Cardiac rehab for heart failure

Heart failure, as you may know, is a condition where the heart fails to pump blood efficiently leading to shortness of breath, fatigue, weakness, swelling in the limbs, rapid or irregular heartbeat, persistent cough, loss of appetite and nausea. You may read our earlier article to better understand the causes and types of heart failure:

We now know that cardiac rehabilitation or cardiac rehab is the best therapy for heart failure, especially when combined with the right medications and surgical or interventional procedures as needed.

What is Cardiac Rehabilitation?

Cardiac rehabilitation is a program designed to help people with heart problems recover, improve their overall health and reduce the risk of future heart problems. It is a team effort involving healthcare professionals such as cardiologists/ physicians, nurses, physiotherapists, dietitians and psychologists. 

What are the phases of Cardiac Rehabilitation?

Phase 1: Inpatient Phase (in the hospital)

Patients with heart ailments such as heart failure might be referred to cardiac rehabilitation right from their hospital stay. The rehab team will assess and evaluate your physical as well as psychosocial abilities and initiate education, early mobilisation, medications and lifestyle modifications.

Phase 2: Outpatient Phase (post discharge)

Once the patient is discharged from the hospital, the rehabilitation will continue at an outpatient care facility. It involves supervised exercise training, education on risk factor management, nutritional guidance, psychological counselling and lifestyle changes.

Phase 3: Training Phase

It focuses on long term cardiovascular health maintenance and involves transition from supervised to a less supervised exercise training.

Phase 4: Maintenance Phase

This phase continues throughout your entire life once you complete the previous 3 phases. Patients are encouraged to make regular exercise a part of their daily routine and adopt healthy lifestyle choices.

How is Cardiac Rehabilitation beneficial in heart failure patients?

  • Makes the cardiovascular system stronger
  • Improves exercise capacity
  • Enhances quality of life
  • Reduces hospital readmissions
  • Improves long term adherence to healthy behaviours
  • Helps control the risk factors which lead to heart failure (e.g., diabetes, hypertension, etc.)
  • Elevates mood and positive attitude towards life

What are the safety measures to be followed during exercise?

  • Consult with your physician before starting or modifying an exercise routine
  • Start gradually and progress slowly
  • Prior to exercise, perform a warm-up routine and end the session with a cool-down period
  • Keep track of your heart rate and symptoms such as chest pain, palpitations, shortness of breath, dizziness, leg cramps and excessive fatigue
  • Stay hydrated, consuming fluids as advised by your physician
  • Take prescribed medicines as directed
  • Exercise in a safe and controlled environment

Hence, enrolling in a cardiac rehab program is a positive step towards taking control of your heart health and enjoying a better quality of life. Remember that you are not alone in this journey, and there is a dedicated team ready to support you in every possible way.


Obesity and Heart Health

Obesity or overweight, a state of excess accumulation of fat in the body, may lead to various diseases. When an individual is obese, their excess body fat can have detrimental effects on overall health as well as on heart health.

The heart has to work harder to pump blood in obese individuals, and this extra strain on the heart can lead to hypertension, heart muscle disease, heart rhythm abnormalities, enlarged heart and heart failure. It has recently come to limelight that a condition called “Obesity cardiomyopathy” accounts for a significant proportion of heart failure and can only be managed by experienced cardiologists.

A recent study by the Indian Council of Medical Research has shown that our country now has 101 million diabetics, with a further 136 million pre-diabetic individuals in need of prevention as shown in the statistics in the Metabolic non-communicable disease health report of India, ICMR.

The study also looked at the number of people with hypertension, central obesity and generalized obesity.

The vicious cycle

There is strong scientific evidence to show that obesity plays a key role in the causation of diabetes, hypertension and cholesterol abnormalities and together they contribute to the condition called Metabolic Syndrome. The vicious cycle of obesity worsening your blood sugar, blood pressure and cholesterol levels which in turn leads to deterioration in lifestyle and pushes one into further obesity, has to be halted right in the beginning. In fact, these are the most sinister precursors of killer diseases like heart attack and stroke. If you are wondering how being obese predisposes an individual to deadly ailments, the excess fat that builds up inside the arteries supplying the heart and brain – a condition known as atherosclerosis – is the culprit.

Timely detection and an early intervention are very important in addressing the obesity burden that the world is facing today. While maintaining an ideal body weight should be high priority right from the age of adolescence, the warning signs that warrant immediate medical attention in obese people are:

  • Fatigue or excessive tiredness
  • Shortness of breath
  • Inability to do their routine activities
  • Excessive snoring and daytime sleepiness
  • Swelling of feet, frequent coughs and colds
  • Chest pain
  • Palpitations

People with obesity not only face many physical challenges but significant emotional challenges too. Obese individuals may develop depression, anxiety, mood swings and eating disorders; hence it is vital to keep your loved ones on a routine medical follow-up and provide them adequate emotional support.

The causes for obesity are many

Lack of exercise, unhealthy food choices, chronic mental stress, long work hours, lack of sleep are some of the modifiable causes of obesity and the Metabolic Syndrome. It is important to identify and treat any underlying medical conditions like thyroid hormonal insufficiency and polycystic ovarian syndrome while correcting the lifestyle factors.

But the solution is simple

Overcoming obesity can be simple with the right knowledge, awareness, help and guidance.

Changes in lifestyle such as making healthier food choices, exercising regularly for at least 30 minutes daily, practicing good sleep hygiene, adopting stress management strategies and keeping a track of the silent killers namely BP, blood sugar and blood cholesterol are the cornerstones of beating obesity.

A simple measure of your waist and knowing your body mass index can reveal a lot about your heart health, talk to your healthcare provider about it. Please refer to our earlier article on this topic:

Below are a few tips that are rather simple to follow and easy on the pocket too:

  • Restrict use of processed and packaged foods
  • Stock your refrigerator / pantry with fresh fruits and veggies
  • Reach out to a variety of nuts and seeds like almonds, walnuts, sunflower seeds etc. as a snack instead of cookies and biscuits
  • Eat whole grains and pulses, limit use of refined grains and flours like maida, polished rice, sugars, and artificial sweeteners.
  • Learn to manage food portions well; use a smaller plate during meal times
  • Our humble buttermilk and lime juice are far better and healthier alternatives to soft drinks and packaged juices
  • Practice a good sleep routine; avoid the use of gadgets and bright screens prior to sleep
  • Ensure adequate water intake
  • Incorporate physical activity in your daily routine – use steps instead of elevators, park your vehicle a bit far away and walk to your office or the supermarket, try a walking break for 5-10 minutes every 1-2 hours while at work and learn; incorporate regular brisk aerobic exercise along with muscle strengthening exercises on a regular basis

In summary, obesity is a universal problem that significantly increases the risk of heart disease and several other chronic ailments. Taking proactive measures to address obesity through lifestyle changes is vital in promoting heart health and avoiding other comorbid conditions.


Anemia in the general population and in heart patients

What is anemia?

Anemia is a condition in which your body does not have enough healthy red blood cells to carry adequate oxygen to your body’s tissues. Having anemia, also referred to as low hemoglobin, can make you feel tired and weak and is often associated with pale skin and nails, and hair fall.

Anemia widely affects people of all age groups and genders. In India, the prevalence of anemia is as high as 38% in women, 22% in men and 40% in pregnant women.

Anemia is diagnosed by a blood test called complete blood count that looks at the hemoglobin level along with cell counts in the blood. The normal value of hemoglobin for women is 12-15.5 g/dl and for men it is 13-17.5 g/dl. Anything below this hemoglobin level is considered to be anemia.

What are the types of anemia?

Nutritional anemia is the commonest type of anemia and is divided into iron deficiency anemia, vitamin B12 deficiency anemia and folic acid deficiency anemia. The lack of the desired amount of vitamins and minerals, also known as micronutrients, in our diet is the main reason why nutritional anemia develops.

The other less common types of anemia may be due to genetic factors, abnormal red blood cells, chronic illnesses and disease of the bone marrow.

Who is at risk of developing anemia?

The following groups of people are at a high risk of developing anemia:

1. Lack of a balanced healthy diet leads to nutritional anemia. People may not be consuming a healthy diet due to lack of knowledge about healthy food choices, lack of financial means to procure healthy food, or due to poorly informed dietary practices such as avoidance diets, crash diets etc.

2. Chronic blood loss such as women in the reproductive age group with heavy menstrual bleeding, individuals with undiagnosed occult blood loss from the gut, and medication-induced bleeding in those who take pain medication for prolonged periods of time.

3. Acute blood loss such as during surgical procedures and road traffic accidents.

4.  Elderly individuals are at a higher risk of developing anemia due to a combination of factors such as poor appetite, dentition related issues, reduced absorption of nutrients from the gut, associated co-morbidities and lack of access to fresh and nutritionally wholesome foods.

5. Pregnant women are susceptible to anemia because of the increased demand posed by the developing fetus.

6. Adolescent girls are prone to anemia due to the alterations in their body physiology and the hormonal changes associated with menstruation.

7. Individuals with any chronic conditions such as chronic kidney disease, liver disease, heart failure and malabsorption syndromes are at high risk for developing anemia.

Why should heart patients be extra vigilant about anemia?

From the above discussion, it is clear that anemia may occur in heart patients who have undergone cardiac surgeries such as bypass surgery or valve surgery, in individuals with heart failure and in almost any cardiac patient with poor nutritional habits. As the heart is the pumping organ responsible for circulating blood to all parts of the body, whenever there is anemia your heart has to work much harder than normal to ensure that the rest of the body gets sufficient oxygen and energy. This means that the wear and tear on the heart muscle is higher when you are anemic and therefore the possibility of the heart becoming weak or failing is also much higher than in normal individuals. In fact, anemia, heart failure and renal failure are a deadly combination as they form a vicious cycle where one worsens the other and leads to rapid deterioration of overall health. Hence, it is very important to diagnose anemia in a timely manner and to treat it at the earliest to avoid further complications. 

What should you do if you have symptoms of anemia or are at risk?

If you are experiencing symptoms such as undue tiredness or fatigue, breathlessness while doing routine activities, or have had a history of surgery or excessive and prolonged bleeding, visiting your physician should be the first step. After running a battery of tests, your doctor will be able to come to a conclusion about what type of anemia you have and advise you on the appropriate interventions to overcome the problem. While dietary modifications and supplemental iron pills are the most commonly employed solutions, intravenous iron infusion and blood transfusion may be necessary in severe deficiency.

What are the nutritional strategies to overcome anemia?

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As a cardiopulmonary dietician, I often guide individuals with anemia on how to improve their hemoglobin level through dietary modifications. Let me walk you through some tips about consuming a diet rich in iron and ensuring that the dietary iron is efficiently absorbed into your bloodstream

There are two types of iron in your food: heme iron that is present in animal sources and non-heme iron that is present in plant sources.

Animal sources of iron – lean meat, chicken breast, meat liver, sardine, oyster, crab, tuna, mackerel, salmon

Plant sources of iron

Nuts and seeds – Nuts, seeds and dried fruits such as figs, dates, pistachios, hemp seeds, pumpkin seeds

Green leafy vegetables – Dark green leaves such as drumstick leaves, spinach, kale

Beans – Chickpeas, kidney beans, soy beans, black beans

Whole grains and millets – such as oats, whole wheat, ragi

Fortified foods – There are a variety of foods that are fortified with iron such as fortified pasta, fortified white rice, fortified orange juice, fortified cereals etc.

Vitamin C helps the absorption of iron in the body and is also essential for cell growth, development and repair of all body tissues, proper functioning of the immune system, and wound healing. Dietary sources of Vitamin C are gooseberry, orange, lemon,  guava, strawberries, papaya, capsicum and broccoli.

Vitamin B12 and folic acid are also important in order for our body to produce healthy red blood cells. Sources of Vitamin B12 for vegetarians are bananas, melons, sprouts, soy milk and tofu.

Folic acid is present in green leafy vegetables, dried beans and peas, nuts, enriched bread, cereals and other grains.

Poultry, fish, dairy products and eggs also contain both these micronutrients.

In summary, anemia is a common medical condition that should be diagnosed and managed early. Regular routine health checks are very useful in picking up the condition in otherwise well individuals. Eating a balanced diet with a focus on locally available iron-rich foods along with vitamin C, vitamin B12 and folic acid containing foods is the ideal way to prevent and manage nutritional anemias.


Move ahead with Heart Failure

Heart failure, a growing medical threat across the globe, not only affects the heart but also the functioning of all the body parts. Individuals with heart failure often face various challenges in their day-to-day life like tiredness and exhaustion, shortness of breath, physical weakness, water logging in the body, frequent infections and mental depression. While it may be very frustrating for the affected person and the caregivers to try to overcome the disease, some simple lifestyle measures actually go a long way in improving the quality of life.

In this post, we would like to share with you the heart-warming story of Mr.S, an 84-year old gentleman, who is currently undergoing cardiac rehabilitation with us.

Mr. S is a retired LIC employee . He has had a medical history of diabetes, hypertension, heart attack, chronic kidney disease and heart failure (ejection fraction 40%). He was taking several medicines to keep his illnesses under control. He lived with his family which included his wife, son, daughter-in-law and grandchildren.

Right after our first interaction with Mr. S, we understood that he had multiple health issues and needed individual attention from the rehab team. His main complaints were breathlessness during physical activity, generalized weakness and inability to lead a normal life. He used a walking stick for support and was unable to climb even a few steps. His ambition was to be able to walk at least a kilometer without any hindrance and difficulties.

After ascertaining that Mr. S’s condition was stable, we started him on a personalized cardiac rehab program comprising of supervised exercise, health education, counseling and dietary advice. He visited our rehab centre two times a week and followed our advice for home exercising on the other days. The exercise sessions were very short to begin with. It consisted of a prolonged warm-up period followed by simple exercises like on-the-spot marching with support, and stepping up and down a step a few times, and some cool-down stretches. He needed frequent rests which we allowed.

Breathing exercises were taught to ensure proper breathing technique to help with his breathing difficulty. Education about his current health problems, red-flag signs to watch out for, exercise and its effects, healthy eating and ways to meet his nutritional requirements, role of medications and their importance and adherence to exercise on a long term basis was an integral part of his program.

The rehab team helped Mr. S set weekly health goals that were small but achievable. In spite of a few inter-current illnesses, Mr. S has made progress and is able to do more. He is now cycling continuously for 15 minutes and working with low-weight dumbbells to improve his strength, after a month of continued efforts.

Sometimes, it does take a longer time to see improvement but close monitoring, baby steps and constant encouragement are the keys to success. Mr. S feels that he still has a long way to go before being able to walk a kilometer but we know for sure that he is much nearer to achieving his goal than he was a month ago.

If you or your loved ones are suffering from heart failure, talk to your Cardiologist about cardiac rehabilitation as it is an approved and mandatory aspect of management in the current era.


Blood pressure and your heart

High blood pressure (BP) or ‘hypertension’ means that the pressure exerted by your blood on the inner walls of your blood vessels is higher than normal. It depends on several factors like pumping capacity of your heart, volume and viscosity of your blood, and state of your vessel wall.

You would have noticed an inflatable cuff from the BP apparatus fixed to your upper arm when someone wants to measure your BP. The electronic device measures your BP by a method called “oscillatory method” whereby inflation of the cuff to a high pressure followed by deflation allows blood flow in the artery in a cyclical pattern that is captured as BP by the device.

You must have heard the term “120 over 80”; this is nothing but the upper limit of normal BP in adults. The upper number denotes systolic BP (SBP) or the peak pressure in the arteries during contraction of the heart and the lower number is the diastolic BP (DBP) or the least pressure in the arteries when the heart is actually filling with blood from the veins. Apart from BP, your heart rate (number of times the heart beats in 1 minute) is also shown on the BP monitor. The normal heart rate in a healthy adult ranges from 60-80 beats per minute in a resting condition.

The most recent international guidelines for hypertension classify BP as Normal, Elevated and High as shown in this table:

If you have never had your BP measured earlier, now is the time! You should not wait for warning signs of hypertension because quite often there are none. That is exactly why hypertension is termed a “SILENT KILLER”. Diabetes (high blood sugar) and dyslipidemia (abnormal cholesterol level) are the other two Silent Killers. All 3 should be measured at least once every year to catch abnormalities early.

Prevalence and Types of hypertension

An article published in the Journal of Hypertension in 2014 estimated that 1 in 3 persons living in cities and towns and 1 in 4 individuals living in rural areas in India are hypertensive.

  • Primary hypertension is the most common type where there is no specific cause for the high BP. General preventive measures like reduced salt intake, high fiber diet, regular exercise and stress reduction techniques should be the first line of management in this case. Medications are often prescribed to control your BP, it is best to take them as advised by your doctor and not stop them on your own.
  • Secondary hypertension is less common and denotes that there is an underlying medical problem for the high BP like kidney disease, hormonal disorder, structural problem in the major artery leaving the heart or other cardiac diseases. Very high BP at the time of diagnosis, blood pressure not responding to medical management and presence of other health issues are clues to this type of hypertension. Appropriate treatment of the underlying cause will help to manage hypertension in this case.

Impact of hypertension on your heart and other systems

Your heart is constantly pumping blood and supplying oxygen and energy to each and every cell in your body through your arteries. The health of your arteries is a very important factor that determines the health of your heart.

  • Constant increased pressure of the blood flowing through your arteries can damage the inner wall and lead to hardening or stiffening – Atherosclerosis. This in turn can lead to heart attack, stroke and other serious problems. Another life-threatening effect of untreated high BP is Aneurysm or weakening and bulging of important blood vessels like those supplying the brain and the major blood vessel leaving the heart. Rupture of these bulging arteries can lead to instant death.
  • Heart failure is one of the common complications of high BP wherein the pumping capacity of the heart drops below normal. This is measured by an echo test and the symptoms are weakness, breathlessness and swelling of feet.
  • Chronic kidney disease is again very common in hypertensive individuals and is due to damage to the blood vessels supplying the kidneys. The kidney function gradually drops which is seen as rising urea and creatinine levels in blood and reduced urine formation.
  • If you have high BP, regular eye checks are a must because an increased pressure in all the arteries including the arteries of the eye is possible. This can lead to damage to the back of the eye called Hypertensive Retinopathy, which can impair vision.
  • Memory loss, dementia and cognitive impairment are neurological complications of hypertension.

With World Heart Day fast approaching (29 September), let us all take a pledge to know our blood pressure and keep it under control!




Getting to grips with heart failure

For someone who has suffered a heart attack, has gone through several tests and life-saving procedures and has a long list of medicines to consume, a diagnosis of heart failure can be depressing. It not only means more medicines and more investigations but also lesser ability to do the things they enjoy and a reduced quality of life. However, the outlook for individuals with heart failure is not so gloomy after all. In fact, if you read this post till the end, you will be convinced that there is so much one can do to manage heart failure better!

The term ‘heart failure refers’ to the inability of the heart to perform its work well. In other words, the heart is not pumping blood effectively leading to all the body parts getting lesser oxygen than they need. The causes of heart failure are:

  • Ischemic heart disease (coronary blocks/angina/infarction)
  • Hypertension
  • Valve problems of the heart
  • Cardiomyopathy (heart muscle weakness)

The complaints typically given by patients are excessive tiredness, breathlessness, reduced ability to do physical activities, swelling of feet, cough at nighttime and discomfort in lying down posture. The cough, swelling of feet etc are caused by accumulation of fluids in the lungs and extremities as a result of the poor pumping of the heart.

While an X-ray chest will often show an enlarged heart and an ECG will show electrical changes, the ejection fraction (EF, an important parameter measured during an echocardiogram) gives a clear indication to the doctor about the cardiac function. The EF in healthy adults is between 50-75%, which means that the normal heart pumps just over half the heart’s volume of blood with each beat. There are 2 types of heart failure based on whether the EF is preserved (50% or more) or reduced (less than 50%). Both types of heart failure can be managed with medicines, limiting fluid and salt intake, and a proper diet and exercise regimen.

How does exercise help heart failure?

This is a very important question and warrants a thorough explanation. When someone is newly diagnosed with heart failure, they will be prescribed specific drugs to help improve the cardiac function and to reduce the symptoms. The number and dosage of drugs will be adjusted in the ensuing days to weeks until the symptoms are under control and the vitals are stable. Simultaneously, there will be changes made to the dietary pattern and fluid intake to prevent the heart from getting overloaded. This is the right time to initiate cardiac rehabilitation and supervised exercise as it benefits the heart in the following ways:

  • Strengthens heart and cardiovascular system
  • Reduces your blood pressure
  • Helps manage your weight better
  • Improves your circulation and the way your body uses oxygen
  • Gives you more energy, which lets you be more active without getting tired or short of breath
  • Makes your muscles stronger and more toned
  • Prevents the heart failure from worsening
  • Graded exercise improves the conditioning of your heart and lungs and allows you to participate in social, physical and sexual activities like normal individuals

While aerobic exercises are a must, strengthening exercises and balance and flexibility exercises are ideal too. It is recommended that individuals with heart failure keep track of how they feel during the exercise session and even after the session. Any excess breathlessness, discomfort, sweating, palpitation, giddiness or disorientation has to be informed to the healthcare provider immediately. Proper warm-up and cool-down are mandatory before and after each exercise session to prevent complications.

The advantages of a cardiac rehab program are that in addition to an exercise expert, there is a dietician who helps plan the meals and fluid intake per day taking into account the various factors like cardiac, renal and metabolic function; and there is a counselor who takes care of the psychosocial aspects such as feeling depressed, unduly stressed or helpless.

So how often should the EF be measured in someone with stable heart failure? The echo test, ECG and blood investigations should be done yearly if there are no new complaints, and more frequently if the clinical condition demands it.