• A 75-year-old women has been referred to you for “reconditioning”.  You have a first appointment with her today, and discuss her goals for an exercise program. The women indicates that her goal is to remain functionally independent for as long as possible. She has been informed by her doctor that she is currently suffering from osteopenia and that she has an increased risk of developing osteoporosis. She also indicates that her balance is not so good, and that she is therefore afraid of falling and breaking her hip.
• On further questioning:
  • She denies chest pain, palpitations, or syncope
  • She has hypertension, well controlled with medication, no other known CV risk factors
  • She is sedentary and has never done any regular exercise or sports
  • She had a resting ECG taken by her GP 6 months ago as part of regular FU which was normal

According to ESC pre-participation screening and cardiovascular risk stratification, what is the most appropriate next step before initiating her exercise program?

• Initiate a low-to-moderate intensity, supervised exercise program without further cardiac testing
  

Now imagine she would enroll in a high intensity interval training study after she has been training with you for the last 3 months, 3 times per week. Would that change your recommendation?

• Yes
  • 
    • Score op -> high risk patient
    • needs a CPET or ECG

Which exercise modality?

• Cardio | Weight-bearing activities/impact where possible
• Dynamic resistance training
  • Important for functionality
  • To strengthen bone mass
  • To improve balance
• Balance training | Avoid falling

So, what would be on your exercise program for the next few weeks

• Frequency
  • Low: start 2x/week, but gradually increase to minimal 3 times per week
  • Focus on success experience | creating a habit
  • Progression: don't go too fast!
• Type: Not too much variation to keep it 'fun', rather build trust by repeating
• Cardio
  • Type: little skill (type A)
  • Not too many different devices
  • Weightbearing activities (osteopenia): stair climbing, walking, low-impact callesthenics
  • Duration: aim for 20-30 minutes (fractionated – minimal bouts of 10 minutes)
  • Talk test, RPE

Case 1:

• Cardio:
  • Example
    • 10 min. treadmill (own pace, flat, talk test)
    • 10 min. cycling (RPM 70, talk test)
    • Gradually increase to 12 min. per device in week 3-4
  • Key points
    • 2-3 devices to start with
    • Breaks between modalities (eg. 30 min cycling is not feasible)
  • Alternatives
    • Step-up exercise: functional, impact, combination of strength and cardio
    • Motivating to do step ups at home/ taking the stairs / walking on her walker treadmill
  • 
• Strength and balance
  • Type (low skill): simple functional exercises (with balance component) and/or fixed equipment
  • Sit to stand / elastic bands on chair, tip toes,….
  • Low load & controlled speed
  • Agonists – antagonists
  • Number of exercises: limited (e.g. 6 in total)
  • Focus LL, basic UL
  • 2 sets /exercise

During the subsequent weeks she is training under your supervision she occasionally reports shortness of breath during exertion but attributes it to “age and deconditioning.” She has no known history of coronary artery disease. During a cycling session, she suddenly collapses and becomes unresponsive.

What is the most likely underlying cause of sudden cardiac arrest in this patient?

• Coronary artery disease leading to ventricular arrhythmia

You check and notice there is no breathing. What is the most appropriate immediate action?

• Call emergency services and start CPR with AED use

Which preventive strategy is most effective in reducing mortality from such events in a private practice?

• Staff training in CPR and access to an AED