Development of a Novel Clinical Decision Support System for Exercise Prescription Among Patients With Multiple Cardiovascular Disease Risk Factors

Abstract

Cardiovascular disease (CVD) risk factors cluster in an individual. Exercise is universally recommended to prevent and treat CVD. Yet, clinicians lack guidance on how to design an exercise prescription (ExRx) for patients with multiple CVD risk factors. To address this unmet need, we developed a novel clinical decision support system to prescribe exercise (prioritize personalize prescribe exercise [P3-EX]) for patients with multiple CVD risk factors founded upon the evidenced-based recommendations of the American College of Sports Medicine (ACSM) and American Heart Association. To develop P3-EX, we integrated (1) the ACSM exercise preparticipation health screening recommendations; (2) an adapted American Heart Association Life's Simple 7 cardiovascular health scoring system; (3) adapted ACSM strategies for designing an ExRx for people with multiple CVD risk factors; and (4) the ACSM frequency, intensity, time, and time principle of ExRx. We have tested the clinical utility of P3-EX within a university-based online graduate program in ExRx among students that includes physicians, physical therapists, registered dietitians, exercise physiologists, kinesiologists, fitness industry professionals, and kinesiology educators in higher education. The support system P3-EX has proven to be an easy-to-use, guided, and time-efficient evidence-based approach to ExRx for patients with multiple CVD risk factors that has applicability to other chronic diseases and health conditions. Further evaluation is needed to better establish its feasibility, acceptability, and clinical utility as an ExRx tool.

Keywords: 1-RM, one repetition maximum; ACSM, American College of Sports Medicine; AHA, American Heart Association; AHA7CVH, American Heart Association Life’s Simple 7 cardiovascular health scoring system; BG, blood glucose; BMI, body mass index; BP, blood pressure; CV, cardiovascular; CVD, cardiovascular disease; CVH, cardiovascular health; DBP, diastolic blood pressure; Ex Rx, exercise prescription; FITT, frequency, intensity, time, and type; HDL-C, high-density lipoprotein cholesterol; HR, heart rate; HRR, heart rate reserve; HTN, hypertension; LDL-C, low-density lipoprotein cholesterol; P3-EX, prioritize personalize prescribe exercise clinical decision support system; PNF, proprioceptive neuromuscular facilitation; RPE, rating of perceived exertion; SBP, systolic blood pressure; SOB, shortness of breath; T1DM, type 1 diabetes mellitus; T2DM, type 2 diabetes mellitus; TC, total cholesterol; VO2R, oxygen uptake reserve; WC, waist circumference.

© 2020 Mayo Foundation for Medical Education and Research.

Figures

Figure 1

The ACSM exercise preparticipation health screening logic model. §Exercise participation is defined as performing planned, structured physical activity at least 30 minutes at moderate intensity on at least 3 days per week for at least the last 3 months. ∗∗Cardiac, peripheral vascular, or cerebrovascular disease. ∗∗∗Type 1 or 2 diabetes mellitus. ˆMedical clearance is defined as approval from a health care professional to engage in exercise. +Light intensity exercise is defined as an intensity that causes slight increases in HR and breathing. ++Moderate intensity exercise is defined as an intensity that causes noticeable increases in HR and breathing. +++Vigorous intensity exercise is defined as an intensity that causes substantial increases in HR and breathing. ACSM = American College of Sports Medicine; CV = cardiovascular; HR = heart rate. ɸAdapted from ACSM’s Guidelines for Exercise Testing and Prescription.,

Figure 2

A clinical decision support system for prioritizing the cardiovascular risk factor or chronic disease or health condition to design the FITT ExRx. aAHA = American Heart Association; BMI = body mass index; CVH = cardiovascular health; CVD = cardiovascular disease; DBP = diastolic blood pressure; ExRx = exercise prescription; FITT = frequency, intensity, time, and type; SBP = systolic blood pressure; WC = waist circumference. bCVH score cut-offs for WC are based on ACSM’s Guidelines for Exercise Testing and Prescription (p 70).cTotal cholesterol is only scored if low-density lipoprotein–cholesterol (LDL-C) is not available. dThe strategy chosen should be based on the CVD risk factor and/or chronic disease and health condition with the FITT ExRx that best fits that strategy’s description, while considering the patient’s preferences, goals, and special considerations (Table 3). eThere is a strong, inverse association between AHA Life's Simple 7 ideal metrics and the incidence of myocardial infarction, stroke, coronary heart disease, and other cardiovascular outcomes, as well as noncardiovascular conditions such as depression, cognitive function, and cancer.fThe CVH scoring system has been adapted from its original version, to accommodate: (1) adjustments in scoring for resting values that are being treated by medication, as any CVD risk factor that is being treated by medication is regarded as having that CVD risk factor independent of the resting value; and (2) the 2017 AHA/American College of Cardiology blood pressure guidelines.gSee Table 3 and the ACSM’s Guidelines for Exercise Testing and Prescription (pp 268-376) for the FITT ExRx and special considerations for each CVD risk factor and/or chronic disease and health condition.