Exercise and Aortic Aneurysm

marybeth: What guidelines can be offered for someone with an aortic aneurysm? Does its size or location make a difference? What about after surgery?

Speaker_-_Gordon_Blackburn: Certainly the size of the aneurysm is a critical issue as well as location. That is a decision between the surgeon and the patient. After surgery, we actually have very little data for patients after aneurysm surgery. The general guidelines are to return to a moderate level of activity. That can occur a few weeks after surgery once the patient feels up to it. The goals of exercise for the post aneurysm surgery patient are focused more on improving functional capacity to decrease the vascular stress during normal daily activities, and aid with weight management and blood pressure control. The patient is still at risk for re-development of an aneurysm, so we will use blood pressure guidelines for activity and focus in on aerobic exercise and tend to steer away from weight training.

RCoren: I have an aortic aneurysm, at the aortic root that is being watched for change before proceeding to surgery. In the meanwhile I have been told to alter my workouts at the gym. I usually use 40-50 pound weights but have been warned not to use more than 1- pounds. This seems so ridiculously light tome that I have, instead, given up the weighs altogether. This bothers me very much. What should I do?

Speaker_-_Gordon_Blackburn: The risk with the aneurysm is that elevations in blood pressure can more rapidly cause deterioration or in worse cases, rupture. With aggressive weight lifting the rise in systolic and diastolic blood pressure can put significant stress on an already weakened tissue and should be avoided.

Speaker_-_Gordon_Blackburn: The specific weight restrictions should be based on your response to any activity and are best known by your cardiologist who knows your specific case. You can consider participation in a supervised monitored program if your cardiologist supports this.

Exercise After Heart Surgery

marybeth: How long after heart surgery can someone resume a weight exercise program? What if the surgery is done robotically?

Speaker_-_Gordon_Blackburn: The typical guidelines are: wait until the sternum is stable before resuming weight training - typically 6 to 8 weeks after the surgery. When the patient does initiate a resistance training program the guidelines are to focus on large muscle groups of the upper and lower extremities and select weights that can be lifted 10 - 15 repetitions (individual lift), achieving local muscle fatigue between the 10th and 15th.

Speaker_-_Gordon_Blackburn: Each exercise should be repeated for at least one set and optimal benefit is gained with two sets.

Speaker_-_Gordon_Blackburn: The activity should be repeated at least twice per week and ideally three times per week on non-consecutive days.

Speaker_-_Gordon_Blackburn: Resistance training is valuable because we all lose strength as we age. Women achieve peak strength at 18 to 20 and men at 20 to 25 years of age. Objects continue to weigh exactly the same.

Speaker_-_Gordon_Blackburn: The data says that patients with corrected heart disease can safely engage in weight resistance training but the cardiovascular benefits are achieved through an aerobic training program. While lifting, patients should avoid straining (valsalva maneuver). If the patient does strain, that is viewed as achieving fatigue.

robert: I had minimally invasive valve surgery 3 weeks ago? I used to cycle long distances. When can I get back to that? When can I start training again?

Speaker_-_Gordon_Blackburn: The benefits of regular exercise for patients with or without cardiovascular disease are well documented. However it is important to differentiate between the guidelines for health benefit and the guidelines for competitive sports.

Speaker_-_Gordon_Blackburn: The heath benefits of exercise are associated with moderate intensity aerobic exercise ( 50 - 75 percent of functional capacity), while many competitive training programs encourage (or require) higher exercise intensities. The focus of competition is too often on winning or placing well in the event, while the health benefits focus on optimal quality and quantity of life. It is not that individuals with heart conditions cannot return to competitive events but the risk vs. the benefits must be considered.

Speaker_-_Gordon_Blackburn: Exercising at higher intensities (greater than 75%) has not been associated with significant added heath benefits. However there is increased cardiovascular as well as orthopedic risk of higher intensity exercise. As the intensity and duration of exercise become extended there is also increased risk of dehydration, hyperthermia and hypothermia that must be considered.

Speaker_-_Gordon_Blackburn: The primary focus of cardiac rehabilitation is to optimize health benefits and minimize risks for patients with heart conditions. The decision as to what level of exercise is appropriate is individualized for each patient and should be discussed with your managing cardiologist.

Speaker_-_Gordon_Blackburn: Cycling is an excellent aerobic activity and, if appropriate, I encourage you to return to it as soon as you are cleared by your cardiologist. Under the supervision of your cardiac rehab staff and physicians they will be able to guide your return to a safe, enjoyable cycling program.

Hypertrophic Cardiomyopathy and Exercise

marybeth: What restrictions are needed for someone with hypertrophic cardiomyopathy? I have heard that weigh lifting should be limited.

Speaker_-_Gordon_Blackburn: With aerobic exercise, the average pressure in the arteries changes little. Systolic pressure goes up but diastolic pressure goes down. However with resistance training, both systolic and diastolic pressure rises. And with, relatively higher weights, systolic and diastolic pressure can go up significantly which can cause the pressure in the heart to rise (which is also a muscle). This can cause further hypertrophy, which can worsen the condition in the long run. Immediately the increase in the systolic and diastolic blood pressure can worsen the obstruction and can lead to worsened symptoms and increases risk.

Cardiac Rehabilitation

marybeth: A friend recently started a cardiac rehabilitation program. He said he is walking at a 4.0 met protocol. What does that mean? How is that protocol system used?

Speaker_-_Gordon_Blackburn: A met is the unit that we use to describe the cost of activity or exercise. One met is the energy cost of sitting in a chair. Four mets is four times resting level.

Speaker_-_Gordon_Blackburn: When establishing an exercise prescription for a patient, we typically recommend 50 to 75 percent of their peak met level. That is determined from a graded exercise test.

marybeth: A friend of mine had recent aortic valve surgery, and was considering cardiac rehab afterwards. His insurance company wouldn't pay, because he was told it was an elective surgery. How can valve surgery be elective? Does insurance cover this program?

Speaker_-_Gordon_Blackburn: I am unclear of the situation regarding the valve surgery, however, since one and one-half years ago, Medicare expanded the coverage of cardiac rehabilitation for valve repair and replacement as far as coverage. Coverage for cardiac rehabilitation varies between insurance companies, therefore your friend may need to check with his insurance company to see his coverage for this service.

marybeth: I had bypass surgery. I want to join a cardiac rehab class. What should I look for in a program? I heard I might need a stress test. Why do I have to do that when I just had bypasses done?

Speaker_-_Gordon_Blackburn: Historically the primary reason for doing a graded exercise test in a cardiology setting was to diagnose CAD. In the past decade we have found that the exercise test can provide information about future risk as well as providing information about your present functional capacity.

Speaker_-_Gordon_Blackburn: To achieve the maximum benefit and avoid the risk it is important that the patient exercise at the appropriate intensity. By doing the exercise test we can determine the maximum or peak capacity and based on that, select the appropriate exact exercise intensity.

Speaker_-_Gordon_Blackburn: In selecting a cardiac rehab program, one of the key things to consider is if the program is certified. The American Assoc of Cardiovascular and Pulmonary Rehab accredit cardiac rehab programs nationally. In addition, guidelines for cardiac rehab programs were recently published in November of 2007 in Circulation, which outline the critical components of a cardiac rehab program and will serve as a good reference.

carrie: How soon after traditional, open heart chest heart surgery can I start a cardiac rehabilitation program?

Speaker_-_Gordon_Blackburn: Cardiac rehabilitation is typically separated into several Phases. Phase I cardiac rehabilitation refers to the inpatient portion of the program. This portion starts as soon as the patient is stable after surgery/heart attack or interventional procedure, either in the intensive care unit or as soon as the patient is transferred to the cardiac care nursing floor. This portion of the program includes range of motion activities, self-paced/low level walking and basic activities of daily living (ie. stair climbing). Phase I activities offset the deconditioning and hemodynamic complications associated with bed rest.

Speaker_-_Gordon_Blackburn: Phase II cardiac rehabilitation starts immediately to shortly after discharge from the hospital. This can be either a medically supervised or self-supervised program. The timing is individualized, based on the patient’s status, interest, overall risk level and ability to travel to and from the supervised program. Phase II can start as early as 3 days after discharge but may not commence until 6 to 8 weeks after open heart surgery when the patient is cleared to resume driving or until the patient is seen and cleared post-op by their cardiologist.

Speaker_-_Gordon_Blackburn: Participation in supervised cardiac rehab programs has consistently demonstrated a 25 to 30 percent reduction in cardiovascular, as well as all-cause mortality as compared to patients who do not participate in a cardiac rehabilitation program.