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The Adult Congenital Heart and the Importance of Exercise and    
By Robert W. Battle, MD  [As Published in the Winter 2006 Edition of Heart Matters  

Progress in the surgical and medical care of individuals with the adult congenital heart has given our
population improved longevity and enhanced quality of life. T oconsolidate this benefit we must now
focus on the aging adult. It becomes essential to avoid acquired adult illnesses that will compromise
survival and well being.

The proven benefits of regular habitual exercise are comprehensive, including a reduction in all
causes of mortality.

Many of you may already know that regular physical exercise along with a balanced and low fat diet are
vital as we endeavor to age while avoiding serious acquired illnesses, such as obesity, high blood
pressure, abnormal cholesterol values, and coronary artery disease. Our industrialized and
mechanized civilization will thwart us at every turn, tempting us toward bad decisions and a sedentary
lifestyle. Success will require commitment, effort, and discipline.

The proven benefits of regular habitual exercise are comprehensive, including a reduction in all
causes of mortality. Mortality reduction is even more pronounced for women when compared to men.
Regular exercise can help prevent high blood pressure and diabetes, and can lower bad cholesterol
(LDL/trigycerides) while raising good cholesterol (HDL).

Exercise may also improve immune function which may reduce infection and certain cancers. It
improves mental health and may prevent or delay cognitive decline. Blood clotting is reduced by
regular exercise and blood vessel function is improved. Overall, the benefits of regular exercise far
outweigh the risks and there are few data demonstrating that strenuous exertion predisposes to a
death that would otherwise not have occurred or that withdrawal from competitive athletics will
prolong life. If the benefits of regular exercise greatly outweigh the risks, why do those with the adult
congenital heart live in an atmosphere of restriction rather than one of permissiveness?

Think of Shakespeare’s famous line “out, out brief candle,” which the American poet
Robert Frost
borrowed to accent the death of a young boy from a sawmill accident. Indeed, the sudden death of any
young person is profoundly tragic and there is something about a strenuous or athletic death that
further heightens the event in our minds, thus amplifying a very rare occurrence in a large population.
It becomes a front page news story and accordingly, exercise and sports were felt to be risky
endeavors and parents naturally restricted their children from even modestly vigorous activity.
Pediatric cardiologists had to respect this sensibility and had further concerns about medical/legal
risks and lawsuits that might ensue.

Those of you in Boston, MA, know well that the death of
Reggie Lewis, a star basketball player for the
Celtics with an ill-defined heart ailment, led to a media and legal barrage against a very respected
physician in that community. Accordingly, it is easy to understand why many of you were restricted as
children, adolescents, and even young adults.

As we begin to reassess the role of regular exercise in our lives, do not blame your pediatri
cardiologist or parents. Rather, let us move forward andfashion a strategy for a healthier, non
sedentary lifestyle as we become adults. As an added benefit, all of you are allowed to smile and
remember all the times you blatantly broke the rules laid before you!

There is a very broad spectrum of individual risk and exercise performance profiles among those with
adult congenital heart defects. One of our participants at the recent ACHA conference in San Francisco
underwent a valve replacement for a congenital valve defect and subsequently competed in and
completed a triathlon!

Twenty years ago we likely would have revolted against this idea and argued for strict exercise
limitation, even abstinence in this population. Those who are the most impaired may well benefit the
most through a series of graduated small steps.

By contrast, those of you with Eisenmenger’s complex or advanced heart failure may require oxygen
for a simple trip to the mailbox or up a flight of stairs. The task for you and your adult congenital heart
doctor will be to help define your overall risk, establish the degree of pre-existing deconditioning,
and then develop a program of regular activity or exercise designed to improve cardiopulmonary
capacity, reduce the risk of acquired adult illness, and make you feel better and live happier.

The first step will be to establish what your specific condition is—remember there is a wide range of
heterogeneity even within those with the “same diagnosis.” Your cardiologist can help establish this. It
is important to note that supervised exercise has been beneficial to adults with advanced congestive
heart failure and new data are emerging for those with idiopathic and/or primary pulmonary
hypertension. Twenty years ago we likely would have revolted against this idea and argued for strict
exercise limitation, even abstinence in this population. Those who are the most impaired may well
benefit the most through a series of graduated small steps.

There are two general types of exercise described as isotonic (or dynamic), and isometric (or static).
Isotonic exercise is a more gradual form of activity that leads to more graduated elevations in heart
rate and minimal elevation in mean blood pressure. Examples of isotonic exercise include walking,
jogging, and long distance cross country skiing.
Isometric exercise includes resistance forms of
training and can result in rapid surges in heart rate and dramatic increases in mean blood pressure.
Examples of isometric exercise include weight lifting, wrestling, and sprinting.

In general, isotonic exercise conveys more cardiovascular benefit and is probably safer in our
population due to more gradual increases in heart rate and on small increases in mean blood pressure.
Isometric exercise can be helpful to build strength. Most forms of exercise are actually a combination
of isometric and isotonic exercise and these two components can be regulated by adjusting specific
activities. For instance, if your cardiologist wants your blood pressure to remain fairly low to avoid
“afterload” stress on your heart, you could still bicycle or row on a stationary rowing machine by making
sure the resistance to pedaling or stroking is low to avoid the isometric stress that occurs with high
resistance. Hence the concept: more repetitions and less resistance.

There are some specific recommendations that apply to the adult congenital population that may be of
help. Scoliosis is common with the complex congenital heart and the associated facet arthritis may
respond well to swimming regularly.

Cyanotics need to be careful with extremes of hot and cold and always remember the importance of
hydration to avoid increases in blood viscosity associated with high red cell mass and dehydration. And
remember, your low oxygen levels lead to higher than normal levels of erythropoietin—more EPO is
what the fittest athletes in the Tour de France want to improve performance!

If you are on a blood thinner such as warfarin (Coumadin), avoid activities that lead to contact and
collision. A heart rate monitor may be useful for those with an implantable defibrillator to keep the heart
rate below the threshold that could trigger an inappropriate discharge for too fast a heart rate. For the
rest of you, I recommend simply judging how you feel. You know your own body and physiology well and
will know when you have had enough. Too much attention to detail can cause “cardiac anxiety.”

If your cardiologist feels that you are in a high risk category and does not advise unsupervised
activities, then you may be a good candidate for a Cardiac Rehabilitation Program. These programs are
available in most communities and have been shown to improve outcomes in individuals after heart
attack, angioplasty, coronary bypass surgery, congestive heart failure, obesity, and the deconditioning
that accompanies aging. Cardiac rehabilitation programs are supervised by expert nurses, exercise
technicians, and adult cardiologists. Participants are carefully monitored and defibrillators are
available, though very rarely needed. Private insurers usually cover the cost if a letter is sent from a
referring cardiologist. Unfortunately Medicare and Medicaid do not cover the cost when congenital
heart disease is listed as the diagnosis! There may be ways around this—have your indication changed
to congestive heart failure, cardiomyopathy, arrhythmia, or valve replacement to cite a few examples.
The emerging benefits conferred to those with idiopathic pulmonary hypertension may ultimately help
our own cause.

In conclusion, a regimen of regular physical activity or exercise is likely to help virtually all congenital
hearts. The more impaired often stand to benefit the most. This may be the most important single factor
in the avoidance of devastating adult diseases now epidemic in the general population. Talk to your
congenital cardiologist about a good plan for you, be patient, and remember that a lot of little steps in
the right direction can move you a very long distance. ■

This is the first in a series of articles, tips, recommendations and programs that David E. Laycock will be
submitting to help you get and stay physically fit so that you may enjoy not only a better outdoor
experience, but, a longer and more productive life.

If you have any questions or comments that you would like to ask of Dave, or you want to contact him
for a personal physical fitness evaluation, personal training etc. just email us at:
The Adult Congenital Heart and the Importance of Exercise and