professor patrick j doherty chair of rehabilitation
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Professor Patrick J DohertyChair of Rehabilitation Clinical specialist in CR
• Sudden Cardiac Arrest (SCA) occurs at a maximum rate of 90,000 per year in the UK
• 80% of arrhythmias are due to ventricular tachyarrhythmia and HEART FAILURE is strongly associated with arrhythmia (Bryant et al 2005, HTA Review)
• There is a need to consider exercise risk for patients with arrhythmia & those fitted with an ICD
• Are patients with arrhythmias any less fit than other cardiac patients?
Arrhythmias
Can clinical history help us predict fitness?
Is exercise safe?
It depends who does it!!
Arrhythmia and exercise:
When is a arrhythmia most likely?
Scenario:23 year old female
Normal stress test during the exercise period Patient achieves 13.4 METS
What happens next?
Normal stress test during the exercise period and achieved 13.4 METS
What happens to our 23 year old after immediate cessation ofexercise whilst standing still on the treadmill
End of exerciseAs expected heart rate reduces
62 seconds into recovery arrhythmia starts and patient collapses
Compared to exercise testing:Is cardiac rehab exercise safe?
• One nonfatal cardiac complication per 35,000 patient hours of exercise participation (Haskell 1978)
• One fatal event for every 116,000 patient hours of exercise participation (ACSM 2005)
• How does it compare to cardiology exercise testing: – Four non-fatal complications per 10,000
• (Fletcher et al 2001)
• Why such a difference?
METs 4.6 7.0 10.2 13.4 17.3 20.0
75% CR training target
Strenuous activity and risk of heart attack
Arrhythmia and normal sleep:Arrhythmias consisting of sinus bradycardia, sinus arrest and second degree heart block are not uncommon in young adults Corrado et al (2001) whilst sleeping
With aging, atrial arrhythmias and ventricular ectopy increase during sleep(Nademanee et al (1997) Shepard (1992) NEGRUSZ-KAWECKA et al (1999)
High incidence of sudden death among young male Southeast Asians during sleep. The pattern of death has long been prevalent in Southeast Asia and is associated with Right bundle-branch block Nademanee et al., (1997)
Greatest risk: exercise or sedentary periods
• People with cardiac disease are 7 times more likely to die suddenly during sedentary activities than during jogging
• The rate heart attacks is highest in sedentary people who decideto do unaccustomed vigorous exercise
• Holter monitoring of daily activity, confirms that most arrhythmia occurs at rest.
• Although some cardiomyopathy patients may demonstrate exercise induced arrhythmias most share a propensity to die fromnon-exercise-related cardiac arrest
• Among 112 patients with sustained ventricular tachycardia, only 15 (14%) were found to have exercise-induced symptomatic ventricular tachycardia
• Refs: (Giri et al (1999). Corrado et al., 2001, RODRIGUEZ et al 1990)
Arrhythmia and Sedentary behaviour:.
AED
ICD patients have taught us plenty about exercise and arrhythmia
Recent ICD Technologies:Integrated Atrial Therapies
Atrium & VentricleBradycardia sensing
Bradycardia pacing
AtriumAtrial tachyarrhythmia preventionAntitachycardia pacingCardioversion
VentricleVT prevention
Antitachycardia pacing
Cardioversion
Defibrillation
Anti-Tachycardia Pacing: well timed little shocks often not noticed by patients*Animation
ICD sensesHR = 180at rest
HR = 7
Click image to view animation
0At rest after ATP
ICD scrutiny during exercise
Hea
rt ra
te (b
pm)
50
250
100
150
200
Exercise time (minutes)1 2 3 4 5 6 7 8 9
3. Onset 4. Stabilityover time
2. Comparison of:•ECG intervals•Atria vs ventricle rate•VT or VF rate
1. ICD threshold e.g 190 bpm
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Arrhythmia
Hemodynamics Metabolism Electro physiology
Reducedparasympathetic tone
(start of exercise)
A L T E R E D
Developed from: Young et al (1984), Gibbons et al (1989), Pashkow et al (1997)
Increasedsympathetic tone
Circulating catecholamines
Psychological state
Cardiac condition
Factors that influence the likelihood of arrhythmia during exercise
Exercise considerations (cont)• Mode of exercise
– most exercises should be performed in standing, – Horizontal lying and seated exercises is associated with reduced ventricular
function (Pashkow et al 1997, Fletcher et al 2001,Pina et al (2003).– Seated exercise, especially using arm work, is associated with reduced pre
load and decreased EDV– This leads to a concomitant decrease in cardiac output compared to the
cardiac response to an equivalent exercise in standing – An increase in heart rate is often used to compensate for reduced pre load – If seated arm exercise is the only option then the intensity of the exercise
should be lowered and the emphasis placed on muscular endurance.• Breath holding and sustained isometric muscle work, especially of
the trunk, needs to be kept to a minimum in patients with low FCand arrhythmia risk
Exercise considerations (cont)• A note of caution is required for those few patients who are at
risk of ICD lead problems
• This situation is often known immediately post operatively and your ICD implant team will have informed you about it.
• In these circumstances it is important to avoid excessive shoulder range of movement and or highly repetitive vigorous shoulder movements
• Light to moderate strength activities performed within a normal range of movement, that closely match functional daily activities have been used successfully in patients with an ICD.
Cardiac rehab patient characteristics• Demographics based on the literature
– mean age of 48 (SD18) range 25-74 yrs
– IHD, DCM, valvular heart disease, ARVC and Brugada syndrome other long QT conditions.
– Mean LVEF of 36% (SD15) (40% of patients < 30% LVEF)
– Mean implantation period 10 (SD 8) months range 3-24
– Mean BMI of 26 (SD 6)
– 1/3 more men than women
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Mean ET time +/- 2 standard errors
maintenancerehabbaselinepre base
Exer
cise
tes
t ti
me
(sec
onds
)800
700
600
500
400
300
10 minutes
*-p=0.002-*
*-p=0.001-*
*? Reliability*
FC & RPP relationship (N=13)Fitchet, Doherty, Bundy, Bell, Garratt, Fitzpatrick (2003) Heart
METs
111098765
RPP
(HR
x s
ysBP
x 0
.01)
240
220
200
180
160
140
120
100
80
60
maintenance
Rsq = 0.1510
rehabilitation
Rsq = 0.3080
base
Rsq = 0.3700
16maintenance
rehabbase
maintenancerehab
base
Mea
n H
AD
sco
res
+- 2
SE
20
18
16
14
12
10
8
6
4
2
0
Clinical level
Anxiety Depression
*---p=0.001---* *---p=0.001---*
The context for arrhythmia risk during exercise:
1. Least physically active people 2. Highly emotive activities 3. Intense start to exercise4. Unaccustomed to the mode of physical activity 5. High relative exercise intensity6. Sudden cessation of exercise
Key message:• Regular skilled exercise incorporating warm up with a self
monitored moderate intensity of exercise followed by a graded cool down is the proven way to reduce the risk of exercise related arrhythmias.
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