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Tips for Safe Exercise With Atrial Fibrillation

Tips for Safe Exercise With Atrial Fibrillation

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What is atrial fibrillation?

Before I explain what atrial fibrillation is, it’s important to understand that normal electrical signals in the heart are timed so that the chambers beat in a coordinated rhythmic fashion (called normal sinus rhythm).

Blood from the top chambers (atria) is transferred down to your lower chambers (ventricles) and then pumped out to your body to meet oxygen and nutrient needs.

Atrial fibrillation (also called “a-fib”) is a common condition that occurs when there is a “short-circuit” or disruption in the heart’s normal electrical conduction system, causing the atria (upper chambers) to beat in a rapid and irregular manner.

With a-fib, the atria beat as fast as 300 to 600 beats per minute.  

The atrioventricular node, which normally transfers the beats propagated in the atria down to the ventricles, serves as a buffer and fortunately does not conduct all these impulses in the ventricles.

Irregular heart beats alter the normal flow of blood through the heart’s chambers (from top down), causing incomplete filling of the ventricles and a reduction in your heart’s ability to pump oxygen and nutrient-rich blood to all parts of your body.

Signs and symptoms

Some people may have no overt symptoms, particularly if their atrial fibrillation is transient and each episode is short-lived.

Symptoms can range from palpitations (the feeling like your heart is fluttering in your chest), shortness of breath, chest pain, dizziness or fainting spells, weakness, or confusion. 

If you think about it, these symptoms make sense.

With atrial fibrillation, your heart muscle is not pumping out enough blood (due to inadequate filling of the ventricles), and without adequate oxygen getting to your brain, lungs, muscles, and other target organs, it’s only logical that you should feel lousy.

A stroke is another concern with a-fib.

It is possible that blood can pool inside the heart, giving rise to a blood clot (thrombus) which, once it breaks off and exits the heart, floats around your circulatory system as a clog waiting to happen.

If it ends up in the brain, then you have a good old-fashioned stroke.

This is precisely the reason why blood-thinning medications like warfarin and aspirin are important

Short video on atrial fibrillation and stroke risk

If you learn better from online videos, I found this short 3D animated clip on atrial fibrillation and its role in stroke.

Causes of atrial fibrillation

In some cases, the cause of atrial fibrillation is unknown.

But in most instances, it occurs in tandem with other health conditions such as hypertension (high blood pressure), previous heart attack, valvular defects, congestive heart failure, or associated comorbidities like obesity.

In my experience working in hospital-based cardiac rehab, it is not entirely uncommon to see a-fib patients after open-heart surgery and angioplasty/stent (particularly after a heart attack).

Treatment options

You should understand that atrial fibrillation is not the end of the world.

Your cardiac specialist will need to run some tests (such as an electrocardiogram or ECG) on you to ascertain how severe (or not severe) your condition is.

In many cases, it can be treated with anti-arrhythmic medication and blood thinners (see stroke risk above).

Other approaches entail using cardioversion to “jolt” the heart back into normal rhythm, or catheter ablation to isolate and zap the specific region of the heart that is the source of the atrial fibrillation.

Exercise guidelines for atrial fibrillation

I am often asked for “right-wrong” or “black-and-white” guidelines for safe exercise with atrial fibrillation, but the short answer is always “it depends” on the individual circumstances.

A-fib often presents in concert with other underlying health conditions, so the exercise prescription cannot be a one size fits all approach.

To follow some random exercise program off the internet could leave you face down and unconscious on the pavement while taking your afternoon walk!

Having said that, the good news is that you CAN exercise safely with atrial fibrillation.  

Have a detailed discussion with your cardiologist and medical management team and find out if there are any specific considerations that would preclude you from doing any certain types of activities.

If you were previously active, then you should let them know what your previous regimen was and what you’d like to achieve now after your diagnosis.

Because the condition can reduce how much blood is ultimately reaching your exercising muscles, you will likely need to start off at a low level and then gradually increase your intensity and duration as tolerated.

A heart rate monitor “may” help you, but the inherent problem is that the numbers might jump around a bit with an irregular heart rhythms.

The most prudent advice is to consult a clinical exercise physiologist with experience working with people with cardiac conditions.

Aerobic exercise guidelines 

You can perform aerobic exercise if it is deemed safe for your condition by your cardiologist.  

Aerobic exercise entails activities that incorporate the large muscles of your body and are continuous and rhythmic in nature (i.e., walking, bike riding, swimming).

You’ll want to customise the frequency, intensity, time (duration), and type of exercise to suit your individual condition and personal preferences.

Exercise frequency

You can perform aerobic exercise anywhere from three to seven (3 – 7) days per week depending on your level of conditioning and exercise tolerance.

If you’re already physically active, you may be able to tolerate more days per week, but if you’re an exercise newbie, then it’s probably better to start off with fewer days per week and work up from there as you adapt.

Exercise intensity

Under normal circumstances (without a-fib), you can use percentages of max heart rate as a gauge of exercise intensity.

But with a-fib, it’s not so straight forward given the variability of the ventricular heart rate.

Commonly prescribed medications such as digoxin, calcium-channel blockers, diltiazem, or beta-blockers alter your heart rate response and therefore may render useless heart rate calculations.

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, consider getting yourself a heart rate monitor or a Fitbit (which also tracks your non-exercise movement habits).

I also recommend using what’s known as Borg’s 6 – 20 rating of perceived exertion (RPE) scale.

Borg Rating of Perceived Exertion Scale

In brief, RPE is a way to use your subjective opinion of how hard exercise is so you can tailor your efforts accordingly.  

In cardiac rehab, we recommend beginning with an RPE of “light to moderate” (11 – 12 on the RPE scale).  If this feels manageable, then you can graduate to “somewhat hard to hard” (13-14).

Another alternative is what’s known as the “talk test.”  

If you can have a conversation with an exercise buddy, then the intensity should be approximately “moderate.”  

If you’re huffing and puffing a bit more but can still maintain the conversation, then this would be “somewhat hard.”  

Anything higher than that to where you genuinely cannot maintain the conversation is likely too hard.

Exercise duration

If you’re new to exercise or very deconditioned after a difficult hospital stay, I would recommend starting off with short, incremental bouts of exercise.

Begin with 5-10 minute intervals of low to moderate intensity activity.  

Perform multiple intervals throughout the day in order to accumulate 30+ minutes per day.  

Progress to longer intervals but slowly reduce the number of times per day you do them.  

Perform longer bouts until you’ve made it to 45 minutes of continuous activity (as tolerated).

Sample exercise regimen for atrial fibrillation

If you’re feeling overwhelmed fearful and have been physically inactive since your diagnosis, this sample graduated exercise plan can help you transition back to your previously levels of activity.

The aim is to perform more exercise bouts for shorter duration early on and progress to longer durations for fewer times per day.

 WeekMinutesTimes per Day
13-56-8
25-104-5
310-153-4
415-203
525-302
630-452
7601

Weight training with atrial fibrillation

I recommend you speak to your doctor before participating in resistance training exercise to ensure there are no medical reasons (aside from a-fib) that would preclude you from lifting weights.  

Generally lighter weights are well-tolerated, but higher intensities might pose a risk in those with underlying high blood pressure, known coronary artery disease (blockages in arteries), ventricular arrhythmias, or congestive heart failure.  

If you can perform lifting exercises under the watchful eye of a clinical exercise physiologist who can monitor your heart rate and blood pressure responses, then you can experiment to find the right weight, reps, and sets appropriate for you.

Medications and their effects on exercise

There are a few medications that are frequently prescribed for people with a-fib.  The main goals are to control or maintain a safe cardiac rhythm and minimise the risk of clot formation (which can lead to stroke).

Common medications include:

Channel blocker

Channel blocking and anti-arrhythmic medications act on your calcium, sodium, or potassium channels and serve to keep your rhythm under control.  

They slow down your heart rate and reduce the strength of the muscle cells’ contractions.  

Examples include Diltiazem and Verapamil (among others).

Sodium channel blockers slow down your heart’s ability to conduct electricity.  

Examples of these medications include Quinidine, Propafenone, and Flecainide.

Potassium channel blockers slow down the electrical signals that contribute to atrial fibrillation and include common meds such as Sotalol and Amiodarone.

Beta-blocking meds can also be prescribed and these act by slowing down your heart rate by blocking the effects of epinephrine.

The end result is a lower heart rate and blood pressure.

Blood thinners

Blood thinners are important because they minimise your risk of clot formation and, consequently, a stroke or heart attack.

Common examples of this include Warfarin, aspirin, Apixaban, or Rivaroxaban.

Interaction of medications, exercise, and atrial fibrillation

If you are prescribed medications, then you may need to alter your exercise prescription.

First, your exercise heart rate will not climb to the same levels it did before you were taking the medications.  

So if you use a “heart rate training range” then the calculations are probably not going to be accurate.  

In this case, use the Borg Rating of Perceived Exertion (RPE) scale.

Try to find an intensity that is consistent with an effort level of around 12 to 13 (moderate to somewhat hard).

Second, you may find that your blood pressure will not climb as high as usual and this can leave you feeling a bit more fatigued than usual.

If so, remember to give yourself time to adjust to the medications and recognise you may need to readjust your workloads.

You can slowly work back up to the higher workloads as you readjust to the meds.

Third, your blood thinners, by very nature, increase your risk of bleeding, both internally and externally.

You may notice easy bruising if you bump your arm or leg against something.  

It’s generally advisable to avoid contact sports since this can increase your risk of internal bleeding.

Work with your doctor to find the medications that get the job done but do not completely bog you out with strong side effects.

This might take a little bit of trial and error, but explain your interest in exercising and ask which ones will be most complementary to getting active again.

Take home message

Atrial fibrillation can be a scary condition, but your best weapon is a thorough evaluation and diagnosis and education on how best to manage it.

I have worked with countless patients with atrial fibrillation and most go on to live completely normal and uneventful lives (no news is good news, right?).

In nearly all cases, they were able to exercise quite safely provided their condition was medically managed and well-controlled.

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Maruti Patil

Tuesday 13th of August 2019

Good afternoon Dr. I am M.S.Patil. I had gone through open heart surgery for severe pulmonary stenosis. It was 110. After operation it is now 25 to 30. I am feeling well. I was told by the doctor that I can do all sort of work exercises. So for first two years, I was determined to do regular exercise. I was feeling well, but last year the problem of missing heart beat was noticed. I posted my problem last year but there was no response from you.

Ok, but my problem is different now. I am doing regular exercise and I am feeling well, but noticed this missing pulse issue. So I consulted my surgeon and he did a Holter Monitor test twice. Then there was a turning point due to stress in my job. I fell into a depression and it took me about six months to come out of this depression. I am now again feeling healthy and going for swimming daily for 45 minutes. My heart rate remains between 60 to 64 beats per minute. The last time when this problem was reported to my surgeon, he suggested to take Orcibest 10mg. Now again I am feeling this missing heart beat. But to feel this missing beat I do not need to feel my pulse. I just feel the skipped beats and feel dizzy for a moment. Also when I take Orcibest 10mg tablet, I notice an increase in heart rate. Please advise what I should do. I feel healthy when I go swimming but this missing pulse appears sometimes.

Dr Bill Sukala

Wednesday 14th of August 2019

Hi Maruti, Thank you for your comment. First, I have gone back and reviewed all your previous comments and can confirm that I responded to each of them. Because I respond to every comment personally, it may take me some time to get around to it because I'm busy with multiple projects. Perhaps you were unable to find my responses at that time. If so my apologies.

As for your current situation where you appear to be having some "skipped beats." The first thing you need to do is speak with your doctor and confirm what kind of skipped or missing beat you're dealing with. If you are experiencing premature ventricular contractions (PVCs), these are generally considered NOT harmful. They can potentially become a problem if they become prolonged and you are symptomatic. You mention you are dealing with some dizziness, so this may be a good reason to speak with your doctor and make absolutely sure that you do not have any problems such as atrial fibrillation.

You mention that you are taking Orcibest. One of the side effects of this medication is dizziness and irregular heart beat. It is possible this is the culprit.

Orcibest side effects: Fast, pounding, or irregular heartbeat Shakiness in the legs, arms, hands, or feet Diarrhea Dizziness and fainting Headache Nausea and vomiting Runny Nose Cough Loss of appetite

Bottom line: please see your doctor and discuss this to ensure that it is nothing more serious. If it's just the medication then you can discuss what to do next with your doc.

I hope this helps.

Kind regards, Bill

john

Sunday 23rd of December 2018

Dr. ; Good stuff here, so lets go with this. In july, 2018 I was surprised to note at my Cardiologist check up- "you're in afib". So, originally it was his path to put me on baby aspirin. Later in August he calls me and says he has reconsidered and wants me to see EP in the clinic he works in. So Dr Yunus sees me in late August 2018, and says given the circumstances of my constant Arrhythmia he schedules a cath ablation in Sept 2018. I go through the procedure and am placed on blood thinners previous to this back to original visit with EP. The ablation was not successful, unfortunately. This past week in late Dec, I went back to visit after the 3 month scarring process to learn he wants now to put more meds into my system, flecainide and metropropol. Seems my condition is more constant than occasional. I'm a long time athlete, work out 4-5x week for 1.5 hours. Combining cardio and lifting. Skiing, cycling, and running. This new routine of drugs scares me, I don't feel like myself. The doctor told me no lifting, puts stress on atrium. Indicated that holding your breath causes that stress. I'm early into this situation- am 61 years of age. 6'1'" 185lbs. Not sure what other steps I need to take in the near term. Just gave up coffee completely this week. Am planning on trimming 10 lbs off my frame. Any other thoughts on my recent acquisition of this situation I'm facing. I have to work out, - but am super bummed about my condition and inability to continue on the path I'm used to after 40 years of my habit of physical activity.

Dr Bill Sukala

Thursday 3rd of January 2019

Hi John, I can certainly feel your frustration. The hardest thing is going from being really active to being told that you can't push yourself. AFib is one of those tricky and unpredictable things too that can really throw a damper on things. I would strongly suggest talking to your doc about a referral to a hospital-based cardiac rehab program. They'll be able to help you with your exercise and perhaps put you on telemetry to monitor your rhythm while you exercise. More importantly, if anything should happen, you'll be in the safest place. Plus that, they'll be abler to give you the best advice relative to your specific medical history. They can interface with your doctor to ensure the best possible care. I have worked with a lot of active people in cardiac rehab and the experience really helped allay their concerns and give them a sense of comfort and control again. As you pointed out, yes, losing weight and cutting out the caffeine will also help you manage it. A-Fib is definitely a wet fish to the face but it doesn't have to be the end of the road where you just wither away. Better the devil you know than the one you don't know. There will be some adjustments ahead, but your best bet is to work closely with your medical management team and find ways to maintain your active lifestyle as safely as possible. Kind regards, Bill

david

Saturday 10th of November 2018

hi i am 72 and have had AF for some years now and i am on Flecainide acetate 100 mg twice a day. I have continued to exercise regularly cycling ( 3 times a week a total of around 200 km a week) and swim three times about 4km in total. i wear a heart monitor when I cycle - and would experience AF maybe 1-2 every 6 months when cycling. Lasts for few minutes to 30 minutes. If I didn't have the heart monitor I would not know I had AF. my big bug bear is that my maximum heart rate varies - sometimes a maximum of 116 and other times 136> I time myself over the same section of a climb - with a maximum of 116 it takes around 9 minutes, when I can get to 136 only about 8 minutes. There is nothing I can do to increase the maximum - it is what it is on the day. I did a stress echo on a treadmill the other day and could only get to 130 bpm after 12 minutes.

Is there anything I can do to have a consistent high maximum heart rate ie around 135. A max of only 116 significantly affects my cycling. Maybe reduce the dosage. Cardiologist didn't have any explanation why my max varies - and on the day there is nothing I can do to increase it - it is what it is. Thanks

Dr Bill Sukala

Sunday 11th of November 2018

Hi David, Atrial fibrillation by its very nature can fluctuate quite a bit and I can certainly appreciate your frustration. You sound like an active guy, so it can be a real kick in the nuts when you can't seem to get into a good groove with your training heart rate. It's hard to say exactly what's going on, but perhaps it may be worth your while to have another talk with your doc about your meds and see if that might be playing a role in this. But variable heart rate aside, sometimes it's better the devil you know than the one you don't know. If your atrial fibrillation was undiagnosed, then that would be far worse. Feel free to stop back and leave another comment after you meet with your doc. It's always useful for others to read your story and perhaps glean some pearls of wisdom (and/or inspiration). Kind regards, Bill

James

Tuesday 9th of October 2018

Cardiologist had me on Bisoprolol...for a year, kept upping the dosages as my last holter monitor showed me with an average HR in the 90's. Eventually was taking 10mg a day. Since June I've been walking almost daily - averaging over 125km/month the past 3 months. But during that time my weight kept increasing, I gained 30lbs and hit 299lbs. Due to developing Tinnitus (an apparently rare side effect) I went off the medication. In 2 weeks with no other changes I dropped 20lbs. Then I read that weight loss is yet another side effect of Beta Blockers. So in summary, people with Afib get put on these drugs, their weight goes up, putting more strain on their heart and the doctors response is to simply increase the dosage making the problem even worse.

Sadly I was hoping exercise and staying away from caffeine, alcohol etc. would be enough to keep my rate manageable, but it slowly but surely is creeping up again. Now I notice after 30 mins on the elliptical my heart rate will shoot up to 180 and stay there for over an hour. I'm worried I'm going to end up hospitalized like I almost was last year when I had a pulmonary edema, found out my heart was enlarged, ejection fraction low, heart at 30% of normal function etc. - which is when I went on the drug (EF improved, functionality almost back to normal). But I simply can't go back to gaining weight again, and eating say 1000 calories a day and being hungry all the time is not the solution either.

Advice?

Dr Bill Sukala

Friday 12th of October 2018

Hi James,

While I can't give any specific advice over the internet, here are some things that I would suggest bringing up in a conversation with your cardiologist.

1) If your heart rate is getting up to a sustained 180 bpm, it would be good to know if you are in sinus rhythm or if you're in atrial fibrillation. If it's the latter, then it would make sense that you have a higher heart rate. The other question is whether or not you are symptomatic. Are you feeling dizzy, light-headed, or short of breath? Perhaps ask your doc if it's appropriate to do a treadmill stress test with full 12-lead electrocardiogram. This might inform the situation a bit more to help determine the best way forward. Also ask if an ablation may be appropriate for you.

2) You mentioned your ejection fraction was compromised. Find out what it is now and how close it is to normal (i.e., around 55% or higher). If it's relatively stable and isn't going anywhere, then this may not play into the picture of how much exercise you can do. Still worth monitoring though.

3) I would strongly recommend getting a referral to a clinical dietitian who has the knowledge, understanding, and experience to work with people who've had some medical issues. Don't go to some wacknut self-proclaimed "nutritionist" who did an online course. It's the same as asking your local mechanic or insurance salesman for nutrition advice (sorry, I had to include that). There is a sh*tload of bad information out there on social media and the internet in general, so I would strongly recommend discussing your diet with a properly qualified nutrition professional. Looking at your IP address, you appear to be located in Alberta. Here are some links to put you on the right path:

http://www.collegeofdietitians.ab.ca https://www.albertahealthservices.ca/info/Page15808.aspx

Hope this helps put you on the right path. Feel free to stop back and leave another comment. Kind regards, Bill

Vashti

Wednesday 12th of September 2018

Hi am 48 had st jude valve tissue MVR surgery 5yrs ago cause of history of rhematic ..but my afib didn't go away.. along wit that my bp spikes up suddenly diastolic 110.. 120 top # 177...am on warfarin am so scared at times why ..and pls help

Dr Bill Sukala

Wednesday 12th of September 2018

Hi Vashti, I'm sorry to hear you're still having trouble with your atrial fibrillation and blood pressure. I cannot give any specific advice over the internet, but I would strongly recommend that you discuss these matters with your cardiologist who will be most familiar with your complete medical history. It will be important for them to evaluate all your medications and dosages to ensure the best outcomes for your arrhythmias and high blood pressure. If you are feeling very anxious, then it may also be a smart idea to speak to a health psychologist in your area who can help you better manage the thoughts going through your mind. Sometimes, if you're feeling anxious, then this can have an effect on your blood pressure and heart rhythm. A bit of mindfulness and meditation may also help you feel more calm on the inside. But the first stop for you should be your cardiologist to get the best available information relative to your medical history. Hope this helps. Kind regards, Bill