Universal Fitness Innovation & Transformation
The terms Coronary Heart Disease (CHD), Coronary Artery Disease (CAD) and Ischemic Heart Disease all refer to a build-up of plaque in the coronary arteries. The terms are often used interchangeably yet CHD is a result of CAD as it is slightly broader than CAD as it encompasses the disease of entire heart, not just the coronary arteries.
Coronary Artery Disease (CAD) is an accumulation of plaque on the walls of the arteries that supply oxygen to the heart. It is widely accepted that meeting the daily physical activity guidelines is strongly associated with flourishing cardiovascular functioning. It is important to note that often clients with CAD will experience one or more additional conditions and for some clients with more severe heart conditions, physical activity is absolutely necessary to maintain physical functioning, independence and quality of life (ACSM, 2016).
Lifestyle choices play a major role in the onset of CAD starting with cardiometabolic conditions. These occur when the body cannot efficiently break down the food (sugar/glucose and fat/triglycerides) that has been eaten, primarily due to insufficient physical activity levels, the quality of food eaten (high in fats and sugars etc) and other lifestyle choices, like smoking. The chemical processes required to maintain health and life become affected. Onset of these conditions is gradual and the conditions can escalate unless the client improves their physical fitness within a safe environment and at an appropriate intensity and progression. When supported by other health enhancing, holistic lifestyle choices (see Figure 1), reaching the recommended daily guidelines for physical activity can actually reverse the symptoms of these conditions in particular when activity starts in the earlier stages. Clients have the potential to transform their lives with your guidance and support and enjoy the vast benefits of engaging in fitness activities that are physical, emotional, social and psychological.
Common cardiometabolic conditions are high cholesterol (dyslipidemia) and high blood pressure (hypertension) (Diabetes is also a cardiometabolic condition – see Diabetes type II). The impaired metabolism of cholesterol is associated with high levels of both cholesterol and low-density lipoproteins in the blood. These often occur side-by-side and both lead to the build-up of plaque or fatty deposits in the arteries which is called atherosclerosis. Over time this plaque hardens, lining and narrowing the walls of the arteries. The plaque can rupture which causes a clot to form which further obstructs the flow of oxygen-rich blood. When this occurs in the coronary arteries it is called Coronary Artery Disease (CAD) and specific associated conditions which are outlined in Figure 1. Unless a client chooses healthier lifestyle choices CAD will progress to chronic heart failure which can include a heart attack (Myocardial Infarction) and sudden cardiac death. A stroke (thrombosis) may also occur in which the blood supply to the brain gets cut off (see Stroke).
Note: Lifestyle choices that have been shown to improve CAD risk factors, including:
*positively impacted by reaching daily physical activity recommendations
Blood pressure is defined as high (hypertension) when systolic blood pressure is over 139 mmHg or diastolic blood pressure is over 89 mmHg. The ACSM (2016) outlines the classes of hypertension and the management of each classification (see table 2).
*treatment determined by highest BP category.
**initial combined therapy should be used cautiously in those at risk for orthostatic hypertension.
***compelling indications include heart failure, status postmyocardial infarction, high coronary artery disease, diabetes, chronic kidney disease, stroke survivor. Chronic kidney disease or diabetes treated to BP goal of <130/80 mmHg.
The pressor response is naturally higher in clients with hypertension, this means that physical activity increases exercise systolic (when the heart muscle contracts) blood pressure more quickly than for the general population. Low intensity, endurance aerobic exercise is known to decrease post-exercise blood pressure in clients with high blood pressure (hypertension) and those who are on the path to high blood pressure. Aerobic training also reduces resting blood pressure by between 5 and 10 mmHg in clients with stages I and II hypertension (ACSM, 2010).
Dyslipidemia is when the blood has a high level of fat (lipids), including cholesterol which is primarily needed in each cell of the body to regulate the stability of the cell membranes. Lipoproteins are proteins that transport cholesterol and other fats in the blood to the cells. The metabolism of cholesterol is very complex. Here we will explain it simply to provide an understanding of what your client may be experiencing physiologically with the intention of supporting you both in creating a tailored fitness programme. The basic lipoproteins are:
The LDLs and HDLs are mostly responsible for transporting cholesterol. When cholesterol and low-density lipoprotein levels are high CAD is more likely to develop. When high-density lipoprotein levels are high the risk of CAD is reduced. The American Heart Association have identified three groups of people based on their need for risk reduction. It was primarily developed for statin prescription however may also be a guide for exercise professionals to support them in designing safe and effective exercise programmes for each client. (ACC/AHA, 2014)]. The groups are as follows:
High cholesterol (hyperlipidemia) does not generally affect a client’s response to aerobic training clients. Cholesterol levels do not decrease however there is a beneficial decrease in the harmful proteins responsible for transporting cholesterol in the blood (LDL-C) and an increase in the ‘good’ proteins (HDL-C) of between 5% and 10%. See Implications for Exercise below.
Myocardial Ischaemia is when the heart doesn’t get enough oxygenated blood from the arteries, mostly due to a blockage in one or some of the coronary arteries. Normally the myocardium extracts almost 80% of the oxygen that is available from the blood. When oxygen uptake is restricted the muscle becomes deprived of oxygen (hypoxic) and the heart increases the blood flow to get the oxygen it needs. Common causes are: Atherosclerosis of the conductance-sized coronary arteries, coronary artery spasms, microvascular disease, and/or tunnelling of coronary arteries (artery tunnels into heart wall/myocardium instead of resting on it). The client may or may not experience symptoms for example, Angina Pectoris or silent ischaemia.
Exercise requires additional oxygen and so the intensity most suited to the client will depend on the severity of their condition. It is important for the client to start with light intensity, with very gradual progression with the fitness goal of increasing the heart’s capacity to extract oxygen from the blood (raise ischaemic threshold). See Implications for Exercise below.
Angina (Angina Pectoris) is a symptom of when an individual’s heart doesn’t get enough oxygenated blood from the arteries (myocardial ischaemia and hypoxia) causing chest discomfort. Episodes can last between 2 and 12 minutes and mostly feels like heaviness or squeezing that starts behind the breast-bone (sternum) and can radiate to the arms, neck, jaw and shoulders. Silent Ischaemia is angina without the symptoms (asymptomatic). When angina and silent ischaemia are stable and chronic (long-term) they can be managed once the client becomes aware of their individual triggers which usually include a certain level of physical exertion, emotional stress or cold temperature. Clients with more severe CAD will experience longer and more intense episodes of discomfort, more frequently than those with lesser symptoms. If a client has unstable angina or silent ischaemia mostly due to extreme anaemia, severe overactive thyroid; pheochromocytoma (adrenal gland tumour that affects release of adrenaline and noradrenaline); malignant hypertension (rapid increase in blood pressure over 180/120mmHg); sepsis (life-threatening infection) etc, urgent medical attention is necessary.
Atrial fibrillation is a condition in which the pumping of the heart and the filling of the chambers of the heart (ventricles) becomes impaired causing an irregular heartbeat (dysrhythmia). The client will experience rapid and chaotic heartbeat and may also experience fatigue; reduced exercise capacity; falls due to dizziness or fainting; and/ or stroke.
Exercise tolerance is generally lower for clients with this condition, yet when done at appropriate intensity, duration and frequency, exercise is safe and very beneficial in this case. The most important highlight for fitness professionals working with clients with atrial fibrillation is the underlying heart disease that caused the condition. Considering the implications for exercise for the underlying cause will take precedence and will greatly guide the client’s fitness programme and goals/ intensity/ duration etc. See Implications for Exercise below.
Chronic heart failure (CHF) is predicted to become a major global public health concern and with 25% of men and 38% of women with CHF surviving five or less years after diagnosis we can clearly see why physical activity is so important for the health of the population. CHF is a syndrome as opposed to a disease, meaning that it is a combination of symptoms that result from disease(s). Clients with CHF have problems because the heart cannot adaquately deliver oxygen to the body, affecting all systems of the body. For example contractions (systolic) become impaired due to myocardial ischemia, myocardial infarction (heart attack) and idiopathic cardiomyopathy (ischaemic heart disease with unknown cause). Between contractions the heart is relaxed (diastolic), the chambers in the heart (left and right ventricles) that fill with blood become impaired and the chamber does not fill as it should. These impairments both decrease cardiac output during exercise (meaning a reduction in oxygen getting to the cells which are particularly necessary for the Kreb’s Cycle to generate energy during aerobic activity). They also increase pressure in the veins that travel to the lungs with oxygenated blood (pulmonary veins) and the central veins closest to the heart (central venous pressure) and in severe cases pressure is also increased in the left heart chamber as it fills (left ventricular filling pressure) when the client is at rest. It is not yet understood why, but when the left ventricle is impaired signs and symptoms rapidly deteriorate and immediate medical attention is needed. Otherwise, although the condition is chronic, it is generally stable, which means that the client may exercise safely once their level of fitness is monitored and they learn to exercise at an appropriate intensity while also learning to understand their body’s physiological reactions to exercise.
Physical activity is widely recognised to have great health benefits for all clients with CHD for example it is known to reduce hypertension and dyslipidemia, decrease neuro-hormonal activation, improve quality of life, and reduce morbidity and mortality. The severity of the various conditions associated with CHD vary greatly as well as the client’s individual response to their treatment (medication, lifestyle changes etc) so each client will require a tailored fitness programme to suit their individual needs.
Some clients will need closer attention, in particular in relation to the intensity of aerobic and resistance activities, as these clients will have more sensitive physiological exercise responses to physical activity (eg. Shortness of breath, leg fatigue due to inadequate blood flow to muscles). For example, clients with chronic heart failure, atrial fibrillation, valvular heart disease, aneurysms, those who are recovering from heart transplants or those who have coronary implants such as pacemakers and defibrillators. In the past is was thought that a physical fitness programme was harmful to such clients, however current research shows that physical activity (aerobic &/ resistance) is necessary for these clients as it will help them maintain physical functioning which translates to independence and quality of life while also having psychological benefits (see table 3 for guidelines on exercise intensity). High-intensity interval training should be avoided with these clients for safety reasons.
What happens when clients start exercising towards meeting the weekly physical activity recommendations? The main physiological benefits according to the ACSM are due to improvements in the ability of the skeletal muscles to use the oxygen that is delivered through the blood (peripheral adaptations eg. Enzyme activity; the density of the capillaries and mitochondria or power houses of the cells). This suggests that low intensity, endurance aerobic exercise is best for clients in these circumstances, with a gradual progression of the duration.
It is important that clients learn to become familiar with their body’s response to exercise using the Rate of Perceived Exertion (RPE) Scale (see Table 4). You, as a fitness professional should also take their heart rate and blood pressure before, during and after exercising, as there are certain blood pressure rates in which fitness activities should be avoided for safety reasons, while also observing the client’s response to exercise to ensure that they maintain an appropriate exercise intensity. Ideally you may educate the client (especially those with high blood pressure) on how to understand the BP reading and more importantly, to learn to get a feel for their RPE and the corresponding blood pressure rate. It is important to note that blood pressure of clients taking certain medications (beta-blockers and ACE inhibitors) will very likely not be accurate as these medications lower blood pressure. In these circumstances the RPE Scale should be used (see Table 4). Table 3 outlines when clients should engage in lighter intensities and when physical activity should be completely avoided until blood pressure has returned to an appropriate level before participating in physical activity.
As already mentioned, lower intensity endurance aerobic training is best for most clients with CAD or CHD. In particular for clients with chronic heart failure it is most beneficial for improving their physical functioning. The client will most likely be working with a cardiac rehabilitation team or other allied professionals, it is ideal for you as the fitness professional to work in collaboration with this team or professional. The client should start on a light-intensity walking programme where you (the fitness professional) observe their exercise responses and support them in learning to observe these responses also. The recommendations of 150 to 300 minutes of physical activity per week still hold, however, with these clients the intensity guidelines have decreased to self-paced physical activity from moderate-vigorous for the general population. Warm-up and especially cool-down should be prolonged in particular for clients on the more severe end of the heart condition spectrum (5-10 mins) (ACSM, 2016).
The client may work towards the goal of gradually increasing to moderate intensity aerobic activity for 30-40 minutes a day (11-14 RPE Scale or 60% of HR reserve (220-age)). Clients who were previously inactive will experience the greatest benefits.
Clients with chronic conditions often prescribed medication for each condition and so some clients may be prescribed five to eight prescriptions. Many of these clients may reduce the number of medications and /or the dosage by working towards reaching recommended physical activity levels and eating a heart healthy diet (ACSM, 2016, pg 73 & 74).
Beta Blockers are often prescribed for hypertension and CVD. They cause heart rate (both resting and exercise heart rate) and blood pressure to decrease by preventing adrenaline (epinephrine) from binding to receptors in the heart. This means that during high intensity aerobic activities heart rate and blood pressure do not increase as normal and so heart rate reserve is not an accurate method of measuring intensity. In this case the Rate of Perceived Exertion (RPE) Scale is more appropriate. Beta blockers may also reduce the client’s capacity to exercise; impair thermoregulation; prevent the heart from adapting to exercise (reduce chronotropic response) and/ or reduce blood pressure after exercising (ACSM, 2016, pg 76).
ACE (angiotensin-converting-enzyme) Inhibitors are prescribed for hypertension and they are least likely to affect exercise performance and the metabolic effects of exercise (Noorbhai et al, 2014). They actually assist with the amount of blood the heart pumps per minute (cardiac output, l/m). They work by relaxing the blood vessels and reducing blood pressure. This means that blood pressure (systolic and diastolic) is lower at rest, during and following exercise. Exercise naturally reduces blood pressure for up to nine hours following physical activity by up to 10-20 mmHg. If a client is also taking ACE inhibitors to reduce blood pressure, they may experience excessively low blood pressure which can cause dizziness. A gradual cool-down of 5-10 minutes of low intensity activity is always imperative to aid venous return and prevent blood pooling in the muscles. Common ACE inhibitors include captopril, enalapril and lisinopril.
Diuretics are also often prescribed to clients with hypertension and while they don’t have an effect on the client’s exercise performance, they do effect the metabolic effects of performance. They act on the kidneys which causes an increase in the excretion of urine which reduces blood pressure by decreasing the plasma volume in the blood (Noorbhai et al, 2014). Resting and exercising blood pressure is lower. Diuretics may also impair the body’s ability to regulate its temperature (thermoregulation). Clients should also learn to do a daily weight check to ensure their diuretic prescription is remaining effective. For example a sudden increase in weight can indicate ineffective urine excretion and so an increase in blood plasma, therefore increased blood pressure. In this case the client should contact their general practitioner. One of the most common diuretic is hydrochlorothiazide (HCTZ).
Statins are the most prescribed medication for clients with high cholesterol and they work on the body by blocking a key enzyme responsible for activating the production of cholesterol in the liver. They are more likely to affect the client’s exercise response than beta-blockers and ACE inhibitors. For example, they increase the likelihood of muscle soreness after exercise and in rare cases can trigger ER (exertional rhabbdomyolysis) whereby damaged skeletal muscle tissue breaks down (eg. Protein myoglobin) and enters the blood with the potential to harm to the kidneys. This is most likely to occur for unconditioned clients performing high-intensity physical activity, especially resistance training and eccentric contractions (where the muscle lengthens on contraction) in hot, humid environments. ER can be avoided when a client maintains a low intensity fitness programme, with gradual progression; watching for the signs and symptoms eg dark coloured urine, muscle stiffness and fatigue; and remaining hydrated. Despite these considerations, performing fitness activities has been shown to have similar health benefits in relation to CHD as statin prescription with the addition of other benefits not available from taking statins (eg. Increased cardiovascular fitness, increased cognitive function, decreased fall risk, weight loss, improved quality of life, decreased risk of diabetes mellitus (type II) while statins increase the risk) (Roberts, 2015).
If a client is in the moderate cholesterol lowering group they will most likely be prescribed an intense statin dosage which aims to reduce LDL-C by ≥50%, while clients in the intensive cholesterol lowing group will most likely be prescribed less intensive statin therapy in case of reaction to the medication. Moderate intensity statins aim to reduce LDL-C between 30% and 49% (ACSM, 2016). It is clear that physical exercise can benefit clients beyond the benefits of medication. The key is for the client to exercise at a safe and appropriate intensity. Research shows that clients taking low-moderate doses of statins do not need to reduce the duration or intensity of their fitness activities while clients taking more intense doses of statins will need to be monitored more closely in case the experiences the symptoms mentioned earlier (Roberts, 2015). Common statins include Lipitor, Zocor and Pravachol.
Each client will be individual, yet most clients with severe symptoms will benefit from starting with shorter duration and lower intensity activities, progressing gradually to moderate intensity.
Cool-down should always be long and gradual to allow the client’s blood pressure to return to normal and to prevent blood pooling in the legs. Especially if they are taking ACE inhibitors and/or diuretics. (5-10mins low intensity aerobic activity and stretch)
In warm climates the client should exercise at cooler times of the day
Instruction isn’t always about speaking, it’s also about listening. Listening to what your client says verbally, and also physically. Look out for the clients exercise response, are they becoming short of breath very easily, watch for the colour of their face, are their legs or ankles swelling? Are they feeling dizzy?
If a client is taking statins, especially more intense dosages and/or if the client has a low level of fitness, it is important to know the signs and symptoms of ER (exertional rhabbdomyolysis) in case they need to contact their physician. Muscle stiffness and/or pain; fatigue and dark-coloured urine (Roberts, 2015).
All clients should be encouraged to become familiar with the RPE Scale, teaching them to learn their body’s response to various intensities so that they can learn to know what intensity is appropriate for the body on any given day.
Beginners may start at 3 x 10 mins aerobic activity at a pace of their own most days, progressing to 1 x 30-40 mins of moderate (11-14 RPE Scale).
Engaging large muscle groups in repetitive activity, eg walking, rowing, cycling etc.
The warm-up and cool-down phases are important to allow the client’s heart rate and blood pressure to increase and decrease gradually (5-10mins low intensity aerobic activity and stretch).
The client should always breathe consistently throughout all activities, in particular resistance training throughout the entire range of motion as holding the breath raises blood pressure considerably.
Relaxing physical activities like yoga and tai chi etc may support clients as stress is also a major factor that contributes to CHD. These activities are generally light-moderate intensity and will allow the client to develop their mind-body connection.
It is important that the client feels safe and supported in their fitness programme. This environment of safety and trust can be supported by working with allied professionals (eg. A member of their cardiac rehabilitation team; their physician or dietician) to reassure the client that their programme is safe.
It is important that the client exercises in a cool and well ventilated space as high temperatures and humidity can increase blood pressure.
Seats for resting should be available for clients who need regular rest periods.
If a client needs assistance with personal care and toileting and is taking diuretics (which increase urination), they should be encouraged to use the toilet before exercising to ensure that their exercise session doesn’t have to be interrupted by a bathroom break.
Encouraging the client to wear a pedometer may support them in reaching their physical activity goals.
Does the club or facility you work in have a defribrillator (AED: Automated External Defibrillator)? Are staff trained to use it in the event of an emergency? The use of the defibrillator may never be necessary, however it may reassure clients with more severe CHD as they may experience fear in relation to exercising.
It is necessary to also review the client’s diet, reducing their intake of added and hidden sugar (fructose); trans-fat (especially fried food) current research shows that a diet high in these two ‘foods’ is strongly linked to heart disease and heart failure.
Clients with hypertension are also strongly recommended to reduce their sodium intake. (4.5g sodium/day or 65mmol/day) and to increase their Potassium intake to 4.7g/day or 120 mmol/day (eg. 1 cup of cooked winter squash = 0.9g; 1 medium baked potato with skin = 0.7g; 1 medium banana = 0.422g etc).
Lifestyle recommendations for clients with high cholesterol (dyslipidemia) are similar to those with high blood pressure (hypertension) with the addition of clear guidelines in relation to dietary fat which are as follows (ACSM, 2016).
Be aware that clients may also have undiagnosed cardiometabolic conditions, For example a client with hypertension may also have undiagnosed for example, diabetes or kidney disease etc. Some possible signs and symptoms include frequent thirst and hunger, frequent urination, unexplained weight loss, fatigue, blurred vision.
Many clients with heart conditions may be fearful of working towards higher exercise intensities, it is important for them to learn to read the signs their body is giving them. The Rate of Perceived Exertion Scale is very useful for this, especially as many cardiovascular medications can make blood pressure readings inaccurate (beta blockers etc). In time the client will learn to become accurately familiar with their body’s exercise response in relation to intensity.
The ACSM (2016, pg 140) recommends clients with Coronary Heart Failure to attend cardiac rehabilitation and to follow this with a home-based programme. Many clients may prefer to carry out their rehabilitation at a fitness club with the support of a fitness professional for motivation and to assist with adherence to their programme. Especially if they realise their fitness professional is aware of how to support their condition specifically they may appreciate the education on how to understand their body’s responses to exercise and how to adjust the intensity accordingly along with supporting them in other health enhancing lifestyle choices or changes.
A buddy system may support clients, especially if they exercise with a friend or family member in similar circumstances.
It is important for your fitness club and facility to promote its willingness and readiness to work with clients with CHD. This will reassure and attract clients who may have previously felt anxious or unsafe.
If there are ‘buddy membership’ rates available it is important to promote this widely.
Some Programme Goals of programme to consider as well as the client’s individual short-term and long-term goals:
Feels almost impossible to keep going
Completely out of breath, unable to talk
Very difficult to maintain exercise intensity
Can barely breath and speak and single word
On the verge of becoming uncomfortable
Short of breath, can speak a sentence
Feels like you can exercise for hours
Breathing heavily, can hold short conversation
Feels like you can maintain for hours
Easy to breathe and carry a conversation
Anything other than sleeping, watching TV, riding in a car etc
· Frequency: 3-5 days per week
· Duration: 20-60 min
· Intensity: 40-50-85% of VO2R
HRR= heart rate reserve; VO2R= oxygen uptake reserve; HRmax= maximum heart rate; RPE= rate of perceived exertion
Lower intensity endurance aerobic training is best for most clients with CAD or CHD.
Both client and the exercise professional observe client’s RPE, especially as the client begins to gradually increase their exercise intensity.
150 to 300 minutes of physical activity per week
Starting with self-paced physical activity gradually increasing to light and moderate intensity aerobic activity for 30-40 minutes a day (11-14 RPE Scale or 60% of HR reserve (220-age)).
Cool-down should be prolonged (5-10 minutes) to allow blood pressure to decrease gradually after exercising. Especially for clients on the more severe end of the heart condition spectrum (ACSM, 2016).
Choose a mode of exercise (free weights, bands or machines) that is comfortable throughout the full range of motion.
Perform between 3 and 20 repetitions (eg. 3-5, 18-20 depending on client’s individual appropriate intensity and capacity) of a combination of resistance training exercises that strengthen the major muscles of the hips, thighs, legs, back, chest, shoulders, arms and abdomen.
Repetitions can be performed at a moderate repetition duration (3 seconds concentric – pause – 3 seconds eccentric) in a controlled manner. For people with high cardiovascular risk or those with chronic disease (hypertension, diabetes) complete each exercise as the concentric portion becomes difficult (RPE 15-16).
Exercise each muscle group 2-3 non-consecutive days per week.
Allow enough time between sets to perform the next exercise in proper form.
Ensure normal, consistent breathing.
Clients with high blood pressure (hypertension) should avoid isometric contractions as they cause an exaggerated increase in blood pressure.
There is such a variation in CHD so each client’s intensity will have to be evaluated independently. It is be ideal to start all clients out on lighter intensities, with gradual progression depending on the severity of their symptoms, condition and response to exercise.
40/50-85% HRR or VO2R 64/70-94% HR max
Or Volitional fatigue (19-20 RPE)
It is important for the client to look at their overall lifestyle choices, to evaluate whether they are health enhancing and what choices can be made to enhance their health. For example, it is important to know whether the client smokes and eats a healthy diet and to guide them in exploring if and what changes they would like to make. Some clients may feel overwhelmed if they have many changes to make and so it may be best for them to start with small 100% achievable short-term goals that will build their self-confidence and encourage them to work towards their long-term goals.
It is very important for the client to evaluate their eating patterns. This will involve the client taking note of their food and drink intake with the aim of evaluating their current diet, identifying and adopting healthier eating patterns. Harvard’s research based Healthy Eating Plate and Healthy Eating Pyramid will support clients in understanding of what a healthy diet looks like in relation to the variety and quantities of each food.
There are heart healthy meal planner mobile phone applications that can support clients in changing their eating patterns. Eg. The healthy heart app, from the Heart Foundation in New Zealand which is a Healthy Heart Meal Planner
The DASH Diet has been shown to improve cardiovascular symptoms and provides a Food Group Servings Check Off Form. If this was to be used by a client they could also add a list of all foods they eat to raise their awareness of what they are eating.
American College of Cardiology/ American Heart Association, (2013), Cardiovascular Risk Calculator, available at: http://www.cvriskcalculator.com/ [accessed 5th April 2016]
Anderson, L., Oldridge, N., Thompson, D., Zwisler, A.D., Rees, K., Martin, N., Taylor, R., (2015), ‘Exercise-based Cardiac Rehabilitation for Coronary Heart Disease – Cochrane Systematic Review and Meta-Analysis’, Journal of American College of Cardiology, 67, 1
DASH diet, available at: http://dashdiet.org/default.asp [accessed 3rd April 2016]
Exercise is Medicine, ‘Exercising with Heart Failure’, available at http://exerciseismedicine.org/assets/page_documents/EIM%20Rx%20series_Exercising%20with%20Heart%20Failure_2.pdf [accessed 5th April 2016]
Exercise is Medicine, ‘Your Prescription for Health Series’, available at: http://exerciseismedicine.org/assets/page_documents/YPH_All.pdf [accessed 6th April 2016]
Mercola, 2015, ‘Elevated Sugar Intake Linked to Significantly Raised Risk of Obesity, Diabetes, and Heart Disease’, available at: http://articles.mercola.com/sites/articles/archive/2015/03/16/added-sugar-heart-disease.aspx [accessed 3rd April 2016]
Moore, G., Durstine, L., and Painter, P., eds. (2016) American College of Sports Medicine: Exercise Management for Persons with Chronic Diseases and Disabilities, 5th Edition, Human Kinetics, Champaign
Green, J., ‘ExRx for Valvular Heart Disease’, National Centre on Health, Physical Activity and Disability, available at: http://www.nchpad.org/970/5161/ExRx~for~Valvular~Heart~Disease, [accessed 5th April 2106]
Green, J., ‘High Cholesterol and Exercise: Helping Your Clients Lower Their Numbers’, National Centre on Health, Physical Activity and Disability, available at: http://www.nchpad.org/874/4979/High~Cholesterol~and~Exercise~~Helping~Your~Clients~Lower~Their~Numbers [accessed 5th April]
Harvard School of Public Health, ‘Healthy Eating Plate & Healthy Eating Pyramid’, available at: https://www.hsph.harvard.edu/nutritionsource/healthy-eating-plate/ [accessed 9th May 2016]
Noorbhai, H., Gabriels, G., and Noorbhai, A., (2014), ‘the effects of common medications in response to exercise and training’, Adv Pharmacoepidemiol Drug Saf, 3, 1, 146
Pescatello, L., Arena, R., Riebe, D., Thompson, P., eds. (2014), ACSM’s guidelines for exercise testing and prescription, 9th Edition, Baltimore: Lippincott Williams & Wilkins
Swain, D., Brawner, C., Chambliss, H., Nagelkirk, P., Paternostro Bayles, M. and Swank, A., eds. (2014), ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription, 7th Edition, Baltimore: Lippincott Williams & Wilkins
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