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Cardio-Athlete (Dr. Blackburn 5/16/12)

Wednesday, May 16, 2012 – Noon


Are you an athlete with a heart condition? Do you need to have heart surgery and are wondering how it will affect your ability to run a marathon, climb a mountain, return to skiing, tennis or cycling? Dr. Gordon Blackburn, Program Director of Cardiac Rehabilitation, Section of Preventive Cardiology, answers questions about cardiovascular disease and exercise.

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Exercise and Valve Disease

fit4life: I am a 59 year old male. I have been a distance runner all my adult life until I was diagnosed with a heavily calcified bi-cuspid aortic valve in 2010. I also have persistent AF resulting from the aortic stenosis. I am still able to "jog" through 4 to 5 miles and cycle fairly aggressively. At some point, I will have AVR. I strongly desire to return to running and cycling post AVR. From a purely hemodynamic performance standpoint and to maximize my exercise capability, would I be better served to select a mechanical valve, such as the ON-X valve, or a bovine bioprosthetic valve? Thank you.

Dr__Blackburn: Heart valves function to provide efficient fwd blood flow through the heart/body. Usually an aortic valve 3 cusps but the bicuspid valve has only 2 and this effects its efficiency. Often well compensated and unknown condition in youth but as function deteriorates over time it is identified in adulthood. Many active people note a decline in performance that is attributed to age but often it is d/t valve dysfunction. AFIB or other arrhythmias, enlargement of the ventricular muscle and decrease in ventricular pumping ability are associated with chronic and deteriorating valve function.

You are aware of the valve problem and are displaying some of the complications associated with AS and the option of AVR has been addressed. The key issue is ongoing regular follow up with your cardiologist to decide when the optimal time for surgery is. Depending on the severity of the AS, the impact on LV performed and the rate of progression, aggressive high intensity exercise is not advised. If your cardiologist / surgeon are providing you with the choices of mechanical vs. bioprosthetic valve there are several issues to consider with regard to return to activity. Neither will prevent you from returning to jogging or cycling. The issues are with respect to ongoing care and longevity/replacement. A bioprosthetic valve does not require long term anticoagulation (Coumadin therapy) but structural decline is noted 10-15yr post surgery. At age 59 you may be looking at a second OHS at age 70-75. The advantage of the mechanical valve is longevity but these valves are more traumatic to the blood passing through and you will require life long anticoagulation therapy.

Issues to consider:

  • If Afib persists post AVR, even if opt for bioprosthetic valve, long term Coumadin therapy may be required. 
  • Cycling is not designed to be a contact sport….but if there was no risk of collision, helmets would not be standard cycling equip. With Coumadin therapy there is increased risk of severe bleeding with a collision 
  • The surgery will impact on CV function and although valve is replaced there will be a time of remodeling and reconditioning to optimize performance. A bicuspid AV is a condition that has been present since birth. The valve function has gradually decreased and with the Afib.

WilliamP: I am 76, on my second aortic tissue valve, bicycle regularly and have no idea where to set my Polar HR monitor for an aerobic workout. Age predicted max. HR or averaging submax Walk, Step test and Best-Fit Formula give very different values for min/max HR for a good aerobic workout. Can I ignore the tissue valve & figure my aerobic zone based on my actual submax HR tests? My submax HR average is 176. I use 70-80% for min/max (123 to 141). What would you recommend/

Dr__Blackburn: My first question - is have you ever had a max exercise test with your cardiologist? We would predict at age 76 your max heart rate would be much less than 176 so it would be advantageous to get an accurate account of your max heart rate as well as your functional capacity so a safe and optimal training program could be developed for you.

RichardG: I am a 60 year old triathlete who has participated in triathlons from a sprint distances to Ironman. Two years ago I underwent surgery to replace a leaking bicuspid aortic valve and upper aorta (5.3 centimeters). My cardiologist wants me to exercise at "reasonable" levels and appears concerned I could wear out the valve too quickly otherwise. A second opinion from another cardiologist was less concerned about the valve but worried what's left of my natural aorta could become enlarged. What do you think? What are the chances the aorta could become enlarged again?

Dr__Blackburn: My concern would be if you have some pre-disposed condition that led to the enlargement of the aorta, which the activity at higher intensities or excessive blood pressure response during activity, could lead to future problems with the aorta. We know that tissue valves have a relative life span of 10 - 15 years; we don't have any data that suggests participation in activity will shorten that lifespan.

taylor: what is a safe exercise for a patient with multi-valve disease before heart surgery?

Dr__Blackburn: It is not the type of exercise it is the intensity we are concerned about, and the severity of your valve disease. Mild stenosis or leaky valves may require no modification in an activity program. But, if you have severe stenosis or leaks in the valve, activity should be significantly restricted. This is something that should be discussed with your cardiologist.

TrishS: After valve and CABG surgery, how soon can you start working your upper body and doing ab work (i.e. sit ups)?

Dr__Blackburn: An important issue is the healing of the sternal incision site, which usually takes 6 - 8 weeks. If the sternum is stable and you have been cleared by your physician, it would be appropriate to return to low resistance/high repetition resistance training.

Guidelines for this type of activity are weights or resistances that you can perform 10 - 15 repetitions per set to local fatigue; one to two sets per session; two to three times per week on non-consecutive days. Avoid straining or holding your breath during the activity.

TrishS: After AVR & CABG surgery, how long do sternal precautions apply for a 61 yr old active female in good shape prior to surgery?

Dr__Blackburn: Sternal precautions would be appropriate until the sternum is well healed and stable, typically this is around 6 - 8 weeks post op but you should clear this with your personal physician.

Exercise and Coronary Artery Disease – post Intervention

DavidT: Can you give us some insight into the degree of revascularization of the heart that is generally possible with adequate training for a CAD patient who has been treated with stents or CABG and has been running at least 20 miles a week for several years? How long does this process typically take to reach maximum benefit, and is there a point of diminishing return for training effort? We’ve heard that interval training may be an optimal way to stimulate revascularization, what is your opinion? Thank you very much for providing this opportunity to learn more about a subject that is very difficult for a lay person to get reliable information on.

Dr__Blackburn: The stent and CABG will give the best benefit for revascularization. If an individual is fully revascularized with intervention or bypass surgery, return to an active competitive exercise program should be with minimal risk. However, if there has been sub-optimal revascularization with the surgery or intervention, the additional revascularization benefit through exercise is uncertain. Exercising at higher intensities for short periods with return to moderate intensity for longer periods (interval training) can optimize performance and has been demonstrated to be safe for patients with known coronary artery disease but no underlying ischemia.

Exercise and Atrial Fibrillation

fit4life: I have a follow-on question regarding treatment for my AF if, as I have been cautioned, the AVR does not cure the AF. My persistent AF is presently asymptomatic. If the AF is not cured post AVR and I do intend to resume distance running and cycling, from a cardiac risk standpoint, should I consider some form of ablation to attempt to cure the AF even if it were still asymptomatic? Thank you.

Dr__Blackburn: The majority of the blood pumping ability is contributed by the ventricles (lower chambers). In sinus rhythm there is an efficient link between the timing of the atrial contraction and the ventricular contraction. In SR the atria contribute approx 10% of the blood volume that goes out with each contraction. This is not provided with Afib when atrial rate is irregular, rapid and uncoordinated. Also Afib may effect Ventricular rate and if the ventricular rate is too fast the chambers cannot fill efficiently and stroke volume (the amount of blood pumped out with each beat) will decrease stroke volume further. If the rhythm can be converted back to sinus this would be ideal both from a health and performance standpoint.

As you identify, the AVR is not a cure for the Afib. The arrhythmia is likely d/t the stress placed on the heart by the AS. The longer a person stays in Afib and the more structural changes that contribute to this problem the more difficult to restore sinus rhythm. Discuss surgical options at the time of AVR and/or ablation/DCCV post op with your surgeon to identify what options are available to you.

Exercise and Heart Failure and Cardiomyopathy

morris_K: I have heart failure. I heard cardiac rehab is good for heart failure but I don't think my insurance covers it. What do you suggest for patients with heart failure?

Dr__Blackburn: At this point in time, most insurance carriers do not reimburse for cardiac rehab if the sole diagnosis is heart failure. We offer individual exercise prescriptions based on the results of an exercise test, your medical condition, your interests and goals. That could be done as a one time visit or participation in a phase 3 self-pay rehab program is also an option. The HF Action Trial that looked at the affect of exercise on patients with heart failure showed significant benefits with respect to improving functional capacity, decreasing mortality, and hospitalization.

MikeR: Is there any *Documented* danger with running (8-9 minute miles) half marathon in patients with moderate Dilated Cardiomyopathy (40% EF / 6.9 cm / beta blocker / ace inhibitor)? On the cardio athlete’s forums, there is almost no one with cardiomyopathies who run.

Dr__Blackburn: Pts. with CM are at increased risk of arrhythmias and sudden death. The severity of the CM and h/o arrhythmia/sudden death greatly increases the risk, as does the intensity and severity of the exercise. Competitive vs. recreational, shorter distances vs. longer distances, controlled pace vs. ‘race’ pace. The question of the speed of running is not tied to a specific pace but rather a relative pace based on your individual ability.

Current guidelines for individuals with CM discourage competitive jogging over 70% of their FC and even recreational participation in jogging should be assessed on an individual basis, but this does not mean moderate jogging is not of benefit. Data from the HF-Action trial with 2331 pts and avg LVEF=25% demonstrated that exercise in the 50-70% range was well tolerated without increased death and for those who were regularly active mortality and hospital admission rates decreased.

However, competition can increase risk because participants may fail to pay attention to pace or signs of excessive stress/exercise intolerance. The risk also goes up with racing and longer distances. Rates of sudden death are 3-5 times higher in marathons than ½ marathons. The majority of the deaths in either occur in the last quarter of the race when dehydrated, hyperthermia, pushing the pace, possibly more myocardial damage.

caroline84: Can you talk about weight lifting limitations in patients with hypertrophic cardiomyopathy. Why are they restricted?

Dr__Blackburn: The heart is a muscle. In the hypertrophic cardiomyopathy state, the muscle is enlarged disproportionately which increases the risk for arrhythmias and sudden death. Patients who engage in heavy weight lifting increase mean arterial pressure (average blood pressure) during the lift significantly. This puts added stress on the heart muscle which can lead to further hypertrophic changes to the heart - or trigger arrhythmic events.

Exercise and Arrhythmias and Pacemakers

F94jL63: Are there considerations / contraindications regarding arrhythmia medications and exercise intensity? Should one try to reach target heart rates when taking medications like Tikosyn and Toprol, which are intended to slow and control heart rate?

Dr__Blackburn: Toprol is a class of medications called beta blockers, which are commonly used to treat coronary artery disease, heart failure, arrhythmias, and hypertension. Beta blockers can significantly reduce peak heart rate levels and functional capacity. To determine the appropriate exercise heart rate, a maximal exercise test on your medications is the only way to objectively assess your peak heart rate and training zone. Beta blocker medication is not a contraindication in and of itself but the reasons why you need a beta blocker or anti-arrhythmic medication must be considered in setting up your activity program. You can talk to your cardiologist about setting up an exercise test.

DavidOH: I had a pacemaker put in a month ago. I play on a softball team locally. Can I continue to play softball? Are there restrictions?

Dr__Blackburn: This is a good question to review with your cardiologist. There may be an advantage to waiting a few weeks to insure the pacemaker wires are well seated in the heart tissue and the pacemaker incision site is well healed. In general, you should be able to return to full participation shortly after the pacemaker is implanted.

Exercise and Aneurysm

nahant: I have an ascending aortic aneurysm and am in afib. How does this impact my physical activities? Thank you

Dr__Blackburn: The significance of Ascending aortic aneurysms depends on the size and rate of progression. exercise may not be contraindicated but this requires ongoing follow up with your cardiologist to insure the activity level is appropriate to avoid aggravating the problem.

Typically low level aerobic activity such as walking or cycling may be appropriate but high intensity weight lifting is contraindicated.

Exercise and Pericarditis

fian: I do several triathlons every summer and have had recurrent pericarditis for almost six months. I have been taking it easy and for the last month and a half my cardiologist has directed me to have no activity. He has told me to keep my heart rate below 85 and I have complied. Yesterday I got a second opinion. He recommended that I do a stress echo test and get my heart rate up to max. If my heart is OK he said I can resume training at full speed. I am concerned that the test may trigger another episode of pericarditis as previous episodes followed exercise by about a day. I am also concerned about getting off the couch and going to max right away. Could you share your perspective on my dilemma?

Dr__Blackburn: I don't think doing a maximal exercise test will put you at increased risk but either do I think it will answer the question as to why you have this recurrent pericarditis. It is important to get a better understanding as to why the pericarditis is recurrent. You may want to consider seeing a cardiologist who specializes in pericardial disorders; A Pericardial Center is available at the Cleveland Clinic. Dr. Klein is the director.

Stress Testing

ShannonL: What are the target vital signs when doing a treadmill stress test?

Dr__Blackburn: There are several reasons for doing a treadmill stress test. The most common clinical reason is to expose underlying ischemic issues. But, for athletes a major concern is finding out what their peak functional capacity, anaerobic threshold, and peak heart rate are so that an optimal training program can be developed. Our goal for any exercise test is fatigue, or onset of symptoms, such as chest discomfort or changes on the electrocardiogram indicating that the heart is not tolerating the activity well (ST depression, arrhythmias).

If you are referring to a peak heart rate or target heart rate for termination of the exercise test we do not rely on that as there is significant variation between individual and impact of medications can dramatically affect heart rate response to exercise.

Exercise and Cardiac Rehabilitation for Heart Patients

curtis96: I have been running on the treadmill and want to switch up my exercise regimen - what are the best types of exercises for cardiac patients - can I switch to the elliptical?

Dr__Blackburn: There is no one exercise that is the panacea for everyone. If you are looking for variety in your exercise program, an elliptical can be a good alternative to the treadmill.

jonathan: how do I choose a cardiac rehabilitation program? is there a list by geographic location I can find one in my home town?

Dr__Blackburn: American Association of cardiovascular and pulmonary rehab (AACVPR) is the national professional association and publishes a directory of cardiac rehab programs. You can contact them for a listing of programs. There is also a national accreditation for cardiac rehabilitation programs that is offered through AACVPR. Both certified and non-certified programs are listed in the directory. See How to Choose a Cardiac Rehab Program.

Charlene: my husband had heart surgery this week. when he gets home - how do I get him involved in cardiac rehabilitation? How long does he need to wait?

Dr__Blackburn: Hopefully cardiac rehabilitation was initiated in the hospital (Phase 1). Outpatient cardiac rehabilitation can be initiated immediately after discharge with your cardiologist's approval. For post bypass surgery patients, incision site discomfort and driving restrictions may delay starting cardiac rehab program for a few weeks. But, post MI and post PCI patients can begin immediately.

Walther_K: Can you explain target heart rate for exercise and what we should be working toward. I seem to go higher than my target a lot of the time. OK?

Dr__Blackburn: The benefits of aerobic exercise occur at intensities between 50 - 80% of peak capacity. This can be measured using a target heart rate If peak heart rate has been measured from an exercise test. If you are predicting peak heart rate based on age and gender alone, the target heart rate you calculate may be significantly off.

Gr8fulBeing: I am a 55 year old female tennis player. I play tennis competitively (level 6.0) and train (aerobic and anaerobic) regularly. I've recently been diagnosed with an elevated Lp(a) 197. What risks am I taking playing tennis?

Dr__Blackburn: Lp(a) is an independent risk factor for development of coronary artery disease. Even though you are a very active and skilled tennis player, exercise will not guarantee that coronary artery disease will not develop. It would be appropriate to have all your coronary risk factors (hypertension, lipids, cholesterol, smoking history, diabetes, body mass index, etc) evaluated to determine your overall risk for developing heart disease. Even at a low global risk for heart disease the presence of an elevated Lp (a) increases your overall risk and would lower the threshold for treating the other risk factors.

Symptoms with Exercise

Frank77: When is shortness of breath with exercise a sign of a problem vs. exercise normal response?

Dr__Blackburn: It is normal for our respiratory rate and depth of breathing to increase with activity and at relatively high intensities, breathing may feel like it is the limiting factor to activity. However, as you have noted, difficulty breathing, shortness of breath, may also be caused by blockages in the arteries or inefficiently functioning valves or arrhythmias. If you feel activity is limited by your shortness of breath, you should follow up with your physician.

noank: After completing 35-50 min of cardio exercise, I sometimes get an aura in my right eye. No other migraine indicators. I had migraines as a child, but not in years. I had a bicuspid aortic valve replaced. What could cause this?

Dr__Blackburn: There are exercise induced migraines. If the aura is your sign of a migraine about to come on and it is always associated with activity you should follow up with a neurologist or your physician.

ritchreg: I'm still doctoring for shortness of breath, chest pain and rapid fatigue 14 mos after bypass (which collapsed) and being stented. I am a swimmer and try to train. I swim until I get a chest pain, hang onto the wall until it goes away and continue. My cardiologist thinks I should stop before the pain and get out of the pool. Do you think it's safe for me to continue in that manner?

Dr__Blackburn: I think your cardiologist is giving you some good advice. Pushing activity consistently to the onset of chest discomfort is a sign that the heart is getting inadequate blood supply. This increases your risk for arrhythmias or other heart problems. Angina or chest discomfort is not a reason to avoid exercise but the program should be designed to keep you below this anginal threshold.

Cardiac Rehabilitation and Preventive Cardiology Exercise Prescription – Cleveland Clinic

Cleveland_Clinic_Host: Dr. Blackburn, can you please tell us about your program at the Cleveland Clinic?

Dr__Blackburn: The Cleveland Clinic is a large tertiary care facility known for its cardiac care. We have specialists in multiple areas of cardiac care, i.e. arrhythmias, heart failure, coronary disease, valve disease and others. When an individual comes to us seeking advice about exercise, we target the appropriate experts and develop individualized care plans to optimize the safety and benefit of activity.

Any male over the age of 45 or women over age 55 considering starting up a regular activity program should be screened by their physician. The vast majority of problems that occur during exercise are secondary to underlying and unknown structural cardiac problems such as coronary artery disease or valve disease. Physical exam and an exercise test can reduce the risk of problems when starting up an activity program.

For athletes with underlying cardiac problems it is important to remember that exercise in the extreme can expose you to increased heart risk. But - avoiding exercise can also increase your risk. Our goal is to provide each individual with an optimal activity program and the awareness of the risks and benefits of regular exercise.

Reviewed: 05/12

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