How to Exercise After a Heart Attack: Guidelines for Getting Started

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Can I exercise after a heart attack? What kind of exercise should I do? How much exercise? What physical activities are safe? Should I enroll in a cardiac rehab program?

You surely have a lot of questions rattling around your head, so the purpose is to answer them and give you some peace of mind.

A heart attack, shorthand speak for a myocardial infarction or cardiac arrest, is a life-altering event that may lead to significant anxiety which can compromise your quality of life.

If you already participate in regular physical activity, a heart attack can be anxiety provoking and take its toll on your mental health when trying to get back to your normal activities.

In my previous posts on exercise for angioplasty/stent, coronary artery bypass surgery, heart valve surgery, implanted cardioverter defibrillator (ICD), and atrial fibrillation, I lightly touched on heart attacks and how the exercise “playing field” changes after you’ve had one. 

But I’d like to assure you that once you’ve had a heart attack, or any other cardiac episode for that matter, your life is NOT over. Pretty far from it.

As a clinical exercise physiologist having worked in cardiac rehabilitation and research settings, I’ve helped a lot of people who’ve had heart attacks and, after receiving professional medical advice, getting proper treatment, and sticking to a robust exercise program, they’ve gone on to live very active and productive lives.

What is a heart attack?

It amazes me that some heart attack patients I’ve worked with had quite large heart attacks but really had no conceptual understanding of exactly what a heart attack is. 

And this lack of awareness only served to make them more anxious and afraid to do any physical exercise.

Heart function basics

In the simplest terms, your heart is just a pump that circulates blood throughout the body. 

But your heart must ALSO pump oxygen- and nutrient-rich blood to itself which it does through the coronary arteries (see image below).

Coronary arteries are a network of blood vessels which wrap around and envelop the heart muscle.

A heart attack, or myocardial infarction (MI), is a medical emergency that occurs when coronary artery disease causes a blockage in the arteries that feed blood to your heart muscle.

The ‘downstream’ heart muscle on the other side of the blockage is starved of oxygen and nutrients and, without immediate medical help, can result in death of the cardiac tissue (muscle) served by the blocked artery.

Timely treatment results in better outcomes, long-term benefits, and a significantly reduced risk of death from a subsequent heart attack. It can also yield a lower risk of developing heart failure and arrhythmias (i.e., abnormal heart rhythms or irregular heartbeat) like atrial fibrillation that can lead to blood clots, a major risk factor for stroke.

Heart attack survivors that are proactive about their heart health work with their medical management team to eat a healthy diet, maintain a lower blood pressure, cholesterol levels, and blood sugar values (if diabetic).

If you’re a visual learner, here is a short clip about heart attacks with 3D animation which succinctly summarises the process.

Angina vs heart attack: what’s the difference?

When a coronary artery has a blockage, chest pain, commonly referred to as angina, is your early warning sign.

But the blockage does not have to be 100%.

In many cases, it is possible to have, for example, a 70% blockage in an artery and have no symptoms whatsoever at rest. 

But under exertion from exercise, such as when walking up a hill or some other sort of strenuous aerobic activity, the heart muscle’s demand for blood (and the oxygen and nutrients it carries) is exceeded by the coronary arteries’ ability to supply it.

For most people, this results in the standard tell-tale symptoms like jaw, chest, back, or arm pain, sweating, lightheadedness, dizziness, or other atypical pain (i.e., referred pain to the low back).

The good news is that this is only a plumbing problem in your coronary arteries and NOT a heart attack (though can turn into a heart attack if left unattended). 

Often when you stop exercise, the pain will go away.

If the pain is predictably consistent with activity, then it is known as stable angina.

Alternatively, when you’re sitting at home in your chair watching TV and the chest pain kicks in without warning, this is known as unstable angina.

Obviously the latter is more critical, but both situations warrant immediate medical attention.

Signs and symptoms of angina

• Chest pain or discomfort (sometimes mistaken for heart burn)
• Shortness of breath
• Pain radiating down the left arm (or both arms), the back, neck, jaw, or the abdominal area
• Feeling queasy/nauseous, vomiting, cold sweat, dizziness
• Atypical pain which might occur in between the shoulder blades or in the lower back (not common, but I’ve seen it in clinical practice)

A heart attack, on the other hand, occurs when the blood flow through a coronary artery is completely blocked.

This may occur suddenly when a blockage in the artery ruptures and the impending blood clot impedes blood flow.

In other cases, an abnormal cardiac rhythm can cause the heart to stop, but this is not the same as ischemic heart disease (blocked arteries).

For people with underlying cardiac risk factors, such things like shovelling snow or playing a ‘weekend warrior’ game of football can precipitate a heart attack.

Time is heart muscle: get help fast!

The onset of angina is your cue to get to the hospital as soon as possible. 

In cardiac rehab, we have a saying which goes “time is heart muscle.”

The quicker they evaluate you, administer clot busting drugs, and/or perform an emergency angioplasty (or bypass surgery), the more likely you are to preserve your heart muscle.

How do you know you’re at risk for a heart attack (or second heart attack)? 

Be aware of the following cardiovascular risk factors which may predispose you to heart problems:

Risk factors for heart attack

The American College of Sports Medicine’s Guidelines for Exercise Testing and Prescription is the bible for exercise physiologists and provides excellent information on exercise after a heart attack.

Cardiovascular disease risk factors

Age

Male: 45 years or older; Female: 55 years or older

Family history

Heart attack, coronary artery bypass surgery, or sudden death in an immediate blood relative (before age 55 in male 1^st degree relative or before age 65 in female relative)

Cigarette smoking

Current smoker or those who quit within the past 6 months. Click here for information on how cigarettes affect your blood vessels.

High blood pressure

Systolic blood pressure of 140 mmHg or diastolic blood pressure of 90 mmHg or greater confirmed by measurements on at least two separate occasions, or taking prescribed blood pressure medication.  This Mayo Clinic article discusses the impact of blood pressure on your heart and body.

Sedentary lifestyle

Not participating in at least 30 minutes of moderate intensity physical activity on at least three days of the week for at least three months

Obesity

Body mass index of 30 kg/m² or greater or waist measurement of 40 inches or greater (> 102 cm) for men and 35 inches or greater (>88 cm) for women. This article in the cardiologist journal Circulation discusses the link between obesity and heart disease.

High cholesterol

Total cholesterol is 200 mg/dl or greater (5.18 mmol/l); LDL cholesterol is 130 mg/dl or greater (3.37 mmol/l); or HDL is less than 40 mg/dl (1.04 mmol/l)

Pre-diabetes

Glucose levels after an overnight fast are between 100 to 126 mg/dl  (5.5 to 6.93 mmol/l) or glucose levels after a 75g oral glucose tolerance test  are between 140 to 200 mg/dl (7.7 to 11 mmol/L).  There is a strong link between diabetes and cardiovascular risk.  If you HAVE diagnosed diabetes, you are at a 2-4 times greater risk of heart attack and stroke.  Keep your blood glucose levels under control.

Protective HDL Levels

HDL is your “good” cholesterol which protects you against heart disease.  A level of 60 mg/dl (1.55 mmol/l) is desirable

For more information on diet after a heart attack, read Gabby Maston’s article on the paleo diet vs. the Mediterranean diet.

Cardiac rehabilitation after a heart attack

Being a former cardiac rehabilitation exercise physiologist, I admit I’m biased when it comes to recommending cardiac rehab after a heart attack.  

But I cannot overemphasize it enough:  GO TO CARDIAC REHAB.

Cardiac rehabilitation programs are staffed by doctors, nurses, exercise physiologists, physical therapists, dietitians, psychologists, and social workers to help you find an appropriate exercise routine, the best way to improve your fitness levels, and get back to your usually daily activities.

Most programs will provide you with three key elements for long-term success:

1. Detailed education about your heart condition, risk factors, and lifestyle changes for good cardiac health;
2. Supervised exercise sessions and education about how to self-manage your frequency, intensity, duration, and types of exercise after a heart attack; and
3. Recommendations for exercise after you complete cardiac rehab and suggestions for ongoing follow-up care (how to prevent another heart attack).

Home-based and hybrid cardiac rehab

Hospital-based cardiac rehab may not be feasible for everyone due to geographic limitations, so home- and hybrid home-hospital based programs have shown promise.

A recent systematic review and meta-analysis in the Journal of the American Heart Association found that home-based cardiac rehab and hybrid cardiac rehab improved functional capacity and are viable alternatives for those not suited to clinic-based cardiac rehabilitation.

Can I exercise after a heart attack?

The short answer, generally speaking, is yes, you can exercise after a heart attack.

A big YES. 

You CAN and SHOULD exercise to improve both your heart function and general health.

But before you exercise either in cardiac rehabilitation or on your own, you must be certain you receive clearance from your cardiologist and/or surgeon (if you’ve had cardiac surgery).

Depending on the condition of your heart and your individual medical history, your doctor may want to perform a treadmill stress test on you just to be sure that your heart is stable enough to withstand regular exercise training (plus it gives you peace of mind too!).

When can I exercise after a heart attack?

The time it takes to get back to exercise after a heart attack will vary from person to person, but you can generally get moving within a day or two after surgery.

While you’re in the hospital, the nurses will probably want to get you up on your feet and have you doing laps around the nurse station at a very low intensity (i.e., snail pace, just one foot in front of the other). 

You’ll likely do multiple bouts of, say, 5-10 minutes at a time.

Once you leave the hospital, you’ll probably be able to carry on with your low-intensity home exercise until your follow-up appointment with your cardiologist (or surgeon). 

This will likely be around 3-4 weeks or so.

You MUST remember that even when you start to feel better, after any heart episode and surgery, there is still healing happening on the inside. 

A heart attack inflicts trauma on the heart and, if you’ve had any damage to the heart muscle, then your ability to exercise may be compromised.

Only your doctor can tell you the extent of heart damage (if any).

As mentioned above, cardiac rehabilitation sessions are also advisable, as this allows you to “test drive” your ticker under the watchful eye of a trained cardiac nurse and exercise physiologist.

Provided you are asymptomatic (no shortness of breath, no chest pain etc) and have no heart rate or rhythm abnormalities on the electrocardiogram, then you will likely be fine to get back to (or start) your exercise regimen.

Benefits of exercise after a heart attack

The benefits of exercise after a heart attack are not too different from those in people who’ve not had a heart attack. 

Though the main point of difference is a particular focus on improving the function of the heart, particularly if there was any damage to the heart muscle itself.

In other cases, some people experience what is known as “stunned myocardium” which is where the heart muscle is not dead, per se, but is injured and may regain some of its contractile properties after a few weeks.

Finally, it is possible to have a heart attack yet not have any damage to the heart muscle – often when treatment is administered soon after the onset of symptoms.

Reasons to exercise after a heart attack

Improved heart function

Regular exercise training helps improve the heart muscle’s ability to use oxygen, resulting in less demand on the heart and a reduced likelihood of future symptoms of angina

Improved body function

This is a simplified way of saying that your exercising body becomes more efficient at extracting oxygen from the blood and using it down at the cellular level (i.e., in your exercising leg muscles). The benefit of this is that your heart doesn’t have to work as hard

Reduced cardiac risk factors

Exercise can help reduce body fat, increase valuable muscle (increase your metabolic rate), reduce blood pressure, improve cholesterol and triglyceride levels, and reduce your risk of developing type 2 diabetes (or help improve your blood glucose control if you’ve already been diagnosed)

Reduced risk of a second heart attack

Following on from above, exercise can minimize your risk of having a second heart attack.  Life can be unpredictable sometimes and you never know when you’re going to have to exert yourself, so being physically trained is a great way to minimize the possibility of another heart attack

Improved psychological well-being

Exercise has anti-depressant and anti-anxiety effects on the body.  It helps you burn off the daily stresses of modern living, and this is even more valuable after having had a heart attack

What’s the best exercise after a heart attack?

The best answer is: it depends.  On you.  

There’s no set in stone rule for which exercise is best after a heart attack, but walking and cycling are quite commonly recommended because they’re practical and easily accessible to most people.

For people that have had a stroke and may not be able to take up walking, arm-based exercises such as an arm ergometer (arm crank) can be a great way to get the heart rate up and challenge the heart to get stronger.

If you have arthritis, the amount of activity you can do may be limited by pain, so water aerobics may provide the exercise benefits but without the stress on your joints.

Weight training (resistance training) is also a viable form of exercise after a heart attack, but it is advisable to build a good cardiovascular exercise base first and then add the resistance training when you’re feeling stronger and have received clearance from your cardiologist.

Inpatient exercise guidelines

The “by the book” exercise prescription for in-patient exercise (still in the hospital) as set forth by the American College of Sports Medicine is as follows, but I will also provide a bit of additional explanation.

Frequency

Early mobilisation

Two to four times per day for the first three days of the hospital stay. This may include a short walk for short distance. Depending on your energy level, you might even find 5 to 10 minutes of walking to be tiring.

Later mobilisation

Two times per day beginning on day four of the hospital stay with exercise bouts of increased duration.

While it’s true you need your rest, bed rest is also the single worst thing for your body. 

Remaining flat on your back in bed can cause stiffness, constipation, and lost of strength. 

The nurses will probably get you sitting up and walking around your hospital room just to place some gravitational load on your body.

Intensity

Suggested upper intensity limits:
Heart rate of 120 beats per minute or less; OR resting heart rate plus 20 beats per minute as the arbitrary upper limit.

Be aware that medications such as beta-blockers (i.e., metaprolol) will lower your heart rate so the numbers may not be an accurate indicator of how hard you’re working.

Even so, it’s still not a bad idea to keep tabs on your exercise heart rate so you know what your individual response is under the effects of your medication regime.

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).

Focus instead on a self-perceived intensity level of light to moderate exertion. If you find yourself short of breath, then cool your jets and  ease up a bit!

Time (duration)

Perform short, intermittent exercise bouts of three to five minutes as tolerated. Incorporate a slower-level walk between bouts or rest if you feel this is necessary (go by how you’re feeling or your energy levels).

The general rule immediately after a heart attack is more exercise bouts per short duration, then ween yourself onto longer durations while reducing the number of exercise bouts until  you’re doing at least 30 continuous minutes of exercise at a light to moderate intensity (see above comments on intensity).

It is important to understand that these are general guidelines and may not be appropriate for you depending on the extent of damage from your heart attack (if any), medications, and other medical considerations. 

Discuss these recommendations with your nurse or cardiac rehabilitation team to find the right inpatient exercise prescription.

Outpatient exercise guidelines

The following post-heart attack exercise prescription is appropriate for when you’ve been re-evaluated by your cardiologist and/or surgeon and have been cleared for more vigorous exercise.

Frequency

Strive to perform at least four days per week and work up to daily (7 days per week).

Intensity

If you’ve had a follow-up treadmill stress test performed by your doctor then, depending on your level of conditioning, you might want to start off as low as 40% of your measured max heart rate up to as much as 80% of your heart rate.

This is casting a wide net, so it really will have to be tailored to your individual needs. 

As mentioned above, if you’re on beta-blocker medications, then your heart rate may not be an accurate reflection of your intensity.

Instead, aim for a self-perceived exertion in the window of “light to moderate to somewhat hard.”   

If you have the opportunity to exercise at a cardiac rehabilitation program, then you will likely receive specific guidance for monitoring your exercise intensity.

Bottom line:  take it easy at first and then gradually progress yourself to higher intensities, paying particular attention to the onset of any signs or symptoms (shortness of breath, dizziness, etc).

Time (duration)

Give yourself a light 5 to 10 minute warm up consisting of light walking and stretching.   

Depending on your level of conditioning (or deconditioning), aim for 20 to 60 minutes.

The obvious implication here is shoot for the lower end when you’re just starting out and progress to 60 minutes as tolerated.

Increase your duration by around 10 to 20 percent per week, though this will have to be tailored to you depending on how fit or unfit you are.

Remember that exercise isn’t all just about your heart and lungs. 

Also pay attention to localized fatigue in your legs.  If your lower extremities experience fatigue, then just slow it down a bit or take a break.

You’ll find with regular training that you can go longer and longer each week throughout your recovery.

Type of Exercise

As mentioned above, walking and cycling are probably the two most common types of exercise due to their easy access. 

They engage the large muscles of the lower body which helps maximise the amount of energy (calories or kilojoules) you burn which in turn helps you lose weight and keep it off.   

Other forms of aerobic exercise may include:

• Arm ergometer (arm crank)
• Combined walking/cycling with the arm ergometer (combined upper/lower body workout)
• Elliptical trainers
• Rowing machine (rowing ergometer)
• Stair climber machines
• Aerobics classes such as step class or newer crazes like Zumba

The bottom line is find a form of exercise that you enjoy and are more likely to stick with.  

Find an exercise buddy and keep each other on the straight and narrow. 

For more information, see my post on “yo-yo exercise” and how to stay on track with your exercise regimen.

Strength training (resistance training) after a heart attack

You can perform resistance exercise after a heart attack, though I strongly advise you to first build a solid aerobic exercise foundation and get clearance from your cardiologist (particularly if you have high blood pressure) before pushing any heavy weights.

Strength exercises may include free weights, machines, or rubber resistance bands. With regular training adaptations, strength conditioning can help you manage strenuous activities with reduced load on your heart.

Though not set in stone, our cardiac rehab team recommended approximately 6 to 8 weeks in cardiac rehab before we’d allow anyone to undertake any heavy lifting. 

But for the most part, lighter weights may be a good idea just to help you learn the movement patterns and develop proper technique.

In the beginning, aim for at least two to three days per week lifting weights that permit around 12 to 15 repetitions, and performing 2-3 sets.

Be sure to EXHALE as you’re lifting the weight against gravity (remember: EXhale on the EXertion).  

Or when in doubt, do NOT hold your breath, as this may increase your blood pressure.

If you carry a lot of fat around your belly, some exercises might need to be modified if your midsection impedes your range of motion.

I would suggest working with your cardiac rehab exercise physiologist for specific guidance on resistance training.  While the benefits of weight training are clearly established, if not done properly it can lead to injury and possibly further cardiac complications.  

Alternatively, send me an email and I’ll do my best to steer you in the right direction.

Yoga and Tai Chi

Yoga and Tai Chi can help you improve your activity level and resume your usual active life.

Yoga

Gentle yoga is unlikely to cause any problems, but if you had open heart surgery after your cardiac event, yoga could place stress on your sternal incision site.

Other types of yoga like hot yoga could potentially cause your blood pressure to drop. If you’re on blood pressure lowering medications, then the effect could be compounded and put you at higher risk of fainting. Speak to your doctor for clearance and make sure your yoga teacher knows about your medical history.

Check out this article by Johns Hopkins Medicine for more information on yoga for heart patients.

Tai Chi

New research has shown that for people with heart problems, Tai Chi can improve quality of life and lower stress, anxiety, and depression.

Tai Chi has been shown to lower blood pressure and lower cholesterol, body weight, and improve C-reactive protein (a marker of inflammation in the body).

For further reading, have a look at this Cleveland Clinic article on Tai Chi and heart health.

Take home message

The bottom line is that exercise after a heart attack is safe, beneficial, and advisable in most cases. Provided you are medically stable and have received clearance from your doctor to return to exercise, you should be able to regain your fitness level.

Cardiac rehabilitation is an important intermediate step to returning to exercise as safely as possible.

The best advice is to work closely with your cardiologist and cardiac rehab team for guidance specific to your condition.

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