American Journal of Medicine, internal medicine, medicine, health, healthy lifestyles, cancer, heart disease, drugs

Exercise Is Just as Important as Your Medication

cycling“They who are accustomed to daily labor, although even weak or old, endure it more easily than the robust or young who are unaccustomed to it.”

Hippocrates Aphorisms1


I tell all my patients that frequent exercise is just as important as their medication in controlling their cardiovascular disease.2 In addition, I tell them that they are not training for competition (with a few notable exceptions), but rather they are exercising for health and, therefore, do not need to exercise to exhaustion.

Recent decades have seen a considerable volume of research involving health benefits derived from regular exercise. A detailed and readable review of these benefits recently appeared in Circulation.3 These authors note that positive elements resulting from regular exercise include the following: Improvement in mood and cognition, self-esteem, energy levels and endurance, sleep quality, muscle strength, atherosclerosis risk factors, cardiac function in healthy individuals and in patients with heart failure, regular bowel function, fertility, serum lipid profiles, immune system function, offspring health, and joint mobility.

Regular exercise also helps to prevent falls in the elderly, maintains bone density, and prevents osteoporosis, slows muscle atrophy of aging and prevents sarcopenia, decreases stress, lowers the incidence of breast and colon cancer, attenuates hypertension, counters diabetes mellitus, improves symptoms in patients with peripheral vascular disease, limits obesity, decreases the risk of stroke, and delays the onset of Parkinsonism and Alzheimer’s disease.2 I know of no other therapeutic intervention that results in so many positive effects.

The current issue of The American Journal of Medicine contains a review that further supports the use of exercise as a therapeutic adjunct in patients with stable ischemic heart disease. I thoroughly enjoyed reading this review4 and found 10 “take home messages” that should translate easily into daily practice.

1. Recent reports confirm that between 1980 and 2000, mortality from coronary heart disease decreased by more than 40%. Only approximately 5% of this reduction in mortality could be attributed to coronary revascularization. This primary decrease in US mortality was due to decreases in major cardiac risk factors as well as improved medical therapy.

2. Regular moderate exercise promotes beneficial anti-atherosclerotic, antithrombotic, anti-ischemic, and antiarrhythmic effects as well as improvement in psychological well-being. Physiological benefits include lowered myocardial oxygen demand, improved coronary blood flow and endothelial function, and increased production of endothelial progenitor cells.

3. Guidelines recommend that patients engage in both aerobic and anaerobic (weight training) forms of exercise for 30-60 minutes 5 times per week. Often, such a program is best initiated in a formal cardiac rehabilitation program.

4. Patients who follow these exercise guidelines can expect to increase their angina threshold, that is, they can exercise for a longer period of time before experiencing angina pectoris.

5. Unfortunately, < 20%-30% of patients eligible for cardiac rehabilitation/exercise training regimens receive referrals to such programs, and of those referred, only approximately 40% actually participate. Even more unfortunate is the fact that women are less likely than men to be referred to or attend a cardiac rehabilitation program, particularly if they are elderly or nonwhite. Patients over age 65 years are commonly not referred despite that fact that these patients have been shown to benefit more than younger patients.

6. Low-risk patients with myocardial ischemia can benefit from home-based programs, which have been shown to be as effective as center-based cardiac rehabilitation. Home-based programs often result in better adherence, particularly in older patients or individuals who do not have easy access to a formal program.

7. Some patients, particularly the elderly, may find it difficult to exercise 5 times per week. Even more moderate exercise regimens have been shown to be of benefit in these individuals.

8. The authors emphasize an intervention that I was taught as a medical student and internal medicine resident: A prophylactic tablet of nitroglycerin dissolved under the tongue just before exercise usually increases exercise capacity in patients with stable, exertional angina pectoris.

9. Patients should be informed that physical inactivity is an important, modifiable cardiovascular risk factor, and that regular exercise decreases the risk for morbidity and mortality associated with ischemic heart disease.

10. And finally, as noted in the headline above this editorial, exercise is just as important as medication in the management of ischemic heart disease.

To read this article in its entirety and to view additional images please visit our website.

–Joseph S. Alpert, MD, AJM Editor-in-Chief

This article originally appeared in the October 2014  issue of The American Journal of Medicine.

Related: Exercise as a Therapeutic Intervention in Patients with Stable Ischemic Heart Disease: An Underfilled Prescription

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