Exercising with Heart Disease: Best and Worst Choices

Exercising after a heart attack, heart surgery, or the diagnosis of a condition such as heart failure or atrial fibrillation can be frightening. According to Verywell, only 17% of coronary heart disease patients do the recommended physical activity. Yet, experts agree that one of the best things you can do for your health and recovery is to get out there and move! 

Regular physical activity will bring down your blood cholesterol, glucose, and blood pressure levels. If you have a few pounds to lose, exercise will certainly help. It will also keep your bones strong and prevent muscle loss that can occur with age or weight loss. Still, it’s important to put safety first and to go slow. Plan to start with light exercise for 20 to 30 minutes three or four times a week. Always talk to your doctor before beginning an exercise program, and don’t neglect to do a short warmup or cool down before getting started to prime your body and prepare your heart and muscles for the workout. 

Stop exercising immediately if you experience symptoms such as trouble breathing, chest pain, or nausea, or if you feel dizzy or have any signs of heart fluttering, an irregular pulse, or tachycardia (a very fast heart rate). Your heart rate shouldn’t exceed 120-150 beats per minute during activity. If you’ve been prescribed nitroglycerin, keep your pills with you at the gym or when you leave the house to do other activities (via MedlinePlus).

Best: Walking

Even if you can only comfortably walk for 10 minutes at a time, do it! It’s better than nothing, and those minutes will add up over time. If you feel up to it or have been working up to it for a while, after a quick warmup, walk for 20 to 30 minutes and then do a cool-down to allow your heart rate and blood pressure to return to normal gradually. Cherie Berkley, MS, advised in an article for Verywell about exercising with congestive heart disease, “If you can’t talk or catch your breath while walking, slow down. Speed isn’t so important at the beginning.” 

In a study published in JAMA, researchers determined that walking an extra 4,000 steps per day, regardless of the speed, reduced the risk of dying for ten years. And the benefits improve with even more steps — those individuals who reported walking 8,000 steps a day were about half as likely to die from any cause, especially heart disease, during the next decade (via Harvard Health Publishing). 

Worst: Push-Ups

If you have recently undergone heart surgery, you must avoid push-ups for at least six to eight weeks while your sternum heals (via Stanford Health Care). The American Heart Association further explains that exercises including push-ups, sit-ups, and chin-ups can activate the “Valsalva maneuver,” when a person bears down against a closed throat to complete a difficult exercise. The Valsalva maneuver indicates straining and is accompanied by a sudden increase in blood pressure and increased pressure on the lungs. There is more force on the chest wall when this occurs, and surgical scars can be damaged. Those with congenital heart disease might need to abstain from these types of exercises for at least a year following surgical intervention. 

While we’re on the subject of pushups: there’s probably no need to stress out about your risk of future heart disease risk based solely on your ability to do push-ups. Perhaps you heard about the study published in JAMA Network Open in 2019, in which researchers determined that among 1,104 healthy firefighters with an average age of 40, those men who could do at least 40 pushups in a minute had the lowest risk of getting heart disease over the next decade. Indeed, those who could complete the 40 push-ups had a 96% lower risk than those who could do no more than 10.

Still, Dr. Guy L. Mintz, director of Cardiovascular Health and Lipidology at Northwell Health’s Sandra Atlas Bass Heart Hospital in Manhasset, New York, cautioned in an interview with Healthline that “This study cannot be applied to the general population who would find it difficult to do pushups…I feel that this study represents a niche group of patients for a niche test. There are many patients including women that cannot do pushups, for example, lack the arm strength, but can do a significant amount of cardiovascular exercise and are physically fit.”

Best: Swimming

Cleveland Clinic emphasizes the many health benefits associated with even short swim periods, including improving the volume of blood pumped out of your heart, oxygenation, respiration, and circulation. Additionally, regular swimming improves both blood pressure and heart rate. If you’ve recently had heart surgery, Dr. Van Iterson of the Cleveland Clinic notes that you should avoid swimming until after your surgical incisions are completely healed. He adds that water aerobics and even underwater walking are other good options for those with heart problems. 

Lisa Purcell, a physical activity specialist, said in an article for Heart Matters magazine that “Your heart has to work much harder in the water compared with when you are out of it because changes to your circulation mean more blood is returning to your heart. When you start exercising, your heart has to work even harder due to the resistance of the water.” She recommends working out at a lower intensity than you would on dry land until you get used to exercising in water and gain awareness of how your body reacts in the pool. The water temperature is very important and should ideally be between 79-91 F. Don’t do swimming activities that require you to hold your breath for long periods under the water. 

Worst: Ultra-long Marathons

A study published in Missouri Medicine in 2012 explains that long bouts of endurance exercise done regularly can negatively impact the heart and large arteries. This includes marathons, Iron-man distance triathlons, and very long-distance bike races. For a week to a week and a half following these sorts of events, the heart can be overloaded with reduced ejection fraction. During this time, biomarkers of cardiac injury can be higher than normal. If this happens repeatedly, permanent damage to the heart can occur. 

In some research, vigorous physical activity was beneficial for up to 60 minutes a day, but more was not better and demonstrated “diminishing returns.” Another study found that running more than 20 miles a week, five days a day, or six to seven miles an hour was associated with fewer survival benefits than more moderate regimens. Meanwhile, 30-minute exercise sessions produced less oxidant stress and improved arterial elasticity more than 60-minute workouts among patients with coronary artery disease. 

The authors of this review recommended avoiding workouts longer than an hour-long or more than seven hours of strenuous endurance exercise per week, taking breaks during workouts, and avoiding repeatedly competing in very long-distance races after the age of 45 or 50. 

Best: Resistance Bands

In one study published in the Brazillian Journal of Cardiovascular Surgery, researchers looked at the effect of resistance exercise shortly after open-heart surgery. They discovered that those who did diaphragmatic breathing exercises, gradually increased their amount of walking throughout the day, and incorporated resistance exercises using dumbbells and shin pads spent less time on the ventilator and in the ICU. While both groups (with and without the resistance exercise) had diminished respiratory health following surgery, the group that did the resistance exercise was able to maintain the predicted distance on a six-minute walk test. In contrast, the group without resistance training demonstrated a significant decrease. The authors concluded that “resistance exercise, applied early, may promote maintenance of functional capacity on coronary artery bypass grafting patients.” 

Kaiser Permanente recommends slowly beginning a resistance training program about a month after a heart attack. After open-heart surgery, you should avoid doing any exercise that pulls on the breastbone for three weeks to ensure that you do not interrupt the healing process. If stents are placed, wait three weeks before beginning your resistance training. If you’ve recently had a pacemaker or ICD placed, wait at least a month before completing any heavy arm movements. 

Worst: Hot Yoga

Cleveland HeartLab explains that in a study published in the European Heart Journal, researchers found that among 27,000 heart attack patients, more events were recorded between 2001 and 2014 when average temperatures were higher. This is likely because very high heat can lower blood pressure, which, although it seems counterintuitive, actually makes the heart beat faster and increases the risk of a heart attack.

It is also evident that when the high and low temperatures for a day are very far apart, the risk of heart attacks increases dramatically. Indeed, heart attack risk skyrockets by 5% for every nine degrees between the low and high temperatures in a day. Although you can’t do much to control the weather, you can be sure to stay cool, maintain hydration, and choose to exercise in a comfortable environment.

Hot yoga, formally known as Bikram yoga, calls for traditional poses to be done in a room that has been heated to over 100 degrees F and is around 40% humidity. This heat makes your heart beat faster. Although it burns more calories than doing yoga in a temperate environment, it can raise body temperature to dangerous levels and should be avoided by pregnant women and people with diabetes or any time of heart problem (via Healthline).

Best: Stretching

A small study (39 participants) published in The Journal of Physiology found that three months of practicing passive leg stretches improved blood flow and heart health. The stretching regimen reduced the risk of vascular events, including heart attack and stroke, by improving blood flow and decreasing arterial stiffness. 

As Dr. Sanjiv Patel, an interventional cardiologist at MemorialCare Heart & Vascular Institute at Orange Coast Medical Center in California, explained to Healthline, “Good blood flow leads to reduced pressure within the system, leading to less damage on the wall of the artery. Reduction in blood flow due to artery/arteries not being compliant can lead to elevated blood pressure, which can increase risk of stroke and heart attack.”

The results of a meta-analysis published in the International Journal of Environmental Research and Public Health in 2020 determined that stretching reduced arterial stiffness and improved endothelial function (endothelial changes are a key reason for the increased risk of heart disease associated with aging), as well as decreased resting heart rate and diastolic blood pressure. Just one stretching session improved the peripheral circulation of patients who had suffered a heart attack. A regular yoga practice prevented or reduced arterial stiffness in elderly participants with high blood pressure. Overall, the authors asserted that stretching might be as effective as aerobic exercise when reducing arterial stiffness. Further research would be needed to verify these findings before doctors can give individual instructions to patients. 

Worst: Heavy Lifting

Although weight lifting is healthy and a great exercise choice for people who want to avoid a slew of diseases, including heart disease, you may need to steer clear if you’ve been diagnosed with certain heart conditions or undergone heart surgery. Dr. Sheldon Sheps, emeritus professor of medicine at Mayo Clinic, states that you shouldn’t lift weights under any conditions if your blood pressure is over 180/110 mm Hg. If it’s higher than 160/100 mm Hg, you should talk to your doctor before doing any heavy lifting. 

The University of Michigan’s Frankel Cardiovascular Center advises patients to avoid chest exercises for at least 12 weeks after open-heart surgery. Then, if your doctor gives his okay, you can start lifting light weights beginning with one set of 15 reps and slowly progressing. They further state that you should never lift weights without first getting your heart pumping with a short warm-up. It is also important to exhale at the point of most exertion. Patients are cautioned to avoid pushing or pulling against a fixed object like a wall or bar to avoid the Valsalva maneuver discussed in the section about pushups above. 

According to Harvard Health Publishing, if you have no angina (chest pain) or symptoms of ischemia (insufficient blood flow), you can probably do some weight lifting, starting with lighter weights and more reps. Talk to your physician before getting started. 

Best: Tai Chi

Although Tai Chi looks slow and fluid, sometimes leading people to believe that it would be better for the mind than the body, it gets your heart rate up and reduces stress; for these reasons, it is widely regarded as one of the best practices to adopt for heart health. In a review of 15 studies including more than 1,850 participants in total, Tai Chi improved quality of life and lowered the chances of mental health issues such as anxiety and depression among individuals with preexisting heart problems. Other studies have proven that Tai Chi can significantly lower blood pressure, cholesterol, body mass index, and the blood markers that indicate inflammation in the body (via ClevelandHeartLab). 

Tai Chi is an excellent, gentle option for people who have recently endured a heart attack or stenting. When researchers divided 29 people into either a “lite” group with tai chi classes twice a week for three months or a “plus” group with classes three times a week for six months, nearly all of the participants said that they enjoyed the classes and would recommend them to a friend. The “plus” group participants demonstrated an objective increase in physical activity, measured using wearable devices (via Harvard Health Publishing). 

Worst: Collision Sports if You Have a Pacemaker

According to a study published in Clinics in Sports Medicine, patients with implantable cardioverter-defibrillator are at an increased risk of sudden cardiac death during intense physical activity. For this reason, it is recommended that all high-intensity sports be completely avoided. Some low-intensity activities, such as golf, are generally okay. The concerns for individuals with pacemakers include a risk of inappropriate shocks, damage to the device, and the questionable benefit of shock delivery during vigorous activity. 

It is important to note that not all physicians agree with these guidelines, which are not based on research but on individuals and collective judgments of the panelists. Only one in ten doctors recommended avoiding all sports more vigorous than golf. However, 76% recommended avoiding all contact sports, and 46% suggested avoiding all competitive sports. Since there is a potential for problems, always take your doctor’s advice when choosing which activities to participate in.

Best: Biking

In one study, people who biked regularly had 15% fewer heart attacks than people who didn’t cycle, even if participants spent fairly little time on the bike overall. People just beginning to increase their level of physical activity might want to start with a target of 50% of their maximum heart rate and increase slowly over time. By adding in hills or going for longer distances as your fitness level increases, you can continue to build your fitness level (via UPMC).

Because cycling is low-impact and easy on the joints, it’s an ideal activity for older people and those with other health problems. In addition to building cardiovascular fitness, cycling is especially beneficial for osteoarthritis. The Mayo Clinic recommends starting with just 10 minutes a day and slowly working your way up to 150 minutes per week, as recommended by the CDC. According to Mayo Clinic, indoor cycling for 45 minutes three times per week will raise your good HDL cholesterol and lower body fat percentage after just three months. 

Worst: Intervals

You probably have friends and associates who swear by their fast and intense high-intensity interval training (HIIT) workouts. If you don’t enjoy exercise, the appeal of garnering the benefits of an hour-long exercise class in just a few minutes could be irresistible. Experts disagree, however, on whether this type of physical activity is appropriate for everyone. Some professionals feel that it moves us further away from a healthy relationship with exercise and diet. They say that it trains our brain to believe that exercise is a punishment and something to bear so that you can move on to more enjoyable tasks. Conversely, people with heart disease have long been encouraged to accept exercise as a part of their everyday life and choose activities they can enjoy, alone or with others (via ScienceDaily). 

HIIT researcher Yuri Feito, Ph.D., associate professor of exercise science at Kennesaw State University, told Livestrong that, in rare cases, interval training could cause the heart to work too hard, especially if you already have heart disease or have risk factors for it, such as hypertension or high blood sugar. Even though some optimistic research shows that the chance of having a cardiac event while doing HIIT, even among people with heart failure, is low, you should still get cleared by your doctor before signing up for this class.

If your doctor does approve of your interval training, consider starting your workout with high-intensity moves and then ramping down throughout the workout so that you end at a very low intensity. In a study published in the Journal of Sport and Exercise Psychology, people who did this type of workout had a more pleasurable experience and were more likely to work out again the following week. 

Best: Rowing

According to Healthline, a rowing machine engages an amazing 86% of your muscles. Rowing is another low-impact option for those who need to take it easy on their joints and is recommended for those with mild osteoarthritis. Because rowing is an intense workout, it helps to improve fitness and cardiovascular health in a short amount of time. A 185-pound person will burn more than 375 calories in just 30 minutes of rowing, more than on an elliptical trainer. In fact, Patrick McCrann, a marathon, and triathlon trainer, told Time that rowing is “one of the best workouts you can do” to build up your heart health. 

Worst: Anything That Gets Your Adrenaline Pumping

People with arrhythmias, such as atrial fibrillation (a-fib), are often scared to exercise. Still, it’s very important to talk to health experts you trust to develop a game plan for staying active. The problem with some types of exercise when you have an arrhythmia is the release of adrenaline, which can worsen certain arrhythmias (via Penn Medicine). Adrenaline is released to speed up the heart rate and “try to make the inefficient heart work harder,” a biological mechanism that was once believed to be protective but is now understood to worsen existing heart damage (via Heart Matters). 

Dr. Mark (Nathan A.) Estes, MD, a cardiologist at the University of Pittsburgh Medical Center, explained to Everyday Health that vigorous exercises that people with a-fib should avoid include strenuous hiking, long-distance running, and high-impact aerobic exercises. Experts also recommend investing in a heart rate monitor if you have one of these condition. If you’re on beta-blockers, it’s also important to remember that they will keep your heart rate low, so your target during exercise should be lower than your peers who aren’t on this type of medication.