Heart Disease (Including High Blood Pressure) and Exercise
development of coronary artery disease is greatly influenced by
lifestyle factors such as diet, physical activity, stress, and smoking.
High blood pressure, high cholesterol, and diabetes also increase the
risk. Heart disease
ranks as the number one cause of death in the US in
general, and it is also the number one cause of death in the elderly. Coronary
artery disease (CAD) is
the primary type of heart disease
experienced in the elderly.
Cardiac rehabilitation is offered after a myocardial infarction, or
heart attack. There are three stages to rehabilitation. In Stage 1, the
patient works with the rehabilitation team while still in the hospital.
Stage 2 is done on an outpatient basis after the patient has gone home
but is still under supervision at the hospital. Stage 3 is an
individual program that the patient follows independently at home. You
will often acquire new clients with heart disease after they have had a
"wake-up call" in the form of a heart attack. Open
communication with the doctor is important to ensure that the client
has been released from the formal rehab program and to learn what
limitations still exist. Fortunately, cardiologists usually give you
specific guidelines for exercise. This is not often true for the
internist or primary care doctor who might not have as much background
or regard for physical activity.
The typical symptoms of CAD include chest pain and difficulty
breathing. Older people sometimes do not experience any chest pain, but
they do experience trouble with breathing. There is also decreased
exercise tolerance and chronic fatigue. If your clients suffer from
chronic fatigue, consistent exercise will actually eventually increase
energy and endurance.
As you continue to read on, you will probably agree that most of the
guidelines or special needs identified for people with heart disease
are good general guidelines to adhere to for training almost all
- Persons with
systolic blood pressure greater than 180 mm Hg or a diastolic pressure
greater than 110 mm Hg should not begin an exercise program until blood
pressure is normalized with medication.
- The signs of an emergency include
chest pain, irregular heartbeat, difficulty breathing, and dizziness.
Watch skin color, respiration rate, heart rate, and blood pressure, and
be vigilant about asking for RPE and general reactions to exercise
(i.e. how are they feeling?).
- You should avoid exposure to
extreme heat or cold as this can put undue stress on an aging body that
is already more sensitive to heat and cold.
- Your client should not eat a large
meal before exercising. There should be at least two hours between a
large intake of food and an exercise routine.
- Ask your clients if they have
taken their medications for that day and check their blood pressure and
heart rate before exercise.
- Do not allow them to exercise if
their blood pressure is 20 mm Hg (systolic) higher than usual.
- Use the Rating of Perceived
Exertion (RPE) scale to measure intensity for clients who are on
medication; medications can change the heart rate response to exercise.
- Individualized exercise programs
are recommended for people with heart disease because it is important
to watch them closely for possible signs of trouble. Save the group
exercise until after these clients have progressed to a certain level
and you are comfortable with their status.
- Avoid isometric exercises for
patients with high blood pressure.
- Do not allow your client to hold
the weight or resistance in one spot; keep it moving because holding it
in place can increase blood pressure to dangerous limits.
- Avoid allowing clients with high
blood pressure to hold a weight above their heads as this can increase
blood pressure beyond safe limits. In fact, avoid "over-the-head"
exercises that use weights with all seniors.
- Make sure your clients breathe
continuously since breath holding while performing resistance exercise
can produce seriously high blood pressures. Have clients count
repetitions out loud with you; this will keep them from holding their
- Use higher repetitions (12 to 15)
and lighter weights for strength training. If the physician has given
you specific HR maximums, follow the "4 beats per repetition at 70%"
rule that you will learn about in the next section of this article.
- Steady state aerobic exercise
should strive for 75% of maximum heart rate unless the doctor says
- High intensity exercise should be
- The client should always warm up
slowly and avoid sudden movements and/or changes in position.
- Offer frequent rest periods; don't
let them overexert themselves.
- Always cool down as long as needed to allow the heart rate to return to normal levels. Don't let clients
rush away before their heart rates have returned to normal.
careful if a client's heart rate remains elevated longer than usual.
This might indicate a necessity to lighten the client's program. If the
client is on the same program that has been established for a while and
you have not made any recent changes, a prolonged elevated heart
rate might indicate that a trip to the doctor is in order.
RESPONSE DURING STRENGTH TRAINING
Whenever a person
performs physical activity, heart rate and blood pressure increase in
proportion to intensity, or how hard work is being performed. Because
of this cardiovascular response to exercise, there is concern when
working with cardiac rehab patients. American College of Sports
Medicine (ACSM) guidelines recommend 60-90% maximum heart rate for
endurance exercises. The most common recommendation is 75%, a safe
level for most post-coronary clients. Steady-state aerobic exercise at
75% of maximum heart rate will most likely elevate systolic pressure to
about 160 mm Hg, or about 35% above normal resting levels. That level
should be maintained for the duration of the steady-state exercise.
It has long
been assumed that strength training causes excessively high blood
pressure responses. According to research done by Dr. Wayne Westcott
and his colleagues, however, this is not true as long as the exercises
are performed properly. In fact, Dr. Westcott found that upper body
strength exercises performed to the point of fatigue produced similar
responses to aerobic activity. A dumbbell curl performed at 75% of 1RM
to fatigue produced blood pressure increases of about 35% at the point
working with larger muscles of the lower body results in higher
systolic blood pressures, Dr. Westcott's research revealed that the
responses were well within safe limits. In a study he conducted where
participants performed 10 repetitions on a leg press to the point of
fatigue, the systolic pressure increased to about 50% above resting
levels at the point of fatigue. The average resting pressure was 127 mm
Hg and the average peak systolic pressure was 190 mm Hg which is far
below the ACSM exercise guideline of 225 mm Hg. Following the final
repetition, blood pressure actually returned to resting levels within
about one minute.
The results of
Dr. Westcott's studies show that properly performed strength training
does not cause excessive or dangerous heart rate response. "Performing
exercises properly" means that we must focus on two major factors: continuous
breathing and continuous movement.
While it is
not practical to monitor a client's blood pressure while
strength-training, it is relatively easy to measure heart rate. Since
heart rate and systolic pressure both increase proportionately, when
you know one, you can estimate the other. In another study conducted by
Dr. Westcott, he researched the heart rate response to strength
training at two levels of resistance. The subjects performed both upper
and lower body strength exercises at 70% and 85% of maximum resistance
to fatigue. On average, they completed about 14 reps at 70% and 7 reps
at 85% of 1RM. In both cases, the participants' heart rates
increased to 123 bpm. This represented about 50 bpm above the resting
rate and just under 70% of their predicted maximum heart rate.
resistance levels produced the same increase in heart rate, the
increase per rep was considerably higher with the heavier weight. At
70% maximum resistance, the heart rate increased about 4 bpm, while at
85% maximum resistance it increased 7 bpm. Because the heart rate
increases more gradually when training with 70% rather than 85%, it
would seem wiser to use the lower weight load for post-coronary
patients. Actually, this might be a wise move for anyone who has risk
factors for heart disease or who is frailer than the average person.
look at a specific example of how you might be able to use this
information. You have a client whose doctor has requested that you not
exceed 50% of his maximum heart rate, which in this case is an increase
of about 40 bpm. If we have this client do 10 repetitions at 70% of his
repetition maximum, his heart rate should rise about 40 bpm. Remember,
each repetition at 70% will increase heart rate by 4 bpm and 10 X 4 =
40. Thus, 40 is our target number. Understanding this process will give
you an easy and reliable way to stick to any guidelines or
restrictions you are given for clients with cardiac conditions.
Fast action is the best weapon against
a heart attack. Why? Because clot-busting
drugs and other artery-opening
treatments can stop
a heart attack. Although they can prevent or limit damage to the heart,
they need to be given immediately after symptoms begin. The sooner they
are administered, the more likely they will succeed and the greater the
chance for survival and full recovery. To be most effective,
medications need to be given within 1 hour of the onset of heart attack
expect a heart attack to happen just as it does in the movies where
someone clutches his chest in pain and falls over. Well, expectations
don't always match reality when it comes to heart attack. As a matter
of fact, many people are totally unaware of the fact that they are
having a heart attack. As a result, they take a wait-and-see approach
instead of seeking immediate care. This even happens to people who have
previously experienced a heart attack because the symptoms of a second
episode might actually differ from those that occurred during the first.
Attack Warning Signs
attacks are preceded by warning signs that begin well before
the actual heart attack occurs. The symptoms include mild pain or
discomfort and might even come and go.
It is vital that everyone learn the warning
of a heart attack:
showing heart attack warning signs needs to receive medical treatment
Don't wait more than 5 minutes at most to
discomfort. Most heart attacks involve discomfort in the
center of the
chest that lasts for more than a few minutes, or the discomfort might
come and go. This discomfort can feel like pressure, squeezing,
fullness, or pain.
- Discomfort in other areas of the upper body. This can include pain or discomfort in one or both arms,
the back, neck, jaw, or stomach.
- Shortness of breath. This often accompanies the chest discomfort, but it also can occur before chest discomfort.
symptoms. These include breaking out in a cold sweat, nausea, or light-headedness.
The first step
to take when a heart attack is suspected is to call 9-1-1. Call even if you are not sure
that someone is having a heart attack.
9-1-1 for an ambulance is
the best way to get to the hospital because:
medical personnel (also called EMS or emergency medical services) can
begin treatment immediately—even before arrival at the
- The heart can stop beating during
a heart attack. Emergency personnel have the equipment needed to
restart the heart.
attack patients who arrive by ambulance tend to receive faster
treatment upon arrival at the hospital.
Can Be Deadly
long to seek medical attention can be a fatal mistake. Patient
delay—rather than a delay in transport to a treatment
facility or delay at the hospital—is the biggest cause of not
getting rapid care for heart attacks. Women, older people, and
minorities are usually more likely to delay seeking help than other
groups of people.
take a wait-and-see approach because they:
- Do not understand
the symptoms of a
heart attack and think that what they are feeling is due to something
- Are afraid
or unwilling to admit
that their symptoms could be serious.
embarrassed about "causing a scene" or going to the hospital for a
not understand the importance of
getting to the hospital right away.
As a result of
this wait-and-see approach, most
heart attack victims wait 2 hours or
more after their symptoms begin before they seek medical help.
can this delay result in death, but it can also lead to permanent heart
damage, an effect that can greatly impair the ability to do everyday
MEDICATIONS FOR HEART DISEASE
medications and high blood pressure pills present the greatest
obstacles and difficulties when it comes to regular exercise. The heart
disease medications that you will most commonly deal with are
beta-blockers and diuretics. Beta-blockers slow down the heart rate and
decrease blood pressure by blocking catecholamine released from the
autonomic nervous system. Common names for beta-blockers are Inderal,
Corgard, and Lopressor. These medications can cause depression,
fatigue, and dizziness, all of which make exercise difficult. Remember,
since beta-blockers decrease heart rate, HR measures are not valid
indicators of exercise intensity for clients taking them. In these
cases, RPE is recommended.
used to treat hypertension and congestive heart failure. They increase
the secretion of sodium and chloride in the urine which leads to fluid
loss. Since water is a major constituent of blood, it contributes
greatly to blood volume. Blood volume, in turn, has a direct impact on
blood pressure. Consequently, any significant changes in the amount of
body fluids will affect blood pressure, so blood pressure is reduced as
a result of water loss. Clients who are taking diuretics usually need
to use the bathroom more frequently. Be aware that this loss of fluid
through diuretic use coupled with the fluid lost from exercise can
easily lead to dehydration. Remember to monitor the client's
fluid intake and allow for adequate water consumption and restroom
breaks. Common brands of diuretics include Lasix, Aldactone, Esidrix,
Hydrodiuril, Oretic, and Thiuretic.
blood pressure is treated by decreasing the amount of fluid in the
body, there is the possibility of postural hypotension. This occurs
when the blood pressure suddenly drops after standing up too quickly
and might lead to dizziness or loss of consciousness. Another problem
that can develop with the use of diuretics is due to a depletion of the
body's potassium stores, a condition called hypokalemia. This
condition causes weakness and fatigue. If you have a client who takes a
diuretic and is complaining of theses symptoms, suggest a consult with
are sometimes needed to help prevent or control coronary heart disease
(CHD) or to
reduce the risk for a first or a repeat heart attack. Even if
medications are needed, however, lifestyle changes still must be
undertaken. As you will see, some of the medications listed for CHD are
also used to lower blood pressure since many people with heart disease
already have high blood pressure. Remember, high blood pressure itself
is a risk factor for heart disease.
Drugs used to
treat CHD include:
Aspirin – helps lower the risk of a heart attack for those who have
already had one. It also helps to keep the arteries open in those who
have had a previous heart bypass or other artery-opening procedure such
as coronary angioplasty. Because of its risks, aspirin is not approved
by the Food and Drug Administration for preventing heart attacks in
healthy individuals. It might actually be harmful for some people,
especially those with no known risk of heart disease. Thus, everyone
must be assessed carefully to make sure the benefits of taking aspirin
outweigh the risks.
Digitalis – makes the heart contract harder and is used when the
heart's pumping function has been weakened; it also slows some fast
(angiotensin converting enzyme) inhibitor –
production of a chemical that makes blood vessels narrow. It is used to
help control high blood pressure and damage to the heart muscle and
might be prescribed after a heart attack to help the heart pump blood
more efficiently. It is also used for people with heart failure, a
condition in which the heart is unable to pump enough blood to supply
the body's needs.
Beta blocker – slows the heart rate and makes it beat with less
contracting force so blood pressure drops and the heart's
work load decreases. It is used for high blood pressure and chest pain
and to prevent a repeat heart attack. This is the main medication that
you will encounter. It makes measuring exertion levels by heart rate
inaccurate because it slows the heart rate.
(including nitroglycerine) – relaxes blood
vessels and stops
channel blocker – relaxes blood vessels and is
used for high
blood pressure and chest pain.
Diuretic – decreases fluid in the body and is used for high blood
pressure. Diuretics are sometimes referred to as "water
cholesterol-lowering agents – decrease LDL
in the blood.
agents – also called "clot busting
drugs." These are given during a heart attack to break up a
blood clot in a coronary artery in order to restore blood flow.
USED TO TREAT HIGH BLOOD PRESSURE
sometimes called "water pills" because they work in
the kidney and flush excess water and sodium from the body.
reduce nerve impulses to the heart and blood vessels. This makes the
heart beat slower and with less force. Blood pressure drops so the
heart doesn't have to work as hard. It makes
exertion levels by heart rate inaccurate because it slows the heart
converting enzyme (ACE) inhibitors prevent the formation of a hormone
called angiotensin II that normally causes blood vessels to narrow. The
ACE inhibitors cause the vessels to relax so blood pressure drops.
antagonists shield blood vessels from angiotensin II. As a result, the
vessels become wider and blood pressure drops.
Calcium channel blockers (CCBs)
calcium from entering the muscle cells of the heart and blood vessels.
This causes the blood vessels to relax so that pressure drops.
reduce nerve impulses to blood vessels that allow blood to pass more
easily so blood pressure drops.
work in the same manner as alpha-blockers, but they also
heartbeat like beta-blockers do. As a result, less blood
through the vessels and the blood pressure drops.
Nervous system inhibitors
inhibitors relax blood vessels by controlling nerve impulses. This
causes the blood vessels to become wider and the blood pressure to go
directly open blood vessels by relaxing the muscle in the vessel walls,
which causes the blood pressure to drop.
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