 Up until the 1950’s, strict bed rest was considered to be the best medicine after a heart attack.  After discharge, moderately stressful exercise such as climbing a flight of stairs was discouraged for a year or more.

 “The patient is to be guarded by day and night by a nurse and helped in any way to avoid voluntary movement or effort” Thomas Lewis 1933  Lewis suffered a myocardial infarction at the age of 45 and gave up his 70-cigarette-a-day habit, being one of the first to realise that smoking damaged the blood vessels

 ↓20-25% in Physical work capacity after 3 wks  ↓ ml circulating blood volume after days producing orthostatic hypotension  ↑Blood viscosity predisposing to thromboembolic events  ↓10-15% in muscle mass and strength per week

 Rehabilitation starts immediately

 SO WHAT DOES THE RESEARCH SAY ??????

Research shows mortality is reduced in post cardiac event in patients who participate in cardiac rehab due to multi risk factor reduction

 Controllable vs. Uncontrollable

 Age > 60  Sex: male and postmenopausal women  Family history of heart disease  Men<55yrs  Women<65yrs

 1. SMOKING  Smokers ↑  Good news is that in the year after you quite smoking your risk of future problems drops by 50%. After 15 years your risk is as low as someone that never smoked.

 High Blood Pressure: 140/90 or >.  Immediate: After exercise systolic may decrease for several hours.  Long term: At Rest B.P may be reduced moderately

 BMI >25  waist circumference Male > 100cm Female > 90cm  Being overweight is bad for your health. Exercise can decrease and control your weight Decrease total fat and intra abdominal fat

 Diet: unhealthy diet is going to lead to obesity

 TOTAL > 5.18mmol High Cholesterol: The higher your LDL (Bad cholesterol) > your risk for heart disease. The higher your HDL (good cholesterol) the lower your risk of Coronary Heart Disease.  12 weeks of endurance training increase HDL and decrease Triglyceride levels

Diabetes > 5.5mmol/L (fasting)  Diabetes: Having diabetes puts you in the highest heart attack risk category. Prediabetic Risk of developing heart disease is high.  Physical activity can prevent and control Type 2 diabetes  Improve glucose tolerance and insulin needs

 Exercise will also help you manage stress  Decrease in anxiety and depression.  Exercise will enhance feelings of well being.

 “ Persons who remain sedentary have the highest risk for all-cause and cardiovascular disease mortality”

 Heart Rate  Resting heart rate  10 – 15 bpm  Stroke Volume (average volume of blood ejected per heart beat)  Stroke Volume   Cardiac Output  Cardiac Output 

 USA – 2 million potential candidates for cardiac rehabilitation only 10 – 20 % participate  Although physicians consider physical training is important for comprehensive care of these patients, the referral is very scarce. Doctors are vital to any cardiac rehab program.  Medical insurance

 There’s no medication that can give the same benefits without side affects

Too Young?

Prevention is better than cure

 1 death per 1.5 million episodes of exercise  The overall benefits of exercise far outweighs The small risk of exercise. Albert et al(2000)

 It is a professionally supervised program to help people recover from Heart attacks, Heart surgery and help patients reduce risk factors.

Phase 1 (inpatient): Physiotherapist Phase 2 (outpatient): 1 to 2 weeks after hospital discharge: Walking Program 2 to 6 weeks Physio/Biokineticist Phase 3 (outpatient): 6weeks up to 12 weeks following hospital discharge. Biokineticist Phase 4 (outpatient): Limited supervision if no complications after 12 weeks

 Muscle wasting  Safer exercise  Supervision  Companionship  Recovery is so much faster

 Cardiac support system  Formal rehabilitation  Guidance on medication, exercise, diet, stress control.  First of it’s kind in South Africa  Started April 2013

 Only five Blue Zones exist in the entire world where people commonly live past 100 years  Common elements:  Active lifestyles Healthy diet

 Okinawa, Japan. Women live longer in Okinawa than anywhere in the world  mountains of Sardinia, Italy  Nicoya Peninsula of Costa Rica  Ikaria, Greece where they have 50% lower rates of heart disease, 20% less cancer, and almost zero dementia.  Loma Linda, California

 "The secret of good health is to move," says 88- year-old Hoei Tabaru, who keeps in shape spearing octopus from the sea, picking vegetables in his garden and by biking through his village on the island of Okinawa. Tabaru, who has never driven a car, hopes modern technology will not transform island life. "The world is too easy today," he says, "at least for an old man like me." Other traits the people living in the blue zones have in common include, less stress and more socializing, strong emphasis on family, a fresh natural plant based diet (eat lots of beans), very little red meat and they exercise daily. Living their lives with a sense of purpose was a big factor. It insures they look forward to getting up in the morning.

 U.S. National Institute on Aging, scientists focused on these longevity  30 % is to have good genes  70% right lifestyle

 Not nomadic anymore (activity has decreased)  Alcohol  Diet has changed from Bushfood to maize  Stress

 FREQUENCY  INTENSITY  TYPE  TIME  PROGRESSION OF PHYSICAL ACTIVITY

 According to ACSM 4 –7 days per week.  IDEAL: First 2-4 weeks walking daily  4-6 weeks 2 days supervised cardiac classes 4 days walk  At 6 – 12weeks: 3 days supervised classes (biokineticist) and 3 days walking.  When starting with resistance training a day rest between is recommended.

 The American Heart association recommends a Target Heart Rate of 40 –75% of Maximal Heart Rate.  Maximum Heart Rate: 220 –Age  Karvonen Method: Cardiac Patients THR = (220-Age) – RHR x (intensity) + RHR Nb: Beta blockers subtract 10bmin  Beta-Blocker decreases Heart Rate  Exercise intensity can also be prescribed at a HR below the ischemic threshold. A pacemaker is normally set at 10% below ischemic threshold.

 Radial or Carotid pulse palpitation  Heart Rate Monitor  BORG SCALE (Rate of Perceived Exertion)  Especially important to use in initial rehabilitation and heart transplant patients. After 1 year 1/3 of transplant patients exhibit normal heart rate response.  RPE of 3 –5 (40 –60%) initially  and 4–7 (50 –75%) after 12 weeks

 A variety of exercises is recommended to improve all components of physical activity  Cardiovascular  Muscular strength and endurance  Flexibility  Balance and agility

 According to American Heart Association 20 – 60min depending on your intensity.  i.e.: the higher your intensity the lower your duration  Patients with limited capacities should exercise daily but shorter sessions eg: 10min

 Progress over a 3-6 month period to a level of moderate (50% MHR) to vigorous exercise (75%MHR).  Do exercises that you enjoy.  In addition to formal exercises patients should be encouraged to gradually return to general activities  eg: household chores, yard work and shopping.

 The truth is until now patients have received little councelling about this.  American Heart Association (2013) have just published guidelines.  A study last year on 1900 heart attack patients revealed the following.  →One third of women received instructions about resuming sexual activities after they left hospital  →Less than half of men got councelling  →44% of these patients still hadn’t had sex a year later.

 After a cardiac event some men experience problems with or maintaining an erection  Can be emotional stress or in rare cases by medication such as beta blockers  Consult with GP  Men who use medication for erectile dysfunction must never use Nitroglycerine for angina. Its dangerous as your B.P can fall dangerously low which can lead to death

 Fewer than 1% of Heart attacks come from having sex.  No evidence that having sex ↑ your risk of having another heart attack.  Like any exercise, sex is good for the heart

 You can have sex as soon as you feel ready (normally 4-6 weeks) after event.  Avoid having sex immediately after a heavy meal  Don’t drink too much alcohol before having sex  Find a position that is comfortable for you  Ask your partner to take the more active role.  Consult your doctor should you get any chest pain during sex

 Chest pain  Abnormal shortness of breath  Unusual Fatigue  Dizziness  Palpitations

How…  - Slow walking or biking with  no/light resistance Why…  Gradually improves blood flow to heart and exercising muscles  Increase body temperature  Helps prevent injuries, muscle soreness

Initially use interval training (fartlec)  Endurance: Rowing, step ups, more cycling, walking, swimming  Muscle strength: Light weights, resistance bands, own body exercises

How…  - Easy walking or biking with no resistance, Why…  Prevents muscle stiffness and soreness  Return the heart, lungs, and muscle activity to resting levels  Cool down will minimize the potential for Arrhythmic episodes

 Any exercise is better than no exercise  Initially a formal program is best  Combination of endurance and strengthening to encompass all parts of the body.