Cardiac Surgery Patients: Think Posture!

If you just had your chest recently surgically opened, the last thing you want to think about is stretching, but after time it becomes very important. You may not physically remember the pain of surgery but your body does. It gradually rounds the shoulders forward, the head is carried slightly more forward, and these changes make the subtle curve in the low back gradually flatten. Many patients when they first attend cardiac rehabilitation complain of pain and spasm to their upper back and shoulders. When I worked in physical therapy I would have many patients present several years after open heart surgery with low back pain. Many had the characteristic posture I described above.

Here are a few suggestion to help you in the healing process.

Be very aware of your posture – if you are sore, think about what posture you are in. Are you seated with your shoulders slumped and head forward? If so adding a lumbar support to your chair will help to straighten your back posture. Another suggestion is to get up and move more frequently.

Pain in the shoulder blade region?

If so begin with gentle chest stretching and shoulder stretching. It is very important you avoid pain. I usually wait until my patients are approximately 6 weeks in recovery before initiating this. Do not take any stretch to pain. Do not bounce stretches.

There are three different postures to get the different muscle groups of the chest. One leg is forward simply to maintain the curve of the low back. Hold the stretch 10 to 15 seconds, repeat 1-2 times. It is ok to do this stretch a few times per day.

   These are other good stretches for the chest

Upper back stretching

The muscles act very similar to pulleys. If one side shortens the other side lengthens. If the muscles of the chest are short the muscles of the upper back are stretched. Prolonged stretch leads to muscle spasm, and this makes many people feel like they have knots in their upper back. There is a great stretch for this.


Reach down grasp opposite knee with hand (left hand grasp right knee). Relax your head pull up gently, hold 10-15 seconds. Repeat with opposite hand/knee. repeat one to two times.

Use a lumbar support in your favorite chair, while driving, or sitting for a prolonged time. You can either purchase one at your local medical supply/pharmacy, or you can simply roll up a small towel and put it in the small of your low back.



Healthy eating tips for heart patients

After heart surgery most patients have a very poor appetite for the first three months.

The first month the medical advice is to eat anything. This isn’t a problem as the body needs extra fuel for healing, but in reality many don’t eat much because food doesn’t taste the same or smell the same. This is thought to be an effect from anesthesia. Most of the time is takes 1-3 months for the taste and appetite to come back to normal. After the first month, patients are instructed to eat a heart healthy diet. That can be a little vague, and different health care practitioners have conflicting ideas of what a heart healthy diet is. In my career it was challenging as one physician  might promote a Dean Ornish vegetarian diet, and the next might promote a Mediterranean  diet, or American Heart Association, Dash diet etc. There are common nutritional principles that all heart patients should try to adhere to.


Tip #1: Know your Caloric needs.

How many calories do you actually need every day? Here are a couple of resources that will help guide you:

Tip #2: Enjoy your food, but eat mindfully

Take the time to fully enjoy your food while you’re eating it (instead of just devouring everything on your plate). Pay attention to hunger and fullness cues before, during and after meals. Be mindful of them and use them to tell you when you’re should be full. Remember it takes about 20 minutes for the food you heave eaten to signal your brain if you are still hungry. For this reason eating slowly, and being aware of the quantity, rather than listening for your body to say it is full. It is ok not to finish everything on your plate.

#3: Avoid oversized portions.

Learn what is the true portion size of the food you are eating. If you are going to overeat eat a larger portion of vegetables. Try using a smaller plate, bowl and glass.  When you’re eating out, try splitting a dish or take home part of your meal.

Tip #4: Foods to eat more often.

 These are all the foods you know are good for you: fruits, vegetables, whole grains, low-fat dairy, etc. Make them the basis for meals and snacks. Try getting 2 cups of veggies, 1.5 cups of fruit and 3 servings of low-fat dairy or lean protein each day.

Tip #5: Decrease the unhealthy foods in the diet

Foods high in solid fats, added sugars, and salt (e.g. cakes, cookies, ice cream, pizza, fast food, sweetened drinks, etc.) should be cut back in the diet. Try to avoid these as part of your daily meal intake.

Tip #6: Hydrate with healthy fluids

Drink water, sparkling water mixed with a splash of juice, tea, or sparkling water instead of high calorie drinks. High calorie drinks include soda, alcoholic beverages, juices, energy drinks and sports drinks. If you are on a fluid limitation, poor the recommended amount of fluid in a container and use it to help you visualize the amount of liquid you should have each day.

Tip #7: Pay attention to added sodium in foods

 Read the labels and choose the lower sodium option for breads, canned goods, and soups. Choose packaged products with labels like “low sodium,” “no salt added,” or “reduced sodium.” Fresh, foods have the least sodium. If it comes from a box, a can, or is ready to eat, it is probably loaded in sodium. Water added usually means sodium added, this is common in poultry. 1500 mgs a day is the recommended amount for heart patients. I had one patient that lost 45 lbs, simply by tracking sodium and adhering to recommendations, it has so far saved him from the disabling CHF symptoms he was experiencing.

Sodium sources are not only food! The medicine cabinet is often an unrecognized source of sodium. Many prescription and non-prescription drugs, such as antacids, ibuprofen, sleep aids, heartburn relievers and cold medicines, have large amounts of sodium. Some antacids have upwards of 250 mg of sodium per tablet. Before taking any medication, it’s always best to consult a doctor, especially if you’re watching your sodium intake for health purposes.  

Most people are unaware of the amount of sodium that comes from our tap water. It varies significantly from state to state, but the public health department in any area should be able to provide information on the exact amount of sodium in the water. Even if a home employs a water-softening system, there’s still a certain amount of sodium in the drinking water, since many of these units use sodium as a softening agent. The amount is solely dependent on the type of system installed and the hardness of the water in that area. Bottled waters, especially mineral waters, can also contain significant amounts of sodium.

Tip #8: Keep your dairy low-fat 

Drinking whole milk is the equivalent of 3 pats of butter, 2% is 2 pats of butter, 1% is one pat of butter. And low-fat cheese is a good substitute for full-fat cheese, but if you are going to use regular cheese, try using a smaller quantity.


Tip #9: Get healthy fats in your diet every day

 When you’re cooking, choose oils high in monounsaturated fats like olive or canola oil. These are better choices, but don’t use large amounts, as oil is high in calories. A pump oil spray is a good way of adding a little oil and avoiding chemicals. Avoid products containing trans fats. Read the labels and avoid hydrogenated oil or shortening or partially hydrogenated oils. This is the same as eating shortening.

Tip #10: Get out of  your comfort zone

Many people won’t try new or unusual foods. They are stuck in a rut of eating the same foods, because it is what they know and like. Try new foods regularly. Especially try different vegetables. If you always cook your foods a certain way, challenge yourself, try sauteing, steaming, fresh, juicing, combining with other foods, adding nuts or seeds to foods.

Tip #11: Know your issues

Some heart patients have to be very aware of vitamin Kin diet, if they are on coumadinKeep your intake of foods rich in vitamin K about the same each day. For example, you may plan to eat only ½ cup of these foods per day. If you like these foods and eat them often, you can eat more, but be consistent. It is a common misconception for patients to think they have to avoid foods rich in Vitamin K, it is more important however to get these in the diet, but as mentioned be consistent and get the same amount each day.

Other’s need to be more aware of the potassium or protein contents of foods.  Certain diseases (e.g., kidney disease and gastrointestinal disease with vomiting and diarrhea) and drugs, especially diuretics (‘water pills’), remove potassium from the body. Potassium supplements are taken to replace potassium losses and prevent potassium deficiency. If you can meet with a dietitian to help you understand what the sources of these nutrients are. If you can’t meet with a dietitian do your research, but don’t ignore the recommendations as many can be life threatening if not adhered to.

Building chest and back muscles after open heart surgery

Once you have your weight restrictions from bypass surgery lifted (and your physician’s permission)  it is time to build back the muscles you lost from surgery.

The muscles are weak from the limited lifting for the last 3 or more months. It is important to go slow and to balance the muscles. In previous posts I write about the importance of posture and stretching after open heart surgery to prevent or manage pain.

The muscles of the chest and back balance one another.

Muscles work like a pulley system, if one group is shortened the other is lengthened. By strengthening the chest muscles the opposing muscles of the back are lengthened. Therefore the back should be worked just as much as the chest to maintain a balance. A common issue is many only train their chest, neglecting the back and this sets the stage for shoulder, neck and back problems down the road. By strengthening both you create a balance to the muscles.

There are many ways one can work the muscles including free weights, dumbbells, resistive bands, or the bodies own resistance – such as push ups. . It is important to start out light. You may have had a 10-20 lb lifting restriction for some time. It is not graduated up but simply lifted.  Therefore don’t start with really heavy weights. Work your way up. Start with a few exercises, see how your body feels the next day. You shouldn’t experience days of pain from the first few workouts, you should be able to tell you worked the muscles but not be suffering.  Don’t overdo it!

Remember it is approximately one full year of healing following surgery.

The bone is knit together but to rebuild the strength, decrease the inflammation and allowing the nerves to heal it takes a full year.  Some precautions to note – if you feel any shifting, cracking or popping of the sternum stop. Try again in a month or two, or modify the movement to avoid the shifting. If you cannot move it without the shifting contact your surgeon.

Breathing with weight training is vital.

Exhale on exertion. This means when you are pushing the weight away from your body breath out. When you are returning the weight to your body breath in. It is extremely important to your heart’s health not to hold your breath.  Holding your breath increases the blood pressure, strains the heart, and for some people can make them light-headed or pass out. Not good when you have weights in your hands to pass out!  This breathing technique should be used with all of your strenuous physical activities or lifting, pushing, or carrying.

The following images of exercises address the key muscle groups lost from open heart surgery.

Start with a light weight – it may be 10 lbs in each hand or it might be 5 lbs, everyone is different but you will appreciate starting with light weights as we expect a little soreness initially. See what works for you. The initial goal is to do many repetitions, gradually build up the amount of weight over time. Try doing each exercise 10 times, if it is easy than next time add a little more weight. If it is difficult, try less weight next time. It is recommended you start with 10-15 repetitions of each exercise, and do it in 1-2 sets the first week or two. You can gradually add in more sets of the 10-15 repetitions. Don’t work the muscles every day, try for 2-3 times per week. The muscles need recovery time.

Chest muscles – note the elbows of the lady in the second picture, this is an example of good technique. Don’t let the elbows come lower than the shoulders as it puts a lot of stress on the sternum and shoulders, and you don’t want to be hurting the next day. Breathe out as you lift the weight up. Don’t hold your breathe!

Shoulder muscles – note only lift the weights to 90* lifting higher than this tends to irritate the shoulders. Be aware to use your muscles not the swinging of your body for momentum. Lift the weight to a slow count of 1 -2, then lower it even slower a slow count of 1-2-3-4. Remember breath out as you lift the weight up.

These are standing fly’s, the knees are bent to support the lower back’s natural curves and prevent injury.                                                                                                                          

Back exercises – standing row. This works the muscles between the shoulder blades.  When doing exercises bent over remember to come back up gradually, as many heart patients experience dizziness when bent over. Again remember to BREATHE!  If you don’t have weights there are resistive bands that can be used. They can be found at your physical therapy centers, medical supply stores or fitness stores. They come in a variety of strengths, remember start light. Make sure you control the band or weight and that it doesn’t control you.                                                                                                                                                                                                                                                                                                               

Weight machines are good. Here is an example of working both the chest and the back. I love lat pull downs and seated rows. Typically I will have patients work these for 1-2 weeks before I introduce the chest press, as the back is far more neglected than the chest muscles in our day-to-day use.  Below are ways of doing the upper back using resistive bands.                                                                                                                                                                                                                                                                                   

I know some of you  are impatient about getting back to push ups. I generally start patients with push ups against a wall initially, gradually moving feet further back. When through the initial muscle soreness, have good breathing techniques then have them begin floor push ups.

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


Is my heart disease cured?

Many patients come through their heart procedures and feel they are cured. Unfortunately for most, heart disease is a chronic progressive disorder of the arteries in which deposits of cholesterol, calcium, and abnormal cells (that is, plaques) build up on the inner lining of the arteries.  Heart disease usually progressively deteriorates over time, whether due to normal bodily wear or lifestyle choices such as exercise or eating habits. This is a hard concept to grasp, and it doesn’t mean it is a death sentence either.

You can do everything right and still have further heart issues.

When patients struggle with this, I point out doing everything right may be why they survived, as approximately 50% of people do not survive their first heart attack.    It is so important for each person to know their body’s signs and symptoms and not ignore them. We don’t really know what makes coronary artery disease aggressive, there seems to be several factors. These factors include inflammation, c- reactive proteins, genetics, lifestyle to name a few. Some patients will have multiple issues for years requiring frequent interventions and then be fine for many years before having another issue. On average coronary artery bypass  grafts  10 years out will be 50% blocked. Some patients will go 20-30 years before needing another intervention, yet others may not even go a week or month before having symptoms. Thirty percent of open heart surgery patients will continue to have angina symptoms after surgery. The drug eluding stents have  much lower rates of re-stenosis than the bare metal stents which average 25-30% restenosis rates, but in both cases the vessels often continue to develop blockages in other locations in the artery. If the bare metal stents are going to re-stenos the usually do so in the first 3-6 months.  It is vital to stay on the platelet inhibitors – Plavix (clopidogrel) as prescribed to prevent complications.

Photo: According to a recent study based on government nutritional data, we're coming up short in terms of eating a variety of fruit and vegetable colors. For instance, 78 percent don't get enough red. How to work in all those colorful vegetables:

Accepting the fact that you will have further heart disease is important.

Be on the lookout for new symptoms, for changes in energy patterns, note if you are becoming less active due to fatigue. Keep your risk factors in the best control possible. Try to get blood pressure, blood sugar, cholesterol numbers to national guidelines. Exercise regularly. Eat a rainbow of color in fresh fruits and vegetables each day. Don’t let stress effect your health, manage your stress as best as possible, consider counseling.  Don’t live in fear, live life to its fullest!!

Play hard.         Enjoy your families.

 Embrace life.          Do something rewarding every day.

Laugh.     Mentor others.   Love


Hot tub and Sauna Safety for Heart Conditions

This is a common question asked by people who have recently undergone a heart issue. It was always a tough one, as some people can and some people shouldn’t. There are a number of concerns for heart patients including elevated heart rates, dehydration, electrolyte depletion, blood pressure issues to be aware of. I have provided you with some education of the benefits and risk. If in doubt of course ask your health care practitioner.

 Vasodilatation –

Benefits: Both steam rooms and dry saunas cause the blood vessels in the skin to dilate, in part accounting for the warm glow appearance afterwards. The blood flow out of the heart increases by 2 or more times after a 10 to 15 minute steam room or sauna exposure.

Risks: However, the blood flow to the internal organs actually decreases, because so much blood is being directed to the skin instead. This can be a problem for those with coronary heart disease. If the heart has to decide where to pump the blood it sends it to the skin to cool the body, and for those with severe blockages the heart then cannot feed itself it’s own oxygenated blood, and then can give symptoms of angina.

People with hard-to-control hypertension (high blood pressure) may experience worsening blood pressure in response to heat exposure. In addition, many blood pressure medications interfere with the normal response of the body to heat exposure.

 Analgesia –
Benefits: Heat has long been recognized as beneficial for folks with fibromyalgia, arthritis and other painful conditions.

Risks: If heat exposure is extreme, excessively prolonged, or if the individual has underlying irritation of the skin, heat can cause the equivalent of a sunburn, or thermal burn. In addition, steam exposure may be a concern if you have had recent surgery (particularly if sutures are still in place) or if you have an open or infected wound. Do not go in a steam room or sauna if you have open wounds.

Diaphoresis (sweating)
Benefits:  The average person will sweat about a pint during a 15 minute session in a sauna, depending on the person’s acclimatization to heat exposure. This has theoretical benefits for cleansing skin pores and some people believe sweating helps clear toxins from the body. This is not well proven and in many instances, is simply not true. In general, people with documented toxicant accumulation in their bodies benefit from specific medical treatment directed at the specific toxicants, rather than sweating. In addition, many of the toxicants of concern these days, for example: pesticides and many metals, asbestos, are not cleared very well through the sweat.

Risks:  The effect of both wet and dry heat to increase fluid loss from the body can also be a problem, particularly if you are already somewhat dehydrated (e.g. after heavy exercise with inadequate fluid replacement or in response to the diuretic effects of caffeine, beverage alcohol, and medications (diuretics). Too much fluid loss can lead to electrolyte imbalance, heart arrhythmias, blood pressure changes, heart rate range changes, light headedness, and fainting.

Dehydration can be a problem in people who have blood vessel blockages to the brain and the heart  The body lacks enough water to fill he blood vessels. Low fluid volume means lower blood pressure. A dehydrated person feels weak and dizzy especially when standing.

Some individuals experience an increase in their migraine headaches in response to dehydration.
There are a number of other medications that can affect the body’s normal response to heat either by inhibiting sweating or by otherwise interfering with the normal physiology, for example, some medications used for psychiatric conditions like schizophrenia. Use of stimulant medications for conditions like ADD or excessive sleeping also increases the health risks from heat exposure.

Dehydration also is dangerous on the kidneys, they will decrease the output of urine and low blood pressure with dehydration can damage the kidneys.

 Calorie Burn:
Benefits: Although exposure to heat increases energy consumption and thereby increases calorie burn, for example, up to 300 to 400 Kcal during a 20 to 30 minute sauna bath, thus helping to promote weight loss, there are clearly more healthful alternatives available, i.e. EXERCISE .

Risks:  Individuals who have been cautioned to restrict exercise intensity by health care providers should be aware that the effects of heat are similar to those of exercise for increasing heart rate. Increasing energy consumption through increased work of the heart can be a concern for people with coronary heart disease, congestive heart failure, valvular heart disease or heart rhythm problems (arrhythmias).


1- Avoid beverage alcohol and excessive caffeine intake and medications that may impair sweating or increase the health risks from heat exposure.

2- Stay in no more than 15 to 20 minutes at a time.

3- Cool down gradually after use. Avoid going rapidly from a hot to a cold environment, e.g. sauna cold shower as this increases the physiologic stress on the body considerably.

4- Drink 2 to 4 glasses of cool water after each session.

5- Don’t take a sauna or steam bath if you are ill, and if you find yourself feeling unwell while in a steam room or sauna, head for the door.

6- Ask your health care provider for advice and recommendations, if you have any concerns about potential health risks from steam room or sauna use.

STEAM ROOMS AND SAUNAS, Doug Linz MD, Medical Director, TriHealth

 If you take a blood thinner (such as Plavix) or blood pressure meds, the heat of a hot tub can combine with the medications to cause you to become dizzy, nauseated or even faint.

When you go in a hot tub, the heated water causes your blood vessels to dilate. In turn, blood pressure drops. If it falls too low, you can pass out.

It may be okay for short periods.

If you are able to carry out moderate exercise without symptoms such as chest pain or shortness of breath, you should be able to tolerate a sauna or soak in the hot tub.

When you get into cold water blood vessels constrict. Any sudden change in temperature leads to a considerable increase in the heart’s workload so moving back and forth between cold water baths and saunas or hot tubs is not a good idea.

Check with your doctor or health clinic to be on the safe side.