Exercising with heart disease

Start slow and add a little more over time. Make it feel  as if when finished feel like you could have done more easily. Begin exercising at this intensity for several sessions before making large increases in your intensity or effort required to be physically active. . Remember the whole goal is to adapt, and by doing so the body is changing how it responds. In the early recovery stage  the exercise prescription is very light. Do you know What exercise prescription is best for you?

Since exercise should be part of your everyday routine in order to make it a lifelong habit  injury avoidance is important to be aware of overuse signs and symptoms, to rest those muscles when needed.  Occasionally cardiovascular disease patients develop Peripheral Artery Disease and symptoms can present similarly to overuse. Pain should signal the body to be aware that something is going on.  Take some time to evaluate that pain, what happens with it, does it always come on at a certain time or point of the exercise or activity? How long does it take to go away? Can it be avoided while being active by another means for instance switching from walking to biking?  Make sure you communicate these findings with your healthcare practitioner as they could be signals of other health conditions related to heart disease and it’s recovery.

Some exercise and activity is better than none, so start slowly. Even a warmup is better than no exercise session here is why  warming up before strenuous activity helps your heart.

Don’t expect results overnight, but do take small steps each day. Move that blood around, push it through the muscles. Make the muscles use the oxygen in the blood  more efficiently. Exercise helps the the heart recover and stay strong.

You might not notice any big changes—especially in your weight—for a few weeks or even months. It is still good for your heart health! It is not all about weight loss. Forget the scale for a while. In fact many who initially start to exercise following hospitalization are  Sedentary at the start and will gain a couple of pounds. It is their muscles getting pumped up, holding and utilizing more blood flow. Generally the focus on how you feel.

 When not to exercise is if you are presenting with Signs and symptoms of heart problems. Exercise should be avoided if  if you are presenting with congestive heart failure, or are presently sick. When returning to exercise following illness 

Symptoms to be alert for include these.

Sodium: What gives Caregivers and Cardiac Rehab Staff Nightmares

Working cardiac rehabilitation, one wants to take time off around Saint Patrick’s day and Easter. Often patients come in with weight up 10 lbs in one to three days, short of breath, swollen, and having elevated blood pressure. When asked, they report celebrating Saint Patrick’s day with sauerkraut and sausage, corned beef and cabbage, with lots of bread on the side, then celebrated Easter early with a ham dinner with gravy.

Caregivers take note, well-intentioned friends and family may have prepared meal or stocked freezers full of sodium laden foods thinking they are helping out during a  medical crisis. Be alert to sodium and it’s effect on heart health.  Programs such as  Meals on wheels also has a tendency to have very salty meals. 

If you find weight up, swollen feet/ankles/belly/face, shortness of breath and elevated blood pressure consider the  dietary sources of sodium. 

Sodium causes fluid retention, weight goes up,  and is often treated with increased diuretics (Lasix, Aldactone, Demedex, Bumex, Zaroxolyn etc.). The body can become resistant to diuretics however, so adding more and more diuretics can be dangerous. These throw off the electrolytes and disrupt the sodium potassium balance of the body, which can set in motion additional heart problems including arrhythmia’s - irregular heart beats that could be deadly. Other side effects of diuretics include:

• increased blood glucose levels
• increased calcium
• increased cholesterol
• potassium loss
• increased uric acid, which might trigger a gout attack in certain people

Bought raw or in a can, corned beef brisket is very salty. One 3 ounce serving of cured corned beef has 964 mg of sodium, 40 percent of your daily value of sodium. In addition to sodium, corned beef is generally made from the fattier brisket areas, so the fat and cholesterol levels tend to be on the high side when compared to some of the more commonly available beef cuts. 1 cup of Cooked Sauerkraut has about 900 mg of sodium. Ham isn’t better - 4 oz. of ham can have between 1000 and 3000 milligrams of sodium. 

Sodium, Salt, Na, MSG, natural flavors, natural spices, Sodium Nitrate,

• Monosodium glutamite,
• Sea salt,
• Disodium phosphate,
• Baking soda,
• Sodium citrate, sodium bicarbonate, sodium algonate, are all names of sodium.

 If your diet is going be high in sodium, eat more potassium-rich foods. Potassium helps to lessen the dangerous effects of sodium. Foods high in potassium include bananas, potatoes, squash, spinach, raisins, cantaloupe, beans and lentils.

Rinsing foods such as sauerkraut, or canned beans or veggies in a colander can remove up to 40%. Read labels and aim for foods with 300 milligrams or less of sodium per serving.

 To learn more about salt and heart health click here

To learn more about how to lower sodium in diet click here.

To learn more about sodium and it’s effects on the body

Calf Pain: It can be serious

Calf Pain is something we don’t ignore in Cardiac Rehabilitation programs. It can be a symptom of a number of things life threatening, severe or minor. So what are we looking for?

Symptoms of blood clot in leg

This is called Deep Vein Thrombosis  or DVT

Only about half of the people who have DVT have signs and symptoms. These signs and symptoms occur in the leg affected by the deep vein clot. They include:

• Swelling of the leg or along a vein in the leg
• Pain or tenderness in the leg, which you may feel only when standing or walking
• Increased warmth in the area of the leg that’s swollen or painful
• Red or discolored skin on the leg

Pulmonary Embolism

Some people aren’t aware of a deep vein clot until they have signs and symptoms of PE. Signs and symptoms of PE include:

• Unexplained shortness of breath
• Pain with deep breathing
• Coughing up blood

Rapid breathing and a fast heart rate also may be signs of PE.

Blood clots occur when blood thickens and clumps together. Most deep vein blood clots occur in the lower leg or thigh. They also can occur in other parts of the body. A blood clot in a deep vein can break off and travel through the bloodstream. The loose clot is called an embolus. It can travel to an artery in the lungs and block blood flow. This condition is called Pulmonary Embolism or PE.

PE is a very serious condition. It can damage the lungs and other organs in the body and cause death. It’s fatal in up to 26% of cases.

Blood clots can form in your body’s deep veins if:

• A vein’s inner lining is damaged. Injuries caused by physical, chemical, or biological factors can damage the veins. Such factors include surgery, serious injuries, inflammation, and immune responses.
• Blood flow is sluggish or slow. Lack of motion can cause sluggish or slow blood flow. This may occur after surgery, if you’re ill and in bed for a long time, or if you’re traveling for a long time.
• Your blood is thicker or more likely to clot than normal. Some inherited conditions (such as factor V Leiden) increase the risk of blood clotting. Hormone therapy or birth control pills also can increase the risk of clotting.

For Prevention measures to avoid blood clots click here

Symptoms of Peripheral Artery Disease

Peripheral Artery Disease is the most common reason for amputations of toes, feet and legs. The risk factors that cause heart disease also cause poor blood flow to other areas of the body. Calf pain while walking is a warning sign for 50% who have blockages in the legs. If peripheral artery disease is an issue it needs to be closely monitored.

Signs and symptoms of P.A.D. include:

• Weak or absent pulses in the legs or feet
• Sores or wounds on the toes, feet, or legs that heal slowly, poorly, or not at all
• A pale or bluish color to the skin
• A lower temperature in one leg compared to the other leg
• Poor nail growth on the toes and decreased hair growth on the legs
• Erectile dysfunction, especially among men who have diabetes
• Pain with walking or climbing stairs

People who have P.A.D. may have calf or leg pain, numbness, aching, or heaviness in the leg muscles pain or discomfort when walking or climbing stairs.  You might also feel include cramping in the affected leg(s) and in the buttocks, thighs, calves, and feet. This discomfort may ease after resting.  About 10 percent of people who have P.A.D. have claudication. This symptom is more likely in people who also have blockages or atherosclerosis  in other arteries.

During physical activity, your muscles need increased blood flow. If your blood vessels are narrowed or blocked, your muscles won’t get enough blood, which will lead to symptoms. When resting, the muscles need less blood flow, so the symptoms will go away.

Learn more about Peripheral Artery Disease

Overuse Symptoms

A calf strain is an injury to the muscle.  When a muscle is strained, the muscle is stretched too far.  So stretching it isn’t going to make if feel better. Less severe strains pull the muscle beyond its normal excursion.  These often are seen when people are doing more walking than they are used to, such as walking treadmills – especially when the grade is elevated. Also these are seen from poor footwear. People who haven’t exercised in years may have poor footwear. I have seen patients come in wearing slippers, heels, broken down shoes that have no shock absorption.  More severe strains tear the muscle fibers and can even cause a complete tear of the muscle. Most commonly, calf strains are minor tears of some muscle fibers, but the bulk of the muscle tissue remains intact.

The amount of discomfort helps to determine the severity of the injury. Calf strains are usually graded as follows:

• Grade I Calf Strain: Mild discomfort, often minimal disability. Usually minimal or no limits to activity.
• Grade II Calf Strain: Moderate discomfort with walking, and limited ability to perform activities, such as running and jumping; may have swelling and bruising associated.
• Grade III Calf Strain: Severe injury that can cause inability to walk. Often patients complain of muscle spasm, swelling and significant bruising.

Muscle Cramping

A muscle cramp is a sudden, uncontrolled contraction of a muscle. This type of pain is most commonly  called a “charley horse.”

Leg cramps occur when the muscle suddenly and forcefully contracts.

Leg cramps usually last less than one minute, but may last several minutes before the contraction subsides. In some patients, the leg cramps occur primarily at night, and can awaken the patient from sleep. When the muscle cramp is severe or long lasting the muscles will be sore for a day or two following.

What causes a leg cramp?
The exact cause of a leg cramp is not well understood, but there are some risk factors that are thought to contribute to this condition:

• Muscle fatigue
• Heavy exercising
• Dehydration
• High weight (not necessarily obesity)
• Electrolyte imbalances
• Medications (statins, prednisone, lasix…)

The most common cause that is typically seen in patients who develop leg cramps is exercising in an unusual way, meaning either more activity or a different exercise. Leg cramps are more common in older patients. Patients who weigh more are more prone to developing leg cramps. Also, some medications can cause side effects of leg cramping. Cramping is something that should be brought to the attention of your health care provider as soon as possible

Sources: National Heart Lung and Blood Institute

http://www.nhlbi.nih.gov/health/health-topics/topics/dvt/

Exercise Induced Angina

Do you get chest discomfort with activity?

This is known as exercise induced angina. Angina is generally caused from not getting enough blood through the arteries to supply the walls of the heart with enough blood flow to adequately pump. Angina can be caused by blockage, injury or spasms. It can be particularly irritating when it comes on with exercise. Here are some things to know about symptoms you might experience when exercising.

• Warm up adequately to prevent angina with activity/exercise.Try to do 5-10 minutes of very light exercise with minimal resistance before pushing the intensity up and before increasing the resistance on your exercise equipment. This allows the arteries to dilate - or widen thus increasing the ability to bring more blood flow to the heart.
• Never try to push through angina, as it is a warning that your heart isn’t getting enough oxygenated blood. When symptoms come on reduce your exercise intensity to see if it will resolve. Many patients can back down for several minutes and the symptoms resolve. If the symptoms do not resolve use your nitroglycerin medication as prescribed.
• Keep documentation of the frequency of the symptoms. In particular you are looking to see if the symptoms are coming on at a specific workload, or if the frequency of the symptoms is increasing.
• If you watch your heart rates, most physicians will advise you to keep your exercise heart rates 10 points below where you get the onset of symptoms. It is recommended you purchase a heart rate monitor – a watch and strap for the chest to be able to gauge your exercise intensity from your heart rate. I am old school and hold allegiance to the Polar Heart Rate Monitors, they will run you about $50.
• Recognize you are not a perfectly tuned machine, some days are going to be rough and you will need to take it easy. Many factors contribute to increased angina symptoms including increased  physical and emotional stress on the body, fighting illness, blood pressure, sleep, temperature being very cold or high heat and humidity, timing of medications, timing type and amount of food in the system, blood sugar, hormones…you get the picture.
• Some patients will always have angina symptoms due to the injury to the heart, the size of the vessels, or spasm. It is important to work with you physician to determine what amount of angina is acceptable. With small vessel disease (microvascular angina) many have to accept a certain amount. It is often graded on a 1-10 scale with 10 being the worst, and some patients were allowed by their physicians to exercise with symptoms of 1-3 on the 1-10 scale if they did not have abnormal blood pressure or ekg changes and were free of symptoms such as shortness of breath. Gradually as they improved their physical conditioning their angina threshold (the intensity of exercise which produces symptoms) increased to where they could tolerate more intense workloads without symptoms worsening.

When is it angina dangerous?

There is a difference in stable and unstable angina. Stable angina is predictable. It can be triggered by emotional stress, exercise, exposure to cold air, after eating large heavy meals. It is relieved with rest, and doesn’t usually have other symptoms such as shortness of breath, profuse sweating, nausea associated with it.

Unstable angina is angina that is different as it can occur at rest or wake you from sleep. It is a change in the stable angina symptoms meaning the symptoms are more frequent, more intense – may require more nitro than usual to relieve symptoms. It may be paired with other symptoms, profuse sweating, nausea, shortness of breath, weakness, a feeling of doom, lightheadedness. If you are experiencing symptoms of unstable angina you must contact your medical provider ASAP. Time is muscle and you don’t want to risk losing heart muscle.

Exercise the key to a happier healthier you

Do you do it?

Most of the push today is for obesity prevention and control, but for heart patients it is essential for growth of collateral vessels so the body forms its own natural bypass around blockages. This is crucial for anyone with peripheral artery disease PAD. In fact the goal is 60 minutes for PAD patients. My last post was on depression, again the use of exercise lifts the spirits, exercise releases endorphins, which are the feel good chemicals that circulate in the body. We can talk about it all day the why you should exercise, but the bigger question do you do it? Can you stick with it? What barriers must you overcome to be able to adopt exercise as part of you day? If exercise benefits came in a pill form most would never question it and take the pill regularly without regard to side effects. Start your program, keep a log of the frequency you are able to do. It doesn’t have to be high intensity or hard, it just has to happen. Do it regularly for a few months, then try to build the intensity a little if you can.

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Health Devices

Today’s technology allows heart patients to monitor their own health changes and be proactive in caring for themselves. I believe we are on a medical breakthrough using the internet and new technologies. In the past one would have to go to their doctor and report transient changes in blood pressure, heart arrhythmia - (palpitations) out of range blood sugars, etc.  The modern healthcare approach is to then order several very expensive tests in hopes of capturing the data and then making changes to the patients care plan once there is evidence of the changes. Today’s rapidly emerging technologies now allow patients to capture this information with home devices which cost much less than the tests ordered by our modern healthcare system.

Let’s look at heart rhythm monitors as an example. Atrial fibrillation is a very common heart rhythm problem, and for many patients they will go in and out of this rhythm. They may feel the heart racing, skipping beats, or feel shortness of breath and fatigue when the rhythm is abnormal. If A fib is dangerous immediate care can be initiated and then  managed with blood thinners to decreased risk of stroke. Therefore it is worth monitoring and catching it earlier vs. later.   There are now  monitors one can purchase for about $200 that would capture the rhythm put it to memory, then you can send to your physician electronically. Other heart arrhythmia that can be detected and managed this way  include heart blocks, abnormally slow heart rhythms, tachycardia -  fast heart rhythms.  The modern course is to order a holter monitor or an event monitor. The holter monitor is worn for 24 hours or more, then it takes up to two weeks for it to be interpreted  dictated and the reports received and acted on by the ordering physicians. Event monitors are placed below the skin and worn for 30 days or more. Consider given the progressive nature of heart problems, that these tests are not  usually run only one time on an individual over the course of their life.

HOLTER MONITOR SCANNING					$312.00
HOLTER MONITOR RECORDING					$345.00

Handheld home devices purchased for about $200 can be used by the patient with  little education,and a plan of care is devised  between the patient and the physician..  This could potentially allow you to  manage their issues more in a much more convenient and timely manner. The device is owned by you and thus can be used over many years. Below is the typical physician algorithm for managing arrhythmia’s.

 

 

With today’s hand held monitors available at a cost of approximately two hundred dollars, patients can capture the irregular rhythm when it occurs, save the data, report it to physicians and have their care evaluated much quicker – provided they can get an appointment with their healthcare practitioner. Wouldn’t it be even better to be able to transmit the information to the physicians email, and then be triaged based on the data?

The problem is $$$$$$$, and the medical system in the US is slow to adopt change. If it cuts in to the profit of healthcare it isn’t likely to be adopted.  This a role where I believe mid level practitioners like PA’s, CNA’s can play a role in triaging care, as the current work demand doesn’t allow most physician the time to undertake electronic care of patients. It may take patients to make the change, those who are under insured, uninsured, or have significant financial obstacles which impede access to traditional care.

On a side note I really enjoyed Eric Topol’s book The Creative Destruction of Medicine. It makes one think about how medicine can change practice models.

With personal technology, doctors can see a full, continuously updated picture of each patient and treat each individually. Powerful new tools can sequence one’s genome to predict the effects of any drugs, and improved imaging and printing technology are beginning to enable us to print organs on demand. Topol offers a glimpse of the medicine of the future—one he is deeply involved in shaping.

Below are a couple of examples of how patients can control and manage their health data:

http://www.misfitwearables.com/health_device_at_a_glance

http://online.wsj.com/article/SB10001424052702303404704577311421888663472.html

http://www.omronhealthcare.com/wp-content/uploads/hcg801405x233_png_405x235_q85-382×220.png

http://www.favoriteplus.com/easy-ecg-handheld-monitor-fp180.php