The multifactorial impact of exercise in cardiovascular diseases Daniel Umpierre, ScD Federal University of Pelotas Graduate Program in Cardiology and Cardiovascular Sciences, UFRGS 

Disclosures • Shareholding: Evidência Saúde (continuing professional education); • Consultancy: ABRASCO/PAHO; Ministério da Saúde (Brasil). 

Me 

Goals • Physical (in)activity as major problem • Exercise in the era of statins • Treating early: exercise in hypertension • Treating lately: exercise in coronary disease and chronic heart failure • Summary 

Physical activity and CVD Morris et al. Lancet, 1953 "Coronary heart-disease and physical activity of work". ‘Jerry Morris’ 1910 - 2009 

Prevention as a primary strategy Ekelund et al. Lancet 2016, 388(10051):1302-10 Sitting time Physical activity (PA) IPD meta-analysis | N = 1 005 791 

Prevention as a primary strategy Ekelund et al. Lancet 2016, 388(10051):1302-10 Sitting time Physical activity (PA) Too much sitting No sweat at all Too much sitting Physically active IPD meta-analysis | N = 1 005 791 

Mora et al. Circulation 2007, 116: 2110 0.7% 0.3% Homocysteine 59% All pooled factors 35.5% 32.6% Inflammatory/ Hemostatic 20.9% 27.1% Blood pressure / Hypertension 14.9% 19.1% Traditional lipids 13.4% 15.5% Novel lipids 11.1% 10.1% BMI 6.8% HbA1c / Diabetes 8.9% 5.0% 0 10 20 30 40 50 60 70 CVD CAD 27 055 women 1500 kcal/wk vs. <200 kcal/wk Multiple factors for CVD risk reduction 

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JAMA, 2014; 311:463-64 

Changes in HDL-cholesterol (mg/dl) -2 0 1 4 7 P = 0.015 Kraus WE et al. N Engl J Med 2002, 347:1483-92 Controls Mod. Volume – Mod. Intensity Mod. Volume – High Intensity High Volume – High Intensity Lipid levels may be a tricky route 

Sex: males Cornelissen, Smart. J Am Heart Assoc 2013, e004473. Exercise training and blood pressure 

Hypertension Sex: males Cornelissen, Smart. J Am Heart Assoc 2013, e004473. Exercise training and blood pressure 

Hypertension Sex: males Cornelissen, Smart. J Am Heart Assoc 2013, e004473. Programs with lengths between 12-24 weeks Exercise training and blood pressure 

Sessions from 30 to 45 min Hypertension Sex: males Cornelissen, Smart. J Am Heart Assoc 2013, e004473. Programs with lengths between 12-24 weeks Exercise training and blood pressure 

Weekly volume from 150 to 210 min Sessions from 30 to 45 min Hypertension Sex: males Cornelissen, Smart. J Am Heart Assoc 2013, e004473. Programs with lengths between 12-24 weeks Exercise training and blood pressure 

Santos et al. J Hypertens. 2016, 34(7):1317-24. Effect from a single exercise session • Assessing subsets of hypertensive patients and exercise prescriptions 

Naci & Ioannidis. BMJ, 2013. 16 meta-analyses 305 RCTs 339,274 participants Coronary artery disease Stroke Prediabetes Heart failure 

Univariate Age VE /VCO2 Training volume % men Ejection fraction % β-blockers Target intensity VO2 peak FC max 1st VT Exercise training characteristics in heart failure Belli et al. Tese de doutorado. UFRGS, 2016. 

Univariate Age VE /VCO2 Training volume % men Ejection fraction % β-blockers Target intensity VO2 peak FC max 1st VT Exercise training characteristics in heart failure Belli et al. Tese de doutorado. UFRGS, 2016. 

Univariate Age VE /VCO2 Training volume % men Ejection fraction % β-blockers Target intensity VO2 peak FC max 1st VT Exercise training characteristics in heart failure Belli et al. Tese de doutorado. UFRGS, 2016. 

Univariate Age VE /VCO2 Training volume % men Ejection fraction % β-blockers Target intensity VO2 peak FC max 1st VT Exercise training characteristics in heart failure Belli et al. Tese de doutorado. UFRGS, 2016. 

Ejection fraction* Age* % men % β- blockers Exercise volume* Target intensity* VO2 peak R = 0.70 P = 0.005 R = 0.35 P = 0.04 *Multivariable model: p = 0.033 

Take-home messages • Prevention matters. Interventions are necessary to increase physical activity levels in general population; • Formal exercise is well integrated with pharmacological therapy and there is some tension in terms of benefits/interests; • High odds for benefits when delivering exercise stimuli for hypertensives; • Exercise is an important player for CHF, but tailoring the prescription may strengthen benefits. 

www.ufrgs.br/lafiex 

The multifactorial impact of exercise in cardiovascular diseases Daniel Umpierre [email protected] Material: www.evidenciasaude.com.br/cardio2016