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.

Chest Pain after having Stent

Chest pain following successful balloon angioplasty or stent is a common problem. Although the development of chest pain after coronary interventions may be not a problem, it is disturbing to patients, relatives and hospital staff.

Possible Causes of Pain:

  • acute coronary artery closure,
  • coronary artery spasm
  • heart attack,
  •  local coronary artery trauma

The distinction between these causes of chest pain is crucial in selecting optimal care.  Early intervention can limit the damage. Management of these patients may involve repeat hospitalization for  coronary angiography and/or additional intervention.

Commonly, repeat coronary angiography following Angioplasty (PTCA) in patients with chest pain demonstrates  lesion to be widely patent/open  suggesting that the pain was due to

  1. coronary artery spasm,
  2. coronary arterial wall stretching
  3.  non-cardiac 

 Coronary arterial wall stretching is common and occurs significantly more often after stent implantation than after PTCA or coronary angiography alone. This may be a result of the overdilation and stretching of the artery caused by the stent implantation and the consecutively high degree of stretching and the elastic recoil is minimized. Kind of like a deflated balloon, the artery doesn’t go back to original circumference.

sciencedirect.com

After getting out of the hospital every little ache and pain makes you think  “Is my heart giving me problems?” It is really difficult not to panic.

Here are some tips that should be of help you to know when to seek emergency care:

  •  Is the discomfort you are feeling the same  or similar to the discomfort that brought you to the hospital? If so, this could be a problem. It is more likely to be a problem if it is similar…don’t wait until it is bad to seek treatment. Time is muscle and we don’t want  you to lose any muscle.
  •  Does the discomfort also have other symptoms that pair up with it? These symptoms might include shortness of breath, profuse sweating, nausea, radiating discomfort into neck, jaw, arms or back.  If there are multiple symptoms you should call 911.
  •  Can you reproduce the pain or discomfort with touch or movement of body. It is less likely to be a heart symptom if you can make it hurt through touch. This is usually muscle or skeletal origin or what is referred to as non cardiac chest pain.
  •  The 4 E test…does the discomfort come on with Emotional stress,  Exercise, after Eating, or with a cold Environment? If so these are common triggers of heart symptoms. If you rest and they go away it probably isn’t emergent but you should notify your doctor as soon as possible. Keep a log of the frequency of these symptoms..when they come on, how frequently, what were you doing when they occurred, how intense was it, and what made them go away.
  • Unstable Angina….this is angina or heart pains that are coming on more frequent, occurs at rest or wakes you from sleep, or you need more nitro than usual to relieve discomfort.                                                                                                                                                                                       

If your symptoms are that of unstable angina you contact your doctor  - call 911

If you suspect you are having a heart attack chew up an adult strength aspirin and call 911.

Do not drive yourself to the emergency room. The ambulance crew is your first line of medical treatment, they will provide you with emergency medications, alert the hospital to your condition so they can manage your care quickly and efficiently. Time is muscle don’t waste any time.

Chew the aspirin even if you take an aspirin a day as regular medicine. The extra one helps more than it hurts. Only chew one not a handful that could causes more problems.

Antiplatelet effect of chewed, swallowed, and dissolved aspirinChewing aspirin hastens its antiplatelet effect, as measured by the reduction in blood thromboxane B2 levels. It took only 5 minutes for patients who chewed aspirin to achieve a 50% reduction in baseline levels, versus almost 8 minutes after they took it in a solution and 12 minutes after they swallowed it whole.Source: American Journal of Cardiology Vol. 84, p. 404.

May 2005 Update

It is best not to lie down. Try to stay calm, do some relaxation deep breathing – think belly breathes – make belly go out when you breath in. Avoid short shallow chest breathing. Focus on staying calm. If you think you are going to pass out try coughing or bearing down like you are having a bowel movement.

If you have Nitroglycerin tablets or spray that were prescribed by your doctor use them.  I can’t tell you how many people forget about their nitro when they need it the most. Place one under your tongue, do not chew it. It should make you have a headache, or cause a flushing feeling, or tingle under your tongue. These are indications that your nitro is fresh. If you suspect your nitro is old (over one year if bottle unopened, or greater than 6 months since bottle was opened) find a fresh bottle. Nitro is a very volatile compound and breaks down rapidly if in contact with air, heat, light, or plastic.

A lesson about the heart: Cardiac Output

Here is some information that is useful to know. It is a little in-depth when it comes to heart function, but I believe education is power and/or a sense of control when it comes to managing a chronic disease.  The more you know, the better you can work with your health care provider to help to manage it. 

Why are certain tests performed? An example is an echo is often performed 3-6 months following a heart attack. This allows the heart time for recovery and remodeling, and gives the healthcare provider a good idea of your cardiac output. Is your ejection fraction diminished, is the stroke volume lower thus decreasing the output? Is the cardiac output lower because the heart chamber is stretched, and weaker – inotropic effect, or due to medications? Does this place additional risk to you? When the ejection fraction is below 30% the risk for arrhythmia increases, thus precautionary measures such as Implanted Cardiac Defibrillators become an issue. Or vise versa if the heart function improved back to safe levels since the event there may no longer be the need, or those wearing external defibrillator vests may no longer be necessary.

The following came from Jewels of Clinical Medicine

What Is Cardiac Output?
Cardiac output is defined as the amount of blood pumped by the ventricles, the lower chambers of the heart, in one minute. Two factors determine cardiac output: stroke volume and heart rate. The equation used is: heart rate x stroke volume = cardiac output. A normal adult heart will have a cardiac output of approximately 4.7 litre( 5 quart) of blood per minute. Exercise will increase cardiac output, since it increases heart rate.

Heart rate
• The number of times the heart beats in one minute is the heart rate. In adults, the average heart rate is 60 to 100 beats per minute. Heart rates are usually higher in children and women. Differences in gender, size, age and fitness can affect the heart rate, as can some medications and conditions. Very fit people have lower resting heart rates. Heart rates increase when people are upset or excited.
Stroke Volume
• Stroke volume is the amount of blood pumped by the ventricles with each heartbeat. An average resting stroke volume is about 2 ounces (60 to 80 milliliters) per beat. Usually only 65 percent of the blood is pumped out of the ventricles during each beat. This is the normal ejection fraction value. Starling’s law of the heart and the inotropic effect are two things that can alter the force of the contraction, causing more of the blood to be expelled with each beat.

Starling’s Law of the Heart
• Starling’s law depends on the amount of stretch in the cardiac muscle fibers. If there is an increase in the volume of the blood pumped into the heart, that increase causes the ventricle to stretch, which in turn increases the force of contraction and the cardiac output. If less blood volume enters the heart, the ventricle does not stretch as much, the contraction is less forceful, and the cardiac output is decreased. This is important to ensure that the heart pumps out only what it receives at a given time.

Inotropic Effect
• If the strength of the contraction is increased without increasing the stretch of the cardiac fibers, cardiac output will be increased. Certain hormones and medications can cause this to happen. Sympathetic nerve stimulation of the heart, for example when a person is scared or excited, is another mechanism of the inotropic effect. Some drugs may also cause a negative inotropic effect and will decrease the cardiac output, which can lead to heart failure. It is extremely important to closely monitor the usage of any medication that has a negative inotropic effect on the heart.

Interesting Fact
• The amount of blood pumping though the body of the average adult is about 5 liters. That is equivalent to the average cardiac output. That means that the heart pumps the total amount of blood in the body every minute.

Heart Disease Health Centre- Dr.Yaseer SK

Nitroglycerine for Heart Symptoms

Nitroglycerine  Facts

One thing that always surprised me in cardiac rehabilitation was the understanding of using Nitroglycerin (nitro).  I think over the years I saw and heard every way imaginable to ensure nitro tablet wouldn’t work if needed. Or the other one is when patients would carry it for years and then not use it when it is most appropriate to use. The take home message is if you are having discomfort that you suspect is heart related use a nitro ASAP.

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How Nitro works:

Nitroglycerin  dilates blood vessels that supply the areas of the heart where there is not enough oxygen thereby delivering oxygen to the heart tissue that needs it most.  The dilation of  veins and arteries  reduces the amount of blood returning to the heart so that the heart does less work and requires less blood and oxygen. Dilation of the arteries  lowers the pressure in the arteries against which the heart must pump. As a consequence, the heart works less and requires less blood and oxygen.

How to store Nitro:

Here is the thing Nitro is a very volatile compound. It breaks down rapidly with light, heat, oxygen, time and exposure to plastic. It is packed in a glass vial because plastic will leach the active ingredient out of it and all you have left is the inert ingredients that hold the tablet together. Therefore don’t transfer it to a container that is plastic, don’t put a couple in a baggy and put them in your wallet. Yes it is a pain in the butt to carry the bottle everyday, but find a way, or use a metal nitro vial which you can wear around your neck.

Heat will break down the nitro tablets. If you carry your Nitro in your pants pocket every day the heat from your body will gradually make the nitro less potent.  What I teach patients is to take a good marker and write on the bottle the date three months from when they started to carry the bottle. That is when it should be considered to replace. Sometimes it can go six months, but if you look at the bottle…hold it up to the light, don’t open it…and the tablets are looking powdery or crumbled….then replace the bottle. If you leave them in your pocket and they go through the dryer…time to replace. If you leave them in your car and your car is 100* or more…replace the bottle. That was a common one…”I leave them in the glove box in my car.”  NO NO NO!

If you have opened the bottle you have exposed the tablets to oxygen. Oxygen breaks down the nitro. Once the bottle has been opened, label the bottle for six months from the time  you opened it. Replace the bottle at six months. A story I would frequently hear that would make me cringe would be when a patients loved one or child would say ” I poured a couple in a paper cup and have them in my cupboard in case they need one while at my house”…UHG!!!! Won’t work sorry!

The bottle is brown to prevent sunlight from destroying the tablets as well. Don’t transfer them to any other bottle, there is a reason they come this way.

When to use Nitro:

The most common mistake in using nitro is when patients would tell me the pain wasn’t bad enough to use it.  The instructions for nitro don’t say wait until the discomfort is 9 out of 10, the instructions are to use the nitro if you have heart symptoms that do not go away with rest.  This means any heart discomfort, no matter how minor if is present for 5 minutes, would indicate using the nitro.  If you wait until you are really in pain, you probably will have damage done to the heart. The point of this drug is to prevent the damage to the heart by improving the blood flow preventing damage from occurring.

  • Sit down
  • Place one tablet under the tongue – most people experience a burning or tingling feeling under the tongue, a headache, a flushed feeling….If you experience this you should always experience this, as this indicates your nitro is fresh.
  • Wait 5 minutes – if the symptoms resolved rest a bit then gradually become active again
  • If the symptoms persist use a second nitro table, again wait 5 minutes, if needed take a third 5 minutes later
  • If you took a third nitro and still have symptoms call 9-1-1.Try to do some deep relaxing breathing, and thinking try not to panic. It’s a good time to use those relaxations skills.
  • Chew an adult strength aspirin while you wait for paramedics

One discussion I frequently have with patients goes as follows: You may carry your nitro faithfully for years and never need it, but if and when you do need it, you want it to be fresh so it can work. On the other hand some will need to use occasional nitro. This isn’t a bad thing. Your physician prescribed it for a reason. Use it!!!! There are common times when people need one…Exposure to cold air, Exertion that is strenuous, Emotional Stress, and after Eating a large heavy meal. Where the medical community get concerned is if you are requiring 2-3 nitro to clear your symptoms, if you are having more frequent symptoms, or if your symptoms are coming on at rest or waking your from your sleep. The escalation in symptoms should be reported to your physician ASAP.

Keep a log of your nitro  use.  Put on your log, the date, what you were doing when the symptoms occurred, and how many nitro it took to clear the symptoms. When you have a followup appointment with either your cardiologist or your primary care physician present them with the log. Sometimes we are able to find a pattern, do your symptoms come on at a certain time of day? Thus we can probably adjust medication timing to prevent this. Do they come on with a certain level of exertion? We call this your angina threshold and we watch to see is the threshold improving or worsening. Often through exercise we can improve the angina threshold.

What about long acting nitro?

There are long acting nitroglycerin medications that slowly release nitro into your system throughout the day. These are usually taken during the hours you are up and active. Rarely are they used twice a day, as your body needs a period of time in which it is free of nitro, or else it gets to where the nitro doesn’t work as effectively. It is still ok to use the fast acting nitro if you are on this medication.

What about the headache from taking Nitro? 

Take a Tylenol.  The headache won’t kill you but the heart attack might.

Prevention measures to avoid blood clots

Common issues following hospitalization include blood clots. Patients often wonder why we force them to get out of bed and move. Prevention of blood clots in the legs and lungs is critical for recovery

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Peripheral Artery Disease

Heart patients often have Peripheral Artery Disease

Peripheral Artery Disease also known as PAD is when the arteries in the legs become narrowed or clogged with fatty deposits, or plaque. The buildup of plaque causes the arteries to harden and narrow, which is called atherosclerosis. It is the same process that causes heart disease. It doesn’t just happen in the heart it can occur elsewhere in the body and this is known as PAD.  When leg arteries are hardened and clogged, blood flow to the legs and feet is reduced. Lower-extremity PAD is a serious disease that affects about 8 million Americans. The hardened arteries found in people with PAD also put them at risk for hardening and narrowing of the arteries to the kidneys and the brain. That is why people with  heart disease are at risk for PAD, kidney disease and stroke.

How do I know if I have PAD?

Working in cardiac rehabilitation I would often encounter patients who ended up having peripheral artery disease and were unaware of it.  Some of the tell tale signs would be pain with walking, or complaining of wooden feeling in the legs when walking. Fatigue, tiredness or pain in your legs, thighs or buttocks that always happens when you walk but that goes away when you rest.  This discomfort often goes away within two to five minutes of rest. This is a  very classic symptom.  Another classic symptom is night pain in legs, calves, feet or toes that wakes you up. Many patients describe having to sit at the edge of the bed and dangle their feet or get up and walk to relieve the discomfort. Be alert as well for slow to heal wounds in the legs or feet, as the poor blood supply limits wound healing is another clue to peripheral artery disease. Changes in the color of your legs, or the temperature – often the limb feels cold, looks whitish or bluish.

Smoking and PAD

If  you are a heart patient and a smoker  you are very likely to have PAD.  Smoking is  the number one cause of PAD.  Studies show that smoking even half a pack of cigarettes per day may increase the risk of having PAD by 30 to 50 percent. If you do smoke it is imperative that you quit as soon as possible. A cardiologist I worked with would tell his patients if you are diabetic and smoke you will lose a limb to PAD it is a matter of when not if.

Diabetes and PAD

The other big risk factor is diabetes. Diabetes makes the arteries narrow and hard thus restricting blood flow. People with diabetes are at higher risk for having PAD.  Some studies have found that one out of three people with diabetes over age 50 has PAD, and PAD is even more common in African Americans and Hispanics who have diabetes.  The challenge of course with this is that if blood flow is reduced wounds do not heal properly, and limbs can become necrotic and require amputations. A challenge with diabetes is that often the patients with PAD will not get the classic leg pain symptoms. For this reason any diabetic with risk factors for PAD should have his/her legs checked regularly.

Testing for PAD

Testing for PAD includes palpating for pulses in the foot and ankle region. If pulses are not easily felt then the next step is a Doppler ABI – Ankle Brachial Index measurement. This is a painless test in which the blood pressure of the arms is compared to the blood pressures in the lower leg. If there is a large difference this suggests PAD.  Other imaging including CT scans may be done. The next step is a segmental MRA -magnetic resonance angiography,- like a heart catheterization  but looking at the vasculature below the heart. 

Treatment of PAD

Treatment is similar to the heart. If the disease is in the small vessels it is better to intervene with risk factor modification and exercise. Yes it hurts to walk but paradoxically walking is the best activity to help re route the blocked blood supply. The more a person walks the more likely they will develop what is known as collateral arteries around the blockage. Other risk factor modification issues include stopping smoking, lowering cholesterol, being physically active, and keeping blood pressure in control.

If the blockage is in primary arteries of the legs or kidneys then interventions include angioplasty, stenting and/or bypassing the blockages. These are all very similar to the interventions done for atherosclerosis of the heart. Once an intervention is done  it is important to understand the issue is not fixed. Like a car it will need continual maintenance. There is high probability that is will continue to develop further blockages even if you modify all the risk factors and walk regularly.

Exercise and PAD

Many Cardiac Rehabilitation programs will also offer a PAD walking program as well. This usually involves walking on a treadmill or riding a bike 5 days per week and working your way up to a one hour walk. Most patients who experience pain while walking think that sound impossible to walk one hour. The walking program is a graduated program in which one works their way up to one hour, and usually it isn’t a fast walk, but may include walking a grade. Most patients find it quite do able once started. Many find the support given through the rehabilitation programs makes all the difference, as they wouldn’t do it on their own, and the education received while attending gives them the understanding needed to cope with this chronic condition.

 From the Vascular Disease Foundation WHY WALK?

Walking can make a real difference for people with peripheral artery disease (PAD). Recent studies show that for many people with PAD, a structured walking program is one of the best treatments for reducing leg pain or cramps (claudication) when walking. In fact, studies show that over time a structured walking program is often more effective and can work better than medicine or surgery in helping people with PAD walk longer and further without having to stop due to pain.

A regular walking program will:

  • Let you do more and stay active.
  • Reduce stress and help you relax.
  • Help you control your blood glucose, blood pressure, cholesterol, and body weight.
  • Improve muscle tone.
  • Lower your chances of having a heart attack or stroke.
  • Give you peace of mind that you are taking care of your health.

For more information visit

http://vasculardisease.org/