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Medicamentos y Ejercicio
Medicamentos y Ejercicio
Many patients who are refewed forphysical therapy take medications that af-
fect either their physiological responses to exercise or their ability to exercise.
Claire Peel
Kurt A Mossberg
m e purpose of this article is to discuss how medicationspotentially can affect
cardiovascular responses to exercise. m e effects of selected medications on
heart rate, blood pressure, and electrocardiographic responses during exercise;
on exercise performance; and on training adaptations are discussed. m e types
of medications included in this review are beta-adrenergic receptor antagonists,
vasodilators, diuretics, digitalis, and antiarrhythmic agents. m e mechanisms of
action and the clinical indications are described for each category of drugs.
Ways in which each of the categories of drugs interacts with exercise responses,
exercise performance, and training adaptations are described. Knowledge of a
person's medications can provide valuable information on current physical
condition and medical history and can alert therapists as to how exercise re-
sponses may be altered. Potential complications that are likely to occur during
exercise can be identijied, facilitating the design of safe and effective treatment
programs. [Peel C, Mossberg KA. Effects of cardiovascular medication on exer-
cise responses. Phys mer. 1995; 75387-396.1
The role of the physical therapist in- Although the incidence of heart dis- how different classes of cardiovascular
cludes monitoring physiological re- ease has decreased in recent years, medications affect responses to activity
sponses to activity and determining conditions that involve the cardiovas- may have an impact on the interpreta-
whether the responses are appropriate cular system remain common in the tion of evaluative findings and treat-
for the individual based on the indi- adult popu1ation.l Hypertension, con- ment planning.
vidual's past and present medical gestive heart failure, and coronary
history. Many cardiovascular medica- artery disease increase in incidence as Most medications that are prescribed
tions have the potential to alter re- persons become older.2 Many patients for cardiovascular disease have either
sponses to both acute and chronic who are referred to physical therapy a direct or indirect effect on the heart
exercise in a predictable manner. for orthopedic, neurological, or gen- or vascular system, including altering
Knowledge of how common drugs eral medical problems may have coex- myocardial oxygen consumption,
alter responses assists therapists in isting involvement of the cardiovascu- peripheral blood flow, and cardiac
assessing the safety and appropriate- lar system. Simple questioning of these preload or afterload. Medications may
ness of exercise and in determining individuals as to the medications that either increase or decrease exercise
the effectiveness of exercise training. they are taking can provide valuable capacity, or alter the expected changes
information about their current condi- in heart rate and blood pressure that
tion or medical history. Knowledge of normally occur with an increase in
activity.39 Medications can also be
effective in controlling an abnormality
(eg, a cardiac arrhythmia) at rest, but
C Peel, PhD, PT, is Associate Professor and Chair, Department of Physical Therapy, The Univer-
sity of Texas Medical Branch, Galveston, TX,77555-1028 (USA). Address all correspondence to Dr not during activity. By documenting
Peel. patients' physiological responses while
they are performing physical activities,
KA Mossberg, PhD, PT, is Associate Professor, Department of Physical Therapy, The University of
Texas Medical Branch. therapists can provide valuable feed-
Alterations in Responses to
Acute Exercise
that can occur under resting condi- Clinical Indications
tions. In addition, agents that block Beta-blockers depress the increases in
both alpha-1 receptors and beta- Beta-blockers were originally devel- HR, BP, and myocardial contractility
receptors have been developed. These oped to treat angina, and now they that normally occur with exercise. The
-
medications are effective in decreasing are also used for hypertension and Figure summarizes the HR and BP
BP by preventing sympathetic stirnula- cardiac arrhythmias. Long-term use responses to activity in both persons
tion of the heart and by producing has been shown to decrease mortality who are asymptomatic and patients
arterial vasodilation. after myocardial infarctions.l8 Their with hypertension, coronary artery
effectiveness in the treatment of angina disease, rhythm disturbances, and
cardiomyopathy.+832l In patients with
myocardial ischemia and angina, beta-
blockers tend to increase exercise
tolerance because of the decreases in
Table 3. Common Examples of Direct-Acting and Indirect-Acting myocardial oxygen requirement.22
Vasodilators Typically, patients are able to exercise
for longer periods before the onset of
Medication angina. The decrease in myocardial
Action Generic Trade oxygen demand is primarily a result of
a decreased HR response, producing a
decrease in rate-pressure product
(RPP). End diastolic volume tends to
Nitrates Nitroglycerin Nitrostat
increase, resulting in an increase in SV
Nitro-bid
and ventricular wall tension. Unfortu-
lsosorbide dinitrate lsordil
nately, greater ventricular wall tension
Calcium antagonists Diltiazem Cardizem
during systole increases myocardial
Verapamil Calan
Nifedipine Procardia oxygen demand, partially offsetting the
Nicardipine Cardene beneficial effects of decreased HR and
Directly affects arterial Hydralazine Apresoline c0ntractility.~3
side of c~rculation Sodium nitroprusside Nipride
Facilitates opening of Minoxidil Loniten For people who are normotensive and
potassium channels for patients with hypertension, data on
Indirect-acting the effects of beta-blockers on exercise
ACEa inhibitors Captopril Capoten performance are unclear. Factors that
Enalapril Vasotec influence the response include the
Alpha-1 antagonists Prazosin Minipress individual's level of physical condition-
Centrally acting Methyldopa Aldomet ing, the specfic pharmacological agent
alpha-agonists Clonidine Catapres (selective versus nonselective), and the
dosage. In both asymptomatic subjects
"ACE=angrotensen-converting enzyme. and individuals with uncomplicated
Category
Medication
Generic Trade
had hypertension. Other researchers2'
have reported maintenance of exercise
performance in well-conditioned sub-
jects taking carvedilol, a nonselective
beta-blocker with alpha-receptor
blocking properties. In general, with
beta-blocker administration, increases
in both SV and arteriovenous oxygen
Thiazides Hydrochlorothiazide Esidrix
Chlorothiazide Diuril
difference appear to compensate for
the decrease in HR. An increase in
Loop diuretics Furosemide Lasix
Furoside fatigue that is often reported with
Potassium-sparing agents Spironolactone Aldactone
initial use of beta-blockers tends to
Amiloride Midamor decrease with regular use.28
Alterations in Responses to
hypertension, nonselective beta- mal exercise capacity in asymptomatic Exercise Training
blockers tend to decrease maximal subjects.25 Cohen-Solal and col-
exercise performance in a dose- l e a g u e ~documented
~~ no effect on Because of the attenuated HR re-
dependent manner.24Beta-1 selective Vo,rnax or duration of exercise in sponse during exercise, the ability of
agents have less of an effect on maxi- individuals who were untrained and persons taking beta-blockers to benefit
from exercise training has been ques-
tioned. After a 4-month program that
involved 90-minute sessions three
times per week at an intensity of 85%
of symptom-limited maximal HR pro-
duced increases in ~o,maxand de-
A creases in submaximal HR in persons
200
with coronary artery disease who were
-WITHOUT BETA BLOCKADE taking beta-blockers.29
Ia0 -WITH BETA BLOCKADE
3
m
60
I
0
mulate exercise prescriptions cannot
be used for patients taking beta-
I I I I I
blockers. Prescriptions need to be
40
0 25 50 75 100 125 150 175 200 based on an exercise stress test that is
FOWFR DLJTPLJT RNI performed whlle the patient is taking
the prescribed medication. Maximal
Flgure. Comparison of heart rate (A) and bloodpresst~re(B) wsponses in individ- HR cannot be predicted for patients
uals taking beta-receptor antagonists versus taking a placebo. Data are summarized taking beta-blockers because the ex-
from several source^.*^^^^ tent of the decrease is affected by the