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Prevention of Cardiovascular Disease

The World Health Organization estimates that 27.5% of people are not getting enough exercise,1 and a separate analysis published in the Lancet attributes 9% of global premature deaths to inactivity.2 Clearly, when sedentary patients increase physical activity, the risks posed by cardiovascular disease are greatly mitigated, but what is the role of the primary care practitioner in this? Moreover, what is the difference between a physical activity recommendation and prescribed exercise?

Firstly, patients at risk of cardiovascular disease or progression thereof should be encouraged to take up any activity. Strong evidence shows that, among inactive adults, even modest increases in activity lowers the risks related to cardiovascular disease including all-cause mortality.3

On the other hand, a robust and growing body of research continually refines healthcare’s understanding of optimal exercise prescriptions for differing cardiovascular disease presentations. Exercise physiology can serve as a resource for medical practitioners, first, in terms of optimizing the exercise plan based on disease state and goals and, next, in terms of implementation. Prescribed exercise refers to clinically recommended, structured, supervised, exercise programs specifically targeted toward defined modifications of a disease state.4 Prescribed exercise is specific and optimised in terms of mode, dose, duration, and intensity to maximise the patient’s return on their investment of time and effort. 

Different disease states may respond differently to varying modes of exercise. For instance, high-intensity endurance exercise may be preferred for chronic coronary disease without heart failure, peripheral artery disease, and heart failure with preserved ejection fraction. On the other hand, moderate-intensity aerobic training may be preferred for heart failure with reduced ejection fraction as well as for atrial fibrillation.4 Within those categories of exercise, research explores further refinement for optimised results. For example, regarding moderating cardiovascular risk factors, a body of research suggests interval training as an effective option in high-intensity endurance training, but even within that definition there are variations in intervals, sessions, and exertion levels.5

Additionally, exercise prescribed for cardiovascular disease should encompass the whole body’s musculature. This will enhance local, physiological adaptations such as skeletal muscle capillary density, capillary-to-fibre ratio, percent type I (oxidative) muscle fibres, and mitochondrial content.6-8 Prescriptions for exercise should also seek to include elements that enhance short-term and long-term adherence. The exercise physiologist can help implement elements connected to higher adherence rates in the scientific literature. These include behavioural goal setting, creating detailed plans, demonstration of the exercise, objective biofeedback, gradually increasing volume and intensity, prompts/cues, and teaching patients to reward themselves for progress.9,10 


1. World Health Organization. Physical activity and sedentary behaviour: a brief to support older people. World Health Organization; 2022 Nov 30.

2. Lee IM, Shiroma EJ, Lobelo F, Puska P, Blair SN, Katzmarzyk PT. Effect of physical inactivity on major noncommunicable diseases worldwide: an analysis of burden of disease and life expectancy. The Lancet. 2012 Jul 21;380(9838):219-29.

3. Dos Santos M, Ferrari G, Lee DH, Rey-López JP, Aune D, Liao B, Huang W, Nie J, Wang Y, Giovannucci E, Rezende LF. Association of the “weekend warrior” and other leisure-time physical activity patterns with all-cause and cause-specific mortality: A nationwide cohort study. JAMA Internal Medicine. 2022 Aug 1;182(8):840-8.

4. Tucker WJ, Fegers-Wustrow I, Halle M, Haykowsky MJ, Chung EH, Kovacic JC. Exercise for primary and secondary prevention of cardiovascular disease: JACC focus seminar 1/4. Journal of the American College of Cardiology. 2022 Sep 13;80(11):1091-106.

5. Ito S. High-intensity interval training for health benefits and care of cardiac diseases-the key to an efficient exercise protocol. World Journal of Cardiology. 2019 Jul 26;11(7):171.

6. Nystoriak MA, Bhatnagar A. Cardiovascular effects and benefits of exercise. Frontiers in Cardiovascular Medicine. 2018 Sep 28;5:135.

7. Klausen K, ANDERSEN LB, Pelle I. Adaptive changes in work capacity, skeletal muscle capillarization and enzyme levels during training and detraining. Acta Physiologica Scandinavica. 1981 Sep;113(1):9-16.

8. Lundby C, Jacobs RA. Adaptations of skeletal muscle mitochondria to exercise training. Experimental Physiology. 2016 Jan 1;101(1):17-22.

9. Howlett N, Trivedi D, Troop NA, Chater AM. Are physical activity interventions for healthy inactive adults effective in promoting behavior change and maintenance, and which behavior change techniques are effective? A systematic review and meta-analysis. Translational Behavioral Medicine. 2019 Feb;9(1):147- 57.

10. Laranjo L, Ding D, Heleno B, Kocaballi B, Quiroz JC, Tong HL, Chahwan B, Neves AL, Gabarron E, Dao KP, Rodrigues D. Do smartphone applications and activity trackers increase physical activity in adults? Systematic review, meta-analysis and metaregression. British Journal of Sports Medicine. 2021 Apr 1;55 (8):422-32.


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