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Jurnal Olahraga
Figure 1 Simplified approach to prescribing physical activity in daily practice for cardiovascular disease prevention using the acronym ACTIVE.
Pre-exercise screening may be triggered by vigorous exertion. The risks for these
A careful history and physical examination are important to adverse events decrease significantly after the CV event, allowing
ensure that patients with CHD do not have residual ischaemic patients to safely enrol in CR as early as 1–2 weeks after hos-
symptoms, uncontrolled HF or threatening arrhythmias that pital discharge.33
Prior to prescribing PA for patients with CHD, physicians
should assess the patients’ exercise tolerance. Peak or symptom-
Table 3 Population studies evaluating the relationship between limited exercise testing should be considered to establish a base-
physical activity (PA) and coronary heart disease (CHD)/ line fitness level, determine the prescribed heart rate range for
cardiovascular disease (CVD) risk training, and evaluate for exercise-induced myocardial ischaemia
or arrhythmias that may alter ongoing medical management.33
Number of Patients should be continued on their usual medications during
Study participants Major findings
exercise testing to simulate the anticipated haemodynamic
Blair et al19 32 421 Inverse gradients for CVD mortality responses during exercise training.
Aerobic Centre across three levels of cardiorespiratory
Longitudinal Study fitness (low to moderate to high). Low
fitness was an independent predictor Exercise recommendations
of mortality among men (relative risk Recently discharged patients with CHD should be referred to
(RR) 1.52, 95% CI 1.28 to 1.82) and
CR for education, counselling and supervision, and monitoring
women (RR 2.10, 95% CI 1.36 to
3.21). of exercise training. After prescreening is completed to identify
Mora et al20 27 055 Inverse relationship between PA and those in whom CR should be delayed or prohibited, the general
Women’s Health incident CVD (p, trend, <0.001) and recommendation for patients is 30–60 min daily of
Study PA and incident CHD (p, trend, moderate-intensity PA for at least 5 days of the week and per-
<0.001) in women, with significance formed at an intensity of 40–80% of the peak heart rate.33 The
attenuated when accounting for risk
factors (p, trend, 0.36 for CVD; p,
subjective rating of perceived exertion using the Borg Scale can
trend, 0.05 for CHD), suggesting a be employed as an adjunctive modulator of exercise intensity.
considerable role of risk factors in the
association.
Sesso et al21 12 516 Significant reduction in relative risk of
Harvard Alumni CHD in more active middle-aged and Box 1 Indications for cardiac rehabilitation
Health Study elderly men compared with less active
men (p, trend, 0.003). Total PA (p,
trend, 0.042) and vigorous activity (p, ▸ Stable angina pectoris
trend, 0.02) showed the strongest CHD
▸ Myocardial infarction (non-ST-elevation myocardial infarction
risk reduction.
(NSTEMI) or ST-elevation myocardial infarction (STEMI))
Donahue et al22 8006 Significant reduction in relative risk of
Honolulu Heart CHD in the more active group within the past 12 months
Programme compared with the less active group in ▸ Undergone cardiac surgery (coronary artery bypass grafting
both middle-aged (RR 0.69, 95% CI (CABG), valve replacement/repair or heart/heart-lung
0.53 to 0.88) and elderly men (RR transplant) or percutaneous coronary intervention (PCI)
0.43, 95% CI 0.19 to 0.99).
▸ Systolic heart failure
Figure 2 Exercise training for secondary prevention of cardiovascular disease. Indications for referral to cardiac rehabilitation and the general
process of developing an exercise prescription for patients are outlined.
MODERATE CONTINUOUS VERSUS HIGH-INTENSITY media, health screening and education, and substantive modifi-
AEROBIC INTERVAL TRAINING cations to the community environment and public health pol-
Recent studies have compared the effectiveness of moderate- icies. A systematic review evaluated 10 studies and found that
intensity continuous exercise training versus high-intensity inter- community-wide programmes led to overall increases in PA,
val training on changes in aerobic capacity and measures of CV number of active residents and associated energy expenditure.49
function in coronary patients with and without postinfarction However, a 2015 Cochrane review of 33 studies involving
HF who were being optimally medically managed. Wisloff et al43 varied interventions and exercise intensities found no evidence
randomised 27 patients with stable postinfarction HF to either to support community-wide programmes for increasing popula-
moderate continuous training (70% of peak heart rate) or high- tion PA levels.50 Notably, the four studies identified as low-risk
intensity aerobic interval training (95% of peak heart rate) three for bias found no effect of community-wide interventions.50
times per week for 12 weeks or to a control group that received
standard advice regarding PA. Improvements in CRF (46% vs
14%, p<0.001), left ventricular remodelling and brachial artery Home-based programmes
flow-mediated dilation (endothelial function) were greater with Home-based interventions are varied in nature but often involve
high-intensity aerobic interval training than moderate continuous an initial educational session and subsequent contact by phone
training. Interval training seems more effective than continuous or letter.51 A 2013 Cochrane review analysed nine studies meas-
exercise for the improvement of aerobic capacity in CHD, but uring self-reported PA with at least 12 months follow-up and
additional long-term studies assessing safety, compliance, and found a moderate and significant pooled effect for remote inter-
morbidity and mortality following interval training are needed.44 ventions.51 Only two of those studies included assessments of
CRF, of which one found no significant difference between
RISKS OF PA groups. Yet, the pooled effect was moderate and positive.51–53
The potential risks of PA should also be considered when physi-
cians prescribe exercise to their patients. Although the most
Internet-based programmes
common risk is musculoskeletal injury, unaccustomed vigorous
Internet-based initiatives represent another emerging area of
PA can trigger adverse CV responses, including acute MI, malig-
growth. One meta-analysis of 34 randomised control trials com-
nant arrhythmias and sudden cardiac death. While musculoskel-
pared internet-based initiatives for increasing PA with usual-care
etal and CV complications from exercise increase with higher
control groups.54 Although these studies were limited by short
intensity PA, regular exercise and enhanced CRF unequivocally
follow-up times (range 2–52 weeks, median 12 weeks) and pub-
confer partial protection against them.45 46 When previously
lication bias, a small but significant effect was noted at 6
sedentary patients initiate an exercise programme, level walking
months.54 A subsequent review included non-randomised and
(2–3 METs) should be strongly recommended, gradually increas-
randomised-controlled trials, experimental studies lacking
ing the walking speed or intensity of exertion over time (2–3
control groups, and single-group observational studies.55 The
months), provided they remain asymptomatic. This ‘progressive
intervention duration ranged from 2 weeks to 13 months
transitional phase’ decreases injury and increases CRF without
(median 12 weeks). Forty-four of the 72 studies (61.1%)
going through a period during which each bout of vigorous
reviewed reported significant increases in PA after the interven-
exercise is associated with large spikes in relative CV risk.47 The
tion. However, only 6 of the 16 studies (37.5%) that included
safety of contemporary exercise based CR programmes is well
extended post-intervention follow-up demonstrated increased
established, with a reported incidence of cardiac arrest and
PA levels that were maintained.55 Additional studies are needed
death approximating 1 in 115 000 and 1 in 750 000 patient
to clarify the effectiveness of these interventions.
hours of participation, respectively.25 26 33
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