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The Cardio Athlete (Drs Blackburn and Mihaljevic 5 2 11)

Monday, May 2, 2011 - Noon

Gordon Blackburn, PhD
Program Director, Cardiac Rehabilitation, Department of Cardiovascular Medicine, Miller Family Heart & Vascular Institute

Tomislav Mihaljevic, MD
Cardiovascular Surgeon,
Department of Thoracic and Cardiovascular Surgery,Miller Family Heart & Vascular Institute


Are you an athlete with a heart condition? Do you need heart surgery and are you wondering how it will affect your ability to run a marathon, climb a mountain, return to skiing, tennis or cycling? Gordon Blackburn, PhD, and Tomislav Mihaljevic, MD, answer your questions about cardiovascular disease and exercise.

More Information

Cleveland_Clinic_Host: Welcome to our "Cardio Athlete" online health chat with Gordon Blackburn, PhD, and Tomislav Mihaljevic, MD. They will be answering a variety of questions on the topic. We are very excited to have them here today! Thank you for joining us, let's begin with the questions.

Heart Rate (Chronotropic) Response

DennisL: Given the different effects that heart related drugs have on heart rates, what data obtained with a heart rate monitor would you advise a cardio-athlete to track for training analysis and personal safety?

Dr_Gordon_Blackburn: Have an exercise stress test on your medications to find out what your chronotropic (heart rate) response is on the meds and have exercise guidelines based on that response.

The heart rate monitor would track the heart rate while exercising - you need to know the correct range to exercise in.

DennisL: In quoting heart rate percentages, do you use a certain formula?

Dr_Gordon_Blackburn: Because of the impact of medications and cardiovascular conditions, peak heart rate cannot be predicted with any sense of reliability or validity and should be assessed directly with an exercise test to provide an accurate heart rate range.

Heart Rate and Beta Blocker

smug: How do you determine your target heart rate if you take beta blockers which lower your rate. I have to work really hard to even get my pulse over a 100?

Dr_Gordon_Blackburn: The exercise test on medications will allow us to identify your specific chronotropic response. from that your individualized heart rate range can be determined.

Peppy: I have a stent in the diagonal and take aspirin and Metropolol Tartrate and statin. Does the beta blocker mask how high my heart rate might be climbing during exercise? How safe is exercise while on beta blockers and as the owner of a DES?

Dr_Gordon_Blackburn: Beta blockers are very common to use after stents with CAD. The beta blocker will alter the heart rate response to activity but does not preclude activity. To find the appropriate heart rate response, we recommend a stress test to find your heart rate response.

Everyone responds differently to a beta blocker so we cannot predict your heart rate response on a beta blocker.  We strongly encourage exercise if you have a stent and on a beta blocker.

MikeN: I have been on a beta blocker for over 10 years and run regularly. I have had probably 8 or 9 echo stress tests since then, always going off the beta blocker before the stress test. Would you recommend stress testing while on the beta blocker to come up with a more realistic or accurate target heart rate

Dr_Gordon_Blackburn: Great question. Exercise tests can be conducted for several reasons. If the test is being performed for diagnostic purposes, we would prefer the beta blocker be discontinued  If the exercise test is being performed for exercise prescription purposes or assess for response while on meds, it is best to stay on all medications as prescribed.

Heart Rate and Pulse monitors

Marlene: Hi - I had stents and angioplasty 4 months ago. I went through a walking program after hospital but I want to get back to running. Can you tell me how to use the target heart rate - I used to just run without thinking about this. Also - what about pulse watches - are those pretty accurate?

Dr_Gordon_Blackburn: We would recommend that you participate in a cardiac rehab program so that the appropriate cardiac exercise intensity can be identified and determine when it is appropriate to return to jogging.

Pulse watches can be accurate and effective to track your heart rate during activity. We would recommend a pulse heart rate monitor that uses a chest strap rather than a wrist to measure heart rate response.

Symptoms with Activity or Exercise

Victoria: I work out at least two days a week, when I do leg exercise, my knee aches a little, and when I wake up in the morning, my left foot seems to fall asleep, or when I first get up, I kinda have to walk on the heel of my feet until it feels comfortable to walk on, what is that?

Dr_Gordon_Blackburn: This may be related to more than one issue. If there is any underlying joint instability or arthritis that may account for knee discomfort  If your pain does not increase over time, there may be benefits to continuing the activity. But if the pain increases you should stop the activity and follow up with your physician. The other issues should see your physician to evaluate.

Blood Pressure Response with Exercise

my_joy: What might cause blood pressure to fail to increase during exercise? The heart rate naturally falls after exercising; with a weakened heart in which the HR suddenly drops following exercise, and is relatively stable otherwise, what therapies are used or recommended to treat deal with this phenomenon?

Dr_Gordon_Blackburn: The one concern would be if the left ventricle is not working well, that would be a cause for failure to increase blood pressure - systolic problem or low ejection fraction.  It could also be if there is diastolic dysfunction, the ventricles do not fill well. These would be concerns

Marathons and Cardiovascular Disease

ScottL: Has the Cleveland Clinic reviewed the research by the Minneapolis Heart Institute pertaining to long-term marathon running and cardiovascular problems? Have you ever thought of doing a similar study to duplicate (or refute) said findings?

Dr_Gordon_Blackburn: We have not considered a study - but the message is that activity is a huge spectrum.  Marathons and ultra marathons are putting a huge stress on the system and expose the patient to larger problems - both cardiac and orthopedic.

tprice54: Are there any special considerations regarding nutrition during a marathon for the owner of a bovine pericardial tissue valve?

Dr_Tomislav_Mihaljevic: There are no particular guidelines except general cardiac guidelines for patients who have valve replacement.

runner4: I had bypass surgery a year ago. I have always been a runner, mostly 5K and 10K races. But I really would like to do a marathon as a goal in the next year. Is that a possibility? How do you suggest I train for that as far as heart rates for training? I don't think my doctor knows what to say about this.

Dr_Gordon_Blackburn: The training should a moderate intensity and our recommendation is to focus on the training rather than the competition. Marathons add extra environmental and physiologic stresses that add to the cardiovascular stress. If you focus in on maintaining target heart rate while doing the marathon - you can control these.

Heart Valve Surgery

Dwight: 54 year old male. Had aortic valve replacement in Sept. 2009 from bicuspid valve. Never had any aorta issues before but have been doing a lot of weight lifting since new valve, My last echo shows everything progressing well but my aorta size has increased by 3 mm. Could this be from weight lifting and 35 min. fairly intense cardio workouts about 4 times a week. Should I cut back somewhat on the weights or cardio or both?

Dr_Tomislav_Mihaljevic: It is not to my knowledge that exercise can be related to enlargement of an ascending aortic aneurysm. It is most likely related to your bicuspid valve. decisions related to future surgery would be related to the size of the aneurysm in the future. We do not advise people to weight lift.

Dr_Gordon_Blackburn: Guidelines is under less than 50% of one lift max. To get to that guideline you should be able to do 15 reps of an activity before experiencing fatigue. Key for you - is regular follow up.

lmgaiso: I have mild AV reg and mild MV reg and I do aerobics. Is it ok to periodically train at 85-100% of HR max? Can exercise stall off the need for an operation

Dr_Gordon_Blackburn: I would not recommend 100% but would recommend 85% - at mild valve regurgitation you can do what you want.

Dr_Tomislav_Mihaljevic: The chance of needing surgery with mild regurgitation is very very low.

elysium: I am a 38-year-old, nonsmoking Caucasian male with a bicuspid aortic valve, an ascending aortic aneurysm of 4.5 cm, and a family history of Marfan Syndrome. My cardiovascular surgeon is recommending that I undergo open-heart surgery this summer to replace the aortic root and valve with a graft and artificial valve. I have been reading on the Cleveland Clinic's website about minimally invasive techniques involving a keyhole incision, rather than cutting through the sternum. Would such a procedure be a possibility in a case like mine, where the surgeon would be replacing both the aortic valve and a large part of the ascending aorta? What would such a procedure be called?

Dr_Tomislav_Mihaljevic: We can replace the ascending aorta and the aortic valve through minimally invasive incision dividing the upper part of the breast bone in the majority of patients.

cuddlefur4: I am a 52 yr. old female and have had five cardiovascular surgeries, including mitral valve repair, aortic valve replacement, abdominal aorta and renal arteries replaced, and a thoracic stent graft. The last major surgery was six years ago, and I was not referred to cardiac rehab. My upper body is weak, and I am able to walk one mile in about 40 min., but I believe I could do more. My dr. will not allow me to join Curves--is it too late for me to do the cardiac rehab? If not, do I need a Rx to do so?

Dr_Tomislav_Mihaljevic: It would not be too late. We would highly recommend a structured cardiac rehabilitation program.

mymvp: Hello, I have been diagnosed with MVP, with severe regurgitation, having no symptoms of chest pain, fluid in the lungs, shortness of breath or swollen ankles. I am told I will need valve repair in the future, depending on my “symptoms ". Currently I race mountain bikes, kayaks, and lift weights. My question is, after surgery at what level or percent can I expect to come back to my fitness? I am 53 years old and at proper weight.

Dr_Tomislav_Mihaljevic: For patients with severe asymptomatic mitral regurgitation we would generally recommend mitral valve repair. The natural history of the disease is not favorable and there is always progression over time. In centers like ours, mitral valve can be performed with a very low risk and greater than 99% repair success rate using robotic or minimally invasive approaches.

This is an elective operation, there is not an emergent indication for surgery.

Patients following successful mitral valve repair can resume all their professional and recreational activities without restriction.

Dr_Gordon_Blackburn: We have had at least a dozen competitive runners and triathletes who successfully returned to their unrestricted athletic activities after mitral valve repair.

Tomlinsonsd: Hello, Do you think cardio (up to 30 miles/week jogging/running) could lead to quicker deterioration of an existing leaky mitral valve before and after repair surgery? (42 year old female no other issues)

Dr_Tomislav_Mihaljevic: There is no evidence that cardiovascular activity after valve surgery, leads to quicker deterioration of the valve repair. We usually advise our patients to resume their athletic activities after the surgery without restrictions.

Tomlinsonsd: Are you seeing any higher percentage of athletes that have had repairs coming back for a re-repair or valve replacement compared to nonathletic repair patients?

Dr_Tomislav_Mihaljevic: No. The most common cause for deterioration of mitral valve repair is for less appropriate repair at the time of surgery rather than the activities after surgery.

lmgaiso: When you say "There is no evidence that cardiovascular activity after valve surgery, leads to quicker deterioration of the valve repair. We usually advise our patients to resume their athletic activities after the surgery without restrictions." Does this apply to all valves?

Dr_Tomislav_Mihaljevic: Yes.

MooreJim: I have been a long time exercise person - I participate in running, boot camps, weight lifting with a trainer and unfortunately a mitral valve problem requires surgery. Very bummed. I wonder what types of options I have to get me back to this level of exercise again. I am 40 years old and worried this will be a new change in life for me.

Dr_Tomislav_Mihaljevic: It does not have to be a big change in your life. Mitral valve prolapse in your age group is relatively common disease.

It can be treated with a very low risk and a high success rate using a robotic or minimally invasive approach. This allows patients to return to essentially unrestricted physical activity within several weeks after surgery.

Long term prognosis is excellent in the vast majority of cases.

Dr_Gordon_Blackburn: I do not recommend boot camps for anyone. There is no cardiovascular benefit to pushing to the extreme - a moderate cardiovascular activity program is recommended.

Tomlinsonsd: Do you see recovery differences based on time on the heart and lung machine? I've heard that minimally invasive robotic surgery for MV repair takes approx. 30 minutes longer than min. invasive repair without robotics.

Dr_Tomislav_Mihaljevic: There are no differences in outcomes in our published experience. Robotic surgery is the least invasive form of mitral valve repair with a repair quality that is equal to alternative surgical approaches - but with less degree of trauma, which translates into faster recovery.

Peter70: I had aortic valve surgery 8 weeks ago and once all the bad weather breaks, I would like to get back to golf. When do you suggest people go back to golf as far as swing after heart surgery.

Dr_Tomislav_Mihaljevic: Typically we advise patients to begin putting 5 - 6 weeks after surgery. Unrestricted golf after 2 months after the operation.

forescore: I am a 50 year old female who had valve surgery 4 years ago. Back to all my normal routines. I do a lot of hiking, walking, yoga. My friends want to do a hike in Colorado this summer and my husband is concerned the altitude may not be good for me with my heart condition. How does altitude affect the heart and exercise?

Dr_Gordon_Blackburn: Congratulations on returning to an active lifestyle. Altitude is a physiologic stressor based on the altitude you climb at but should not preclude you from doing the hiking.

However, you may need to decrease your pace secondary to the decrease partial pressure of oxygen at altitude.

Exercise and Coronary Artery Disease After Stents

Peppy: I have heard different information about the level and intensity of exercise for heart/stent patients - especially in women. I love aquatic Zumba and water jogging for an hour at least. I've read that too intense exercise can cause inflammation in the arteries. Your thoughts please?

Dr_Gordon_Blackburn: There is very good recent studies that have shown that intervals of high intensity exercise at 80 - 85% of capacity with a baseline of 65% capacity to exercise offer greater cardiovascular benefit than sustained moderate exercise.


Dr_Gordon_Blackburn: The fact that you have documented coronary disease does put you at an added risk for future events but does not preclude you for returning to an active lifestyle. Focus should be on optimally managing your cardiovascular risk factors which includes regular activity and diet.

Peppy: Is there evidence that a certain amount of daily exercise lowers the atherosclerosis burden in the arteries? Can exercise help reverse the plaque burden?

Dr_Gordon_Blackburn: Exercise is a component of risk reduction strategies for cardiovascular disease. Aggressive risk reduction programs have demonstrated mild regression. Primary target should be to prevent progression.

Weight Lifting

lmgaiso: I have mild AV reg and mild MV reg and I lift weights. On the one hand, I have been told that I can lift weights all I want as long as I use strict form and stop at least one rep before complete muscular failure (CMF) if I can only perform less than 20 repetitions and if I am performing more than 20 reps, I can go to CMF. Is this good advice? On the other hand, I have been told to avoid valsalva at all costs and that valsalva cannot be avoided if the weight lifted is 85% or > of your 1 rep max, which would imply stopping before 85% of CMF (for example, stopping after rep #6 when using a weight were can perform 10 reps). I am confused. What guideline should I follow?

Dr_Gordon_Blackburn: Definitions of exhaustion would include the inability to lift the weight or the performance of the valsalva maneuver - or 3 - an alteration in form. If anyone of the three is met, that should be the termination for the set. Significant muscle strength and tone can be achieved with weights that can be lifted 12 - 15 reps per set to the point of local fatigue.  Two to three sets to each muscle group is recommended two to three times per week on non consecutive days..

Types of Training

KurtH76: I had 3 stents put in last year. I joined a health club and have been working on the treadmill and some light weights but interested in changing it up a bit. I would like to maybe try some other types of equipment. Are there differences in what treadmill vs. stepper vs. elliptical can offer? Can I start a weight lifting routine? I am a 64 year old male, about 5 pounds over weight, was pretty fit before all this started.

Dr_Gordon_Blackburn: The benefits from stepper, treadmill and elliptical are all comparable. Changing the motor pattern with the different devices can reduce orthopedic stress and the variety may be motivational to stay with the activity program. At 64, strength has declined from your peak in the 20s so we would recommend a moderate resistance training program.

DennisL: You talked about the recent studies on interval training being better for cardio athletes Are there any heart rate targets and times suggested?

Dr_Gordon_Blackburn: Typical ranges for aerobic exercise have been between 50 - 70% of peak capacity. At higher intensities heart rates can reach 80 - 90% of peak heart rate. However the ratio should be approx. 4 - 10 minutes at the lower intensity with periods of 30 seconds - 1 minute at the higher intensities. This should be approved by your cardiologist or cardiac rehab staff to ensure it is safe for you.

dbec: Bootcamps are a fabulous workout - your earlier comment said that you would not ever recommend them. Is this your recommendation for every patient who has a heart condition ? if so why?

Dr_Gordon_Blackburn: From a physiologic benefit standpoint, cardiovascular benefit standpoint - there is no significant added benefit to pushing at a continuous high intensity level. Other than personal satisfaction.

Matt: 40 yo male, had bypass surgery 12 weeks ago. Want to go back to riding bike. Was cycling about 40 miles at a time. Is that pressure on the arms ok for my sternum?

Dr_Tomislav_Mihaljevic: Yes - 12 weeks time - sternum should be healed. The concern is more your cardiovascular status rather than the sternum. We would recommend a follow up appointment with your cardiologist before you begin cycling.

Dr_Gordon_Blackburn: There is more significant arm and chest torque associated with mountain cycling on a cross country terrain vs. road cycling.

K_W: have rheumatoid arthritis and for years have been a swimmer to take pressure off my joints. I had a stent 6 months ago and did cardiac rehab. There, they talked about getting the best benefit from exercising in my THR. Unfortunately when I swim, I don't think I am getting or staying in that range. Are there any tips regarding water exercises I could do that would exercise my heart but be good to my joints?

Dr_Gordon_Blackburn: Water aerobics or water exercise is an excellent modality for patients with orthopedic limitations. Target heart rates are usually significantly lower for swimming than treadmill walking.  To use a target heart rate range for treadmill activity will be too high for a swimming program.


ncmom88: Six months ago I had a dual chamber pacemaker put in for bradycardia. I want to start playing softball again this Spring. What precautions, if any, do I need to take.

Dr_Gordon_Blackburn: The guidelines for baseball and softball are it is ok to go out and play with a pacemaker but there are extra precautions to take. Collisions can occur which can damage the pacemaker or leads. One suggestion is to put padding over the pacemaker itself for extra protection

petra: My husband had a pacemaker last month. Are there any restrictions as far as getting back to activities - such as golf, skiing, lifting above the head - as far as how the pacemaker would work or dislodging anything?

Dr_Gordon_Blackburn: Recommend waiting at least 6 weeks to full golf activity due to swing to insure that all the leads are well fixed. During this time, we recommend that we focus on perfecting his putting game.

Ebsteins Anomaly

alycemccall: Hi. My son has Ebsteins Anomaly. We found out recently that his heart has started to enlarge. Before this he was playing football, since finding out we have removed him from the JV Team at school. With the heart being enlarged, is there a higher chance of something happening on the field? His Dr any contact sport is still ok so I was just wondering your opinion on the topic.

Dr_Gordon_Blackburn: The Bethesda guidelines say that he should be removed from competitive sports and contact sports.

Dr_Tomislav_Mihaljevic: He should be followed closely and if enlargement continues, additional therapy may be required.

Dr_Gordon_Blackburn: It is not that we are recommending that we no activity - just removed from contact and competitive sports. Appropriate activities would be cycling or walking programs.

Atrial Septal Defect (ASD)

dbec: My right ventricle is still enlarged following surgery to repair ASDs, will the size ever reduce to 'normal' levels given that I am still exercising?

Dr_Tomislav_Mihaljevic: This may or may not happen. Most patients experience a decrease in the right ventricular size, but the measurable decrease is seen at the earliest 6 months after the operation. The exercise is not aggravating the situation.

Arrhythmias (Abnormal Heart Rhythms)

rlwhyle1: I have had A-FIB, I underwent Cardioversion to correct it, But, my concern is that at times my heartbeat is very irregular, Example: beat 3, skip, beat 13, skip, beat 7, skip a beat etc. Any ideas?

Dr_Gordon_Blackburn: If you are having symptoms, you should see your doctor for further follow up.

Dr_Tomislav_Mihaljevic: A comprehensive work up would be recommended including a 24 hour ekg monitor.

DRJ110145: Am 65 yr old male. Has 4 vein pulmonary ablation 18 months ago for atrial tach. about 18 months ago. Prior to about 3-4 years ago had nee swimming 1 mile 4-5 days a week. Began using a treadmill for 1 hr 4-5 days a week on a hill program getting elevation to 7 degrees. No apparent stress; however, I tend to get "sensations" in the anterior part of my chest (above nipples and towards the shoulder joint. I also have mild pectus excavatum. These episodes coma and go, but cause anxiety and am on 10mg of paxil daily. Could these sensations be a result of the pectus and lack of upper body training since I have stopped swimming? I discontinued swimming because of cramping in the arch of my feet. Thanks you

Dr_Gordon_Blackburn: We don't know what the symptoms are - but it may require a holter or stress test to evaluate this more. Follow up with your cardiologist

Dr_Tomislav_Mihaljevic: Pectus is a common chest wall abnormality which does not cause chest pain.

cotomand: Dr. Blackburn, I am 41 yrs old and I was diagnosed with arhythmogenic right ventricular cardiomyopathy...I had a VF in 01/2011..I received a defibrillator and in 03/2011 I have had other two VF events 9the defibrillator shaked me twice). I am an athletic guy. semipro basketball player..9 I am from Easter Europe)...How much exercises I can do and when I can start driving again (ALSO I am on satolol BID)

Dr_Gordon_Blackburn: You have a very complicated situation. Return to any form of competitive activity is not recommended for patients with your condition. However, a moderate intensity program may be appropriate - please check with your physician.

Dr_Tomislav_Mihaljevic: You may also want to consider catheter based ablation to treat your arrhythmia.

Groin Pain After Heart Surgery

leon: I had an aortic aneurysm repair and aortic valve replacement (due to stretching out) 14 years ago(was 39). Got back into full sports 6 months later. Had reop 5 years ago. Feel great but very annoying pains in groin where standby bypass was done during reop. This restricts sports due to pain. Local Doctors not sure if anything can be done. Seems to be nerve problems. Can CCF do anything for this?

Dr_Tomislav_Mihaljevic: It is most likely damage to the nerve that supplies the skin in the upper thigh. We typically would not recommend reoperations to address this problem - we would recommend a pain specialist to help you with this pain.

Diagnostic Testing

lmgaiso: In what case for an athlete would 3-D echo be beneficial over 2-D echo? When would a transesophageal echo provide benefit over a regular 2-D echo

Dr_Tomislav_Mihaljevic: This depends upon the reason for the echo - the underlying diagnosis and the anatomic location of the heart disease. Generally speaking TEE is typically recommended for patients with mitral valve regurg although standard 2D transthoracic echo is sufficient for diagnosis of the vast majority of common cardiac conditions.

Tomlinsonsd: Thank you very much for your chat session, it has been very informative.

Dr_Gordon_Blackburn: Thank you for having me.

Dr_Tomislav_Mihaljevic: Thanks for the chat today.

Reviewed: 05/11

This information is provided by Cleveland Clinic as a convenience service only and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. Please remember that this information, in the absence of a visit with a health care professional, must be considered as an educational service only and is not designed to replace a physician's independent judgment about the appropriateness or risks of a procedure for a given patient. The views and opinions expressed by an individual in this forum are not necessarily the views of the Cleveland Clinic institution or other Cleveland Clinic physicians.

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