While the American Heart Association (AHA) released a statement that exercise in general is safe, given appropriate modifications in patients with heart failure, the AHA also stated that 4 to 20 percent of all MIs occur during or soon after exertion. One of the side effects of heart failure is decreased stroke volume due to which many patients suffering from impaired cardiac output also suffer from reduced aerobic capacity. Many of these patients have less than 50 percent of the maximal cardiac output of a healthy person at peak exercise. As activity and exercise intolerance can be associated with uncomfortable side effect such as chest pain, shortness of breath, fatigue and dyspnea, often patients suffering with heart failure are scared and intimidated of incorporating exercise into their daily routine, despite understanding that exercise and healthy diet are a crucial aspect of a good heart health. Therefore, previous advice to avoid physical activity in patients suffering with chronic heart disease to avoid worsening of cardiovascular condition or sudden cardiac death may not be correct. Exercise, whether at home, gym or rehabilitation center can have positive effects on patient cardiac, respiratory and musculoskeletal systems, overall improving patients’ fitness with positive benefits on their mental health and self-esteem. Patients with CHD exhibit a wide range of cardiorespiratory fitness. The degree of limitation is related to the severity of the underlying disease, type of repair, and, sometimes, lack of participating in regular physical activity. To incorporate exercise into the activity intolerance care plan, the AHA suggests an approach that ensures that physical activity assessment is included, and the exercise plan is tailored to patients’ needs.
Here is a nursing guide to exercise assessment that can help establish an optimal exercise plan for patients diagnosed with activity intolerance.
An important part of assessing a patient’s readiness for physical activity is collecting an activity history. Nurses that take care of patients with chronic heart disease should perform this test/questionnaire at every visit, as the patient’s condition may often change. Nurses can either choose to use accelerometry, which tends to be more accurate or use following questionnaires as useful testing tools -the International Physical Activity Questionnaire (IPAQ) and The Habitual Activity Estimation Scale (HAES); however, these tools have not been validated for patients with chronic heart disease. Another important part of this assessment is paying attention to patient’s or family’s concerns in terms of physical activity and limitations, as this can be very useful when building an activity intolerance care plan and setting future goals. Another important assessment is the cardiorespiratory assessment that looks into patients’ basic cardiac function and involves diagnostic tests such as ECG, EKG, and even pulse oximetry. Based on the test result, clinicians, such as nurses can get a better idea of patients’ cardiorespiratory fitness and identify possible limitations, and possibly treat underlying diseases. TheEchocardiography will measure ventricular function, providing the clinicians with data about patients’ ejection fraction, pulmonary artery pressure and the diameter of the ascending aorta, and detects the presence and degree of RVOT/LVOT obstruction. The Electrocardiogram is an ideal screening test to detect arrhythmias. Sometimes, patients will be put on a 24-hour Holter monitor to detect any palpitations or syncope as well as clinicians will try to assess the frequency and precipitating factors of such an event. Pulse oximetry helps clinicians determine oxygen saturation at rest and during exercise, pointing out to possible risks and factors of hypoxia. Exercise tests can be a useful tool to determine any risks and limitations during exercise while the patient is still in a controlled environment. Many patients with chronic heart failure are unaware of their aerobic limitations, putting them at increased risk of complications due to exercise. This test can make them more aware of their limitations and may be a better test to establish activity/exercise tolerance compared to questionnaires. Exercise testing, such as the treadmill exercise test, can measure physiological data that are reflective of a patient’s response to increase in exercise. While different equipment may be used, most exercise tests are continuous, with ramped up increase in workload, and continuous monitoring of vital signs and symptoms such as dyspnea or fatigue. Patients performing the treadmill test will have their ECG, pulse oxygen and blood pressure measured continuously during the exercise test, while the clinician is monitoring any changes. Clinicians should be looking out for blood pressure responses to exercise, exercise induced arrhythmias, changes in heart rate and ECG. Another exercise test, a more comprehensive, but also more expensive is the cardiopulmonary exercise test, also referred to as the functional exercise testing. During this test, the percent of oxygen, carbon dioxide, and respiratory flow is measured in both inspired and expired gasses during the exercise. This test can provide information such as the maximal effort, peak oxygen uptake or ventilatory efficiency ratio.
Implementing an appropriate exercise plan for patients with heart disease can have a beneficial effect not only on their physical but also mental health and prevent complications due to unawareness of possible risk with exertion.
- de Ferranti, Sarah D., and Eric V. Krieger. “Physical activity and exercise in patients with congenital heart disease.” UptoDate,January 2021
- Morantz, Carrie. “AHA releases statement on exercise and heart failure.” American family physician 68.5 (2003): 969.