Domain I Study Guide

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The physiologic and metabolic responses to exercise testing associated with heart disease, hypertension, diabetes mellitus, obesity, and pulmonary disease

Heart Disease

Exercise has been proven to decrease coronary inflammatory markers, stress and damage to the coronary arteries, and increase new blood vessel growth and vascular regeneration; all of these are likely to promote faster recovery from a myocardial infarction (MI).

Regular exercise can also decrease blood platelet adhesiveness, fibrinogen levels, and blood viscosity; a of these will reduce the risk of clotting in the blood and reduce the likelihood of a second MI

Exercise has even been proven to prevent, slow, and even reverse vasculature atherosclerosis plaque development, allowing for an increase in ischemic threshold during daily activities or exercise

by increasing the ischemic threshold, there will be a profound impact of alleviating symptoms such as claudication in individuals with PAD

Hypertension

endurance exercise lowers systolic and diastolic blood pressure values by 5-7 mm Hg; individuals with or at risk of developing hypertension will see a slowed response in rising blood pressure when they engage in regular endurance exercise

Diabetes Mellitus

Response to exercise in individuals with Type 2 diabetes is both tremendously positive and fast; this is due to an improved insulin sensitivity which, in turn, can result in a lowered medication requirement and greater control of blood glucose levels

Obesity

Individuals whom are obese will see the greatest results from exercise if it is paired with caloric restriction and proper eating habits

Exercise performed by obese individuals will promote regional fat loss, specifically in the abdominal area, which will result in improved psychosocial well-being; even if there is not a significant reduction in body fat or body weight, that individual will have produced countless other health fitness benefits

Pulmonary Disease

Based on ACSM resources, scientific literature does not consistently support the claim that exercise plays a role in reducing e pathologies of pulmonary diseases. However, exercise is proven to bring a noticeable increase in the quality of life of individuals with pulmonary diseases.

Regular exercise allows the individual with pulmonary disease to exercise longer and at higher exercise intensities.

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The anatomy and physiology cardiovascular and pulmonary systems

Anatomy: the main two components are the heart and vasculature

heart is made of up 4 chambers (upper: right and left atria, lower: right and left ventricles)

vasculature includes veins and venules, arteries and arterioles, and capillaries

Physiology: the cardiovascular system is to deliver oxygenated blood and nutrients to the cells and to remove waste from the cells

Right ventricle pumps deoxygenated blood through the pulmonary artery to the lungs for oxygen loading and carbon dioxide unloading to be sent back to the left atria through the pulmonary vein following the pulmonary circulation (gas exchange)

Once in the left atria, oxygenated blood moves into the left ventricle where it is driven out of the chamber, through the aorta, and dispersed throughout the body

once oxygenated blood leaves the heart, it is now in the systemic circulation where it is carried by arteries and arterioles to various locations throughout the body

as vasculature becomes more distal from the heart, arteries branch into smaller arterioles, which then branch and merge with the capillaries

once in the capillaries, gas and nutrient exchange occurs; blood is now deoxygenated

deoxygenated blood is then moved out of the capillaries and into the venules which eventually combine to form veins as they become more proximal to the heart

the veins then deliver deoxygenated blood back to the right atrium where the cycle is repeated

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Cardiorespiratory terminology (angina pectoris, tachycardia, bradycardia, arrhythmia, hyperventilation)

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Pathophysiology of myocardial ischemia, myocardial infarction, stroke, hypertension, and hyperlipidemia

Myocardial Ischemia - imbalance between myocardial oxygen supply and demand; commonly characterized as stable or unstable ischemia

Stable ischemia - often a result of increased oxygen demand of the heart (i.e. exercise); when there is an impairment in the ability to properly deliver efficient oxygen to the cardiac tissue, the result is angina and decreased exercise capacity.

symptoms decrease as exercise decreases and terminates and the heart requires less oxygen supply

Unstable ischemia - often seen with symptoms at rest and during a time minimal exertion, making it a much more severe condition

under no circumstances should individuals with unstable ischemia participate in exercise or exercise testing

Myocardial Infarction - heart attack; death of cardiac tissue, or necrosis

a myocardial infarction (MI) is a serious condition where there is complete obstruction of blood flow to the cardiac myocardial tissue

this obstruction is caused by the formation and buildup of atherosclerotic ace in the elastic and smooth lining inside of the arteries

Stroke - the sudden onset of weakness, numbness, paralysis, slurred speech, aphasia, problems with vision and other manifestations of a sudden interruption of blood flow to a particular area of the brain. Strokes typically affect certain areas of the body based on the location of the part of the brain that was affected

the main cause of a stroke is an underlying cardiovascular or pulmonary disease; hypertension, atherosclerosis leading to CAD, dyslipidemia, heart disease, and hyperlipidemia are common pathologies

Hypertension (HTN) - defined as a persistent elevation in either systolic (>140 mm Hg) or diastolic blood pressure (>90 mm Hg) measurements; can be categorized as wither primary or secondary

Primary HTN - accounts for 90-95% of all known cases and does not have an established pathology (idiopathic)

Idiopathic - a condition that arises spontaneously or from an obscure or unknown cause

Secondary HTN - accounts for a small fraction of cases of HTN and is associated with several different identifiable causes such as renal disease, stress, drug-induced side effects sleep apnea, neurological disorders, and several others

The most common characteristic of of both primary and secondary HTN is increased peripheral resistance; this is caused by chronic vasoconstriction or by vascular plaque buildup

Vasoconstriction - narrowing of the peripheral arterioles

Arterioles lose elasticity in hypertensive individuals because of the increased presence of fibrous collagen tissue; this buildup decreases proper arteriole function, which is crucial to normal blood flow regulation

Hyperlipidemia - elevated blood cholesterol and triglyceride levels

this condition is caused by a combination of genetic and environmental factors

High-density lipoproteins (HDL) are responsible for assisting with the removal of lipids from blood circulation through a process called reverse cholesterol transport; for this reason, we refer to HDL-C as the "good" cholesterol

When HDL-C levels fall below 40 mg/dL, reverse cholesterol transport is hindered and leads to further vascular lipid accumulation, which in turn leads to accelerated atherosclerosis rates

Excessive amounts of LDL-C ("bad" cholesterol) is associated with increased risk of atherosclerosis and coronary artery disease (CAD)

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The effects of myocardial ischemia, myocardial infarction, hypertension, claudication, and dyspnea on cardiorespiratory responses during exercise

Myocardial Ischemia - an imbalance of oxygen supply and demand; there is a shortage of oxygenated blood flow to the heart muscle tissue; manifests as angina pectoris

during exercise, myocardial oxygen demand increases; HR increases to meet that oxygen demand

this relationship is linear and continues until the individual reaches maximum exercise capacity; in an ischemic individual, this capacity is limited by the insufficient oxygen supply

this leads to impaired oxygen delivery to target muscles and limits the exercise capacity; this is called the "ischemic threshold"

Myocardial Infarction - this occurs when there is injury or death of the muscular tissue of the heart

as seen in individuals with myocardial ischemia, an ischemic threshold is identified and should be avoided at all cost; myocardial oxygen supply is insufficient and will cause angina symptoms to arise at which point exercise should be terminated

Hypertension - elevated blood pressure measurements

in a hypertensive client, systolic blood pressure levels can get extremely high (<250 mm Hg); this increase in arterial pressure drastically increases the likelihood of MI or stroke

In addition, repeated periods of high-intensity exercise can further exacerbate endothelial damage

Beta-blockers can help attenuate the HR response and necessitate the need to use RPE for exercise intensity monitoring

Claudication - (intermittent) claudication is the most common symptom of peripheral artery disease and is characterized by repeatable aching, cramping sensation, or fatigue affecting the calf muscles in one or both lower extremities

common characteristics of claudication arise during/after weight-bearing exercises and typically dissipate once exercise is ceased; maximal capacity is affected

the extent of claudication during exercise determines the severity of peripheral artery disease

Dyspnea - dizziness, lightheadedness

during exercise, appropriate breathing is essential to ensuring there is efficient oxygen uptake for the heart and skeletal muscles; improper breathing techniques can cause dizziness and lightheadedness because of an insufficient supply of blood to the brain

individuals with dyspnea should be even more careful when exercising at submaximal or maximal workloads because of this symptom; sufficient oxygen uptake is crucial

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Oxygen consumption dynamics during exercise (heart rate, stroke volume, cardiac output, ventilation, ventilatory threshold

During exercise, HR will typically increase linearly with an increasing workload until HR maximum is reached; this is also typically the point of exercise maximum

training has little to no effect on HR max, however, training can definitely decrease an individual's HR at any given sub maximal workload; this indicates a higher fitness level

Stroke volume (SV) - the amount of blood pumped with each beat

SV increases with world, similar to HR, but only up to approximately 40-60% VO2 max in the general population. In untrained individuals, SV is seen to decrease beyond 40-60% while, in highly trained individuals, this number increases

As SV increases with training, resting HR will decrease; this happens because more blood is being per beat so the heart does not have to beat as often while at rest

Cardiac Output - the product of SV and HR; it is also a measure of the volume of blood pumped minute

Cardiac output increases steadily during graded intensity exercise to approximately 50% VO2 max

Pulmonary ventilation - volume of air is inhaled and exhaled per minute; this is the product of the frequency of breathing and tidal volume

tidal volume - the volume of air moved per breath

Pulmonary ventilation increases linearly with work rate up to about 50-80% of VO2 max, after this point, ventilation begins to increases exponentially; this is called the ventilatory threshold

trained individuals can work at much higher rates than untrained individuals before reaching the ventilatory threshold

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Methods of calculating VO2 max

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Cardiorespiratory responses to acute graded exercise of conditioned and unconditioned clients

Graded exercise test - either a maximal or submaximal bout of exercise during which the intensity increases in predetermined increments

EP-C's will use graded exercise tests to determine a baseline fitness level which can be compared at future time points to assess fitness improvements or lack-there-of

VO2 Response

during incremental exercise, VO2 will increase slowly within the first few minutes of exercise and will eventually plateau (steady-state) at each submaximal exercise intensity

steady-state VO2 will continue to increase until maximal oxygen uptake (VO2 max) is reached

VO2 max is often used as an indicator aerobic fitness and endurance exercise performance; this is because a higher VO2 max indicates greater capacity to create ATP via oxidative energy production and a greater ability to supply the energy required to support higher intensity exercise workloads

Cardiovascular Response

During exercise, HR will typically increase linearly with an increasing workload until HR maximum is reached; this is also typically the point of exercise maximum

Throughout the lifespan, trained individuals will have a lower resting HR than those who are untrained; HR also declines with age

training has little to no effect on HR max, however, training can definitely decrease an individual's HR at any given sub maximal workload; this indicates a higher fitness level

Stroke volume (SV) - the amount of blood pumped with each beat

SV increases with world, similar to HR, but only up to approximately 40-60% VO2 max in the general population. In untrained individuals, SV is seen to decrease beyond 40-60% while, in highly trained individuals, this number increases

As SV increases with training, resting HR will decrease; this happens because more blood is being per beat so the heart does not have to beat as often while at rest

Cardiac Output - the product of SV and HR; it is also a measure of the volume of blood pumped minute

Cardiac output increases steadily during graded intensity exercise, if the increase goes beyond 50% VO2 max in an untrained individual , HR will rise order to mediate that increase in d being pumped.

In a trained individual, there is a much greater capacity to increase cardiac output because of their capacity to have a greater increase in SV than that of an untrained individual

Pulmonary Response

Pulmonary ventilation - volume of air is inhaled and exhaled per minute; this is the product of the frequency of breathing and tidal volume

tidal volume - the volume of air moved per breath

Pulmonary ventilation increases linearly with work rate up to about 50-80% of VO2 max, after this point, ventilation begins to increases exponentially; this is called the ventilatory threshold

trained individuals can work at much higher rates than untrained individuals before reaching the ventilatory threshold

Blood Pressure (BP) Response

Systolic blood pressure - the pressure in the arteries during ventricular contraction (systole) and is influenced heavily by changes in cardiac output

Diastolic blood pressure - the pressure in the arteries when the heart is relaxed (diastole) and is influenced heavily by total peripheral resistance (TPR)

TPR - the overall resistance to blood flow by the blood vessels; TPR is determined by the systemic resistance throughout the entire vasculature ---> thus, it is determined by the relative proportion of the vasculature that has undergone vasodilation versus vasoconstriction during exercise

This is an explanation of why DBP stays relatively stable during exercise

All of these measurements are seen to be slightly decreased in trained individuals during sub maximal workloads as opposed to slightly elevated in untrained individuals