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Old 09-11-2008, 11:10 AM   #1
Maximus Lewin
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Working with post-heart attack client on muliple medications

Hello,

I have been working with a 45 year old male with serious health problems for the past five months. He told me upon presentation that he had the physiology of a 60 year old due to years of inactivity (a consultant, lots of time traveling). He is 6', 190#, reasonably lean, Indian descent.

the evening following his initial session in May (very light, 200 meter farmers walk with 8KG Kettlebell, 21 swings x 4, slow pace) he felt chest pain and went to hospital: he was initially diagnosed with angina, but then subsequently needed open-heart surgery to unblock completely blocked artery.

Post-surgery, he started working with me (with docs permission and some restrictions) and had vastly improved cardiovascular function, reporting he felt better than he had in years.

In July, on vacation in Mexico, he had a mild heart attack, possibly due to botched initial operation. He was operated on again, and residual plaque was removed.

He is now working with me on a regular basis, along with his wife who is in good health, if a bit out of shape. He has no restrictions of any kind from his MD.

He takes the following medications:
  • Plavix
  • Diavan
  • Toporal
  • Omega-3 (pharmaceutical mega-dose)
  • gugalipid (OTC)
  • Aspirin (325 mg)

He seems to be having trouble in anything remotely resembling a Metcon, but interestingly his rowing is pretty good:

500 Meters in 1:55
2000 Meters in 9:00
5K in 23:30

Does anyone know why this would be so based on the above meds (blood thinner to blame?)?

Also, of course, he is extremely weak in the chest and cannot even do one knee push-up as a result of the open-heart operation. Any suggestions? I have him doing incline push-ups against the wall, presently.

Any information would be appreciated.
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Old 09-11-2008, 12:32 PM   #2
Christian Mason
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Re: Working with post-heart attack client on muliple medications

Disclaimer here that I'm not a doctor, or a physiologist.

I believe a lot of blood thinning medications have the side effect of lowering the max pulse. The Toporal (aka metoprolol http://www.medicinenet.com/metoprolol/article.htm) is probably big component here.


Cardiac output (obviously what drives metcon) is the product of stroke volume times heart rate. Generally in heart attacks there is some loss of stroke volume, but the amount various greatly depending on the amount of damage to the muscle of the heart.

Toporal reduces the contraction force of the heart (reducing stroke volume) and also blocks some of the sympathetic nerve action that is responsible for the increase in heart rate. These are both considered to be good things, since they'll reduce the heart's demand for oxygen and help it to survive and repair itself. Together though they will take a pretty big chunk out of his cardiac output and therefore metcon ability. This is in addition to whatever losses in SV where caused by the heart attacks in the first place.

I'm assuming that if his doctor has OKed training he has enough cardiac capacity about resting remaining to exercise and rehab his heart, but his response to exercise will be less pronounced than someone in good health.

I'm not sure why his rowing is as good as it is though.

Hope this helps.

-- Chris

p.s. you mentioned "no restrictions" from his MD. Does his MD understand the intensity that apparently goes with Crossfit? It can certainly benefit him, but you probably want to make sure they understand they are OKing.
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Last edited by Christian Mason : 09-11-2008 at 12:38 PM.
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Old 09-11-2008, 06:38 PM   #3
Danielle Marcellino
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Re: Working with post-heart attack client on muliple medications

I work in cardiac testing and have done time in card. rehab as well.

Toprol- is a beta blocker, it slows heart rate
Diovan- reduces the constriction of the bloodvessels

the meds that he is on definately will bring his performance down (as their job is to reduce the stress on the heart) and some people are much more sensative to them than others. It's like torture to get many of my post-event patients just CLOSE to 85% of their max hr, let alone have them bust out a crossfit work out. i give him credit for going at it, but i would definately watch him closely.
the work outs are usually so intense that often i just want to lay on the ground when im done (BAD IDEA, i know), i would be sure to get him to cool down slowly, and watch his blood pressure immediate post exercise, watch for lightheadedness and the chest, jaw and/or arm pain. even if you get him to "break through" his medication and get the hr up, it usually bottoms out right away after exercise, so be prepared.
the metcon training is a tough up hill battle against his meds... he will come around alittle but i have yet to see many get back to their athlete performances they did before the meds.
definately have him make his cardiologist aware of the intensity of cross fit (he will prlly frown upon it).
good luck, keep him motivated!!!
hope i helped alittle

oh, and his rowing is prob a result of his height more than anything.. its a tall guy sport
~Dani
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Old 09-11-2008, 07:34 PM   #4
Andrew Wilson
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Re: Working with post-heart attack client on muliple medications

He NEEDS to see an Exercise Physiologist!!!
MDs do not have specialization in cardiac exercise rehab, so they're advice is extremely limited!!
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Old 09-11-2008, 09:18 PM   #5
Maximus Lewin
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Re: Working with post-heart attack client on muliple medications

Thank You all for the advice.

I am, of course, scaling any Metcons way, way back. I'm trying to help the guy rehab his heart, and I'm erring on the side of caution and a gentle touch.

I'm just looking for small improvements over time.

I'm not exactly sure what an exercise physiologist does.
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Old 09-13-2008, 06:08 PM   #6
Eddie Gulley
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Re: Working with post-heart attack client on muliple medications

Disclaimer: I am in no way a physician or have any formal medical training of any sort.

I am in somewhat the same boat as your client but have generally beaten the disease or all indications are that I have anyway. I had a heart attack 4 years ago. 43 yr old male (now) 5'9" and #205 at about 15% body fat.

I did not have bypass surgery or stents but do have 100% blocked Right Coronary Artery and Left Circumflex. Fortunately, I have always been very active and religiously exercised so I had developed collateral bloodflow that overcame the slowly narrowing arteries. After my heart attack I had an angiogram, to look at my arteries and my doctor suspects that the heart attack was prompted by the last bid of blood flow closing off in the main arteries and the collaterals completly taking over. Due to stress at work, The main arteries were most likely in a spastic state causing constriction that was the heart attack event.

I had been on long term treatment for high cholesteral (genetic disorder) and had just not been paying enough attention to diet to prevent the buildup of plague. Stress also hurt here.

After my heart attack, I continued Cholesteral therapy (lipitor) but started a beta blocker, plavix (anti-coagulant) and isosorbide (vasodialator). It took a while but I finally convinced my Cardiologist to stop the beta blocker because of its hindrance of exercise performance. Subsequent exercise performance has improved significantly (Fran of 7:05 this week as RX'd). It doesn't appear that my other meds affect.

Once your patient embraces the life-long need to exercise and will make a real commitment to follow a lifestyle change diet he too could most likely stop his beta blocker. My Dad has had quad bypas twice and doesn't take a beta blocker.

His physician will most likely want to see that he is seriously following a cardiac intensive exercise program which will improve collateral bloodflow and strengthen his heart and want to see a trend of improving lipids but the beta blocker isn't a must. It will decrase his HR and in a lot of cases not even allow intensive exercise.

Hope this helps. Your patient can do more to help himself than you can as his trainer. Consistent exercise and a prevention of future stress and lipid build-up and he should safely be able to CrossFit with appropriate scaling. Personally, I do not plan on having any future heart incidents and am hitting about 50% of the WODs as RX'd and plan on 100% within the year. Metcon is my weakness but I am focusing on that as a weakness that "CAN" be improved.

Exercise isn't dangerous for a cardiac survivor it is necessary to prevent the need to survive another cardiac event. Prevention is key.
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Old 09-16-2008, 12:56 PM   #7
Danielle Marcellino
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Re: Working with post-heart attack client on muliple medications

Quote:
Originally Posted by Maximus Lewin View Post
Thank You all for the advice.

I am, of course, scaling any Metcons way, way back. I'm trying to help the guy rehab his heart, and I'm erring on the side of caution and a gentle touch.

I'm just looking for small improvements over time.

I'm not exactly sure what an exercise physiologist does.

EP's literally study how the body functions under the stress of exercise. a good ep will know the in's and out's of cardiac and pulmonary. BUT they arent easy to find because most of us have either been thrown into a hospital working specifically with one thing.. or have just stepped down from EP and are regular personal trainers... people dont know what to do with EP's i feel like we are a dying breed.
(ive heard a few negative comments about exercise phys on crossfit because EPs tend to be SO text book oriented and crossfit is definately a "thinking out of the box" kind of program")
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