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November 30, 2012

Afraid to Exercise?

by alive

A heart attack is one of the most frightening things you can experience. Many people don’t survive. And of those who do, there is a lingering doubt and fear. Will it happen again? Invariably, many link their previous heart attack to some form of physical exertion, and have an aversion to physical activity forever after.


You may know exercise helps. You may even know many people with a heart condition benefit from it.

But you may also be thinking: how risky is it? After all, for a long time, people were advised not to stress their heart by doctors, including through exercise. You may have been cautioned not to exert after discharge, and every well-meaning person around suddenly wants to protect you from even the most minor tasks you want to do.


So what’s the truth?


Some Facts and Figures

Research performed in the last 25 years has demonstrated that exercise is stressful. But properly controlled exercise stress in the right dose causes your heart-lung system to adapt, becoming better and stronger.


As far back as the late 1980s, meta-analyses showed that cardiac rehab (CR) was associated with reduced death from both cardiac and all-causes. (O’Connor et al 1989; Oldridge et al 1988). More recently, Clark et al (2005) reviewed 63 randomised controlled trials (these are considered to give us the most reliable scientific evidence in healthcare). They found that at two years follow up after CR, CR reduced mortality by 47% and decreased the incidence of heart attack by 17%, compared to people who didn’t do CR. CR also produces financial savings by reducing re-hospitalization rates and improving re-employment (Pell 1997).


A study by Scheinowitz and Harpaz (2005), evaluated 3,511 patients with a history of myocardial infarction, coronary artery bypass grafting and risk factors for coronary artery disease, participating in exercise training, for 69 months. The total number of patient-hours was 338,688. Untoward events had a of 1/58,902 patient-hours/year (0.02%).


11 were non-fatal events and two were fatal. In the latter case, 1 was successfully resuscitated. For those who experienced events, these occurred within the first four weeks of starting the program. One third of the patients who experienced cardiovascular events, resumed the exercise program with no further complications.


So the general consensus seems to be that CR is a desirable thing for heart patients. As long as careful monitoring and progression takes place especially when starting a program, CR not just increase your fitness, it will reduce the chance of another heart attack.


When Do I Begin?

In fact, whether you knew it or not, you actually started even before discharge. While you were warded, you may recall a very unpopular person – the physio. After you were medically stable, she got you out of bed into a chair to sit, then back in again. She eventually got you walking around. At that point, you were already doing more than what patients 20 years ago were told to do – stay in bed. So in fact, physical movement in your initial vulnerable state, could be considered a form of exercise.


How Should I Start?

When you’re ready to start a formalized exercise program, the most important thing is to start slowly.

Depending on the procedure, you may also be restricted. For example, if you’ve had an incision in your leg from an angiogram, you may not be able to drive. If you’ve had a chest incision from surgery, you can’t perform certain arm movements. Meanwhile there are other things you can do, and that’s what we’ll take for our starting point.

What sort of exercise should you start with?

In CR I always get patients started out with activity similar to what they are already doing. For example, you walked out of the hospital didn’t you? You walked to the nearby coffee shop for breakfast? Then, your exercise will comprise walking because it’s something you don’t have to learn.


What makes it exercise is that it will be controlled by different parameters.


This is the FITT concept that we talked about in our “How to Start Exercise Part 3” article.

You see, while walking to the downstairs coffee shop slowly is easily achieved, walking and maintaining that speed continuously for 5 minutes and up, may be a challenge.

It’s this sort of controlled challenge that your body needs to adapt to by becoming fitter.


In CR, we often start patients with 5-10 minutes on the treadmill or stationary bike. Many find this a challenge, but surprisingly manageable. That gives them the confidence to take up the “What’s Next?” challenge and wonder, “Could I do 15?”

I favour building up the duration first before ramping up the intensity. I like my patients to finish each CR program with the ability to walk at least 30-45 min continuously on the treadmill, at an RPE of 11-13.

Once the cardio aspect is under your belt, I like to introduce strength training, using bodyweight, dumbbells or elastic resistance.


What About Weights?

Surely, as a heart patients, there must be some things I CAN’T do? Like lift weights?

Well, it is true that lifting weights, especially if you haven’t done it before, can be stressful. There is a tendency to hold your breath, blood pressures increase, and so on.

However, think about what happens when you stand up from a chair. Effectively, you have done one rep of a squat exercise! And if you were to get up and sit down again a number of times, you’d have effectively done one set of squats!

Not exactly a ‘weights’ exercise…

… but very similar!








In the same way, don’t think of resistance exercise as lifting heavy weights. Think of the resistance exercise for your CR as doing daily tasks, but in a formalized way. We don’t want to make you a champion powerlifter. But we do want you to have muscle fitness to the point that daily activities become easier.


That being said, we usually wait a few weeks after you’ve started your cardio exercise before starting you off slowly on resistance exercise. This depends on how much damage you’ve had to your heart muscle.


What Are The Symptoms To Look Out For?

A typical heart attack has been described to me by patients as “heavy” squeezing feeling, like something very heavy sitting on the chest.

When you’re exercising, be aware of any chest discomfort or similar sensation you have when you had your event. This may be a feeling of

  • Pain, pressure or tightness below the breastbone
  • Pain or dull ache that goes into your jaw, neck, teeth, shoulders and arms
  • Pain in the back or abdominal region.
  • Dizziness, shortness of breath, or unusual fatigue

Any of these should be reported to the cardiac nurse/ exercise physiologist immediately.



Safety – Importance of RPE/ ECG Monitoring

How do you know whether your symptoms are the signs of impending doom, or if it’s still safe? That’s where monitoring comes in. I’ll only mention two commonly used measures.

The first is the RPE which we first discussed in How to Start Exercise Part 2. For CR, I ask patients to keep from 3-6 on a 10 point chart. On the 20-point RPE we use in the hospital, I get them to aim for an RPE of 11-13.


This is important because the heart medications prescribed often affect your resting and exercise heart rate. For example, beta-blockers slow it down. If we were to rely on the heart rate method to determine how hard you should exercise, you would have to work very hard to get the target heart rates determined by the heart rate method. This can be very dangerous.



Using the RPE is a way of assessing how hard you are working, based on how you are feeling. It is an important gauge because regardless of heart rate, how hard you work corresponds with (generally) how hard you feel you are working. So we use the RPE very extensively during cardiac rehab.


Next is telemetry. For this, you’ll wear a monitor, is attached to your body with adhesive electrodes. They pick up electrical signals from your heart and transmit it to the telemetry station, where they will be monitored while you exercise. This is very important in determining if the discomfort/ pain you feel is due to a cardiac event or not. The cardiac nurse can recognize what looks like a heart attack or other dangerous waveforms and communicate this immediately to the exercise physiologist, who will then do the necessary


In all things, we weigh the benefits against the costs. Consistently over the last two decades, CR has been shown to benefit people with heart problems far more than it has harmed them. As long as your CR is guided by a team of qualified professionals, you will be taken through a progression that will be safe and ultimately, let you reap all the promises that exercise has to offer.

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