IJCS | Volume 32, Nº4, July/August 2019

322 Araújo et al. Exercise/sport & cardiovascular Health: an update Int J Cardiovasc Sci. 2019;32(4):319-325 Viewpoint exercise would always be an exception and it should be restricted to very special cases and often for a very limited period of time. 13 Non-aerobic fitness as a valuable prognostic marker for all-cause mortality Claudio Gil Araújo Q: For several decades, exercise prescription for cardiac patients was primarily based on aerobic exercises, such as slow and brisk walking, running, cycling, swimming and rowing. Other types of exercise were undervalued and hence, poorly quantified. This approach was based on consistent research studies that identified cardiorespiratory (aerobic) fitness as well as regular aerobic exercise as strongly related to favorable healthy outcomes, including better health-related quality of life and all-cause mortality. More recently, several studies have shown that non-aerobic fitness is also very important for health and even possibly associated to survival. Should non-aerobic fitness be regularly assessed during physical examination or clinical evaluation? A: Recently, the American Heart Association has suggested that the cardiorespiratory (aerobic) fitness, ideally measured by cardiopulmonary exercise testing, should be considered as a clinical vital sign. 1 On the other hand, there are recent data indicating that, especially in older subjects, adequate or above the sex- and age- median values of non-aerobic fitness – muscle strength/ power, flexibility, balance and body composition – are strongly associated with all-cause mortality. 14,15 Some years ago, 15 using the sitting-rising test (SRT) – a simple, reliable and safe assessment tool for simultaneous evaluation of the four non-aerobic components of physical fitness –, we were able to show that low SRT scores (SRT composite scores from 0 to 3) resulted in a five times higher mortality in middle-aged and older subjects in the following six years as compared with good SRT scores (SRT composite scores from 8 to 10). Indeed, among those scoring 10 – able to sit and rise from the floor without showing unsteady performance and without using hand or knee for support –, the all- cause mortality rate was extremely low. 15 More recently, we have presented preliminary results indicating that maximal muscle power relative to body weight, one of the components of both non-aerobic andmusculoskeletal fitness, is also strongly related to all-cause mortality. 14 It is interesting to point out that, when comparing the top and bottom quartiles of data distribution, the relative risks were extremely high (5 to 10 times higher), depending on the variable and sex of the subjects. It is worthwhile to note that these very high relative risks are considerably higher than those usually seen in studies on classical risk factors for coronary disease, such as hypertension, dyslipidemia and family history. In summary, yes, it is time to incorporate the assessment of non-aerobic fitness as a valuable clinical tool in nearly all populations. Perhaps, the recently published sex- and age- reference values for SRT could be useful in this context. 16 Isometric handgrip training as an important strategy to treat hypertension Philip J. Millar Q: Some decades ago, adult hypertensive patients were advised not to carry weights, including grocery bags or their own children or grandchildren, negatively affecting their quality of life. Exercises with a significant isometric (static) component were particularly forbidden. However, several experimental and epidemiological studies have shown that resistance exercises were not so risky and, indeed, could be beneficial for hypertensive patients. Recently, a special exercise protocol called isometric handgrip training (IHT) has been proposed to reduce systolic and diastolic resting blood pressure. Is there good evidence to recommend IHT to treat hypertensive patients and if so, is there any group of patients that will respond more favorably to IHT? A: Initial fears over completing isometric exercise were related to the potential for increased blood pressure responses and increased risk for a cardiovascular event. 17 However, short duration isometric contractions at low- to-moderate intensities (e.g. 1-2 minutes at 30-50% of maximal voluntary contraction) produce blood pressure responses in line with those observed during dynamic aerobic exercise. 18 Also, submaximal isometric exercise may be associated with a lower rate-pressure product (less myocardial oxygen demand) and a higher diastolic blood pressure response (greater coronary perfusion pressure), which together, would lower the risk of exercise-induced myocardial ischemia compared with a similar-intensity dynamic exercise. 18 Over the last 25 years, a number of research groups around the globe have shown that submaximal IHT (or isometric leg exercise) can reduce resting blood pressure in both normotensive and hypertensive populations. A recent meta-analysis of 16 randomized control trials