Welcome, my name's Dr. Warrick Bishop. I'm a cardiologist, an author and a keynote speaker. I'm CEO of the Healthy Heart Network. I'm all about trying to help people live as well as possible for as long as possible. Heart disease is huge in Australia. Every 20 minutes someone suffers a heart attack. Most of these could probably have been avoided if only we knew what to do. This podcast is all about helping you understand. blood pressure, weight, cholesterol for better health. If you enjoy this podcast, I would be honoured for a five-star review. You can share it with your family and friends. It may well save someone you love. Hi, my name is Warrick Bishop and welcome to my podcast and videocast station. Absolutely delighted today to catch up again with Dr. Jason Kaplan, a kindred spirit in... that we are both cardiologists who are looking to try and prevent people having events. And if they do, then trying to make sure they don't have any further. Afternoon, Jason, how are you? Good afternoon, Warrick, and great to join you again. Thank you. Look, I really appreciate you making the time. And I know already I've had listeners feedback and find our previous podcasts really valuable. Thank you for making the time and thank you for those listening. And I do appreciate the feedback. Look, today, Jason, I think one of the things that comes around regularly, one of the things you and I deal with with our patients is exercise. And I know you encourage people to exercise. So do I. So if it's all right with you, how about we talk about that? That'd be great. And Warrick, it is one of the most important things that I think we can do in preventative cardiology and empower our patients to do. But I think a lot of patients or people listening may be told by their doctors, well, just exercise. But we know that in a way, if exercise... If the cardiovascular and physical benefits of exercise were bottled up into a drug, it would become the world's best-selling drug because the biological effects are myriad, not just on the cardiovascular system and the heart. And the amazing thing, Warrick, is that... The heart is able to remodel up to the age of 70 with athletic endeavors. So it's still possible to improve the size of the heart cavity, improve the pumping function of the heart, and have positive cardiovascular benefits purely from a physical point of view. But the actual metabolic effects on vascular function and on peripheral muscles as well are definitely ongoing. But people are told exercise. what we really need is an exercise prescription. This is what are the, what and how much are the best forms of exercise for, I guess what you and I do is cardiovascular, is for cardiovascular health. But then also, you know, we all have patients in our practice that want to do more. They want to do more than just exercise for cardiovascular health. And there are a lot more, what I call master's athletes now where, where people want to exercise more than just for recruitment. They're exercising for a goal. And then how do we advise them? And then the last part is how do we advise patients who actually have underlying cardiovascular disease? And the most common form in my practice is coronary artery disease. How do we give them the best advice about exercising to improve their cardiovascular health? Well, you've certainly laid out a roadmap for plenty for us to cover. My immediate comment is, of course, you and I both know exercise is almost a magic pill and it is the secret sauce. So people can exercise. It's absolutely fantastic. But I think one of the things that I'd really like to tease you out on is imagine I'm one of your patients. Imagine I'm carrying. 10 to 15 kilos more than I should. Imagine my cholesterol is off a bit. My sugars are up a bit. My blood pressure is up a bit. And you've got a calcium score on me, which is 437. And I'm 60 years of age. What I'd like you to do, Jason, is speak to me as if I were your patient so that people can almost imagine they're sitting in on a consultation within your own office. Right. Well, that's a great example. You don't have to call me Dr. Bishop. You can call me Warrick. Okay. Right. So, Warrick, I think we'd start off by, I guess, asking about, you know, symptoms with at least to make sure that we're not... Ask me. Would you have any cardiovascular symptoms, any chest discomfort or shortness of breath when you exercise? Look... Jason, I used to exercise a lot. These days when I exercise, I'm a little bit puffy, but I've put on a few kilos since my younger days. The wife, she loves me dearly and cooks beautiful food, which I can't say no to. And the kids have slowed me down. I'm not exercising as much. So yeah, sometimes I'm a bit short of breath. I've lost a fair bit of condition. And Warrick, you're keen to get back into a more regular exercise program. Look, I probably am. I had a mate just the other day dropped dead and it just made me realise that you've got to look after yourself. He wasn't that unfit either. It was a bit of a shock to everyone. So Warrick, I'm going to be upfront with you. In terms of when we think about what your cardiovascular risks are at your age with a calcium score of 400, over 400, being overweight, high cholesterol and some high blood pressure, Your global cardiovascular risks are not low. In fact, you clearly fall into an intermediate to higher risk for any event over the next 10 years. But what I can tell you now is that your cardiorespiratory fitness is going to be correlated with your cardiovascular longevity. So the fitter aerobically you are, the longer you are going to live. And the exercise is going to... supplements treatment of your cardiovascular risk factors. So it will help lower your blood pressure, it will help improve your lipid profile, it will help you lose weight, not to mention feel much better. So what I think is important for us in the first instance, and this is what I do for most patients in your situation, is I think we should perform an exercise stress test for a number of reasons. I can get a really good baseline of what your level of fitness is. And we can do this on a simple treadmill in the room next door. I can also see what happens to your blood pressure and heart rate with exercise. It's also important with a calcium score of over 400 to make sure that there is no lack of blood supply to the heart. Recent research shows that calcium scores over 400 have the same risk as a coronary heart disease equivalent. So it's really important that we make sure there's no... what we call ischemia, lack of blood supply to the heart. And we do that with the best test, I believe, is stress echocardiogram. We'll take some pictures before and after exercise and have you hooked up. And that will help me also give you a guide as to some guidelines to exercise that you can start an exercise program. Do I have to do that stress test without any training or preparation for it? Because I don't think I'll do as well as I would have the day to go, Jason. Warrick, I would say that's okay too because I think it's good for us to get a baseline, good for me to see. how your heart performs under a little bit of stress. One of the things that I think is really important is we make sure that your blood pressure doesn't rise too high, that there are no abnormal heart rhythms with exercise, and that you are safe to start an exercise program. So that's okay if you don't do well this time because the next time we do it, it gives a lot of motivation to get better. So what I think we're going to do is do a stress test. And then I think that we're going to start you on what I would say. It's a safe initial cardiovascular exercise prescription. And provided your stress test is okay, which I'm sure it probably will be, we should then start to think about what prescription of exercise is going to give you the most cardiovascular benefits. And there's been a lot of research into this over the last couple of years, and we certainly are honing in at what a good amount of exercise is. And I think at first, especially as you haven't done a lot of exercise, you know, over the last few years, we should think about moderate intensity exercise to start off with. So you should be doing somewhere between 150 to 300 minutes a week of moderate intensity exercise. And this can be simple as walking at four kilometers an hour, gardening, some doubles and doubles tennis. some recreational cycling, all of those are moderate or moderate intensity exercise. And when you're doing moderate exercise, some of you may have heard recently about some of this, the exercise in the zone two. So you're exercising at not a very high heart rate, but you are a little bit puffed, but you're still able to talk to someone next to you. So you're not really pushing it too hard, but that should be around 150. to 300 minutes of exercise a week. Jason, with the kids and work and cleaning up around the house and helping the missus, it's going to be hard to find that time. Are there any shortcuts? Can I jump on a stationary bike and go full tilt for 15 minutes? Could I get around it that way? Warrick, you read my mind. So you can achieve the same cardiovascular benefits in reducing that to somewhere between 75 to 150 minutes a week of more vigorous exercise. So this is what you might have heard about called high-intensity exercise or interval training or continuously exercising at a high level. So say, for example, do you like running, Warrick? Look, I used to, but the knees just don't work as well if I run anymore, even in spite of getting decent soft-soled shoes. So I love running, but probably more of a walker. So even if you were to think about walking or even light jogging at around six and a half kilometres an hour, this is not a very fast pace. For those of you that like, for people that may like running, you can go up to nine to ten kilometres an hour. That's as vigorous as a set of singles tennis. for example, is good, or even cycling at around 20 to 25 kilometres an hour. But as well, there are high intensity exercise classes at many local gyms or with trainers, and there are various different forms of doing interval training. And there hasn't been one form that has been better than the other in terms of... cardiovascular outcomes, but doing some form of interval training can help improve overall cardiorespiratory fitness. Sorry, when I was a fair bit younger, I used to go to the gym and lift a few weights. Is it useful to put that into the sort of suggestions you're recommending for me? So great question. Weights are actually really wonderful for muscles, and these increase, will overall improve your oxygen uptake and utilisation. Resistance exercise is also great for oxygen transport and delivery. Men, I think it's important to build strength and muscle, especially as we age. We do get some muscle atrophy. But the effects on metabolism and cardiac function are often best seen with more moderate intensity endurance exercise or aerobic exercise. While I think weights... form an important part too often i see in my practice um patients want to do too much weights and neglect the neglect aerobic activity and especially as you have high blood pressure aerobic activity is one of the most powerful tools we have against treatment of high blood pressure at improving especially improving endothelial endothelial function endothelium is the lining of your arteries so improving this is very helpful in um in in high blood pressure so i'd say weights are good but you must if you're going to do weights i would encourage you to do it as part of a high intensity exercise get your heart rate up And now that you've told me I've got all this in my heart and calcium and so forth, am I okay to still tap the missus on the shoulder in bed at night? Are we still okay? Is that exercise actually? Do we get to count that? I think that is exercise. You probably can count it. And I think, you know, once you're happy that you've passed, you know, happy with the stress test, I would say that is absolutely fine and I think important for quality of life. And you should, I think it is absolutely fine to do. Okay. I guess one of the questions we might get. people often patients always ask me it was what heart rate to exercise to so i i you know as you're starting embarking on this exercise journey i would say to you the purchase of a uh heart commercially available heart rate monitor would be a great start to just help you gauge what heart rate you are different levels of exertion and something i very often recommend to my patients The broad rule of thumb in terms of your maximum heart rate when you're exercising is 220 minus your age. Just remind me how old you are again, Warrick. About 60. So we think about your maximum heart rate is around 160. But I think that it's really important to think that there is a standard deviation around that maximum heart rate. So that is a guide. And most training. heart rates would recommend around 17 to 85 percent of that maximum heart rate but it's it's a guy it's a it's a guide only and the amazing thing the heart is a remarkable uh remarkable organ that it can tolerate high heart rates for for quite a long time what's really interesting but if you really start if you really overdo it and your heart rate is way above that 160 for many hours, that's where you may start to get some very minor changes and potentially damage to the heart. Look, let's wrap up the mock session, but I think it's really valuable to hear the way you'd approach this particular conversation with your patients. A couple of things that I'd add in, and I'm sure you factor these in as well as my experiences. I'll often engage and find out what people enjoy doing because, well, my own experiences, you know, I bought a rowing machine, think it would be fantastic exercise, which of course it is. It's good for every part of your body. But my personal experience was I found it incredibly unsatisfying. So I found it terribly boring. I used it for maybe six goes and sold it. And that really made me realize when I speak with people, as I'm sure you do, Jason, you've got to find what they enjoy doing and encourage them through that. And I think that's super important. I also speak to. incidental exercise you had trying to walk a bit further trying to take the lift instead of the stairs and so forth i'm guessing you've got some of those sort of i look absolutely and i think what you can encourage to do whatever you enjoy doing because then you're going to do it and you're going to love doing it. I think the other things about that exercise is, you know, often exercising in groups or with a buddy is great because being accountable to someone. I tell my patients if you're going to book your training sessions in advance and pay up front so you've got more reasons to turn up because often it's part psychological as well and motivational as well. I know like some mornings I train once a week with some friends at 6 a.m. and getting up at 5.15 to do it since it's a big deal. But when you're there, it's fantastic. And also the thing is the heart cannot really, the heart for in terms of aerobic exercise, the heart really can't tell the difference between different forms of aerobic exercise. Whatever you love doing, whether it's rowing, cycling, running, you know, brisk walking, tennis, it's going to be beneficial. for the heart. Look, I had someone ask me a question the other day, which I think I know the answer to, but I'd love your comment on it. I was talking about exercise and they said, what actually happens as you get fitter? What are the changes? So, you know, you start barely able to jog a kilometre, you know, five weeks down the line, you're jogging four kilometres or five kilometres away. What are the major metabolic changes occurring there, would you say, Jason? That is a wonderful question, and it occurs in multiple levels. I like to think about it in four areas, both in muscle, in metabolism, which mostly occurs in the liver, in vascular function, and then in the heart. So in terms of the muscle, as you start to exercise more you change the type of muscle fibers that you have and you're better able to take up oxygen to increase And also the mitochondria are better able to utilise energy. So you're able to increase exercise by better uptake of oxygen. In your metabolism, you certainly make changes in better utilisation of blood glucose by the muscles and have effects on lowering triglycerides. And exercise can reduce weight. What's also really important and something that doesn't get talked about is the small vessel function or the endothelial function. So exercise has really positive effects on the lining of the blood vessels. And then it allows those very small blood vessels to dilate better and allow more oxygen to our organs, which is wonderful and also actually reduces blood pressure. And then the last part, probably what we focus on a lot and what I see a lot in my practice, taking care of a lot of athletes and master's athletes. And what I mentioned at the start is we see cardiac remodeling. So especially for more endurance exercise, as you get improved aerobic fitness, the heart side. gets bigger in a healthy way so we call it healthy healthy physiologic remodeling we also see that um that the heart becomes more compliant and for each heartbeat the heart is able to pump out more blood and that's something that we call stroke volume and so often when you exercise as well you'll start to see your resting heart rate drop and that's why you see very very fit people they have heart rates in their 40s and that's actually not necessarily a bad thing it's because They're hearts that become very efficient. Look, I'm going to wrap this up. Before we do, I'm going to just underline how valuable exercise is. And we didn't even touch on the mental health aspects, which are huge. And you know this because I'm sure you've seen it with your own patients. But just we haven't got time to cover it. For those listening, there is an enormous emotional upside to exercise and the sort of levels of exercise that Jason alluded to before for your heart, those sort of levels of exercise will actually be as effective as the first line antidepressant medications that we use in clinical practice these days. Having said that, what I'd like to do is wrap up with... A moment of integrity, because I know both you and I practice what we preach. So I exercise through walking. I walk to work and I probably get an hour to two hours a week out of walking doing that. I try and swim once a week. That's about 30 odd minutes. And I do weights and that's probably 30 minutes. to 45 minutes a week so i that's what i do jason what do you do so look generally on a weekly basis i do one high intensity exercise session using using weights and aerobic exercise i generally go for sort of a light a light jog we have a a great dog that loves walking twice a day. So I'll at least do one of those walks. And then on Sundays, my wife and I do a yoga session together as well. So usually that's the average week. And then when I've got time, I'll be at the park with the kids and try getting a hit of tennis as well. Look, absolutely brilliant session. Really appreciate you sharing exercises. just so fundamentally important to improving your health span. Jason, thank you so much for sharing. For those listening, as always, if you have any queries or questions, drop us a note at info at droregbishop.online. In the meantime, please share this if you think it'd be valuable to someone else. And I hope you live as well as possible for as long as possible. Take care and bye for now. Join the Healthy Heart Network and become part of our growing community. If you're interested in your heart health and risk of heart attack, then join the Healthy Heart Network for only $5 as a lifetime member. This represents $55 worth of value. 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