Everything you Wanted to Know
In this edition of Patient Pulse, we’re pleased to welcome Dr. Hicham Skali for a discussion on returning to exercise after a cardiovascular event. Dr. Skali is a staff cardiologist and member of the Non-invasive Cardiovascular Imaging Program and Preventive Cardiology section at Brigham and Women’s Hospital (BWH). He is also the Director of the BWH Cardiac Rehabilitation program and an Assistant Professor of Medicine at Harvard Medical School.
In this webinar, Dr. Skali addresses:
- The definition of a cardiovascular event
- Factors to consider when beginning or re-starting exercise after a cardiovascular event
- How to incorporate different types of exercise into your life
- The value of cardiac rehab
After a cardiovascular event, remember to…
- Talk to your doctor about your readiness to start exercising
- Consider what happened and where to start
- Start slowly
- Keep it easy
- Stay active
- Consider cardiac rehab
It’s a pleasure to be here and talk with all of you. So, I’m going to talk about exercise after a cardiovascular event. So what is a cardiovascular event? What I’d like to talk about really is patients who have had:
- Either a heart attack or had angina, which is chest pain that happens with exercise and often is a result of poor blood supply to the heart muscle
- A stent in their coronaries or had bypass surgery
- A valvular procedure, either an aortic valve or a mitral valve procedure, be it a repair or replacement
- Acute heart failure or fluid overload as their doctors might have told them; they’re on a diuretic chronically, but are stable
And then the other type of cardiovascular event that patients might have had is either pulmonary embolus or blood clots in the lungs, or blood clots in the legs, as well as patients who have had a stroke.
So when someone has had one of these events, it’s usually a milestone of some sort in their lives. And so, often people will start asking okay, what have I done, what should I do now, and other than medications, diet, cholesterol, blood pressure (which are extremely, extremely important), physical activity is also important and a great tool on the way to recovery and mending. So the first thing that I would recommend for patients is to talk to your doctor, either if the event has happened recently to schedule a follow-up visit soon after the discharge, if the patient has been hospitalized or they had a procedure, or within the following one to four weeks essentially. And it is important for the patient to understand what they had to really try to comprehend what happened, what the underlying mechanism is, what the prognosis is, where they stand now, and what the rest of the treatment plan is.
Remember that when someone has a sore throat or pneumonia and then takes antibiotics, it may be one event and then they move on – but for these conditions, these are usually chronic conditions and we really have to prevent them from happening again and we have to understand the whole spectrum of management and the treatment. So, it’s also very important to discuss the medications you take with your doctor and update the medication list. Often when patients are hospitalized, their medications might have changed. And if they have undergone a procedure or surgery, to discuss physical limitations that may be temporary and discuss what warning signs or symptoms that the patient should be concerned about or stop if they start to exercise.
So I think having a frank and open discussion with your physicians, after an event, is extremely important. Now if the event has happened several months or several years ago, it might be also a good opportunity to discuss with your doctor if you’re planning on doing a new exercise program, enrolling in a gym, working with a trainer, etc. Discuss that ahead of time with your physicians.
The factors that I’d like you to consider is really first of all, thinking about where are you starting from. Is it someone who’s used to exercise regularly at some kind of activity level, be it mild, moderate, or very intense? Or someone who has actually never been much of an exerciser or very little, basically walks from the parking lot to wherever they’re going and back to their car, tries to find the closest parking spot, never takes the stairs, and so on? So where you’re starting off is always an important indicator of how you’re going to start exercising. If it’s someone who’s actually been used to exercise regularly, this cardiovascular event might set them back, and it might be important to reset their expectations, reset their progress, and so on. And not say “well, I ran a marathon, you know, two months ago and I had this event happen to me now, maybe I should start planning for my marathon again next month.” That would not be very advisable.
And the next thing to consider is the type of event that the patient might had. Did the event result in a mild impairment? So, there was no surgery, there was minimal intervention, it was not very invasive, and the patient recuperated their level of physical activity close to where they were before. Or did the event result in a significant limitation, such as surgery or debilitating stroke, and there might be significant adjustment to be made soon after the event before the patient starts exercising? And there it might be important to discuss with physical therapy or occupational therapy to have an initial evaluation if the patient is still hospitalized.
One thing that’s common, though, to all of these settings is to really start slow. The heart is a muscle and needs to recover from an acute event, whatever that may be. It could be a heart attack, it could be volume overload, it could be surgery – but it is important to start slow and really what I would call the colloquial “play it by ear,” is listen to your body and adjust your progress accordingly…but you have to start slow. Sometimes it could be just walking two or three minutes and then progressively increasing that. And aim for maybe 15 to 20 minutes by week four or six. That might be conservative for some people, but it may be a big achievement for others. So, it’d have to be adapted to the person.
Remember, don’t be too harsh on yourself. Expect to have some good days and some other days you might not have slept well; it might be 90 degrees and 90% humidity. Remember that and don’t be too hard on yourself and say “well, maybe I had a bad today, tomorrow will be a better day.” And so, I would stick with walking for a few weeks, feel comfortable with that, make sure you have an appropriate hydration strategy. Make sure you are able to listen to your body. Make sure that you’re able to elicit and consider the symptoms that you might have. And one thing that’s really important in terms of exercise, some people might go with a smart watch and looking at their heart rate and so on, but really I think one basic metric that people can use is what we call the RPE or the perceived effort and how hard are you working out if you’re walking or climbing stairs. Do you feel like you’re breathing hard? That may mean that you are working too hard, or you can actually take it up another notch and walk a little faster, a little more briskly, and so on.
If you have the ability to monitor your blood pressure and heart rate with a smart watch for example, you can see some of these variables change. It’s also important to keep it easy, as I said, for at least the first two to four weeks. Maybe walk for a few weeks before increasing intensity and start jogging and start running. Maybe some people don’t like or are not up for walking and running, so they could swim, they could bike, they can garden. Doing laundry is a great exercise. One of my favorite questions that I ask my patients to gauge how active they are: where is their laundry? Is it in the basement, is it upstairs? How do they carry their load? Do they split their loads in multiple ones? But it’s important, again, to start with a few minutes every day and increase that progressively.
Avoid heavy weights initially, especially if you had surgery and had a sternotomy, meaning an opening in your chest. I think that’s very important. And avoid a really hot day when it’s very hot or very humid. If it’s very cold and you’re going to need to shovel snow, I would advise against that in the beginning after a cardiovascular event until you have actually made sure that your body and you have recovered well enough to be able to go out in the cold.
Once you have started exercising and feel good with it and so on, it’s very important to stay active throughout the day. So, think about it as little snacks through the day where you get short bursts of exercise throughout. So go for a walk, do some chair exercises. If you have a dog, go out walking with it. As I said, doing laundry is not just washing it, but it’s also the folding. Some light yard work as well. If you have grandchildren or children that are young and you go into the park or playing with pets, I think it’s important.
And often I advise my patients that if it’s hot and humid or if it’s very cold, they can go in the mall and walk in the mall. You know, I joke with them that they could leave their wallet in the car so that way they don’t even have to spend the money. Some people feel like if they’re in a mall, they have to buy something. Leave your wallet in the car and just walk. The air is conditioned, and there is no risk of traffic accidents, and so you can walk back and forth from one end to the other and give yourself 10, 20, 30 minutes until you feel comfortable.
Find other activities. You can look at your senior centers for yoga, tai chi, dancing, water aerobics. All of those are activities that will get your muscles moving and will get your blood flowing. It’s important to stay active. It’s important that it do something that you like, it’s something that you want to do that you can continue doing over time, not just for a week or two or six months, but something that you can do for a very long time. So it’s very important that you enjoy, and you look forward to doing it.
And then one last thing that I’d like to mention, for patients who have had a condition or diagnosis that’s eligible for cardiac rehab, I would strongly encourage you to discuss that with your doctor. Say “hey, doctor, I had a stent placed, do you think I could benefit from cardiac rehab?” The doctor usually will prescribe that, but sometimes they don’t, or they don’t feel like you would be interested. So I would strongly encourage you to ask “would I be eligible for cardiac rehab? Do you know of a good cardiac rehab program? Do you think there is one that’s close by that you could refer me to?” And I would advise to start that within the first two to four weeks after your diagnosis and enroll there very quickly.
There are several components to cardiac rehab. It’s not just about exercise, it’s about education, it’s about stress management, it’s about diet advice and assessment, it’s about making sure that you’re tolerating your medications, your blood pressure is measured, and you go to that program for about three months or so. And so it allows you to have this monitoring, build back up that confidence to exercise on a regular basis after that cardiovascular event that you’ve had.
So as we mentioned, discuss with your doctor so you’ll be able to better understand your condition, your treatment plan, and where you stand. Think about it. What it is that happened to you, what were you doing beforehand, and what is the event that you had in terms of limitation? If you were exercising already, I would restart slowly. If you are starting now, I would start slow. Keep it easy initially and then progressively make it harder and longer. And stay active. Think about it, find the activity that you would like that you will enjoy, and you’ll continue doing for a very long time. And if it is applicable, consider cardiac rehab and discuss about that with your physician.