September 2018 Issue

Focus on Fitness: Exercise After a Heart Attack
By Jennifer Van Pelt, MA
Today's Dietitian
Vol. 20, No. 9, P. 52

September is National Cholesterol Education Month, an important time to remember that 1 in 8 Americans has high cholesterol, a primary risk factor for developing CVD and having a heart attack. Exercise for primary disease prevention is widely recommended and publicized. However, exercise for secondary prevention hasn't been emphasized as much, despite strong endorsement in clinical guidelines. Of patients who survive a heart attack, only about 15% meet guideline recommendations for at least 30 minutes of moderate aerobic exercise five days per week within two weeks of discharge from the hospital.1 Participation in cardiac rehabilitation—also recommended by guidelines—is low, due to a combination of inconsistent physician referrals, inaccessibility in many geographic areas, and lack of patient engagement. Only about one-third of patients complete cardiac rehabilitation after a heart attack, despite very strong evidence that it improves clinical outcomes.2,3 Researchers have concluded that increasing regular exercise after a heart attack is an urgent priority, and interventions that increase physician referrals and patient participation in cardiac rehabilitation, as well as motivation and adherence to exercise after rehab ends, are needed.1-3

It wasn't too long ago that patients were prescribed bed rest and inactivity after a heart attack. Now, guideline recommendations and scientific evidence endorse exercising—with physician clearance—as soon as possible after a heart attack. Encouraging clients who are heart attack survivors to participate in cardiac rehab programs can help reinforce exercise's importance in preventing future heart attacks. Before starting rehab, clients can expect to be assessed for previous exercise history and preferences, current fitness level, physical injuries or conditions that may affect ability to exercise, and severity of heart disease. Rehab professionals will prescribe an exercise program that progresses the client from low- to moderate- to vigorous-intensity aerobic exercise and includes resistance training to develop muscular strength. Clients will be monitored thoroughly during exercise and periodically exercise-tested to determine progress. Recently, some guidelines have begun recommending high-intensity interval training (HIIT) for certain patients, as some studies have suggested that HIIT more effectively improves cardiac function, depression, and fatigue compared with moderate-intensity aerobic exercise.4,5 The benefits of HIIT for patients recovering from heart attacks are still under research.

Motivation to continue attending cardiac rehab sessions may be a problem for some clients, especially those with transportation issues. Some facilities are now offering telerehabilitation services, which allow patients to do cardiac rehab exercises at home. Cardiac monitoring is performed remotely in these cases, and patient visits to the facility are minimized. Provided the patient is comfortable using technology, telerehabilitation is a new, more convenient alternative to traveling to several sessions per week for several months.

Another new alternative to conventional cardiac rehabilitation is tai chi. In February, I summarized new research on cardiovascular exercise, including a November 2017 study that was the first to evaluate tai chi for this indication and found that it can be a viable replacement for cardiac rehab due to its safety (even for high-risk patients), adaptability to different fitness levels, ability to be practiced at home, and appeal to patients who are intimidated by traditional rehab exercises.6

Generally, once cardiac rehab is completed, patients will receive guidance on appropriate exercise to maintain on their own. For heart attack survivors, the American Heart Association recommends at least 40 minutes of moderate-intensity exercise (eg, brisk walking, cycling, jogging) at least three to four days per week. Maintaining a regular exercise routine not only helps prevent additional heart attacks but also can help reduce blood pressure and cholesterol such that medications may no longer be required. Weight loss and stress management are additional benefits of regular exercise after a heart attack.

Despite the numerous guidelines on exercise and CVD, strong consensus regarding the best type of exercise for someone who has had a heart attack still doesn't exist. Currently, exercise type and duration typically are individualized for each patient, depending on their condition, comorbid conditions, and exercise experience and preferences. Guidance for clients who have survived a heart attack, have completed cardiac rehab and/or have clearance to exercise from their physicians, and need assistance with establishing an appropriate long-term exercise program can include the following:

• Walking is the best aerobic exercise to start with for anyone at any fitness level. Clients can start by walking around their house and yard, up/down stairs, or on a treadmill. Start gradually and work up to increasing speed to a brisk pace, with arms swinging, until the walking session is 30 to 45 minutes. For clients with movement limitations, advise that they start with chair walking—sitting down while marching their feet and swinging their arms. For those with arthritis or other joint problems, water walking is an excellent alternative to land walking.

• Perform strength-training exercises at least two or three times weekly, even starting without weights if fitness level is low. As with aerobic exercise, increase resistance gradually. Strength training also can be performed in a chair or in water. Clients with high blood pressure should avoid lifting heavy weights and holding their breath while strength training (a common occurrence).

• Stretching is important for flexibility and preventing injuries. Clients with a low fitness level or movement limitations can stretch using a chair or other support, or perform stretching in water. Stretch gently after each aerobic and strength workout, with stretches for all major muscle groups. Stretching often is overlooked and underrated as an exercise for heart attack survivors. One small study found that stretching exercises increase peripheral circulation and vascular functioning in heart attack survivors.7 Starting with stretching exercises also can help clients overcome fear of exercise after a heart attack—starting slow and easy until they gain confidence to do more.

• For clients who were very active before their heart attack, slowing down may be challenging, and they may be at higher risk of injury or heart damage if they exercise too intensely. Advise them to be honest about their exercise routine that existed before the heart attack so medical professionals are aware they were previously very active and will need to make accommodations in post heart attack exercise recommendations. A HIIT workout modified for their heart condition may be appropriate for these clients.

• Encourage clients to try tai chi, qigong, gentle yoga, and meditation for their physical and mental benefits. Hot yoga and any yoga poses that increase blood pressure should be avoided.

• For clients who have had a percutaneous coronary intervention, coronary artery bypass grafting, or other surgical intervention (eg, valve placement), upper body exercise movements will need to be avoided initially or performed while being monitored. Before adding any exercises more vigorous for the upper body than walking or gentle stretching, these clients should consult their physician.

— Jennifer Van Pelt, MA, is a certified group fitness instructor and health care researcher in the Lancaster, Pennsylvania, area.

References
1. Kronish IM, Diaz KM, Goldsmith J, Moise N, Schwartz JE. Objectively measured adherence to physical activity guidelines after acute coronary syndrome. J Am Coll Cardiol. 2017;69(9):1205-1207.

2. Peters AE, Keeley EC. Trends and predictors of participation in cardiac rehabilitation following acute myocardial infarction: data from the behavioral risk factor surveillance system. J Am Heart Assoc. 2017;7(1):e007664.

3. Widmer RJ. Cardiac rehabilitation in 2017: factors that determine its benefit. American College of Cardiology website. http://www.acc.org/latest-in-cardiology/articles/2017/07/14/08/27/cardiac-rehabilitation-in-2017. Published July 17, 2017.

4. Choi HY, Han HJ, Choi JW, Jung HY, Joa KL. Superior effects of high-intensity interval training compared to conventional therapy on cardiovascular and psychological aspects in myocardial infarction. Ann Rehabil Med. 2018;42(1):145-153.

5. Price KJ, Gordon BA, Bird SR, Benson AC. A review of guidelines for cardiac rehabilitation exercise programmes: is there an international consensus? Eur J Prev Cardiol. 2016;23(16):1715-1733.

6. Salmoirago-Blotcher E, Wayne PM, Dunsiger S, et al. Tai chi is a promising exercise option for patients with coronary heart disease declining cardiac rehabilitation. J Am Heart Assoc. 2017;6(10):006603.

7. Hotta K, Kamiya K, Shimizu R, et al. Stretching exercises enhance vascular endothelial function and improve peripheral circulation in patients with acute myocardial infarction. Int Heart J. 2013;54(2):59-63.