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.

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.

old shoes

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/

Making Trails for Exercise

Exercise is all about making trails

Recently I encountered a patient who I had worked with 18 years ago, he was back for his second heart procedure. He was very excited to see me to discuss how my advice made such a difference. I couldn’t for the life of me remember what advice I gave him nearly twenty years ago. He proceeded to inform me I told him to go walk the trails in the woods. Here he was looking fit, strong, and healthy. He was here for a quick tune up as heart disease is progressive, tune ups are required. So we set about reviewing his risk factor profile, and he looked good. He had been walking the trails in the woods nearly every day!

This gets me to thinking about making trails.  What kind of trails do you make? Maybe you think you don’t make any trails because you walk a treadmill or ride a bike. Here is how my friend Nate Burns and staff make trails in cardiac and pulmonary rehabilitation programs.  Cardiac and Pulmonary Rehabilitation Walks Trails  Every year they do a different theme walk, and map out interesting stops along the way. You could add up your miles and consider where your travels have taken you, or you could work towards a goal of a certain destination.

My favorite trails are  hiking, biking, cross country skiing, beach trails and are accessible in some form year round. A goal one year was to get a guide of all the hikes at the nearby National Lakeshore Park Sleeping Bear Dunes and walk each one, now that is a yearly goal. This can also be done with your local land conservancy, or your conservation district, your local parkland.

How many trails can you find in your community? Are you up to the challenge?

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Heart of Diabetes

 Exercising daily and eating a well balanced diet with the proper portion sizes are the best prevention for diabetes.

The relationship between diabetes and heart disease is striking. Many do not even know they have diabetes or are pre-diabetic. If you are overweight, or have a family history of diabetes it is important to work with your health care practitioner to watch your blood sugars control.  Many clients I have worked with through the years were able to get their pre-diabetic blood sugar values back to normal through diet and exercise. Many diabetics can reduce the medications for blood sugar control as well if they are able to adhere to the lifestyle choices of exercise and following a diabetic diet of good food choices and portion control.

Those that have diabetes need to be extra cautious to keep there blood sugars in the tightest control possible, as when the blood sugars are chronically elevated this sets the stage for dramatic increases in the prevalence of heart disease. Overeating sets the stage for insulin resistance. An analogy to help understand this is  filling a gas tank, you can only put so much gas in before it spills out. When we consume more calories than the body can use the body secretes more insulin and it circulates in the blood stream. The cells get adapted to the increased insulin this is called insulin resistance. This allows higher concentrations of blood sugar to circulate in the body. The higher blood sugars assault  the body, the eyes, heart, kidneys, nerves, arteries  throughout especially those to the legs and kidneys, setting the stage for not only heart problems but peripheral vascular problems, the most common reason for amputations. Exercise is critically important and should be adhered as it gets rid of the high concentrations of sugar circulating in the blood stream, and prevents them from doing more damage.

It becomes even more challenging too, as the most common symptom of heart problems – chest discomfort is less likely to be experienced by the diabetic patient, as the nerves that send the pain  signal to the brain do not relay the message. Thus symptoms are more likely to be shortness of breath, flu like symptoms, extreme fatigue, weakness in the diabetic patient. The hemoglobic A1c value is especially important to understand. The values are listed below.

Protect your kidneys

It isn’t easy to be a heart patient, there are so many medication and lifestyle consideration to prevent further injury or illness.

Common heart medication interact with our foods and other medications.  NSAIDS increase heart problems, Coumadin requires watching vitamin K, Grapefruit interacts with many heart medications, some diabetes medications increase heart risks, some heart medications increase risk for diabetes. Now we have a another  to be concerned about. Here is a new advisory the combination of NSAIDS and hypertensive drugs. This is challenging as we encourage patients to exercise and often there are side effects of sore muscles and joints. Based on this the recommendation for sore muscles and joints should be to use  ice and stretch…avoid the Motrin, Advil, Ibuprofin, Moabic, etc. The other challenge is to get the orthopedic physician and the cardiologist to work together to prescribe the safest medication regiment for you. Most importantly do not stop your anti-hypertensive medications without first consulting your physician, sudden withdrawal can be very problematic.

side effects and contraindications: antihypertensives

Adding a non-steroidal anti-inflammatory drug (NSAID) to dual antihypert ensive therapy (a diuretic plus either an ACE inhibitor or an angiotensin receptor blocker) is associated with an increase in risk for kidney injury, according to a large new retrospective study published inBMJ.

Adding a non-steroidal anti-inflammatory drug (NSAID) to dual antihypertensive therapy (a diuretic plus either an ACE inhibitor or an angiotensin receptor blocker) is associated with an increase in risk for kidney injury, according to a large new retrospective study published in BMJ.

Analyzing data from nearly half a million people taking antihypertensive drugs, researchers found 2,215 cases of acute kidney injury after a mean followup of 5.9 years. People on dual therapy were not at increased risk for acute kidney injury. However, when NSAID use was added to dual therapy, there was a modest but significant increase in risk (rate ratio 1.31, CI 1.12- 1.53). The increase in risk was highest in the first month of treatment.

The authors concluded that “increased vigilance may be warranted when” NSAIDs are used with dual antihypertensive therapy, especially in the early treatment period.

In an accompanying editorial, Dorothea Nitsch and Laurie A Tomlinson write that the safety of dual therapy still remains to be demonstrated and that the study likely “underestimates the true burden of drug associated acute kidney injury” in patients taking antihypertensive therapy and NSAIDs. Physicians should inform patients taking antihypertensive therapy about the possible risks of NSAID use and should ”be vigilant for signs of drug associated acute kidney injury in all patients.”

Here is the BMJ press release:

Triple mix of blood pressure drugs and painkillers linked to kidney problems

Absolute risk still low, but doctors and patients should be vigilant

Research: Concurrent use of diuretics, angiotensin converting enzyme inhibitors, and angiotensin receptor blockers with non-steroidal anti-inflammatory drugs and risk of acute kidney injury: nested case-control study

Editorial: Safety of co-prescribing NSAIDs with multiple antihypertensive agents

Patients who take a triple combination of blood pressure drugs and common painkillers are at an increased risk of serious kidney problems, especially at the start of treatment, finds a study published on bmj.com today.

Although the absolute risk for individuals is low, it is still something doctors and patients should be aware of, say the researchers.

Acute kidney injury (also known as kidney failure) is a major public health concern. It occurs in more than 20% of hospital inpatients and is associated with around half of all potentially preventable deaths in hospital. It is often triggered by adverse reactions to drugs, but little is known about the safety of different drug combinations.

So a team of researchers from the Jewish General Hospital and McGill University in Montreal, Canada, set out to assess whether certain combinations of drugs to lower blood pressure (antihypertensive drugs) and non-steroidal anti-inflammatory drugs (NSAIDs) are linked to an increased risk of kidney injury.

These drugs are commonly prescribed together, particularly in elderly people with several long term conditions.

Using the world’s largest computerised database of primary care records (CPRD), they identified 487,372 people who received antihypertensive drugs between 1997 and 2008. Drugs included angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs) and diuretics, with NSAIDs.

Patients were tracked for nearly six years, during which time 2,215 were diagnosed with acute kidney injury that prompted admission to hospital or dialysis (7 in 10,000 person years).

The results show that patients taking a double therapy combination of either a diuretic or an ACE inhibitors or ARB with an NSAID were at no increased risk of kidney injury. However, a triple therapy combination of a diuretic with an ACE inhibitor or ARB and an NSAID was associated with a 31% higher rate of kidney injury, particularly elevated in the first 30 days of treatment during which it was 82% higher.

These results remained consistent after adjusting for confounding factors and controlling for other potential sources of bias.

The authors conclude that, “although antihypertensive drugs have cardiovascular benefits, vigilance may be warranted when they are used concurrently with NSAIDs.” They add: “In particular, major attention should be paid early in the course of treatment, and a more appropriate choice among the available anti-inflammatory or analgesic drugs could therefore be applied in clinical practice.”

In an accompanying editorial, researchers at the London School of Hygiene and Tropical Medicine say this study “is an important step in the right direction” but “probably underestimates the true burden of drug associated acute kidney injury.”

They suggest that clinicians advise patients of the risks and be vigilant for drug associated acute kidney injury, and say “the jury is still out on whether double drug combinations are indeed safe.”

http://cardiobrief.org/2013/01/10/acute-kidney-injury-associated-with-dual-antihypertensive-therapy-and-nsaids/