UPDATE on Exercise

[Lisa Salberg]

The Right Workout for Those With Congenital Heart Defects

BODY:

TUESDAY, June 8 [HealthDayNews] -- Children, teens and young adults with
genetic heart disease can exercise recreationally but need to get advice from
their doctors about the kinds of physical activity that are safe, a new American
Heart Association scientific statement recommends.

The statement, published in the June 7 issue of Circulation, is meant to help
doctors counsel patients who have an increased risk for sudden death while they
're doing physical activity.

This includes people with a number of kinds of genetic heart disease such as:
hypertrophic cardiomyopathy; arrhythmogenic right ventricular cardiomyopathy;
Marfan syndrome; and ion channel diseases, including long QT syndrome, Brugada
syndrome and catecholaminergic polymorphic ventricular tachycardia.

The statement was prepared by the Working Groups of the American Heart
Association Committee on Exercise, Cardiac Rehabilitation and Prevention, and
the councils on Clinical Cardiology and Cardiovascular Disease in the Young.

"This document does not address organized competitive sports, including
community sports teams, school and professional sports. Rather, it covers what
these patients can do in a wide range of recreational, sporting and physical
activities outside the competitive arena," Dr. Barry J. Maron, association
committee chairman and director of the Hypertrophic Cardiomyopathy Center,
Minneapolis Heart Institute Foundation, said in a prepared statement.

The statement makes it clear that people with these genetic heart diseases
can and should exercise.

"The impetus of the document is to emphasize that the mere presence of a
genetic cardiovascular disease should not be regarded as a reason to be
sedentary. Instead, this document tries to discern which exercises are
preferable and which should be avoided, as well as help clinicians make
decisions about how they advise their patients when it comes to recreational
exercise," Maron said.

[Lisa Salberg]

Re: UPDATE on Exercise

This is a partial reprint of the article:

The panel also found it useful to express specific exercise recommendations in terms of those activities that should be avoided by patients with clinically diagnosed GCVD:


"Burst" exertion (or sprinting), characterized by rapid acceleration and deceleration over short distances. Exercise of this type is encountered in a variety of sports, such as basketball (particularly full-court play), soccer, and tennis. Therefore, preference is given to recreational sporting activities such as informal jogging without a training regimen, biking on level terrain, or lap swimming, in which energy expenditure is largely stable and consistent, even over relatively long distances or periods of time.

Extremely adverse environmental conditions, which may be associated with alterations in blood volume, electrolytes, and state of hydration and thereby increase risk, such as greatly elevated or particularly cold temperatures disproportionate to that which the athlete is accustomed to in temperate climates (ie, >80°F [27°C] and <32°F [0°C]), high humidity, or substantial altitude.

Exercise programs (even if recreational in nature) that require systematic and progressive levels of exertion and are focused on achieving higher levels of conditioning and excellence, as in road running, cycling, and rowing. Patients with GCVDs such as HCM, in which limiting dyspnea may occur with exercise, should be discouraged from any exertion that provokes these symptoms. These individuals are also advised against systematic training during which they are extended beyond the physical limits imposed by their underlying disease and the average aerobic state expected at that age.

Excessive participation in sporting activities that otherwise would be regarded as recreational if performed in moderation, eg, downhill skiing continuously over an entire day versus more limited and selective skiing over the same time period.

Exercise-related and adrenergic-type activities or stress that conveys a risk for cardiac events, specific to certain disease states. For example, in LQTS, swimming, abrupt loud noises (such as from a race starter’s pistol), and diving have been implicated as triggers for sudden death, particularly with certain mutant genes (ie, KCNQ1 [or LQT1] for swimming and KCNH2/HERG [or LQT2] for auditory triggers).1,3,4,8,55–61 However, such laboratory-based molecular information is unlikely to be available to clinicians prospectively making exercise recommendations. Patients with rare conditions such as CPVT,13,15 in which many forms of exercise are associated with catecholamine release that triggers ventricular tachycardia, should be cautioned against virtually all forms of vigorous physical activity. The same restriction should be adopted for that subgroup of ARVC patients that shares with CPVT both effort-induced polymorphic ventricular tachycardia and a mutant ryanodine receptor.10 It is also of note that a temperature-dependent dysfunction of the SCN5A gene for cardiac sodium channel has been characteristically observed in patients with Brugada syndrome (and Thr1620Met missense mutation).74 This increased temperature sensitivity could predispose some Brugada patients to life-threatening arrhythmias either during a febrile state or when body temperature increases during intense physical exertion.

Intense static (isometric) exertion, such as lifting free weights, may prove to be adverse by inducing a Valsalva maneuver and dynamic left ventricular outflow obstruction in HCM75 (as well as the risk for traumatic injury in the event of impaired consciousness) or by increasing wall stress and weakening of the aortic media in Marfan syndrome, particularly if aortic dilatation is already present.62,73

Patients with diseases associated with impaired consciousness (eg, syncope and near-syncope) are subject to considerably higher risk for traumatic injury while engaged in certain sports such as free weight and bench-pressing maneuvers, downhill skiing, diving, ice hockey, rock climbing, motorcycling, and horseback riding, and this factor should be taken into consideration in making recommendations to individual patients with GCVD.

Although data are lacking, it is reasonable to specifically caution patients with GCVD, particularly those with catecholamine-sensitive or auditory-triggered arrhythmia syndromes such as LQTS and CPVT, against amusement park rides (eg, roller coasters and thrill-related or frightening rides) because these are associated with intense stress and emotion due to sudden acceleration in heart rate and abrupt changes in centrifugal or centripetal forces.

Paired athletic activities in which a second party may be at risk should the individual with GCVD suddenly incur bodily injury or impairment of consciousness and incapacitation, eg, in recreational sports such as scuba diving and rock or mountain climbing. Water sports such as scuba diving or diving from platforms into pools are also generally unacceptable by virtue of their exposure of patients with GCVD (for whom syncope is a not-uncommon manifestation) to the risk of underwater drowning and reduced probability of rescue.

Extreme sports (such as hang gliding and bungee jumping) are activities that are best avoided because they require the expenditure of particularly substantial physical energy and incur psychological demands that are exceedingly unpredictable, placing individuals with GCVD in compromised circumstances in which the likelihood of injury is substantial and the possibility of rescue from a traumatic or cardiovascular event is greatly reduced.

Concomitant use of substances or compounds professed to promote enhanced physical performance but that also harbor the potential for adverse effects, particularly when associated with disease states or extreme environmental conditions, ie, cocaine, anabolic steroids, or dietary and nutritional supplements such as ma huang, an herbal source of ephedrine (ie, elemental ephedra) and a cardiac stimulant that is potentially arrhythmogenic.76–79

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Physical Education Class
Issues related to recreational exercise often arise with regard to compulsory physical education classes in junior high or elementary school. In the former, the required levels of exercise in physical education classes vary considerably but often involve vigorous exertion and circumstances that are difficult to control. For example, although many components of such classes may be truly recreational, others clearly are not and can be regarded as competitive in nature, ie, prolonged aerobic events such as the traditional timed 600-yard (or 400-meter) run and the President’s Physical Fitness Award. On the other hand, in elementary school physical education class, sports activities may involve nothing more than innocent play.

Although in the view of some very conservative clinicians, it might seem most prudent for patients with GCVDs to largely avoid any involvement in school-structured physical education, we recognize that profound personal and psychological stigmata can be associated with such selective, targeted, and often unnecessary gym class prohibition. Indeed, in some states, such children are placed in alternative health classes, which results in further ostracism by their peers. In the event that the patient and family judge it important, for social and peer-related reasons, to retain some level of participation and normalcy among peers (as is often the case), careful and detailed review of physical education class requirements should be undertaken by the parents in concert with school officials and their physician, during which the principles of safe recreational activities are agreed upon.

This process will define acceptable portions of the curriculum and exclude activities that can be regarded as intense or competitive (particularly those involving burst exertion) although it may be challenging to distinguish recreational from competitive activity under these circumstances. In this regard, it should be determined whether physical education instructors will agree to (or are capable of) monitoring the patient’s activity level in accord with the medical recommendations. Therefore, the degree to which a child or adolescent with GCVD can or should participate in physical education class requires a large measure of individualization.

[Darren1]

Re: UPDATE on Exercise

WOW!! That is awesome news. Somehow, I knew that being inactive was not good for a HCM heart any more than being "over active".

[Lisa Salberg]

Re: UPDATE on Exercise

I knew you would like this article Celtic!

[Darren1]

Re: UPDATE on Exercise

what made you think that I'd like someone telling me it's ok to be active?!? I'm not an exercise freak.. no, really.. I'm not!

[LynnS]

Re: UPDATE on Exercise

Lisa,

Am I correct in assuming that doing periodic sets of 'double-time' during splash aerobics class is considered a 'burst exertion' and should be avoided? For the record, I am not doing the short stints of 'double-time' but am rather keeping a constant pace throughout as best I can. Otherwise, I am thinking that splash aerobics is a decent option for aerobic workout...thoughts??

Just curious,
L

[Burton Borrok]

Re: UPDATE on Exercise

For years and years whenever I got in a pool I was instantly cold and consequently started swimming right away. In under a minute I was panting away and getting into trouble, although at the time I didn’t know why.

Twenty plus years ago, when I first moved to California, we had a pool in the complex that soaked up the sun all day. I started swimming laps, and got to the point where I could do twenty smooth, continuous laps without stopping or getting over tired. Our development where I live now has a gorgeous pool, restricted to homeowners and guests – but mostly empty. I wouldn’t even consider jumping in the pool again – I don’t think I could walk home from such an attempt. Geez, I don’t think I could walk home from the pool – period.

For those of you who can enjoy splash aerobics – I envy you. About doing such things as double-timing in the pool, the buoyancy of the water will help, and I would assume it would depend solely on your own body’s ability to deal with it. If you feel the strain, you’re overdoing again. If it’s pain free, it’s probably good for thee. Just don’t do so much that you collapse later.
Burt

[michael obrien]

lisa that was a great article I cant believe I hadnt seen it yet.I can do some things like walk 1-2 miles lift 4 lb weights etc.some days I feel like I can do more.--- other days I dont feel as well.I was always wondering about scuba diving .It was something that I always wanted to try before I left this planet,I wonder if anyone out there has done it.I wish Ididnt fall back into self pity now and again.but this article gives the alls clear to alot of things.I just have to figure out how to stay consistently motivated be well all mike

[Lisa Salberg]

Sorry dear NO scuba ... there are many other things you can do
Snorkel may be possible WITH a buddy and in calm waters - talk to your doctor about individual cases.

Lisa