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[Literature Review: Cardiac Care]

American Journal of Physical Medicine & Rehabilitation

Issue: Vo lume 79(3), May/June 2000, pp 292-297

Copyright: 2000 Lippincott Williams & Wilkins, Inc.

Publication Type: [Literature Review: Cardiac Care]

ISSN: 0894-9115

Accession: 00002060-200005000-00012

Keywords: Implantable Cardioverter Defibrillator, Exercise Testing

Prescribing Exercise Training for Patients with DefibrillatorsLampman, Richard M. PhD; Knight, Bradley P. MD

Author Information

From the Department of Surgery (RML), St. Joseph Mercy Hospital; the Department of Physical Medicine and Rehabilitation (RML), Cardiac Electrophysiology

Laboratory (BPK), and the Division of Cardiology (BPK), Department of Medicine, University of Michigan Medical School, Ann Arbor, Michigan.

Reprints:All correspondence and requests for reprints should be addressed to: Richard M. Lampman, PhD, St. Joseph Mercy Hospital, Department of Surgery, 5333

McAuley Drive, Suite RHB#2111, Ann Arbor, MI 48106.

Disclosures:Performed at St. Joseph Merc y Hospital and the University of M ichigan M edical School, Ann Arbor, Michigan.

ABSTRACT

Patients withan implantable cardioverter defibrillator (ICD) often refrain from physical exercise for fear of

precipitating a life-threatening arrhythmia or receiving an ICD shock. However, most of these patients are able to

safely exercise if they are provided appropriate clinical guidelines. This review describes the factors that enter

into the development of an exercise program for patients with an ICD.

Routine exercise training has many physical and mental health benefits and can usually be safely enjoyed by

most patient populations.1Patients with an implantable cardioverter defibrillator (ICD) would benefit from

exercising but often are apprehensive and avoid even mild physical activity for fear of triggering an arrhythmic

event, which could result in sync ope and/or an ICD shock. It has been repo rted that 63% of young ICD recipients

studied worried about engaging in exercise.2

Data supporting the effectiveness of ICD therapy for sudden death prevention have greatly increased the use

of these devices.3-5However, little is known regarding exercise therapy in this unique patient population. Only a

few case reports exist regarding exercise training in patients with an ICD who are undergoing cardiac

rehabilitation.6, 7The purpose of this article is to outline a clinical approach for helping patients with an ICD to

begin systematically and to maintain an individualized exerc ise pro gram that minimizes the risks and maximizes the

health benefits of routine exercise. Issues specific to ICD function and to patients with structural heart disease

must be c onsidered.

Usual Cautionary Advice and Benefits of Routine Exercise

Restrictions for patients with ICD on exercise are usually general rather than specific. Patients are restricted

from heavy lifting or ipsilateral arm raising above the head for 6 wk after the procedure to avoid lead

dislodgement. After this period, patients should be encouraged to be physically active. Patients are often

cautioned to limit their activities and to follow guidelines suggested by their physicians curtailing activity if any of

the following symptoms occur: shortness of breath, lightheadedness, chest pain, etc. Competitive athletics are

not usually recommended and may be contraindicated in the case of high-intensity competitive and/or contact

sports. Although these are reasonable cautionary measures, they tend to restrict physical activity rather than to

encourage safe, routine exercise. Routine exercise training when medically advised establishes realistic goals and

optimal training protocols to help ensure patient safety.

A routine exercise program will enhance the ability of each patient with an ICD to perform activities of daily

living, participate in recreational activities, and in some cases, engage in competitive sports. The medical benefits

for these patients include the following: reduced risk factors for cardiovascular disease, reduced fatigue,

improved endurance, increased muscular strength, enhanced sense of well-being, and reduced perceived stress.

It is important that physicians show c oncern and compassion for the patient's special needs and conc erns,

emphasize the benefits of routine exerc ise, and provide reassurance that routine exerc ise can be safely

performed when done appropriately.

Review of ICD Function

An exercise physiologist or physical therapist should have a fundamental understanding of ICD function.
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Implantable defibrillators have been designed to reliably terminate ventricular tachyarrhythmias by delivering a

shock to the heart. However, current ICD models can be programmed to deliver a burst of rapid pacing (anti-

tachycardia pacing) during ventricular tachycardia. This pacing technique can only be used to terminate

relatively slow ventricular tachycardias but can also avoid the need for a painful shock. Current ICDs also provide

back-up bradycardia pacing.

Heart rate remains the primary method of tachycardia detection. The ICD diagnoses ventricular

tachyarrhythmias when the heart rate exceeds a programmable "cut-off" rate and then delivers therapy. The cut-

off rate is selected on an individual basis, depending on the slowest ventricular tachycardia. The exercise

physiologist or physical therapist should know the programmed device's cut-off rate for each patient participating

in an exercise training program. A problem arises when a nonlife-threatening tachycardia, such as sinus

tachycardia or atrial fibrillation, with a rapid ventricular rate exceeds the cut-off rate of the ICD, and the patientreceives unnecessary therapy. Current devices have sophisticated algorithms used to distinguish sinus tachycardia

from ventricular tachycardia based on its gradual onset or atrial fibrillation from ventricular tachycardia based on

its irregularity. However, inappropriate therapy continues to be a common problem for ICD recipients.

Patient Evaluation

Determination of Underlying Cardiac Function.The presence and severity of underlying heart disease have

an impact on exercise prescriptions and on the expectations regarding improvement in health and well-being.

Therefore, it is important to determine the baseline functional status and severity of ventricular dysfunction

before prescribing an exercise program. Implantable defibrillator recipients are a heterogeneous group. A

majority of patients with ventricular tachyarrhythmias has left ventricular dysfunction. A recent multicenter trial,

the Antiarrhythmic versus Implantable Defibrillators (AVID) study, included 500 patients treated with an ICD. 5

Patients studied had a mean age of 65 yr and were mostly men (78%) with coronary artery disease (81%). The mean

left ventricular ejection fraction was 0.32, and one-half of the patients had symptomatic congestive heart failure.

Noncoronary causes of ventricular dysfunction among ICD recipients include nonischemic dilated cardiomyopathy,

hypertrophic cardiomyopathy, valvular disease, and congenital heart disease.

Patients with significant structural heart disease are usually limited to lower intensity physical activities.

Furthermore, patients with certain types of heart disease should be restricted from strenuous exertion. These

include right ventricular dysplasia, hypertrophic cardiomyopathy with obstruction, and severe pulmonary

hypertension. In contrast, a few patients with ICD have no identifiable structural heart disease. These patients

have primary rhythm abnormalities, such as long Q-T syndrome and primary ventricular fibrillation. Patients with

normal left ventricular function would be expected to have an exercise tolerance typical of the normal

population. However, some of these arrhythmias are catecholamine-dependent and can be triggered with

exercise. Therefore, consultation with the patient's electrophysiologist is important before prescribing an

exercise program for these patients.

Some patients with an ICD may wish to participate in competitive sports. The 26th Bethesda Conference in

1994 provided guidelines regarding eligibility for competition in athletes with cardiovascular abnormalities.8The

guidelines state that ICD recipients with or without structural heart disease should not participate in moderate or

high-intensity competitive athletics. Low-intensity competitive sports that do not constitute a significant risk of

trauma to the defibrillator are permissible if 6 mo have passed since the last ventricular arrhythmia requiring

intervention.

Baseline Physiologic Testing.Patients with an ICD should undergo a standard graded exercise tolerance test

9-13before starting an exercise program. The exercise test provides physiologic parameters for appropriately

devising an individual exercise program, can detect exercise-induced arrhythmias, and can provide reassurance to

the patient that exercise is safe.14, 15A standardized exercise testing protocol should be followed during

baseline testing, using either a motor driven treadmill or cycle ergometer.9-13Good clinical judgment should be

used in deciding an appropriate test according to a patient's ability and limitations. Ideally, the test chosen

should be one that elicits a maximum cardiorespiratory (maximum heart rate) response before a patient is limitedby peripheral skeletal muscle fatigue. The protocol by Bruce et al.10has been used in many published reports, is

brief, and has normative values published for heart rate, blood pressures, and oxygen uptake ([latin capital V with

dot above]O2). Other well-established tests are available,9-13and Pollack 11reported a comparative analysis of

four different maximal exercise testing protocols for serial and maximal heart rate, [latin capital V with dot

above]O2, and ECG determinations. Ramping protocols have recently gained popularity for overcoming limitations

of multistage exercise tests.12Although pharmacologic stress tests, such as a dobutamine echocardiogram or an

adenosine thallium test, are useful for the noninvasive detection of coronary artery disease, they do not provide

the appropriate hemodynamic parameters for use in prescribing an individualized exercise prescription. 9, 13-16

Measured maximum oxygen uptake ([latin capital V with dot above]O2 max) is the best objective measure of the

functional capacity among patients with heart disease and provides useful information for the exercise

physiologist or physical therapist. Oxygen uptake can be estimated from the exercise hemodynamic data or

external workload achieved.
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Elements and Components of an Exercise Prescription

Mode of Activity.Body positioning during exercise is an important consideration for some patients, especially

for those with compromised cardiac function. Stroke volume and end-diastolic volume change little from rest in a

normal person during supine exercise. During upright exercise, both parameters increase and plateau within 3-5

min. In a patient with cardiac dysfunction, left ventricular filling pressure tends to increase more during supine

exercise compared with upright exercise. In patients with angina, supine cycling, compared with the same

identical submaximal work in the upright position, results in a higher heart rate and angina develops at a lower

rate pressure produc t for a given amount of work; the ST segment depression may be greater because of the

greater left ventricle volume.9Therefore, if a patient has a history of ventricular arrhythmias provoked by

ischemia or heart failure exacerbations, it is recommended that upright exercise training (walking, biking, stair

climbing) exercises be performed rather than prolonged supine activities (recumbent cycling, swimming). Those

patients with preserved ventricular function should be able to participate in most physical activities.

Warm-Up and Cooldown.The pre- and postexercise periods are important times to warm-up thoroughly and

to cooldown appropriately. A warm-up period of easy physical activity for 3-5 min allows for proper cardiovascular

adjustments, may minimize the risk for exercise-induced cardiovascular complications (ischemia, arrhythmias), and

reduces a patient's perception of fatigue. Also, during the postexercise period, a mild cooldown period may

eliminate the potential for ischemic or arrhythmic responses and allows the cardiovascular system to more slowly

return to normal resting conditions.

Frequency, Intensity, and Time.Three intensity levels of aerobic exercise have been proposed (Table 1)

when initially prescribing exercise for patients and are based on the patient's clinical status and initial physical

fitness level.1Participation at each level can improve health and functional capacity. Levels I, II, and III are

classified, respectively, as follows: adjuvant health training (a low level of effort intensity used to assist medical

treatment); health training/recreation (a moderate level of effort intensity used to improve health risk factors

and to participate in recreational activities); and fitness training/sports (a fairly high intensity of effort necessary

for competitive sports-a patient with an ICD and free of significant heart disease may stay with 70-80% of maximum

heart rate and participate in low-intensity competitive sports).

TABLE 1 Exercise training levels (modified from Lampman1)

If percent heart rate reserve is used in determining an appropriate exercise training heart rate in patients

not having ischemia or significant arrhythmias, 50-75% of heart rate reserve added to the resting heart rate

([maximum heart rate - resting heart rate] 50% - 75% + resting heart rate) has been purposed.9Recent work

suggests that it cannot be assumed that percent heart rate reserve provides equivalent intensities to %[latin

capital V with dot above]O2 max

but that perc ent heart rate re serve is an indicator of a perc entage of the

difference between resting and [latin capital V with dot above]O 2 max.31, 32Anaerobic threshold measures,

obtained either by determining this value by expired gas analysis 33or by estimating it using double product,34

may also prove valuable in determining an appropriate exercise training intensity.

Patients can graduate from the less vigorous to the most strenuous levels as they progress or stay at a level

that is safe and appropriate, depending on their medical status. The optimal length of time for each exercise

session is from 20 to 30 min but may be as long as an hour.

ECG Monitoring

Patients with normal cardiac function and no history of exercise-induced arrhythmias should be able to

follow the exercise prescription without ECG monitoring but may consider initially to undergo a monitored
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Key Words: Implantable Cardioverter Defibrillator; Exercise Testing

IMAGE GALLERY
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