Parts 1, 2 and 3 appeared in FloridaMD October, November and December issues
Lack of Exercise
On August 17, 2015, the American Heart Association (AHA) released Recommendations for Physician Activities in Adults. This document, found in electronic format in Appendix 5, is very closely aligned with the experience of the author and is therefore highly recommended. To be clear, every patient should know that no one knows background, indications, lack of indications, dangers, or necessary advice better than an individual’s physician. This means that in every case, regardless as to what is found in a generic document of this type, the patient should obtain clearance from his or her physician before accepting outside recommendations for drugs, other therapy, and even mild exercise. Here are the exercise definitions and recommendations.
There can be no doubt that being physically active is important in preventing heart disease, stroke, and peripheral vascular disease. These diseases are responsible for over 50% of ALL deaths in the United States and the modern world. Here is the actual recommendation from the AHA in their written words from the referenced document:
“To improve overall cardiovascular health, we suggest at least 150 minutes per week of moderate exercise or 75 minutes per week of vigorous exercise (or a combination of moderate and vigorous activity). Thirty minutes a day, five times a week is an easy goal to remember. You will also experience benefits even if you divide your time into two or three segments of 10 to 15 minutes per day.
For people who would benefit from lowering their blood pressure or cholesterol, we recommend 40 minutes of aerobic exercise of moderate to vigorous intensity three to four times a week to lower the risk of heart attack and stroke.
Physical activity is anything that makes you move your body and burn calories. This includes things like climbing stairs or playing sports. Aerobic exercises benefit your heart, and include walking, jogging, swimming or biking. Strength and stretching exercises are best for overall stamina and flexibility.
The simplest, positive change you can make to effectively improve your heart health is to start walking. It’s enjoyable, free, easy, social and great exercise. A walking program is flexible and boasts high success rates because people can stick with it. It’s easy for walking to become a regular and satisfying part of life.”
The following comments have been added by the authors.
It is our experience that most people desiring to reduce risk of atherosclerosis can at least walk or jog slowly. Many are able to do more vigorous exercise such as biking, aerobics classes, and weight training. For this text, if an individual is able to meet the AHA Guidelines given above, that will work quite well. For the remainder of this section we will focus on minimum requirements.
Everyone, when well enough, should be on a regular exercise program. Excuses are often made such as: (i) I do a great deal of walking in my job, or, (ii) “I am a very active person”. Despite these contentions, we have found that formal programs add very significant benefit to almost everyone.
Walking or jogging in your neighborhood at a predetermined time is excellent exercise and clearly helps prevent heart disease. Participants will need formal Exercise Attire, including, proper footwear and a watch for timing activities. Get what you need – this will ultimately be listed among the best investments you will ever make. Follow these tenets:
- You will have to overcome the tendency to “not start”. This is a form of fearing the unknown or the new. Do not let start-up inertia ruin your exercise program.
- Virtually everyone can walk or jog slowly for 20 minutes in a safe and assessable neighborhood. Start off by walking or jogging slowly for 20 minutes every other
- Increase your program to include 20 minutes every
- When you are completely comfortable with 20 minutes every day, increase your activity time to 30 minutes. Your goal is to get to 60 minutes per day.
- It is acknowledged that for all kinds of reasons, activity will be missed on occasions. This should be kept to a minimum, but it will happen and ultimately should not change the pace of your progress.
- Almost universally, exercise will make you feel better and commonly a certain level of addiction will result.
- Some individuals will not be able to walk or jog due to various ailments, which are mostly bone and muscle related. For these individuals, swimming is highly recommended as it is non-weight bearing and is aerobic.
- The KEY features of this program are DEDICATION and FORMALITY.
1. Soteria Cardiac Platform – Testing
The Soteria Cardiac Platform provides a great deal of diagnostic information for consideration by the physician and patient. When a patient undergoes Registration, Framingham Analysis, and Soterogram testing, by a simple count, 24 diagnostic parameters are obtained. Table 10 lists these Diagnostic Inputs in the left column. In the right column, the Treatment Protocols discussed in this document are correlated; also included are the appropriate Document Sections.
To complete this discussion, Table 11 is provided as a Treatment Guideline which importantly correlates Soterogram Results with Treatment Guidelines and Protocols for Tobacco Use, Hypertension, Diabetes, Elevated Blood Lipids, Obesity, and Exercise.
The anticipation is that this information will be helpful to physicians and patients in creating individual treatment plans. Our goal is to reduced cardiovascular morbidity and mortality!
The Framingham Risk Profiles for: (i) Coronary Artery Disease (CAD), (ii) Cerebrovascular Disease (i.e. Stroke), and (iii) Peripheral Vascular Disease (PVD) are the most respected question and answer profiles in frequent use and known to be based on the largest and longest-followed database in cardiovascular history. The Demographics and Risk Factors entered during Registration are carried-forward to this module. This allows the three mentioned Risk Profiles to be calculated and displayed. Body Mass Index (BMI) is also automatically calculated and displayed.
The Coronary Heart Disease Risk Profile returns the Framingham Estimate of the patient’s risk of having a myocardial infarction (i.e. Heart Attack) over the next 10 years. This is given as a percentage. For example, a patient may have a 30% chance of having a Heart Attack over the next 10 years. This is based on the patient’s age, gender, and cardiovascular Risk Factors as presented at Registration. This includes Tobacco Use History, Total Cholesterol, HDL Cholesterol, Blood Pressure, and other factors.
The Stroke Risk Profile in similar fashion returns the Framingham Estimate of the patient’s risk of having a cerebrovascular accident (i.e. Stroke) over the next 10 years. This is given as a percentage.
Again, in like fashion the PVD Risk Profile returns the Framingham Estimate of the patient’s risk of developing peripheral vascular disease over the next 4 years (i.e. not 10 years).
It is important to point out Framingham is a statistical generalization. The findings are based on patients that “look like” the target patient, but are NOT the target patient. We very often see disconnects between Framingham and the Soterogram, for this reason, when considering the target patient, the Soterogram results are more central and Framingham is used as a guide.
This module returns Ankle / Brachial Index (ABI). This is the ratio of Ankle Systolic Pressure divided by Brachial Systolic Pressure. This measurement is indicated when a physician wants to have a si mple physiologic assessment of the peripheral vascular system. If there is no significant drop in Systolic Pressure between the brachial level and the ankle level there is a degree of confidence that no high-grade arterial lesions are present throughout the aorta, iliac, common femoral, superficial femora/ popliteal, and tibial vessels. If, to the contrary, a reduced Ankle / Brachial Index (< 0.90) suggests arterial obstruction located between the brachial artery and the ankle level. It should be noted that this test does not specify the location of the obstruction(s).
It is also known that the presence of peripheral vascular disease is highly correlated with the presence of coronary artery disease. In fact, 90% of patients with symptoms of peripheral vascular disease have significant coronary artery disease. For this reason, physicians include ABI in the evaluation of coronary artery disease. It should be pointed out that peripheral disease is a late marker of coronary artery disease and often develops a decade later than coronary artery disease. This means that a negative ABIgram cannot be interpreted that coronary or generalized atherosclerosis is not present. On the other hand, a positive ABIgram carries a high-degree of coronary atherosclerosis. For this reason, the ABIgram and the Soterogram are often performed at the same time and are covered by most Carriers by using Coding Modifier 59.
The ABIgram is actually a subset of the PADogram and also directed toward the peripheral vascular system. However, the PADogram in addition to taking bilateral systolic measurements at the brachial and ankle levels, includes bilateral thigh and calf level systolic pressure measurements. These additional measurements allow the PADogram to return arterial obstruction level results. The PADogram is performed when the ABIgram is positive for peripheral vascular disease and therefore, when more detailed information is necessary in the diagnosis of peripheral vascular disease.
By Jeffrey K. Raines and Zoraida Catherine Navarro
Appendix 1 – Hypertension Guidelines
Appendix 2/2A – Diabetes Guidelines
Appendix 3 – Blood Lipids Guidelines
Appendix 4 – Obesity Guidelines
Appendix 5 – Exercise Guidelines
Physicians and patients receiving this document will also be given either a Disk or Memory Stick with the appendices listed above for their personal use. For general information or to obtain information mentioned in this document, please contact the Soteria Medical, LLC main office, by telehone, Email, or standard mail.