I have received numerous requests for an article on exercise after angioplasty with and without stent placement after my other articles on exercise after bypass surgery, heart attack, heart valve surgery, general open heart surgery, atrial fibrillation, and implantable cardioverter defibrillators. Ask and ye shall receive!
What is angioplasty?
Before we get into what angioplasty is, you must first understand that coronary artery disease causes narrowing of the blood vessels that feed blood to your heart.
It can result in symptoms like pain and/or pressure in the chest, neck, back, jaw, arms (collectively called angina), or, if left untreated, a heart attack (myocardial infarction).
A cardiac catheterisation procedure is often performed to determine the extent of the blockages in your arteries and, if necessary, angioplasty may be performed with or without stent placement.
The term angioplasty comes from the Greek words angio meaning “vessel” and plasticos meaning “fit for moulding” but in very simple terms, it’s just another name for a heart plumbing job.
The full name for the procedure is percutaneous transluminal coronary angioplasty (PTCA). Translation: percutaneous means they pass an inflatable catheter through the skin (at your femoral artery in your groin area) traveling through the lumen (the space within your artery), up into your aorta, and then enter into your coronary blood vessels (the arteries that serve blood to the heart). Another common name for the procedure is percutaneous intervention or PCI.
Once the blockage is visualised, the doctor then passes the catheter into the blockage and inflates a small balloon to widen the blood vessel and reestablish blood flow.
What is a stent?
A stent is commonly inserted during angioplasty. A stent is a little wire mesh which keeps the artery open after the balloon has been removed and minimises the chance of the artery blocking up prematurely (restenosis).
The main types of stents include a bare metal stent and a drug-eluting (medicine-coated) stent, the latter of which helps prevent scar tissue from blocking the artery.
Angioplasty and stent procedure in images
Below is another example which prominently shows the difference in blood flow after arterial stenting.
A number of cardiac medications are commonly prescribed to help minimise the risk of your artery reoccluding (blocking up again), as well as reducing cardiovascular disease risk factors (to prevent another blockage).
The thing you have to remember is that when it comes to coronary artery disease, it’s not always a case of the doctor “fixing it” with surgery. There is always a risk of blockages in other arteries.
So while I’m not a fan of pumping people full of medications, there are times where they can be a valuable adjunct to reduce your risk of a heart attack whilst making lifestyle changes.
Once you get your risk factors under control (i.e., lose weight, quit smoking, start exercising, reduce blood sugar (if diabetic), then you can discuss with your doctor the possibility of reducing or discontinuing some or all of your medications.
Beta-blockers slow down your heart rate which also helps to reduce blood pressure and, consequently, workload on the heart. They also help relax your blood vessels which can help improve blood flow and reduce or prevent chest pain (angina).
Blood thinning medications like aspirin and Clopidogrel (Plavix) reduce the ability of your blood to clot, making it easier for blood to flow through narrowed arteries and reducing your risk of a heart attack.
Nitrates (such as nitroglycerin) are a common anti-angina medication which relax and widen your blood vessels to allow more blood flow to your heart muscle. Nitroglycerin comes in small tablets that you place under your tongue when having chest pain.
Statins are prescribed to lower your blood cholesterol. They work by blocking precursor substances needed to synthesise cholesterol. Statins can help reduce the accumulation of plaque in your arterial walls which may reduce the chances of another blockage forming.
Calcium channel blockers
Calcium channel blockers affect the muscle cells in your arteries which help the blood vessels relax and widen. This results in increased blood flow through your coronary arteries thus reducing or preventing angina. Certain calcium channel blockers slow the heart rate which reduces workload on your heart.
Angiotensin Converting Enzyme (ACE) inhibitors block an enzyme that produces angiotensin II, a substance which constricts your blood vessels. By blocking the formation of this substance, it helps relax your blood vessels to reduce blood pressure and workload on your heart.
Most importantly, lifestyle changes are crucial after surgery. A combination of regular exercise, a prudent diet, quitting smoking (if you smoke), stress management, and behaviour modification to help you stick with it are all key pieces of the lifestyle puzzle.
Angioplasty is not a “cure” for your coronary artery disease. Like with medications, the procedure simply buys you more time to make important lifestyle changes which can reduce your risk of arteries reoccluding (blocking up again) or other arteries plugging up for a first time.
For more information on diet for people with coronary artery disease, please read Gabby Maston’s guest post on the paleo diet vs. the Mediterranean diet.
Benefits of exercise
It’s common sense. We all know exercise is good for us, but here’s a laundry list of benefits to put you in an exercising kind of mood:
- Reduced risk of a heart attack (or second heart attack if you’ve already had one)
- Improved heart function (i.e., lower heart rate and blood pressure means less workload on the heart)
- Increased anginal (chest pain) threshold. The more fit you are, the harder you have to work to elicit chest pain (if there are blockages present)
- Improvements in oxygen delivery (via the blood) and consumption (in your muscles)
- Enhanced fuel selection with exercise (i.e., your body can tap into fat easier with better conditioning)
- Body composition improvements (i.e., reduction in fat, particularly dangerous fat around the organs)
- Improved blood sugar control and insulin sensitivity (if you have diabetes)
- Increased functional ability (i.e., easier to perform activities of daily living like lifting boxes, gardening, cleaning the house)
- Increased quality of life
When can I exercise?
After your surgery, you’ll probably feel great (provided you’ve not had a heart attack or other complications) because your heart muscle is now getting lots of oxygen through the newly reopened arteries. But you must remember, even if you’re feeling better, know that there IS still healing happening on the inside.
I recall a client I had back in 2007. He called me up and said, “hey, I hear you’re the heart exercise guru. Can you start training me today?”
Me: “Well, not sure about the guru bit, but maybe I can help you. When did you have your angioplasty?”
Client: “Two days ago.”
Me: “Right, ok, I’m going to grab you by the scruff of your neck, pull you back down to planet Earth, and save you from yourself. I’m glad you’re enthusiastic about getting back into exercise, but you still have some recovery and healing time ahead of you before we can work together.”
It’s important to give yourself at least a couple weeks of low activity recovery time after leaving the hospital. This means you can get out and do walks around the neighbourhood on level terrain, but leave the steep hills and pumping iron to Arnold (for now).
If you’re planning on doing some hard exercise (aerobic or strength training), I’d advise you to ask your cardiologist if a post-angioplasty treadmill stress test is appropriate. If you can tolerate high workloads without any signs or symptoms (ie., chest pain, shortness of breath) or unexpected arrhythmias on the electrocardiogram, then this is pretty good assurance that you’ll be able to push the higher exercise intensities on your own.
Whether or not you do a pre-exercise stress test, be sure to get your cardiologist’s approval before you get into any structured exercise (gym workouts, tennis, golf, etc). Make sure you understand the effects of your medications on the exercise response.
Aerobic exercise guidelines
When you’re first released from the hospital, it’s important that you’re up on your feet and moving around a bit but keeping the intensities low to allow for healing. Even if you think you can do a lot more, err on the side of caution and take it easy.
The following is an illustration of a sample exercise plan which may serve as a rough guide (provided your surgical team agrees). The aim is to wean yourself from shorter to longer exercise durations by minimizing how many exercise bouts you perform each day.
|Week||Minutes||Times per Day|
How often can I exercise?
Start off with 3 to 4 days per week and work up from there. If you were previously active before surgery, then you do have the advantage of muscle memory and a residual training effect, but as I stated above, you need to “test out” your body during exercise and the effects of medication on your exercise response. Once you establish your fitness foundation, gradually work up to daily exercise sessions.
How hard can I exercise?
The answer is always the same: it depends. Exercise intensity can be a tricky one because depending on your current level of conditioning, you may be able to tolerate higher workloads than someone who was previously inactive before their angioplasty procedure. If you had a heart attack, then this can further complicate matters.
If you’re looking for a training target heart rate, then here are some basic calculations you can do. I’ll give examples below basing the calculations on a 50 year old man with a resting heart rate of 60 beats per minute.
Method 1: Straight heart rate calculation
1) Determine your theoretical max heart rate by subtracting your age from 220. So:
220 – 50 = 170 bpm
If you have an actual MEASURED max heart rate from a stress test, then use that number instead.
2) Then calculate training percentages based on 170 bpm. So if you wanted to exercise at, say, 50 to 65% of your max heart rate, you’d calculate it as:
170 x .50 = 85 bpm
170 x .65 = 111 bpm.
Therefore your training heart rate range would be 85 – 111 bpm.
For 60 to 75%, it would be:
170 x .60 = 102 bpm
170 x .75 = 128 bpm
Therefore your training heart rate range would be 102 – 128 bpm.
Method 2: Karvonen method (aka heart rate reserve)
The Karvonen or heart rate reserve method is a little trickier but I’ll do my best to make it clear.
1) As above, subtract your age from 220 to get your theoretical max heart rate. So it’s 220 – 50 = 170.
2) Then subtract your resting heart rate from the result of step 1. So 170 – 60 = 110.
3) Now calculate your training heart rate percentages from this. If we use the 60 – 75% range it would be calculated as follows:
110 x .60 = 66
110 x .75 = 83
4) Now add your resting heart rate to these numbers. So:
66 + 60 = 126 bpm
83 + 60 = 143 bpm
Therefore, your training heart rate range would be 126 to 143 bpm.
I would advise starting at the lower percentages and see how you fare. It’s not a perfect science so you may need to adjust them if the training ranges are too easy.
If you have a hard time finding your pulse, get yourself a heart rate monitor or a Fitbit (which also tracks your non-exercise movement habits). Click on each image to check out features and thousands of Amazon user reviews.
Also remember that if you’re taking medications that alter your heart rate (i.e., beta-blockers), then none of these calculations are going to be worth much. In that case, you’ll need to rely on what exercise physiologists call the “talk test.” If you can have a conversation with the person next to you while doing your exercise, then the intensity is probably sufficient.
The Borg rating of perceived exertion (RPE) 6 to 20 point scale is also quite useful. The logic behind a 6 to 20 scale is that most people at rest or doing light activity have a heart rate between 60 to 90 bpm. If you’re working very hard, then you’re going to be around 170 to 200. So Borg decided to just drop the zeros and create a scale which is consistent with most heart rates at a given workload. This is particularly useful if you’re taking medications that slow your heart rate. There is a bit of a learning curve to it, so if you’re enrolled in a cardiac rehab program after your surgery, have the staff exercise physiologist explain the scale to you.
How many minutes should I do aerobic exercise?
I suggest easing into it. Start off with 10-20 minute bouts of exercise and then work up from there. Also pay attention to how you feel both immediately after and the following day. If you feel absolutely drained by doing 20 minutes, then perhaps scale it back a bit and build up your conditioning to longer durations.
If you need to do several small intervals to accumulate your daily exercise minutes, then break them down into small intervals you can tolerate. You might do 10 minutes, have a break, do another 10 minutes, have a break and then do a final 10 minute walking bout. You’ve just accumulated 30 minutes of activity. I often suggest working up to longer durations of 45+ minutes as tolerated.
Which types of aerobic exercise are best?
There are not set in stone guidelines for this, but aerobic exercises that incorporate the large musculature of your body (i.e., hips and legs) will give you the most exercise bang for your buck. Also be sure to pick exercises you enjoys since that will increase the likelihood you’re going to do it.
Aerobic exercise precautions
- Get your doctor’s clearance to exercise first. Ease into it and carefully work your way up to higher intensities and longer durations.
- Perform a gradual 5 minute warm up to allow your heart and blood vessels to adapt to the exercise. Jumping straight into high intensity exercise could potentially aggravate the stent and cause it to collapse (particularly immediately post-angioplasty).
- While in the early recovery phase (1-2 days immediately post-op), avoid overexerting yourself with strenuous/vigorous exercise (unless advised to do so by your cardiologist or surgeon). Pushing too hard can cause a sharp spike in your heart rate and blood pressure which might cause the stent to collapse (it can and does happen). Use the ol’ KISS acronym: Keep It Slow and Steady.
- Walk or cycle on level surfaces to establish your fitness foundation. You’ll be able to handle the hills in due time. If you find yourself huffing and puffing, that should be an indicator to ease up on the accelerator!
- Limit your exposure to environmental stressors such as extreme cold, heat, or strong winds. Any of these can make your usual exercise pace seem much more difficult.
Adverse signs and symptoms
Pay attention to any signs or symptoms associated with exercise. Stop exercise if you experience chest pain, tightness, or discomfort, pain radiating down the arm or jaw, back pain between the shoulder blades, or shortness of breath, If it does not resolve by itself or continues to get worse during rest, seek emergency medical attention.
Angioplasty resistance / weight training guidelines
One of the common questions I get from my readers is “can I lift weights after an angioplasty/stent?” The short answer is probably yes, but how much weight you lift is going to depend on a number of factors that will need to be discussed with your cardiologist.
Here are some questions you’ll need to bring up with your medical management team (i.e., cardiologist, nurses, cardiac rehab team):
- Did you have a heart attack?
- Was there any damage to your heart muscle?
- Do you have any arrhythmias stemming from the heart attack?
- Do you have high blood pressure?
- Are you taking medications to lower your heart rate and blood pressure?
- During the cardiac catheterisation, did they note how widespread the coronary artery disease was (i.e., one artery, two arteries, triple vessel disease)?
- Did they stent all the offending arteries or were there still arteries with lower levels of plaque they chose not to stent?
- Were you a regular weight lifter before your procedure?
- How much weight were you lifting?
By no means is this an exhaustive list, but they are questions that need to be addressed. If you had damage to your heart muscle, arrhythmias, or high blood pressure then high intensity weight lifting might be contraindicated (not advised).
If you had arteries with coronary artery disease which were not stented, then there is still a chance these plaques could rupture while lifting heavy weights.
If you were a weight lifter before the procedure then you might be able to tolerate weight training better than someone who is completely new to the gym.
How often can I lift weights after the procedure?
Consider starting off with 2 times per week and see how your body responds. Then consider working up to 3 – 4 days per week as tolerated.
How much weight can I lift? Can I lift heavy weights?
The answer is: it depends. More than likely, you’ll be able to lift again, but how heavy you lift is going to depend on a number of factors. Refer to the list above regarding weight training considerations. You’ll really need to discuss this with your medical management team.
How long should my weight lifting sessions be?
There’s no resolute answer to this since it’s going to depend on how many exercises you do and how many sets and reps of each exercise. This will be a bit of trial and error, but I would suggest paying attention to how you feel immediately after and the following day. If you feel exhausted and run down, then you may need to adjust the training duration.
What types of resistance exercise is best?
Resistance training comes in all shapes and sizes. You can lift barbells, dumbbells, body weight, cables, kettle bells, or get creative with set of TRX straps.
With the recent rise in high intensity training, I’m often asked questions like “can I do Cross-Fit after an angioplasty/stent procedure?”
Resistance exercise precautions
- Like with aerobic exercise, get your cardiologist’s clearance for exercise.
- Before you get into weight training, I would advise building a good aerobic base first. If you can tolerate reasonably high workloads, then this will provide more assurance that you can tolerate weight training.
- Perform a light to moderate 10 minute cardio warm up on the bike or treadmill to allow your blood vessels to dilate a bit. Jumping straight into heavy weights with no warm up could cause a sharp spike in blood pressure which might affect your stent.
- Following on from above, beware of weight lifting in very cold or hot climates. If in a cold climate, be sure get in a warm up. In a hot climate, be sure you’re wearing breathable clothing that allows for proper cooling. Use a fan to help cool your body. Environmental stressors (either hot or cold) can force your heart to work harder than it would at an ambient temperature.
Take home message
The bottom line is that you can exercise safely after an angioplasty and stent, but you do need to take some precautions.
Whether you’re into aerobic or resistance training, speak with your cardiologist about your particular medical and exercise history and ask lots of questions.
If you were a hardcore fitness nut before your procedure, ask about getting a treadmill stress test (if feasible) to see how durable your ticker is.
I would also recommend attending cardiac rehab, as this is another way to get some feedback on your particular condition.
Pay attention to how your body responds to exercise while on medications.
Once you adapt to the precautions, there’s no good reason why you can’t live a healthy and active lifestyle again.