Pacemaker

Question:

I am starting a client who had an aortic valve rupture leading to a graft, pacemaker and beta blockers. This was due to a bacterial meningitis infection, not due to any heart or artery disease. This client is in his mid 60s and has a history as an elite swimmer (teens/20s) and marathoner (30s). He was not assigned any cardiac rehab and experienced a very quick recovery, both from the meningitis-related coma and the subsequent cardiac surgery. His current program is 30 to 60 minutes on the elliptical, three to four times a week "at a good clip." He is a highly disciplined former athlete who wishes to lose about 20 pounds and regain endurance and strength to pursue active leisure activities such as biking and rowing. How do I program cardio for this client?

Answer:

I find it more than a little scary that it doesn’t appear you have been given any guidance from this client’s physician. Even a former athlete in good health for the circumstances will have precautions because of the medication prescribed, the pacemaker and the fact that there may be lasting damage and/or limitations from the valve rupture and subsequent surgery and graft. Do you know exactly what kind of device your client has? Is it equipped with a rate of activity response feature? If so, does it have a maximum level? Do you know about beta blockers and how they affect heart rate? How will you measure exercise intensity? It is very important to have answers for these questions, and you should be prepared to work closely with a physician or other medical professional to design a safe and effective program for this client.

Let’s take a quick look at pacemakers and implantable cardioverter defibrillators (ICD). An ICD is a small device that's placed in your chest or abdomen. This device uses electrical pulses or shocks to help control life threatening, irregular heartbeats, especially those that could lead the heart to suddenly stop beating.

Doctors also treat irregular heartbeats with another device called a pacemaker. An ICD is similar to a pacemaker, but there are some differences. Pacemakers can only give off low energy electrical pulses. They are often used to treat less dangerous heart rhythms, such as those that occur in the upper chambers of your heart. Most new ICDs can act as both pacemakers and ICDs.

Pacemakers can be equipped with a rate of activity response feature. This feature allows the pacemaker to pace faster during periods of physical exertion or stress. The body's metabolic activity increases with exercise and stress. Heightened metabolic activity in turn increases the need for more blood supply to muscles and other organs. Newer pacemakers with rate of activity response features can measure the body's metabolic activity (with sensors) and increase heartbeats by accelerating the pacing rate during exercise and stress. After exercise or stress, the pacing rate returns to the previously programmed setting.

Different rate of activity response pacemakers use various sensors to measure metabolic activity. One type of pacemaker contains a sensor that detects vibration related to activity. The pacing rate accelerates when the pacemaker senses increased vibration. Another type of pacemaker has a sensor that detects the rate of breathing. The pacing rate increases when a person breathes faster. Other types of pacemakers contain sensors that measure changes in body acidity, pressures inside the heart chambers and body temperature, etc. Each of these sensors has its strengths and weaknesses. Because no one sensor method is perfect, some pacemakers now incorporate multiple sensors to more accurately gauge the body's metabolic activity.

It is important to understand these features and look to the physician for guidance. I would also suggest you take a strong look at your credentials and be prepared to send this client to another trainer if you feel at all uncertain of your skill level. In my opinion, a personal training certification by itself is not adequate to safely and effectively work with this client. I would want to have some cardiac rehab experience or clinical exercise background before taking on a client of this nature. Are you working within your scope of practice?

I am assuming you have already gotten written clearance from your client’s physician. You mention that there was no cardiac rehab assigned for your client. Has he been cleared by the cardiologist for a general exercise program? Are there any restrictions? Have you asked the physician for guidelines or limitations?

Following is an excerpt from an article intended to provide guidance for the physician when working with athletes under the age of 40 who have genetic cardiovascular disease and other heart problems not lifestyle related. This next section in italics is taken straight from the article:

“Furthermore, these recommendations are not intended for individuals with the following clinical features: history of important cardiac symptoms including syncope or other important episodes of impaired consciousness; prior cardiac operation (including surgical septal myectomy for obstructive hypertrophic cardiomyopathy [HCM] and aortic root reconstruction for Marfan syndrome) or heart transplantation; presence of an implanted cardioverter-defibrillator or pacemaker; and clinically overt and potentially life-threatening arrhythmias or other evidence of high-risk status. The presence of any of these features requires individual clinical judgment in adapting the present exercise recommendations.

Activities that should be avoided (this is a partial list):

• "Burst" exertion (or sprinting), characterized by rapid acceleration and deceleration over short distances. Exercise of this type is encountered in a variety of sports, such as basketball (particularly full-court play), soccer and tennis. Therefore, preference is given to recreational sporting activities such as informal jogging without a training regimen, biking on level terrain or lap swimming, in which energy expenditure is largely stable and consistent, even over relatively long distances or periods of time.
• Extremely adverse environmental conditions, which may be associated with alterations in blood volume, electrolytes and state of hydration and thereby increase risk, such as greatly elevated or particularly cold temperatures disproportionate to that which the athlete is accustomed to in temperate climates (i.e., >80 degrees F [27 degrees C] and <32 degrees F [0 degrees C]), high humidity or substantial altitude.
• Exercise programs (even if recreational in nature) that require systematic and progressive levels of exertion and are focused on achieving higher levels of conditioning and excellence, as in road running, cycling and rowing. Patients with GCVDs such as HCM, in which limiting dyspnea may occur with exercise, should be discouraged from any exertion that provokes these symptoms. These individuals are also advised against systematic training during which they are extended beyond the physical limits imposed by their underlying disease and the average aerobic state expected at that age.”

This was only a small portion of the article. The point I am trying to make here is even younger physically active people with pacemakers need a physician’s individual clinical judgment for each case. My best recommendation to you is to work closely with a physician to establish guidelines if you are within your scope of practice. If you are not qualified to work with this client, or do not find the physician cooperative, then refer this client to a clinical exercise specialist.

References:

1. Carrie A. Morantz "ACC statement on preparticipation cardiovascular screening for competitive athletes". American Family Physician. August 1, 2005. FindArticles.com. 14 Aug. 2008.
2. Maron BJ, Chaitman BR, Ackerman MJ, Bayes de Luna A, Corrado D, Crosson JE, Deal BJ, Driscoll DJ, Estes NA 3rd, Araujo CG, Liang DH, Mitten MJ, Myerburg RJ, Pelliccia A, Thompson PD, Towbin JA, Van Camp SP. Recommendations for physical activity and recreational sports participation for young patients with genetic cardiovascular diseases. Circulation 2004 Jun 8;109(22):2807-160.