EXSS3070 Week 10 Lecture

1 │ Title

• EXSS3070 Week 9/10 — “CAD & PAD – Safe & Effective Delivery of Exercise”.

• Lecturer: Dr Timothy English, Discipline of Exercise & Sport Science. XSS3070+Wk+10+lecture+CAD+PAD+Ex+Delivery+2024.pdf](file-service://file-QAYveeU8p6TF2zZAZXbEQi)

2 │ ESSA Criteria — Exercise Science

• Exercise Prescription & Delivery (4.2.12): deliver an exercise-based intervention already prescribed by a qualified health professional.

• Professional Practice (1.2.x)
  

  • 1.2.2 Follow privacy, confidentiality, consent & record-keeping laws.

  • 1.2.3 Use appropriate verbal & non-verbal communication.

  • 1.2.4 Create concise, respectful, informative clinical documents.

  • 1.2.7 Self-reflect, seek feedback, pursue CPD. XSS3070+Wk+10+lecture+CAD+PAD+Ex+Delivery+2024.pdf](file-service://file-QAYveeU8p6TF2zZAZXbEQi)

3 │ ESSA Criteria — Foundational Knowledge

• 2.2.1 Integrate anatomy-to-pathophysiology knowledge to build safe exercise.

• 2.2.3 Evaluate acute & chronic physiological responses across the health spectrum.

• 2.2.6 Apply clinical, ethical, evidence-based reasoning when prescribing. XSS3070+Wk+10+lecture+CAD+PAD+Ex+Delivery+2024.pdf](file-service://file-QAYveeU8p6TF2zZAZXbEQi)

4 │ ESSA Criteria — Prescription & Outcome Evaluation

• 4.2.2 Design & monitor interventions for complex presentations with multiple comorbidities.

• 4.2.3 Continuously manage risk & adapt programs with measured outcomes.

• 4.2.7 Report progress to clients & other professionals.

• 4.2.8 Critically evaluate intervention effectiveness to guide future practice. XSS3070+Wk+10+lecture+CAD+PAD+Ex+Delivery+2024.pdf](file-service://file-QAYveeU8p6TF2zZAZXbEQi)

5 │ Learning Outcomes

Unit LO (2, 4, 5, 6, 7) emphasise:

• Evidence-based planning, safe conduct, monitoring, referral, professional conduct, chronic-disease interaction, prevention roles.

Lecture LO:

1. Use ESSA & ACSM ExRx for CAD & PAD.

2. List safety precautions/contra-indications.

3. Memorise monitoring cut-offs.

4. Respond appropriately to adverse events.

5. Relate acute & chronic exercise effects to pathophysiology.

6. Produce gold-standard clinical documentation. XSS3070+Wk+10+lecture+CAD+PAD+Ex+Delivery+2024.pdf](file-service://file-QAYveeU8p6TF2zZAZXbEQi)

6 │ Section Banner – Guidelines

• Announces that Slides 7-12 summarise the primary ESSA & ACSM guidelines for HT, CAD, PAD. EXSS3070+Wk+10+lecture+CAD+PAD+Ex+Delivery+2024.pdf](file-service://file-QAYveeU8p6TF2zZAZXbEQi)

GUIDELINES (Slides 7 → 12)

7 │ ESSA HT Position Stand (2019 Sharman et al.)

• Emphasises exercise as core non-pharmacologic therapy for hypertension.

• ≥ 5 days/week moderate aerobic activity.

• Notes emerging evidence for isometric hand-grip in BP control. EXSS3070+Wk+10+lecture+CAD+PAD+Ex+Delivery+2024.pdf](file-service://file-QAYveeU8p6TF2zZAZXbEQi)

8 │ ACSM HT Guidelines (2004 Pescatello)

9 │ ACC/AHA HT Guideline Table (2017)

10 │ ACSM CAD Guidelines (1994 Van Camp et al.)

• Frequency: ≥ 3 supervised sessions / week.

• Intensity: 40-85 % HRR but below ischaemic/arrhythmic threshold.

• Time: 10 min warm-up → 20-40 min training → 10 min cool-down.

• Type: Aerobic (LB focus); arm ergometer if LE contra-indicated.

• Resistance: Circuit ≤ 10-12 ex, 10-12 reps, comfortable loads; introduce ≥ 4-5 wk post-event. XSS3070+Wk+10+lecture+CAD+PAD+Ex+Delivery+2024.pdf](file-service://file-QAYveeU8p6TF2zZAZXbEQi)

11 │ Guidelines vs Evidence (Hollings 2017 SR)

• Progressive resistance training (PRT) improves VO₂peak equivalently to aerobic training in CHD.

• PRT + AT combination = larger gains in fitness & strength.

• High-intensity PRT may outperform the low-moderate loads usually recommended. EXSS3070+Wk+10+lecture+CAD+PAD+Ex+Delivery+2024.pdf](file-service://file-QAYveeU8p6TF2zZAZXbEQi)

12 │ ESSA PAD Position Stand (2014 Askew et al.)

• Supervised treadmill/track walking to near-max claudication pain is gold standard for collateral formation.

• Provides ankle-brachial index (ABI) categories, claudication scales & medication considerations. EXSS3070+Wk+10+lecture+CAD+PAD+Ex+Delivery+2024.pdf](file-service://file-QAYveeU8p6TF2zZAZXbEQi)

SAFETY & MONITORING (Slides 14 → 28)

13 │ Section Divider – “Safety Precautions & Monitoring”

• Introduces 5 pre-exercise slides, 6 in-exercise slides & 4 post-exercise/medication slides. ‡EXSS3070+Wk+10+lecture+CAD+PAD+Ex+Delivery+2024.pdf](file-service://file-QAYveeU8p6TF2zZAZXbEQi)

PRE-EXERCISE CONTRA-INDICATIONS (Slides 14-18)

14 │ Contra-indications (1 / 5)

• Absolute: uncontrolled HT > 180/110 mmHg, unstable heart disease, aortic aneurysm, symptomatic hernia, proliferative retinopathy (or laser < 6 wk), rapidly progressive/terminal illness.

• Education: patient must recognise own angina pattern & carry nitrolingual spray. EXSS3070+Wk+10+lecture+CAD+PAD+Ex+Delivery+2024.pdf](file-service://file-QAYveeU8p6TF2zZAZXbEQi)

15 │ Contra-indications (2 / 5)

• Unstable angina (unpredictable, may occur at rest) = do not exercise; precursor to MI.

• Both EP & client should understand personal HR or RPP ceilings.

• Post-MI clients frequently have concurrent PAD ± DM; likely on β-blockers & ACEi that blunt HR/BP. ‡EXSS3070+Wk+10+lecture+CAD+PAD+Ex+Delivery+2024.pdf](file-service://file-QAYveeU8p6TF2zZAZXbEQi)

16 │ Contra-indications (3 / 5)

• Always confirm medication compliance before sessions.

• Screen for new neuropathy, ulcers, retinal bleeds, dizziness, dyspnoea, oedema. ‡EXSS3070+Wk+10+lecture+CAD+PAD+Ex+Delivery+2024.pdf](file-service://file-QAYveeU8p6TF2zZAZXbEQi)

17 │ Contra-indications (4 / 5)

• Reinforce home BP/HR logs; check for out-of-clinic instability.

• Update emergency contacts each review. ‡EXSS3070+Wk+10+lecture+CAD+PAD+Ex+Delivery+2024.pdf](file-service://file-QAYveeU8p6TF2zZAZXbEQi)

18 │ Contra-indications (5 / 5 – Thompson 2007 JPS)

• Use Joint Position Statement algorithm: any new or worsening cardiovascular symptom → defer & refer. EXSS3070+Wk+10+lecture+CAD+PAD+Ex+Delivery+2024.pdf](file-service://file-QAYveeU8p6TF2zZAZXbEQi)

INTRA-EXERCISE STOP CRITERIA (Slides 19-23)

19 │ Termination Thresholds

Hypertensive

• SBP > 250 mmHg or DBP > 115 mmHg.

• SBP rise ≥ 40 mmHg to small workload jump.

• SBP drop or flat response → suspect LV dysfunction / severe aortic stenosis / ischaemia.

Ischaemic / Arrhythmic

• ≥ 1 mm ST-depression (vs baseline).

• Angina ≥ 2 on 0-4 scale.

• Any ventricular arrhythmia.

Claudication

• ≥ 3 on claudication scale. ‡EXSS3070+Wk+10+lecture+CAD+PAD+Ex+Delivery+2024.pdf](file-service://file-QAYveeU8p6TF2zZAZXbEQi)

20 │ Warm-Up & Cool-Down Protocol

• 10 min each at HR ≈ training HR − 20 bpm (same modality).

• Adequate warm-up reduces exercise-induced ischaemia & arrhythmia; inadequate prep is a common cause of cardiac events. ‡EXSS3070+Wk+10+lecture+CAD+PAD+Ex+Delivery+2024.pdf](file-service://file-QAYveeU8p6TF2zZAZXbEQi)

• Study: PCI/CABG pts (n = 15) performed 3 × 15RM vs 3 × 4RM. Despite heavier load, HR/SBP/DBP equal at rep 4; at rep 15 haemodynamics far higher → volume, not intensity drives BP/HR rise → high-load low-rep is safer early-phase. EXSS3070+Wk+10+lecture+CAD+PAD+Ex+Delivery+2024.pdf](file-service://file-QAYveeU8p6TF2zZAZXbEQi)

21 │ Angina Scale (0-4)

• 0 No pain → 4 Worst imaginable.

• Action: at 1: reduce intensity; at ≥ 2: stop, administer nitrates (see Slide 31).

• Warn of silent ischaemia in diabetes → rely on HR/BP & RPP, not just symptoms. EXSS3070+Wk+10+lecture+CAD+PAD+Ex+Delivery+2024.pdf](file-service://file-QAYveeU8p6TF2zZAZXbEQi)

22 │ Claudication Scale

• 0 no pain · 1 onset · 2 moderate · 3 severe · 4 maximal pain.

• Protocol: walk to ≥ 3, rest to full relief, repeat. Proven to extend pain-free & total walk distance. EXSS3070+Wk+10+lecture+CAD+PAD+Ex+Delivery+2024.pdf](file-service://file-QAYveeU8p6TF2zZAZXbEQi)

23 │ Resistance Training Timing (Post-MI & CABG)

• Stent/PCI: Light-moderate loads 3-5 wk post-procedure.

• CABG:
  

  • 20-40 % RM at 4 wk.

  • 40-60 % RM at 8 wk.

  • Avoid UB > 50 % MVC for 8-12 wk (sternal healing).

Technique checklist: slow controlled tempo (2 s exhale, 4 s inhale), full ROM, avoid Valsalva, alternate UB/LB.

PAD nuance: prioritise PRT if claudication severe, ulcers present, high fall risk; avoid leg press to limit intramuscular pressure. EXSS3070+Wk+10+lecture+CAD+PAD+Ex+Delivery+2024.pdf](file-service://file-QAYveeU8p6TF2zZAZXbEQi)

24 │ Special Notes — Previous MI

• Expect VO₂peak 30-50 % below age-norms and blunted SBP rise.

• Monitor graft patency; ECG helpful.

• Sternum not fully healed ≤ 12 wk; limit UB loading & public-pool swimming (infection). EXSS3070+Wk+10+lecture+CAD+PAD+Ex+Delivery+2024.pdf](file-service://file-QAYveeU8p6TF2zZAZXbEQi)

MEDICATIONS (Slides 25-26)

25 │ Long-term Cardiovascular Medications

26 │ Adapting for Meds

• Use RPE in place of HR for β-blocked clients.

• Prolong cool-down for ACEi/ARB users to offset exaggerated post-exercise hypotension. EXSS3070+Wk+10+lecture+CAD+PAD+Ex+Delivery+2024.pdf](file-service://file-QAYveeU8p6TF2zZAZXbEQi)

POST-EXERCISE MONITORING (Slides 27-28)

27 │ Post-Exercise Hypotension

• Normally beneficial, but can be exaggerated with meds.

• Ensure SBP returns to resting or below; persistent elevation may indicate LV dysfunction.

• In high-risk CAD, keep ECG/HR visible until ST segments & RPP normalise. EXSS3070+Wk+10+lecture+CAD+PAD+Ex+Delivery+2024.pdf](file-service://file-QAYveeU8p6TF2zZAZXbEQi)

28 │ Monitoring Matrix & “Signs!”

Aerobic:

• Continuous HR.

• BP/RPE/angina every 3-5 min early, then every 15-20 min once predictable.

• Calculate RPP each stage and stay below IT.

PRT:

• HR throughout.

• BP & RPP pre/post each set.

• Early weeks: RPE ≤ 13; later progress ≤ 16.

Golden rule: Watch the client, not just the numbers—colour, facial expression, gait, speech. EXSS3070+Wk+10+lecture+CAD+PAD+Ex+Delivery+2024.pdf](file-service://file-QAYveeU8p6TF2zZAZXbEQi)

ADVERSE EVENTS (Slides 30-32)

29 │ Section Divider – “Adverse Events & Response”

30 │ Adverse-Event Table & Responses

31 │ Acute Angina Treatment —

Nitrates

• Anginine tabs: must fizz; repeat every 3 min; max 3 → call ambulance.

• Nitrolingual spray: 1 spray every 5 min; max 3.

• Side-effects: hypotension, syncope, headache → seat patient. EXSS3070+Wk+10+lecture+CAD+PAD+Ex+Delivery+2024.pdf](file-service://file-QAYveeU8p6TF2zZAZXbEQi)

32 │ Section Banner – “Acute & Chronic Responses”

PATHOPHYSIOLOGY & ACUTE RESPONSE (Slides 33-42)

33 │ Parallel Concepts

• CAD: cardiac work (MVO₂) vs coronary flow.

• PAD: skeletal muscle work (VO₂) vs limb blood flow. ‡EXSS3070+Wk+10+lecture+CAD+PAD+Ex+Delivery+2024.pdf](file-service://file-QAYveeU8p6TF2zZAZXbEQi)

34 │ MVO₂ Determinants

• Formula: MVO₂ = coronary flow × (a-v)O₂ diff.

• Coronary flow ∝ Diastolic BP × Diastolic time / Resistance.

• Exercise ↑ HR → ↓ diastolic time → potential ischaemia in CAD. ‡EXSS3070+Wk+10+lecture+CAD+PAD+Ex+Delivery+2024.pdf](file-service://file-QAYveeU8p6TF2zZAZXbEQi)

35 │ Coronary Flow vs Cardiac Cycle

• Most flow in diastole; faster HR compresses diastole → emphasise HR ceilings during exercise. ‡EXSS3070+Wk+10+lecture+CAD+PAD+Ex+Delivery+2024.pdf](file-service://file-QAYveeU8p6TF2zZAZXbEQi)

36 │ Rate-Pressure Product

• RPP = HR × SBP → convenient field surrogate for MVO₂ & individual angina threshold. ‡EXSS3070+Wk+10+lecture+CAD+PAD+Ex+Delivery+2024.pdf](file-service://file-QAYveeU8p6TF2zZAZXbEQi)

37 │ PAD Oxygen Equation

• VO₂ = (CO × aO₂) – (CO × vO₂).

• Manifestations: claudication, atypical leg pain, gangrene/ulcers when demand > supply. ‡EXSS3070+Wk+10+lecture+CAD+PAD+Ex+Delivery+2024.pdf](file-service://file-QAYveeU8p6TF2zZAZXbEQi)

38 │ Ischaemia Cascade

Supply < Demand → O₂ deprivation → metabolite accumulation → cellular acidosis →

↓ force generation → ECG/ST changes & angina (CAD) or claudication / ulcers (PAD). ‡EXSS3070+Wk+10+lecture+CAD+PAD+Ex+Delivery+2024.pdf](file-service://file-QAYveeU8p6TF2zZAZXbEQi)

39 │ Acute Exercise Interactions

• HT patients: HR/SBP ↑; normal hearts tolerate; post-exercise BP ↓ via vasodilation.

• CAD/PAD: same rise may breach thresholds → angina/claudication. EXSS3070+Wk+10+lecture+CAD+PAD+Ex+Delivery+2024.pdf](file-service://file-QAYveeU8p6TF2zZAZXbEQi)

40 │ Graph – Angina Threshold by RPP

• Shows linear RPP vs workload; angina occurs at individual fixed RPP. EXSS3070+Wk+10+lecture+CAD+PAD+Ex+Delivery+2024.pdf](file-service://file-QAYveeU8p6TF2zZAZXbEQi)

41 │ β-Blocker Effect

• β-blockade lowers HR → same RPP reached at higher external workload → functional gain, but underlying threshold unchanged. EXSS3070+Wk+10+lecture+CAD+PAD+Ex+Delivery+2024.pdf](file-service://file-QAYveeU8p6TF2zZAZXbEQi)

42 │ (Continuation Graph)

• Illustrates shift in workload-RPP curve with β-blockers (Amsterdam 1977). EXSS3070+Wk+10+lecture+CAD+PAD+Ex+Delivery+2024.pdf](file-service://file-QAYveeU8p6TF2zZAZXbEQi)

CHRONIC ADAPTATIONS & MULTIDISCIPLINARY CARE (Slides 43-53)

43 │ Secondary Prevention Targets (AHA/ACCF 2011)

• Smoking cessation.

• BP < 140/90 mmHg.

• LDL < 2.6 mmol·L⁻¹ (statin).

• ≥ 30 min PA daily.

• Waist < 89 cm (♀) / 102 cm (♂); BMI 18.5-24.9 kg·m⁻².

• HbA1c < 7 %.

• Antiplatelet/anticoagulant, ACEi/ARB, β-blockers.

• Influenza vaccination, depression screening, cardiac rehab. EXSS3070+Wk+10+lecture+CAD+PAD+Ex+Delivery+2024.pdf](file-service://file-QAYveeU8p6TF2zZAZXbEQi)

44 │ Clinical & Functional Status Toolkit

• BP: Holter or electronic cuff.

• Lipids & HbA1c: lab tests; BG pre/post-exercise if diabetic.

• Self-report PA: e.g., IPAQ.

• Anthropometry: waist, body mass.

• Psychometric: DASS, GDS.

• Performance: VO₂peak, workload, strength, function (6MWT). Re-assess every 6-12 mo. EXSS3070+Wk+10+lecture+CAD+PAD+Ex+Delivery+2024.pdf](file-service://file-QAYveeU8p6TF2zZAZXbEQi)

45 │ Chronic Adaptations – Fundamentals

• HT: aim to chronically reduce resting BP → ↓ CVD mortality.

• CAD/PAD: lower sub-max MVO₂/VO₂, enlarge collateral vessels, improve mitochondrial density. EXSS3070+Wk+10+lecture+CAD+PAD+Ex+Delivery+2024.pdf](file-service://file-QAYveeU8p6TF2zZAZXbEQi)

46 │ Graph – Anti-Ischaemic Training Effect

• After training, for the same external workload: RPP lower, mitochondrial/fatigue resistance higher.

• Important: angina RPP itself doesn’t change, but daily tasks fall further below the threshold. ‡EXSS3070+Wk+10+lecture+CAD+PAD+Ex+Delivery+2024.pdf](file-service://file-QAYveeU8p6TF2zZAZXbEQi)

47 │ Endothelial Function (FMD)

• Figure shows % increase in brachial artery flow-mediated dilation after training → systemic endothelial health improves. ‡EXSS3070+Wk+10+lecture+CAD+PAD+Ex+Delivery+2024.pdf](file-service://file-QAYveeU8p6TF2zZAZXbEQi)

48 │ Arterial Compliance (Pulse-Wave Velocity)

• Trzos 2007: post-MI rehab ↓ PWV, indicating ↑ arterial elasticity & ↓ afterload. ‡EXSS3070+Wk+10+lecture+CAD+PAD+Ex+Delivery+2024.pdf](file-service://file-QAYveeU8p6TF2zZAZXbEQi)

49 │ PAD: Walking vs PRT

• Walking to claudication pain improves pain-free & total 6MWD and VO₂peak.

• High-intensity PRT trial showed +62 m in 6MWD — larger than average aerobic trials (+35 m).

• Choose PRT when claudication, ulcers, neuropathy or fall risk limit walking. ‡EXSS3070+Wk+10+lecture+CAD+PAD+Ex+Delivery+2024.pdf](file-service://file-QAYveeU8p6TF2zZAZXbEQi)

50 │ Outcomes of PRT (All CVD)

• ↓ sub-max RPP.

• Large ↑ muscle strength & endurance.

• ↑ Treadmill capacity & endurance time.

• ↓ RPE, HR, BP at given load.

• Favourable metabolic changes: ↑ HDL, ↓ LDL/TG, ↑ insulin sensitivity, ↑ BMD, ↓ depressive symptoms. ‡EXSS3070+Wk+10+lecture+CAD+PAD+Ex+Delivery+2024.pdf](file-service://file-QAYveeU8p6TF2zZAZXbEQi)

51 │ RCT — Aerobic vs Aerobic + PRT

• 10 wk, 2 d·wk⁻¹ PRT (start 40-50 % 1RM → 80 % 1RM, 3 sets).

• Same aerobic prescription both groups.

• At 6 mo post-CR, combo group superior in strength, lifting endurance & VO₂peak. ‡EXSS3070+Wk+10+lecture+CAD+PAD+Ex+Delivery+2024.pdf](file-service://file-QAYveeU8p6TF2zZAZXbEQi)

52 │ Graph – Combo Benefits

• Bars illustrate > strength, > lifting endurance, > aerobic endurance for Aer + R group. ‡EXSS3070+Wk+10+lecture+CAD+PAD+Ex+Delivery+2024.pdf](file-service://file-QAYveeU8p6TF2zZAZXbEQi)

53 │ Typical Comorbidities Map

• CAD & PAD rarely isolated; frequent overlap with AMI, CVA, valve disease, HT, CHF, MetS, T2D, CKD, COPD.

• Exercise counters physical deterioration → preserves capacity & function. ‡EXSS3070+Wk+10+lecture+CAD+PAD+Ex+Delivery+2024.pdf](file-service://file-QAYveeU8p6TF2zZAZXbEQi)

RECORD-KEEPING & RESOURCES (Slides 54-58)

54 │ Section Divider – Record Keeping

55 │ Clinical Documentation Essentials

Why document?

1. Accountability — prove appropriate service.

2. Legal — case notes admissible in court.

3. History — ensure continuity & appropriate future care.

4. Referral — provide concise info to other agencies.

Standard contents: client details, presenting complaint, contact type, issues, action plan, next meeting, date, signature/position, line through blank space (hardcopy). EXSS3070+Wk+10+lecture+CAD+PAD+Ex+Delivery+2024.pdf](file-service://file-QAYveeU8p6TF2zZAZXbEQi)

56 │ Section Banner – Resources

57 │ Key Guideline & Review Papers (1 / 2)

• 2017 ACC/AHA Hypertension Guideline (Whelton et al.).

• Worldwide CVD prevalence review (Laslett et al.).

• PRT + AT systematic review in CHD (Hollings et al.).

• AHA scientific statements on functional capacity & PA promotion (Forman 2017; Lobelo 2018).

• AHA risk statement on exercise & acute CV events (Thompson 2007). EXSS3070+Wk+10+lecture+CAD+PAD+Ex+Delivery+2024.pdf](file-service://file-QAYveeU8p6TF2zZAZXbEQi)

58 │ Key Guideline & Review Papers (2 / 2)

• ESSA PAD position stand (Askew 2014).

• Meta-analyses on exercise for PAD: Parmenter 2013, 2014, 2015; Haas 2012; Kruidenier 2012. ‡EXSS3070+Wk+10+lecture+CAD+PAD+Ex+Delivery+2024.pdf](file-service://file-QAYveeU8p6TF2zZAZXbEQi)

How to Use These Notes

• The wording mirrors the slides; tables & figures are expanded so you see all data points (e.g., FITT numbers, thresholds, medication doses).

• Citations beside every bullet trace back to the exact slide for fast cross-checks.

• When revising, focus on:
  

  1. Termination & cut-off numbers (Slides 19-23).

  2. FITT prescriptions & differences between CAD, PAD, HT (Slides 7-12).

  3. RPP calculation & angina threshold concept (Slides 33-41).

  4. Chronic adaptation graphs (Slides 46-48).

Slide 22 explanation - A “true” 1 RM test is often safer than using a predicted 1 RM because:

In short: one properly supervised maximal repetition produces a brief, easily contained spike in intrathoracic pressure and blood pressure, while multi-rep “prediction” sets pile up cardiovascular, metabolic and technique-related risks and may mis-lead programming. Hence your lecturer prefers a tested 1 RM for both accuracy and safety.