Medical+and+Clinical+Considerations

=Medical and Clinical Considerations=

When testing and prescribing an exercise programme for a client diagnosed with dyslipidaemia or hyperlipidaemia there are several medical and clinical considerations. Things to consider when testing and prescribing exercise are Coronary Heart Disease (CHD) risk factors, contraindications to exercise, the effects of pharmacological on exercise and specific dyslipidaemia or hyperlipidaemia condition.


 * CHD risk factors**

It is well established that there is a strong correlation between high blood lipid levels and CHD, in particular those with elevated Low Density Lipoproteins (LDL). As a result dyslipidaemia or hyperlipidaemia is a risk factor for CHD. As such a complete medical and lifestyle history should be obtained in order to determine CHD risk factors (see Table 1).

Table 1. CAD risk factors
 * ~ Positive risk factors ||~ Criteria ||~  ||~   ||~   ||~   ||~   ||~   ||~   ||~   ||
 * Family history |||||||||||||||||| Myocardial infarction, coronary revascularisation, or sudden death before 55 years of age in ||
 * |||||||||||||||||| father or other first degree male relative or before 65 years of age in mother or other first ||
 * |||||| degree female relative. ||  ||   ||   ||   ||   ||   ||
 * Cigarette smoking |||||||||||||||| Current cigarette smoking, or smoking cessation within previous 6 months. ||  ||
 * Hypertension |||||||||||||||||| Systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg measured on two separated occasions, or ||
 * |||||||||| individual is taking anti-hypertensive medication. ||  ||   ||   ||   ||
 * Dyslipidaemia |||||||||||||||||| TC ≥ 200mg/dl, or HDL-C < 40mg/dl, or LDL-C ≥ 130mg/dl, or on lipid lowering medication. ||
 * Impaired fasting glucose |||||||||||||||| Fasting blood glucose ≥ 110mg/dl, measured on two separate occasions. ||  ||
 * Obesity |||||||||||||||||| Body mass index ≥ 30kg/m 2 or waist circumference >102 cm for men and >88 cm for women. ||
 * Physical inactivity |||||||||||||||||| Not participating in regular exercise program or not meeting the minimum physical activity ||
 * |||||||||||||||||| recommendations from the ACSM and AHA (150min/week or more of moderate intensity ||
 * |||| aerobic exercise). ||  ||   ||   ||   ||   ||   ||   ||
 * ~ Negative risk factors ||~  ||~   ||~   ||~   ||~   ||~   ||~   ||~   ||~   ||
 * High HDL-C |||||| Serum HDL-C ≥60mg/dL ||  ||   ||   ||   ||   ||   ||

From the results of the CHD risk factor table (Table 1) individuals should be classified into one of three groups; low, moderate or high risk.
 * Low CHD risk: Individuals who are asymptomatic with no more than one risk factor.
 * Moderate CHD risk: Individuals who have two or more risk factors.
 * High CHD risk: Individuals who are symptomatic or have known cardiovascular, pulmonary or metabolic disease.

For those patients diagnosed with hyperlipidaemia or dyslipidaemia categorised in the low risk group, medical supervision is not required for exercise testing at moderate to vigorous intensities. Those categorised in the moderate risk group, medical supervision is recommended exercise testing at vigorous intensities (VO 2 max >60%). Those categorised in the high risk group, medical supervision is recommended exercise testing at both moderate and vigorous intensities.

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 * Contraindications to exercise**

Dyslipidaemia and hyperlipidaemia and the resultant atherosclerosis is not in itself a contraindication to exercise. However, many individuals diagnosed with dyslipidaemia and hyperlipidaemia present with other co-morbidities which may exclude individuals from participating in an exercise program .Table 2. outlines the absolute and relative contraindications to exercise. As such a complete medical history should be obtained prior to any exercise testing in order to rule out any contraindications to exercise. If individuals present with any of the below mentioned contraindications medical clearance is recommended prior to exercise testing or starting an exercise program. Individuals with absolute contraindications should not participate in exercise testing and subsequent exercise programme unless prescribed by a medical physician.

other acute cardiac event || Left main coronary stenosis || symptoms of hemodynamic compromise || Severe arterial hypertension; resting diastolic blood pressure >110mmHg or resting systolic blood pressure >200mmHg or both || tract obstruction || infarction || Chronic infectious disease e.g. hepatitis, AIDS || body aches or swollen lymph glands || Uncontrolled metabolic disease e.g. diabetes || adequately || **Table 2. Absolute and relative contraindications to exercise testing**
 * ~ Absolute Contraindications ||~ Relative Contraindications ||
 * Acute myocardial infarction (within 2 days) or
 * Unstable angina || Moderate stenotic valvular heart disease ||
 * Uncontrolled cardiac arrhythmias causing
 * Uncontrolled symptomatic heart failure || Tachydysrhythmias or bradydysrhythmias ||
 * Symptomatic severe aortic stenosis || Hypertrophic cardiomyopathy and other forms of outflow
 * Suspected or known dissecting aneurysm || High degree atrioventricular block ||
 * Acute myocarditis or pericarditis || Ventricular aneurysm ||
 * Acute pulmonary embolous or pulmonary
 * Acute systemic infection, accompanied by fever,
 * || Mental or physical impairment leading to inability to exercise
 * || Known electrolyte abnormalities ||

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 * Pharmacological Effects on Exercise**

Certain medications used for the treatment of dyslipidaemia and hyperlipidaemia may have a negative impact on exercise. In addition, the use of combination medications may have increased negative effects of exercise. When prescribing an exercise programme for a client with dyslipidaemia or hyperlipidaemia, it must be taken into consideration what medications an individual has been prescribed. Careful planning must therefore be taken in prescribing exercise to clients on the above mentioned medications. It may be necessary to incorporate increased rest periods or reduce intensities to accommodate the adverse side effects associated with the above mentioned medications.
 * Statins: May cause myopathy, myalgia, muscle weakness or muscle cramps during exercise.
 * Fibrates: Muscle weakness or pain during exercise may be seen with a combination therapy of Fibrates and Statins.
 * Cholesterol absorption inhibitors: May cause fatigue. Combination therapy with Statins may cause muscle weakness or pain during exercise.

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 * Specific dyslipidaemia or hyperlipidaemia conditions**

There are many different types of dyslipidaemia and hyperlipidaemia conditions that an individual may present with. Several of these conditions react differently to exercise. Of particular note, those diagnosed with a familial dyslipidaemia may not experience the same alterations in lipid profile following exercise compared to a healthy population. More specifically, those diagnosed with familial triglyceridaemia may not have the same levels of improvement in blood lipid profiles as healthy individual. On the other hand, hyper-α-lipoproteinaemia is characterised by high concentration levels of HDL. This hyperlipidaemia is seen to be beneficial to health as high levels of HDL have been inversely correlated with atherosclerotic disease.

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