Good Information for the heart patient

The two articles below are from American College of Sports Medicine and are position stands. Both of these articles are helpful for the heart patient to understand in the care and prevention of heart conditions. A couple of things to point out to the rehabilitating heart patient would be, the expected drop in blood pressure from exercise is 5-7 mmHg, but can remain lower for quite some time afterwards. This is why you must be alert for dizziness, lightheadedness, fainting, especially after getting up from lying or seated positions.

The article mentions controlled hypertension.Understand you blood pressure as there are levels of hypertension mild moderate and severe. Exercise is not recommended when blood pressure is elevated in the severe ranges.  Most should focus their effort in keeping the intensity mild to moderate. This is harder than you think keeping exercise light to moderate, be patient.

The second article, yes there are risks involved with exercise and they can be life threatening. What can you do to lower the risk? The intensity of exercise is important to understand. Learn about MET levels and exercise intensity here after you finish reading the article.

Exercise and Hypertension

Hypertension (HTN), one of the most common medical disorders, is associated with an increased incidence of all-cause and cardiovascular disease (CVD) mortality. Lifestyle modifications are advocated for the prevention, treatment, and control of HTN, with exercise being an integral component. Exercise programs that primarily involve endurance activity prevent the development of HTN and lower blood pressure (BP) in adults with normal BP and those with HTN. The BP lowering effects of exercise are most pronounced in people with HTN who engage in endurance exercise with BP decreasing approximately 5-7 mm Hg after an isolated exercise session (acute) or following exercise training (chronic). Moreover, BP is reduced for up to 22 h after an endurance exercise bout (e.g., postexercise hypotension), with the greatest decreases among those with the highest baseline BP.

The proposed mechanisms for the BP lowering effects of exercise include neurohumoral, vascular, and structural adaptations. Decreases in catecholamines and total peripheral resistance, improved insulin sensitivity, and alterations in vasodilators and vasoconstrictors are some of the postulated explanations for the antihypertensive effects of exercise. Emerging data suggest genetic links to the BP reductions associated with acute and chronic endurance exercise. Nonetheless, definitive conclusions regarding the mechanisms for the BP reductions following endurance exercise cannot be made at this time.

Individuals with controlled HTN and no CVD or renal complications may participate in an exercise program or competitive athletics, but should be evaluated, treated, and monitored closely. Preliminary peak or symptom-limited exercise testing may be warranted, especially for men over 45 and women over 55 yr planning a vigorous exercise program (i.e., ≥ 60% V̇O2R, oxygen uptake reserve). In the interim, while formal evaluation and management are taking place, it is reasonable for the majority of patients to begin moderate intensity exercise training (40-<60% V̇O2R) such as walking. When pharmacologic therapy is indicated in physically active people it should, ideally: a) lower BP at rest and during exertion; b) decrease total peripheral resistance; and, c) not adversely affect exercise capacity. For these reasons, angiotensin converting enzyme (ACE) inhibitors (or angiotensin II receptor blockers in case of ACE inhibitor intolerance) and calcium channel blockers are currently the drugs of choice for recreational exercisers and athletes who have HTN.

Exercise remains a cornerstone therapy for the primary prevention, treatment, and control of HTN. The optimal training frequency, intensity, time, and type (FITT) need to be better defined to optimize the BP lowering capacities of exercise, particularly in children, women, older adults, and certain ethnic groups. Based upon the current evidence, the following exercise prescription is recommended for those with high BP:

Frequency: on most, preferably all, days of the week

Intensity: moderate-intensity (40-<60% of V̇O2R)

Time: ≥ 30 min of continuous or accumulated physical activity per day

Type: primarily endurance physical activity supplemented by resistance exercise


Exercise risk for cardiovascular event

Habitual physical activity reduces coronary heart disease events, but vigorous activity can also acutely and transiently increase the risk of sudden cardiac death and acute myocardial infarction in susceptible persons. This scientific statement discusses the potential cardiovascular complications of exercise, their pathological substrate, and their incidence and suggests strategies to reduce these complications. Exercise-associated acute cardiac events generally occur in individuals with structural cardiac disease. Hereditary or congenital cardiovascular abnormalities are predominantly responsible for cardiac events among young individuals, whereas atherosclerotic disease is primarily responsible for these events in adults. The absolute rate of exercise-related sudden cardiac death varies with the prevalence of disease in the study population. The incidence of both acute myocardial infarction and sudden death is greatest in the habitually least physically active individuals. No strategies have been adequately studied to evaluate their ability to reduce exercise-related acute cardiovascular events. Maintaining physical fitness through regular physical activity may help to reduce events because a disproportionate number of events occur in least physically active subjects performing unaccustomed physical activity. Other strategies, such as screening patients before participation in exercise, excluding high-risk patients from certain activities, promptly evaluating possible prodromal symptoms, training fitness personnel for emergencies, and encouraging patients to avoid high-risk activities, appear prudent but have not been systematically evaluated.

Regular physical activity is widely advocated by the medical community in part because substantial epidemiological, clinical, and basic science evidence suggests that physical activity and exercise training delay the development of atherosclerosis and reduce the incidence of coronary heart disease (CHD) events (1-4). Nevertheless, vigorous physical activity can also acutely and transiently increase the risk of acute myocardial infarction (AMI) and sudden cardiac death (SCD) in susceptible individuals (5-7). This scientific statement presents the cardiovascular complications of vigorous exercise, their pathophysiological substrate, and their incidence in specific patient groups and evaluates strategies directed at reducing these complications. The goal is to provide healthcare professionals with the information they need to advise patients more accurately about the benefits and risks of physical activity.

Most studies of exercise-related cardiovascular events have examined events associated with sports participation in young subjects and with vigorous exercise in adults. Vigorous exercise is usually defined as an absolute exercise work rate of at least 6 metabolic equivalents (METs), which is historically assumed to equal an oxygen uptake (V˙O2) of 21 mL·kg-1·min-1. Six METs approximates the energy requirements of activities such as jogging. Six METs is an arbitrary threshold and does not account for the fact that the myocardial oxygen demands of any physical activity are more closely related to the V˙O2requirements relative to maximal exercise capacity than to the absolute work rate per se. Consequently, exercise work rates < 6 METs may still place considerable stress on the cardiovascular systems of unfit and older individuals.

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.

How Laughter Impacts Your Heart Health

When is the last time you had a good guttural laugh? You know the kind, where you feel like you are short of breath, your stomach and face muscles feel sore, the kind that puts a smile on your face when you think of it later?  This kind of laughing has similar effects on the body as exercise does, lowering blood pressure, reducing stress hormones,  and burning calories.

There are some claims that children laugh more than 300 times a day, whereas adults laugh less than 20 times a day.  Studies have shown people with heart disease responded less humorously to everyday life situations.  They generally laughed less, even in positive situations, and they displayed more anger and hostility. Other studies have shown higher instances of conditions such as heart disease and dementia among those who live in isolation. Many who are socially isolated don’t get the opportunity each day to smile and laugh.  If you struggle with social isolation, challenge yourself to find a way to laugh. It may be laughing at yourself, watching a funny movie, doing laughing exercises, joining a laughing group,or  finding laughs on the internet. Challenge yourself to laugh.

Here are a couple of links to videos of laughing exercises:

Laughing Workout

Laughter Exercises

Do You Know Your Heart’s Ejection Fraction?

Today I ran into a young woman I assisted in Cardiac Rehabilitation after she had a heart incident. One of the first things she said to me with a smile on her face was that her ejection fraction had increased from 15% to 55%. This means her heart essentially is functioning within normal limits of 50%-70%  in it’s pumping ability. She went on to tell me she was off to go snowshoeing in the woods. I was so proud, as working with patients over time you learn and share a lot about your lives, and for her this was huge!

Ejection fraction is a measurement of the percentage of blood leaving your heart each time it contracts.

When the heart beats, it contracts or squeezes and then relaxes. During heart contraction, it pushes the blood within the pumping chamber  out. When your heart relaxes, the chambers or ventricles refill with blood. No matter how forceful the contraction, it doesn’t empty all of the blood out of a ventricle. The term “ejection fraction” refers to the percentage of blood that’s pumped out of a filled ventricle with each heartbeat.

A normal LV ejection fraction is 55 to 70 percent. The ejection fraction may decrease if:

  • A heart attack has damaged the heart muscle such that it cannot forcefully contract
  • The valves of the heart are not working properly
  • Blood pressure has been uncontrolled  for a long period of time
  •  Weakness of the heart muscle, such as dilated cardiomyopathy

I get great gratification in this patient announcing this for another reason. I have a history of arguing with cardiologist about teaching patients their heart’s condition by reading their medical reports with them. As part of the intake to cardiac rehabilitation the charts are reviewed so both the patients and the clinicians have a solid understanding of their heart condition and the plan to manage the heart condition. Many patients enter rehabilitation with their last echo cardiogram or other studies showing the patient has a severely reduced ejection fraction. Some people will always have a reduced ejection fraction and others will recover depending on the severity of condition. A late presenting large heart attack may have permanently reduced pumping ability of the heart, where as a stent placed early in a heart attack may improve within a very short time. Other conditions slowly change over time, getting better or worse these include hearts that have cardiomyopathy, or pacemakers.

I believe heart patient’s understanding of their ejection fraction an important part of managing their health. The cardiologist was worried I would scare his patients.  The cardiologist  felt people would psychologically not improve if they knew their ejection fraction was low.  Many people with a reduced ejection fraction will not have any significant functional limitations or symptoms. I have worked with people with ejection fractions in the 8-10% who can function pretty normal including performing weight or resistance training exercises. On the other hand some folks with an ejection fraction of 30-40% can feel symptoms of fatigue or shortness of breath with mild exertion.

For many through building structured exercise they can improve the muscular strength of their body thus reducing the effort the heart has to work to meet the demands for oxygenated blood. Exercise does improve the ejection fraction in many studies, but if it doesn’t it still  improves the functional ability and quality of life of most individuals. Cardiac Rehabilitation programs often will note  an improvement in patients  ejection fraction. It is typical to undergo echo cardiogram studies approximately three month post intervention or event. I believe it is more of an insurance reimbursement issue which makes  most scheduling occur at 3 months post, but also gives the heart time to recover and medical management to be fully effective, and this is typically how long a cardiac rehabilitation program lasts.

When the overeager patient comes in and wants to give themselves a workout equivalent to a stress test on their first few sessions  of cardiac rehabilitation to prove to themselves they are ok,  we will  use information such as their ejection fraction to determine  and educate how much effort they should safely perform.  Then there is the  scared patient who has been living with a reduced ejection fraction and had short of breath and  gets a bi-ventricular pacemaker  the cardiac rehabilitation staff encourages them to increase their workloads as their ejection fraction is likely much improved and now can feel safe pushing the intensity. Reviewing this information with you healthcare provider can help you to understand your heart and any limitations it may have.

Read more about ejection fraction here

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