The impact of exercise and physical activity on young people living with a heart condition

The impact of exercise and physical activity on young people living with a heart condition is an issue that often comes up at myheart meetings or is discussed amongst our members

As such, CRY has always been committed to supporting a range of research projects, looking at these issues and striving to gain further understanding about the benefits of physical activity for young people with a diagnosed heart condition, as well as ‘safe’ parameters for exercise.

CRY’s Research Fellows have been involved in the publication of a raft of internationally acclaimed research looking into this area and one things remains unanimous across all findings; physical activity is almost always beneficial for overall health and well-being and far outweighs the risks associated with a sedentary lifestyle.

Recently, two important research reviews – spearheaded by doctors who both have an association with CRY’s research programme – have been published in Heart (the journal of the British Cardiac Society) to help ‘unpick’ some of the myths regarding physical activity and inherited heart conditions and to clarify whether exercise really can be the best medicine.

Former CRY Research Fellow, Dr Sabiha Gati, is now Consultant Cardiologist at Royal Brompton and Harefield (RBH) NHS Foundation Trust. Dr Gati has also been a huge supporter of myheart for several years, taking on a supervisory role at many meetings.

Here, we look at a published review carried out by Dr Gati, entitled; ‘Exercise prescription in individuals with hypertrophic cardiomyopathy: what clinicians need to know’.

Dr Gati, can you briefly describe the objectives of this literature review and why you felt it was so important to evaluate existing, published research?

In the last few years, we are seeing a favourable outcome in our patients with hypertrophic cardiomyopathy (HCM). There is emerging evidence that most deaths in HCM are occurring at rest rather than with exercise. Previous exercise guidance for patients with HCM was limited to low intensity physical activity only. However, there is new data emerging that supports the idea of moderate exercise being beneficial for these individuals.

In fact some individuals with the mild form of the disease and with a low risk profile may also take part in vigorous exercise following discussions with their specialists. The current exercise and sports cardiology guidelines from the European Society of Cardiology (ESC), the American Heart Association (AHA) and the American College of Cardiology (ACC)on the management and treatment of HCM have been updated and support a more liberal approach to exercise and sports participation in HCM. This review provided the general physicians and patients with the evidence that is available to support the notion of exercise in HCM and how best to prescribe it.

What were the main findings and recommendations of this review?

In summary, the key conclusions drawn from this research review were as follows:

Exercise is beneficial for cardiovascular health and light and moderate exercise should be encouraged in all able individuals with hypertrophic cardiomyopathy (HCM) A detailed comprehensive risk evaluation of all individuals with HCM is recommended to formulate a safe exercise prescription plan.

The current European Society of Cardiology guidelines and the 2020 AHA/ACC guideline for the diagnosis and treatment of patients with HCM recommend a liberal approach to exercise in HCM. Asymptomatic individuals with a mild phenotype and absence of high-risk features for sudden cardiac death (SCD) may engage in all competitive sports

Longer term follow-up studies are required in individuals with HCM who exercise vigorously with important considerations to age, sex, ethnicity and sporting disciplines and ESC-risk score

Can you explain to our myheart community how your findings might impact young people (particularly young people) who are living with a heart condition and who are keen to take part in exercise and sport?

It is well recognised that a sedentary lifestyle may result in a detrimental effect in patients with HCM both physically and emotionally. As clinicians we should be encouraging the current minimum physical activity recommendations and also give guidance to those individuals who are limited by symptoms.

We know, based on the evidence in the literature, that moderate exercise is safe. If you are keen to take up exercise, speak to your specialist, ensure that a detailed risk evaluation has been undertaken and discuss a shared exercise plan with realistic goals.

Generally, how can people living with heart conditions know what a ‘safe’ and recommended level of exercise and physical activity is?

The recently ESC guidelines in sports cardiology and the updated AHA/ACC guidelines in management and treatment of HCM support light to moderate exercise in all individuals with HCM. They also provide guidance of other heart conditions too. Most individuals with HCM may engage in recreational sports of low to moderate intensity and competitive sports of low intensity.

Among patients who want to engage in more intensive exercise, a comprehensive assessment is recommended, which considers symptoms, family history, functional capacity, cardiac function, and risk profile. A full complement of cardiac investigations is recommended including an echocardiogram, exercise stress test, cardiovascular magnetic resonance (CMR) and prolonged ECG monitor.

We recommend that all patients whether with HCM or another heart condition should engage in the minimal physical activity recommendations of 150 minutes of moderate exercise per week divided over 4-5 sessions and preferably 300 minutes per week in able individuals, if symptoms permit, to maximise the benefits of exercise.

They may wish to discuss arranging an exercise stress test with their specialist which can be particularly useful when prescribing exercise because it provides relevant information about functional capacity, exercise induced rhythm abnormalities and your body’s response to exercise.

Apart from walking, patients without symptoms or rhythm abnormalities during moderate levels of exercise may still be able to do gentle cycling, stationary cycling, treadmill, or low intensity weights, at a heart rate below 75% of the maximum predicted for age and to avoid any exercise that induces symptoms.

We would generally advise avoiding sudden explosive exertion such as sprinting. Exercise programmes are also not recommended particularly those that involve systematic training with increasing intensities and workload. We would advise on a gradual warm-up for at least 10 minutes before starting exercise and a cooldown post exercise. We would also advise avoiding exercise during a fever or diarrhoeal symptoms as this may precipitate electrical abnormalities of the heart. Individuals should abstain from exercising in extreme adverse environmental conditions.

If individuals would like to engage in free weights, the general advice is to do six repetitions up to three times followed by 2 minutes of rest to prevent fluctuations in blood pressure. Individuals should not push more than 20% of their body weight with the upper limbs and more than 50% of their body weight with the lower limbs in the initial stages of weight training. This may be increased at a later stage if it does not result in a heart rate exceeding 70% of the maximum predicted for age.

In what cases – if ever – might an individual be advised against exercise?

Individuals considered to be high risk including those who have survived a cardiac arrest, experienced unexplained loss of consciousness, report exercise induced symptoms, or have multiple high-risk features (such as obstruction to the blood flow across the left chamber outflow tract (LVOT); significant left chamber wall thickness; fatal rhythm abnormalities from the bottom chambers – NSVT >120bpm) should confine themselves to low intensity only. This equates to <55% of their maximum heart rate.

Can you tell us about any new research (current or upcoming) which you’re involved with?

There is some limited evidence that reduced size electrical complexes/traces of the heart on the electrocardiogram (ECG) may be associated with scarring in the heart muscle, which may predispose to serious life-threatening electrical abnormalities and sudden cardiac death (SCD).

There is no guidance on reduced ECG traces for young individuals and athletes. Their correct interpretation is crucial for identifying athletes with disease and at risk of SCD. Some athletes experience SCD despite normal standard cardiac tests.

We, therefore, propose to study athletes and young people aged 17-35 years old using cardiovascular MRI and genetic analysis to determine the significance of reduced ECG traces. These results should enable informed clinical decisions (at national and international level) following pre-participation screening evaluation and help ultimately to identify young individuals and athletes who are genuinely deemed to be at risk of sudden cardiac death (SCD) whilst providing appropriate reassurance to those with normal QRS voltages.

And finally Dr Gati, do you have any further insight that you’d like to share with CRY’s ‘community’ about the ongoing positive impact of CRY’s research programme?

I am passionate about research into the athlete’s heart as well as imaging and electrical changes associated with the risk of sudden cardiac death. I have made significant contribution to the CRY screening programme and it’s phenomenal that we have screened almost 300,000 young individuals in the UK.

The CRY screening programme has been pivotal in supporting research in young exercising individuals. The results of some of this data collected via CRY’s screening programme have been published and revealed that one in 300 young individuals in the UK harbours a potentially serious cardiac condition. Early detection of affected individuals results in proactive management strategies.

We have to thank all the supports of CRY who have made this possible and I hope they will continue to generously donate to the charity for this valuable work.

This study is being conducted in collaboration between CRY and Royal Brompton and Harefield hospital charity. Dr Nikhil Chatrath is one of CRY’s current Research Fellows, based at St George’s, University of London.

In the same journal, ‘Heart’, Dr Chatrath published a review looking at; “Physical activity and exercise recommendations for patients with valvular heart disease”

Can you briefly describe the objectives of this research, and why you decided to focus on valvular heart disease (VHD)?

This is a condition that can actually affect people of all ages – although there is a subset of young individuals who can have congenital defects associated with the heart valves (either the mitral or aortic valve). So, the purpose of looking specifically at valvular defects was to help us analyse the potential impact of exercise.

We know that when we do physical activity we put additional stress on the heart – which normally is good for us. But strenuous exercise can also cause a widening of the heart muscle or the aorta, and as such, researchers often hypothesise that in some people with an underlying heart condition (such as valvular heart disease) this could be exacerbated by very high levels exercise.

In the first instance, we wanted to review the literature available, looking at various studies amongst both athletes and the general public to assess the effects of both exercise and that of a more sedentary lifestyle. And, it’s important to note that as part of this research review, we looked at European Guidelines (all comprising 3-4 multi centre studies), so it was a thorough and comprehensive project.

Generally, how people who have been diagnosed with Valvular Heart Disease (VHD) living with heart conditions know what a ‘safe’ and recommended level of exercise and physical activity is?

The good news is that, by and large, all individuals with mild to moderate valvular heart disease (whether ‘leaky’ or causing a ‘stiffening’ of the valve’) can still exercise without restrictions. Although, of course there are caveats if any new symptoms appear and we would always suggest seeking the advice of your doctor or cardiologist for further assessment. In cases where VHD has been deemed ‘severe’, then it is more than likely that an athlete (or individuals who regularly train at a high level) would be advised to refrain from professional sport and so-called strenuous activity.

If, however, a patient with severe VHD remains symptomless and has undergone an evaluation from their healthcare professional, with ongoing monitoring (e.g. to determine normal heart rhythms, no increase in blood pressure) then low to moderate physical activity is still encouraged and normally considered safe.

What other conclusions did you draw from this important research review?

Overall, we were reassured by these findings and the fact they aligned with our current understanding and recommendations for ‘safe exercise levels’ in those people living with VHD.

However, what was interesting – and perhaps a cause for some concern – was the fact we also ‘uncovered’ a general lack of data and research looking at VHD in young people and its impact on lifestyle and exercise considerations. So much of the research carried out globally to date (looking at inherited and congenital heart conditions in young people) have focused on arrythmias and cardiomyopathies. VHD affects a small – but significant – amount of younger people and it feels as though the research focus has gone slightly under the radar.

However, thanks to ongoing funding from CRY families, we have recently been working on some important and pioneering new studies looking at heart valve issues, which will further inform our understanding of the impact on risk of sudden cardiac death and how we might improve diagnosis in asymptomatic young people.