Download Absolute and relative exercise risk for patients with arrhythmias

BACR Conference
Exercise risk for patients with arrhythmias:
a safe and pragmatic approach
Prof. Patrick Doherty
[email protected]
Question?
– Are all patients with arrhythmia and those with
an ICD truly high risk?
– We know exercise is effective so why not allow
patients with arrhythmia to be benefit?
– Is it safe?
• Does the type of exercise matter
– How to exercise with reduced risk?
Why is exercise still considered risky: Paradox!
A lack of regular physical activity and exercise carries a higher risk
for early heart disease and premature death. However, sometimes
trained and apparently healthy athletes die suddenly during or
immediately following exercise
For example
James Fixx, the celebrated American marathon
runner wrote, prior to his premature death from a MI,
"...runners are much like ordinary mortals. They can, sad to say, get
sick. They can even die”
Arrhythmia risk in people presumed healthy:
USA data on marathon running (vigorous by any definition) over a
30-year period (215,413 runners) found the overall prevalence of
sudden cardiac death during the marathon was thus 0.002%,
strikingly lower than for several other variables of risk for
premature death.
The authors concluded that:
Although highly trained athletes may harbor underlying and
potentially lethal cardiovascular disease, the risk of sudden cardiac
death associated with marathon running was exceedingly small
(1 in 50,000)
Timothy D Noakes http://www.sportsci.org/jour/9804/tdn.html
How often and where does arrhythmia occur?
• Sudden Cardiac Arrest (SCA) occurs at a maximum rate
of 100,000 per year in the UK with a 5% survival rate
• 80% of arrhythmias are due to ventricular
tachyarrhythmia and HEART FAILURE is strongly
associated with arrhythmia (Bryant et al 2005, HTA Review)
• Question. Is exercise to blame for this rate of death:
• Answer: NO
• Why: Because 70% of UK adults are considered sedentary so
exercise, alone, can’t explain the incidence of SCA
What does the literature say about the likelihood
of cardiac events with exercise
Beckerman et al (2005) more often than not only vigorous testing and vigorous
exercise is effective at provoking arrhythmias.
Pina et al 2003: between 4 to 20% of MI’s occur during or soon after exercise
and the risk increases in persons who do not regularly exercise
Pigozzi et al (2004) found that vigorous exercise training is not associated with
prevalence of ventricular arrhythmias in elderly athletes.
Lauer et al (2005) Men whose heart rate decreased less than 25 beats in the
minute after they stopped the exercise test more than doubled their risk of
sudden death than those whose rate returned to normal faster.
Thompson et al (2003) approximately 5% to 10% of myocardial infarctions are
associated with vigorous physical activity in novice performers
Belardinelli R. (2003) Exercise can induce or prevent arrhythmias dependent on
dose
Conclusion: The relative risk of both exercise-related myocardial infarction and
sudden death, due to cardiac arrest, is greatest in individuals who are the
least physically active and perform unaccustomed vigorous physical activity
Greatest risk: exercise or sedentary periods
Normal sleep:
Bradyarrhythmias consisting of sinus bradycardia, sinus arrest and
second degree heart block are not uncommon in young adults
Corrado et al (2001)
With aging, bradyarrhythmias decrease in frequency while atrial
arrhythmias and ventricular ectopy increase (Nademanee et al (1997)
Shepard (1992) NEGRUSZ-KAWECKA et al (1999)
Sedentary behaviour:
People with cardiac disease are seven times more likely to die
suddenly during sedentary activities than during jogging (moderate
activity)
Giri et al (1999) The rate MI with vigorous exertion was 12 times
higher than at rest, and the risk was greatest among the least active
Holter monitoring of daily activity, including rest, is more
effective, than exercise testing, at revealing cardiac arrhythmia
Arrhythmia risk cont.
•
Although some ARVC/D patients may demonstrate exercise induced,
catecholamine related, arrhythmias those with right ventricular anterior wall
involvement share, along with patients with Brugada, a propensity to die from
non-exercise-related cardiac arrest (Corrado et al., 2001)
•
Among 112 patients with sustained ventricular tachycardia, 15 (14%) were
found to have exercise-induced symptomatic ventricular tachycardia. Re-entry
at any time of the day or night is the most likely electrophysiologic
mechanism (RODRIGUEZ et al 1990)
•
Between 1981 and 1988, the Centers for Disease Control and Prevention
reported a very high incidence of sudden death among young male Southeast
Asians who died unexpectedly 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)
•
Habitual snoring has long been associated with an increased risk of sudden
death during sleep. In patients with clinically significant obstructive sleep
apnoea, there is reasonable information indicating excessive mortality in the
absence of treatment. This mortality is predominantly cardiovascular and
tends to occur during sleep. Shepard, (1992)
Factors that influence the likelihood of arrhythmia during exercise
Autonomic
neural dominance
Circulating
catecholamines
A
Hemodynamics
L
T
E
R
Psychological
state
E
Cardiac
condition
D
Metabolism
Electro physiology
Arrhythmia
Reduced
parasympathetic tone
(start of exercise)
Developed from: Young et al (1984), Gibbons et al (1989), Pashkow et al (1997)
9
How likely is arrhythmia
during Exercise testing?
reason for ending test arrhythmia
DVLA
Count
3
number
tested
149
percentage
occurance
2.0%
angina
34
755
4.5%
arrhythmia
76
279
27.2%
General assessment
3
80
3.8%
chest pain
89
3707
2.4%
post MI
8
224
3.6%
dyspnoea
2
94
2.1%
post PCI
3
51
5.9%
218
5339
4.1%
a
test reason
Total
a. Manchester Heart Centre data (2000 to 2006)
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
• How does it compare to cardiology exercise testing:
– Four non-fatal complications per 10,000
• (Fletcher et al 2001)
• Why such a difference?
***CR exercise is much easier than
vigorous exercise testing
Important points from the literature and clinical settings:
•
Most patients referred with arrhythmia tend to end the test due
to fatigue
•
Approximately 1:4 cardiac patients referred with arrhythmia
will demonstrate arrhythmias during or shortly after exercise
•
Exercise arrhythmias tend to occur at relatively high levels of
aerobic fitness (>8METs) or cardiac demand (RPP>280)
•
A very small percentage of patients referred with chest pain are
likely to end the test due to arrhythmia
•
Patients unaccustomed to vigorous exercise have a far higher
likelihood of exercise induced arrhythmia
•
Immediate cessation of strenuous exercise is an arrhythmia
provoking situation
ICD patients have taught us plenty about exercise and arrhythmia
Arrhythmia & ICD: Points to consider prior to exercise
• Adapt ET protocol and exercise regime so that warm up and cool
down are default characteristics
• Essential information required prior to exercising:
– ICD parameters:
•
•
•
•
•
–
VT or VF settings including SVT criteria
ATP or Shocks therapy
Detection threshold
Rapid onset criteria
Sustained rhythm criteria
Beta blockade usage and dose
Doherty, P (2006) British Journal of Cardiac Nursing, 1(7):327-31
ICD scrutiny during exercise
2. Comparison of:
•ECG intervals
•Atria vs ventricle rate
•VT or VF rate
Heart rate (bpm)
250
200
1. ICD threshold e.g 190 bpm
150
3. Onset
4. Stability
over time
100
50
1
2
3
4
5
6
Exercise time (minutes)
7
8
9
Important aspects of the exercise session
• Warm-up and cool down period, lasting between 10 to 15
minutes, so that the cardiovascular system has time to adjust to
increasing demand (Fletcher et al., 2001, Pina et al., 2003)
• The main part of the training programme should consist of:
– graded aerobic circuit training approaches, lasting 30 to 40
minutes
– incorporate multijoint movements with body weight and
moderate resistance
– Pacing and rating their own exertion is very important
• (ACSM, 2006a, Duncan et al., 2005, Fitchet et al., 2003,
Fletcher et al., 2001, Lampman and Knight, 2000, Pashkow et
al., 1997).
Exercise dose response
• Frequency and intensity relationship
– RCT of intensity and frequency in 492 sedentary,
healthy ♂ & ♀aged between 40 and 60 years,
• walking was the primary intervention Duncan et al. (2005).
– Walking (hard or moderate intensity) led to
significant improvement in fitness (10%) and
improved lipid profile, over two years
– This raises questions about how fit people need to be?
Defining fitness: symptom free ET outcome
18
How fit does a patient need to be?
16
14
12
UK, DVLA value
95% CI METs
10
Gender
8
Male
6
USA disability value
Female
4
N=
77
34
190
92
18 to 29
351
154
391
202
40 to 49
30 to 39
Age (years)
218
130
92
64
60 to 69
50 to 59
70 & over
Exercise considerations (cont)
• In general most exercises should be performed in standing, with
horizontal and seated arm exercises kept to a minimum.
• Seated arm exercise is associated with:
– reduced venous return, reduced end diastolic volume, a
concomitant decrease in cardiac output and increased
likelihood of arrhythmia (Fitchet et al., 2003, Lampman and
Knight, 2000, Pashkow et al., 1997).
– If seated exercise is to be performed:
• the intensity of exercise should be lowered
• the emphasis placed on muscular endurance.
• Mild leg exercise combined with arm exercise, reduces the
haemodynamic response compared with strict arm work (Toner et al.,
1990).
• Breath holding and sustained isometric muscle work of the
abdominal region, especially during arm exercise, needs to be
kept to a minimum in patients with low FC and arrhythmia risk
Meeting the minimum requirements for health
• Continuous physical activity of 30 minutes or more is
considered most effective, although multiple activity sessions
of 10 to 15 minutes duration, on the same day, have also
demonstrated significant health improvement (ACSM, 2006a,
Blair et al., 2004, Fletcher et al., 2001).
• Physical fitness is soon lost if training is not continued at a
level sufficient to maintain the effect (ACSM, 2006a, Fitchet et
al., 2003, Fletcher et al., 2001, Franco et al., 2005, Pina et al.,
2003, Rees et al., 2004).
• You need to be sure that patients have considered how and
where they will continue their moderate physical activity
programme when they finish with you.
Summary
• Arrhythmia or the presence of an ICD should not preclude
patients from exercise
• An evidence based CR exercise session is very safe and highly
effective
• The risk of arrhythmias within well designed, moderate
intensity, exercise programmes in far less than the risk
encountered as part of a normal daily life
• At the very least all patients should be advised about physical
activity:
–
–
–
–
Benefits
Safe exercise principles
Best practice
Need for a sustained approach
• If you don’t advise them no one else will!!
• Thank you for listening!
•
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•
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