The 6th York Cardiac Care Conference

1. The 6th York Cardiac Care Conference Exercise and Arrhythmia: A pragmatic and safe approach

2. Aim: to help resolve the following clinical scenario Patients with arrhythmia and also those with an ICD (1) seek advice on exercise and (2) would like to join your conventional CR programme. How would you risk stratify this patient group? Generally what considerations would you have about prescribing exercise/physical activity? Do you have any clinical concerns about exercising these category of patients.

3. 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

5. 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 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)

6. AED mounted on wall in health club, gym or exercise facilityAED mounted on wall in health club, gym or exercise facility

7. Is the literature clear on the likelihood of cardiac events with exercise Beckerman et al (2005) confirm that vigorous testing and vigorous exercise is effective at provoking arrhythmias. Pina et al 2003 American Heart Association Committee on exercise, rehabilitation, and prevention: 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. Thompson et al (2003) approximately 5% to 10% of myocardial infarctions are associated with vigorous physical activity. Belardinelli R. (2003) Exercise can induce or prevent arrhythmias 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

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10. Most patients referred with arrhythmia tend to end the test due to fatigue 1:4 patients referred with arrhythmia will demonstrate exercise test induced arrhythmias A very small percentage of patients referred with chest pain are likely to end the test due to arrhythmia Exercise induced arrhythmias tend to occur at relatively high levels of aerobic fitness (>8METs) Patients unaccustomed to vigorous exercise have a far higher likelihood of exercise induced arrhythmia

12. Anti-Tachycardia Pacing: well timed little shocks often not noticed by patients This animation shows the delivery of ATP therapy for VT.This animation shows the delivery of ATP therapy for VT.

13. 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

14. ICD scrutiny during exercise

15. 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?

17. Exercise dose response Frequency and intensity relationship Hard or moderate intensity high frequency (Duncan et al., 2005, Lee et al., 2003). Duncan et al. (2005). complex randomised trial of intensity and frequency in 492 sedentary, healthy men and women aged between 40 and 60 years, who used walking as the primary intervention Walking (hard or moderate intensity) led to significant improvement in fitness (10% increase in CRF) and improved lipid profile, over two years This does raise the question about how fit people need to be?

19. Now we know it’s safe lets be pragmatic:Physical activity and exercise design 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 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).

20. 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 then the intensity of exercise should be lowered and the emphasis placed on muscular endurance. Mild leg exercise, for example alternate heel raises, when 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

21. Mode of exercise

22. 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.

23. Summary Arrhythmia or the presence of an ICD should not preclude patients from exercise The risk of cardiac complications 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 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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