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KEY
POINTS
1. The
term
MET
in
exercise
testing
stands
for
metabolic
equivalent
of
task
or
simply
metabolic
equivalent,
and
is
a
physiological
measure
of
energy
cost
of
physical
activity.
One
MET
unit
is
3.5
ml
of
oxygen
per
kg
per
minute
(245
ml
for
a
70
kg
man)
or
1
kcal
(4.18
kj)
per
kg
per
hour.
This
would
mean
that
the
resting
caloric
consumption
for
a
70
kg
person
would
be:
70
MET
units
per
hour
or
1680
kcal
in
24
hours.
Very
slow
walking
at
3
km
per
hour
(1.875
miles
per
hour)
doubles
the
energy
consumption.
2. The
source
of
energy
for
physical
activity
is
ATP.
a.
In
anaerobic
glycolysis,
each
mole
of
glucose
produces
2
moles
of
ATP
and
2
moles
of
lactic
acid.
The
subsequent
metabolism
of
lactate
in
the
extra-skeletal
tissue
claims
the
oxygen
debt.
Lactic
acid
production
results
in
generation
of
CO2
by
buffering
of
bicarbonate
to
CO2,
and
this
increases
the
respiratory
quotient
(RQ
=
CO2
eliminated
/
O2
consumed)
to
a
value
>
1.
b.
32
ATP
molecules
are
produced
when
glucose
is
metabolized
to
CO2
and
water
in
oxidative
phosphorylation.
c.
One
creatine-P
molecule
in
muscle
is
the
source
of
one
ATP
at
1
to
1
ratio,
and
the
total
muscle
content
is
about
450
mmol
(the
concentration,
15
mmol
per
liter
of
muscle
water).
3. There
are
two
types
of
muscles:
a. White
muscle:
has
larger
diameter
fibers,
low
myoglobin
content,
and
less
mitochondria,
larger
creatine-
P
and
glycogen
content,
and
fewer
capillaries,
and
is
involved
in
quick
production
of
ATP
by
anaerobic
glycolysis.
White
muscles
are
involved
in
work
of
short
duration
and
high
intensity,
such
as
sprinting
and
weight
lifting.
b. Red
muscle:
the
opposite
of
white
muscle,
has
more
myoglobin,
and
uses
glucose
and
fatty
acids
from
circulation
for
slow
and
sustained
work.
4. Common
measures
of
exercise
intensity:
a. Heart
rate
b. Tidal
volume
c. Respiration
rate
d. Oxygen
consumption
e. CO2
production
rate
f. Work
load
g. Plasma
lactate
h. Arterial
blood
gas
i. Subjective
Rating
of
Perceived
Exertion
(RPE):
Borg
Scale
5. Oxygen
consumption
rises
linearly
with
increasing
work
load,
and
then
reaches
the
peak
(VO2max),
which
is,
in
a
normal
healthy
person
about
8
to
12
fold
of
the
resting
level,
about
35
to
40
ml
per
kg
per
minute.
In
world
class
athletes
this
value
increases
up
to
80
to
90
ml
per
kg
per
minute.
The
world
record
is
97
ml
per
kg
per
minute.
6. Anaerobic
threshold
(AT):
The
work
load
at
which
lactic
acid
accumulation
begins
so
serum
lactate
is
increased,
and
RQ
is
greater
than
1,
and
this
occurs
at
about
60%
of
the
maximum
work
load.
Both
VO2
max
and
AT
are
reduced
by
heart
disease
and
sedentary
life
style.
AT
is
a
good
predictor
of
endurance
performance.
After
AT,
metabolic
acidosis
stimulates
ventilation
in
addition
to
the
stimulation
by
increased
CO2
production,
and
PCO2
falls
below
normal.
7. In
a
normal
person
without
lung
disease,
ventilation
and
gas
diffusion
are
not
a
limiting
factor
for
oxygen
delivery;
cardiac
output
(CO)
is
the
limiting
factor.
8. Cardiac
Output
(CO)
=
SV
x
HR.
In
a
healthy
young
individual,
CO
increases
about
4
fold;
a
3
fold
increase
is
due
to
increased
heart
rate,
and
a
1.33
fold
increase
is
due
to
increased
stroke
volume:
3
x
1.33
=
4.
9. Blood
pressure
(BP)
increases
slightly
during
exercise,
mainly
systolic
BP,
because
of
the
increased
CO.
Although
peripheral
vascular
resistance
decreases
markedly
but
proportionately
less
than
the
increase
in
CO,
hence
the
slightly
higher
BP.
10. Cardiac
consumption
of
oxygen
increases
more
than
3
fold
with
peak
exercise
mainly
because
of
the
increased
HR,
but
also
because
of
increased
systolic
BP,
and
the
best
indicator
myocardial
oxygen
consumption
is:
HR
x
Systolic
BP.
11. The
increased
oxygen
consumption
of
the
heart
must
be
met
mainly
by
coronary
vasodilation
because,
unlike
skeletal
muscle
which
extracts
only
of
the
oxygen
delivered
in
resting
state
and
therefore
has
a
room
to
increase
the
extraction
during
exercise,
cardiac
muscle
extracts
50%
of
oxygen
at
rest,
and
therefore
further
increase
in
oxygen
consumption
must
come
largely
from
increased
coronary
blood
flow.
This
explains
why
angina
occurs
with
coronary
stenosis.
12. BORGs
Rating
of
Perceived
Exertion
(RPE)
scale
was
originally
15
(6
to
20)
and
is
updated
to
12
(0,
0.5,
1
to
10).
RPE
measures
the
subjective
perception
of
the
level
of
difficulty
of
exercise.
RPE
of
4
to
6
corresponds
to
70
to
85%
of
maximum
heart
rate
(220
age),
and
this
level
of
exercise
is
recommended
for
a
healthy
person.
For
a
patient
with
heart
disease
the
target
is
a
heart
rate
of
70%
of
the
maximum.
13. Karvonen
Formula
is
another
formula
widely
used
to
determine
the
appropriate
level
of
exercise
for
a
person
with
heart
disease
(target
heart
rate
zone)
and
is
estimated
as:
Lower
limit:
[(max
heart
rate
resting
heart
rate)
x
0.7]
+
resting
heart
rate
Upper
limit:
[(max
heart
rate
resting
heart
rate)
x
0.8]
+
resting
heart
rate
14. Oxygen
consumption
=
CO
x
(arterial
oxygen
content
mixed
venous
oxygen
content).
Another
way
of
determining
oxygen
consumption
is:
(O2
content
of
inspired
air
O2
content
of
the
expired
air)
x
ventilation
volume
23. A
sudden
death
during
exercise
is
one
of
the
dangers
of
exercise,
but
overall
chance
of
sudden
death
is
lower
in
a
person
who
regularly
exercises
than
in
a
person
who
does
not,
including
those
with
a
heart
disease.
24. Hyponatremia
is
common
in
marathon
running,
and
contributing
factors
include
water
drinking,
Na
loss
from
sweating,
and
release
of
water
when
glycogen
is
metabolized;
each
g
of
glycogen
contains
2.7
ml
of
water,
and
a
typical
glycogen
consumption
is
about
6oo
g
in
a
marathon
run.
25. About
80%
of
energy
for
vigorous
exercise,
e.g.
marathon
run,
comes
from
metabolism
of
carbohydrates,
mainly
glycogen.
Fat
is
a
minor
source
of
energy
during
peak
exercise.
Transportation
of
fatty
acid
from
adipose
tissue
to
the
muscle
is
a
slow
process,
as
fatty
acid
must
be
bound
to
albumin
for
transportation.
26. In
a
healthy
normal
person,
cardiac
output
during
a
peak
exercise
increases
about
4
fold
of
the
resting
level,
and
3
fold
increase
is
due
to
increased
heart
rate,
and
1.33
fold
increase
due
to
increased
stroke
volume.
27. Since
oxygen
consumption
during
peak
exercise
increases
10
to
12
fold,
while
CO
increases
only
4
fold,
the
difference
is
explained
by
increased
oxygen
extraction
by
the
muscle.
Typical
increase
in
oxygen
extraction
is
about
3
fold;
oxygen
saturation
drops
from
arterial
to
mixed
venous
blood
from
100
to
75%
at
rest,
and
at
peak
exercise
from
100
to
25%.
28. The
best
estimate
of
myocardia
oxygen
consumption
during
exercise
is
the
heart
rate
and
systolic
BP;
since
the
heart
rate
triples,
and
systolic
BP
increases
somewhat
during
exercise,
myocardial
oxygen
consumption
increases
more
than
3
fold
during
peak
exercise.
29. Increased
myocardial
oxygen
consumption
during
exercise
is
met
mostly
by
increased
coronary
blood
flow,
because
even
in
resting
state
the
heart
extracts
50%
of
oxygen
delivered
(the
rest
of
the
body
extracts
only
25%),
it
does
not
have
much
room
to
increase
the
extraction
further.
This
is
the
reason
why
angina
is
common
when
a
person
with
severe
coronary
stenosis
exercises.
30. Chronic
isotonic
exercise
tends
to
cause
dilatation
of
the
left
ventricle
(athletes
heart),
and
this
is
mainly
responsible
for
the
higher
CO
and
higher
VO2max
in
a
trained
athlete.
Since
SV
is
greater,
for
the
same
maximum
heart
rate,
CO
is
greater.
31. At
rest,
these
trained
athletes
have
bradycardia.
A
person
who
has
150
ml
of
SV
needs
the
heart
rate
of
only
33
per
minute
in
order
to
have
CO
of
5
liters
per
minute.