Cardiac rehabilitation

Why is Physical Activity so important?

Whatever your current health we can all benefit from physical activity. A British Heart Foundation (BHF) report found that around 20 million UK adults are inactive and that 39% of adults do not meet physical activity recommendations to achieve health benefits and to protect their heart.  Exercise plays a very important role in your recovery following a heart attack, diagnosis of heart failure or following heart surgery.

Exercise Definitions:

Current guidelines state that to gain health benefits we all need to do physical activity on most days of the week, at a moderate intensity level for 30-45 minutes.  But what do we mean by using terms such as physical activity, exercise, physical fitness and health-related fitness?

Physical activity is a bodily movement with a significant increase in energy expenditure; such things as walking your dog, gardening and cleaning.

Exercise is structured, planned and repetitive movements that are done to maintain or improve one or more of the characteristics of physical fitness; such as circuit training, resistance training, and a gym programme.

Physical Fitness encompasses characteristics such as your stamina, flexibility, balance etc.  Your physical ability refers to your ability to perform physical activity.

Health-related fitness refers to your ability to perform your daily activities.  Doing physical activity or exercise on most days of the week can help to increase your ability to perform your daily activities more easily. Health-related benefits, especially for someone with heart disease (or someone at high risk of heart disease), are the following;

• Increased exercise threshold for the onset of chest pain (angina)
• Improved cholesterol levels
• Reduced blood pressure
• Improved blood sugar control
• Reduced anxiety & depression
• Improved ability to perform daily activities
• Increased confidence & sense of well-being
• Improved rate of return to work & leisure activities
• Reduced visits to the doctor & hospital admissions
• Reduced dependence on cardiac medications
• Improved feelings about being able to cope after a heart attack or surgery

What is encouraging is that these changes are possible with light to moderate exercise. 

How often should I be exercising to gain health benefits?

We gain the most benefit from doing physical activity on a regular basis, rather than once or twice a week.  In order to gain the maximum benefit to your health, you should aim to do at least 30 minutes of physical activity on five or more days per week (total 150 minutes per week). These 30 minutes can also be performed as 2 x 15mins, 3 x 10mins.

All physical activity/exercise should be progressive. 

In the early days/weeks of recovery keep the walking to a steady pace for the duration of your walk. As it begins to feel a little easier, start to build up your overall time and distance that you are covering.  Aiming to eventually incorporate a steady paced warm up, with a brisker walk in the middle; feeling warmer, breathing a little deeper but always being able to talk, slowing down over the last 5 minutes to allow your heart & body to return to its normal state.

When participating in physical activity/exercise always make sure:

• You stay hydrated, have a bottle of water with you
• You have your GTN spray with you (if prescribed)
• You have not eaten a heavy meal within 1.5 hours prior to exercise
• You are wearing comfortable clothing
• You do not have a temperature or feel unwell e.g. fever, sore throat, headache
• You have taken your regular medications & have not experienced any new side effects
• You have had no recent changes in your symptoms; new or worsening chest pain, breathlessness, dizziness, palpitations
• You have no worsening joint issues e.g back/knee pain
• You always exercise at a level that represents exertion without discomfort

Please note: If you experience any chest pain, dizziness or excessive shortness of breath, you must stop your exercise & follow the GTN procedure as necessary if prescribed.

If you do experience any issues these can be discussed with your local Cardiac Rehab Team.

Your Cardiac Rehabilitation Professional will have discussed with you when you can start doing other forms of exercise e.g. cycling, swimming. If you are unsure please contact us to discuss.

BORG SCALE explained

When we are participating in physical activity or exercise, we need to think about how we are feeling; how hot we are? what is our breathing like? can we talk? is it only a one-word answer that we can manage? are we feeling it in our muscles?

During physical activity or exercise we want you to rate your perception of exertion (RPE), i.e. how heavy and strenuous the exercise feels and how tired you are.  All work requires some effort, even if this is only minimal.  This is true also if you only move a little, e.g. walking slowly

Use this scale from 6 to 20, with 6 meaning ‘No exertion at all’ and 20 meaning ‘maximal exertion’.

Borg RPE Scale (Gunner Borg, 1970, 1985, 1998)

It’s your own feeling of effort and exertion that is important, not how this compares with other people.  Look at the scale and the expressions and then give a number. Use any number you like on the scale, not just one of those with an explanation behind it.Try to appraise your feeling of exertion and fatigue as spontaneously and as honestly as possible, without thinking about what the actual physical load is.  Try not to underestimate and not to overestimate your exertion. 

Exercise is important to recovery, and the Worcestershire Cardiac Rehabilitation Teams offer an 8-week exercise/education programme (7 weeks exercise and 1 week lifestyle education) led by Specialist Nurses and Fitness Instructors. This can be completed in class or through a home programme.

Patients are invited for a pre-assessment where the cardiac condition, medications, fitness goals, and exercise modifications are discussed. A physiotherapy assessment will be completed if any modifications are required, to ensure safe and effective exercise.

Each patient has their own individual targets and considerations and will be given a specific target heart rate range (THRR) for exercise. This will be based on resting pulse, age, and medication. Pulses are reviewed during the class-based exercise session.

Blood pressure is monitored prior to exercise when deemed necessary, and patients can share any updates, concerns or issues with the team.

The session begins with a ‘warm-up’ led by the fitness instructor. It includes a combination of movements lasting between 12 – 15 minutes and the intensity will gradually and comfortably increase. Stretches will be performed.

The main part of the session is a circuit consisting of 10 – 12 exercises. Specific muscle groups are targeted with each exercise and advice given on appropriate technique and intensity. Pulse checks are carried out during this section, as well as asking patients how they are finding the session in terms of breathing and muscles. 

The final part of the session is the ‘cool down’. It lasts 5 – 10minutes and gradually reduces the speed and size of movements. This is combined with a series of stretches to reduce tightness and soreness in the muscles.

At the end of the session, there is a 10-minute sit down period where we offer advice, active relaxation and education on heart-related matters or address any other concerns. Finally, patients receive a final pulse check to ensure their heart rate has returned to within 10 beats of what it was at the start of the class.

Please report side effects as there are alternatives that your GP/cardiologist can prescribe.

Heart attack/angina patients:

Surgical patients may be on some extra medications:

References:

• NHS (2019) Furosemide https://www.nhs.uk/medicines/furosemide/
• NHS (2018) How long should I wear compression stockings after surgery? https://www.nhs.uk/common-health-questions/operations-tests-and-procedures/how-long-should-i-wear-compression-stockings-after-surgery/
• NHS (2018) Anticoagulant medications https://www.nhs.uk/conditions/anticoagulants/

Cholesterol is a fatty substance produced by the liver. There is some cholesterol in the foods we eat. Some cholesterol is important to maintain body function and health. Cholesterol can be broadly divided into good and bad cholesterol.

High cholesterol is mainly due to consuming fatty food, lack of exercise, being overweight, smoking and drinking alcohol. It can also run in families.

Terminology to understand:

• Total cholesterol (TC), also known as serum cholesterol, is your overall cholesterol level. We like this below 4mmol/L.
• HDL cholesterol also known as good cholesterol, soaks up bad cholesterol (LDL). We like this above 1.0mmol/L.
• LDL cholesterol can cause clogging in arteries. We like this to be below 1.8mmol/L, but in some patients <1.4mmol/L.
• Non-HDL cholesterol is your total cholesterol minus the good cholesterol (HDL).
• Triglycerides, also known as trigs, are a type of blood fat. They are a source of energy but too much can be a risk for heart disease. We get a supply from the liver, but also our diet.

Sources: NHS website, NHS Guidelines, Heart UK

Information on healthy eating for your heart can be seen in the below video 

Quitting smoking is one of the most beneficial things for your overall health. Chemicals in cigarettes cause the artery walls to become sticky which encourages fatty materials to stick to them and clots to form blocking the arteries. When you give up smoking, your risk of further heart problems is dramatically reduced.

For help and advice on quitting, please speak to your GP or Cardiac Rehabilitation nurse.

Alcohol Guidelines

Too much alcohol is bad for your health, and the current guidelines advise no more than 14 units per week for both men and women spread over at least 3 days. Try to ensure several alcohol-free days each week.

14 units is equivalent to 6 pints of average-strength beer or 10 small glasses of lower-strength wine.

Binge drinking is to be avoided; this would be approximately 4 pints of average-strength beer for men (3 pints for women) or three quarters of a bottle of wine for men (2 large glasses for women).

There is also lots of unnecessary calories in alcohol. A glass of wine can contain 158 calories! A bottle of average strength wine per week adds up to 32,400 calories.

Check your unit consumption with the Alcohol Change unit calculator: Alcohol Change UK's unit calculator.

Sources: Census 2021, NHS website.

There are usually driving restrictions after a heart attack/heart surgery. The length of the restriction will depend on individual diagnosis/treatment/surgery and also the type of vehicle you drive. For more information please contact your Cardiac Rehabilitation Team.

There is advice on the DVLA website: www.gov.uk/government/organisations/driver-and-vehicle-licensing-agency

PLEASE NOTE: We advise that you inform your car insurance company.

It is natural to have concerns about returning to work after being diagnosed with a heart condition or following heart surgery/stenting.

Consider the following factors:

• What heart condition do you have?
• What treatment have you had?
• What type of work do you do?
• How far do you need to travel to work? Do you need to drive?
• How stressful is your job?
• What is your current level of confidence?
• What help/support can your workplace offer?
• Are you self-employed?
• What is your financial position?
• Do you have any family commitments? e.g. are you the main carer for a loved one

Your Cardiac Rehabilitation nurse, GP, and/or Cardiologist can give you advice about returning to work.

Emotional Health and Your Heart

Having a heart problem can affect your emotional health.

Emotional health, wellbeing and mental health are all different ways of describing how we think and feel and our ability to cope with whatever life throws at us. Your emotional health can change as you move through different stages in your life or deal with physical ill-health.

Having a heart problem can cause you to feel stressed, worried, scared, shocked, vulnerable, alone, unhappy, or you may just take in your stride. We are all different. You may have good and bad days. This is normal and should pass with time. You may have lifestyle changes to make and plans that have to change. All these things can lead to feeling emotionally low but usually resolve.

There are plenty of positive things you can do to help. Eat well, be active within the limits set by your cardiac rehab team, practice relaxation techniques, make sure you get enough rest and sleep and do not drink too much alcohol or smoke. Talk to someone, your cardiac rehab team is available to talk to.

Of course, unmanaged stress, depression and anxiety in the long term are risk factors for heart disease and other illnesses. They can lead to high blood pressure, raise your heart rate and increase cortisol in your blood which makes it sticky.  These feelings can also lead to unhealthy life choices like smoking, too much alcohol, eating fatty and sugary foods and being sedentary. Avoid these, as there are much healthier ways of coping. Spending time in the outdoors, keeping in touch with family and friends, learning a new skill or taking up a new hobby. Do something you are good at to boost your self-esteem. 

If you are feeling low or overwhelmed, unhappy or tearful, not sleeping or irritable and it is stopping you from getting on with life over several weeks,  then please seek help.

For more help and support contact your Cardiac Rehab Team or GP.

Other useful contacts

• BHF helpline - 0300 330 3311 and BHF website
• Samaritans - 08457 909090
• Mind infoline - 0300 123 3393
• www.calm.com  - meditation and sleep. App available from App store
• www.nhs.uk - mindfulness
• Other Apps worth trying include: Headspace, Insight Timer, Pumpkin, Synctuition, and Uplift
• Worcestershire Healthy Minds. self referral to: www.hacw.nhs.uk/healthyminds - 01905766124 

Anxiety Management

Relaxed Breathing Techniques:

• Abdominal (diaphragmatic) breathing: Place your hands on your stomach, breathe in and feel your stomach rise, breathe away and let your stomach fall.

• 7/11 technique: breathe in for a count of  3, out for a count of 5, in for 5, out for 7, gradually work up to in for 7 and out for 11, the longer you breathe out the more relaxed you will feel.

• Square breathing: Breathe in for 3, hold for 3 and out for 3, try and extend the out breath to 4, 5, 6.

• Nasal breathing: block one nostril with your thumb, breathe in through the other open nostril for the count of 3, 4, 5, use index finger on same hand and block open nostril, remove thumb and slowly breathe out of other nostril, then back in that nostril and out of the other.

• Slowly breathe in and out --- count 1, slowly in and out count 2, slowly continue up to 10 and then just be in the moment, don’t judge or control your thoughts.

Relaxing Techniques:

• Progressive muscular relaxation: Clench fist harder and harder, then relax and notice the feeling of relaxation, allow it to spread throughout your body, start at head, brow, cheeks, jaw, and work down your body to your toes.

• Concentrate on different parts of your body head to toes and just imagine your muscles softening.

• Healing Colour Visualization (choose a colour of your choice): Imagine the colour entering the top of your head and gently washing down throughout your body, slowly healing any tightness, pain or blocked areas of emotion/illness.

• Practice “Mindfulness” i.e. gardening, walking, focus on the task, the main aim is to be in the moment, and observe your thoughts. Avoid allowing your mind to wander or ruminate, accept your thoughts and be kind and compassionate to yourself, smile at yourself aiming to avoid entering the internal debate.

• Visualization: Create a special place, somewhere you have visited or imagined, use all senses, see, hear, feel and make the experience relaxing and peaceful. Anchor and reinforce that feeling in your own way with a physical anchor e.g clench your fist or squeeze two fingers together. When you need to access that relaxed feeling/visualization, you can then use your anchor to re-experience it.

• Find an enjoyable task to unwind, read or take a long walk.

• Carry a notebook, and write your worries in it, challenge your worries or thoughts and if they keep coming up, throw them away.

• Imagine you have a worry drawer, write down or imagine you are writing down your worries, put it in the drawer and say I need the answer in the morning. While still sleepy, in the morning imagine opening the drawer to find the answer.

• Spend 30 mins every morning just writing anything and put it away, aim to do this for 8 weeks. This invokes your creative side.

• Dissociate from the problem, stand back and take another person's view.

• Say to yourself “STOP” loudly.

• Exaggerate; blow the whole worry out of content and laugh (Children laugh more than 300 times a day, Adults less than 20). Set a goal to laugh 5 times a day.

• Use Positive thoughts; acknowledge what you are good at “No skill is too small”!

• Separate yourself from your anxiety, wind it down like a dimmer switch, put it in a box or throw it away.

Controlling panic attacks:

• Hold your breath and count to ten.

• 7/11 breathing

• Do something active (tap dance as it’s impossible to pass out while dancing!)

• If it is inappropriate to dance think about dancing, smile to yourself and move your toes!!

• Encourage yourself, be confident (Don’t exaggerate things out of control!)

• Become the observer, stand back and distract yourself.

People with heart disease and their partners are often understandably anxious about resuming sexual activity. But sex is no more likely to trigger chest pain or breathlessness than any other type of physical activity.

Anxiety and emotional stress can affect how you feel and can also contribute to erectile dysfunction. This can also be a side effect of some of your heart medication. It is important to discuss this with your Doctor or your Cardiac Rehab Nurse.

Viagra type medication can be used with caution, but not if you have used your GTN spray or you are on a long-acting nitrate, as it can lower your blood pressure too much. Your GP, Consultant or Cardiac Rehabilitation nurse can give you advice.

The classes listed here are run by BACPR qualified exercise professionals. There are other classes/gyms you may wish to join instead, or carry on your own exercise, for example walking. Any exercise classes attended will have done their own risk assessments and do not come under the indemnity of the hospital.

Below is some of the recent feedback we've received from patients:

"You feel you are not alone. The team are very supportive. Gentle encouragement all the way."

"An enjoyable, hard-working experience."

"The exercise is great discipline and the meeting with peers who have been there too is encouraging. The team answered all our questions."

"Found the classes very useful. Well-structured to enable development and confidence. Good information was given by the staff throughout."

"The Cardiac Rehab staff are extremely competent in what they do."

"Excellent Instructors and Nurses. I would be extremely likely to recommend this service."

British Heart Foundation website - For all general advice, education and exercise classes

mymhealth.com - connecting nurses, clinicians and patients to enable remote/home-based healthcare with self-management tools

www.cardiac-rehabilitation.net - Cardiac Rehabilitation Finder: find your nearest Cardiac Rehab Programme

www.lifeaftercardiacarrest.com - Information provision for survivor and family

www.suddencardiacarrestuk.org - Peer to peer support network

www.nhs.uk - Information on conditions and treatments

www.facebook.com/Exercise.Fitness.Health - Health and wellness resource

Once you are discharged from hospital you should take it steady. We would like you to go for walks as able. We would like you to walk continuously for the time rather than stopping and starting. Walk at a conversational pace. We do not want you to feel short of breath or exhausted afterwards. Recovery is different for everyone, but here is some general guidance for initial recovery:

Elective stent insertion

Take it easy for a week following stent insertion. Your arm may be sore following the procedure.

ACS (heart attack, angina):

Take it easy for 4 weeks, by not doing anything vigorous or moving anything heavy (lifting, pulling, pushing). Usual day to day things like getting washed and dressed, using the stairs, making drinks and food, are okay. We would like you to be active, and once you’re comfortably moving around your home, take a walk outside. Build up the distance gradually.

Heart surgery (valve repair/replacement, bypass/TAVI)

Take it easy for 12 weeks, by not doing anything vigorous or moving anything heavy (lifting, pulling, pushing). For open heart surgery patients, keep your upper body movements symmetrical, to aid healing of your chest bone. Shoulder shrugs are good way to ward off frozen shoulder.

Heart Failure (reduction in the ability of the heart to pump adequately for the body’s demand)

Following diagnosis of heart failure, it is important that you keep active. If you are suffering with fluid overload (fluid in legs, abdomen or lungs) your health care practitioner will advise you about your medication and treatments, we would not want you to push yourself with exercise if you are fluid overloaded. There may be days where you feel too fatigued to exercise, please listen to your body, patients often experience “good and bad” days. Walking is a good exercise, but if you struggle with this exercise adaptations can be offered by our fitness instructors or seen on the British Heart Foundation website.