Physical activity and exercise training are designed to help patients recover their age-and gender-appropriate exercise capacity following an acute clinical episode or other circumstances that focus the need for improving exercise tolerance. Given that there is a definable risk associated with exercise in patients with cardiovascular disease, guidelines for physical activity and exercise training should be formulated in such a way as to reduce the likelihood of exercise-related complications. The primary outcome of a successful physical activity and exercise training prescription is an enhanced exercise tolerance. However, physical activity and exercise training are also positive tools with which the clinician may help patients to focus changes in other aspects of their lifestyles that might contribute to minimizing the impact of the disease process and/or to reducing the risk of subsequent clinical events.

There are discrete differences between physical activity guidelines and exercise training prescriptions. Activity guidelines are primarily related to the potential role of increased levels of physical activity in reducing the risk of cardiovascular disease. The results of several epidemiologic studies have demonstrated that habitually active individuals develop cardiovascular disease at a slower rate than their more sedentary peers, regardless of whether the activity is occupational or recreational.<sup>4 Blair S.N., Kohl H.W., Pattenbarger R.S. , e al. Physical fitness and all-cause mortality JAMA 1989 ;  262 : 2395-2401

Cliccare qui per andare alla sezione Riferimenti, 52 Paffenbarger R.S., Hyde R.T., Wing A.T. , e al. The association of changes in physcial activity level and other lifestyle characteristics with mortality among men N Engl J Med 1993 ;  328 : 538-545  [cross-ref]

Cliccare qui per andare alla sezione Riferimenti, 53 Paffenbarger R.S., Wing A.L., Hyde R.T. Physical activity as an index of heart attack risk in college alumni Am J Epidemiol 1978 ;  108 : 161-175

Cliccare qui per andare alla sezione Riferimenti</sup> There is evidence that the risk of cardiovascular disease decreases in a manner somewhat proportionate to the amount of activity performed.<sup>52 Paffenbarger R.S., Hyde R.T., Wing A.T. , e al. The association of changes in physcial activity level and other lifestyle characteristics with mortality among men N Engl J Med 1993 ;  328 : 538-545  [cross-ref]

Cliccare qui per andare alla sezione Riferimenti, 53 Paffenbarger R.S., Wing A.L., Hyde R.T. Physical activity as an index of heart attack risk in college alumni Am J Epidemiol 1978 ;  108 : 161-175

Cliccare qui per andare alla sezione Riferimenti</sup> Additionally, physically active individuals seem to be less subject to the triggering of myocardial infarction when performing unaccustomed heavy activity.<sup>1 Albert C.M., Mittleman M.A., Chae C.U. , e al. Triggering of sudden death from cardiac causes by vigorous exertion N Engl J Med 2000 ;  343 : 1355-1361  [cross-ref]

Cliccare qui per andare alla sezione Riferimenti, 34 Hoberg E., Schuler G., Kunze B. , e al. Silent myocardial ischemia as a potential link between lack of premonitoring symptoms and increased risk of cardiac arrest during physical stress Am J Cardiol 1990 ;  65 : 583-589  [cross-ref]

Cliccare qui per andare alla sezione Riferimenti, 45 Mittleman M.A., Maclure M., Tofler G.H. , e al. Triggering of acute myocardial infarction by heavy physical exertion—protection against triggering by regular exertion N Engl J Med 1993 ;  329 : 1677-1683  [cross-ref]

Cliccare qui per andare alla sezione Riferimenti, 69 Willich S.N., Lewis M., Lowell H. , e al. Physical exertion as a trigger of acute myocardial infarction N Engl J Med 1993 ;  329 : 1684-1690  [cross-ref]

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Activity guidelines generally take advantage of the very low risk of exercise-related complications during low-intensity exercise. These complication rates are low enough that guidelines can be released in public information documents, designed for a wide variety of consumers, including those with known cardiovascular disease or at high risk for its development.<sup>2 American College of Sports Medicine ACSM's Guidelines for Exercise Testing and Prescription   Baltimore: Lehmann, Williams and Wilkins (2000). 

Cliccare qui per andare alla sezione Riferimenti, 3 Balady G., Chaitman B., Driscoll D. , e al. Recommendations for cardiovascular screening, staffing and emergency policies at health/fitness facilities: A joint position statement by the American College of Sports Medicine and the American Heart Association Med Sci Sports Exerc 1998 ;  30 : 1009-1018

Cliccare qui per andare alla sezione Riferimenti, 54 Pate R.R., Pratt M., Blair S.N. , e al. Physical activity and public health: A recommendation for the Centers for Disease Control and Prevention and the American College of Sports Medicine JAMA 1995 ;  273 : 402-407

Cliccare qui per andare alla sezione Riferimenti</sup> However, regardless of whether increased activity is to be undertaken as increased low-intensity activity or as part of a prescribed exercise program, individuals should be screened to identify those with a high risk of complications or those who might benefit from participation in a medically supervised program. Simple and effective screening instruments are readily available,<sup>2 American College of Sports Medicine ACSM's Guidelines for Exercise Testing and Prescription   Baltimore: Lehmann, Williams and Wilkins (2000). 

Cliccare qui per andare alla sezione Riferimenti, 3 Balady G., Chaitman B., Driscoll D. , e al. Recommendations for cardiovascular screening, staffing and emergency policies at health/fitness facilities: A joint position statement by the American College of Sports Medicine and the American Heart Association Med Sci Sports Exerc 1998 ;  30 : 1009-1018

Cliccare qui per andare alla sezione Riferimenti</sup> as are schemes for the level of supervision required of various classes of exercise.<sup>3 Balady G., Chaitman B., Driscoll D. , e al. Recommendations for cardiovascular screening, staffing and emergency policies at health/fitness facilities: A joint position statement by the American College of Sports Medicine and the American Heart Association Med Sci Sports Exerc 1998 ;  30 : 1009-1018

Cliccare qui per andare alla sezione Riferimenti</sup> Regardless of whether an individual is healthy or has known stable cardiovascular disease, the general recommendation for activity programs is that individuals should accumulate 30 minutes of moderate intensity aerobic exercise on most days of the week.<sup>54 Pate R.R., Pratt M., Blair S.N. , e al. Physical activity and public health: A recommendation for the Centers for Disease Control and Prevention and the American College of Sports Medicine JAMA 1995 ;  273 : 402-407

Cliccare qui per andare alla sezione Riferimenti</sup> Generally this may be taken as walking at a comfortable pace, not even necessarily for 30 minutes at a time but to accumulate 30 minutes on most days of the week.

Exercise prescription is primarily focused on using relatively higher intensity exercise to achieve specific goals relative to restoring the age- and gender-appropriate exercise capacity. In formulating an exercise prescription, the clinician must accept the slightly increased risk of exercise-related complications that accompanies higher intensity exercise, using highly specific individual criteria in an attempt to achieve the optimal trade-off between an enhanced exercise training effect and the management of the risk of exercise-related complications. In this article, we will, in some detail, discuss the nature of the exercise prescription as background information needed for the development of an appropriate exercise prescription. Further, we will discuss strategies for monitoring exercise training.