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Athletes and High Blood Pressure

February 5, 2010 By Larry Creswell, MD 167 Comments

In a previous blog post, I talked about the general problem of high blood pressure, or “hypertension.” Today, I thought I’d focus our discussion about hypertension specifically on the issues that athletes face.

Here at the blog, we’ve talked about many UNcommon cardiovascular problems that athletes might confront. But hypertension is different. In fact, high blood pressure is the MOST COMMON cardiovascular problem discovered in athletes. If you don’t have this problem, you almost certainly know fellow athletes who do. And if you don’t have high blood pressure now, you might develop high blood pressure as you age. So….this is a problem worth knowing about.

First, some definitions….and we’re talking about adults here….

The NORMAL blood pressure is 120/80.

Benefits of Exercise

Randomized clinical trials have shown that physical activity is associated with a decrease in the blood pressure for all patient groups: those who have a normal blood pressure at the outset, those with high normal blood pressure or “pre-hypertension,” and those with high blood pressure. Regular and moderate aerobic exercise can reduce the blood pressure by up to 10 mm Hg. Similarly, moderate intensity resistance training (using light weights and high number of reps) can reduce the blood pressure by 3-6 mm Hg.

Regular exercise provides a real benefit. Among the physically active, the risk of developing hypertension is 50% less than for the inactive population. Nonetheless, there will be individuals who DO develop hypertension despite engaging in a regular exercise program. Those at particular risk include: African-Americans, the elderly, the obese, those with diabetes, and those with chronic kidney disease.

Evaluation of the Blood Pressure in Athletes

I’ve talked several times here at the blog about how important it is for athletes to have a physician. The BP should be checked at every visit. For student athletes, the BP should be checked at a pre-participation physical examination. It is important to remember that the BP varies over time. No single measurement should govern treatment decisions. If the BP is elevated at the doctor’s office, it may be wise to re-check the blood pressure in a more relaxed setting such as the home. You may need to work with your physician on how best to do this.

Some behaviors are known to be associated with elevated BP: increased sodium (salt) intake, tobacco use (any form), various over-the-counter medications (cold remedies, decongestants, “diet pills”), ergogenic aids (caffeine, Sudafed, cocaine, human growth hormone (HGH), anabolic steroids), various prescription medications (particularly non-steroidal anti-inflammatory drugs such as Motrin and oral contraceptives), and various dietary supplements.

Treatment of Hypertension in the Athlete

The first approach to treatment will involve “non-pharmacologic” therapy–treatment WITHOUT medications. Since we know the list of “bad” behaviors (noted above), our first efforts should be to eliminate these. We should also note that regular physical activity is helpful in this regard….but if you’re reading here, you’re probably already an athlete. Other useful measures include: ensuring adequate potassium intake (particularly for endurance athletes) and a variety of relaxation techniques (meditation, yoga, Tai Chi, etc.).

If medications are needed to control an athlete’s hypertension, several broad categories of medications are available. Each category has its own benefits and drawbacks. Anything I say here is a simplification, and there is an art and science to the selection of blood pressure medications for a patient. You will need to work carefully with your physician to choose an approach that WORKS FOR YOU.

1. ACE (angiotensin converting enzyme) inhibitors. Examples include: Altace, Zestril, lisinopril, enalapril. May be the drug of choice for athletes. There are few side effects if they are used in individuals who do not have kidney disease. Athletes taking ACE inhibitors may experience a sudden decrease in the BP just after a workout (potentially leading to blackout or syncope), so they should be aware of this possibility and have a cool-down period at the end of each workout.

2. Calcium channel blockers. Examples include: Norvasc, Calan, Isoptin, Cardizem. These medications are also useful in the athlete. They do not lead to a decrease in exercise capacity. They can lead to a decrease in the heart rate and contractility (strength) of the left ventricle (heart’s main pumping chamber), but this is compensated for by an increase in the stroke volume (the amount of blood the heart ejects with each heartbeat).

3. ARB’s (antiotensin receptor blockers). Examples include: Avapro, Atacand, Cozaar. These medications are similar to the ACE inhibitors. Again, they have a favorable side effect profile.

4. Central alpha-agonists. Examples include: Catapres, Tenex. These medications are not generally useful for the athlete. Side effects include: fatigue, orthostatic hypotension (decrease in the BP related to body position), and fluid and electrolyte imbalances.

5. Diuretics. Examples include: hydrochlorothiazide (HCTZ), Lasix. These should generally be avoided in the athlete. There is an increased risk of heat-related illness, impaired exercise capacity, cramps, and even arrhythmias. In hot weather, these medications may lead to unacceptably high losses of magnesium and potassium.

6. Beta-blockers. Examples include: Inderal, Lopressor, Toprol, Labetalol, Coreg. This is another category of drugs that should generally be avoided in the athlete. They lead to a significant reduction in maximum exercise capacity along with decreased cardiac output and VO2 max. They are also associated with increased perception of exertion and impaired temperature regulation.

Participation Recommendations for Athletes with Hypertension

Prudent recommendations for athletes with hypertension are summarized nicely in a report from the 36th Bethesda Conference on Eligibility Recommendations for Competitive Athletes with Cardiovascular Abnormalities. For athletes with high normal blood pressure or mild hypertension, there should be no restrictions to exercise or sports participation. The blood pressure should be checked every 2-4 months. For athletes with moderate or severe hypertension, activities should be restricted until the blood pressure is controlled.

Banned Substances

The World Anti-Doping Agency (WADA) publishes a listing of medications or other substances that are banned for use by athletes during competition. Athletes should be aware of the ramifications (for their particular sport and circumstance) if they choose, along with their physician, to use medications which are included on the banned list.

Hypertension (High Blood Pressure)

October 19, 2009 By Larry Creswell, MD 6 Comments

Last week, somebody stopped me to ask me a few questions about blood pressure….and high blood pressure, in particular. The gist of the questions was to learn how high the blood pressure could be before he should be concerned. So here’s a little information about blood pressure.

What is the blood pressure?

The normal blood pressure is 120/80. The numbers are measured in millimeters (mm) of mercury (Hg) and are expressed as a systolic pressure (top number) over a diastolic pressure (bottom number). And hypertension is the medical term we use for high blood pressure. We call it systolic hypertension if the systolic pressure is >140 mm Hg or diastolic hypertension if the diastolic pressure is >90 mm Hg.

In the outpatient setting, the blood pressure is usually measured in the arm using a blood pressure cuff. It’s important to remember that the blood pressure is not completely constant, but rather fluctuates during the day according to activity. Frequent measurement of the blood pressure will help to find the “typical” blood pressure for any individual.

The blood pressure typically rises with patient age. There is usually a continuous rise in systolic blood pressure throughout life. The diastolic pressure usually increases until the 50’s, then levels off, and potentially falls later in life.

How common is high blood pressure?

Hypertension is the most common medical problem in the United States. Defined as a blood pressure of 140/90 mm Hg or greater, and including individuals who take blood pressure medication, nearly 65 million Americans (about one third of the population) have hypertension. And another 25% of Americans have “pre-hypertension,” a systolic blood pressure of 120-139 mm Hg or a diastolic blood pressure of 80-89 mm Hg.

Why is high blood pressure bad?

It turns out that, independent of any other risk factors you might have, high blood pressure is associated with an increase in future heart attack (myocardial infarction [MI]), heart failure, stroke, and kidney disease. In fact, for each increase of 20 mm Hg in the systolic blood pressure or 10 mm Hg in the diastolic blood pressure, there is nearly a doubling of the risk of mortality for heart disease and stroke. It’s pretty sobering.

Treatment of high blood pressure

For individuals with no other medical problems (completely healthy otherwise), the goal of treatment is to lower the blood pressure to 140/90 mm Hg. For individuals with any adverse risk factors (diabetes, chronic kidney disease, coronary artery disease, carotid artery disease, peripheral arterial disease, aortic aneurysm, history of smoking, or elevated blood lipids), the goal of treatment is to lower the blood pressure to 130/80 mm Hg.

For all individuals with hypertension, one focus should be on lifestyle modifications that may foster a lower blood pressure. This would include a prudent diet with reduced saturated and total fat intake and reduced salt intake; physical exercise; weight reduction in patients who are obese or overweight; and moderation of alcohol intake. Vigorous attention to these measures may be sufficient in some individuals to lower the blood pressure to the target range.

Most individuals with hypertension will need medications to lower the blood pressure. And there are a great many medications available for this purpose. It’s impossible to generalize here about which particular medications will be most helpful in any individual patient. It’s important to work with your physician to find the best medicine (or combination of medicines) to treat your hypertension effectively. Athletes may want to avoid beta-blocker medications which blunt the heart rate response to exercise.

A Preseason Check-up (Specifically for Men)

February 5, 2018 By Larry Creswell, MD 1 Comment

This is the time of year I get inquiries about pre-season medical check-up’s. I’ve written previously on this subject, including how to find a doctor in your area. I’m frequently asked, though, exactly what type of check-up is needed. Here’s my take.

Today, let me focus specifically on adult male recreational athletes. I’ll deal specifically with women in a follow-up post.

First, in terms of screening adult recreational athletes for sports-related heart risks, adult men are the group where we might expect to get the most “bang for our buck.” We know that men account for the vast majority of victims of sports-related sudden cardiac death, not only in large populations involving all types of sports, but also in very specific sports such as long-distance running and triathlon. There’s a very real reason to be looking for hidden heart disease in male athletes.

Second, in contrast to women, “healthy” men in their 20’s, 30’s, 40’s, and even 50’s are unlikely to make periodic visits to the doctor (except for injury) and very often do not have a current primary care provider (PCP). It may have been years—perhaps back to high school or college—that many men last had a complete physical exam in some context other than for a musculoskeletal injury, which typically requires a rather narrow focus. As a result, there’s often been little opportunity for discussion between adult male recreational athletes and a healthcare provider about any heart risks associated with sports participation.

Let me share how I would approach a pre-season check-up for an adult male recreational athlete who does not already have a PCP….

Although I’m a heart specialist, here I would need to put on my generalist hat to make the most of the encounter.

I would have 3 goals:

Identify any cardiovascular conditions that required further evaluation or treatment as well as any risk factors for future heart disease that could (and should) be modified;
Make an assessment of the patient’s cardiovascular risks of exercise in order to offer appropriate advice about safe forms of exercise; and
Identify any non-cardiovascular conditions that required follow-up with another doctor.

Before the Office Visit

One of the most important parts of a check-up is sharing what we call the “medical history,” an accounting of everything medically-related that’s already happened to a patient. This would include:

Past medical history (childhood illnesses, adult illnesses, surgical or other procedures)
Immunizations
Injuries
Medications and supplements
Allergies
Family history (illnesses that run in the family)
Personal and social history (smoking, drinking, sexual activity and habits, substance use/abuse, work history, travel history)
Review of symptoms (yes/no answers to a long list of questions about current symptoms).

In addition, I would also want to collect information about insurance coverage, the names and contact information for any other current and previous medical providers, and an outline of an athlete’s current exercise habits.

Depending upon the complexity of a patient’s situation, gathering all of this information could be rather time-consuming. So, in order to make the most of our available face-to-face time at the upcoming office visit, I find it helpful to collect as much of this information as possible well ahead of the office visit. I like to use 2 forms:

A general purpose medical history form such as the Health Care Consumer Questionnaire.
American Academy of Family Physicians Preparticipation Physical Evaluation forms. These forms are used ordinarily for secondary school-based screening programs, but I am fond of the first page of the History Form, which asks a series of questions (#5 through #16) related specifically to heart risk. I ask patients to complete items #1 through #51 on the first page and to discard the other pages.

When I’ve received these completed forms, I would review them and consider the possible need to gather additional information ahead of the office visit such as:

records from other physicians or hospitals
results from any heart-related diagnostic tests that may already have been completed (eg, ECG, chest x-ray, echocardiogram, Holter monitor, stress test, laboratory tests, pulmonary function tests, carotid Doppler studies, coronary calcium scoring CT scan).

Lastly, I would make a determination about any new diagnostic testing that may be helpful on the day of the office visit and schedule those tests, if any, for the morning of the office visit. If I think such testing will be helpful, I would have a telephone call with the patient ahead of the visit to explain the need for these tests.

At the Office Visit

I would plan for an office visit of approximately 45 to 60 minutes.

The first portion of the office visit is devoted to an interview. I generally spend half of the visit time on the interview. We often say that the medical history provides 80%+ of the clues to diagnosis.

First, I ask what motivated the patient for wanting the visit. There are many possible motivations. Next, we would have a chance to review the information that had already been provided about the patient’s medical history. I would take the time to clarify and better understand anything in the history that was specifically related to the heart. We would focus on those history items and on any symptoms related to exercise. I would finish by asking the patient if there were any additional, specific concerns that we should address at this visit.

The second portion of the office visit is devoted to a physical exam. Here, I would offer a complete, head-to-toe physical exam, but with special emphasis on the cardiovascular system. The exam would include:

Measurement of the height, weight, and vital signs (blood pressure, heart rate, respiratory rate, temperature)
Screening neurologic exam
Examination of the head, neck, ears, eyes, nose, and throat
Respiratory exam
Cardiovascular exam (heart, carotid arteries, abdominal aorta, arteries of the arms/legs)
Abdominal exam, including check for hernias
Genito-urinary exam
Rectal and prostate exam, in men older than 40 years
Examination of the skin

The third portion of the exam is devoted to a discussion, or wrap-up. Here, we would discuss my findings from the medical history and the physical exam and my assessment of the patient’s overall and heart health.

For the majority of patients–those who do not have any heart-related symptoms or any abnormal physical exam findings–we would spend some time discussing the utility of screening tests such as ECG, echocardiogram, laboratory testing (eg, fasting glucose, fasting serum lipid levels), or stress testing, along with the advantages, disadvantages, and potential costs. Together, we would decide if any of these tests would be helpful. There is a place for such screening tests, but only with thoughtful discussion first.

For other patients, we might identify some new heart-related condition–or at least the possibility of one. As examples, we might find that the blood pressure is elevated or note the presence of a heart murmur. In this situation, we would talk about what sort of diagnostic tests might be needed to further clarify a problem and perhaps what treatment(s) would be needed for any conditions we discovered. Needless to say, there are many potentially useful tests, depending upon the patient’s circumstances, so we won’t go into detail here. In the case of potential inherited disorders, we might need to consider evaluating other family members as well.

In either situation, if additional testing were needed we would make a plan for getting those tests completed. We would also plan for how I would share those results with the patient (eg, by telephone or during a follow-up visit). I would ordinarily make plans to visit with the patient again to discuss the results of any important testing and to resume with our wrap-up once all of the important information was at hand. If more specialized heart care were needed, I would discuss referral to the appropriate specialist (eg, general cardiologist, electrophysiologist, interventional cardiologist, specialist in congenital heart disease) and, in some cases, I would turn over the patient’s care to that specialist.

Next, we would discuss how the patient’s overall and heart health related to his/her plans for exercise and sports participation. Together, we would settle on a list of activities that would be “safe” and, likewise, settle on a list of any activities that should be avoided. We would talk about potential warning signs of heart troubles and how to be vigilant for these. If the patient required a “doctor’s letter” or some sort of pre-participation form to be completed, we would go over that form together and review its requirements. I often complete such letters or forms and return them to the patient by mail sometime after the visit.

We would then make an inventory of any other medical problems (that were not heart-related) that needed follow-up and work together to settle on an appropriate action plan. Examples of such medical problems could include: colon cancer screening in men older than 50 years, that would require a gastroenterologist visit; eyesight troubles that might best be evaluated by an ophthalmologist; periodic screening for sexually transmitted illnesses, which might best be accomplished by a primary care physician; dental care which would best be provided by a dentist; and depression, that might best be evaluated by a psychiatrist. The list of possibilities is virtually endless; this is why there can be tremendous value in having a PCP.

Before we finish the wrap-up, I would take time to have a discussion about any questions or concerns the patient brought. I usually suggest that patients bring a written set of questions that we can answer these one by one.

Finally, I would make a recommendation about when the patient should next be seen for another check-up. For “healthy” patients–those without chronic medical conditions that require monitoring–I generally suggest a check-up every 3 years for men <40 years old, every 2 years for those 40-50 years old, and every year thereafter.

Related Posts:

Heart Rate Variability: Application in the Endurance Sports

June 30, 2017 By Larry Creswell, MD Leave a Comment

This past week, an excellent article by Charles Wallace, entitled “What’s Your Heart-Rate Variability? It May Be Time to Find Out,” was published in the Wall Street Journal. My good friend, exercise physiologist and coach, Alan Couzens, contributed on the practical aspects of using heart rate variability (HRV) in the training of endurance athletes generally, and his coached athlete, Inaki de la Parra, specifically.

Since then, several readers inquired about previous columns I’d written for Endurance Corner on the topic of heart rate variability, noting that links at my blog to those columns were no longer working. My apologies! I’d need my own IT person to keep track of the many old links.

Here’s part 2 of the original Endurance Corner columns….

Part 2: Application in the Endurance Sports

In previous columns I wrote about resting heart rate and heart rate recovery and more recently about the basics of heart rate variability (HRV), where we developed some basic definitions and terminology. Today’s column looks specifically at the use of HRV in endurance training. We’ll talk about how and when to measure HRV; how HRV might be used to help guide your training; and about some of the hardware and software tools that are available to help you make use of HRV.

Measuring HRV

HRV can be measured at any time of day, over any length of time, and with any desired relationship to exercise. For endurance athletes, we might consider measurements of 3 sorts: “resting,” “during exercise,” or “post exercise.” And keep in mind that we’re measuring HRV as our window into the body’s autonomic nervous system, with its parasympathetic and sympathetic components, hoping this can somehow be related to training.

One important consideration is the circadian pattern of HRV. HF and rMSSD are highest in the early morning, decrease throughout the daytime, to an afternoon low, then increase until the following morning. In contrast, LF/HF follows the opposite pattern, peaking in the afternoon. This circadian pattern has implications with regard to how and when HRV should be measured. In order to eliminate the influence of this circadian effect—and to focus more solely on the influence of the autonomic nervous system—daily (or weekly, etc.) measurements ought to be made at the same time of day.

The most commonly used—and best understood—measurement is the resting HRV. The ideal time for measurement is just after waking, while still supine. A recording of the EKG to gather R-R interval measurements is made for just a few minutes. The resting HRV can also be measured in the sitting or standing positions, but there is more variability, or noise, in these measurements. Whichever choice is made for body position should probably be used for all subsequent measurements.

The use of exercise HRV is limited because the instantaneous HRV is very much related to the intensity of exercise during the measurement. The use of post-exercise HRV is limited because these measurements tend to be influenced greatly by post-exercise blood pressure regulation that, again, is dependent upon the intensity of exercise preceding the measurement. It appears that exercise and post-exercise HRV indices might well be correlated to fitness level, but difficulties with establishing constant conditions during their measurement will limit their utility for most athletes and coaches.

Another important consideration is variability from measurement to measurement. The day-to-day variation in the time domain indices (eg, rMSSD) is much less than for the frequency domain indices (eg, LF/HF). As an example, the coefficient of variation for rMSSD may be as high about 10-12%. As a result, some authorities advocate using a rolling several-day average for rMSSD, rather than simply a single-day measurement.

Finally, it is important from a statistical standpoint, to have some idea about the smallest meaningful change for any of the indices. Again as just one example, the smallest meaningful change for rMSSD may be around 3%.

HRV and the Training Cycle

In the endurance sports, the use of HRV has been studied in 2 general settings—the short term and the longer term.

In the short term. On any given training day, intense exercise will lead to a decrease in HRV and this effect can persist for 24-48 hours or so. Based on this observation, some have suggested that intense training only take place again once the HRV has returned to its baseline. Indeed, there is some evidence that training guided by this strategy might result in better performance gains over some period of time. When using this strategy, though, it’s important to remember that factors other than the ANS (eg, sleep, hydration, environmental conditions) also play a role in the HRV and these factors should be kept in mind when interpreting the results. Some of the commercially available HRV devices are designed specifically for this application.

In the longer term. For many endurance athletes, training comes in cycles. There are block periods of trainings followed by some sort of rest. At the end of some blocks might come tapering before an event. The use of HRV to help guide training in these various phases of training is not yet particularly well understood. I can share some generalities, though.

Thinking about a cycle of training for moderately trained, recreational endurance athletes, moderate intensity training leads to increases in aerobic fitness and a corresponding increase in HRV. Over that cycle, we would also expect a gain in fitness or performance, a decrease in the resting heart rate, and an increase in the rate of heart rate recovery after exercise. For that same group of athletes, a taper, or reduction in training load might ordinarily lead to a subsequent increase in HRV.

There is particular interest in the possibility of using HRV as a tool for identifying negative adaptation to training—to avoid the problems of overreaching or overtraining. Unfortunately, the results of studies that were designed to produce training scenarios of overtraining have produced conflicting results; some have resulted in markedly decreased HRV and others have resulted in markedly increased HRV. As a generalization, though, we might expect that accumulated fatigue would be indicated by an increase in resting heart rate together with a variable effect on HRV and that overtraining might be indicated by decreases in both resting heart rate and HRV. In general, an otherwise unexplained reduction in HRV may be an indication of fatigue. Quantities such as the natural log of the rMSSD (Ln rMSSD) have been proposed as an index of fatigue, or a marker of “readiness to perform.”

Here’s the rub, though. In elite athletes and recreational athletes with long training histories, these typical changes have been less consistent. It turns out that HRV responses to training are not only specific to an individual but also to both the recent and remote training history. The most important observation is that the relationship between HRV and fitness is simply different in well-trained athletes: there can be increases in HRV with no corresponding increase in fitness over a training cycle and there can also be decreases in HRV despite increases in fitness.

Hardware and Software

A variety of hardware and software tools are available for athletes and coaches who are interested in using HRV to help guide their training plans.

Omegawave. In triathlon circles, Omegawave is probably the most familiar name in HRV technology. Their system for individual athletes includes a heart rate monitor/chest strap that communicates by Bluetooth with a subscription-based mobile software app. The device is used to make a 2-minute recording of the resting HRV. Then, using proprietary algorithms (invisible to the user), the software calculates an index of Cardiac Readiness along with Cardiac Readiness Elements that include “stress,” “recovery pattern,” and “adaptation reserves.” The software also generates a table of appropriate training zones based on heart rate and an index of aerobic readiness. Omegawave touts the utility of their system in helping athletes determine their “readiness to train.” I’ve used the Omegawave system and found it very easy to use. The down side, of course, is that it’s a bit of a black box. Athletes just don’t know exactly what’s being measured or reported.

BioForce HRV. Like the Omegawave system, the BioForce system includes a mobile app together with web-based software that are designed to work with a hear rate monitor (eg, Polar). An index of HRV, again not explicitly defined, can be measured during a 3-minute rest period and stored for comparison with succeeding days. Included with the system is a book, “The Ultimate Guide to HRV Training,” where training recommendations are based primarily on the day-to-day changes in HRV. Like the Omegawave system, the user is blinded to what exactly is being calculated or derived for the HRV index.

Ithlete. Another similar product is the ithlete HRV system which uses a proprietary heart rate monitor or finger probe, together with a mobile app, to calculate an index of HRV. ithlete offers the advice that a large drop in HRV from one day to the next should prompt the athlete to back off from training. Like the Omegawave and BioForce systems, the user is blinded to what exactly is being calculated.

Heart Rate Monitors. Some heart rate monitors (eg, Polar, Suunto) include a feature that allows for data collection and reporting on R-R intervals that serve as the basis for any HRV calculations.

Kubios HRV software. Made available for free download by the Biosignal Analysis and Medical Imaging Group at the University of Finland, and intended originally for use by scientific investigators, Kubios HRV software allows for calculation of the most common time and frequency domain measures of HRV. Inputs can come from an ASCII file of R-R interval data or from some standard heart rate monitor data files (eg, Polar, Suunto). This software is probably the best (and cheapest) tool for athletes who might want to derive particular measures of HRV and relate them to their training. The Kubios user’s guide includes not only instruction on the software but also general information about the underpinnings of the various HRV indices.

Physionet software. Another option for free, open-source software comes in the form of a HRV Toolkit from the Division of Interdisciplinary Medicine and Biotechnology at Beth Israel Hospital/Harvard Medical School. These tools do not have a graphical user interface like Kubios, but do allow for calculation of many of the relevant HRV indices and graphical representation of the results.

Some Thoughts and Recommendations

HRV technology might well be most useful for dedicated amateur and elite endurance athletes who are looking for additional ways to monitor their training, make day-to-day adjustments to their training patterns, and avoid the negative adaptations of overreaching or overtraining. But from what we know from the rather limited studies of elite endurance athletes, HRV may not have the same, predictable relationships to a training cycle that have been observed in less-trained recreational athletes and non-athletes.

In thinking about the hardware and software tools that are currently available, the Omegawave, Bioforce, and ithlete systems might be best suited for athletes who want to use HRV monitoring for the “short term” application I described above. A Kubios-based approach might be more suitable for athletes who want to use HRV monitoring during and through various training blocks. There seems to be a real opportunity for the heart rate manufacturers and the training data analysis/repository vendors (eg, TrainingPeaks) to offer some easy-to-use, mathematically transparent tools for everyday athletes.

Realize that none of this is particularly simple, at least not yet. The serious endurance athlete who wants to make use of HRV monitoring might do well to use a Kubios-based approach to track some indices for a season and to simply gain familiarity with the process. In so doing, you’d become aware of how various HRV indices related specifically to each phase of your training. You’d become aware of both positive and negative trends in that regard. You’d then be in a position to see how best to make use of HRV in conjunction with other markers like fatigue, performance, resting heart rate, exercise heart rate, and heart rate recovery.

There’s no doubt in my mind that the use of HRV technology will become more widespread in the endurance sports, particularly as we learn more about the real-world experiences of well-trained recreational athletes. Stay tuned.

Heart Rate Variability: The Basics

Returning to Exercise (and Training) After Heart Surgery

May 1, 2016 By Larry Creswell, MD 45 Comments

I’ve had a bunch of requests for a blog post on getting back to exercise or training after heart surgery. These requests usually come from: 1) athletes who are contemplating an upcoming operation and are already worried about if/when/whether they’ll be able to get back to exercise afterwards or 2) athletes who’ve recently had successful operations and are looking to become active once again, but are looking for reassurance that it’s safe to do so. I marvel every time I see an athlete patient get back to exercise after heart surgery, so I’m always encouraged by these inquiries.

For today’s discussion, let’s confine ourselves to what I call “conventional” heart surgery—the whole collection of heart operations that use a chest incision, with splitting of the breast bone (sternum), and make use of the heart-lung machine for cardiopulmonary bypass during the procedure. We’ll save for another day those procedures that are “less invasive” in some way, use some other incision or approach, and those that don’t make use of the heart-lung machine. As examples, I’m talking about common operations like coronary artery bypass grafting (CABG) or heart valve repair or replacement.

At the outset, we need to have a big disclaimer. Athlete patients are all different. Their operations are different, too—even when we’re talking about just the commonly performed operations. And because athletes and operations are all different, I can only generalize here.

If you’re an athlete patient, please use this post to become educated about some of the issues and help gather your thoughts for conversations with your own doctor(s). This is the only way to settle on plans that are right for you.

Athletes in this situation should remember that there are very real issues with the safety of exercise. My best advice is to take things slowly and consult with your doctor(s) frequently.

Athletes and Operations are Unique

Athletes who need heart operations can be different in many ways. Some need operation for congenital, or inherited, conditions they’ve had since birth (eg, atrial septal defect [ASD]). Others need operation for acquired conditions that take many years to develop (eg, coronary artery disease, aortic aneurysm). In still others, an emergency operation may be needed for some sort of acute problem (eg, aortic dissection).

In many cases, athletes will have conditions where the heart function is preserved, but some will have conditions where the heart has suffered some sort of damage, and become weakened, over time. Some athletes will be healthy except for their heart condition and others will have other medical conditions that affect not only the operation, but also the recovery.

Finally, athletes will come with all sorts of sports backgrounds and all sorts of future goals. Some will be young and others will be old. Some will be recreational athletes, some will be exercisers, and some will be competitive athletes. Some will have had high fitness levels before operation, and others will not. The demands of the various sports are different, too. Some have highly “dynamic” nature (eg, running). Others have a high “static” nature (eg, weightlifting).

Heart operations are different, too. In some cases, operations can be curative. In others, the operation might better be thought of as “mending a broken heart.” Moreover, in some cases the underlying heart condition can take a long time to improve, even if operation is successful.

For all of these reasons, there can be no “one-size-fits-all” prescription for return to activity, exercise, and training. Instead, the prescription must be individualized.

Healing Up

Things need to get healed up after operation. This should be obvious.

The surgical wounds need to heal after surgery. The skin incision ordinarily heals very quickly. With either skin staples or absorbable sutures beneath the skin, the surgical wound usually seals in the first few days. It’s worth paying attention to instructions for showering, bathing, and swimming. Any infection of the surgical wound can be a major setback to healing. Pay attention to instructions to watch for swelling, redness, or drainage that might be signs of infection.

Deeper, the breast bone (sternum) is like any other broken bone. We wire the sternum back together and in most cases, the bone knits back together just like any other broken bone. This is a process that takes many weeks, but we often say that the bone regains about 75% of its strength in the first month, so long as healing proceeds correctly. During the first month, we generally restrict activities that place stress on the sternum as it heals. We ask patients to avoid pushing, pulling, reaching, or even just carrying heavy objects (more than 10 pounds). Many surgeons also restrict driving for the first month. All of these activity restrictions are important because exercise early after operation must usually involve the lower body, rather than the upper body.

Deeper still, the heart itself must heal up. Regardless of the exact operation, the handiwork here usually involves needle and thread. The tissues are sewn together or new materials (eg, heart valves) are sewn into the heart. Although the tissues or devices are fixed securely in place, it takes many weeks or even months for the affected tissues to heal completely. Your surgeon will be in the best position to comment on the expected period of time that will be needed for healing and to offer advice about any longer term risks to the affected tissues, devices, or prosthetics used that might come with various forms of exercise.

One final point is that healing may be impaired in some patients. Conditions such as diabetes, a suppressed immune system (eg, from illness or medications such as steroids), or even just poor nutrition before operation can delay healing substantially.

Is the heart mended? Or good as new? Does the disease continue even after the operation?

Thinking ahead to physical activity after operation, one very important consideration is: how healthy is the heart now? Have we cured the problem? Or have we mended the problem? Or, perhaps, have we introduced some new problem?

The important question to consider is: Does my current heart situation place me at increased risk for a future problem? And, if so, how big is that risk?

As one example, sometimes an athlete will need operation to correct an atrial septal defect (ASD), an inherited condition. If this condition is found before any damage has occurred to the heart or lungs, operation is curative and athletes can generally return to any form of sports activities after they’ve healed up.

As another example, sometimes an athlete will need coronary artery bypass surgery after a heart attack, or acute myocardial infarction (MI), in medical terms. The “plumbing” can be fixed with operation so that blood flow is restored past all (or most) of the blockages in the coronary arteries. It turns out, though, that it can take up to 2 years for the ruptured plaque that caused the MI to become stabilized. During that time, the best advice might be to limit strenuous exercise because of the increased risk of repeat MI.

In yet another example, sometimes an athlete will need operation for repair of an aortic aneurysm. Most often, a portion of the enlarged aorta is “repaired” by replacing the blood vessel with a synthetic, fabric substitute. After successful operation, though, there may still be mild enlargement of the remaining aorta that deserves surveillance over time for possible enlargement. Sports activities with a high “static” component (eg, weightlifting), where there can be large increases in the blood pressure, may not be advisable, for fear of accelerating aortic enlargement over time.

These are just 3 examples. The scenarios are virtually endless.

New Medications

For some athletes, things can be so “normal” after heart surgery that no new medications are needed. Sometimes, medications that were required before the operation are no longer needed. These athletes are fortunate.

For other athletes, though, new medications can be needed either because of the underlying heart condition or because of new hardware that’s been added. As an example, aspirin, beta blockers, and statins are often recommended for athletes who’ve had operation for coronary artery disease. Each of these medications will have implications for the athlete. As another example, blood thinners like warfarin (Coumadin) might be prescribed for an athlete with a mechanical heart valve. The anticoagulants also bring a potential risk of unwanted, serious bleeding in the event of bodily injury. This is a factor which must be weighed when settling on what types of physical activity are safe.

Cardiac Rehabilitation

Cardiac rehabilitation, or “rehab” for short, is a supervised program that includes medical evaluation, development of a physical activity program specific for the patient, educational services, and individual and group exercise where the vital signs and EKG can be monitored. The structure of these programs may vary by location, but will usually involve both an inpatient phase and an outpatient phase.

At many heart surgery programs, the inpatient phase of cardiac rehab begins within the first couple days after operation, with both educational and exercise components. There are usually educational offerings about nutrition, medications, lifestyle modifications, and community resources. There is also an exercise component that is tailored to the patient, usually involving walking at first, where there is close monitoring of the vital signs, the heart rhythm, and the oxygen level in the blood stream. It’s important early after operation, together with the patient and family, to establish expectations and goals about physical activity.

Cardiac rehab continues with an outpatient phase, where patients can enroll in a monitored exercise program, often in a group setting, with several sessions per week. Athletes may sometimes fail to see the value in such a program, but these programs can actually provide some much needed structure to the early return to exercise. Most importantly, these programs can provide confidence for the athlete that once they leave a structured setting, things will still be okay with their heart and safety during exercise. I’d recommend a full cardiac rehab program for all athletes who are looking to return to exercise after operation.

For most patients, walking is the most appropriate exercise early after operation, with an emphasis on moderate exertion and increasing duration.

Support

Having a good support system is important for any patient after heart surgery. It’s particularly true for the athlete who is returning to a formal exercise or training program after heart surgery. You can envision this support system as having a set of layers.

Closest to home, athletes will benefit from a family that helps to encourage a return to physical activity and works to make this possible. Family is usually the best support for ensuring continued good nutrition, ensuring restful sleep (including naps), and seeing to other various needs after the patient returns home from the hospital.

When it comes to returning to structured, independent exercise, I believe that a group setting is often best. We all know that it’s more motivating when we have friends to meet for the morning run or ride. In the case of athletes with recent heart surgery, it’s also reassuring for the athlete to know that company is nearby if some sort of medical problem crops up during an exercise session. Even if this possibility is unlikely, a group of fellow exercisers can provide some needed confidence.

Being able to share experiences with other athletes who’ve had similar surgery can often be helpful, even if those athletes aren’t close to home. There are a variety of support groups with an online presence, but two of my favorites are the Ironheart Foundation and Cardiac Athletes. Both offer an opportunity to network with similar athletes, learn from their experiences, and also have a forum to “give back.” You’re not alone. Many other athlete patients are dealing with the same or very similar situations.

Lastly, for athletes who are looking for some good reading material, one good resource is a book entitled “Heart to Start,” by cardiologist James Beckerman, MD. I’ve written a review about this book previously here at the blog. The book describes a gradual, structured path to resuming aerobic exercise and conditioning once cardiac rehab is completed.

Follow-up

It’s wise for athlete patients to put together a robust framework of medical support as they return to physical activity after heart surgery. Your “team” should include at least your heart surgeon, your cardiologist, and your primary care provider. At the beginning, there might also be a nutritionist, your cardiac rehab specialist, or physical therapist, as well. Perhaps you can think of other important team members as well.

Continuous dialog with your team is essential. Only you will be able to describe your goals and ambitions and ask for feedback about the advisability and safety issues. Don’t assume that your doctor(s) will understand what it means to train for the masters national swimming championship or a marathon or a 70.3 triathlon. If you envision several hours of aerobic exercise as well as strength training each weak, be prepared to describe this in detail, with expected exertion levels or heart rates, so that your doctor(s) can know exactly what you have in mind. Don’t hold back.

Athletes should arrange for periodic visits with their doctor(s) so that they can discuss their plans for physical activity, share their experiences, both good and bad, develop plans, agree on any restrictions, and monitor progress. This is good advice for any athlete, but particularly good advice for athletes who have had heart surgery.

In thinking about what sorts of exercise or training is safe for their athlete patients, doctors don’t always have a bunch of accumulated scientific evidence to rely upon. I’ve written previously here at the blog about consensus recommendations about the safety of sports for young, competitive athletes with various cardiac conditions. These recommendations weren’t developed specifically for adult, recreational athletes after heart surgery, but they may provide a starting point for discussion. Often, though, doctors must rely upon judgment and personal experience with similar patients.

Warning signs of a problem

I’ve talked previously about 5 important warning signs of potential heart problems: chest pain/discomfort, unusual shortness of breath, palpitations, blacking out (or nearly so), and unusual fatigue. Athletes should be vigilant about these general warning signs and report them to their doctor(s).

There may also be additional warning signs to watch for, that are very specific to the type of surgery an athlete has had. Some examples would include:

For those with a mechanical heart valve, stroke symptoms (temporary or permanent loss of sensation or muscle weakness) would be important
For those with coronary artery disease, return of angina symptoms (chest pain/discomfort) would be important
For those with aortic aneurysms, return of chest, back, or abdominal pain would be important
For those with arrhythmias, return of an irregular heartbeat or palpitations would be important.

Sometime in the first few weeks after operation, you should have a discussion with your doctor(s) about any specific warning signs that are most important for you. And then you should be vigilant.

Summary

Let me summarize the important points:

Each athlete’s situation will be different
Whatever the approach to returning to activity, pay attention to getting healed up, as a first priority
Participate in a cardiac rehab program
Consider your “new,” current heart situation as you make plans about the safety of exercise
Rely on your support network as you return to physical activity
Assemble a medical “team” to help as you return to physical activity
Make a list and be vigilant about warning signs that are specific to your circumstance

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