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Regular, habitual physical activity is one of the most effective defenses against cardiovascular events.1 But at what point and for whom do the risks of vigorous exercise outweigh the benefits?
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In a small minority of patients, typically those with existing heart disease, vigorous exercise can induce heart attacks, and even death. Yet there is little research on how to identify patients most at risk.1 A statement from the American Heart Association (AHA) — prepared in collaboration with the American College of Sports Medicine (ACSM) — seeks to help fill the gap.1
The statement offers physicians strategies to identify such at-risk patients and help them manage their physical activity levels.
"The general recommendation from the CDC [Centers for Disease Control and Prevention] and the ACSM is that everyone should engage in 30 minutes of moderately vigorous exercise—the equivalent of brisk walking—and that primary care physicians should recommend this on most, if not all, days of the week for all patients without orthopedic problems or other limitations," says lead author Paul D. Thompson, MD, FAHA, chief of cardiology at Connecticut's Hartford Hospital.
But he notes more careful management is needed for patients who have serious hereditary or congenital cardiovascular abnormalities or extensive coronary artery disease (CAD). Such patients likely need exercise testing and tailored, incremental exercise programs under medical supervision, the joint statement suggests.
IDENTIFY RISK
When considering a vigorous exercise program for patients, physicians should evaluate patients' atherosclerotic risk profiles and perform exercise testing on those at greatest risk of—or asymptomatic for—underlying CAD, the statement recommends.1
For asymptomatic patients with type 2 diabetes or other metabolic diseases, the American College of Cardiology and AHA suggest exercise testing prior to starting a vigorous exercise program, while ACSM recommends exercise testing before beginning a moderate to vigorous exercise program.2–4 Consensus also differs slightly on pre-participation exercise screening for middle-aged to older adults (see "FYI").2–4
The statement also recommends physicians regularly check for—and alert patients to—prodromal heart disease symptoms that an exercise program might exacerbate. These include chest pain; indigestion/heartburn; excessive breathlessness; increasing fatigue, ear or neck pain; dizziness; palpitations; vague malaise; or severe headache.
TAILOR EXERCISE
Not all patients can expect to exercise vigorously 30 minutes a day, five times weekly, says Tim Church, MD, MPH, PhD, director of the Preventive Medicine Research Lab at Pennington Biomedical Research Center, Louisiana State University System in Baton Rouge. But his research suggests that even half that amount is beneficial: In a study of previously sedentary, overweight or obese postmenopausal women, Church and colleagues found that ramping up to 10–15 minutes a day of moderate intensity physical activity notably improved the women's fitness levels.5
The ramp-up is key, note Church and other experts. People put themselves at highest risk when engaging in unaccustomed vigorous physical activity, such as jogging or shoveling snow. A slow, incremental increase in activity provides additional cardiovascular screening opportunities and helps prevent muscle soreness, Church says. He suggests morbidly obese people simply walk down a hallway for the first week, progress to two trips during the second week, and slowly work up to a trip or two around the block.
A good rule of thumb is to exercise enough to be mildly to moderately short of breath, but not to the point of breathlessness; if a person can no longer carry on a comfortable conversation, they are pushing themselves too hard, Thompson adds.
Patients with known cardiac disease should warm up and cool down 5 minutes at each exercise session, and everyone should moderate exercise intensity according to heat, cold, and altitude.1
EMPHASIZE BENEFITS, OPPORTUNITIES
Physicians also can suggest patients use behavioral intervention programs to get moving. Lifestyle changes and counseling help 25–30% of initially sedentary and unfit people achieve the guidelines' recommended amount of exercise over 2 years, according to several studies.6,7
The guidelines advise physicians to refer patients to community-based walking and exercise programs and distribute lists of exercise resources—but to restrict recommended fitness centers to those equipped with resuscitation equipment and staff trained to manage cardiac emergencies.
"Physicians underestimate the influence they have on changing
behavior," Church says, adding that simply addressing the importance of
exercise is most valuable for these patients. 
Footnotes
A table of recommendations on exercise testing before exercise training in at-risk patients is available for physicians at http://circ.ahajournals.org/cgi/content/full/115/17/2358/TBL4.
More information about national programs to encourage healthy lifestyles is available at Active Living Partners, http://www.activeliving.info/index.cfm; Shape Up America, http://www.shapeup.org; and America on the Move, http://aom.americaonthemove.org.
References
2. Gibbons RJ, Balady GJ, Bricker JT, et al.: ACC/AHA 2002 guideline
update for exercise testing: Summary article: A report of the American College
of Cardiology/American Heart Association Task Force on Practice Guidelines
(Committee to Update the 1997 Exercise Testing Guidelines).
Circulation 106:1883–1892, 2002.
3. American College of Sports Medicine: Guidelines for Exercise Testing and Prescription. 7th ed. Baltimore, Lippincott Williams & Wilkins, 2005.
4. Maron BJ, Zipes DP: 36th Bethesda Conference: Eligibility
recommendations for competitive athletes with cardiovascular abnormalities.
Journal of the American College of Cardiology 45: 1313–1375, 2005.
5. Church TS, Conrad PE, Skinner JS, et al.: Effects of different
doses of physical activity on cardiorespiratory fitness among sedentary,
overweight, or obese postmenopausal women with elevated blood pressure.
JAMA 297:2081–2091, 2007.
6. Dunn AL, Marcus BH, Kampert JB, et al.: Comparison of lifestyle and
structured interventions to increase physical activity and cardiorespiratory
fitness. JAMA 281:327–334, 1999.
7. Writing Group for the Activity Counseling Trial Research Group:
Effects of physical activity counseling in primary care.
JAMA 286:677–687, 2001.
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