Exercise and Heart Disease: How Much Activity Helps and How to Start After a Heart Attack

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• Benefits that begin with a single session
• Small effects repeated day after day
• The weekly exercise recommendation
• Where the benefit levels off
• Cardiac rehab after a heart attack
• Strength training for older age
• Full Transcript

Benefits that begin with a single session

Exercise brings benefit right away, cardiologist Dr. Paul D. Thompson, MD, tells Dr. Anton Titov, MD. He cites his collaborator Linda Pescatello of the University of Connecticut, who has studied what happens after a single exercise session: blood pressure is lower afterward.

He explains that blood pressure rises during exercise and that receptors in the neck, the baroreceptors, which lower the pressure when it is high, probably reset as a result. In his account, systolic blood pressure stays slightly lower for about 13 hours, about half a day, after one session, even though the person has not gotten in shape.

Small effects repeated day after day

Blood fats show a similar pattern in Dr. Thompson's research. In men running the Newport Marathon, in 1979 as he recalls it, triglycerides were 90 on the morning of the race and 30 the morning after. In untrained men, his group showed that even a 30-minute exercise session lowers triglycerides slightly the next day.

Glucose also goes down the day after exercise. Dr. Thompson thinks many of the good things exercise does are small effects repeated day over day, so a session every day lowers glucose and blood pressure. His conclusion: you do not need to get in shape, but you do need to exercise.

The weekly exercise recommendation

The weekly recommendation for lowering heart disease risk, as Dr. Thompson presents it, is 150 minutes per week of moderate exercise or 75 minutes per week of vigorous exercise. He stresses that the figure is per week, not per day. His examples of moderate exercise are brisk walking and walking at a good pace; his example of vigorous exercise is jogging. He recommends these amounts as a minimum.

Where the benefit levels off

The relationship between exercise and heart disease risk is what Dr. Thompson calls a U-shaped curve. People who do nothing, whom he calls couch potatoes without meaning to pick on them, have the highest risk. Going from nothing to something gives a big, steep reduction.

After that, the decline softens and smooths out; he describes it as an asymptote. Going from a lot of exercise to a lot more brings little additional benefit, and he says there seems to be a little rise at the far end of the curve with tons of exercise.

Cardiac rehab after a heart attack

After a heart attack, Dr. Thompson says, people should go to cardiac rehab. He calls these exercise programs excellent because the nurses and exercise staff can advise patients on how hard to push themselves and on other risk factors, and can see how the patient is doing to make sure no referral back to the doctor is needed.

If cardiac rehab is not possible, he suggests the same recommendation given to the general public: 150 minutes of moderately vigorous or 75 minutes of vigorous exercise, once the patient has the doctor's permission after the heart attack. He adds that he thinks everybody should exercise.

Strength training for older age

Strength training becomes important with age, in Dr. Thompson's view, although he notes it is separate from the heart attack question. He suggests weightlifting for the arms, shoulders, and legs. He points out that grip strength is one of the best predictors of survival and that walking does little for it. Another great predictor, he says, is the ability to stand up from a chair without pushing off with the arms, called sit to stand.

His practical advice is to ask a local exercise facility for a gentle series of exercises for grip, legs, shoulders, and arms. Dr. Thompson, who says he is 79, frames it as training for old age: the goal is to avoid becoming so weak that a person ends up in a nursing home because they cannot get out of bed on their own.

Full Transcript

Dr. Anton Titov, MD: Exercise for heart disease, exercise as prevention and treatment of coronary artery disease. You were first author of a national statement on exercise against cardiovascular disease. On your blog you wrote that patients do not need to get in shape to benefit from exercise. Professor Thompson, how much exercise does a patient with heart disease need? How should a patient begin exercise after a heart attack?

Dr. Paul D. Thompson, MD: So that is a lot of questions, a lot of good questions. First of all, you get benefit from exercise right away. One of my collaborators, Linda Pescatello with the University of Connecticut, has studied what happens after a single exercise session.

Dr. Paul D. Thompson, MD: After a single exercise session your blood pressure is lower. That is probably because while you are exercising you stimulate these receptors in your neck, the baroreceptors. The baroreceptors, if the pressure is high, lower the pressure.

Dr. Paul D. Thompson, MD: During exercise your blood pressure goes up, the baroreceptors reset, and so for about 13 hours after an exercise session, believe it or not, your blood pressure, your systolic blood pressure, is lower for about a half a day after the exercise session. Now, you did not get in shape, you just exercised, and your blood pressure is slightly lower. I think I told you earlier about my study where we measured cholesterol levels in men running the Newport Marathon in 1979, I think it was. Their triglycerides were 90 the morning of the race; they were 30 the morning after the race. They went from 90 to 30.

Dr. Paul D. Thompson, MD: We have shown in untrained men, people who are not physically trained, that even a 30-minute exercise session lowers your triglycerides slightly the next day, an hour, a little more reduction the next day. So you do not have to get in shape to get the benefit of exercise. We think a lot of the good things that happen with exercise are small effects repeated day over day.

Dr. Paul D. Thompson, MD: Your glucose goes down the day after exercise. So if you lower your glucose a little bit with an exercise session every day, you lower your glucose level, your blood pressure. So you do not need to get in shape, but you do need to exercise.

Dr. Paul D. Thompson, MD: The recommendations to use exercise to lower the risk of heart disease go something like this: 150 minutes per week, not day, 150 minutes per week of moderately vigorous exercise, moderate exercise, such as brisk walking, walking right along, walking with a good pace, or 75 minutes of vigorous exercise like jogging, okay? 150 minutes, 75 minutes per week of moderate or vigorous exercise. There is actually what we call a U-shaped curve. What does that look like?

Dr. Paul D. Thompson, MD: The people with the highest risk of heart disease are right here. They do nothing. Those are your so-called couch potatoes.

Dr. Paul D. Thompson, MD: I am not picking on you couch potatoes; I am just giving you a name. As you get some exercise, the reduction is actually pretty steep. Going from nothing to something gives you a big reduction, and then that decline kind of softens out.

Dr. Paul D. Thompson, MD: We call it an asymptote. Sharp and then smoothing out. So when you get down here, a lot of exercise, you do not get a lot of benefit from going from a lot of exercise to a lot more exercise.

Dr. Paul D. Thompson, MD: There actually seems to be a little rise on this far end. You come down and then just go up a little bit if you get tons of exercise, something we talked about later. So what I recommend people do is that they do a minimum of 150 minutes per week of moderate or 75 minutes per week of vigorous exercise.

Dr. Paul D. Thompson, MD: Now, what about after a heart attack? After a heart attack you should go to cardiac rehab. There are exercise programs set up for people who have had a heart attack, and these are excellent programs.

Dr. Paul D. Thompson, MD: Why? Because the nurses and exercise people who do it can advise you on how hard to push yourself, they can advise you on dealing with the other risk factors, and they can see how you are doing to make sure you do not need to be referred back to your doctor. But those are my general rules of thumb.

Dr. Paul D. Thompson, MD: If you have had a heart attack, you need to go to cardiac rehab. Now, let us suppose you cannot go to cardiac rehab. It is the same sort of recommendations we give for the general public, which is 150 minutes of moderately vigorous or 75 minutes of vigorous exercise, once you have your doctor's permission after your heart attack.

Dr. Paul D. Thompson, MD: But I do think everybody should exercise. Now, one thing that is not part of the heart attack deal, but I also think it is important as you get older, is to do some weightlifting for your arms, for your shoulders, for your legs. One of the best predictors of survival is grip strength, believe it or not.

Dr. Paul D. Thompson, MD: And you do not do much for your grip strength walking. Another real great predictor of survival is your ability to, they call it sit to stand, to get out of a chair, to stand out of a chair without using your arms to push yourself forward. So what I suggest people do is that they go to their local exercise facility and say, "Look, I am 75 years old."

Dr. Paul D. Thompson, MD: I wish I was 75 years old. I am actually 79 years old. But you go to your exercise facility and you say, "Look, I want to get a series of exercises for an old dude like me to do."

Dr. Paul D. Thompson, MD: And you do those exercises, and you want the person to be gentle with you. But some exercise for your hand grip, some exercises for your leg strength, some exercises for your shoulder, because a lot of people get shoulder problems, for your arms, so that you have muscle strength as you get older. You do not want to live by being on the statin and all that sort of stuff and wind up so weak that you wind up in a nursing home simply because you cannot get out of bed on your own.

Dr. Paul D. Thompson, MD: So it is important to train for old age.