Why Do Cardiac Patients Need to Take it Easy?
December 2, 2014 11:18 PM Subscribe
Small heart attack, successful stent insertion, all signs perfect and my buddy's in the best shape of his life. No detectable tissue damage, no angina, and a perfect stress test. So...why, exactly, does he need to avoid certain activities?
I have a friend in his early 50's, in excellent condition (he's a gym guy). 3 months ago, he had a heart attack. They found 100% blockage in a blood vessel and put in a stent. Another vessel was left as-is with 50% blockage (he's taking massive Lipitor and losing a few pounds). He's on blood thinner, beta blocker, and aspirin. His heart's fine, with a normal clench ratio of 60% and his EKG and stress test are perfect. If there was tissue damage, it's done him no registrable harm. He walked >5 miles/day for a couple of months, which (along with the increased flow due to the stent) put him in great cardio shape.
He's approved for almost all activity, but cardiologist wants him to avoid weight-lifting to failure, heavy snow shoveling, etc. He asked why (given that, on paper, he's never been healthier), and the doctor couldn't offer a clear reason. So he assumed the doctor was just covering his ass.
The other day he was mowing his lawn, and there's a steep hill which can only be mowed by repeatedly shoving the mower up the hill like an animal. As a gym guy, this normally feels enjoyable. But when he finished, he didn't experience the familiar pleasant post-exercise dilation. No pain, but there was an awareness he'd done too much AND IT'S NOT OKAY. Same thing when he jumps up off the couch and sprints up the staircase. The twitchy high exertion is too much and it's not okay. No pain, no angina, no windedness...just a feeling that the body's not catching up.
So doctor was right. But what exactly is happening? Can anyone explain the mechanics here; the nature of this weakness and limit? He can accept it better (and gently work around its borders) if he understands the physical underpinnings.
Until now, the limit of what he should do has always been the limit as what he CAN do. Apparently, now, what he should do is somewhat less than what he can do. This is very alien territory for him. That remaining 50% blockage has been around for a while, so that's not it. So why this sudden change post-heart attack and post-stent? Is it the meds (standard combo of blood thinner and beta blocker)?
I have a friend in his early 50's, in excellent condition (he's a gym guy). 3 months ago, he had a heart attack. They found 100% blockage in a blood vessel and put in a stent. Another vessel was left as-is with 50% blockage (he's taking massive Lipitor and losing a few pounds). He's on blood thinner, beta blocker, and aspirin. His heart's fine, with a normal clench ratio of 60% and his EKG and stress test are perfect. If there was tissue damage, it's done him no registrable harm. He walked >5 miles/day for a couple of months, which (along with the increased flow due to the stent) put him in great cardio shape.
He's approved for almost all activity, but cardiologist wants him to avoid weight-lifting to failure, heavy snow shoveling, etc. He asked why (given that, on paper, he's never been healthier), and the doctor couldn't offer a clear reason. So he assumed the doctor was just covering his ass.
The other day he was mowing his lawn, and there's a steep hill which can only be mowed by repeatedly shoving the mower up the hill like an animal. As a gym guy, this normally feels enjoyable. But when he finished, he didn't experience the familiar pleasant post-exercise dilation. No pain, but there was an awareness he'd done too much AND IT'S NOT OKAY. Same thing when he jumps up off the couch and sprints up the staircase. The twitchy high exertion is too much and it's not okay. No pain, no angina, no windedness...just a feeling that the body's not catching up.
So doctor was right. But what exactly is happening? Can anyone explain the mechanics here; the nature of this weakness and limit? He can accept it better (and gently work around its borders) if he understands the physical underpinnings.
Until now, the limit of what he should do has always been the limit as what he CAN do. Apparently, now, what he should do is somewhat less than what he can do. This is very alien territory for him. That remaining 50% blockage has been around for a while, so that's not it. So why this sudden change post-heart attack and post-stent? Is it the meds (standard combo of blood thinner and beta blocker)?
This may not be viewed as an answer to your question - mods please delete if it's not - and please disregard if it's not helpful.
But, my father died last year of heart failure. After repeated minor heart attacks (he was in his sixties). He had some blockage, but like your friend relatively minor. He, like your friend, was a fit man and had been a lifelong exerciser accustomed to pushing himself regularly to the limit.
Despite the repeated heart attacks and doctors' warnings, he was unable to reconcile the new commandments to avoid exercise/activity that would a) put a significant strain on his heart and b) risk raising his blood pressure, albeit temporarily. He was fine on the stress tests and things, too. Until he wasn't.
I wonder, weekly now rather than daily, how much longer he would have lived, if he had listened to the doctors and avoided triggering subsequent minor heart attacks and literally and simply wearing his heart out by ignoring their advice and pushing to his limits by bike riding, slashing the hillside, ocean swimming, lap swimming, packing up most of his shed and practically an entire house including bending and lifting boxes etc.
He couldn't help it, I know that intellectually, but his selfishness and stubborness robbed his four children of their dad for weeks, month, maybe even years with him. He never got to meet my second daughter.
The doctor is, no doubt, covering their ass, they're covering your friend's ass, too. You say: "given that, on paper, he's never been healthier" - this is not true. His arteries have never been so clogged. His heart has never been so old, and has never had a heart attack. A 50 year old man who's had a heart attack is - barring extraordinary circumstances - not the healthiest he's ever been, that's crazy.
Unpredictable things can happen to weak hearts and their arteries when put under stress. He may not drop dead - my dad, for all that, died in his sleep - but he is risking further damage in areas that are already damaged. Far easier to change the lifestyle now with relatively little cost, than to have to change it later with a major cost.
Best of luck,
posted by smoke at 2:16 AM on December 3, 2014 [23 favorites]
But, my father died last year of heart failure. After repeated minor heart attacks (he was in his sixties). He had some blockage, but like your friend relatively minor. He, like your friend, was a fit man and had been a lifelong exerciser accustomed to pushing himself regularly to the limit.
Despite the repeated heart attacks and doctors' warnings, he was unable to reconcile the new commandments to avoid exercise/activity that would a) put a significant strain on his heart and b) risk raising his blood pressure, albeit temporarily. He was fine on the stress tests and things, too. Until he wasn't.
I wonder, weekly now rather than daily, how much longer he would have lived, if he had listened to the doctors and avoided triggering subsequent minor heart attacks and literally and simply wearing his heart out by ignoring their advice and pushing to his limits by bike riding, slashing the hillside, ocean swimming, lap swimming, packing up most of his shed and practically an entire house including bending and lifting boxes etc.
He couldn't help it, I know that intellectually, but his selfishness and stubborness robbed his four children of their dad for weeks, month, maybe even years with him. He never got to meet my second daughter.
The doctor is, no doubt, covering their ass, they're covering your friend's ass, too. You say: "given that, on paper, he's never been healthier" - this is not true. His arteries have never been so clogged. His heart has never been so old, and has never had a heart attack. A 50 year old man who's had a heart attack is - barring extraordinary circumstances - not the healthiest he's ever been, that's crazy.
Unpredictable things can happen to weak hearts and their arteries when put under stress. He may not drop dead - my dad, for all that, died in his sleep - but he is risking further damage in areas that are already damaged. Far easier to change the lifestyle now with relatively little cost, than to have to change it later with a major cost.
Best of luck,
posted by smoke at 2:16 AM on December 3, 2014 [23 favorites]
Your buddy presumably knows the benefit of resting after workouts -- you don't do the same muscle group every day, because the muscles need recovery time after the micro-level damage you do to them during a workout. Well, that's what this is, only this was a major amount of damage done to a muscle that cannot rest. It's going to take a lot longer to recover from to a full level of output, and may well never recover fully. Portions of his heart essentially died during that attack.
posted by Etrigan at 5:35 AM on December 3, 2014 [10 favorites]
posted by Etrigan at 5:35 AM on December 3, 2014 [10 favorites]
Response by poster: DrRotcod (who's not a doctor!): thanks for the links! There's no reason for ischemia, silent or not. The congestion has been relieved...there are no significant lingering pockets of blockage to trigger another attack. And blockage was what caused it; he has no congenital issues, etc. Stent thrombosis or other stent malfunction is of course a concern, but there's no sign any such thing has taken place in his case. He's not showing enzymes in his blood work to indicate any small subsequent incidents.
Etrigan : my understanding is that "a full level of output" for a heart - and an individual's shortfall therefrom - is a measurable thing, and that measurement is made during the echo procedure in the form of a clench ratio. His clench ratio is perfectly normal, so the level of output seems - if I understand things correctly - unaffected. I (and he) may NOT be understanding it correctly, and, if so, that explains the doctor's caution and my friend's mowing (and staircase sprinting) experiences.
posted by Quisp Lover at 10:09 AM on December 3, 2014
Etrigan : my understanding is that "a full level of output" for a heart - and an individual's shortfall therefrom - is a measurable thing, and that measurement is made during the echo procedure in the form of a clench ratio. His clench ratio is perfectly normal, so the level of output seems - if I understand things correctly - unaffected. I (and he) may NOT be understanding it correctly, and, if so, that explains the doctor's caution and my friend's mowing (and staircase sprinting) experiences.
posted by Quisp Lover at 10:09 AM on December 3, 2014
Everyone else has the cardiac issues covered, and I imagine that's 99% of what's going on here, but I occasionally take beta blockers for public speaking anxiety and I experience weird exertion limits if I have to do any strenuous physical activity after I've taken it. It's not like I feel winded, which is where your lungs can't keep up with your oxygen needs, it's more like I'm just not able to get enough oxygen period, which makes sense with the way beta blockers work; they decrease your heart rate, so your heart rate isn't as responsive when you exercise and may not be able to keep up as well. Anyway, if the beta blockers are a new medication for him, that might be contributing to the issue a little.
posted by dialetheia at 10:24 AM on December 3, 2014
posted by dialetheia at 10:24 AM on December 3, 2014
Response by poster: Both of DrRotcod's links - concluding that exercise is okay after stenting - tested only light exercise. So it seems my friend's cardiologist is already being quite liberal in allowing him to do anything short of extreme exertion (ala smoke's father).
Risk of stent thrombosis (i.e. clotting) does, indeed, seem to be the issue here. And there's not a ton of data re: the effect of different levels of exercise on people of different ages and constitutions. All we know is that a little exercise is probably okay, and super-exertion is probably not. So the cardiologist's advice is probably right, and there's no drawing sharp lines.
None of this addresses my friend's "too much" sensation during sudden high exertion activity. But dialetheia may well be right about beta blockers being the problem.
Thanks, all; this helped a lot.
posted by Quisp Lover at 10:34 AM on December 3, 2014
Risk of stent thrombosis (i.e. clotting) does, indeed, seem to be the issue here. And there's not a ton of data re: the effect of different levels of exercise on people of different ages and constitutions. All we know is that a little exercise is probably okay, and super-exertion is probably not. So the cardiologist's advice is probably right, and there's no drawing sharp lines.
None of this addresses my friend's "too much" sensation during sudden high exertion activity. But dialetheia may well be right about beta blockers being the problem.
Thanks, all; this helped a lot.
posted by Quisp Lover at 10:34 AM on December 3, 2014
IANYFD, but these types of feelings could be caused by a beta blocker. It simply doesn't allow your heart to go fast when your body would be otherwise telling it to speed up to pump more blood/oxygen through your body. Physiologic things can happen to people on beta blockers that normally would cause the body to become tachycardic (like let's say having a fever and going into septic shock, with low blood pressure) and people with beta blockers on board keep ticking along in the 50s and 60s when their rate should probably be in the 110s or 120s. That is absolutely not going to feel normal to someone who is used to having their heart rate adjust to doing strenuous exercise (nor should it!).
That being said, your friend should not be lulled into a false sense of security by having his stent. It's simply not as easy as saying "he got stented, they didn't see other significant blockages, therefore he has nothing to worry about." Yes, stents can thrombose, but an atherosclerotic plaque can also rupture at any time and create a new blockage that wasn't there before. This Wikipedia article is heavy on the technical language, but they key portion is as follows:
A vulnerable plaque is a kind of atheromatous plaque – a collection of white blood cells (primarily macrophages) and lipids (including cholesterol) in the wall of an artery – that is particularly unstable and prone to produce sudden major problems such as a heart attack…. Increased hemodynamic stress, e.g. increased blood pressure... correlates with increased rates of major cardiovascular events associated with exercise, especially exercise beyond levels the individual does routinely.
See also: why people over 55 shouldn't shovel snow.
"Barry Franklin, director of preventive cardiology and cardiac rehabilitation at the William Beaumont Hospital in Royal Oak, Michigan, said lifting and tossing heavy snow with a wide shovel can make the shoveler's heart rate and blood pressure suddenly shoot up.
Cold temperatures can compound the risk for people with heart problems, constricting blood vessels and reducing blood flow to the heart.
Franklin, who has written several scholarly articles on why people die when shoveling snow, said that "in general, we find that people who experience cardiac arrest - sudden cardiac death during snow shoveling - are typically middle-aged or older. They are typically individuals who are generally inactive, almost invariably inactive, who once a year or once every 10 years go out and do vigorous physical exertion that is shoveling snow.
"And most have a history of either hypertension, cigarette smoking, high cholesterol, previous heart attacks - almost invariably, many are overweight or obese."
Snow removal is a strenuous activity that works the arms, Franklin said, which takes more physical stamina than exertion involving the legs. Also, he said, people tend to hold their breath when they shovel, which puts extra strain on the body.
In general, Franklin advises people who are 55 or older to resist the temptation to clear their sidewalks and driveways when it snows, even with a snowblower."
(in terms of your friend, I know you reiterated that he is an active guy and not one of these 'weekend warriors' alluded to in the article - but he also has known heart disease and thus all the other points about snow shoveling putting stress on the heart absolutely still apply! Unfortunately, some people are just prone to heart disease - I've sadly known of a number of cases of very healthy looking/active folks who experienced heart attacks or cardiac arrest during a marathon etc. Medical science hasn't found a way to totally evade genetic destiny yet)
posted by treehorn+bunny at 11:15 PM on December 3, 2014 [2 favorites]
That being said, your friend should not be lulled into a false sense of security by having his stent. It's simply not as easy as saying "he got stented, they didn't see other significant blockages, therefore he has nothing to worry about." Yes, stents can thrombose, but an atherosclerotic plaque can also rupture at any time and create a new blockage that wasn't there before. This Wikipedia article is heavy on the technical language, but they key portion is as follows:
A vulnerable plaque is a kind of atheromatous plaque – a collection of white blood cells (primarily macrophages) and lipids (including cholesterol) in the wall of an artery – that is particularly unstable and prone to produce sudden major problems such as a heart attack…. Increased hemodynamic stress, e.g. increased blood pressure... correlates with increased rates of major cardiovascular events associated with exercise, especially exercise beyond levels the individual does routinely.
See also: why people over 55 shouldn't shovel snow.
"Barry Franklin, director of preventive cardiology and cardiac rehabilitation at the William Beaumont Hospital in Royal Oak, Michigan, said lifting and tossing heavy snow with a wide shovel can make the shoveler's heart rate and blood pressure suddenly shoot up.
Cold temperatures can compound the risk for people with heart problems, constricting blood vessels and reducing blood flow to the heart.
Franklin, who has written several scholarly articles on why people die when shoveling snow, said that "in general, we find that people who experience cardiac arrest - sudden cardiac death during snow shoveling - are typically middle-aged or older. They are typically individuals who are generally inactive, almost invariably inactive, who once a year or once every 10 years go out and do vigorous physical exertion that is shoveling snow.
"And most have a history of either hypertension, cigarette smoking, high cholesterol, previous heart attacks - almost invariably, many are overweight or obese."
Snow removal is a strenuous activity that works the arms, Franklin said, which takes more physical stamina than exertion involving the legs. Also, he said, people tend to hold their breath when they shovel, which puts extra strain on the body.
In general, Franklin advises people who are 55 or older to resist the temptation to clear their sidewalks and driveways when it snows, even with a snowblower."
(in terms of your friend, I know you reiterated that he is an active guy and not one of these 'weekend warriors' alluded to in the article - but he also has known heart disease and thus all the other points about snow shoveling putting stress on the heart absolutely still apply! Unfortunately, some people are just prone to heart disease - I've sadly known of a number of cases of very healthy looking/active folks who experienced heart attacks or cardiac arrest during a marathon etc. Medical science hasn't found a way to totally evade genetic destiny yet)
posted by treehorn+bunny at 11:15 PM on December 3, 2014 [2 favorites]
The bottom line is that if your friend is feeling not OK, (in case this isn't glaringly obvious in the case of a heart attack survivor) he really ought to talk to his cardiologist about it rather than just researching it on the internet. Hopefully that sort of goes without saying.
posted by treehorn+bunny at 11:18 PM on December 3, 2014
posted by treehorn+bunny at 11:18 PM on December 3, 2014
Response by poster: With both the “vulnerable plaque” and snow-shoveling risks, we're discussing two extremely rare perils, whose risk factors are more about lifestyle than cardiac history.
Snow shoveling causes nearly 100 fatal heart attacks in the US annually, surely mostly people with heavy undiagnosed blockage. And even among them, under 100/year is an extraordinarily low rate (how many people over 55 with undiagnosed heavy blockage shovel snow each year? Hundreds of thousands?). So snow shoveling’s not a particularly dangerous activity even for them. My friend doesn’t have undiagnosed blockage. And he’s not inactive, obese, or a smoker (the risk factors stressed by the doctor in that article).
Vulnerable plaque, same. "Patients can lower their risk for vulnerable plaque rupture in the same ways that they can cut their heart attack risk: Optimize lipoprotein patterns, keep blood glucose levels low normal, stay slender, eat a proper diet, quit smoking, and maintain a regular exercise program." He does all that. His docs attribute his heart issues to hereditary factors (cholesterol), not lifestyle ones.
The problem being a healthy, vigorous 50 year old with a history of heart attack due to (resolved) blockage is that you're an edge case, thrown in with the older, fatter, more sedentary and unhealthy folks who most often populate the cardiology ward. Both links reveal that lifestyle choices are the real culprit, not the cardiac history. He doesn’t make those lifestyle choices.
treehorn+bunny: the doc just suggests taking it easier, period, and declines to provide specific justification. This thread helps explain why: first, he probably knows it's just beta blocker stuff (and he's been steadily reducing his dosage). Second, extreme activity makes him even more of an edge case. There aren't tons of heart attack/stent patients as young and vigorous, so there's not a ton of data on how such activity affects prospects for rare negative outcomes.
posted by Quisp Lover at 8:17 AM on December 4, 2014
Snow shoveling causes nearly 100 fatal heart attacks in the US annually, surely mostly people with heavy undiagnosed blockage. And even among them, under 100/year is an extraordinarily low rate (how many people over 55 with undiagnosed heavy blockage shovel snow each year? Hundreds of thousands?). So snow shoveling’s not a particularly dangerous activity even for them. My friend doesn’t have undiagnosed blockage. And he’s not inactive, obese, or a smoker (the risk factors stressed by the doctor in that article).
Vulnerable plaque, same. "Patients can lower their risk for vulnerable plaque rupture in the same ways that they can cut their heart attack risk: Optimize lipoprotein patterns, keep blood glucose levels low normal, stay slender, eat a proper diet, quit smoking, and maintain a regular exercise program." He does all that. His docs attribute his heart issues to hereditary factors (cholesterol), not lifestyle ones.
The problem being a healthy, vigorous 50 year old with a history of heart attack due to (resolved) blockage is that you're an edge case, thrown in with the older, fatter, more sedentary and unhealthy folks who most often populate the cardiology ward. Both links reveal that lifestyle choices are the real culprit, not the cardiac history. He doesn’t make those lifestyle choices.
treehorn+bunny: the doc just suggests taking it easier, period, and declines to provide specific justification. This thread helps explain why: first, he probably knows it's just beta blocker stuff (and he's been steadily reducing his dosage). Second, extreme activity makes him even more of an edge case. There aren't tons of heart attack/stent patients as young and vigorous, so there's not a ton of data on how such activity affects prospects for rare negative outcomes.
posted by Quisp Lover at 8:17 AM on December 4, 2014
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I'm not saying this is definitley what is happening, but its a potential explanation.
As for why his doctor reccomends lower-intensity exercise. There are some reported cases of people developing stent thrombosis following high-intensity exercise. But there is also some evidence that sub-maximal exercise is good for people with coronary stents.
I am not a doctor, and this shouldn't be taken as medical advice. If he's concerned he should go and talk to his cardiologist and ask for more information and advice, as these are important things to clarify.
posted by DrRotcod at 2:13 AM on December 3, 2014 [2 favorites]