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Heart Sense Helpathon: Fifth in a Series

In earlier posts in this blog we have discussed stretching exercises, aerobic exercises such as walking, biking, running, and balance exercises.  A fourth type of exercise that many people diagnosed with heart failure as well as those in good health can do safely is resistance exercises which build muscle endurance by challenging targeted muscles through a certain number of repetitions.  

But be sure to avoid straining. 

You are not the candidate to crouch and stand while hoisting heavy barbells over your head.  Before you start, look at these tables of contraindications established by the American Heart Association Science Advisory Committee which are at the end of this blog post.  I suggest you take them to your cardiologist and also show them to the rehabilitation specialist or trainer who will devise your exercise routine. The full article is in the medical journal Circulation here.

Usually, you will start with one set of repetitions, then in future sessions go to two sets with a brief rest in between the two sets.  Some examples of resistance exercises:

  • knee extensions and hamstring curls done with weights strapped to your ankles
  • knee extensions and hamstring curls done sitting on a machine such as a home gym
  • lifting your hips up off a training table or a mat on the floor while squeezing a ball between your knees and again with a ball under your legs
  • lying down on a training table or mat and opening and closing your knees with an elastic theraband around your thighs for resistance
  • Rotating the trunk of your body and doing rowing exercises with resistance bands 
  • Squats and lunges are practical exercises that help prepare your body to get out of a chair or up off the floor.

If you use a machine such as a leg press, as I do, the resistance comes from the weights stacked on the leg press as, sitting down or lying on your back, you push a heavy bar down with your feet, until your knees are almost straightened out, and then bring your knees back up.  The amount of resistance is easy to control because you can add weights to the machine or take them off, making the pushing exercise more difficult or easier.  Typically you don’t have to physically lift weights onto the machine and take them back off.  The machine is made with a column of weights and you simply insert a metal pin into the weight level that is correct for you.

To determine the appropriate weight you should use in doing an exercise, the American Heart Association Science Advisory Committee says to first find out the maximum amount of weight you can push when doing that exercise.  Then take only a percentage of that maximum.  Starting out, that would be 30 percent to 40 percent for the upper body and 50 percent to 60 percent for the hips and legs.  “Most studies of previously sedentary adults with and without heart disease, including those with heart failure, reported training workloads of 50 percent to 80 percent” of maximum weight the person could tolerate, the advisory committee reported. 

If you or your trainer or therapist have any doubts about your ability to test your maximum weight-bearing strength for an exercise, don’t do a test.  Just approximate your maximum based on what weight you comfortably handle, the committee advises. 

“For most people, if they can lift a weight 12 to 15 times before having to stop, that weight corresponds to about 50 percent of their maximum capacity,” says  Kerry J. Stewart Ed.D., director of clinical and research exercise physiology, Johns Hopkins University School of Medicine.  Dr. Stewart works with heart patients and is co-author of the guidelines for resistance training adopted in 2007 by the American Heart Association. 

It is very important for people with heart problems to use the correct breathing pattern while doing resistance exercises. To avoid putting strain on your heart, exhale on the part of the exercise that takes exertion and inhales on the part that does not as you return to your normal position.

Heart Sense Helpathon
Woman Making Heart Shape with Hands

Times to Exhale

  • when you push the leg press down with your feet
  • when you push up from a squat
  • as you do an ab crunch
  • as you move your legs up in a leg curl
  • as you curl your arm upward in a bicep curl

By using this breathing pattern, instructs my trainer Randy Rocha, who is a certified athletic trainer and strength and conditioning coach,  you don’t build pressure.  He explains:  “That’s one of the biggest concerns with people with heart trouble — that they’ll get on a machine and they’ll try to do a certain amount of weight and they’ll hold their breath and everything builds up inside, their blood pressure increases and that’s where they get into a lot of trouble and that’s why people with heart conditions may think that exercise is bad.”

Breathing correctly while doing strength training is not automatic with me.  I have to think about my breathing and remember when to exhale and when to inhale.  As I began doing resistance exercises, Randy continually prompted me to exhale when exerting myself, even though I was not aware of holding my breath.

Never hold your breath deliberately when straining.  But it may happen briefly.  “Some breath-holding is unavoidable,” Dr. Stewart says, “but try to avoid extended holding and strain.  Too much strain can raise the blood pressure to very high levels which put unnecessary strain on the heart.” 

I hope you find you are healthy enough to engage in resistance exercises to build your strength and endurance.  I enjoy this strength training.  Please be sure to get your individual program structured at a heart rehabilitation center or by a certified trainer.

Recommendations for the Initial Prescription of Resistance Training

Resistance training should be performed 

  • in a rhythmical manner at a moderate-to-slow controlled speed, 
  • through a full range of motion, avoiding breath holding and straining (Valsalva maneuver) by exhaling during the contraction or exertion phase of the lift and inhaling during the relaxation phase, and 
  • alternating between upper and lower body work, to allow for adequate rest between exercises. 

The initial resistance or weight load should 

  • allow for, and be limited, to 8 to12 repetitions/set for healthy sedentary adults, or 10 to 15 repetitions at a low level of resistance, for example, <40% of 1 repetition maximum, for older (>50-60 years of age), more frail persons, or cardiac patients 
  • be limited to a single set, performed 2 days per week, and
  • involve the major muscle groups of the upper and lower extremities, eg, chest press, shoulder press, triceps extension, biceps curl, pull-down (upper back), lower back extension, abdominal crunch/curl-up, quadriceps extension or leg press, leg curls (hamstrings), and calf raise.

[Source:  American Heart Association Science Advisory, Resistance Exercise in Individuals With and Without Cardiovascular Disease:  2007 Update] 

Absolute and Relative Contraindications to Resistance Training 

Absolute Contraindications:

If you have any of these conditions, do not do resistance exercises:

  • Unstable (Active) coronary heart disease. This means you are having symptoms of chest pain or shortness of breath even though you are on treatment.
  • Decompensated heart failure. You are having symptoms of heart failure such as shortness of breath, fatigue, and fluid retention even though you are being treated for heart failure. 
  • Uncontrolled arrhythmias
  • Severe pulmonary hypertension (mean pulmonary arterial pressure >55 mmHg) 
  • Severe and symptomatic aortic stenosis
  • Acute myocarditis, endocarditis or pericarditis
  • Uncontrolled high blood pressure (>180/110 mmHg). If your blood pressure is this high or higher, do not do resistance exercise until you get more treatment and your blood pressure falls below 160/100.  
  • Aortic dissection
  • Marfan syndrome
  • Avoid high-intensity resistance training (80 to 100% of 1-RM (one repetition maximum) if you have active proliferative retinopathy or moderate or worse nonproliferative diabetic retinopathy. 

Relative Contraindications:

If you have any of these conditions, consult a doctor before participating in resistance exercise:

  • Major risk factors for coronary heart disease (diabetes, smoking, high blood pressure, high cholesterol)   
  • Diabetes at any age. If diabetes is controlled, resistance exercise is okay and even recommended by the American Diabetes Association.  
  • Uncontrolled high blood pressure (>160/>100 mmHg). You can exercise if your blood pressure is below this level, even while taking medications to control blood pressure.
  • Low functional capacity (<4 METs). Mets are a measurement of exercise capacity
  • Musculoskeletal limitations – If the problem is so severe that it severely limits walking.
  • Implanted pacemaker or defibrillator