Yes! Again do 5 to 10 minutes or more of light exercises stepping down in intensity followed by slow stretches as this protects the heart against a sudden blood pressure drop leading to palpitations and dizziness and also helps start the recovery process between sessions.[3:244,288][4:129][5:115]

Yes. There are many good pulse watches now being sold at reasonable prices. They are being used all over the globe in many institutions including college, university, military and hospital settings. They have many various features but the more useful for cardiac athletes includes audible alarms for programmable upper and lower training heart rates and coded transmission to avoid 'cross-talk'. Otherwise you could be exercising at someone elses heart rate if they too are wearing an uncoded pulse watch!

Do NOT exercise if you do not feel well, no matter how keen you are. You have a cardiac history don't forget, so play it safe. It is unsafe for you to exercise when you have a viral infection, in other words a sore throat or a temperature. Wait another 2 days once your symptoms have all gone to be absolutely sure and then start up again gradually.

Below is a programme which is suitable for most cardiac rehab patients. You must however ask your doctor/physician or nurse-specialist if you are permitted to perform this type of exercise programme. It is not usually recommended for patients with high blood pressure, CHD (Coronary Heart Disease), frequent arrhythmias or poor cardiac reserve.[2:49] Please refer to the individual exercise recommendations for the cardiac conditions you may have.

Resistance Training Programme:

Mode: Circuit weight training, using machines or free weights, or a combination of both. All major muscle groups, including upper body exercises, dynamic, repetitive motions.[3:247]

Exercises: A total of 8 to 10 alternating upper then lower body exercises, emphasising large muscles groups, 'compound' exercises (example: half squats) as opposed to 'isolation' exercises (example: biceps curls). Full normal ROM (Range Of Motion).[3:268][5:115]

Warm-up: You should increase your heart rate almost stepwise up to your lower training heart rate, over 10 to 15 minutes. Starting with gentle joint stretching, calisthenics, jogging on the spot, etc...

Intensity: 40% to 60% of 1 RM (Repetition Maximum) or maximum repetitions in allotted time.[3:269]
40 - 60% 1 RM Beginner
50 - 70% 1 RM Intermediate
60 - 80% 1 RM Advanced

Repetitions: more than 10 and less than 25 (refer to '1 Rep Max' calculation).

Sets/Circuits: 2 to 3

Rest phase: if performing sets of an exercise always give yourself at least a 1 minute rest period but no shorter than this and no longer than 3 minutes rest. Ideally your heart rate should get down to 100 beats per minute (depending on medication) or within 10 beats of your resting pulse before you attempt another set of exercise. Duration: 10 to 60 minutes of continuous activity depending on your fitness level.
10 - 20 minutes Beginner
20 - 30 minutes Intermediate
30 - 60 minutes Advanced

Cool-down: intensity and pulse rate should be gradually stepped down over 10 minutes and finish with gentle stretching exercises. This hopefully will guard against sudden blood pressure drops caused by suddenly stopping. You should feel rested and not fatigued within an hour following the exercise. If you do still feel fatigued you need to reduce your intensity and or duration

Warning: avoid the valsalva manoeuvre and isometric exercises.

Frequency: 2 to 3 sessions per week

Stent patients can start swimming after 3 weeks, but heart attack and CABG patients must wait until 4 to 6 weeks (the same is true for cycling). When you do go why not identify yourself to the lifeguard and ask if you can leave your GTN spray (with your name on), inhaler or diabetic food with them? Be aware that hot and humid air is more likely to make you feel unwell if you are a heart patient. Do not dive head first into water which is on the cold side as it may stop your heart momentarily. Avoid excessive breath holding and underwater swimming as it puts the heart under unnecessary dangerous stresses. When you get up and out of the water do so slowly as the water has been providing bouyancy to and squeeze on your blood vessels and so you may feel dizzy and experience palpitations if you move too quickly.[5:108]

This is not normally recommended for people with CHD (Coronary Heart Disease), high blood pressure, frequent arrhythmias or poor cardiac reserve. This is okay after 5 to 6 weeks of a supervised cardiac rehabilitation programme if the nurse / therapist and doctor/physician agrees. Do NOT however start lifting heavy weights because the static effort involved pushes your blood pressure and heart rate up to dangerous levels. Even if you have selected a light to moderate weight and are doing around 25 repetitions of a movement, as soon as you tire and that weight begins to move slowly, you are straining too much. The same is true of other 'static' or isometric type exercises. You should avoid the Valsalva Manoeuvre at all costs.[2:49]

No. Heart rate drops quite quickly post exercise depending on how fit and young you are. Therefore it is better to count your pulse over 10 or 15 seconds.[2:36][4:86]

Quick Heart Rate Conversion Chart:

Pulses in: 10 seconds / 15 seconds

9      x 6 = 54 (bpm)
10    x 6 = 60
11    x 6 = 66
12    x 6 = 72
13    x 6 = 78       x 4 = 52
14    x 6 = 84       x 4 = 56
15    x 6 = 90       x 4 = 60
16    x 6 = 96       x 4 = 64
17    x 6 = 102     x 4 = 68
18    x 6 = 108     x 4 = 72
19    x 6 = 114     x 4 = 76
20    x 6 = 120     x 4 = 80
21    x 6 = 126     x 4 = 84
22    x 6 = 132     x 4 = 88
23    x 6 = 138     x 4 = 92
24    x 6 = 144     x 4 = 96
25    x 6 = 150     x 4 = 100
26    x 6 = 156     x 4 = 104
27    x 6 = 162     x 4 = 108
28    x 6 = 168     x 4 = 112
29    x 6 = 174     x 4 = 116
30    x 6 = 180     x 4 = 120
31                       x 4 = 124
32                       x 4 = 128
33                       x 4 = 132
34                       x 4 = 136
35                       x 4 = 140
36                       x 4 = 144
37                       x 4 = 148
38                       x 4 = 152
39                       x 4 = 156
40                       x 4 = 160
41                       x 4 = 164
42                       x 4 = 168
43                       x 4 = 172
44                       x 4 = 176
45                       x 4 = 180

Yes! This needs to be a minimum of 5 to 10 minutes of slow stretching followed by light exercises in order to get your heart rate up, gradually in a step-like way, to your lower Target Heart Rate (THR) percentage, or a Rating of Perceived Exertion (RPE) of 11 to 15. This will reduce your risk of joint injuries and palpitations.[2:50][3:244,288][4:129][5:109]

By the time you experience symptoms of angina, dizziness, excessive breathlessness, etc, it is too late. In other words you have already stressed your heart unnecessarily too hard. You need to know you are exercising/training hard enough and effectively enough before you get any of these adverse symptoms. The best way is of course to take your pulse and to know what is a safe and effective exercise/training heart rate range for you and your unique cardiac history. Then there is the RPE Scale, the 'Talk Test', the Dyspnoea Scale, and the Angina Scale.[2:21,56][3:214,260][4:89][6:12]

At the wrist: Lightly place the first two fingers of your hand on the thumb side of your other wrist. You will feel the pulsations between the tendons in the centre of your wrist and the wrist bone directly down from your thumb. Count your pulses for 10 or 15 seconds and multiply by 6 or 4 respectively to get pulses per minute, or use the quick conversion chart below.

At the neck: Be aware that some people have very sensitive pressure sensors in their neck arteries which slows the heart rate if pressed. Check with your doctor/physician first to find out if you are one of these people before you attempt to take your pulse at your neck. If it is alright for you to take your pulse here you must first find your 'Adam's Apple' (or voice box) at the front upper part of your neck with your first two fingers. This is the structure that moves upward when you swallow. Move 1 to 1 and a half inches to the right or left side of your voice box and under the strap-like muscle (sternocleidomastoid) to feel your pulse. Count your pulses for 10 or 15 seconds and multiply by 6 or 4 respectively to get pulses per minute, or use a quick conversion chart.[4:86][5:110]

If you are still having difficulty locating your pulse in either of these two places then ask a trained person to show you how to do it and then keep practising until you can do it with ease.

You should use the Percent of Heart Rate Reserve method (%HRR) or Karvonen method.

Karvonen formula: THR = [(HRmax - HRrest) x %Intensity] + HRrest

Where: THR = Target Heart Rate
HRmax = maximum heart rate achieved during an ECG stress test or if not known 220 - age HRrest = resting heart rate (standing) (HRmax - HRrest) = Heart Rate Reserve (HRR)

Example: A Cardiac Athlete with a resting HR of 70 bpm (beats per minute) who achieved a HRmax of 110 bpm on a graded exercise test before stopping due to shortness of breath, fatigue and mild ECG ST-segment changes. The training intensity recommendations for this person were decided at 60% - 70% of HRR range.

First the heart rate for 60% of the HRR was calculated:

THR = [(110 - 70) x 0.6] + 70
THR = [40 x 0.6] + 70
THR = 24 + 70
THR = 94 bpm

Then the heart rate for 70% of the HRR was calculated:

THR = [(110 - 70) x 0.7] + 70
THR = [40 x 0.7] + 70 THR = 28 + 70
THR = 98 bpm

Therefore the exercise intensity of 60% - 70% of HRR would be: THR = 94 - 98 bpm. A bit low for some but tailored to the fitness level of this Cardiac Athlete none the less. This cardiac athlete is very probably on heart rate suppressing medicines. Very probably anti-anginals such as nitrates, Beta-blockers and calcium channel blockers.[2:34][3:50,151][4:130][5:46,163]

This needs to be 3 to 5 days per week for best results depending on your fitness level and cardiac history. If you trained 6 to 7 times per week you increase your risk of musculo-skeletal injuries such as strains and sprains.[2:41][3:289][4:222][5:55,108]

You can judge the intensity of any exercise or activity by using the following 'tools of the trade', preferably in this order:

1) by taking your pulse and making sure you stay within the Target Heart Rate Zone recommended for your cardiac condition(s), or use Resting Heart Rate plus 20 to 30 beats if you are on strong heart rate lowering medications

2) by using an RPE of 11 to 15 (do not go over 17)

3) by using the 'Talk Test' and other Breathlessness Scales

4) by looking out for warning signs and symptoms of over exertion such as; chest pain, dizziness, headache, irregular pulse, shortness of breath, etc...

Food in the stomach places extra demands on the heart and circulation. If you exercise straight after a meal you will tire sooner and may end up feeling dizzy. If you have washed this down with a cup of strong coffee this may make your heart beat faster and more irregular and your blood pressure may go up. Alcohol does all of these things as well as mask the warning-signs of angina pains. Therefore you must wait ideally 2 to 3 hours after a heavy meal before exercising. A smaller meal and wait about one and a half hours.[2:14][3:150,260]

To begin with you should aim to do 15 to 20 minutes of aerobic exercise per day. You may have to break this up into 5 minute sessions throughout the day up to a total of 15 to 20 minutes. Later when you are fitter try to do 20 to 30 minutes as this is what gives the greatest health and fitness gains. Over 30 minutes burns more fat but has a higher risk of musculo-skeletal injuries such as strains and sprains.[2:40][3:43,289][4:222][5:55,108]

Between exercise bouts: Before doing another bout (or set) of exercise make sure your heart rate is down to 100 beats per minute or within 10 beats of your resting pulse.[2:45]

Between exercise sessions: If your early morning pulse rate is slightly higher than normal this might mean that you are in the early stages of a fever or that you are over doing your training and may need another day of rest.

Yes! There is no better way of knowing how hard you are stressing that heart of yours than taking your pulse and recognising what is the safe maximum you can take it to.[2:34]

Yes! If your condition has changed recently do NOT exercise and report these changes immediately to your doctor/physician so that they can be checked out before you resume your exercise / training programme.[2:55][3:206,260]

Here are some of the things you should report:

1) Angina coming and going at rest.
2) For those of you who monitor your blood pressures at home, a
    resting systolic (top number) blood pressure over 200 mmHg or
    resting diastolic (lower number) blood pressure over 100 mmHg.
3) A significant drop of 20 mmHg or more in resting systolic blood
    pressure from your daily average level which can not be
    explained by medications.
4) Increased breathlessness.
5) Illness or fever.
6) Palpitations or irregular pulse.
7) A resting heart rate of more than 100 beats per minute.
8) Dizzy spells.
9) Persistent back pain, or chest pain.
10) Swollen ankles and feet.
11) Problems with your diabetes.
12) Joint or muscle problems likely to limit your exercise tolerance
      and stress your heart more.

Stop exercise training if you experience any of the following:[2:21,56][3:214,260][4:89][6:12]

1) Fatigue.
2) Light-headedness, pallor, breathlessness, nausea.
3) Increasing angina (up to a rating of 2 or CP++).
4) An extremely fast pulse.
5) Increasing palpitations or irregular heat beats.
6) An inappropriate drop in heart rate at rest or with increase in
    workload.

It may be impractical to use heart rate for deciding exercise training intensity if you are on beta receptor blocking (and calcium channel blocking) medications because they will slow your exercising heart rate by anything from 15 to 60 beats per minute. Therefore, as a rough guide use your Standing Resting Heart Rate and add 20 to 30 beats per minute to this to calculate a safe, beginning exercise training intensity. You will have to adjust this figure depending on the dose of your medication(s). The alternative is to use the Borg perceived exertion rating (RPE) of 12 to 13 as an appropriate intensity to begin with.[2:56,148][3:151][5:59]

The most accurate way for you to find a safe weight/resistance to lift is to very carefully find your '1-REP MAX'. After a suitable 5 to 10 minutes warm-up to your Training Heart Rate Range which is appropriate for your cardiac condition, select a weight which is moderately light and lift it once. If you can do this easily without straining and without holding your breath, repeat this procedure with the next increment in weight/resistance. Keep repeating the procedure until you find a weight/resistance you would not be able to lift without straining or holding your breath. This last weight/resistance you lifted is your '1-Rep Max'. Now calculate what 40% for this is by multiplying your 1-Rep Max by 0.4 and use this as your starting weight/resistance. See how many reps you can do with it. You should be doing around 20 to 25 repetitions of the exercise at this weight/resistance to begin with. Now calculate 70% (0.7) of your 1-Rep Max. This is the maximum you should gradually work up to. Never ever do lethan 10 reps. The formula is just a guideline. A starting point. You will very probably have to adjust the weight/resistance so that you do not do any less than 10 reps.[2:49][4:105][5:109]

Grading scales have been provided for use with cardiac patients during exercise testing in order to monitor the severity of angina and how it progresses with increasing workload.

The Angina Scale:

1) CP+  Light, barely noticeable
2) CP++  Moderate, bothersome
3) CP+++  Severe, very uncomfortable
4) CP++++  Most severe pain ever experienced

Where CP = Chest Pain.

When your chest discomfort reaches 2 on the above scale you must stop whatever exercise or activity you are doing and sit down and rest. If the pain or discomfort does not go away within 5 minutes of stopping take your anti-angina medication (tablet or spray). If the chest pain or discomfort does not go away in another 10 minutes after taking your anti-angina medicine you must telephone your emergency number immediately and get a paramedic ambulance to take you to the nearest hospital emergency room for checks and tests.[2:12][3:215][5:96][6:44]

At all other times keep a detailed record of your angina in your training diary and describe:

1) The pain.
2) Location of the pain.
3) Duration of the pain.
4) What may have contributed to it.
5) What helped to make it go away.
6) What was your exercise intensity at its onset.
7) Any recent adjustments made to your cardiac medications.

About 3 million years ago a distant ancestor found that his/her pelvis was different because it made bipedal (two legged) walking easier between branches and on the ground. The muscles of the body, including the heart, were already more used to low intensity, aerobic, low fuel burning activities with the very occasional quick acceleration to a short lived, anaerobic activity. These distant ancestors did an average of 44 hours per week hunting and gathering which meant at least a 10 mile walk per day. The body design of 3 million years ago has changed very little but our lifestyles have changed dramatically. We now sit in front of a computer, television screen and behind a steering wheel for more than 44 hours per week. We no longer see bipedalism as a useful form of transport. Our muscles, including our hearts, are now weak, under used and not very healthy.[1] So getting back to the original question. The answer is aerobic bipedal exercises are best for improving the health and fitness of the heart. They work because they are of a sustainable low to moderate intensity, continuous, repetitive, rhythmical, of low impact and use the large muscle groups of the legs, arms and back. Examples of this type of activity includes: brisk walking, hiking, jogging, cycling, rope skipping and even swimming.[2:31]

The following exercise programme is recommended for all ischaemic (inadequate blood flow) cardiac conditions such as angina, angioplasty, stent, MI and CABG patients. Please also refer to the individual exercise recommendations for the various cardiac conditions you may have.[2:50]

Mode: rhythmic, steady state (aerobic) exercises which use major muscle groups.

Examples:brisk walking, hiking, jogging, step exercise, rope skipping, skating, cycling, rowing, swimming or cross-country skiing.[2:31]

Warm-up: this should be gradually stepped up in intensity for more than 10 minutes. Start with stretching exercises, then do gentle calisthenic type exercises, jog on the spot, etc... to get your heart rate up to your lower Target Heart Rate or a Rating of Perceived Exertion (RPE) of 11 to 15.[2:50]

Intensity: should be in the range of 40% to 80% of Heart Rate Reserve (HRR)

40 - 60% HRR Beginner
60 - 70% HRR Intermediate
70 - 80% HRR Advanced

Only go onto the next intensity level when you can comfortably do 30 minutes or more of continuous aerobic exercise at your present intensity.[2:32,56]

12 to 14 on the Borg Rate of Perceived Exertion (RPE) Scale [2:36]
5 to 7 on the Modified Borg RPE Scale
5 to 7 on the Modified Borg RPD Scale

Duration: 10 to 60 minutes of continuous aerobic activity depending on your fitness level.[2:32,61]

10 - 20 minutes Beginner
20 - 30 minutes Intermediate
30 - 60 minutes Advanced

Cool down: lower your heart rate from your training zone in a stepwise fashion gradually over 10 minutes finishing with stretching and relaxation activities. Allow your heart rate to get down to 100 beats per minute or within 10 beats of your resting pulse before you head for the shower.[5:115]

Frequency: repeat sessions 3 to 5 times per week.[2:32]

During summer try to exercise in the morning or evening when it is cooler and drink more glasses of water than you would normally do. The only disadvantage of exercising at these times is probably rush-hour traffic fumes. Such pollution can reduce your exercise tolerance by 4% and make you get angina sooner due to there being less oxygen but more carbonmonoxide present in the air. During the winter months do your exercise more toward mid-day and be aware of the added stresses that cold air, buffeting winds and undulating hills can place on your heart. You may experience your angina quicker on colder days.[2:49][3:90][4:148,217]

The RPE (Rate of Perceived Exertion) scale was devised by Borg and is a 15-point scale ranging from 6 to 20 with exertional descriptions at every odd number. The RPE response has been shown to correlate highly (80 - 90%) with cardiorespiratory and metabolic variables such as breathing rate, oxygen uptake, blood lactate concentrations and heart rate.

The Borg RPE Scale:

6
7   = Very, very light (eg: sitting reading/watching TV, relaxed)
8
9   = Very light
10
11 = Fairly light
12
13 = Somewhat hard
14
15 = Hard
16
17 = Very hard
18
19 = Very, very hard (eg: trying to run fast up a very steep hill)
20

If you are not on heart rate lowering medicines add a zero to the end of the RPE score you have chosen to describe how hard an exercise / activity was and compare this with your peak exercising heart rate. For example an RPE of 12 becomes 120 and the cardiac athlete takes her pulse and finds it is 118 bpm! This is very close to 120. An RPE of 12 - 13 is approximately 60% of HRR and an RPE of 15 is the equivalent of 90% HRR. Therefore cardiac athletes should be using a conditioning RPE of 12 to 15.[2:22,36][3:213][4:87][5:156]

This scale has been designed to work alongside the angina scale in order to determine exercise severity.[2:12][3:215]

The Breathlessness Scale:

1) SOB+  Onset Mild, noticeable to patient but not observer
2) SOB++  Mild Mild, some difficulty, noticeable to observer
3) SOB+++  Moderate Moderate difficulty, but can continue
4) SOB++++  Severe Severe difficulty, patient cannot continue

Where SOB = 'Shortness Of Breath'.

An SOB of 1 to 3 is adequate for an exercise conditioning response.

Grading scales that have been designed for patients with respiratory disorders can also be used as a cardiac rehabilitation tool. Below is an example of this.

The RPD (Rate of Perceived Dyspnoea) Scale:

0 = None
1
2 = Just Noticeable
3
4 = Mild
5
6 = Moderate
7
8 = Severe
9
10 = Unbearable

An RPD score of 2 to 6 is adequate for a conditioning response.[12:4]

Some people prefer to use a 10 point rating scale when there is no easily demonstrated relationship between their heart rate and a rate of perceived exertion due to the cardiac medications they are taking. Borg has provided the following revised ratio scale for this purpose.

The Modified Borg RPE Scale:

0    = Nothing at all
0.5 = Extremely easy
1    = Very easy
2    = Easy
3    = Moderate
4    = Somewhat difficult
5    = Difficult
6    =
7    = Very difficult
8    =
9    =
10  = Maximally difficult

A rating of 3 to 5 is considered adequate for a training effect.[2:22][3:213][4:88][5:156,159][6:13]

This is a simple method of deciding if the exercise/activity you are doing is too strenuous or just right. It is determined by how short of breath you are. If you can talk whilst exercising/training then the intensity of exercise is probably 'Light' (less than or equal to 40% of maximum capacity or HRR) and will not help to improve stamina much, but it is nevertheless excellent for preventing coronary disease. If conversation becomes a bit jerky, the exercise is probably moderate (50-70% of maximum capacity or HRR) and will help improve physical capacity. If you can no longer talk at all, the level of exercise is too high and you must ease back a bit.[5:110]

Static straining whilst holding your breath results in increased systemic arterial blood pressure. This is detected by special blood pressure sensors in the walls of the main arteries. Heart rate is then slowed automatically to try to offset this high blood pressure. The raised blood pressure means the heart has to contract more forcibly against it which increases the work of the heart and its requirements for oxygen but at the same time increased thoracic (chest) pressure slows coronary blood flow and reduces venous return to the heart. There is a 'supply and demand problem' with oxygen carrying blood to the heart. Not a very safe situation to be in if you have a cardiac history! The correct way to breath when performing resistance type exercises is to breath out for a 2 second count on the up movement or contraction/effort phase and breath in for a 2 second count on the down movement or relaxation phase.[2:49][3:39,56]

Information to be compiled

The exercise programme that is recommended for heart valve patients is similar to that of CABG surgery patients and other ischaemic cardiac conditions (stable angina, angioplasty, stent and MI patients) so please refer to the recommendations for Angina patients above.

Ideally you should have a post-operative exercise ECG test prior to starting a supervised hospital-based cardiac rehabilitation programme six to seven weeks after the surgery and to complete this before commencing training on your own.

Initially you should just concentrate on doing low to moderate intensity and duration aerobic type exercises.

The breast bone that was opened for the operation may take many months to heal. So you may feel muscular pain, especially in the centre of your chest, neck, back and arms. For this reason heavy lifting should be avoided for at least three months following the operation.

It is recommended that you keep with you at all times a card that has on it details as to the exact make and model of heart valve that you have, the manufacturers name, the valve size and position and when it was put in. This will help the doctor or technician to monitor your heart valves success between the yearly echocardiograms you should be having. It will also be very useful information if ever you are taken to hospital.

As you are a cardiac athlete and you are used to keeping details of your exercise training you might also like to keep a record of some of your echocardiogram results such as your left ventricular ejection fraction, stroke volume, left ventricular mass and flow velocities across the valve but this would need to be negotiated with your doctor / physician.

If you experience any worsening of symptoms such as fever, fatigue, breathlessness or increased angina go back to your doctor/physician without delay and get it checked out.

As more condition-specific tips are received from cardiac athletes and recommendations published in the scientific literature they will be posted under this subheading.[5:108,147]

Post Implant:
Hopefully your pacemaker has been sited near to your non-dominant and least used arm. Do not worry if this is not so. The doctor probably had a good reason for not doing this.

You must limit weight-bearing arm movements on the side you had the pacemaker implanted so that the pacemaker wires have a good chance to become well embedded into the heart muscle.

The pacemaker implant site may take a few weeks to completely heal and for the bruising to go away. While there is bruising you may feel some muscular pain in your chest or shoulder. For this reason you might like to avoid heavy lifting until this has completely gone.

Follow-up:
Keep on you at all times your Pacemaker Identification Card which you should have been given soon after the pacemaker was implanted.

If you do not yet have one of these ask if you can have it. If you have not received your next follow-up pacemaker check appointment do not assume it will eventually come in the post. Telephone the hospital department that does the checks and ask them to confirm your next pacemaker check appointment date and time and write this on your calender or in your diary. It is very important to turn up for these pacemaker checks. As a cardiac athlete who indulges in frequent episodes of high-rate pacing, you may need to have slightly more frequent follow-up checks in order to more closely monitor battery depletion. If you can not make your appointment for some reason or other please notify the hospital as soon as you can so that your appointment slot can be offered to someone else who needs it. Be sure to ask for a new appointment for yourself.

If you experience any worsening of symptoms report it immediately to your doctor/physician without delay and get it checked out. You should report any dizziness, increase in breathlessness or fatigue, persistent chest muscle twitch or hiccups, bruising, redness, swelling, increase in palpitations, a pulse below the lower pacing rate, itching, tenderness, inflammation, or discharge around the pacemaker wound site or any of the symptoms you experienced before you had the pacemaker inserted and of course any angina.

Pre Exercise:
Ideally you should have a post-operative exercise ECG test prior to starting a supervised hospital-based cardiac rehabilitation programme six to seven weeks after the procedure and to complete this before commencing training on your own.

Type of Exercise:
A suitable exercise training programme depends very much on your underlying heart conduction abnormality, what type of pacemaker system was implanted and your other cardiac history.

The exercise programme that is generally recommended for pacemaker patients is similar to that of all ischaemic cardiac conditions (stable angina, angioplasty, stent, MI and CABG patients) so please refer to the recommendations for Angina patients above.

Initially you should just concentrate on doing low to moderate intensity and duration aerobic type exercises and build up your fitness and stamina.

Eventually you should be able to do most activities and sports but not 'contact sports' as they could potentially damage your pacemaker.

Care must be taken with activities/exercises that involve excessive Range of Movement (ROM) in the shoulders as this increases the likelihood of crushing the pacemaker wire between the first rib and collar bone. This is sometimes refered to as a 'clavicular pinch'. A few examples of excessive shoulder motion can be seen in certain yoga postures, seated overhead presses, swimming butterfly and two-handed racket or golf swings.

Self-Regulation:
You can calculate safe and effective exercise training heart rates by use of the standard Karvonen equation explained on the web pages above. The maximal training heart rate of 80% of HRR (or 85% of MHR) can be programmed into the pacemaker as the maximal pacing rate.

As a cardiac athlete with a pacemaker it is adviseable to occasionally record your exercising, peak exercise and recovery blood pressures alongside your pulse rates.

Rate Responsiveness:
Some pacemakers have activity sensors which detect body activity and adjust the pacing rate accordingly. Some of these pacemakers are 'semi-automatic' and self-adjusting. Others need to be fine-tuned by the doctor or technician at your pacemaker follow-up checks.

There are many pacemaker parameters which are useful to the cardiac athlete and these can all be adjusted. The ADL (Activities of Daily Living) rate should be programmed to provide adequate cardiac output during your typical daily activity. The Activity Acceleration slope determines how quickly you get up to your exercise training heart rate. A Rate-Adaptive AV feature mimics normal physiological responses to vigorous exercise. The Upper Sensor Rate and Upper Tracking Rate should be programmed to provide a cardiac output that meets your metabolic demand during exercise without provoking symptoms such as angina, etc. The Activity Deceleration slope determines your recovery rate after exercise.

Diagnostics:
In order to monitor how successful any programming changes are the appropriate diagnostic functions should be set to 'on'. This is like having your very own internal 24 hour ECG recorder and will help to fine-tune the pacemaker to you and your sporting lifestyle.

As more condition-specific tips are received from cardiac athletes and recommendations published in the scientific literature they will be posted under this subheading.[3:232][5:108,146]

The exercise programme that is recommended for stable angina patients is common to all coronary heart disease patients (stable angina, angioplasty, stent, MI and CABG patients) and is described above on these web pages.

It is highly recommended that you have a graded exercise ECG test in order to discover what is your angina threshold. In other words at what heart rate you begin to get your exertional angina or ECG ST segment depression changes of greater than 1 mm from that of your resting traces.

You should not do straining, breath-holding, isometric-type exercises such as press-ups and highly competitive, intermittent, explosive type sports such as squash or racket ball may be dangerous.

Warm-ups and cool-downs need to be prolonged at 10 to 15 minutes each and avoid very cold or windy weather and exercising too soon after a meal.

In your training use the 'Angina Rating Scale' and stop exercising when you reach an angina rating of 2 (CP++). If your chest pain, tightness or discomfort does not go away within 5 minutes of resting, sit down and take your nitrate tablet or spray as you have been instructed. If the angina still does not go away after a further 5 to 10 minutes and has lasted a total of 15 minutes, telephone your emergency number immediately without delay and ask for a paramedic ambulance to take you to the nearest hospital emergency room for tests.

If you experience any change in your symptoms or worsening of your angina go back to your doctor/physician without delay and get it checked out.

As more condition-specific tips are received from cardiac athletes and recommendations published in the scientific literature they will be posted under this subheading.[2:49][5:49,57,183][6:44]

The exercise programme that is recommended for bypass graft patients is common to all ischaemic cardiac conditions (stable angina, angioplasty, stent, MI and CABG patients) so please refer to the recommendations for Angina patients above.

Ideally you should have a post-operative exercise ECG test prior to starting a supervised hospital-based cardiac rehabilitation programme six to seven weeks after the surgery and to complete this before commencing training on your own.

Initially you should just concentrate on doing low to moderate intensity and duration aerobic type exercises.

The breast bone that was opened for the operation may take many months to heal. So you may feel muscular pain, especially in the centre of your chest, neck, back and arms. For this reason heavy lifting should be avoided for at least three months following the operation.

If a vein was removed from your leg for the bypass graft, you may feel discomfort or numbness in this leg and have some ankle swelling. Keep your doctor/physician informed of this.

If you experience any worsening of symptoms such as fever, fatigue, breathlessness or increased angina go back to your doctor/physician without delay and get it checked out.

As more condition-specific tips are received from cardiac athletes and recommendations published in the scientific literature they will be posted under this subheading.[3:232][5:108,146]

The exercise programme that is recommended for heart attack patients is common to all ischaemic cardiac conditions (stable angina, angioplasty, stent, MI and CABG patients) so please refer to the recommendations for Angina patients above.

Ideally you should have a post-MI (Myocardial Infarction) exercise ECG test prior to starting a supervised hospital-based cardiac rehabilitation programme six weeks after the heart attack and to complete this before commencing training on your own.

Initially you should just concentrate on doing low to moderate intensity and duration aerobic type exercises.

Depending on where the heart attack was and how big it was will determine how quickly your heart recovers its pumping ability. The spontaneous natural healing process is quite rapid over the first twelve weeks so exercise improvements will be the most dramatic over this period of time.

As a heart attack patient it is adviseable to occasionally record your exercising, peak and recovery blood pressure readings along side your pulse rate.

If you experience any worsening of symptoms such as fever, fatigue, breathlessness or increased angina go back to your doctor/physician without delay and get it checked out.

As more condition-specific tips are received from cardiac athletes and recommendations published in the scientific literature they will be posted under this subheading.[5:54]

Before using any of the following information it is strongly advised that you discuss it first with your doctor/physician and specialist nurse at your next follow-up appointment.

It is highly recommended that a medically supervised graded ECG stress test be performed with oxygen consumption measurements taken before starting on the exercise training programmes described below.

The heart transplant patient can do a combined Aerobic and Resistance training programme. Both of these programmes are described on the web pages above.

As the transplanted heart has no vagus (sympathetic and parasympathetic) nerve supply it is very important to do a very gradual warm-up because it usually takes 6 to 10 minutes for the transplanted heart to reach a stable rate for any particular workload (approximately 2 to 3 times slower than a non-transplant heart). That is up to 30 to 50% of maximum capacity (HRR). Once you get above this intensity the transplanted heart will increase rapidly in rate. Therefore start with gentle stretching of the muscles to be used in the coming exercise, then other gentle warm-up exercises. This releases hormones into the circulation, which in turn tells the heart to speed up and pump harder. After this 10 minutes warm-up you can go into your endurance (aerobic) training. Corticoid therapy also puts you at slightly higher risk of tendonitis or muscle rupture therefore you have another good reason to do a slow, gradual warm-up.

Intensity for continuous moderate effort should be set at 60% of maximal capacity or HRR determined by exercise ECG test or alternate periods of high workload (70% max.) and low workload (50% max.) for interval training. The resting heart rate of a transplanted heart will be higher than that of a non-transplanted heart and so this must be considered when calculating Training Heart Rate Ranges.

The initial goal is to do at least 30 minutes and build up gradually to a session lasting 45 to 60 minutes. This should be repeated at least 3 times per week.

It always takes far longer for the heart transplant patient to return to a resting heart rate. The heart rate will sometimes remain high for one or two minutes after stopping exercise before it begins to drop to its resting rate. Therefore you need a relatively long active recovery period at 30 to 40% of maximum capacity or HRR.

Due to the high risk of infection to you, wait 5 to 6 months after the operation before resuming swimming and wait 3 months after you have received treatment for any rejection episode before resuming swimming. NEVER attempt to exercise/train during episodes of organ rejection.

When doing resistance training do not hold your breath while lifting the weight and do not strain. Learn the stop signs and symptoms on these web pages.

Both types of exercise training programmes help prevent problems associated with the taking of immunosuppressant drugs, limits the atrophy of muscle due to corticosteroids, slows the loss of bone density (a side effect of prednisone, one of the drugs taken to prevent organ rejection) and reduces arterial hypertension as a side-effect of taking cyclosporin.

Exercise training will reduce the resting heart rate of the transplanted heart and increase its aerobic capacity thereby improving fitness for day-to-day activities.

If you experience any worsening of symptoms such as fever, fatigue, breathlessness or angina go back to your doctor/physician without delay and get it checked out.

As more condition-specific tips are received from cardiac athletes and recommendations published in the scientific literature they will be posted under this sub-heading.[3:49][11][14]

The exercise programme that is recommended for stent patients is common to all ischaemic cardiac conditions (stable angina, angioplasty, stent, MI and CABG patients) so please refer to the recommendations for Angina patients above.

It is adviseable to complete a supervised hospital-based cardiac rehabilitation programme before commencing training on your own.

Initially you should just concentrate on doing low to moderate intensity and duration aerobic type exercises.

As the risk of re-blockage and the risk of dislodgement of the stent by MRI scanner is greatest in the first 6 months after the procedure you are advised to wait this time before doing any vigorous or resistance type exercises and only do this type of exercise if your doctor/physician says you can.

If you experience any recurrence of symptoms or increased angina go back to your doctor/physician without delay and get it checked out.

As more condition-specific tips are received from cardiac athletes and recommendations published in the scientific literature they will be posted under this subheading.[3:230][5:146]

The exercise programme that is recommended for angioplasty patients is common to all ischaemic cardiac conditions (stable angina, angioplasty, stent, MI and CABG patients) so please refer to the recommendations for Angina patients above.

It is adviseable to complete a supervised hospital-based cardiac rehabilitation programme before commencing training on your own.

Initially you should just concentrate on doing low to moderate intensity and duration aerobic type exercises.

As the risk of re-blockage is greatest in the first 6 months after the procedure you are advised to wait this time before doing any vigorous or resistance type exercises and only do this type of exercise if your doctor/physician says you can.

If you experience any recurrence of symptoms or increased angina go back to your doctor/physician without delay and get it checked out.

As more condition-specific tips are received from cardiac athletes and recommendations published in the scientific literature they will be posted under this subheading.[3:230][5:146]

Before using any of the following information it is strongly advised that you discuss it first with your doctor/physician and specialist nurse at your next follow-up appointment.

The following evidence-based recommendations are for stable chronic heart failure patients with New York Heart Association Functional Classification (NYHA) One, Two and Three but NOT Four.

Recent research has shown heart failure patients can benefit greatly from an exercise programme that consists of aerobic/steady state, interval and resistance exercise sessions.

The aerobic exercise session is the same as that described on the web pages above for all ischaemic cardiac conditions (stable angina, angioplasty, stent, MI and CABG patients). If you are not quite at the beginner level (more compromised patients) then short multiple daily sessions of 5 to 10 minutes may be necessary until fitness improves. Your eventual goal should be to perform continuous aerobic exercise for a maximum of 30 minutes.

Interval training using a stationary cycle should consist of work phases of 30 seconds at an intensity of 50% of maximal effort and recovery phases of 60 seconds. Maximal effort can be determined by first pedalling for 3 minutes without any resistance and then increasing the work rate by 25 Watts every 10 seconds until it is impossible to pedal without straining. When this happens stop. Now multiply this maximal wattage by 0.5 to calculate 50% which you will use for your interval training. During the recovery phase you should pedal at 10 Watts. On a treadmill work and recovery phases of 60 seconds each may be used.

Again, the recommended resistance training programme is the one described on the web pages above. If you have been cleared to do this programme by your medical practitioner you must avoid the valsalva manoeuvre and isometric exercises at all costs.

If you experience any worsening of symptoms such as fever, fatigue, breathlessness or angina go back to your doctor/physician without delay and get it checked out.

As more condition-specific tips are received from cardiac athletes and recommendations published in the scientific literature they will be posted under this sub-heading.[5:163][9][10][12][13]