Is It Safe to Exercise After a Heart Attack? with Tamanna Singh, MD

Podcast Transcript

John Horton:

Hello, and welcome to another Health Essentials Podcast. I'm John Horton, your host.

A blood-pumping workout puts extra demands on your heart. You can feel it, too, with every thumping beat of that life-sustaining muscle in your chest. But if you've ever had a heart attack and experienced the crushing pain that comes with it, the thought of your ticker straining during exercise can be terrifying. So what should you do when it comes to movement and activity after a heart attack? That's what we're going to talk about today with sports cardiologist Tamanna Singh. Dr. Singh is one of the many experts at Cleveland Clinic who visit our weekly podcast to help us better understand our bodies and what they can do. Now, let's see what she has to say about breaking a sweat after you recover from a heart attack. Welcome to the podcast, Dr. Singh. Thanks for giving us a few minutes of your time.

Dr. Tamanna Singh:

Thanks so much for having me.

John Horton:

So as a cardiologist, your work obviously focuses on the heart, but it sounds like you spend a lot of time with patients talking about how they feel and emotionally react to a cardiovascular illness and go over what it means to truly live with the condition that they have.

Dr. Tamanna Singh:

Yeah. I think a lot of times, we underestimate the trauma that can occur when someone has a heart attack or suffers from cardiac arrest or when their heart stops, or stops beating, I should say. And by underestimating that experience that your patient or, perhaps, a colleague or a friend, is going through, you're really not providing the space for them to really comprehend what happened and then develop a plan that can help them move through the emotions and get to a place of comfort and reassurance.

The biggest thing with cardiovascular illness is people always ask themselves, "I had a heart attack already, it's going to happen to me again?" Or "I have heart failure, does that mean I'm going to die before I see my grandkids?" So there's a lot of implications that cardiovascular disease can have on just general quality of life in the now and moving forward.

John Horton:

Well, and we're going to tackle one of those realities of what it means to live today. We're talking about exercise and how it fits in. But before we get specifically to that, can you walk us through what a heart attack actually does to your heart, and what it means for your heart moving forward?

Dr. Tamanna Singh:

So when someone has a heart attack, what basically happens, or really, the most common type of heart attack is the heart vessels or coronary arteries, which lie on top of the heart muscle, can have a cholesterol plaque that accumulates within those vessels. And as plaque continues to build, it basically makes the orifice of that vessel smaller and smaller. And what can happen is that limits the ability for oxygen and blood and nutrients to flow to the parts of the heart muscle that vessel supplies. With a heart attack, what can happen is a piece of that little cholesterol plaque can actually break off, attract a lot of molecules that form a blood clot or what we call a “thrombus,” which abruptly stops the blood from flowing to that specific part of the heart muscle. If you don't get blood and oxygen to a muscle — similar to the biceps in your arms or your cast or your core — basically, what happens is people feel pain and tissue starts to slowly get sick and die.

And so we oftentimes say time is heart muscle, or time is muscle, in the cardiovascular world, because the greater amount of time that heart muscle does not get oxygen and blood flow the more likely it is to die. And so at this point, with the advancements we have and the technological amazement of the cardiovascular field, we're really able to get people who have heart attacks straight to the hospital where they can undergo a procedure to very rapidly get rid of some of that plaque or push that plaque to the walls of a vessel with something called the stent, and thereby improving nearly instantaneously the blood flow and oxygen delivery to that specific part of the heart muscle. And if we can recover blood flow, we can revive that tissue. And if we revive that tissue, that means that part of the heart muscle won't die, it will recover.

John Horton:

Wow. So it can come all the way back because that's, I think, your big worry — you feel like you're going to be compromised forever with this, but it sounds like if you respond fast enough, you can get that blood flowing again, and that heart muscle can recover fully.

Dr. Tamanna Singh:

Yeah, no, exactly. If you don't respond, or if someone has the sensation of, perhaps, having a heart attack or maybe has some lingering chest pain or exercise intolerance, something is just not right that they aren't aware enough or just don't know how to comprehend their sensation, people can have heart attacks at home, not go to the hospital, not have anything done, and in those situations, their heart muscle may get stunned, may die and may not recover. So this is where education is incredibly important. We really try to advocate for education for our patients, for our communities so people can learn how to recognize when someone or when you yourself are having a heart attack. Get 911, get your emergency medical services on board, be directly taken to a hospital with the capacity and the capabilities to tackle your heart disease right away so that we can minimize any lasting effects of the heart attack on your heart muscle.

John Horton:

Well, that's great advice, Dr. Singh. And I think it can't be emphasized enough how people need to take that sort of chest pain very seriously and react right away.

And you were talking about the heart recovering, which brings me to this question, if you've had a heart attack, do you have an increased risk to have another one?

Dr. Tamanna Singh:

Yeah. I mean, similar to a lot of diseases out there or even injuries, oftentimes, we say if you get Achilles tendonitis once, it's going to probably happen again, or you're at greater risk of developing that similar injury. It's very similar for heart attacks and for the heart muscle. In fact, 1 in 5 people will likely be readmitted to the hospital for a second heart attack within five years. And I really want to preface that by saying just because you've had a heart attack does not mean that there's a 100% certainty that you are going to have another. I'll use a personal anecdote as an example. My father had a heart attack, oh, gosh, maybe 17 or 18 years ago now, and knock on wood, he's been doing very well without recurrence. So the biggest takeaway after your first event is what can you do and take control of to prevent you from becoming that statistic.

John Horton:

Well, first of all, that's great news with your father. I'm guessing that he has had the benefit of some very good care from family members, too, over the time. So if you're going to have a heart attack, having a daughter who's a cardiologist is definitely a perk.

Dr. Tamanna Singh:

Well, I wasn't a cardiologist at the time, I was still in college, but it's very interesting to be a cardiologist now and talk about cardiac disease with my dad, who was also a physician. But I do remember being stunned when that happened, but really being grateful, and him also developing a semblance of reassurance and confidence after his first heart attack, really committing to staying active and staying healthy, and staying in charge of his well-being. And I think those types of things that he's done have really empowered him to continue to stay healthy and to prevent that recurrence.

John Horton:

Well, your story has taken us right into our main focus here today, and that's on exercising after a heart attack. And obviously, that's something that gets people … you're a little worried about trying it because you are worried about putting too much stress on your heart and maybe having another episode. So yes or no, should you exercise after a heart attack?

Dr. Tamanna Singh:

Yes.

John Horton:

All right.

Dr. Tamanna Singh:

Yes, yes, yes. I love to yell that from the top of a mountain.

John Horton:

I like it, nice and simple.

Dr. Tamanna Singh:

Yeah. I mean, exercise is going to look very different for everybody, right? Having a heart attack is a very isolated, solo, oftentimes, a lonely experience, right? Something has just happened to you, has just happened to a pivotal life-providing organ within your body. There is going to be stress and trauma, and concern, and fear that revolves around having that event. But the one thing that I always tell my patients, whether they've been sedentary to start with or they're a competitive athlete looking to get back out onto the field or in the pool or out on the road, is exercise is a huge and very important part of the recovery process and also the preventive process. We want to prevent further attacks, we want to prevent further damage to the heart and we also want to make the heart strong, and exercise can do that.

John Horton:

Now, how quickly after you have a heart attack, and you go in, you get worked on, how soon do people start activity right after that?

Dr. Tamanna Singh:

It really depends upon the individual, but from a standard perspective, we typically advise patients who have just had a heart attack, who perhaps, I think, the most common scenario is they've had a stent placed in that vessel again to open the vessel to allow for blood flow and oxygen delivery to the part of the heart muscle that was compromised at the time of the heart attack. We typically advise those individuals to get enrolled into a cardiac rehabilitation program, which is basically a supervised exercise program with nursing, with medical staff where patients are hooked up to an EKG. So basically the heart rhythm and the rate are monitored, their blood pressures are checked, and they're taken through a graded protocol over about a three-month period of time or 36 sessions, which is the standard. They're taken through this graded protocol that helps to improve their aerobic capacity, as well as their strength.

So it can be as early as two weeks for the most typical patient, which is probably someone who's not particularly physically active. For my individuals who are very active, oftentimes, I do have to remind them that, "Just because you've had a heart attack right now and you're a competitive athlete, it doesn't mean that you can go out and run a marathon tomorrow or within two weeks." We still want to take a nice gradual approach to return to sport or return to that particular intensity of activity, being mindful of the fact that the heart did just go through an event itself as well, and we want to stimulate recovery in a nice, graceful, smooth, uneventful manner.

So typically for competitive athletes, they will want to move, I encourage them to move. Their protocol will look a little different, perhaps, be of a greater intensity than the standard cardiac rehab would provide. And then, when it comes to returning to competition, I typically advise to — and this is a bit variable, there's no clear guideline for this — but depending upon how an individual is doing, what the damage looked like, return to competitive sport may be as little as six months or in as long as about a year.

John Horton:

So if I heard right, it sounds like the idea is you should start moving right away and just to start getting things going again and all that, and then gradually build up.

You had mentioned working with athletes and people who exercise a lot, whether it's going out and running or lifting weights, cycling, swimming … if you're in that camp, odds are you're somebody who likes to push things a little bit. After a heart attack, what are the warning signs that you should listen to a little closer so that you don't cause bigger issues?

Dr. Tamanna Singh:

So the biggest warning sign is really developing symptoms that were very similar to when you had your cardiac event in the first place. So oftentimes, I'll talk to patients and I say, "Do you remember what your chest discomfort or your symptoms were at the time of the heart attack?" And most people do remember that. And usually, angina or chest discomfort or the symptoms of a heart attack tend to stay consistent if you're to have a recurrent event. So the first thing I say is just be able to recognize those symptoms and if they recur, call your provider, go to the emergency department, really seek out additional care. Other symptoms and signs can include feeling a little more tired, more winded, more short of breath at lower intensities, perhaps, than you would have suspected.

So let's say you're getting back to running, you're doing a jog, and outside of just maybe some deconditioning that, perhaps, you accrue just between the time of the event and returning to your run, ask yourself, "Am I feeling a little more winded than I used to feel? Are my paces a little slower, and is that in isolation when I compare other variables that could impact my performance like sleep, nutrition, hydration?" So what do I mean by that? Someone who maybe runs a seven-minute mile may say, "You know what, I'm starting to notice that my pace is 705, 710 minutes per mile, but nothing else in my life has changed. Everything is constant." That could be a very subtle red flag for me and a reason for me to say, "You know what? We really should investigate if there is any recurrent cardiovascular episode or event, or something going on here that needs to be managed."

Sometimes, some people can feel like they're getting lightheaded or dizzy, they may pass out with exercise. That would be a big red flag. So I think the big takeaway here is really become accustomed to communicating with yourself, with your body, connecting what's going on physically with what's going on in your mind. A lot of my athlete patients are really attuned to every little thing that's happening in their body from one specific feeling in a joint to another feeling, perhaps, in a muscle. So use that to your advantage. And it's something that I would even guide my patients who aren't competitive athletes, who aren't familiar with consistent exercise programs to start doing, really listen to your body, become attuned to what's going on, because the more you can reflect on those sensations, the more feedback you can give to providers like me.

And oftentimes, I have people come to my office saying, "You know what? I wasn't sure if I should come today. I feel silly talking to you about this. I don't think this is really important," but everything is important for us. The more information you can provide as a patient to people like me, the more we can either provide reassurance if that's to you, or we can develop a plan of action if something is actually going on. So really try not to minimize what you're feeling, and it's your privilege and it's your right, and you should feel empowered to share everything that's going on, even if you're unsure whether it's relevant or not. Again, the more information we can get together, the more clinical context we can create in your healthcare, the more we can be more precise, what we need to be actionable versus when we can provide reassurance.

John Horton:

So listen to your body and make sure to pass that message on to your healthcare provider. That's great advice.

So the way that you've laid this out, it sounds like you start pretty slowly in coming back. So you're literally going to be walking a little bit at first, and really slowing things up and then building. I think the thing that everybody worries about, particularly if you are somebody who exercises a lot or competes, is whether you can get fully back into high-intensity activities, whether it's, like I said, running or lifting heavier weights or just really competing. I mean, is that a door that's going to reopen for you?

Dr. Tamanna Singh:

Yeah. It definitely can be reopened. I have many patients who are competitive athletes who have successfully returned to competition. I think one patient who comes to mind is a triathlete. She does many Ironman competitions, and within about six to 12 months, she was back at her next Ironman after her heart attack.

John Horton:

Wow. Six to 12 months after a heart attack and she's back?

Dr. Tamanna Singh:

Yeah. But you know what I will say to that is it really, again, depends upon the nature of the heart attack, how complex the heart attack was, how much heart muscle was damaged or was stunned, what the contractile function of the heart looks like, and what was the complexity of the procedure. So there are so many different factors that go into the timing of returning to competition, whether or not you would be able to return to competition at that same intensity. But we, within the athlete world, are surprised many times, and I think it just takes a good relationship between the athlete patient and a provider to determine when it is appropriate or when we feel like it's a safe time to get back to a high-intensity level of sport and what we can do to minimize any cardiovascular complications that could potentially manifest from that.

So the more I think you invest, again, on the front end into a nice slow steady recovery, the more you adhere to the medications that you may need to take, whether it be for a lifetime or first period of time, and the more you communicate with your provider, the more successful we are going to be in getting you back to a level of sport that you were accustomed to, or you may even surpass that. You may find that you're able to do more now that whatever was going on in the heart has actually been fixed or has been improved. So never sell yourself short.

But I will also say that there are situations where people may not be able to return to the same intensity, and then, we have to develop new expectations and new goals within that new sphere of what life and activity may look like.

So I'm a perpetual optimist. I am always going to advocate for however much we can do for our patients and for movement, and development of movement practice and activities, but as a little bit of a realist, we also have to sometimes just be cognizant of the fact that it may take a little more time than we anticipated, or we may have to change what our goals are, do a little bit of reflection. And just because things may not be as intense as they were before, it doesn't mean that your quality of life is going to suffer. Oftentimes, people find quality and joy in different types of movement or in different levels of activity in different sports. So it could go either way. But like I said, I'm usually pretty optimistic when it comes to return into competition.

John Horton:

I love the silver lining way of looking at things. So that's always a good way to go through life. I feel like our conversation has come full circle here, which brings me to, I guess, a final question. We talk so much about the physical side of recovery and what you do, but in your experience, how hard is it to get past that mental aspect of exercising again and trusting your heart after a heart attack?

Dr. Tamanna Singh:

It really depends. It depends upon the individual. It depends upon what experiences they've gone through in the past that, perhaps, have been similar or comparable with respect to, perhaps, an event or an episode that did create a bit of an arrest in their activity or their competition. How did they cope? How did they manage through that, and what was their emotional journey through that experience? That's often going to dictate how they respond to the stress and the trauma of having a cardiovascular event. There are some people who are incredible at coping. There's some people who have great support systems. There are others who are not, and there are others who do have significant post-traumatic stress and who require a lot of support, whether that be from me, a psychologist, a therapist, family, or any other individual or group of individuals who can provide what that individual needs, so it really is going to depend upon that person.

But what I will say is, for a lot of our athletes who feel like cardiac rehab may be very easy for them, I still encourage them to go because there's something to be said about a shared experience, meaning that even if you go for several sessions, you will be among other people who have had a cardiovascular event or who have undergone cardiac surgery, maybe similar to yours, maybe a little different, but that shared experience allows for some bonding, for some allowance of being able to share how you're feeling, being able to share, perhaps, emotions that maybe you didn't feel comfortable sharing with your family or your friends or your provider.

So that's one way I think to use something like cardiac rehab, which is yes, a physical structure for social support. I always encourage anyone who's gone through a cardiac event to speak about it with a psychologist or a therapist or a counselor or a psychiatrist, really, because I think you need to find some closure in order to develop the reassurance to move forward, feeling safe and feeling confident.

And the more you do, the more you allow for yourself to get back into movement, whether it be with people at your side, monitoring your heart or monitoring your blood pressure, the more confident you're going to become. So even within that scope of fear, just like any injury or any life experience where sometimes people want to go back into their shell or stay within a bubble, or just not go outside and try to re-approach whatever they were doing before their event, I think giving yourself a little grace and taking that first step forward is going to help you start to build some confidence and reassurance, and we're always here to help. That's part of our job and that's part of our role, I think, as providers and in the healthcare field, but definitely, reach out to people who are experts in helping you come back, whether they be sports psychologists, general psychologists and whatnot. I think they personally really do help a lot in scenarios like these.

John Horton:

Well, that was so wonderfully stated, Dr. Singh. So we've covered so much ground here today, but before we part ways, is there anything else you'd like to add regarding exercising after a heart attack?

Dr. Tamanna Singh:

Please exercise.

John Horton:

Yes. Yes, that was the one big thing. Yes, yes, yes, to exercise after a heart attack.

Dr. Tamanna Singh:

Yes. An exercise does not have to be something where you're at the gym for three hours every day. It can be as simple as walking for 20 or 30 minutes a day at your workplace, getting out of your chair three times a day for 10 minutes, but give yourself fat confidence, support your body, support your mind with movement because I think movement really pays back in dividends with respect to just mental health and mental well-being, but physical health, cardiovascular resilience, like I've said many times before, we can really control a lot of the risk factors that cause heart disease, like blood pressure and cholesterol and sugar management and weight management. If we can control all those things with exercise, we can reduce our risk of developing a cardiovascular event or cardiovascular disease by about 88%. And I challenge anyone to tell me if there's another disease out there that you can't impact that grade with just lifestyle. So tell your friends to move, you move with your friends, but just get active, get out there, get away from your screens, and I promise you, you will never regret any practice of movement or getting out there and being active. You'll always feel good after.

John Horton:

Well, Dr. Singh, I'm ready to go out for a run or walk right now. So-

Dr. Tamanna Singh:

…Great.

John Horton:

...I guess, it's a perfect time to say goodbye.

Dr. Tamanna Singh:

I did my job.

John Horton:

So thank you so much for joining us today, and I look forward to having you back on.

Dr. Tamanna Singh:

Awesome. Thanks for having me.

John Horton:

A heart attack is a serious and scary health event, but having one does not mean the end of exercise for you. In fact, physical activity may be the key to not having another heart attack. So don't be afraid to get sweaty.

If you like what you heard today, please hit the subscribe button and leave a comment to share your thoughts. Until next time, be well.

Speaker 1:

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