Promotion
of Physical Activity for Children and Adults With Congenital Heart Disease-A
Scientific Statement From the American Heart Association. Circulation. 2013;127:2147-2159
Keywords: congenital heart disease (CHD), physically active lifestyles, sedentary lifestyle, lack of exercise/sedentary lifestyle, cardiorespiratory exercise test
Translator’s notes.
In addition to some simple congenital heart diseases (CHD) that can be completely cured, there are a number of CHD that, even after successful corrective surgery, may still have lesions that require intervention in the future. There are also a few congenital heart diseases that are not curable and can only be improved clinically through palliative surgery and medical therapy. All of these patients are at risk for cardiac insufficiency and arrhythmias and require lifelong follow-up and treatment. How to maximize the protection of cardiac function and improve quality of life is a challenge that patients, their families and healthcare professionals need to face and address together.
This article is a report published by the American Heart Association on promoting active physical activity in children and adults with preexisting heart disease to improve their physical and mental health. This report repeatedly emphasizes the need for both children and adults to adopt an active lifestyle under the guidance of a professional, following a thorough clinical and physical assessment by a specialist, to avoid the physical and mental disease risks associated with sedentary lifestyle. It is important to note that the recommendations in this report are based on expert opinion due to the lack of relevant studies.
This report not only details the clinical considerations for physical activity in patients with preexisting heart disease, but also includes a section on methods and strategies for health care professionals to promote physical activity in patients.
Overview
The American Heart Association (AHA) recognizes the importance of a physically active lifestyle in promoting the health and well-being of children and adults with congenital heart disease (CHD). When providing medical counseling to patients with congenital heart disease, health care providers should emphasize the importance of daily physical activity and that a less sedentary lifestyle is clinically appropriate for patients with congenital heart disease. Because there is a lack of research on the effects of physical activity in patients with preeclampsia, the current recommended guidelines are based on research on the benefits of physical activity in healthy children and adults. There is no evidence to suggest the need to restrict participation in recreational physical activity in patients with preeclampsia, except for those with comorbid severe arrhythmias.
It is important to recognize the physical and psychological health benefits of physical activity for the majority of the preconditioned population who are inactive and at risk for physical activity intolerance, obesity, and psychosomatic disorders. Encouraging appropriate daily physical activity in patients with prediabetes should be a core component of the counseling services adopted for each patient. A physically active lifestyle is important for children and adults with prediabetes. Although only higher intensity exercise can improve cardiorespiratory and skeletal muscle function, moderate intensity physical activity can be very beneficial to health.
This scientific report makes a clear distinction between physical activity, which is a broader concept that includes all types of physical activity, and physical exercise (fitness exercise), which is planned repetitive physical activity to improve physical performance.
Health care providers must recommend physical activity based on the clinical status of each patient, focusing on the health benefits of physical activity and promoting appropriate activity for all patients. An active physical activity lifestyle can be adopted by almost all patients with preeclampsia. Pediatric and adult patients with preeclampsia are encouraged to achieve the recommended level of physical activity. Only a minority of patients with preeclampsia have conditions that significantly interfere with physical activity performed at home and among friends. Only individual precardiac conditions (e.g., presence of ventricular arrhythmia risk) require activity restriction.
The cardiopulmonary exercise test can evaluate the relationship between mobility and intermediate regression in patients with precordial disease and predict complications and morbidity and mortality. The risk of exercise-related complications can also be assessed by observing changes in the cardiovascular system during exercise. The cardiopulmonary exercise test provides an understanding of the patient’s extreme or subextreme exercise capacity, which can help evaluate the patient’s ability to engage in recreational and physical activity and increase the patient’s and family’s confidence in participating in physical activity.
Review of Existing Guidelines
Existing physical activity guidelines recommend that healthy adults participate in muscle-strengthening activities at least 2 days per week, with a cumulative total of 75 minutes of high-intensity exercise or 150 minutes of moderate-intensity exercise per week, with each exercise session lasting at least 10 minutes.
Children are recommended to be active for at least 60 minutes per day, at least 3 times per week in high-intensity activities, and at least 3 times per week in exercises that build muscle and bone strength. High-impact explosive aerobic exercises (e.g., high jump) are best for building muscle and bone strength as opposed to aerobic exercises. Appropriate children limit prolonged sedentary activity and time spent indoors. children 5 years of age or older should not watch more than 2 hours of television per day, and young children younger than 3 years of age should not watch television.
Benefits of physical activity
The benefits of regular physical activity include physiological improvements in skeletal muscle, vascular and immune system function, prevention of obesity, and psychological benefits in improving mental, cognitive and social functioning. The health risks of physical inactivity include hypertension, diabetes, obesity, depression, cancer, and atherosclerotic cardiovascular disease. Due to the low level of daily activity in the preconditioned population, obesity and cardiovascular disease risk factors are prevalent compared to healthy children. Given that most patients with prediabetes currently survive into adulthood, these risk factors for acquired heart disease are of great relevance, and corresponding physical activity to counteract these risks is necessary. Children with precocious heart disease commonly have poor gross motor, fine motor, and visual motor development. Previously thought to be mainly related to early perioperative complications, it is now believed that this is not the only factor, but is also associated with lack of activity in daily life.
Assessment of physical activity
Evaluating physical activity habits in children and adults with preexisting heart disease should be an integral part of the health assessment in follow-up visits.
Methods and strategies for health care providers to promote patients’ participation in physical activity
Clinical factors to consider when participating in physical activity
The risk of sudden death is the primary concern. However, preexisting heart disease is not the most common cause of sudden death from exercise. Sudden death is more commonly seen in familial hypertrophic cardiomyopathy, sudden cardiac death syndrome, myocarditis, dilated cardiomyopathy, long Q-T syndrome, or coronary artery malformations with sudden death as the primary presentation. Although sudden death can also occur after surgery for certain precordial diseases, such as in patients with aortic stenosis, Mustard or Senning, few of the sudden death events occur in association with physical activity or exercise. Thus, from the limited data available, the risk of sudden death associated with physical activity appears to be negligible in most children or adults with precordial disease.
Nevertheless, there are still complications of precordial disease that can affect the type or intensity of physical activity. Healthcare professionals should encourage patients to engage in safe and enjoyable physical activity, taking into account the clinical status of each patient at the time.
If a patient with preeclampsia has a co-morbid arrhythmia, physical activity should be guided by the physical activity guidelines published by the Heart Rhythm Society (HRS).
Complications affecting physical activity in precardiac disease include ventricular insufficiency, aortic dilatation, syncope, hypoxia, use of anticoagulants, and intracardiac implantation of devices. The medical staff should perform a standard examination for each patient, including a cardiogram, cardiac ultrasound, and cardiopulmonary test to assess their physical activity capacity. In the absence of actual evidence that better identifies the risks associated with physical activity, the method of identifying risk is more or less necessarily subjective, but must also be individualized. Counseling recommendations to patients must ensure that they accurately understand the benefits of physical activity as well as the associated risks.
(1) Cardiac insufficiency
Patients with significant cardiac insufficiency can participate in many recreational sports and physical activities, but should limit competitive sports. The reason for this is that high-intensity competitive exercise may cause ventricular fibrillation.
Patients with coronary artery compression or myocardial ischemia, pulmonary hypertension, or severe valve stenosis are encouraged to participate in low- to moderate-intensity noncompetitive activities, including walking, bowling, cricket, bocce ball, curling, baseball or softball, golf, or tai chi. For patients with cardiac insufficiency combined with arrhythmias, HRS guidelines should be followed.
(2) Aortic dilatation without connective tissue disease
Dilation of the aortic root and ascending aorta can occur in people with normal cardiac structure and in a variety of precordial diseases. Among these, conical trunk malformations and aortic valve diastolic malformations are the most common. Although cardiac malformations vary, they share common pathologic features of the aortic wall, including abnormalities in the transfer growth factor beta signaling pathway. Isolated aortic dilatation often puts physicians in a dilemma when recommending physical activity. In those with significant aortic root dilatation (aortic ID >;99%; percentile) aortic wall changes are pathologic and can lead to aortic aneurysm and coarctation. The risk of developing a coarctation is mainly related to the aortic internal diameter. Adult patients may even undergo prophylactic aortic root or ascending aortic replacement.
The risk of aortic coarctation must be taken into account when recommending activities for patients. The stress on the aortic wall is proportional to blood pressure, and blood pressure during exercise is generally related to the intensity of the exercise. Dynamic exercise usually causes a significant increase in cardiac output, while static exercise increases cardiac afterload. However, in both static and dynamic exercise, there is a risk of inducing aortic coarctation because the stress on the aortic wall is related to the degree of blood pressure. Therefore, these patients should limit the intensity of activity regardless of the type of activity. Usually moderate intensity activities are safe. If the patient desires to participate in resistance training such as weight lifting or static type exercises, it is recommended to complete only one maximum amount of weight lifting and to use appropriate techniques such as avoiding the Valsalva maneuver (i.e., deep inhalation followed by breath hold, or deep exhalation followed by breath hold) during repetitive movements.
(3) Syncope
Certain precordial diseases such as valvular stenosis, arrhythmias, pulmonary hypertension, or sinus node insufficiency can present with exertional syncope and should be considered. Clinicians should actively study the clinical data of patients presenting with syncope on exertion.
Patients at risk for syncope, whether exertion-induced or exertion-related, should choose activities that do not endanger their own or others’ safety. Encourage such patients to participate in activities such as walking, racquet sports, English soccer, baseball or softball, table tennis, dancing, tai chi, yoga, bowling, and cricket. Avoid horseback riding, gymnastics, rock climbing and prolonged scuba diving. Swimming, cycling, skating and surfing may be supervised unless syncope episodes are more frequent.
(4) Hypoxia
Some precardiac diseases, such as those with intracardiac shunts combined with elevated pulmonary resistance, may present with cyanosis after activity. In general, the presence of hypoxia after activity is the threshold for limiting the amount of activity. Such patients should be encouraged to participate in physical activity within the limits of what feels comfortable through self-adjustment. The “talk test,” an activity intensity that allows easy conversation with others, is helpful in helping patients determine the intensity of activity. The possible effect of altitude on oxygen saturation should also be considered for patients living on a plateau or preparing to travel to mountainous areas.
(5) Taking anticoagulants
Patients who are on anticoagulation therapy are encouraged to participate in activities that are less prone to physical collisions such as walking, jogging, swimming, cross-country skiing, and bicycling because of the potential for bleeding due to injury during activity. Avoid sports that are prone to physical collisions, such as rugby, competitive martial arts, boxing, and ice hockey where there is a physical punch.
For sports where unintentional body impact may occur, such as volleyball, basketball, baseball, scuba diving, and ice skating, factors such as the patient’s bleeding history, current medication and anticoagulation strength, and the patient’s skill and comfort in performing a particular sport should be considered.
(6) Intracardiac device implants
For patients with intracardiac implanted devices such as pacemakers and intracardiac implanted defibrillators, the first consideration in activities is to protect the device and the device lead to prevent soft tissue injury caused by the impact of the device. Sports with the potential for direct blows to the chest or device, such as rugby, boxing, and ice hockey with body impact, are discouraged.
It is believed that intracardiac defibrillators may not provide adequate protection in the event of arrhythmias requiring electrical shocks during physical activity. Surveys have shown that only 10% of physicians encourage patients with implanted intracardiac defibrillators to participate in low-intensity exercise, such as golf.
There are no corresponding activity guidelines for those with implanted right ventricle-pulmonary artery banding tubes, pulmonary stents, or prosthetic valves.
Clinical evaluation prior to recommending physical activity for patients with preexisting heart disease
A thorough and detailed assessment of each patient’s previous activity intensity, exercise tolerance, exercise mode, and physical fitness must be performed. Find out if there are any symptoms of exertional discomfort, such as angina, dyspnea, palpitations, vertigo, or syncope.
Even in the absence of these symptoms, many preexisting heart conditions require objective evaluation before recommending a particular exercise to the patient. A formal exercise trial is recommended to better determine the patient’s exercise risk, to understand the patient’s ability to participate in submaximal exercise so that the patient can successfully participate in physical activity, and to give the patient and family confidence that even patients with limited maximal exercise can safely enjoy higher intensity exercise if no significant risk factors are identified during the cardiopulmonary exercise trial. In addition, the exercise test allows patients to understand that they do not need to exert themselves in their daily physical activities and participation in fitness exercises, and that optimal health benefits can be achieved with less intense exercise (i.e., the talk test, which is the intensity of exercise that allows for comfortable conversation)). Ensure that patients understand that maximal exercise capacity is not related to daily physical activity, and that patients in a suboptimal state of health can improve their health status by increasing their physical activity level with fitness exercise.
Counseling for physical activity promotion
Physical activity counseling can be provided by a trained internist, nurse, occupational exercise counselor, or health consultant. For patients with preexisting heart disease, it is important that occupational health counselors complete the following items.
(1) Those who have undergone successful radical surgery for precordial disease and have no residual lesions may be promoted for physical activity according to guidelines for healthy populations.
(2) Require and encourage patients and families to meet the recommended daily physical activity standards
(3) Ensure that patients and themselves are aware of the health risks associated with prolonged physical inactivity and that health risks remain even when physical activity guidelines are met.
(4) Having patients or parents report patients’ participation in physical activity.
(5) The Activity Habit Assessment Scale provides an easy way to understand the proportion of time spent inactive, mildly, moderately, and vigorously active each day.
(6) Explain to the patient the impact of all clinical treatments and changes in treatment on physical activity, such as interruptions in treatment (e.g., discontinuation of anticoagulants), changes in cardiac function, etc.
(7) Use patient-centered communication to create a willingness to change the patient’s status quo. If possible, refer them to an experienced vocational counselor.
(8) Encourage pediatric patients to participate in physical activities conducted at school
(9) Emphasize the benefits of light and moderate physical activity and interrupt prolonged periods of quiet with light physical activity.
(10) Advise parents to strictly limit the amount of time their child spends watching television or using electronic devices. Emphasis is placed on each clinical follow-up visit – no television for young children until age 3 and no more than 2 hours per day for children age 5 or older.
Counseling for those with physical activity limitations
(1) Promote physical activity in all patients with preexisting heart disease, including those whose clinical condition requires activity limitation, and encourage patients and families to be able to enjoy the types of physical activity that are appropriate.
(2) Ensure that patients and families understand the reasons for activity restriction and are informed of the activities available to enable them to make appropriate choices.
(3) The health care provider avoids general statements about “non-contact sports” or “non-competitive sports” that are difficult for the patient or family to understand.
(4) Give patients and family members the opportunity to ask questions and inquire about the situation. Ask patients about their physical activity at each visit.
(5) Evaluate and monitor exercise response every 3-5 years in patients at risk for physical activity-related conditions. For those with potentially increasing risk factors, increase the frequency of evaluation.
(6) Teach patients to use the “talk test” to monitor activity intensity, as being able to talk comfortably during activity will limit activity to 60-80% of maximum activity.
(7) Encourage patients with malignant ventricular arrhythmias to participate in alternating low- to moderate-intensity dynamic and static activities
(8) If episodic syncope is a concern, encourage activities without significant risk of injury, such as walking, jogging, cross-country skiing, racquet sports, golf, and non-confrontational martial arts.
(9) Patients with post-exertional hypoxia are encouraged to participate in activities of an intensity that does not exacerbate their hypoxia to dangerous levels.
(10) For patients with combined aortic dilatation, encourage light to moderate dynamic exercise, using the “talk test” to control exercise intensity.
Requirements for health care workers who provide consultation
(1) Health care workers should understand the physical and mental health benefits of regular physical activity and be able to fully understand and discuss the benefits of physical activity with patients.
(2) Health care workers should receive training on counseling and promotion methods in addition to cardiopulmonary testing, and acquire and master knowledge about physical activity.
(3) Special patients may be referred to exercise specialists who hold certification from the American College of Sports Medicine.
(4) Health care professionals should provide strategies that are appropriate for different places in daily life, school, workplace, and community, respectively, so that children, adolescents, and adults can easily engage in active lifestyles.
In addition, it is recommended that activity facilities be added at the outset of community design, such as ease of transfer, ability to walk safely, and conduct daily school activities. Cardiac clinical centers are designed to promote an environment where children can be active, such as placing blocks, car toys, and drawing whiteboards, removing televisions, game consoles, and fragile decorations, and clearly communicating to parents the benefits and risks of activity and inactivity.