HEART PROBLEMS
Hypertension Coronary Heart Disease Cardiac Rehabilitation Programs
Coronary arteries supply the heart muscle; these vessels become partially occluded by lipids causing disrupted blood supply to the heart (known as angina). Where vessels are totally occluded a heart attack (MI) results. As a result in part of the aging process (vessels losing their elasticity) or as lifestyle (fat-rich diet and little exercise), blood pressure (BP) can rise.
120/80 BP is normal o Over 140/90 is considered mildly hypertensive and the person should consult their GP for a release to exercise.
Hypertension frequently has no symptoms noted by the client and is dubbed ‘the silent killer’. Damage to internal organs, specifically the heart and kidneys, can occur over a period of time without the person being aware of anything being wrong. Medication is frequently given to reduce the effects of heart disease and hypertension. Exercise may help to reduce BP.
Hypertension
BP> 140/90 or on medication The silent killer Contributors include: o Smoking o A diet high in saturated fat o Excess weight o Lack of physical activity
Preventative measures ‘Regular physical activity can reduce your relative risk of hypertension by 19-30%’ ‘A low level of CV fitness in middle age increases your risk of hypertension by 50%’ (American Council of Exercise –ACE) General rehabilitative requirements
Exercise Diet Weight loss (if appropriate) Compliancy with GP’s recommendations
‘Low to moderate intensity CV exercise is equal to high intensity CV exercise in terms of reducing blood pressure’ This is particularly beneficial for obese or older adults. Please note: medication can affect both BP and HR during exercise and therefore HR monitoring should NOT be used to gauge exercise intensity.
Exercise Guidelines CV
Low impact 3-7 days per week 50-85% max HR (be aware of effects of medication) Continuous rather than interval 30-60 mins duration Extended (5-10 mins) warm up and cool down Progress slowly
Resistance
Progress slowly 2-3 days per week 1-3 sets, 10+ reps No overhead exercises No exercises with the head below the heart Focus on breathing Avoid wearing a weight training belt No isometrics Use unilateral exercises if severe hypertension
Coronary Heart Disease
Heart Attack (MI) Angina Coronary Artery Disease (CAD)
Although on the decline since the mid-twentieth century, CHD still accounts for 40% of all deaths in the U.S.
The Health of the Nation Physical inactivity doubles the risk of heart disease, stroke, CV disease, NIDDM and obesity! Consider the graph below. Heart disease is the biggest killer in the western world and has a phenomenal human and financial cost associated with it. Major risk factors for coronary heart disease include age, smoking, high cholesterol, diabetes, high blood pressure and inactivity itself. However what’s even more interesting is the mediating effect how fit we are has in this whole equation.
Adjusted Death Rate per 10000 per year
Physical fitness and all cause mortality in men (Blair et al., JAMA, 1989)
140 120 100
0
80
1
60
3
40
2
20
2 3
1
0 0
Low Medium
High
Fitness Levels In other words being physically fit helps to minimise the effect of these other factors.
Number of CHD Risk Factors
Inactivity also has a direct role to play itself. When we consider the relative risk of inactivity to our health it comes in at number 4. The fourth biggest risk factor. And the top four share very similar scores on the graph below. Physical Inactivity: The 4th Primary Risk Factor
Relative Risk
2.5 2 1.5 1 0.5 0 Smoking High Blood Fats
High Blood Pressure
Inactivity
Not only this when we consider the prevalence of physical inactivity i.e. how many people are inactive versus smoke or have high cholesterol look where it comes in.
% Population
Population prevalence of CHD Risk Factors
60 50 40 30 20 10 0 Hypertension
Smoking Cholesterol Inactivity
Inactivity is considered the 4th primary risk factor for CHD but the number 1 most prevalent! It is the biggest cause of death in the world!
CARDIOVASCULAR DISEASE Cardiovascular disease is an umbrella term for a number of conditions that affect the heart and vital blood supplies. This section introduces you to some of the CV diseases and the risk factors. The American Stroke Association says that the leading cause of death worldwide is heart disease followed by stroke. WHO (the World Health Organisation) released these figures in 2005. Worldwide deaths for all cardiovascular disease – 17.5 million No 1 cause for death in the western world
Key Terms Atherosclerosis – partially occluded artery, hardening of the arteries Plaques – deposits of fats in the arteries which cause occlusion Angina – heart pain as a result of partial occlusion of the coronary arteries MI – heart attack, heart muscle dies a s a result of total occlusion Stroke – vascular occlusion in the brain, a ‘brain attack’
Atherosclerosis
Stiffening of the artery walls o Increasing deposits of collagen fibres o Declining resilience of elastic fibres Maximum function gradually declines o Decreases in peak air flow and gas exchange o Decreases in vital capacity o Weakening of respiratory muscles Reduced ability to perform vigorous exercise
This is a term for a number of conditions that thicken the artery wall and reduce its elasticity. Usually due to disposition of atheromas (collections of cells and lipids) in the large and medium-sized arteries serving the heart and other parts of the body.
Plaques Cells and lipids (fats) that are being carried around the blood are deposited on the inside of the arteries, developing what are called plaques. The effect of this is that lumen (the inside of the artery) is narrowed and the artery wall is less elastic as a result.
Smoking Smoking is known to cause heart disease and stroke and is responsible for 21% of all deaths from heart disease. The chemical make-up of cigarettes elevates the myocardial oxygen demand and at the same time reduces oxygen transport, causing the CV system to work harder to obtain sufficient oxygen supply. Cigarette smoking lowers high density lipoprotein (HDL), which has an impact by accelerating the deposition of fats in the arteries.
Hyperlipidemia (High Cholesterol) Cholesterol is a fat-like substance found naturally in the body. It is essential for many metabolic functions. Cholesterol is manufactured in the liver and eating animal fats increases this production. In the blood, cholesterol binds with the proteins and is called lipoproteins. There are three types of cholesterol; HDL (high density lipoprotein), LDL (low density lipoprotein) and VLDL (very low density lipoprotein). LDL and VLDL cholesterol is released by its protein binders and attaches onto the artery wall contributing to the build-up of plaques and the narrowing of the lumen vessels. We can think of these low density lipoproteins as ‘bad’ cholesterol. HDL cholesterol acts to transport cholesterol to the liver where it is metabolised and therefore is protective. Individuals therefore who have a lower level of HDL cholesterol, or individuals who have overall high levels are considered to be at greater risk of coronary artery disease (CAD). High density lipoproteins can therefore be considered ‘good’ cholesterol. Stress, high saturated fat diet, smoking and drinking all increase the blood levels of LDL cholesterol. Triglycerides are the chemical form in which most fat exists in food as well as in the body. They’re also present in blood plasma and, in association with cholesterol, form the plasma lipids. Triglycerides is plasma are derived from fats eaten in foods or made in the body from other sources like carbohydrates. Calories ingested in a meal and not used immediately by tissues are converted to triglycerides and transported to fat cells to be stored. Hormones regulate the release of triglycerides from fat tissue so they meet the body’s needs for energy between meals. An excess of triglycerides in plasma is called hypertriglyceridemia. Its is linked to the occurrence of coronary artery disease in some people. Elevated triglycerides may also be as a consequence of
other disease, such as untreated diabetes mellitus. Like cholesterol, increases in triglyceride levelscan be detected by plasma measurements.
Hypertension Defined as persistent, chronic, sustained elevated blood pressure, most types are what is called essential hypertension meaning there is no attribution to a specific cause. Secondary hypertension refers to hypertension caused by specific factors such as kidney disease and obesity. A hypertensive individual’s heart has to work harder to overcome peripheral vascular resistance. In general the higher the BP, the greater CAD risk. Hypertension is a silent killer; it is frequently symptomless or has symptoms so ‘mild’ that the person does not notice them.
Angina Angina is chest pain or discomfort that occurs when your heart isn’t getting enough blood. Coronary arteries supply the heart; partial occlusion of the arteries reduces the blood supply and causes pain in the heart muscle. Angina is common with 1 in 50 people in the UK suffering it. Stable Angina The pain is usually brought on by physical activity and relieved by rest. It usually lasts three to five minutes. Stable angina usually has a stable pattern. The symptoms usually go away if medication is given. Unstable Angina As the name suggests , there is no pattern to this type of angina and it may come on at rest. The pains are usually more frequent, severe and last longer than stable angina. It often does not respond to medication. Medications Glyceryl Trinitrate (GTN) to ease the symptoms is taken as a spray or tablet under the tongue. Other medications such as beta-blockers may be given to prevent the problem becoming worse.
Myocardial Infarction (MI) This is a heart attack caused by total occlusion of the coronary arteries. There are different types of heart attack – some are sudden and frequently cause death immediately whereas others go on for a period of time and feel quite mild to the sufferer. The coronary arteries that supply the heart wall muscle are a little like a tree. Where the occlusion occurs dictates the severity of the MI. Occlusion of the blood vessels cause the death of the heart muscle it supplies and can cause permanent damage.
Stroke Every year approximately 150,000 people in the UK have a stroke (that is one every 5 minutes) and most are over 65 years old. Stroke is the third most common cause of death in the UK and is a leading cause of disability (more than 250,000 people live with a disability caused by stroke). A stroke is a brain attack, and the effects are sudden. Stroke can be caused by two problems: either a blockage (blood clot, air bubble or fat globule), or a bleed, when a blood vessel bursts in one of the blood vessels in the brain.
BENEFITS OF EXERCISE Preventative It is known that exercise is beneficial for the cardiovascular system and may help to lower blood pressure and stress. Regular physical activity has been shown to reduce the relative risk of developing hypertension by 19-30% - in fact low cardio-respiratory fitness level in middle age has been associated with a 50% greater risk of developing hypertension, as reported by the American Council of Exercise (ACE). Rehabilitative Conditioning the body through CV training and resistance training makes general daily activities easier to perform, reducing the daily effort the heart has to make. Exercise also engenders feeling of well-being and confidence that may be lacking following an MI or diagnosis of a serious CV condition. Improves the hearts ability to supply the body with the nutrients it requires both at rest and during exercise.
Increased heart and lung volume Increase total blood and haemoglobin volume Increase stroke volume Increase Cardiac Output Decrease resting heart rate Increase capillarisation Hypertrophy of the cardiac walls
Improves the muscles ability to respond to work load
Increase number and size of mitochondria Increase strength of connective tissue
Improves overall health
Decrease blood pressure (if high) Increase HDL cholesterol profile Decrease body fat Decrease total cholesterol Decrease LDL cholesterol profile
EXERCISE GUIDELINES
Endurance activities; walking, swimming, cycling should be the core of the exercise program As aerobic condition improves (after a minimum of 12 weeks in post MI clients) add 1-2 sets of low resistance, high rep resistance training (10+) If the person has very high BP use unilateral exercises to reduce the effects of vasoconstriction Avoid holding breath and isometric exercises because these can cause large fluctuations in BP Avoid exercise that places the hands above the head / heart, or the head below the heart. This increases the work the heart has to do Do not use a weight training belt (vasoconstriction) Do not use high intensity alternative overload techniques Aim for regular exercise, 3-6 times per week with a total exercise duration of 30-60 minutes Start the program for those with low fitness levels at 10-15 minutes, increasing in 5-minute increments every 2-4 weeks until the 30-60 minute goal is met Cool down should be more gradual and longer than usual, to allow for the safe return of blood from the working muscles It is extremely dangerous for an individual with CV problems to suddenly stop exercise
Intensity Guidelines
Moderate intensity exercise (40-75% of Maximum oxygen uptake) may be most effective in lowering BP Use Borg scale or similar to gauge effort Drugs client may be taking may alter the hearts response to exercise Therefore normal HR does not apply
Medication/Intervention Guidelines
Be aware of the affects of diuretics (commonly prescribed as part of the treatment for heart conditions) increased need for urination may result in the client avoiding water intake and therefore lead to dehydration If the person has had a bypass operation, frequently the veins required to perform this operation are taken from the legs This can lead to some venous return problems. Leg movement, particularly in plantar flexion can aid recovery and increase and improve circulation.
Cardiac Rehabilitation Program
Phase I: o Inpatient phase o Post MI, onset of Angina, CHD related hospital admission, cardiac surgery, or 1st diagnosis of heart failure o Evaluation, Education, Risk Factor Assessment
Phase II: o Early post-discharge period o Home visits, phone contact o Supervised use of the “heart manual” – a self-help program shown to reduce anxiety, depression and readmission
Phase III: o Structured exercise program in hospital setting o Begins approx. 6 weeks after phase I begins and lasts 12 weeks o Promotes weight management, cessation of smoking, and vocational rehabilitation
Phase IV: o Long-term maintenance of physical activity & lifestyle change o Community based o Personal Trainers o BACR Phase IV Exercise Instructor Training o www.bacreducation.co.uk/
Exercise Guidelines CV
Low intensity based on GP recommendations 3-5 days per week Keep below GP recommended maximum intensity 20-30 mins duration Extended (8-10 mins) warm up and cool down
Resistance
Only after 3+ months of asymptomatic CV training Low impact 1-3 sets, 10-20 reps Focus on breathing and rest between sets Seated or standing No overload Unilateral No isometrics