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.
Think about how hard activities can become as you lose muscle. Activities such as getting up and out of a chair without using your arm strength, getting off the floor, walking up and down stairs while carrying objects, carrying in groceries from the store, maintenance of your home, lifting or holding a grandchild. These are concerns patients I have worked with bring to me. Things they would like to do but don’t have the strength to handle.
My answer is building muscle, which we can do at any age. I have had people with heart disease in their 90’s working with weight machines. I start most with dumbbells or soup cans and build them up to exercises using their own body for resistance, then if able get them to the weight machines. The results are not always noticeable in the physique, but rather in the abilities to do perform activities of daily living. As we age we develop many orthopedic – bone and joint issues which limit ability to do traditional strengthening exercises – such as weight machines. Don’t let that stop you from performing strengthening exercises. There are many ways to work around the barriers. Find an ACSM certified exercise specialist in your community to assist you, or a physical therapist. Work these exercises into a daily routine, not just a quick fix for a particular issue. Stick with these exercises, if you have to stop, so be it but build them back into your routine as soon as possible. Your body will thank you!
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.
The last time I strapped skinny boards to my feet and threw myself down a hill was 30 years ago. Yesterday, I did it again.
The people at the Vasa Cross Country Ski Trail, held a benefit for women’s heart health. Somehow, I got talked into participating as a heart disease survivor. They promised me that I would only have to ski as far as I wanted and there would be chocolate and hot soup when I was finished. “Ok” I thought, “I can handle that.” I figured that I’d put on a pair of skis, putz along the trail a bit, talk to a few people and head back to the fireplace for that chocolate. It would be a cake walk….a chocolate cake walk.
I got up, put on four pairs of leggings, two sweatshirts and pinned a hand warmer over my pacemaker to keep it warm. Over everything, I put on what I call my “Superhero” T-shirt. It has a detailed diagram of a human heart with a pacemaker-defibrillator. My girlfriend Andrea, picked me up and we headed out. I was a bit nervous. It had been a long time since I had done any kind of skiing. I wasn’t sure if I could handle the exercise in the cold. I didn’t know how it would affect my heart. The last thing I wanted to do was end up lying in the snow somewhere along the trail.
The venue was a sea of red and pink when we arrived. It was a good mix of experienced skiers and casual weekend skiers. I noticed that everyone seemed to have their own skis and we were one of the few who needed to rent equipment. The three “Lodge Dogs” helped me put on my boots with much sniffing and tail wagging. One was a huge droopy eyed bloodhound and let him have a good long sniff so he could search me out if I didn’t come back. I wondered if they could tie a cask of bourbon around his neck.
Tripping over the doorsill, I went out and stepped into the binding of the skis. They shot forward of their own volition! Good Lord, I had demon skis locked onto my feet. A friend gave me some quick instruction and we wobbled off down the trail. Just about the time I was starting to think that this wasn’t so bad after all, we came to the first hill. Trees on each side of the trail had large fluorescent triangle signs, I checked my map to see what they might mean. Steep hill. Oops.
An Olympic ski jump could not have looked steeper at this point. The hill dropped off like a cliff, zigged to the right, zagged to the left and then dropped off again. Someone in a one-piece spandex suit with flames went zipping past me and down the hill. I was sure I heard screams of terror as he disappeared over the precipice. The demon skis on my feet began to slide forward. “No, No,” I begged. “Don’t make me go there!”
It was too late. I gained speed. No amount of flailing my arms or feeble snow plow attempts could slow me. Well, one thing could. Falling down. At least you don’t roll far with six foot boards on your feet. I blinked the snow out of my eyes and realized that I was OK. I survived. One problem though, I had absolutely no idea how I was going to get up. There was nothing left to do, but laugh. My laughter echoed through the woods and was joined by that of my friends
Pat, the more experienced of our little group came to rescue me. She tried to stop just above me, but tumbled over me instead. Now there were two people helplessly lying in the snow and laughing. As we struggled to untangle our poles, skis and bodies, I felt something hit me in the behind. It was Andrea’s ski. She was no fool. Removing her skis at the top of the hill, she was now walking towards us. Other skiers whizzed past us as we removed skis, got to our feet and put them back on again. Brushing the snow from my clothes, I looked back at the hill. It was a gentle curving slope, not a cliff after all
Once you’ve fallen and given up any semblance of dignity, you’ve got nothing to lose. We were off again. The trail was beautiful. Snow was gently falling as we passed from hardwood forest to cedar swamp and stands of pale gray birches. Someone who passed before us wore Valentine tinsel and I would see the occasional tiny red heart left behind in the snow. The vibrant red looked like punctuation points in the expanse of whiteness. First I thought they were geranium petals and wondered that they should be there. Then I remembered seeing the woman wearing the tinsel at registration.
I found my stride. Step, glide. Step glide. The only sounds were the whisper of gentle wind in the tree tops, the quiet staccato of snowflakes hitting the paper number on my back and the sound of my skis sliding in the snow. Step, glide. Step glide. Nothing existed, but the winter landscape and I.After the climb up another hill, I paused while my heart beat dropped to an acceptable level. My friends were nowhere in sight. I had no idea whether I was still on the right trail or not. I fished the soggy map out of my pocket. According to it, I had not yet passed the halfway mark of the six kilometer trail.
SIX KILLOMETERS! What happened to “Ski as far as you want?” Where were the short cuts back to the lodge? WHERE’S MY CHOCOLATE? Oh well, might as well go forward. At least I wouldn’t face climbing back up that killer hill.
Step, glide. Step glide. One foot moving past the other. Time stopped. All the cares of the world dropped away. If ever there was a Zen moment in my life, this was it. I relaxed and became one with my surroundings. The only time I was called back into the present was when my heart would demand a rest at the top of another hill. Other skiers past me in both directions, I graciously stepped aside and smiled as they passed. Greetings were exchanged with people I have never met nor will likely see again. Step, glide. Step, glide. I was at peace with the entire world and all its inhabitants.
The trail turned to the West in the direction of the lodge. Unfortunately it also brought me to directly face the wind, the occasional snowflakes changed to a veil of wet slushy snow. My red scarf caught the snowflakes and was chill around my neck. Each breath I took brought cold air in contact with my lungs and the wires from my pacemaker. I knew that I needed to get out of the weather soon. Picking up the pace, I worried about leaving my friends behind. Hoping they would understand, I no longer waited along the trail for them to catch up.
Step, glide. Step, glide. Where the heck was that lodge? Every time I came to a bend in the trail or the top of a hill, I expected to see it. Signs with arrows pointing towards the finish taunted me. How much further could it be? Then I realized how far I had come. Five years ago, I was lying in a hospital bed not knowing if I was going to survive. Four years ago, I was still learning how to live. Three years ago, I wanted to ski this trail, but the weather was to cold and I had to pass on the event. Two years ago, I was beginning to speak out on heart disease. Last year I became a Womanheart Champion. This year, I was cross country skiing in my super hero T-shirt. Who knows what waits on the trail ahead?
The snow stopped stinging my face, even though it still fell. The tired muscles felt energized. My cold hands were strong as they gripped the poles to propel me. There was another hill ahead. I climbed. It was steep and at times my skis slipped backwards, but I would catch myself and push on. As I crested the hill, I saw large banners and bright flags marking the finish line. Just the day before the area was filled with cheering crowds as professional racers competed in the 27 Killometer Vasa Races.
There were no crowds today, only a large old bloodhound sitting at the gate. Did he know I was coming? The lack of cheering spectators made no difference to me. The big dog wagged his tail as I raised my poles in triumph. I’d done it. I beat the odds and won. I survived.
My friends came in about a half hour later, by then I had time to warm up a bit and change into dry mittens and boots. They had no idea what this day had meant to me. We were all cold and tired, but I had a new idea of what my limits are…..absolutely none. Now, where’s my chocolate?