,University of Western Australia,Perth,WA,AustraliahCaring Futures Institute,College of Nursing and Health Sciences,Flinders University,Adelaide,SA,AustraliaiAustralian Centre for Health Services Innovation and Centre for Healthcare Transformation,School of Public Health and Social Work,Queensland University of Technology,Brisbane,Qld,AustraliajTelethon Kids Institute,Australian National University,Canberra,ACT,AustraliakFaculty of Medicine,University of Queensland,Brisbane,Qld,AustralialFaculty of Medicine,Wesley Medical Centre,Brisbane,Qld,AustraliamBaker Heart and Diabetes Institute,Melbourne,Vic,AustralianBaker Department of Cardiometabolic Health,University of Melbourne,Melbourne,Vic,AustraliaoUHasselt,REVAL/BIOMED(Rehabilitation Research Centre),Hasselt University,Hasselt,BelgiumpDepartment of Exercise Sciences,University of Auckland,Auckland,New ZealandReceived 19 June 2023;accepted 27 June 2023;online published-ahead-of-print xxxPatients with cardiovascular disease benefit from cardiac rehabilitation,which includes structured exerciseand physical activity as core components.This position statement provides pragmatic,evidence-basedguidance for the assessment and prescription of exercise and physical activity for cardiac rehabilitationclinicians,recognising the latest international guidelines,scientific evidence and the increasing use oftechnology and virtual delivery methods.The patient-centred assessment and prescription of aerobic ex-ercise,resistance exercise and physical activity have been addressed,including progression and safetyconsiderations.KeywordsCardiac rehabilitation?Secondary prevention?Coronary disease?Cardiovascular disease?Exerciseassessment?Exercise prescription?Physical activity?Position statement*Corresponding author at:Dr Christian Verdicchio,Faculty of Medicine and Health,University of Sydney,Sydney,NSW,Australia;Centre for Heart RhythmDisorders,University of Adelaide and Royal Adelaide Hospital,Adelaide,SA,Australia;Email:christian.verdicchiosydney.edu.au;Twitter:c_verdicchio1Co-first authors?2023 The Author(s).Published by Elsevier B.V.on behalf of Australian and New Zealand Society of Cardiac and Thoracic Surgeons(ANZSCTS)and the CardiacSociety of Australia and New Zealand(CSANZ).This is an open access article under the CC BY license(http:/creativecommons.org/licenses/by/4.0/).HLC3932_proof 24 July 2023 1/14Please cite this article in press as:Verdicchio C,et al.A Clinical Guide for Assessment and Prescription of Exercise and PhysicalActivity in Cardiac Rehabilitation.A CSANZ Position Statement.Heart,Lung and Circulation(2023),https:/doi.org/10.1016/j.hlc.2023.06.854IntroductionCardiovascular disease(CVD)is the leading cause of deathand disease burden globally 1.Improvements in diagnosis,treatment and long-term management have improved survi-vorship and reduced hospitalisations following a cardiacevent,howevertheyhavealsogreatlyincreasedthenumberofpatients requiring ongoing and lifelong CVD risk manage-ment 2,3.To reduce the risk of future events,internationalguidelines recommend all eligible patients have access to,andparticipate in,secondary prevention programs,includingcardiacrehabilitation4,5.Cardiacrehabilitationisacomprehensive,multidisciplinary intervention consisting ofpatient assessment and individualised risk profile manage-ment,dietary advice,exercise prescription and physical ac-tivity counselling and psychosocial support 6.The NationalHeart Foundation of Australia,the Australian CardiovascularHealth and Rehabilitation Association(ACRA)and the Na-tional Heart Foundation of New Zealand all promote cardiacrehabilitation and have online resources that can provide re-ferrers with a list of local services available for their patients.Exercise-based cardiac rehabilitation has demonstrated effec-tiveness for reducing hospitalisations and myocardial infarc-tion rates,whilst improving risk profile,exercise capacity andquality of life in patients with coronary disease 7,8.Exerciseprogrammingalso benefits patientswith other cardiovascularconditions such as heart failure(both reduced and preservedejection fraction)9,10,atrial fibrillation 11,peripheralvascular disease 12,congenital heart disease 13,valve dis-ease 14,pulmonary hypertention 15 and,more recently,with cardio-oncology patients 16.A graduated program of structured exercise and physicalactivity is a core component of comprehensive cardiac reha-bilitation 17.Recent studies have described new exercisetrainingtechniques,which haveimprovedour understandingof the physiological adaptations from exercise training acrossdiverse patient groups.Furthermore,recent data have alsoprovided a greater understanding of technology and virtualdelivery methods for the prescription of exercise and physicalactivity within cardiac rehabilitation programs.A patient-centred approach is important,and communication with pa-tients should be non-judgemental and respectful.Shared de-cision making,where patients and their carers are activelyinvolved in the care process,results in personalised in-terventions that are more likely to improve engagement,treatment adherence,and clinical outcomes 18.Concomi-tantly,health professionals should consider evidence,guide-lines and behaviour change theories,techniques,and toolswhen collaborating with patients,identifying their individualexercise and physical activity needs,values and preferences.Realistic short-and medium-term goal setting may beconsidered,andfollow-upshouldbediscussedandsupportedby the entire multidisciplinary team as they are central to thepatients rehabilitation journey 18.The objective of this position statement is to providepragmatic,evidence-based guidance for the assessment andprescription of exercise and physical activity by all cliniciansworking within cardiac rehabilitation(e.g.,exercise physiol-ogists,nurses,physiotherapists)in the Australian and NewZealand context.Specifically,the aim is to summarise theassessment and prescription recommendations for aerobicexercise,resistance exercise and physical activity for all pa-tients referred for secondary prevention of their recent car-diac event or a new diagnosis.To do this,a multidisciplinarywriting group was convened comprising of experts fromrelevant disciplines,with regional,gender and cultural rep-resentation to ensure diversity.A consensus process wasthen followed to draft,review,and refine the document.Theposition paper was then submitted to the Cardiac Society ofAustralia and New Zealand,ACRA,Exercise and SportsScience Australia,and the Australian Physiotherapy Asso-ciation for endorsement.Aerobic ExerciseAerobic exercise is defined as any activity that uses largemuscle groups that can be maintained continuously and isrhythmic in nature 19.Common forms of aerobic exerciseinclude walking,jogging,cycling,rowing and swimming.The benefits of aerobic exercise training within cardiacrehabilitation are well established 7,8.Cardiometabolicbenefits include(but are not limited to)improved insulinsensitivity and glycaemic control,reduction in inflammatorymarkers,reduced visceral fat,improved vascular functionand blood pressure control,improved lipid metabolism,improved skeletal muscle structure and function and modestimprovements in left ventricular function 10,20,21.AssessmentThe ACRA cardiac rehabilitation core components state thatall patients should receive“an individualised initial assess-ment that includes physical,psychological and social pa-rameters”17.This assessment enables the development andimplementation of an individualised exercise program basedon the aerobic exercise or functional capacity of the patient.An aerobic exercise assessment should be conducted toassess the patients aerobic exercise capacity.Prior to per-forming any exercise assessment,it is imperative that clini-cians consider all relevant contraindications(Table 1).Thegold-standard assessment for aerobic exercise capacity is acardiopulmonary exercise test(CPET)conducted on either atreadmill or cycle ergometer with gas analysis.However,thistest is limited to predominantly tertiary centres in Australiaand New Zealand due to the cost and specialised equipmentand staff required to conduct it.Several methods forassessing aerobic exercise capacity and functional exercisecapacity,and the pros and cons of each are summarised inTable 2.Prescribing and Progressing AerobicExerciseFigure 1 summarises the recommended clinician workflow inrelation to assessment,prescription and progression of2C.Verdicchio et al.HLC3932_proof 24 July 2023 2/14Please cite this article in press as:Verdicchio C,et al.A Clinical Guide for Assessment and Prescription of Exercise and PhysicalActivity in Cardiac Rehabilitation.A CSANZ Position Statement.Heart,Lung and Circulation(2023),https:/doi.org/10.1016/j.hlc.2023.06.854aerobic exercise training.Informed by a comprehensiveclinical history and exercise assessment,the fundamentalprinciples of exercise prescription should be applied:Fre-quency,Intensity,Time,Type,Volume and Progression(FITT-VP)22.Frequency(F)considers how often the patientcompletes the exercise.Intensity(I)is the level of effort thepatient should be exercising at based on assessment of theirexercise capacity.Absolute intensity refers to the energyrequired to perform an activity(e.g.,caloric expenditure,absolute oxygen uptake,metabolic equivalent of task).Whereas relative intensity refers to the energy cost of theactivity relative to the individuals maximal capacity(e.g.,%maximumoxygenconsumptionorheartratereserve,perceived exertion).For individualised exercise prescription,a relative measure of intensity is recommended,especiallyfor deconditioned individuals 22.Time(T)is the durationof each exercise session.Type(T)is the mode of exercise to becompleted.Volume(V)is the total amount of exercisetraining,a product of frequency,intensity and time.Pro-gression is the commencement,advancement and progres-sion of intensity or volume over time 15.It is important tohighlight that rest or recovery within and between sessionsshould also be promoted for patients to maximise theiroverall health status and adaptations to exercise.Table 3provides FITT-VP recommendations for an individuallytailored aerobic exercise prescription at a moderate-high in-tensity.Table 4 provides a summary of the definitions oflight,moderate,high,andvery-highintensitieswhenassessing or prescribing exercise or physical activity.Moderate-Intensity Continuous TrainingVersus High-Intensity Interval TrainingIn Australia and New Zealand,exercise prescription guide-lines for cardiac rehabilitation have historically been moreconservative compared to those in Europe and America,focussing on low-to-moderate intensity exercise,with lesstechnical assessment of aerobic capacity 23.Moderate-intensity continuous training(MICT)is beneficial and safefor all patients with coronary disease and is strongly rec-ommended 6,24.More recently,high-intensity intervalTable 1Absolute and relative contraindications to exercise and physical activity.*Absolute ContraindicationsRelative Contraindications#Progressive worsening of exercise tolerance or dyspnoea atrest or on exertionover previous 35 days(uncompensated heart failure)2 kg increase in body mass over previous 13 daysUnstable anginaConcurrent continuous or intermittent dobutamine therapyBlood glucose,4.0mmol/L or.15.0mmol/L withsymptoms of weakness/tiredness,or with ketosisDecrease in systolic blood pressure with exerciseAcute systemic illness or feverNYHA functional class IVRecent embolism(,4 weeks)Complex ventricular arrhythmia at rest or appearing withexertionThrombophlebitisSupine resting heart rate?100 bpmActive pericarditis or myocarditis*Severe symptomatic aortic stenosisModerate aortic stenosisRegurgitant valvular heart disease requiring surgeryBlood pressure.180/110 mmHg(evaluated on a case-by-case basis)Previously undiagnosed atrial fibrillationSternal Instability Scale grade 12(minimally to partiallyseparated sternum)Sternal Instability Scale grade 3(completely separated)Resting heart rate.120 bpmOrthostatic blood pressure drop of.20 mmHg withsymptomsThird-degree atrioventricular block without pacemaker*Adapted from HeartOnline 52;American College of Sports Medicine Guidelines for Exercise Testing and Prescription 22;El-Ansary et al.34.*During recovery,limit to light to moderate intensity exercise until left ventricular dysfunction has resolved.#Relative contradictions are a guide only and should be combined with clinical judgement at every session.If in doubt,medical advice should be sought beforecommencing an exercise or physical activity assessment or session.Rapid weight gain may be a red flag for heart failure.Abbreviation:NYHA,New York Heart Association.Exercise in Cardiac Rehabilitation3HLC3932_proof 24 July 2023 3/14Please cite this article in press as:Verdicchio C,et al.A Clinical Guide for Assessment and Prescription of Exercise and PhysicalActivity in Cardiac Rehabilitation.A CSANZ Position Statement.Heart,Lung and Circulation(2023),https:/doi.org/10.1016/j.hlc.2023.06.854Table 2Types of aerobic exercise,muscle strength and physical activity assessments.Type of assessmentDescriptionProsConsAerobic CapacityCardiopulmonary Exercise Test(CPET)Incremental treadmill(Modified Bruce,Naughton,Balke protocols 52),or leg/arm ergometer test(Ramp protocol)withconcomitant expired air analysis.Gold standardValid and reliableTailored exercise prescriptionInvestigates the physiology of exerciseintolerance 53Assesses ventilatory responses toexerciseAssesses ventilatory thresholds(VT1 andVT2)Heart rate response to peak exerciseBlood pressure responsePeak VO2prognostic markerRequires supervision by an allied healthprofessional with extensive experienceand training in the ability to interpret anelectrocardiogram 54Medical Practitioner on site 55Generally limited to tertiary medicalcentres,often with specialist cardiacservicesExpensive equipment requiredG