Heart Attack and Exercise

By Igor Klibanov

Your client or someone you know had a heart attack. It’s now behind them and they want to get back to their daily life as fast as possible, and prevent that from ever happening again. The good news: they’re alive. The bad news: if they don’t change something about their life, the future isn’t bright.

  • They’ll be tired all the time, which could affect the amount of things they’re able to get done in their day.
  • A heart attack could change their heart’s rhythm, requiring regular trips to the cardiologist
  • They have a chance of suffering another heart attack in five years or less.

That’s if they don’t change something about their life. But, if they take their heart attack for what it is (a warning sign), and make some necessary changes, they can live a long and healthy life afterwards.

In this article, we’re going to cover:

  • Interesting statistics about heart disease in Canada
  • What happens to the body after a heart attack
  • The three factors that predict both the quality and quantity of life after a heart attack
  • How soon they should start exercising after a heart attack
  • How they should exercise differently if they’ve had a heart attack
  • One warning sign during exercise that tells you to stop the workout, and see a doctor immediately

Heart Disease in Canada

  • About one in 12 Canadians lives with heart disease. Chances are you either currently have, or at one point will have a client with heart disease.
  • Every five minutes, one Canadian with heart disease will die. This is where we shine as fitness professionals because much of heart. disease is preventable with a combination of exercise, proper nutrition, and sleep.
  • Of the people who are at risk for heart disease, 49% are at what’s considered to be “high risk” – the vast majority of those are over 40.

Fortunately, as fitness professionals, we can help prevent heart attacks with exercise and lifestyle modifications.

The Body after a Heart Attack

You live your life, humming along, your ticker is ticking and you never really think about how it works. Then, you have a heart attack. Your ticker stops ticking.

  • Part of the heart muscle dies, so that part can’t contract. If it can’t contract, it can’t deliver as much oxygen to the rest of the body. Cardiac output decreases by 30-50%.
  • The ejection fraction also decreases. Ideally, it’s 60%. After a heart attack, it can drop as low as 35% (so the heart pumps only 35% of the blood that it contains).
  • The part of the heart that was “attacked” (in medical terms, “infracted”) gets thinner and longer, so it can’t contract as hard.
  • Scar tissue develops in the heart. Scar tissue is strong, but it doesn’t allow for full expansion of the muscle. The heart, essentially, becomes stiffer.

As a result of this, quality of life certainly declines:

  • If your client was an active person before the heart attack, and liked to play tennis, hike, etc., their capacity to carry out those activities will be limited.
  • They’ll also have constant anxiety about another heart attack – not fun.
  • Any time they get chest pain, they might think another heart attack is coming on (and you, as the trainer will too).
  • They might get dizzy and sweat without much effort.
  • They might get pain or swelling in their legs.

…and other undesirable symptoms.

Fortunately, the more serious and aggressive they are about their recovery, the better their quality of life will be afterwards. It’s not inconceivable that with the proper approach, their life post heart attack may actually be better than their life before the heart attack.

Quality and Quantity of Life after a Heart Attack

After a heart attack, what people often want to know is, “how much do I have left to live?” and “what will my quality of life be like afterwards?” Valid questions.

Three factors that help answer those questions:

  1. Ejection fraction. As mentioned in the previous section, this is how much blood your heart pumps out with each beat. It should pump out 62% of its blood with each beat. The lower it is, the higher the probability of an early death, as well as poor quality of life.
  2. Degree of adequacy of blood supply to the heart (this is called “myocardial ischemia”). The less blood you get to the heart, the more likely you are to suffer an early death.
  3. The single best predictor of both quality and quantity of life after a heart attack: your cardiovascular fitness. In the cardiovascular research, they use a unit called METs – metabolic equivalents. If fitness is tested to be below four METs, the likelihood of early death is very high. I know that using METs is not helpful outside of a laboratory, so how does it convert to “real life?” If someone can’t walk at a pace of approximately four miles per hour (that’s a fast walk) for a prolonged period of time, well… that’s not good. Fortunately, improving endurance is where we, as fitness professionals, really shine.

While it’s still controversial whether exercise and nutrition has any effect on ejection fraction, what’s clear (and obvious) is that exercise and proper nutrition certainly help improve blood supply to the heart, and exercise is pretty much the only thing that can improve cardiovascular fitness, making it a first-line treatment post-heart attack.

Exercising after a Heart Attack

You know those old school recommendations of “oh, you had a heart attack – you should take it easy.” Better to do the opposite – get on the bike and start pedaling.

How long after a heart attack should someone start exercising? That’s what the researchers in this meta analysis wanted to find out. They accumulated studies that began exercise at four different time periods:

  • Evolving: under six hours after a heart attack
  • Acute phase: six hours-seven days after a heart attack
  • Healing phase: seven-28 days after
  • Healed phase: 29 or more days after

What the researchers found was that if exercise was initiated in the six hour-seven day period, people recovered much better than if they began after seven days.

According to the previous meta analysis, if exercise is begun six hours – seven days after a heart attack, the undesirable changes (weakening and stiffening of the heart) don’t occur to the same extent. Whereas, if someone waits for a month or more, some irreversible changes will have occurred by then, like the deposition of excess connective tissue on the heart, making it stiffer than before the heart attack.

The immediate question is “doesn’t exercise so soon after a heart attack increase the risk of another heart attack?” Fortunately, the researchers did not find that to be the case.

In the “clinical implications” of that meta-analysis, the researchers state that;

Most rehabilitation post-myocardial infarction [that’s medical terminology for heart attack] programs start at least four to six weeks after hospital discharge… early exercise training could attenuate left ventricular remodelling and improve cardiopulmonary capacity in patients with myocardial infarction after hospital discharge (around one week).

So, there you have it – you should be training clients within one week of having a heart attack (after getting the doctor’s clearance, of course).

How to Train after a Heart Attack

Now we know that you shouldn’t wait for a long time after a heart attack before exercising. But should you be taking it easy with your clients? Should you use a lower intensity?

The answer quite clearly is “no.” A higher intensity is actually required to have the beneficial effects on the heart. Translation: just going for a leisurely walk is not good enough (unless the walk makes your client huff and puff).

One study compared two exercise intensities: moderate intensity (65-85% of maximal heart rate), and high intensity (over 85% of maximal heart rate). What they found was that high intensity improved their cardiovascular fitness more than moderate intensity. But, this was more than one week after a heart attack.

In the initial period after a heart attack (up to one week), it’s better to do low to moderate intensity exercise and over time raise the intensity.

What about strength training? That’s what this study wanted to find out – should you just do cardio after a heart attack, or should you also do strength training? To answer that question, researchers divided participants into two groups:

  • Group 1: only cardio, at 65-85% of maximal heart rate
  • Group 2: cardio (same as above) plus strength training

The results: the group that did cardio AND strength training had improved ejection fractions. The group that did only cardio did not improve ejection fraction.

What should the duration of exercise be each time? Ideally, the answer comes from numerous studies that have done head-to-head comparisons of different exercise durations, like 30 minutes vs. 60, or 20 vs. 40, etc. Unfortunately, such a study has not yet been done (at least to my knowledge). But, the studies that do show improvements in cardiovascular health after a heart attack had people exercising for 20-60 minutes.

The frequency recommended by the American College of Sports Medicine (ACSM) is at least times per week.

In summary, exercise prescription after a heart attack is as follows:

  • Type: cardio and strength training
  • Intensity:
    • For cardio: over 65% of your maximal heart rate
    • For strength training: 30-70% of your maximum
  • Duration: 20-60 minutes
  • Frequency: Four times per week

Perhaps, as more research becomes available, these recommendations will change, but as it stands right now, this is the gold standard.

A Word of Warning

Your client is now on their way to better heart health, so they’re exercising on a regular basis, using the guidelines put forth in this article. But, there is one thing to be very cautious about: their blood pressure (BP).

BP should rise during exercise. That’s normal, and in fact, desirable. It should not shoot through the roof, but it should rise (the degree of the rise will depend on the intensity). The problem happens if it actually fails to rise, or even falls. If this happens, you should stop the workout, and have your client go to see a doctor immediately.

If you’d like to learn specifically how to exercise if your client has high blood pressure (including one little-known exercise that drops blood pressure 15/7 mmHg with just eight minutes per day, three days a week), and heart-healthy foods, you can download the special report here.


Igor Klibanov is the author of five books on fitness and nutrition, as well as the CEO of one of Toronto’s premier personal training companies, Fitness Solutions Plus. He was selected as one of the top five personal trainers in Toronto by the Metro News newspaper, and has performed approximately 400 speaking engagements, many of which have been to some of Canada’s largest corporations (including RBC, IBM, Intact Insurance, and others).

Additionally, he has multiple programs for personal trainers to enhance their skills and is a regular speaker at various personal training conferences, including can