Many people are unaware of the importance of aerobic exercise in helping regain one’s sense of wellness and health. It has many beneficial effects on the body and mind. You only need to think back and remember the exhilaration you have felt after vigorous physical exertion to realise this. It is important that you make exercise a regular part of your life.
Years of inactivity may have been one of the contributing factors to your having developed heart disease. On the other hand, it is possible that you may have been pretty active and still developed a coronary due to other factors. Even marathon runners are known to get heart disease especially if they have a genetic heritage, a Type A personality or an unhealthy lifestyle.
Exercise by itself is not enough. Do not lull yourself into a false sense of security that if you begin to exercise regularly, it will be enough. You must be careful not to overdo the exercise as many people who have had a heart attack tend to do. There is evidence to suggest that people who exercise for prolonged periods may have a higher risk of recurrence than those who exercise moderately. One theory is that vigorous exercise leads to the formation of free radicals, which damage the walls of the coronary artery. However, it is important that you get at least half an hour of aerobic exercise daily.
Mr Bhalla, a 44-year-old businessman had, in his own words, lived a ‘debauched’ life. He had smoked 40-60 cigarettes ever since he started smoking in school. He would stay up late partying with his ‘lady friends’ as he put it, all the while downing generous quantities of alcohol. He rarely rose before 10 in the morning. For Mr Bhalla exercise was a dirty word. One day he was suddenly struck down by severe chest pains. The doctor he consulted made a diagnosis of coronary insufficiency and started him on medication. Mr Bhalla stopped smoking and joined a gymnasium where he worked out for three hours every morning. Within a few months, with the exception of exercise, he had gone back to his old lifestyle and had even started smoking again.
Unfortunately there was no change in the underlying pathology in the blood vessels. One night he woke up with a severe crushing sensation in the chest and was moved to hospital. The ECG showed a large infarct. Luckily for him the attack was aborted with streptokinase. Mr Bhalla told his cardiologist that he had been certain that exercise would prevent him from having another attack. The physician told him that an angioplasty could help but it would be a waste unless he stopped smoking and modified his lifestyle. Mr Bhalla’s answer to this was, “I’ve always believed that I would die young, so let me make the most of life.” Three months later he had another fairly extensive infarction and was admitted to hospital. Incorrigible as always, he was caught smuggling in some alcohol and cigarettes!
Once you know you have coronary artery disease you should be cautious about starting vigorous exercise such as jogging, tennis or squash except under medical supervision. You will have to accept the fact that your arteries are diseased. Before starting any exercise programme other than walking, it is a good idea to have an exercise stress test and thereafter never exceed a level of more than 10-20 beats per minute less than the level at which abnormalities appeared on the ECG. Check with your doctor for the exact pulse rate that is safe for you.
There is no hurry and you should allow enough time for the disease to regress. If you wish to restart vigorous exercise, it is a good idea to train with an exercise physiologist as part of a cardiac rehabilitation programme. It is preferable not to get involved in competitive sport till you have made substantial changes in your Type A behaviour.
Numerous research studies have shown the health benefits of exercise, especially in that it promotes health and longevity. People who exercise regularly live longer and have a lower death rate from a host of diseases including cardiovascular disease and even cancer. It also promotes a general feeling of wellbeing, health and fitness. Exercise improves the strength of the bones and prevents their thinning — known as osteoporosis. People who exercise regularly feel much more active and are able to get more done. Most important exercise can bring back a sense of pleasure in life as it is an excellent antidepressant and mood elevator. Exercise is known to release large quantities of endorphins that stimulate the pleasure centres of the brain.
Mr Verma’s case demonstrates the importance of exercising regularly. Tired all the time, he was unable to concentrate on work. His family physician had him undergo a number of tests but could find nothing wrong. So he started Mr Verma on a course of antidepressant medication which made him feel worse. He consulted Dr Nishant, a psychiatrist, who while talking to him discovered that Mr Verma led a totally sedentary lifestyle.
He would get up in the morning, have a quick breakfast and drive off to the office. Late in the evening he would return home to watch TV, eat his dinner and go to bed. He said he was too tired to have sex with his wife. The psychiatrist suggested an exercise routine but Mr Verma initially ruled it out saying, “I don’t get any time at all. My business keeps me busy and I’m too tired when I get home at night.” Dr Nishant then started Mr Verma on a course of deep hypnotherapy to motivate him towards becoming physically active. After a few sessions of hypnotherapy Mr Verma started getting a great desire to exercise. On his return each evening, he would park his car a kilometre from the house and walk home. Surprised at how much better he felt, he enrolled in aerobics and yoga classes. A few months later Mr Verma sent Dr Nishant a thank you note, in which he mentioned that he was feeling full of energy again and was getting much more work done and was enjoying an active sex life.
Exercise has a beneficial influence on the heart. Studies show that those who are more active have lower rates of heart disease. Athletes and active people have a lower resting heart rate; hence the heart has to do less work. Similarly in response to exercise, the increase in heart rate is much less in an active person than in someone sedentary, showing that the heart becomes more efficient.
Exercise also has the effect of increasing the number of small vessels in the heart, thereby helping the development of alternative blood supply called collaterals. In case of a block, these collaterals reduce damage to the heart by providing alternative channels of blood supply. Exercise also benefits the blood cholesterol. It raises HDL cholesterol and decreases levels of LDL cholesterol and the triglycerides. This has a significant effect in preventing the progression of your disease and when combined with dietary and other changes, can lead to regression of the atherosclerotic plaque in your arteries.
There is a strong link between obesity and coronary artery disease. People who exercise regularly are much less likely to be overweight; while overweight patients with coronary artery disease who exercise regularly after a coronary, can lose weight. This reduces the work the heart has to do as there is less weight to be carried and less of fat tissue to be supplied with blood. The effect of exercise on the mind reduces anxiety and depression, both of which are known to increase the chance of another heart attack. More importantly, it improves the quality of life as it makes one feel fit and this makes life seem worth living.
You can develop a safe and enjoyable exercise programme, once you have an understanding of the effects of the different types of exercise on your body. It is a good idea to have a menu of exercise as this will help prevent you from getting bored with doing a single type of exercise. Apart from exercise, you also need to become more active by undertaking more physical activity.
You will hear much about aerobic and anaerobic exercise and this can be confusing even to a professional. These terms refer to the type of energy-producing mechanism and the mode of oxygen consumption during exercise. To understand the difference between aerobic and anaerobic exercise one must remember that the muscles of the body use oxygen to burn the nutrients to produce energy.
During exercise, the body’s oxygen requirement rises. If the respiratory and circulatory systems are able to deliver enough oxygen to the tissues, the body uses the aerobic metabolic pathway to produce the energy. If not, then the body uses the anaerobic pathway to provide the extra energy for the exercise. Very vigorous or sudden short bursts of exercise trigger the anaerobic pathway and this leads to an oxygen deficit/debt which is gradually made up when the person rests. The anaerobic metabolic pathway is not as efficient as the aerobic pathway and produces many waste products that take time to clear.
On the other hand, aerobic exercise uses glucose and fatty acids to produce energy, with adequate oxygen available at the tissue level. This type of energy production is much more efficient than the anaerobic type and has the advantage of burning up fats. Aerobic exercise is slower and more prolonged than the anaerobic type. There is a training effect and over a period of time one usually has to increase the intensity with which one needs to exercise to achieve the same effect.
On the whole, the body becomes much more efficient in people who exercise regularly because they can exercise at a higher intensity and still remain in the aerobic range. There is a difference between becoming active and doing aerobic exercise and this is an important distinction that you need to understand if you want to get the full benefit of exercising. It is aerobic exercise that increases the HDL levels and has some of the other beneficial cardio-protective effects.
During aerobic exercise, the heart rate rises. It is important that you keep it below that recommended by your doctor. Your cardiologist will advise you as to the level you should exercise at, during each stage of your recovery. Do not try to implement an exercise programme without the advice of your doctor.
Isotonic exercise is a form of exercise where your muscles move, as in an exercise workout or aerobic exercise. One gets this form of exercise while doing weight training with light weights. The Isotonic form of exercise helps build strength and endurance. One should aim to do this at least thrice times a week, or ideally, five times a week.
Isometric exercise is a form of exercise, where your body exerts pressure against resistance and there is not too much movement. Exercising with heavy weights or devices such as a Bullworker or hydraulic exercise machine also provides this type of exercise. Isometrics do increase muscle mass but also cause a rise in blood pressure and hence should be avoided if you have hypertension. One needs to also understand the difference between training for strength and for endurance. When a person trains for strength, he lifts weights and does other types of exercise that increase the ability to produce short bursts of energy. On the other hand, in endurance training one builds up stamina and the ability to continue exerting oneself over a long period. Endurance training relies mainly on sustained aerobic exercise.
A minimal amount of exercise may be enough to maintain one’s health i.e. absence of disease. On the other hand, fitness is the ability to do sustained exercise and to feel good. The connection between fitness and health may be somewhat unclear. A marathon runner may have coronary artery disease without recognising it. He may be able to run long distances and still have a heart the bestseller attack, as happened to Dr James Fixx, author of The Joy Of Running. On the other hand, a person who walks for half an hour, thrice a week, could be as healthy as someone who runs 20-30 miles every week.
In this programme one will aim for both fitness and health. Research shows that 80% of the benefits of exercise are received by those who do a moderate amount of physical exertion. If you walk for half an hour, five times a week or an hour, thrice weekly you will get most of the benefits of exercise. To get the effect of increased fitness one needs only to increase the speed at which one walks, so that one enters the aerobic range as indicated by your pulse. Remember that it is more harmful to start an intensive exercise programme and then stop. Aim for the type of exercise that you think you will be able to integrate into your lifestyle on a permanent basis.
The aim is to build the capacity to undertake slow prolonged periods of exercise. To begin with there is nothing better than walking. If you observe the precautions it is impossible to harm yourself by walking. The goal is, over a period of time, to build up your exercise capacity so that you can walk for at least half an hour 5-6 times a week, or for an hour thrice a week, at a speed that allows you to remain at the aerobic level. Some people with heart disease are able to do much more but it is wiser not to overdo it for the first year.
In addition to walking, it is useful to do some stretching exercises that make your body more flexible and strong. Yoga offers excellent stretching exercise and is a part of the Ornish programme. There are other body awareness and stretching routines that are equally effective.
I do not recommend that you try to learn yoga from a book. You may harm yourself doing the asanas or postures without supervision. People with high blood pressure would be advised not to do any postures which require much straining. Yoga should be learned from a good teacher who is well-versed in its use with cardiac patients, since not all asanas should be done and certain of these may cause difficulties. As there is no dearth of yoga teachers in India this should not be an obstacle.
Remember that yoga mainly involves stretching and is not a substitute for aerobic exercise. Some individuals have started groups modelled after Dr Ornish’s reversal of heart disease programme, using yoga and diet. They have however, eliminated the personality and psychological group therapy and are therefore likely to be less effective.
Most coaches at gymnasiums or at commercial exercise centres have a very limited knowledge of the effects of exercise on people with medical conditions so be careful when taking their advice. Many coaches are used to training sports persons and attempt to push people to do a lot of exercise. This can be dangerous for a coronary patient.
It is very important that you remain active throughout the day. Many heart patients adopt the sick role and allow others to do everything for them. Remember that you can do things for yourself and even if you did not earlier, you should start doing so now. Walk to the other end of the house to get yourself a glass of water or do your own small odd jobs. Get out of the car to walk the final mile to the office or to your home. Park some distance away from any place you are going to, so that you can walk a little.
You could also take up a hobby such as gardening or carpentry which requires some physical effort. Remember that activities are health promoting but may not be aerobic exercise. A lot of patients say, “My work requires me to be quite active and so there is no need for further exercise.” Most activities are ‘stop and start’ exercise and may not raise your heart rate to bring it into the aerobic range. Even if it does, it is for a short while only. Aerobic exercise requires that your pulse rate be raised to 50% of your maximal heart rate for at least 20-30 minutes depending on the intensity of the effort.
There are many types of exercise which provide aerobic exercise and you should choose the low intensity ones. The ideal aerobic exercise is walking and this can be combined with walking meditation such as mindfulness training or a smiling meditation. Good alternatives to walking are swimming and exercising on a stationary exercise bicycle or walker. Sports such as golf are ‘stop and start’ exercises and do not offer much aerobic exercise but provide plenty of activity, companionship and pleasure for those who enjoy golf. Walking is the healthiest form of exercise for a patient with cardiac disease as it is difficult to harm oneself while walking and it is much less likely that you will overdo things.
One should only start an aerobic walking programme four weeks or more after an attack or surgery, unless you have been advised otherwise by your doctor. It is wise to amble and stroll for the first few weeks after an attack. Later, it is desirable to gradually increase the amount of exertion by walking slightly faster till your heart rate as measured by your pulse is 50% of your maximum heart rate. As you continue, due to the training effect you will find that you will have to exert yourself a bit harder to keep your heart rate in the training range. When you can comfortably walk for half an hour at the 50% level then you may want to increase the training rate to the 60% level till you can comfortably do it for half or even one hour.
Once you can do a fair amount, you may want to attempt other types of exercise to provide some novelty, such as swimming or cycling on a level road. You should be careful not to exceed your target training pulse rate. To do this, work out slowly and take your pulse often. While many patients do go back to playing high intensity games like tennis, squash or running, it is generally safer to avoid them. While the risk of anything happening while you are exercising is low, it is real. And once you have coronary disease it is definitely advisable to avoid the extra risk. If you do want to get back to vigorous exercise it is safer to do it under the close supervision of your doctor or guided rehabilitation programme.
It is good to include some form of indoor exercise in your routine as you may not want to exercise outdoors or it may not always be possible to do so. Having a plan that includes indoor exercise can help you stick to your exercise programme. The forms of indoor exercise recommended are a stationary exercise bicycle or a hydraulic stepper. You need to avoid an exercise bicycle with a rowing attachment as pedalling and rowing at the same time can be a very high intensity workout. Keep the resistance at the lowest level to start with and go slow. Another cheaper alternative is to have a small stable 6” high stool or step, which you can step on and off. Avoid running on the spot or skipping with a rope. If you plan to do a low intensity aerobic workout, plan to do it on a mattress or padded surface to avoid injury. Also ensure that the shoes you wear during exercise are comfortable well-padded sports shoes. This is so even if you are in great shape and doing an indoor aerobic workout.
Some cardiologists feel that it is enough to walk a little and to gradually increase the amount as long as one does not feel any discomfort. While this approach may be enough for the average person, it is not advisable if you want to obtain the maximum benefit from your exercise. Your training goals are related to the measure of fitness that you desire. If you walk thrice a week for an hour or half an hour 5 days a week, it will provide you with enough aerobic exercise to be healthy and fit. Your aim while walking or doing any other exercise is to raise your resting pulse rate to 50-60% of the maximal pulse rate at your age level. If you want to do more intensive exercise than that, it should be closely supervised by your doctor and, if possible, an exercise physiologist.
The maximum heart rate that is allowed varies with age. To calculate it, subtract your age from 220. For healthy people it is recommended that they do not exceed 80% of their maximum heart rate. With coronary artery disease it is better not to exceed 70% and that too, after some months of training. If you have been inactive or have recently been found to have heart disease then you should start at levels below 50% of your maximal heart rate and gradually build it up at a rate no higher than 5% every 2 or 3 weeks. Let your cardiologist advise you about the rate at which you should increase your level of exercise. Remember there are two components to exercise, intensity and duration. By keeping your pulse rate within the exercise levels recommended you will be safe as long as you are aware of the effect it is having on you. If you experience any discomfort or tiredness, cut back temporarily. Begin by trying to walk for a few minutes and then gradually build up the length of time, without hurrying it at all.
Taking your pulse is quite easy. All you need do is to place the pads of the first and second finger about half an inch above the wrist line on the side of the thumb. If you vary the pressure a little you should feel the pulsation of the artery. Count the beats for ten seconds starting from zero. When you multiply it by 6 (there are sixty seconds in a minute), you will get your heart rate in beats per minute. Practise taking your resting pulse until you are confident that you are doing it right.
Avoid taking your pulse for a full minute while exercising. Instead, count your pulse for ten seconds and then multiply it by six. You could get inaccurate results if you actually take your pulse for a full minute because your heart decelerates rapidly after exercise.
There are a number of electronic instruments that can give you an immediate indication of your pulse. A small quartz watch is also available that gives you an indication of your pulse and blood pressure when you touch a small sensor. These instruments can give you an instant and accurate reading and are useful.
If you get attacks of angina, feel breathlessness or tired while exercising, stop immediately. Ask your doctor what to do. A small dose of a nitrate before you begin can often help.
It is best not to exercise on a full stomach as a certain amount of blood is diverted to the digestive system after a meal. Exercise at this time can lead to fainting or an anginal attack.
Similarly, on very cold days or at high altitudes, you will need to be careful.
It is not a good idea to exercise if you have fever or flu-like symptoms.
If you find yourself getting stiff the day after you have exercised, it is a good idea to take the day off and cut back on your exercise for a few days.
Take time to warm up at the beginning and to cool down after you finish exercising. If you are walking, this may mean that you walk slowly when you start and when coming to the end of your walk. Alternatively you may do some stretching exercises before and after you finish.
One of the most important things is to motivate yourself to do the exercise for the first few weeks and after that you will find it easier to stick to your exercise programme. The first thing to do is to make a start by taking action now. Once you find that exercise makes you feel better you will find that you will automatically want to exercise.
You can also use your visualisation exercises to motivate yourself to exercise regularly. What you need to do is imagine yourself doing the exercise and enjoying it. Then go further into the future and imagine yourself healthy and vibrantly fit as a consequence of the exercise. Conversely you can also imagine yourself procrastinating and not exercising and then see yourself unhealthy.
This will lay down tracks in the mind that automatically build motivation to exercise. If you find that this is not enough, you can also give yourself verbal suggestions as in the chapter on self-hypnosis.
There is evidence from recent research that vigorous exercise is associated with the release of free radicals in the body. This is known to accelerate the atherosclerotic process. Therefore stick to moderate exercise.
Many cardiac patients are afraid of resuming normal sexual activity after a heart attack. The fear is that they may overstrain or have another heart attack. The risk of having a heart attack during sexual intercourse has been overstated and is in fact extremely low. The risk in heart patients has been estimated to be between 1 to 3 per million deaths.
Dr Alexander Lowen, the author of the book Sex, Love and Your Heart mentions that in a Japanese study of 30,000 deaths, only 35 were known to have occurred during sexual activity. Of these 28 occurred when a man was having intercourse with a woman other than his wife. The implication is that it is not sexual activity, but guilt that is the killer. One forensic expert noted that death in such circumstances usually occurs in unfamiliar surroundings after a big meal with alcohol.
Gentle leisurely lovemaking is safe once you can walk briskly for about 20 minutes without distress and if your heart rate goes over 120 beats per minute without ischemia on an exercise stress test. The only precaution that you may take is to use a nitrate beforehand if your doctor advises this. To start with, avoid vigorous lovemaking and stop at the very first sign of discomfort.
For both men and women, sex is significant part of life and has an important role to play in strengthening the bonds of a relationship. Experiments with animals on a high fat diet have shown that those who are physically handled more frequently are less likely to develop atherosclerotic changes in their arteries. Touch is an important part of lovemaking and holding each other and cuddling can be therapeutic. Apart from this, lovemaking is a good aerobic exercise and can add a lot to one’s pleasure in life and has a powerful anti-depressant effect!
Dr James Lynch, author of Broken Heart, talks about the consequences of loneliness on health. He notes that married men have a lower risk of heart disease. He observes that in the first six months after the death of a spouse, the risk is much higher.
Unfortunately many doctors are embarrassed to talk about sex and some are not very enlightened. One cardiac patient told me about the experience of his doctor telling him, “Don’t start servicing your wife yet.” Another was told by his cardiologist, “Don’t you think that you are too old to think about such things.” It is common for some patients to experience a little difficulty with sex initially, because of anxiety. So foreplay is all that you should attempt at first. Gradually you can allow other things to happen.
Some men may face difficulties with their erection. Sometimes the medication you take may be responsible for your erectile problems. Sometimes it is anxiety.
If you discuss your sexual difficulties with your doctor, he will be able to change the medication if he feels it is the cause of your problem. Sometimes, before changing medication, your doctor may advise that you have a nocturnal penile tumescence (NPT) test. During the night, one normally has erections 3-4 times during the R.E.M. phase of sleep and the NPT test records them. Patients with an organic cause for their impotence do not have a normal erection during R.E.M. sleep. This test frequently helps differentiate impotence due to medication and other organic causes, from that caused by anxiety.
After being on a diet and exercise programme for some time many patients report that their sexual ability has improved. They are having harder erections and able to make love for longer period. This is because as the arteries open up more blood reaches the sexual organs. The reduction of anxiety due to self-hypnosis and or meditation also helps tremendously.