The importance of exercise
Graduated exercise after a heart attack is an important part of your recovery to improve your cardiovascular fitness and reduce your risk of a future heart event.
Many people worry about the safety of exercise after they've had a heart attack. The natural reaction is to avoid exercise so you don't damage the heart, but the reality is that inactivity leads to poorer heart function and earlier death. It's much more dangerous to be sitting on a couch doing nothing than exercising at a suitable level.
The heart is a muscle. Like any other muscle in the body, it gets stronger with exercise. There are many reasons why regular exercise needs to be an important part of your life following a heart attack.
Regular exercise can:
- Lower your risk of further heart problems, hospital admissions and premature death. It also lowers your risk of non-cardiac related causes of death
- Lower your blood pressure and help people with type 2 diabetes to keep blood glucose levels in the correct range
- Improve your fitness and strength making it easier to undertake normal daily activities
- Reduce your risk of depression and anxiety
- Improve your quality of life
- Improve your sleep and energy levels, reducing tiredness and fatigue
Developing the confidence to exercise again is one of the most common issues for people recovering from a heart attack. One of the most effective ways of increasing your confidence is to join a cardiac rehabilitation programme. Exercising with a support person such as a family member or friend can boost your confidence and motivate you.
Even if you're aware of the benefits of exercise after a heart attack, knowing when to start and how much activity or exercise to do can be daunting.
Ideally, you should begin your post-heart attack exercise regime as part of the cardiac rehabilitation programme, run by your local hospital or primary care provider. If you're unable to attend cardiac rehabilitation, or if it's not available in your area, then it's important to talk to your GP, cardiologist or cardiac nurse about what is safe for you.
In the first four to six weeks, your focus will be on low levels of activity. The focus should be on short bouts or 'snacks' of activity, becoming more frequent as your recovery, fitness and confidence progresses. Initially you may start by doing several two to three minute walks to your neighbour's mailbox throughout the day.
As your confidence and fitness increases, you may increase the duration of each walk, aiming is to achieve 30 minutes of activity each day. It doesn’t matter how you accumulate your 30 minutes. For example, it could be five six-minute walks or two fifteen-minute walks throughout the day - or any other combination that equals 30 minutes.
Once you're achieving your 30 minutes a day, you may look to increase the intensity of your activity, to make it a little harder. This can be done by adding some hills in to your walk or increasing your speed.
If you've had bypass surgery, you will have to avoid upper body strength training exercises and upper body aerobic activity (such as a rowing machine or cross trainer) until the wound has healed. You will also have to avoid water-based exercise until the wound has healed because of risk of infection. Get clearance from your doctor before starting either of these options.
In the interim you can do lower body resistance exercise or lower body aerobic exercise (other than swimming).
The intensity and duration of your exercise will depend on a number of factors including:
- How long ago you had your heart attack
- The severity of your heart attack and your heart disease
- The amount of exercise you were doing prior to your heart attack and your previous level of fitness
- Any other illnesses or injuries you might have
It's important to go at your own pace. Listen to your body and watch for any cardiac warning signs such as angina, lightheadedness or shortness of breath. In the early days, even low levels of activity such as walking to your mailbox and back may prove a challenge. But once you're further along in your recovery, you will want to increase the intensity and duration of your exercise. Your aim is to build up to five 30 minute sessions of moderate intensity exercise per week.
The talk test can be a useful way of measuring your intensity. When you're exercising to a moderate intensity you should be able to talk but not sing or whistle.
It's good to include a variety of exercise. Not only is this better from a health perspective, but variety can make exercise more enjoyable so you'll be more likely to stick to it. Include a variety of aerobic activity and some strengthening activities, such as yoga, pilates or some kind of resistance training.
Aerobic activity (also referred to as 'cardio') is exercise that increases the demand on the heart to pump oxygenated blood to the working muscles. It increases your heart rate and breathing rate in a way that can be sustained over the course of the exercise session (as opposed to very intense exercise such as sprinting which can only be done in very short bursts). Most low to moderate intensity exercise will be 'aerobic' or 'cardio' exercise.
Some good examples include:
- Using the 'cardio' machines at the gym (ie rower, cross-trainer, treadmill, arm grinder)
If you suffer from arthritis, joint pain or other medical conditions such as asthma, aerobic exercise can still be achievable and enjoyable.
As well as cardio exercise, it is also good to do some strengthening activities, such as yoga, pilates or resistance training.
Yoga focuses on strengthening muscles and improving flexibility, some more intense forms of yoga may also be considered cardio training. Pilates also improves muscle strength and balance, as well as flexibility and endurance. Both yoga and pilates also have mental health and relaxation benefits which can help with stress and anxiety.
Resistance training (also known as strength training or weight training) is also useful. One way to do this is to get a programme at your local fitness centre - but it is vital you inform your trainer that you're recovering from a heart attack. If your trainer is unsure about what you can and can't do, put her/him in touch with your doctor. Alternatively you can visit this register of clinical exercise physiologists who are specialised in giving exercise to people with CVD.
Alternatively you can do strength training in your own home. Once again it is important to check in with your doctor or nurse before starting any exercises, and if you've had open heart surgery you will need to wait 12 weeks and have approval from your doctor before you start upper body exercises. If you want some exercises that you can do at home talk to your GP, nurse or cardiac rehab nurse about getting a green prescription. You can also refer yourself to the green prescription programme.
Warming up and cooling down
A warm-up is very important to prepare your body for exercise. When you perform a light warm-up, your body widens its blood vessels which enables better blood flow around the body. If you don't warm up and you start your exercise without preparing the body first, you increase the chance of experiencing angina. A warm-up may involve light walking on flat ground for five to ten minutes before increasing the intensity.
You should always do a proper cool-down following exercise. Stretching is best done when the body is warm, so is a great cool-down option. A proper cool-down and stretching can help prevent or minimise any muscle soreness the following day.
You can find some great stretches on the ACC website.
Climate and exercise after a heart attack
It is important you consider the climate you are exercising in. When exercising in warm and/or humid environments (i.e. summer or a swimming pool), your heart and the rest of your body need to work harder to keep your body cool. One way your body keeps cool is through sweating, so it's important you stay hydrated with water, to replace this fluid while exercising when it is warm.
Certain exercises that are sometimes performed in yoga and/or pilates classes may be considered unsafe for people with heart disease. Caution must also be shown when performing certain resistance / weight training exercises. You may hear these exercises referred to as 'contraindicated exercises'.
The natural response when we try to lift anything heavy is to hold our breath, however this breath-holding can limit blood flow to the heart and may cause lightheadedness or fainting. Any resistance exercise that forces you to hold your breath while lifting should not be performed, or the weight should be reduced.
Always let your instructor or your trainer know you have a heart condition before the exercise class or joining an exercise facility. Always check with your doctor before starting a new form of exercise.
You also need to take care to ensure your exercise doesn't become too intense. A good rule of thumb is that you should be able to talk while exercising – if you find you can only say a couple of words before needing to gasp for air, the exercise is probably too intense.
Always check with your doctor first before starting or resuming competitive spots, or other more intense kinds of exercise.
The quantity of exercise you can do will depend on the severity of your condition, your level of fitness prior to your heart event and any other illnesses or conditions you may have.
If you're in your very early days, your focus will be on returning to normal activities. Once you're further through your journey, you should be looking to incorporate regular exercise into your daily life.
The important thing is to build up gradually. Your ultimate aim is to do 150 minutes a week, but if you're exercising for the first time, it may be more realistic to set a smaller target of 90 minutes a week. Once this has become consistent increase the goal to 120 or 150 minutes.
How you achieve your total weekly minutes is up to you. For most people, the 150 minute total will be made up of five 30-minute sessions. But depending on your other commitments, you may find it easier to vary the length of the sessions and do more some days and less the next. Remember to adhere to any limits your cardiologist has placed on the length of your exercise.
You can find more tips and information on our benefits of exercise page.
The talk test can help you measure the intensity of your exercise. It’s ok to be a little short of breath, but you should still be able to maintain a conversation. If you experience any of the following symptoms stop and seek medical advice:
- Chest tightness
- Extreme shortness of breath
It can be normal to experience some muscle soreness after performing exercise for the first time in a while. If you are finding that this persists for a couple of weeks or you are excessively tired after your exercise sessions, it could be a sign you are over doing it.
Following a heart attack, some people may still experience episodes of angina during physical activity and this can affect their confidence to exercise. If you experience angina it's important that you recognise it and know what to do. You must stop and follow the chest pain/angina action plan. You should also discuss this with your doctor and ensure that you carry your medication to treat episodes of angina if your doctor has prescribed this.
Make sure you take your GTN spray with you when exercising.
It is normal to have some shortness of breath with exercise. But it can be hard to know when shortness of breath is at an acceptable level or when it signals something more serious.
The talk test is one useful way of measuring exercise intensity. You should have enough breath to hold a conversation but not enough to whistle or sing.
If you have extreme shortness of breath, slow down or stop exercising. If your shortness of breath seems disproportionate for the level of exercise you are doing, contact your doctor or health professional.
Even if you don't have a hospital-run cardiac rehabilitation programme in your area, there may still be a local cardiac club, which you can join for support. These clubs are also useful for people who have completed cardiac rehabilitation and want ongoing support.
A green prescription is also a great way to stay motivated.
If you don't have a local cardiac club, find someone else or a group of people who can exercise with you. Having an exercise partner/support person:
- Keeps you motivated
- Takes your mind off the exercise
- Reduces any anxiety you may have around exercise
- Allows you to spend quality time with a family member or friend
Goal setting is another great way to stay motivated. Make sure you set yourself SMART goals. They are goals which are:
- Specific (rather than saying I'll do more exercise, specify what it is you're going to do and when)
- Measurable (use time frames and/or distances such as "I will walk 20mins or I'll walk to the shops and back")
- Achievable (for example, it may not be possible for you to become the next New Zealand 5km national champion, however it may be achievable for you to complete a 5km fun run or walk)
- Realistic (for example, if you set yourself a goal of swimming three times a week, make sure you can realistically get to the pool three times a week, afford the entry fee etc.)
- Time bound (State when you're going to complete the goal by...eg "for the next three months I will...")
An example of a SMART goal is: “I want to be physically active for at least 30 minutes per day, four days a week for the next 10 weeks”.
Arthritis or joint pain
If you have a joint condition such as arthritis, avoiding exercise is one of the worst things you can do. When you exercise and move the joint, you're using the muscles around the joint. These muscles help to support the joint and reduce the stress on the joint itself. If you don’t use these muscles, with ageing they will reduce in size and strength, making the condition worse.
The best type of exercise for people with joint discomfort is non-weight bearing, low impact such as swimming and cycling. Even the resistance from walking in water can be beneficial for your heart. Low impact exercises such as tai-chi or yoga are also great ways of keeping your muscles and joints active, whilst benefiting your heart health.
For those prescribed an inhaler for a respiratory condition such as asthma, it is important you carry this with you when exercising and take it as recommended by your GP. To get the most benefit from the inhaler, you should take your normal dosage 10-15 minutes prior to starting exercise, allowing plenty of time for it to take effect.
If you have been diagnosed with diabetes, you should check your blood sugar levels before and after exercise for the first week or two. For most people, blood sugar will drop during exercise as the body uses the sugar in the blood as 'fuel' for exercise.
The amount the blood sugar level changes during exercise will be different for everyone. It will also be affected by:
- The duration and intensity of the exercise
- Your medications (the time you took them and their dosage)
- Any food/drink consumed before/during exercise can all affect your blood sugar
It is important you do not let your blood sugar get too low (hypoglycaemia), so checking it before exercise will alert you to have a snack prior to exercise if it is on the low side.
It is important that you carry a source of easily absorbed sugar (i.e sweets) while exercising, in case you feel your blood sugar getting too low. As your exercise becomes regular, you may notice your blood sugar levels become lower more frequently. If this occurs, you may want to discuss with your GP as you may need to alter your medication.
Note: Those taking insulin are at most risk of hypoglycaemia during exercise and it is strongly recommended you check your blood sugar before and after all exercise sessions.
One of the easiest ways to make a positive change to your health following a heart attack is to spend less time sitting. Where possible, incorporate some of these suggestions below:
- Take a break from the computer/work station every 30 minutes to grab a drink of water (drinking water will also remind you to break up the sitting with increased trips to the bathroom)
- Park your car a small distance from your destination
- Use the stairs where possible
- Return your shopping trolley to the store
- Walk to the dairy/shops rather than drive
- Wash your car
- Stand up and go for a walk or do some stretches during the TV advertisement breaks
- Get off the bus a stop or two early and walk the rest of the route to your destination
- Walk the dog – don’t just watch the dog walk
Whilst these don’t seem a lot on their own, if you do several of these each day, it will have a significant effect over time.
Once you've recovered from your heart attack, regular aerobic exercise will be a crucial part of your long-term treatment. Check out Sport New Zealand or search our Heart Help Directory for an exercise group near you.Find a local exercise group